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Representative terms from entire chapter:
public stealth
raft
TElE ANTHER\ VACCINES IS lT SAFE? DOES IT WORK]
IOM released The Anthrax Vaccine: Is It Safe? Does It Work? in March 2002.
in tire Waite of anthrax infections and cleatl~s that resulted fi-om bioterror-
ism in fall 2001. Congress requested tire study because of concerns raised
about tire safety and efficacy of tire antI~rax vaccine widen tire Department
of Defense (DoD) instituter! a mandatory vaccination program in 1998. The
IOM report reviewer! tire data available on tire safety, efficacy, amuck manu-
facturing of tile licensecl anthrax vaccine, I
INH)1?,3~s!r(:~ 711E ii CRI/~(~AL i.~S IN HE-AL7~
The committee recommenclec! that DoD continue anc! improve moni-
toring efforts to detect airy adverse health effects causer! by AVA anct other
vaccines, and that the procluction, testing,, ant! licensure of a new anthrax
vaccine requiring fewer closes and pr oducing fewer local reactions
is neeclecI.
Tire Assistant Secretary of Defense for Health Affairs described the
r eport as tile most extensive r eview of tile science underlying, a'~tI,rax vac-
cine ant! b°°d resews for military person. Within mottles of tire report's
release, DoD reintroduced its Anthrax Vaccine l~nn~unization Program,
beginning wield those service members co~siclered to be at Weigher risk and
essential to tile accomplisI~me~t of military missions. As part of tile civil-
ian response to bioterrorism concerns, tire Department of Heath and
Human Services (DHHS) alas also made efforts to stocIcpile AVA. At tire
saline tine, Motif DoD and DHHS are pursuing tire development of''next
generation" anthrax vaccines as urged in the IOM report.
Q~v t'~ Q^~t
In 1996, tire Institute of Medicine launcI~ec! a large-scale, ongoing
effort focused off evaluating ant! improving the nations quality of case
which is now in its theirs pleases The first please of tile IOM Quality Initiative
documented tire serious and far reacI~ing nature of tire nations overall
quality problen~ inclucling tile pervasiveness of n~eclical errors which
account for thousands of patient cheaters every year as describer! in To Err is
Hump (19991. In tire initiatives seconc] please tire report Crossing t1'e
Quality C/?as~n: A New Health System for t/~e 21st Century (2001) was r eleased
offering a comprel~ensive vision for flow tire i~ealtl~ system ant! larger pol-
icy environment Origin be transformed to meet
six key aims namely treat care is safe effective
patient-centerec! timely efficient and equitable.
Taxis report stimulated a national conversation
about wheat needs to change on bile environmen-
tal level at tire health care organizations ant!
small practice levels as well as at the level
where patients and clinicians interact. Taxis clialogue leas led to numerous
public anti private sector efforts to reform the healths care system at each
of tI~ese levels. These efforts include: national employers working to put
safety practices into place in hospitals; health care providers acting to
reclesign care clelivery acid experiment witty innovative financing; ancI fed-
eral and local agencies including the Agency for HealtI~care Research and
*echo IO[~1 QU31;1Y llIlitIatIVe
d(.~ni.~d tale SerIouS
and fa' reaching nature of
the nations overall quality
p'*0bl~o..
HIGHLlGH]~D Rri3(}~s
Quality (Al{RQ) and tile Centers for Medicare/Medicaid Services (CMS), pl o-
ducing quality report cards al d paying for quality demonstrations, among
otiose activities.
r --a---= ~ I~~~~~~~J
Crossing the Quality Chasm also has provided a very important fi-ame-
work for tile il,~plementatio'~ or third please of tile lOM's Quality l'~itiative.
This phase includes three different types of efforts all focuses! old r eclucing
e~lviro'~l~ental barriers: developing reposits Blat lay out a strategic direc-
tio~ for a particular area within tire framework of tire Quality Chasm r eport;
designing demonstration ideas or tools and tecl~iques, which aid in il~ple-
me~ti~g that strategic direction; and fostering collaborations between tire
IOM acid aiders wire are working to redesign tile health system.
Tire following upcoming and released reports and convening activities
reflect tire b~-eadtI~ and diversity of issues that must be facet! to improve
the quality of health care in tire U.S.:
· At tire request of else Secretary of the Department of Healths and
Human Services (D~HS), tire IOM cleveloped boIc}
icleas Flat could be enactec! at the state and com-
munity level to respond to system ills and guicle
future larger scale reform. Tire ensuing report,
Fostering Rapid Advances in Hec`It/~ Core: Learning
from System De~no'Jst'-atio'~s (2002), focused on
~ edesigning primary care ant! care for ti~ose with
At tI3e re9~t of the
Sexy of shed
Department <~f Ittealit, and
Hunlan Services' the t0M
40~oped bold ideas*.~o
(respond tO System i! ISeas
chronic conditions, creating an i~fo~matio~ and
communications technology inn astructure, making health insult ance cover-
age available and affordable at tire state level, and refor~ni~g ~nall~ractice
to make it patient-centered, safety focused and nonjudicial.
· In January 2003, tile IOM issued tire repo't Priority Areasfor National
Action: Transforn?i/~g Healt/? Care Quality (2003), also at tire request of DHHS.
Tire ~ eport r ecommencIs 20 priority areas that collectively span preventive,
acute, chronic, and palliative care, and two interventions- care coordina-
tion ant! self-management/health literacy- Pleat cross each of these
domains. As a follow up to taxis report, the IOM is I~osti~g a summit in
January 2004 that will involve both national ant! focal leaders in clevelop-
ing work plans for redesigning care at the community level for seven of tire
20 priority areas. The areas of focus include asthma, congestive impart fail-
ure, clial~etes, major depression, and pain management for tl~ose with
advancer! cancel; as well as two crosscutting areas: care coordination and
patient self-~anagen~ent. Tunis summit will provide con unity leaclers
7
v~~ 7~~ art I Amp jamb Off HE-AL71-]
with tools ant! tecI~niq~es for overcoming barriers to in~proving care in
Otiose five areas, as well as ideas anct support front Oliver con unities acid
national leaders respectively.
· I(ey Capabilities of an Electronic Health Record (2003) identifies a set of
eaglet core functions that should be i'~corporatecl into electronic health
Scores to guicle standarc! setting bodies ant! software clevelop~nent organ-
izatio~s. otiose functio~alities can also serve as a too! for heat-care
organizations as tizzy compare different IT systems, and consider which to
adopt. These functionalities may guide tire federal ~,ove~nn~e'~t as tired
consider ways to encourage I~ealth-care organizations to implement elec-
tronic health recorcis.
· Tire Quality Chasm report also reco~n~nencled that an i~tercliscipli-
~ary summit of leaders be I~eld to develop next steps for health professions
education. Taxis summit was hosted by the IOM and held in June 2002 anc!
involves! 150 leaciers from education oversight organizations practice
environments purchasers consumer groups ant] professional associations
among others. Tire summit participants ideas
and tire resulting report Hea/tI~ Professions
Eclucatio'7: A Bridge to Q~'ali~ (2003) icicle a mix
of approaches wilds a central message that
efforts to reform health professions education
should be interdisciplinary. The approaches inclucle those related to over-
sigI~t processes tire traipsing environment research public reporting and
leaclersI~ip. Tire goad is an outcome based education system that better p~-e-
pares clinicians to meet both the needs of patients acid tire requirements
of a cI,angin~ health care system.
· In Lendershi,v by Exa'~ap/e: Coordi'?ati'~g Goveran~ent Roles ill l~nproving
Health Care Quality (2003J tire IOM recommends treat tire federal govern-
ment use a multi-prong approach inclucling rewarcling I~igl~ quality
providers wizen Riley purchase health care services leveraging their regula-
tory power to establish clinical clata reporting requirements; using their
own health care delivery systems e.g. tire VA (Department of Veterans
Affairs) as laboratories to learn what floes and does not work for a 21st
century healths systemic and finally applying health services research as they
seek to develop the knowledge base and tools treat support quality
enl~ancen~ent.
ehoris tO tefOrn] health
A ~ ~ ~
Paws eouL'at.~n
sh(.~d be interdisCIplinary.
$
Hiui-~-~9 Roars.
FOoD ~~S UoDEx
Tire Food C/?en?icnis Codex (FCCJ project is an activity of tire IOM's Foot!
ant! Nutrition Boarc! that alas been supporter! by tire U.S. Food and Drug
AcI~ninist~ ation (FDA) for 40 yeas s. Tire Codex is an impost tent component of
national foot! safety defenses. It was establisi~ec! following the passage
of tl~e Food Additives amentin~ents to tl~e fecleral Food, Drug, acid
Cosmetic Act in 1958. To ciate, four eclitions of the Fooc/ CI?e'~?icals Codex
(1966, 1972, 1981, and 1996) leave been published, as well as tire First
(1997J, Second (2000j a'?c/ Thi'd (2001) Supplen~e'~t to the Fourt/? Eclitio''. Tire
Fifth Edition is due for publication ifs late 2003. Tire FDA, by reference,
incorporated into tire Coc/e of Fec/eral Regr`/ations many specifications pub-
fished in tire fist tiered eclitio'~s of tile Food C/?emica/s Cociex. Canada,
Australia, and New Zealanc! have also acioptec} the Codex as part of Elixir
food regulatory systems.
The FCC establishes standards for the purity of food chemicals to
ensure consumer safety and promote uniform quality in production of such
chemicals. The First Edition was limiter! to chemicals treat are acIdec] direct-
ly to foods to achieve a clesirec] technological function. Succeeding eclitions
upgraded tire specifications for these substances and addled specifications
for processing aicIs, Silica come into contact witty foods cluring processing
lout do not Sconce part of the, as well as tonne
that are regardec! as foods lather titan as acicli- i'ECC-~ Is ~ terns ream
fives. More recently, "functional" ing~eclie~,ts, finely used by many Janus
which purportecIly perform a function in the facturers in food chen~cals
Truman hotly but not on tire food itself, leave been
addec] to Ellis list. Tire FCC leas continued to
expand and evolve as able FDA approves new food additives ant! as
advances ale Marie in scientific and manufacturing metI~ods and tecI~nolo-
gy. Tile Fifth Editions will contain Bore titan 1000 monographs, many of
totem new, ant! will feature a tI~orougl~ revision of FCC specifications.
and ingredients Iabels.
In able current era of globe' sourcing, which leas promoted tire entry of
many suppliers of food chemicals and ingredients fiom other countries
into tile United States market, tire FCC provides identity, strengths, and
purity specifications for food chemicals that are recognized nationally and
internationally. "FCC~grade" is a term routinely user! by many manufactur-
ers in food chemicals and ingredients labels. Users of these substances, in
turn, often require from suppliers fiat sucks substances be FCC compliant.
In recognition of these standards, tire FCC has been incorporated into the
cat
Art 'Lyle I~ {)7 ~ lPE~ CPl] I(~L I.~3~,
food additive legislation of several countries amuck is user! worIc~wide among
n~a~ufacturers acid users of food chemicals and ingredients.
FCC specifications are continuously updated I~asec! on science acid in
accordance wield the rapidly increasing pace set by FDA approvals. Without
frequent updating of the FCC, American consumers could be exposed to
many new food aciclitives for which thieve would be Rio agreed upon purity
specifications. As concertos increase about tire protections of tire food sul~-
ply fi-o~n inte~tio`~al contamination tire FCC also provides a scientific basis
for scat ee~i~g food chemicals and ingredients. Tire primary goal restrains: to
clefi~e tire quality of fooct-gracle cI~e~nicals in terms of icle'~tity7
strength acid purity based on tl~e elements of safety amuck good
~ . .
manuractu~ng practices.
1~L THREATS TO ~ EALl ~ ~
Tire lOMs interest and involvement in addressing tire challenges of
emerging microbial retreats to health leas spanned more titan a decade
ant! yielder! severe
ant! global security.
important contributions
to public lath
In its 1992 report Emerging l'?fectio'~s: Microl~ia/ Threats to Hec:It17 in tile
United States, the Institute of Meclicine pointed to major cl~allenges for else
public I,ealtI~ research and medical care communities in detecting ant!
managing infectious disease outbreaks
and monitoring the prevalence of endemic
Etnc3~-ing Infertions~ Microbial
Threats [o Health iI7 the United
Sfal:~. provide~'tI~e basis for
the CDC:Ps Nat't,~! Center for
nfe`~ti o u s D i S£~S ~ 994 dH ]
~ 998 strateg'~ plans to address
the threat off twig infe`~:~s
HOLtIORO.~*
(:)
diseases. The ~ epo't s ~-eco~nn~endations
proviclec! tire basis for tire Centers for
Disease Control anti Prevention s (CDC)
National Center for- Infectious Diseases
1994 and 1998 strategic plans to acIdress
tire thereat of emerging infections national-
ly. The lOM report is credited also as tire
catalyst for tire National Security Council s
charge to tile Committee on International Science Engineering and
Technology (CISET) of tI1e WIlite House National Science and TecIlnology
Council to consider tire global threat of infectious diseases.
To furtI~er illuminate tIlese issues, tile Centers for Disease Control and
Prevention, along witty the National lustitutes of Healths, asked the lOM to
convene the Forum on Emerging Infections (1996) now known as tire
HIctILlGI-~D REl)~Ryr^S
Forum on Microbial Threats, to foster continuing and structures] opportu-
nities for clialogue around areas of sheared concern among stalcel~olclers
within the public ant! private sectors. In r ecent years, sucks cat oss-sector clia-
togue leas precipitates! collaborative consideration ant! action around dis-
eases on Nan heat, microbial and disease vector r esistance, biological
treats and terrorism, tire impact of globalization on infectious disease
emergence, ant! tl~e infectious causes of carbonic diseases.
IOM's most recent report, Microbia/ Threats to HealtI7: En7e'~ge'?ce,
Detections, acid Respo'?se (2003, examines the complexities and challenges
posed by infectious diseases and tire colic esponding Fence treat contribute
to else emergence and reemergence of Close tale eats. Tire report recognizes
tire vulnerability of populations in all nations as a thereat not only to per-
sonal healths, but also to public safety, economic stability and development,
and 'rational and international security.
Building on the factors of emergence icle~tified in the 1992 report, taxis
report explores an expander! number of human-microbe interactions that
contribute to disease. Moreover; tire r eport
describes how the convergence of any number of
factors (e.g., biological, ecological, and political)
creates an environment in which infectious dis-
eases can emerge acid Second rooted ilk society.
Tire ever-worse~i~g HIV/AIDS pa'~ciemic, tire
esurgence of once manageable diseases, such as
*A coiiv6~0 of HEY
~ ~ n~ ber of [~' ~ (~*,
biological ecologic
Political) Creates all envy
ron~nent in which ~nfec-
tI(7US ~iSCdSCS CdI] CI~(gO
anti Ib`~ome rooted ~n
SoCiely.
tuberculosis, tire emergence and spread of drug
resistance and newly identifiecl pathogens sucks
as tire SARS virus, and tire first use of biological terrorism in tire United
States reflect tire formidable problems treat challenge incliviclual agencies,
governments, acid markets. Tire report's recommendations propose a
range of actions neecieci to keep pace with our microbial competitors and
to define meaningful and sustainable solutions. Specific guiclance is provict-
ecl to improve and entrance domestic and global public health capacity,
infectious disease reporting and surveillance systems, workforce educa-
tion, and the availability and development of effective countermeasures to
clisease. Tire report's recommendations are currently uncler consideration
by numerous fecleral and national ant! international decision -.
[~;1R,~.~\r(- 'art I4~ CRI]~AL iS~StIES Ifs IDEALS
DIETARY ~~:~E INTAKES fOR [~1f,, ~~RBOHY-~~
Fond' Iffier' army
A~o Aches
ACtOs! Cno~..~ao~..' PRoTElN! AND
More titan 60 years ago, tire Food acid Nutrition Boarc] issued its first
set of Recommenclec! Dietary Allowances (RDAs) for vitamins minerals
protein and energy in response to tire Wa' Depa'-t~nents concern during
World War 11 over the nutritional fitness of new recruits malnutrition
among existing to Cops and tire need to provicle adequate nutrients to mal-
nourisI~ed populations after Riley were liberated by Allied troops. Since
1941 RDAs slave served as tire basis of almost all fecleral and state food
and nutrition programs and policies ant! leave been revised nine times
witty tire list of RDAs growing fiord eaglet to 27 nutrients in 1989.
Since the publication of tire 10th and last edition of tire Recommended
Dietary A/Iowances in the Unitec! States in 1989 and the Recon~menclec! Nutrient
Intakes in Canada in 1990 new information leas e~ergect about nutrient
requirements that warranted the development of upcIatec! guidelines. Over
tire vast eight years tire IOM leas implemented an expanded system for
determining the RDAs ant! Oliver nutrient baser! reference values now
called Dietary Reference Intakes (DRIs). The new DRls are leased on scien-
tifically grouncled relationships between nutrient intake and indicators of
goof] I~ealtl~ as well as tire preventions of cl~ro'~ic diseases in annarentlv
healthy populations.
fir r ~ ~
In this recent report, Dietary Reference Intakes for Energy, Carbohydrates,
Fiber, Fat, Fatty Acids, CI~olestero/, Protein, a''d An~i`?o Acids, tire sixths in a
series providing Dietary Reference Intal~es (DRIB)
clevelopec] jointly by Ames ican and Canadian sci-
entists, tire DRI recomme~clations are expanded
~~. to meek the body's frailly
~ utritional needS Wil'Ie
mlnIn117~.g rISk Ior chronlC
d`~' adulls should con
semen 45 to 65 percept t'[
their total calories from
carbohydrates' 20 to 35
pat from fat, and ~ (3 to
3!; '~t fan proteins
to include carbol~ycirates fiber; fat fatty acids
cholesterol protein and amino acids collective-
ly renown as the macronutrients as well as ener-
gy amuck physical activity. Tire report recommends
that to meet the bodys daily nutritional neecIs
winkle ~ninimizing risk for chronic disease aclults
should consume 45 to 65 percent of their total
calories frown carbohydrates 20 to 35 percent
from fat and 10 to 35 percent from protein. These are of considerable
i nportance to federal agencies in Piglet of tire growing concerns related to
Ft r,
11~}~ kr~r~.:
consumption of specific dietary components such as bans fatty acids or
cholesterol and increased risI; of chronic diseases, inclucli~g cardiovascular
disease ant! cancer Tire acceptable ~ anges for cI~ilctren are similar to tl~ose
for aclults, excels treat infants acid younger cI~ilcire~ need a somewhat i~igI~-
er propo'-tion of fat in their cliets. These ranges may be more useful! and
flexible fo' dietary planning titan single maximum values r econ~mencied in
the past.
Sponsors of tire report, including tire U.S. Departments of Agriculture
a'~d of Healths ant! Hun~an Services, as well as Healths Canacla, a clivisio~ of
tire Canadian government, also asked tire Academies to specifically provide
guidance by defi~i~,g "dietary fiber" for tire pur-
pose of regulating 'nutrition labels on foods, and
on determining adverse Stealth consequences of
consuming sugar added to foods such as cakes
and beverages compared to other sugars such as
those naturally found ire fruits ant! dairy proct-
ucts. New products that meet regulatory definitions of fiber have recently
been marketed, yet isolation procedures and definitions of tire tern vary
greatly creating, tire neec] for a uniform concept. If aclopteci for use in foot!
regulations, tire new set of definitions will cletermine which fi~er-like food
acIclitives are counted as fiber on tire mandatory nutrition facts food labels.
Sponsors of chew report
.~.z~sked ti~e Acade~s io
Specifically provide go jU"
ance by defining '`dieli;try
[ther''*~.
Tire r eport~s recom~ne~clations pi ovicle tire basis for tire current review
acid upcIate of Dietary Guicleli~es for Americans, to be completed by 2005
by an advisory committee to tire U.S. Departments of Agriculture and of
Healths and Human Services, and similar evaluations in Canada.
AcIclitionally, a follow-on study by tire Food and Nutrition Board is uncler
way. Requested by Healths Canada, tire U.S. Food and Drug Adn~inistration,
ant! tile U.S. Department of Agriculture, it is to provide specific guidance
on flow to adapt tire DRls for use as reference values off foot} labels. Taxis
will facilitate harmonizing food labels between tire two countries, a move
strongly supported by tire foot! industry. In a related study, tire U.S.
Department of Agriculture leas asI
/~(F l~ Ft,']-~a CRI1'l(~AL iSSt'ES IN ilEAL7~
ROTECTING ~~H PARTIC] PANTS
Tire explosion of knowledge emanating Mom basic science efforts, sucks
as tire Human Genome Project, will lead to previously unimagined tI~era-
pies ant! an eta of ir~clividualized meclici~e. The translation of discoveries
in funcIamental and applier! science into useful clinical and public health
inte~ve~tio~s clepends upon rigorous clinical trials involving large contorts
of patients with appropriate phenotypes for studies. Such trials in turn,
require a strong ant! effective system to pi otect tire individuals wire partic-
ipate in totem. Mounting concerns about tire well-being of research partic-
ipants acid tile capability of existing approaches to erasure participant
protection, led tire Department of Healths and
~ ~.a Set of com plenlentary
e`Ee~s anti activities are
necessary to enSure adds
9~e prt')~.iOn for
reSearci] partiCIpantSe
Human Services to com~nissio~ a comprehensive
assessment of tire national system for providing
participant protections. A fast-track first report,
Preserving P'`blic Trust: Accreditatio'~ acid Human
Research Participant Protections Programs (2001),
focused on tire potential value of accreditation.
1~ tight report and ill the seconc! please report, Responsible Research: A
Systems Approach to Protecting Research Participants (2002i, the case was
macie that a set of complementary elements and activities are necessary to
ensure adequate protection for research participants. Pilot testing accrecI-
itation was identifier! as ogle promising approach to improve the system.
Tire reports also recommenc] that fecleral oversight be extencled to all
r research regardless of tile sponsor; call for greater public participation in
Else ethical oversight of research; and make recommendations about eclu-
cation coordination monitoring ant! othe~-topics.
Tire reports leave resulted ilk a number of actions by tile federal govern-
~nent. Tire Office for Human Research Protections (OHRP), tire Food ant]
Drug AcI~ni~istration (FDA) tile National institutes of Heat ant! tire
Department of Veterans Affairs coordinate tire clevelopment and dissemi-
~ation of ethnics education practices. In addition OHRP ant] FDA require
that researcl, organizations are notified of deficiency warnings and r elated
communications by regulatory agencies ant] are harmonizing safety moni-
toring guidance inclucling standard pi actices to clefine ant! report adverse
events. Tire Secretary s Advisory Committee for Human Research
Protections will acicI'ess a number of tire committees recommendations
ant! advise tire Secretary of DHHS flow to proceed. Legislators also have
citec! tire ~ eports and intend to build on tire co~n~nittee s r ecom~nencIatio~s
in legislation to extent! federal oversight to all research.
{flGu~J!~7~n 17~s
A number of tire report's recomme'~cIations can be in~ple~ne~ted witi~-
out direct government action. Their explicit incorporation into tire accrect-
itation sta~darcIs of tire Association for tire Accreditation of Human
Research Protection Programs and the Partnership for Human Research
Protection is a notable early result. Tire committee's recomn~endatio`~s
leave been widely cliscussec! in the research community ant! elsewhere, ant!
metes oftl~e lOM's Clinical Research Rou'~dtable leave consiclerec! flow
to imple~ne~t then. Other organizations also are evaluating tire reports
ant! ~ietern~ining tl~ei'. next steps ilk Piglet of tire recon~mendations.
pAL LlAT-~NfE AN D EN 0~ ~~ ~E
tic ~
~ [-HEIR tAMIt-~S
~,\~E FOR ~~> DREN Flats
In 1997, tire Institute of Medicine publisI~ec] Approaching Death:
n?provi'~g Care at the Earl of Life, tire first comprehensive, eviclence-basec!
report on taxis subject. Improving Palliative Carefor Cancer follower! in 2001,
builcling and extending on tile earlier report, witty a focus on tire quality of
palliative ant! encl-of-life care for cancer patients.
In a new report, When Chi/ciren Die: Imyrovi'~g Palliative anc! End-of-Life
Care for Chilciren airy Their Families (2002), tire IOM examines care for cl~il-
ctren with fatal or potentially fatal n~eclical concii-
tions and tI~eir fannies. Although finest children
leave some cI~a~acte~-istics and problems in co~n-
mo~ witty very ill adults, tipsy also present special
concerns and complexities. For example, where-
as aclults most often die of Impart disease and
otiose chronic conditions, tl~e leading causes of Neatly in cI~ildi~ooci are
problems relater! to prematurity ant! cl~ildbirtI~, congenital anomalies, ant!
intentional and unintentional injuries. A cl~ilct's Neatly may be tire most
stressful and painful experience treat a family can face.
A chilldl~s dearth Clay 1~` the
',7~t stressful anti painful!
experience that ~ fancify
can face.
Unfortunately, children and families too often fad! to receive palliative,
e~cl-of-life, and bereavement care that meets tI~eir special physical, psycI~o-
logical, and spiritual needs. To improve care, tire report recommends
changes in four broac! areas:
· Organizing anti delivering cervices: Develop care guidelines and pro-
tocols as a basis for assigning responsibility and evaluating and taken
r
Improving performance;
15
BIND OWE Firms CRI11~AL i.~lJES IN IDEALS
.
Finallcillg care: Eliminate hospice coverage requirements for a 6-
montI~ prognosis and tire foregoing of curative ant! life-prolonging care;
reduce restrictions on palliative care benefits, including consultations ant!
parent counseling;
· Educating health professionals: Provide t~ndergracluate, graduate, post-
graduate, and continuing educations in palliative, end-of-life care, and
bereavement care tailorec! to the responsibilities of every professional Gino
cares for children; Alice
· st`~engt/?el~ing the knowledge base: Set priorities for research in pallia-
ti`re, end-of-life, Alice bereavement care.
Since the report was released ilk miti-2002, a group of clinicians, eclu-
cato'~s, researcl~ers, and policy ant! financing experts leave organized to
promote tire implementation of the report's rec-
ommenciations. Legislation baser] on several of
the committee's proposals has been introducer!
in Congress, and the National Institutes of Healths
leas publisher! priority areas for research in pedi-
atric palliative and encI-of-life care
tegisIati(~n based on Sever
al of the comm'tiee's pros
P058~5 Ilas been ;~d
~ I] ~~.~S.. ~
IMM(~N SAfETY
Tire Immunization Safety Review Committee was established at tire
request of tile Centers for Disease Control ant! Prevention and tile National
institutes of Health to provicle inclepenclent timely ant! objective assis-
tance to tile Department of Health and Human Se-vices in evaluating the
available evidence on a series of in~unization safety concertos. For each
hypothesis to be examined the IOM committee assesses Motif tile scientif-
ic eviclence acid tile significance of tile issue foil society. Tile scientific
assessment leas two components: an examination of tire epide~niological
ancI clinical evidence regarding a possible causal relationship between the
immunization and the acIverse event; anti an examination of experimental
evidence for ally biological mechanisms relevant to tile hypothesis.
Tile significance assessment addresses such considerations as the burden
of tile health risI
OCR for page 17
Hi0~) p~33~5
tions. Titus fat; tire committee has consiclerec! tire issues of multiple immu-
nizations and immune dysfunction, hepatitis B acid demyeli~ati'~g disor-
clers, SV40 contamination of Polio vaccine and cancel; vaccinations and
sudden unexpected cleated in infancy, ti~i~erosal-containing vaccines ancI-
neuroclevelopn~ental clisorclers, and measles-mumps-rubelIa vaccine
and autism.
Tire project s})o'~sors, CDC and the NIH, have responded quicI
IN~PA/~\r(~ 1~- F(1rI-~ CRIlY(~A! I.~S IN HI~`AL71-]
ing the goals of the program. In tl~e process of providing rapid and timely
advice to CDC, tire IOM Committee on Smallpox Vaccination Program
lmple~nentation leas held several meetings ant! issued four letter reports
treat leave contributed significantly to improving CDC's implementation of
tire program.
Based on tire committee's recom~nendatio'~s, CDC has put into opera-
tion act active su~-veilla~ce system to supplement else data collected by tile
Pre-event Vaccinations System and to Whelp ensure Fiat all adverse events fol-
lowi~g s~nalIpox vaccination are reported and investigated. 1~ tI~eir efforts
to encourage Congress to pass a smallpox vaccine compensation program,
professional groups representing some of the first smallpox vaccine recip-
ients citec! tire committee's recognition Fiat informed consent of tire vac-
cinated individuals could be affected by tI~eir understanding of the com-
pensation available (or lacks thereof for serious adverse reactions or subse-
quent medical costs. The committee's recom-
menciations about critical education and com-
munications issues prompted CDC to develop
ant! implement informational streets for I~ouse-
hold contacts of vaccine recipients and to
prospective vaccine recipients witty information
about the status of compensation issues.
AcIditionally, CDC leas built ill a great deal of
flexibility foil states to define priorities for pre-
pa~edlless, i~ClUClillg pausing to evaluate and consider next steps. Taxis is
congruent with the com~nittee's recommendations about balancing nation-
al goals with local needs and circumstances.
BaSe(] on the Comnlitiee/S
re~mnnendatit.~, cOc
haS put into operation an
active Surveillance Syste
tt, sup~3~t t~ 48~.~. ~~
I$~d by the Pre-~`ent
va<;~n system.*.
Tile National Vaccine Advisory Committee (NVAC) and tire Advisory
Co~n~nittee Ott immunization Practices (ACIP) Inane quote of IOM reports
ant! recommendations at their meetings in February 2003 (NNIAC) ant! June
2003 (AClP). IOM's call for a pause to evaluate the program anti ensure its
continuing safety was part of tire (liscussion at NVAC and ACIP meetings,
and ultimately, helped witty the development of those committees' recom-
menciations for a delay in the vaccination program to ensure caution and
allow for adequate evaluation. Additionally, tire April 2003 General
Accounting Office report assessing tire progress of tire smallpox vaccina-
tion program compared recommendations macle in tire IOM reports witty
CDC's implementation of the program, and identified areas of tire program
that needed improvement.
How- Rears
Tur Fir or P~c Ht4~n
.. .. .
In 1988, tl~e IOM publisl~ec! The Fume of Public Health. Tire report
defined public health as wheat society floes collectively to assure tire concli-
tions for people to be Meaty acid presented strong evidence to indicate
treat tire public stealth system tire organizational mechanism for achiev-
i'~g tire best population I~ealtl~ was ilk Sisal ray. Although tire r eport
described tire public stealth system as the govern~ne~tal public healtI,
agencies and "tire associated efforts of private acid voluntary organizations
ant! inctividuals," it focused specifically on ways to stre~g,-tI~en governmen-
tal public health i',fiast~ucture. In 2001, a new IOM committee was con-
vened witty else clears to create a fi amewo~-k for
assuring populations healths its tire United States
that would be mole inclusive than that of the
1988 report and tight could be effectively com-
municated to and actec! upon by diverse commu-
nities. In tire new report, The Future of t/~e Pub/ic's
Health in the 21st Ce'~h''Ay, tile committee exam-
ines Motif tire governmental component of tire
public I~ealtl~ system and tire potential contribu-
tions of Oliver sectors and entities. Tire report
reviews tire nation's public Stealth capabilities
and presents a comprehensive framework for
how the government public health agencies,
worI
[~N,lIN(t 1~E ~(Jr] l/~3~ CRI116~AL i55~lrs I,\ arm-
ings of over twenty major national and state public health and
professional leadership organizations Congressional briefings and meet-
ings witty members of the press. At tire fecleral level CDC bias acloptecI tire
report as tire frameworks or starting point for its strategic planning process.
Several programs within CDC slave used the report to launch activities to
strengthen tire public health worlcforce acid to improve public healths
system performance.
Else report was also featured at tire joint meetings of National
Associations of County and City Healths Officials anti Association of State and
Tea ritorial Health Officers ifs September 2003. In acIdition tire major
public heat organizations leave cleveloped committees to i~npleme~,t tile
report recommendations.
A related report Who Will Keep the Public Healthy? Eclucating Public
Health Professionals for the 21st Century, was released on November 4 2002
and leas since become tire focus of mucks planning ant! activity related to
developing tire public Baltic workforce. Tire Public Health Workforce
Development Collaborative leas made tire r eport tire focus of strategic plan-
ning efforts—aclopting tire core recommender! competencies generating a
set of curricula anc! cleveloping a research agencia. Tire Council on
Linkages between Academia and Public Healths Practice continues to devel-
op tire strategy to assure that tl~e nation co'~sid-
ers certification of public Stealth professionals.
Tire Association of ScI~ools of Public Health leas
macie several issues and recommendations in the
report a priority for discussion and actions at its
upcomin meetings. The American Public Healths
Association is developing a convener project
which will include an annual forum at tire annual APHA meeting to report
Ott tire progress made to implement recommendations. Act e~tI~usiastic
reception by the American College of Preventive Medicine led to adoption
of a strongly worded resolution by tire American Meclical Association to
advance tire role of the physician in public health and re-constitute tire
medicine-public health initiative.
The Public Healll' Work
force DOYOlOPR7~[
Art ~ ~ ~ ~ l-A ~ ~ ~ ~
the teport the focus of Lits]
straten~c nIan hi nu efforts
HIGI11-~-~) PEl)~S
Georgia State University r ecently developer! a new untlergracluate MPH
program based on tire proposed framework and recon~mendations of tire
Who Will leveed the Public Healthy? report. If approved, as expected, by the
Board of Regents, Georgia will be tire first state to adopt ilk full tl~e
recommender! Framework.
Selected Recommendations for Global Health
ant] Infectious Disease
Microbial Threats to Health: The United States should seek to enhance the global
capacity for response to infectious disease threats, focusing in particular on threats
in the developing world U.S. federal, state, and local governments should direct the
appropriate resources to rebuild and sustain the public health capacity necessary to
respond to microbial threats to health, both naturally occurring and intentional.
C DC, DoD, and NIH should develop new and expand upon current intramural and
extramural programs that train health professionals in applied epidemiology and
fielcl-based research and training in the United States and abroad.
The U.S. Secretary of Defense, the U.S. Secretary of Health and Human Services,
and the U.S. Secretary of Homeland Security should work closely with industry and
academia to ensure the rapid development and deployment of vaccines for natura~-
~y occurring or intentionally introduced microbial threats to national security.
Further, CDC, FDA, professional health organizations, academia, health care cleliv-
ery systems, ancl industry shock expand efforts to decrease the inappropriate Else
of anti~nicrobials in human medicine. (Microbial Threats to Health: Emergence,
Detection, anc! Response, 2 003 ~
Global Emerging Infections Surveillance: Support for the Global Emerging
Infections Surveillance and Response System of the Department of Defense and the
facilities that sustain it should be increased to allow GEIS to completely fulfill its
potential Pursuit of collaborative, we~-coordinated relationships with international
organizations, U.S. Government agencies tincturing other DoD laboratory entities),
and relevant agencies of foreign governments shots be continued and expanded
to the extent possible. (Perspectives on the Department of Defense Global Emerging
Infections Surveillance and Response System: A Program Review, 2001 ~
Brain Disorders in Developing Countries: Extend and strengthen existing systems
of primary care to deliver health services for brain clisorclers. Secondary and tertiary
centers should train and oversee primary care staff. orovicle referral canacitv and
~ ,,
orovicle ongoing supervision and support for primary care systems in developing
countries. Make cost-effective interventions for brain clisorders available to patients
who will benefit. (Neurological, Psychiatric, and Developmental Disorders: Ivleeting
the Challenge in the Developing World, 2001 ) ~
