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• The full-text guideline is available in English to the public on request (for free or for a fee). • Theguidelinemusthavebeendeveloped,reviewed, or revised within the past 5 years. The clearinghouse also states that it will not exclude a guideline if a systematic review is conducted that identifies specific gaps in the evidence base for some of that guideline’s recommendations. The major changes from the older criteria are that documentation must be provided showing that a guideline is based on a systematic review of the evidence and an assessmentofthebenefitsandharmsoftherecommended and alternative care options. Mary P. Nix, MS, health scientist administrator with the National Guideline Clearinghouse, said the changes originated with a suggestion from the IOM. “Our editorial board thoughtweshouldfollowupwiththeIOMrecommendation that the National Guideline Clearinghouse revise its definition of a guidelineandchangeourinclusioncriteria,”saidNix. “Previouslywewantedsystematicreviews,but we didn’t specify it in our criteria, and now we will be actually stating it.” Introducing greater rigor into guideline creationappearstobeneeded,asstudiescontinue to show questionable practices by groups assembling such guidance. For ex-

ample, a recent article in Mayo Clinic Proceedings looking at 149 interventional medicine subspecialty guidelines found only 46% graded the quality of evidence and only 38% commentedonconflictsofinterest.Whenthe researchers looked at 3425 recommendations with graded evidence, 11% were supported by level A evidence (randomized controlled trials or meta-analyses), 42% by level B evidence (single randomized controlled trial or nonrandomized trials), and 48% by level C evidence (expert opinion or case study) (Feuerstein JD et al. Mayo Clin Proc. 2014; 89[1]:16-24). Joseph D. Feuerstein, MD, lead author of the Mayo study and a gastroenterology fellow at Beth Israel Deaconess Medical Center in Boston, said he appreciates that for some interventions, rigorous clinical trials may be unavailable to authors writing guidelines. “Our feeling is that guidelines should be restricted to areas where there is strong evidence,” Feuerstein said. “When strong evidence is not there, then maybe we really should have a separate document with a best practice statement saying we don’t have strong evidence, this is just expert opinion, and we can’t say this defines quality of care.” He said such a distinction is important because guidelines without rigorous evidence are not only used by physicians; they

can also be used by insurers, quality assessment organizations, and malpractice lawyers, who can misinterpret such recommendations as defining quality of care and mistakenly punish or reward physicians. Harold C. Sox, MD, emeritus professor of medicine at Dartmouth College’s Geisel School of Medicine, Hanover, New Hampshire, is working with others to bring more rigor to clinical practice guidelines. He has high praise for the IOM report and the efforts by the National Guideline Clearinghouse, but he thinks more can be done to eliminate “statements about the use of procedures that don’t meet a high standard for evidence.” Sox said he and Sheldon Greenfield, MD, chair of the IOM committee that issued the 2011 report and professor of medicine in the University of California, Irvine School of Medicine, are trying to develop methods for measuring a guideline’s adherence to standards. “So, just like Consumer Reports, you’ll have some guidelines with 2 stars, some with 3 stars, and some with 5, all based on their adherencescoretothehighstandards,”saidSox, who is also on JAMA’s editorial board. “We feel that if you have quality standards and publish adherence to those standards, the customers—people who use guidelines—will choose the ones with better adherence.”

Estimate of New Chronic HCV Cases Lower Than Expected Bridget M. Kuehn, MSJ

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he number of US individuals living with chronic hepatitis C virus (HCV) infection is about 500 000 fewer than previously estimated, according to new findings from the US Centers and Disease Control and Prevention (CDC) (Denniston MM et al. Ann Intern Med. 2014;160[5]: 293300). But despite this large change in prevalence, the new estimate still finds a substantial population of individuals with chronic HCV in the United States. The CDC’s new estimate is based on HCV testing of individuals participating in the National Health and Nutrition Examination Survey (NHANES) between 2003 and 2010. Of the roughly 30 000 tested, 273 (about 1%) tested positive for chronic HCV infection. If extrapolated to the wider US population, this would suggest that there are 2.7 million US individuals currently living with 1188

HCV compared with the 3.2 million predicted based on NHANES data from 1999 to 2002. The reason for this apparent decrease is not clear, according to the authors. It may be a statistical glitch; the old estimate falls within the confidence interval for the analysis. Another possibility is that increased death rates (Ly KN et al. Ann Intern Med. 2012;156(4):271-278) among those with HCV over the past decade may have reduced the overall population living with the disorder, said Scott D. Holmberg, MD, MPH, chief of epidemiology and surveillance for viral hepatitis at CDC and one of the study's authors. It is unlikely to be the result of more successful treatment of HCV during the interval between the 2 estimates because only about half of HCV-infected individuals are ever tested, and many of those who are diag-

nosed with the infection never receive medical care for it, according to the authors. “Whether this decline in numbers of infected people is real or not, there are still millions of people infected with hepatitis C,” said Holmberg. “This emphasizes the urgency of getting people tested, into care, and treated.” Both the old and new estimates likely underestimate the total prevalence of chronic HCV infection in the United States. NHANES doesnotincludehomelessindividualsorthose in prison, who are known to have high rates of HCV infection. According to Holberg, these uncounted populations would likely raise the estimates by about 500 000. The US Food and Drug Administration has approved 4 new medications for HCV infection in the past 3 years, and more than a dozen new drugs are under devel-

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opment. There has been a renewed push by the CDC and infectious disease experts to head off HCV complications by boosting treatment. New guidelines for HCV treatment were issued in Januar y (http: //hcvguidelines.org/).

But the costs of HCV care may be a barrier to many patients, particularly the lower-income and marginalized populations who are disproportionately infected. (The new study found higher rates of chronic HCV infection among individuals

aged 40 to 59 years, those who are black, and those with lower income and education.) The most recently approved treatment costs more than $80 000 per course, and some insurance companies do not cover these new therapies.

World Leaders Push to Prepare for Global Threats Bridget M. Kuehn, MSJ

Centers for Disease Control and Prevention

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ord from the World Health Organization (WHO) that a mosquito-transmitted virus called chikungunya was spreading on Saint Martin sent French officials scrambling to implement health security plans in December. They were not alone; the US Centers for Disease Control and Prevention (CDC) also snapped into action, issuing an alert to clinicians (http://1.usa.gov/1dz8kuU). The French territory shares an island with Dutch Sint Maarten, and both are popular destinations for Europeans and Americans. No one was surprised that by February officials had confirmed transmission of the virus in other Caribbean nations, including Sint Maarten, Martinique, Guadeloupe, Saint Barthelemy, the British Virgin Islands, and Dominica. In fact, public health leaders have been expecting it for years. Chikungunya, which causes fever and incapacitating joint pain, has been on the rise globally since 2004, according to the WHO. The CDC and the WHO’s Pan American Health Organization in 2011 had issued a chikungunya preparedness plan anticipating that eventually sporadic cases of the disease imported into the Caribbean by travelers from endemic regions would allow the disease to grab a foothold in the Americas. The situation is the latest in a string of outbreaks—including severe acute respiratory syndrome, H1N1 influenza, and Middle East Respiratory Syndrome—to demonstrate that fighting emerging infectious disease threats requires a global approach. To meet this challenge, leaders from the United States and more than 2 dozen other nations announced on February 13 the launch of the Global Health Security Agenda. The agenda is a plan to help all nations become better prepared to quickly identify and stop the spread of infectious diseases, curb the emergence of drug resistance, and reduce the likelihood

of an accidental or intentional introduction of a disease. “With our globalized world, a threat anywhere is a threat everywhere,” said CDC director Tom Frieden, MD, during a press briefing. “We have the ability to make our country and the rest of the world safer from infectious threats.”

Global Involvement Laura Holgate, senior director for weapons of mass destruction, terrorism, and threat reduction at the National Security Council, explained during the briefing that increased international travel can enable diseases to spread faster than ever before. Yet 80% of the world’s countries are not prepared to respond to an infectious threat. The agenda will set goals for all countries to meet to ensure that they have systems in place to prevent outbreaks when

possible, quickly detect those that do occur, and mount an effective response. Frieden said upper-income countries are being asked to bolster their own systems and to consider offering technical or financial assistance to less wealthy countries. Middle-income countries are being connected with technical support, and lowincome countries are getting assistance to establish laboratory networks, train disease detectives, and create emergency operations centers. Tom Inglesby, MD, director of the Center for Health Security at the University of Pittsburgh Medical Center, said the United States and many other countries already have significant health security initiatives under development, but that the agenda will help to solidify specific goals and build momentum. Participants will meet annually to make new commitments and share progress.

Current or previous local transmission of chikungunya virusa

aAs of February 10, 2014. Does not include countries where only imported cases have been documented.

Chikungunya transmission is widespread in Asia and Africa, and has been documented in France and Italy, according to the US Centers for Disease Control and Prevention. But the disease recently has begun spreading in the Caribbean, triggering a multinational public health response.

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Estimate of new chronic HCV cases lower than expected.

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