Measles, mumps, and rubella: the need for a change in immunisation policy

There is growing evidence that the present policy of childhood immunisation in the United Kingdom is inadequate. It is unlikely ever to achieve complete eradication of the congenital rubella syndrome and measles, and the problem of mumps has not even begun to be addressed. After a coordinated campaign to increase uptake of immunisation in Fife the uptake of rubella immunisation in teenage girls increased from 75% in 1981 to 94% in 1985 and the uptake of measles vaccination in preschool children from 55% in 1981 to 81% in 1985. There are a few girls each year who do not accept rubella immunisation, whose immune state is unknown, and who are consequently at risk of rubella during future pregnancies. Despite the increased uptake of measles vaccine over the past four years there is currently an epidemic of measles in Fife, with 544 notified cases in the first quarter of 1986. In 1984, 19 Fife residents were admitted to hospital because of complications of mumps. The time is ripe for a complete reassessment of the national immunisation policy.     

Content of general practice.

Eight general practitioners participated in a survey of content of general practice. This is useful as an indicator or morbidity in the community as well as of workload of general practice. A total of 3164 consultations were recorded, of which 2764 (87%) were because of an illness and the rest (13%) for other reasons like medical examinations, antenatal check, family planning advice, pregnancy tests, pap smear and vaccination. The old and the young have high consultation rates for an illness, men consulted as often as women. The most common illness seen was upper respiratory tract infections, accounting for 37% of all illnesses. Other common minor illnesses were skin infections (6%), genito-urinary infections (5%), minor musculoskeletal (6%) and gastrointestinal (6%) complaints as well as minor injuries and cuts (4%). Major disorders form an unusually low proportion (18%) of all illnesses seen, in comparison with figures from United Kingdom. The common major disorders seen were hypertension, asthma, chronic rheumatic disorders and diabetes. Circulatory disorders were remarkably rare, accounting for only 1% of illnesses. Psychological disorders, both major and minor, were also rarely seen, accounting for only 1% of illnesses which is in marked contrast with figures from the United Kingdom. Factors contributing to these notable findings are discussed.     

Vaccination in the control of influenza

Although killed influenza vaccine given by injection is protective, able to reduce sickness absence in industry and to control influenza in the armed forces, it has not so far been possible to demonstrate more than a small effect on the disease in otherwise healthy adults in industry and offices in the United Kingdom. The reasons are probably the poor rate of acceptance of vaccine, the relatively low incidence of clinical influenza in most years, and the incomplete protection given by the vaccine. Until major epidemics can be accurately forecast it is suggested that influenza vaccination may most usefully be used on a selective basis, namely for protecting those with illness predisposing to a severe effect from influenza; persons in institutions such as schools and homes for the elderly; key workers in the general population; and persons over the age of 65 years among whom considerable mortality occurs in winters when influenza is prevalent.     

Glandular fever-like illness associated with sulphasalazine

A patient with ulcerative colitis is described in whom a glandular fever-like illness was associated with the use of sulphasalazine which recurred in part on re-exposure to the drug. This complication has been previously described three times from the United States but not from the United Kingdom.     

Maternal mortality and psychiatric morbidity in the perinatal period: challenges and opportunities for prevention in the Australian setting

Maternal mortality associated with psychiatric illness in the perinatal period (pregnancy to the end of the first year postpartum) has until recently been under-reported in Australia due to limitations in the scope of the data collection and methods of detection. The recent United Kingdom report Why mothers die 2000-2002 identified psychiatric illness as the leading cause of maternal death in the UK. Findings from the last three reports on maternal deaths in Australia (covering the period 1994-2002) suggest that maternal psychiatric illness is one of the leading causes of maternal death, with the majority of suicides occurring by violent means. Such findings strengthen the case for routine perinatal psychosocial screening programs, with clear referral guidelines and assertive perinatal treatment of significant maternal psychiatric morbidity. Data linkage studies are needed to measure the full extent of maternal mortality associated with psychiatric illness in Australia.     

广州市越秀区2011-2015年学校聚集性疫情流行特征分析

目的 分析越秀区2011-2015年学校各类聚集性疫情的流行特征和处理情况,为应对学校聚集性疫情提供依据.方法 采用SPSS20.0统计软件包对收集到的聚集性疫情率、比、中位数进行描述性统计分析,多样本率比较采用Kruskal-Wallis秩和检验,不同变量间相关性采用Pearson秩相关分析.结果 共报告聚集性疫情538起,病例数2 910例,种类有手足口病、流感样病例、水痘和诺如病毒感染性腹泻.流感样病例疫情和水痘疫情在幼儿园罹患率最高,流感样病例为2.41％,水痘为1.36％ (P=0.003;P=0.000).夏秋季是手足口病高发季节,高发场所在托幼机构,其中2015年手足口病聚集疫情由EV71病毒引起占采样起数的61.54％,3-6月是流感样病例暴发疫情的高发季节,水痘发病的高峰集中在4-6月及12月一次年1月,诺如病毒感染性腹泻高峰于9-12月及次年1月、3月.手足口病和水痘疫情,首发病例至报告处理的时间间隔(天)和首发病例至末例病例出现时间间隔(天)呈正相关(r=0.969,P=0.000;r=0.869,P=0.000).结论 幼儿园是聚集性疫情防控的重点单位,学校聚集性疫情要做到早发现、早报告、早处理,并通过广泛的宣传教育提高水痘、流感、EV71手足口病疫苗接种率来提升人群免疫水平.     

水痘疫苗不同免疫策略的卫生经济学评价

目的: 比较水痘疫苗不同免疫策略的成本和效益。方法: 通过问卷调查的形式获取浙江省因罹患水痘导致的直接和间接经济负担;结合浙江省水痘流行特征数据,应用Matlab软件建立浙江省水痘传播动力学模型,预测从2017年开始后续40年（2017-2056年）采用水痘疫苗不同免疫策略（不接种疫苗、接种一剂、接种两剂）时水痘病例发生情况;以不接种疫苗策略为对照,计算效益-成本比,并对设定的主要参数进行敏感性分析。结果: 完成浙江省105例水痘病例调查,人均直接和间接经济负担分别为506.84元和1045.39元,合计1552.23元。40年间,接种一剂疫苗累计发生709.08万例水痘病例,比不接种疫苗（1759.89万例）减少了59.71%;疫苗接种费用总投入为23.66亿元,所获得的总收益为337.41亿元,效益-成本比为14.26：1。若接种两剂疫苗,40年累计发生272.49万例水痘病例,比不接种疫苗减少了84.52%;总投入和总收益分别为44.95亿元和443.09亿元,效益-成本比为9.86：1。敏感性分析结果显示,无论接种一剂还是接种两剂,疫苗价格均最为敏感,其次为无疫苗状态下的水痘发病率。结论: 浙江省将水痘疫苗纳入免疫规划符合经济性原则,建议将接种一剂甚至两剂全程纳入免疫规划。     

Immunisation before school entry: should there be a law?

An epidemiologist questions whether laws mandating vaccination of children before school entry are necessary in Britain to reduce the incidence of diseases such as measles, mumps, and rubella. Using vaccination against measles as his example, Noah compares the coverage rate in the United States, where 46 states have school immunization laws, with coverage rates in Norway, the Netherlands, Sweden, Finland, and England and Wales, where immunization before school entry is not required. The United States has achieved a high vaccination rate for school age children, as have the Scandinavian countries and the Netherlands without enforcement laws. Noah concludes that better organization of health services and increased promotion of vaccination among health personnel and the public may be sufficient to raise Britain's overall immunization rate without legislation.     

Diagnostic differences in psychogeriatric patients in Toronto, New York and London, England.

National statistics on psychiatric illness in the elderly patient from Canada, the United States and the United Kingdom suggest great differences in morbidity in these three centres. The present study shows that these differences stem mainly from different diagnostic habits in the three countries, but also there were more alcoholics in the Canadian sample. In particular, the diagnostic bias of the New York psychiatrists towards diagnosing most elderly patients as senile was not shared by their Toronto colleagues. Some patients were psychiatrically well, in spite of receiving a psychiatric diagnosis, and could have been helped without hospitalization. In addition, some depressed patients were labelled senile. Recommendations include improvement of catchment and treatment facilities for the elderly alcoholic and the provision of psychogeriatric diagnostic centres.     

A short history of vaccination in Australia

It is almost 50 years since infant vaccination for diphtheria, pertussis and tetanus became routine in Australia. Since then, the incidence of vaccine-preventable diseases has declined dramatically. We have used existing records and the recollections of experts to compile a history of vaccination in Australia, focusing on vaccines in the current childhood schedule.     

Reactivation of latent melioidosis

Reports of melioidosis in residents of European countries are rare. We describe a case of reactivation of latent melioidosis in a United Kingdom resident. The case demonstrates the lack of clinical response to chemotherapy despite proven in vitro sensitivity of the organism to the drugs used. It is important to consider melioidosis as a cause of septicaemic illness in patients who have travelled to, or been resident in South-East Asia.     

Measles vaccination by the intradermal route

Live further-attenuated measles vaccines have been given to two groups of children in the United Kingdom by either the intradermal or subcutaneous routes. The responses have been measured by antibody titration and reaction studies. Intradermal vaccination has been shown to be acceptable on both counts.     

Immunization of US children with Hemophilus influenzae type b polysaccharide vaccine. A cost-effectiveness model of strategy assessment

Hemophilus influenzae type b (HIB) is the leading cause of bacterial meningitis in the United States. Efforts are under way to develop vaccines immunogenic in children younger than 18 months, but clinical efficacy of a previously developed HIB polysaccharide vaccine has already been established in children aged 18 months or older. We developed a cost-effectiveness model to evaluate immunizing US children with this HIB polysaccharide vaccine pending development of a more immunogenic product. The model permitted comparison of the impact of alternative strategies for use of the vaccine, including universal use at 18 or 24 months of age, use of a second dose after primary immunization, and use in high-risk groups such as day-care-center attendees. Universal vaccination at 18 or 24 months of age resulted in similar estimates of disease prevented, as a consequence of the higher expected efficacy and duration of immunity for the vaccine when given at 24 months. Overall, the implementation of routine childhood immunization against HIB at 18 months of age was the most cost-effective strategy. Universal vaccination at 18 months of age combined with a second dose for day-care-center attendees would substantially increase the number of cases prevented, with a minimal increase in costs. Universal vaccination with a two-dose schedule beginning at 18 months of age could prevent the most disease.     

A large rubella outbreak with spread from the workplace to the community

CONTEXT: Childhood vaccination has reduced rubella disease to low levels in the United States, but outbreaks continue to occur. The largest outbreak in the past 5 years occurred in Nebraska in 1999. OBJECTIVES: To examine risk factors for disease, susceptibility of the risk population, role of vaccine failure, and the need for new vaccination strategies in response to the Nebraska rubella outbreak. DESIGN, SETTING, AND PATIENTS: Investigation of 83 confirmed rubella cases occurring in Douglas County, Nebraska, between March 23 and August 24, 1999; serosurvey of 413 pregnant women in the outbreak locale between October 1998 and March 1999 (prior to outbreak) and April and November 1999 (during and after outbreak). MAIN OUTCOME MEASURES: Case characteristics, compared with that of the general county population; area childhood rubella vaccination rates; and susceptibility among pregnant women before vs during and after the outbreak. RESULTS: All 83 rubella cases were unvaccinated or had unknown vaccination status and fell into 3 groups: (1) 52 (63%) were young adults (median age, 26 years), 83% of whom were born in Latin American countries where rubella vaccination was not routine. They were either employed in meatpacking plants or were their household contacts. Attack rates in the plants were high (14.4 per 1000 vs 0. 19 per 1000 for general county population); (2) 16 (19%), including 14 children (9 of whom were aged <12 months) and 2 parents, were US-born and non-Hispanic, who acquired the disease through contacts at 2 day care facilities (attack rate, 88.1 per 1000); and (3) 15 (18%) were young adults (median age, 22 years) whose major disease risk was residence in population-dense census tracts where meatpacking-related cases resided (R(2) = 0.343; P<.001); 87% of these persons were born in Latin America. Among pregnant women, susceptibility rates were 13% before the outbreak and 11% during and after the outbreak. Six (25%) of 24 susceptible women tested were seropositive for rubella IgM. Rubella vaccination rates were 90.2% for preschool children and 99.8% for school-aged children. CONCLUSIONS: A large rubella outbreak occurred among unvaccinated persons in a community with high immunity levels. Crowded working and living conditions facilitated transmission, but vaccine failure did not. Workplace vaccination could be considered to prevent similar outbreaks. JAMA. 2000;284:2733-2739.     

A hepatitis B vaccination programme for inner metropolitan Sydney neonates.

OBJECTIVE; To review the effectiveness of a hepatitis B vaccination programme for high risk infants within a mobile urban population. DESIGN: A follow-up study of 1429 infants enrolled consecutively in the programme from September 1987 to December 1988. SETTING: The programme was established in early childhood centres within inner metropolitan Sydney, an area where 30% of residents were born in non-English speaking countries and where doubts had previously been expressed about the efficacy of vaccination. PARTICIPANTS: Neonates born to mothers who were surface antigen positive, born in selected countries with a 5% prevalence of surface antigen carriage, Aboriginal or intravenous drug users. OUTCOME MEASURES: Documented vaccination given by early childhood centre nurses. Some adjustment was made for parents' reports of vaccination given elsewhere. RESULTS: Two vaccinations were given to 87% and three to 73% of these infants. If we include vaccinations apparently given elsewhere we estimate that 92% may have been fully protected. CONCLUSION: The programme produced high rates of compliance with vaccinations within a population where the delivery of such a service was thought to be difficult. Experience with the current State policy for hepatitis B vaccination indicates that it may not optimally reduce the pool of surface antigen carriers within our community.     

Periodic health examination, 1994 update: 1. Obesity in childhood. Canadian Task Force on the Periodic Health Examination.

OBJECTIVE: To update the 1979 Canadian Task Force on the Periodic Health Examination recommendation on screening for childhood obesity by reviewing any new evidence concerning health risks in childhood and adulthood, and effective preventive or therapeutic interventions. OPTIONS: Detection: routine measurement of height and weight, use of skinfold thickness measurements, calculation of body mass index (BMI). Intervention: diet, exercise, behaviour modification and comprehensive family-based weight-reduction programs. Components of these interventions could be offered routinely or reserved for children and families who perceive obesity to be a present or potential problem. OUTCOMES: The task force reviewed the probability of obese children become obese adults as a risk factor for adult heart disease and overall related illness and death in adult life as well as obesity as a risk factor for physical and psychologic illness in childhood. EVIDENCE: A MEDLINE search for relevant articles published between January 1981 and February 1991 was undertaken. VALUES: The task force's evidence-based rules for recommendations were used. BENEFITS, HARMS AND COSTS: If weight reduction in childhood were shown to prevent physical or psychologic illness in childhood, or illness and death in adult life, screening and treatment should be recommended. Screening for obesity may cause anxiety on the part of the child and family; malnutrition in children as a result of parents becoming overly anxious about the health risks of obesity has been reported. Most weight reduction programs have limited long-term effectiveness and can be costly. RECOMMENDATIONS: There is insufficient evidence of short-term or long-term benefits from screening for or treatment of childhood obesity to recommend such screening or recommend against it. There is fair evidence to recommend against very-low-kilojoule diets for preadolescents. There is insufficient evidence to recommend for or against exercise programs or intensive family-based programs for most obese children. VALIDATION: These recommendations are similar to those of the American Academy of Pediatrics and the US Preventive Services Task Force. SPONSOR: These guidelines were developed and endorsed by the Canadian task force, which is funded by Health Canada.     

Antibody concentration and clinical protection after Hib conjugate vaccination in the United Kingdom

CONTEXT: The schedule for Haemophilus influenzae type b (Hib) vaccination of infants in the United Kingdom consists of 3 doses given at 2, 3, and 4 months of age. Many countries include a fourth dose (booster) of Hib vaccine in the second year of life on the basis of declining Hib antibody concentrations after the primary series. Few data are available to show that this fourth dose is actually necessary. OBJECTIVE: To evaluate long-term clinical protection against Hib disease and Hib antibody concentrations following primary Hib vaccination without a booster dose. DESIGN, SETTING, AND SUBJECTS: Clinical protection study conducted between October 1992 and March 1999 in the United Kingdom, in which children developing invasive Hib disease despite vaccination in infancy with 3 doses of Hib conjugate vaccine were reported by pediatricians through an active, prospective, national survey. Separate antibody studies were conducted among 2 cohorts of children (n = 153 and n = 107) vaccinated at 2, 3, and 4 months of age with Hib conjugate vaccine and followed up to 43 and 72 months of age. MAIN OUTCOME MEASURES: Age-specific vaccine effectiveness, derived from the observed number of true vaccine failures after 3 Hib vaccine doses compared with the number of cases expected based on the age-specific rates of invasive Hib disease obtained prior to the introduction of Hib vaccines; and proportion of children in the 2 cohorts with Hib antibody concentrations of less than 0.15 and less than 1.0 microg/mL. RESULTS: Ninety-six true vaccine failures occurring after 3 vaccine doses were detected. During the study period, an estimated 4,368,200 infants in the United Kingdom received 3 doses of vaccine; therefore, the vaccine failure rate was 2.2 per 100,000 vaccinees (95% confidence interval, 1.8-2.7 per 100,000). Although vaccine effectiveness declined significantly after the first year of life (P<.001), it remained high until the sixth year of life (99.4% in children aged 5-11 months vs 97.3% in those aged 12-71 months). The proportion of cohorts 1 and 2 with anti-PRP antibody levels of less than 0.15 microg/mL increased between 12 and 72 months of age (6% at 12 months, 8% at 43 months, and 32% at 72 months; chi(2)(1) = 18.25; P<.001 for trend). CONCLUSIONS: Our results suggest that anti-PRP antibody levels and clinical protection against Hib disease wane over time after Hib vaccination at 2, 3, and 4 months of age without a booster dose at 2 years of age. The decline in clinical protection is minimal, however, suggesting that a booster dose of Hib vaccine following infant vaccination is not essential. JAMA. 2000;284:2334-2340.     

Cot deaths in Australia, 1985

A survey has been carried out of the pathology of cot deaths in Australia. Infection seems to play a bigger role in deaths in Melbourne than in some other areas such as Western Australia, but a smaller role than in the United Kingdom. The number of subclinical lesions that are found in infants who have suffered a cot death seems to be similar to that in the United Kingdom. The high cot death rate in Tasmania appears to be a truly elevated rate and not due to diagnostic variables. The "possibly preventable" postperinatal death rate in several areas is high. Many individuals are carrying out excellent research related to cot deaths in different parts of the Commonwealth. However, many appear to be working almost in isolation, and a need exists for one or more centres in Australia to carry out and coordinate studies of the background factors and of the pathology of all postperinatal deaths.     

Use of immunization as strategy for outbreak control of varicella zoster in an institutional setting

Background

Outbreaks of varicella gets reported often in India. However, outbreak in health care providers living in closed institutional setting and role of vaccination as post exposure prophylaxis for control of outbreak has not been studied extensively. This paper presents epidemiological investigation and control strategy undertaken in such scenario.

Methods

This is an epidemiological investigation of chickenpox in nursing students which highlights role of early identification and appropriate control strategy to prevent explosive outbreak in high risk vulnerable population. Vaccination of all susceptible in addition to isolation of cases, quarantine of suspects and proper screening for new cases was the major control strategy adopted.

Results

The index case was imported and all eight cases occurred within the incubation period of the case. Two cases occurred in students previously vaccinated for chickenpox. No second or third wave of infection occurred showing vaccination as effective tool in outbreak control strategy.

Conclusion

Early identification of cases and vaccination of all susceptible contributed to effective control of the outbreak.     

Pneumococcal serotypes causing bacteremia and meningitis: relevance to composition of pneumococcal vaccine.

The capsular type of 160 strains of pneumococci isolated from blood or cerebrospinal fluid of patients in Alberta and Ontario between June 1978 and August 1980 was determined. Of the 83 known serotypes 36 were represented, and the type distribution was similar to that reported from the United Kingdom and the United States. Although only 111 (69.3%) of the strains belonged to the serotypes represented in the licensed pneumococcal vaccine, if related types within the same serogroup are also included 132 (82.5%) of the strains belonged to the types or groups represented in the vaccine, However, because the vaccine is not recommended for persons aged less than 2 years, from whom 30 strains were isolated, and because 28 strains from those 2 years of age and older were of nonvaccine types or groups, one can presume that 58 (36.3%) of the 160 bacteremic and meningitic infections would not have been prevented by prior vaccination, even if the vaccine were completely effective.