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PubMed2005

Passive immunisation of preterm infants with palivizumab against RSV infection.

Palivizumab is a monocloncal antibody used for prevention of respiratory syncytial virus infection. This study reviews the literature regarding evidence of efficacy, safety and cost-effectiveness. The only randomised controlled trial into efficacy of palivizumab in preterm infants demonstrates clinical benefit and suggests a favourable safety profile. Further studies, however, do not provide evidence that costs saved by the reduction in hospitalisation would outweigh actual costs of the immunization for the recommended indications. There is considerable controversy over which groups of patients to include in immunization programs and analyses of cost-effectiveness are complicated by the fact that incidence of RSV infection, rates of hospitalisation and ventilation, health care costs and economic resources are variable among different health care systems and settings. Studies of cost-analysis, despite their implicit weaknesses, do not currently support the widespread use of palivizumab. In the absence of high quality cost-benefit analysis, we currently only recommend the use of palivizumab in infants at high risk of severe bronchiolitis, such as those with active chronic lung disease of prematurity. To illustrate current practice we also present data from an audit of the use of palivizumab in a regional centre in the North-East of England.

Antibodies, Monoclonal↗

PubMed2002

[Investigation of the delayed type hypersensitivity reaction in atopic patients].

INTRODUCTION: In the last decades the prevalence of atopic diseases has increased highly in developed countries. Although the reasons for this increase are not clear, it has been hypothesized that a reduction in infections and immunization programs may contribute to the increased prevalence of atopic diseases. AIM: In the present study the relationship between tuberculin response and atopic disease was investigated. METHODS: A total of 1012 children vaccinated with BCG were included in the study. All the children were given five tuberculin units PPD, and PPD indurations were recorded after 72 h. The test result was considered to be positive if the induration size was greater than 9 mm. The atopic anamnesis (atopic dermatitis, rhinitis, conjunctivitis, asthma, urticaria) in the children and their families were investigated using a questionnaire. RESULTS: 608 individual (60.1%) had positive and 404 (39.9%) had negative tuberculin test. Positive atopic personal anamnesis was found in 31.74% in children with positive tuberculin skin test, whereas 39.85% was found in children with negative tuberculin test (p < 0.009, Fischer-test). Similarly more positive family anamnesis for atopic diseases was found among children with negative tuberculin test. In children with negative tuberculin test the prevalence of allergic conjunctivitis and rhinitis was significantly higher as compared to the group with positive tuberculin test. CONCLUSIONS: The authors found an inverse correlation between tuberculin response and atopy status. The observed decreased tuberculin sensitivity in atopic individuals is, however, probably not the cause, but rather the consequence of the disturbed immune regulation in atopic diseases.

Adolescent↗

PubMed1997

Tetanus surveillance--United States, 1991-1994.

PROBLEM/CONDITION: Despite the widespread availability of a safe and effective vaccine against tetanus, 201 cases of the disease were reported during 1991-1994. Of patients with known illness outcome, the case-fatality rate was 25%. REPORTING PERIOD COVERED: 1991-1994. DESCRIPTION OF SYSTEM: Physician-diagnosed cases of tetanus are reported to local and state health departments, the latter of which reports these cases on a weekly basis to CDC's National Notifiable Disease Surveillance System. Since 1965, state health departments also have submitted supplemental clinical and epidemiologic information to CDC's National Immunization Program. RESULTS: During 1991-1994, 201 cases of tetanus were reported from 40 states, for an average annual incidence of 0.02 cases per 100,000 population. Of the 188 patients for whom age was known, 101 (54%) were aged > or = 60 years and 10 (5%) were aged < 20 years. No cases of neonatal tetanus were reported. Among adults, the risk for tetanus increased with age; the risk for persons aged > or = 80 years was more than 10 times greater than the risk for persons aged 20-29 years. All deaths occurred among persons aged > or = 30 years. The case-fatality rate (overall: 25%) increased with age, from 11% in persons aged 30-49 years to 54% in persons aged > or = 80 years. Only 12% of all patients were reported to have received a primary series of tetanus toxoid before onset of illness. For 77% of patients, tetanus occurred after an acute injury was sustained. Of patients who obtained medical care for their injury, only 43% received tetanus toxoid as part of wound prophylaxis. INTERPRETATION: The epidemiology of reported tetanus in the United States during 1991-1994 was similar to that during the 1980s. Tetanus continued to be a severe disease primarily of older adults who were unvaccinated or inadequately vaccinated. Most tetanus cases occurred after an acute injury was sustained, emphasizing the need for appropriate wound management. ACTIONS TAKEN: In addition to decennial booster doses of tetanus-diphtheria toxoid during adult life, the Advisory Committee on Immunization Practices (ACIP) recommends vaccination visits for adolescents at age 11-12 years and for adults at age 50 years to enable health-care providers to review vaccination histories and administer any needed vaccine. Full implementation of the ACIP recommendations should virtually eliminate the remaining tetanus burden in the United States.

Adolescent↗

PubMed1983

Detection of human malignant melanoma antigens by immunofluorescence and autologous postimmune antimelanoma sera.

The objectives of this study are to demonstrate the specificity of sera from melanoma patients undergoing autologous immunization and to localize melanoma antigens on a cellular level. Five melanoma patients were immunized with autologous melanoma cells and Bacillus Calmette-Guerin. This immunization program was conducted at Tulane University. Indirect immunofluorescence using both viable and fixed melanoma cells was employed. Four of five postimmune sera were reactive to five of seven melanoma cell lines. Two of the four reactive antisera showed positive binding with two additional melanoma lines obtained from other laboratories. All these sera were negative against seven nonmelanoma lines. Negative controls consisted of sera from 65 nonimmunized melanoma patients and 140 nonmelanoma patients. Membrane immunofluorescence (MIF) demonstrated sequential full MIF, capping, polarization, and extrusion of antigen-antibody complexes on the cell surface. MIF inhibition showed shedding of melanoma antigens in the culture medium. Ethanol, methanol, formalin, trichloroacetic acid, and acetone yielded sharp MIF. Isopentane and isooctane gave bright cytoplasmic fluorescence. In conclusion, this study provides suggestive evidence for the existence of common melanoma antigens as defined by the postimmune antimelanoma sera. These antigens may be localized in the membrane or within the cytoplasm.

Antigens, Neoplasm↗

PubMed2000

Correlation between atopic diseases and tuberculin responses.

BACKGROUND: In recent decades, the prevalence of atopic diseases has risen steadily in developed countries. The reasons for this increase are not clear. It has been hypothesized that a reduction in infections and immunization programs may contribute to the increase in the prevalence of atopic diseases. We investigated the relationship between tuberculin response and atopic disease. METHODS: A total of 538 (73.0%) atopic and 198 (27.0%) nonatopic children vaccinated with BCG were included in the study. All the children included in the study had neither been given BCG nor tuberculin skin-tested in the previous 6 months, nor did they have a condition known to cause anergy. All the children were given five tuberculin units PPD, and PPD indurations were recorded after 48 h. RESULTS: The PPD induration size was 6.8 +/- 5.6 mm (mean +/- SD) in atopic children and 7.4 +/- 5.9 mm in nonatopic children. The difference between the two groups was not significant (P > 0.05). The PPD induration sizes of children with asthma, rhinitis, and atopic dermatitis were found to be similar. The children with atopic dermatitis had lower PPD induration size, but this was not statistically significant (P> 0.05). The rates of negative (< 5 mm skin induration) and intermediate (5-9 mm) responses were 32.6% and 30.5% in atopic children and 30.2% and 32.4% in nonatopic children, respectively. Positive tuberculin responses (PPD > 10 mm) were recorded in 36.9% of atopic children and 37.4% of nonatopic children. Total serum IgE levels of atopic and nonatopic children were 623.35 and 46.78 IU/ml, respectively. There was no correlation between serum total IgE level and PPD induration size (r = - 0.0012, P = 0.737). CONCLUSIONS: We did not find any relationship between tuberculin response and atopy status later in life in BCG-immunized subjects. We need further studies to clarify the effect of BCG on the development of atopy.

Adolescent↗

PubMed2000

The effect of indomethacin on hepatitis B virus replication in chronic healthy carriers.

BACKGROUND: A chronic HBsAg carrier state, a major cause of viral spread in a community, is one of the consequences of hepatitis B virus (HBV) infection. Although successful immunization programs have been initiated to eliminate the virus, there is still a large number of people with HBV infection worldwide. This study was designed to investigate the effect of indomethacin treatment on HBV markers in humans, in comparison with a control group. METHODS: In total, 65 chronic 'healthy' HBV carriers were involved in the study. Patients were divided randomly into two groups. Group I (n = 42) received oral indomethacin 75 mg daily for 6 months. Group II (n = 23) acted as control. Patients in both groups were followed up for 6 months, during which laboratory tests, including viral parameters, were performed periodically. Liver biopsy was done in 17 patients (11/42 of the indomethacin group and 6/23 of the control group). RESULTS: All liver biopsies showed grade 0-2 and stage 0-1 HBV in both groups (P > 0.05). HBsAg positivity did not change in any patient in either group. Five patients who had positive HBeAg in group I became negative 4 months later, while patients in group II continued to be positive at 6 months (P < 0.001). Similarly, all patients receiving indomethacin exhibited a total anti-HBeAg immunoglobulin response at 6 months, while the control group remained the same during this period (P < 0.05). HBV DNA, as detected by polymerase chain reaction in 20/22 (91%), was negative in group I at the end of 6 months. No change was observed in group II (P = 0.007). CONCLUSIONS: Although no biochemical analyses were performed on prostaglandins in the present study, the results suggest that the prostaglandin pathway may be involved in the pathogenesis of the immune response against HBV, and that the suppression of viral replication is achieved as indicated by the disappearance of HBeAg and HBV DNA in healthy chronic HBV carriers.

Adult↗

PubMed2004

Guillain-Barré syndrome in children.

In industrialized nations with widespread immunization programs, Guillain-Barré syndrome is the most common cause of acute paralytic illness in children and adults. The incidence of the disease has been estimated to range from 0.5 to 1.5 in 100,000 in individuals less than 18 years of age. Approximately 15% of children with Guillain-Barré syndrome develop respiratory failure and require mechanical ventilatory support. Prospective randomized treatment trials in childhood Guillain-Barré syndrome are wanting; however, smaller case series studies using historical controls suggest that both plasmapheresis and administration of human immunoglobulin could be helpful in reducing morbidity in children with Guillain-Barré syndrome. The prognosis for recovery in children is generally excellent, with the majority of children achieving a complete functional recovery within 6 months from the onset of illness. Studies using an animal model of human Guillain-Barré syndrome, experimental allergic neuritis, have expanded our understanding of the pathogenesis of the disease and suggest new directions for exploration in the treatment of this disorder.

Adolescent↗

PubMed1985

Response to measles vaccine in Haitian infants 6 to 12 months old. Influence of maternal antibodies, malnutrition, and concurrent illnesses.

To study the factors affecting the serologic response to measles vaccination, we evaluated 595 Haitian infants from 6 through 12 months of age, and their mothers, at the beginning of an immunization program. Thirty-four per cent of the infants had preexisting serologic evidence of measles infections by 11 months of age. Among infants more than nine months of age, those who had had measles had a significantly lower nutritional status than those who had not (P less than 0.01). After vaccination, seroconversion rates increased from 45 per cent at 6 months to 100 per cent at 12 months. The lowest rate of vaccine failure compatible with acceptably low rates of natural infections could be achieved by vaccination after eight months of age. Infants born to mothers with low levels of antibody to measles (hemagglutination-inhibition antibody titers less than 1:40) were significantly more likely to have had natural measles (P less than 0.01) or to have seroconversion after vaccination (P less than 0.001) at 6 to 10 months of age than were infants born to mothers with higher of age than were infants born to mothers with higher titers. Malnutrition and acute infections did not affect seroconversion rates. These data support the World Health Organization recommendation to administer measles vaccine in under-developed countries as soon after nine months of age as possible, regardless of nutritional status or the presence of minor illnesses.

Age Factors↗

PubMedDate not supplied

Poliomyelitis in selected African and Asian countries.

The most common cause for the persistence of poliomyelitis in developing countries has been the failure of routine immunization programs to provide > or = three doses of poliovirus vaccine to a high proportion of infants. However, a more worrisome pattern of disease can be attributed more to vaccine failure than failure to vaccinate, as illustrated by epidemics in selected African and Asian countries during the 1980s. The efficacy of oral poliovirus vaccine (OPV) has been shown in these and other instances to be considerably lower in developing countries than in industrialized countries, indicating that reliance on routine administration of OPV alone will not be sufficient to achieve global eradication of wild poliovirus transmission. Because more aggressive approaches will likely be needed to achieve global eradication of poliomyelitis, various tactics have evolved over the past decade. The most promising approach has been the use of biannual national vaccination days, which have been used with great success in Latin America. However, these campaigns have certain drawbacks, including enormous OPV requirements and difficult logistics. A second approach, which has been used primarily in the West Bank and Gaza, involves the use of combined schedules of OPV and enhanced-potency inactivated vaccine (IPV). This approach requires far fewer contacts and doses of OPV; allows for more reliable and consistent serum neutralizing antibody responses in both the short- and long-term; and for boosting of secretory antibody responses in both the nasopharynx and gastrointestinal tract.(ABSTRACT TRUNCATED AT 250 WORDS)

Africa↗

PubMed2004

Detection of antibodies to squalene: III. Naturally occurring antibodies to squalene in humans and mice.

An ELISA-based assay is described for the measurement of antibodies to squalene (SQE) in human serum and plasma. The assay was adapted from the previously described assay for murine antibodies to SQE (J. Immunol. Methods 267 (2002) 119). Like the murine SQE antibody assay, the human antibody assay used sterile cell culture 96-well plates coated with SQE (20 nmol/well). Phosphate-buffered saline (PBS)-0.5% casein was used as both a blocking agent and dilution buffer. The assay has a high through-put capacity and is reproducible and quantitative. This assay was used to evaluate samples from three different human cohorts. The first cohort was retired employees of the United States Army Medical Research Institute of Infectious Diseases (USAMRIID alumni). The mean age was 68 (N=40; range 58-82). Most were vaccinated with the U.S. licensed anthrax vaccine (AVA) and most had received several other vaccines through a USAMRIID special immunization program. The second cohort was of similar age (N=372; mean age 67; range 54-97) from the normal population of Frederick, MD and were not vaccinated with AVA. The third cohort (N=299) was from Camp Memorial Blood Center, United States Army Medical Department Activities, Fort Knox, KY. (No additional volunteer information is available.) Using this new ELISA method, antibodies to SQE were detected in all three of the cohorts. IgG antibodies to SQE were detected in 7.5% and 15.1% of the samples from the USAMRIID alumni and Frederick cohorts, respectively. These differences were not significantly different (chi((1))(2)=1.69, p=0.19). In contrast, no IgG antibodies to SQE were detected in the Fort Knox cohort which is significantly different than the Frederick cohort (chi((1))(2)=49.25, p<0.0001). IgM antibodies to SQE were detected in 37.5% and 32.3% of the samples from the USAMRIID and Frederick cohorts, respectively, but there was no significant difference between the cohorts. In the Fort Knox cohort, 19.4% of the samples were positive for IgM antibodies to SQE, which was significantly different from the Frederick cohort (chi((1))(2)=14.23, p=0.0002). Although the age of the volunteers from the Fort Knox cohort is unknown, the demographic of the donors at the blood bank volunteers is 85% 17-21 years of age. This suggested that the prevalence of antibodies to SQE may increase with age. This was confirmed with mouse studies in which the presence of antibodies was monitored as a function of time. No antibodies to SQE were detected in female BALB/c, B10.Br and C57BL/6 mice at 2 months of age, but they reached a maximum prevalence with 100% and 89% of animals testing positive for IgG and IgM antibodies to SQE, respectively, in the C57Bl/6 mice at 18 months of age. BALB/c and B10.Br mice also developed antibodies to SQE over time, but were at a lower prevalence than those observed in the C57BL/6 mice. Thirty-five of the 40 volunteers in the USAMRIID were vaccinated with AVA (mean no. doses=26; range 3-47). Comparison of the prevalence of antibodies to SQE from the AVA immunized group with the Frederick cohort revealed that there was no statistical differences for IgG (chi((1))(2)=2.3, p=0.13) or IgM (chi((1))(2)=0.33, p=0.56). When the data from the USAMRIID and Frederick cohorts were combined and analyzed for the presence of antibodies to SQE with respect to the sex of the volunteer, females (40.8%) were found to have a higher prevalence of IgM antibodies to SQE than men (28.4%) (chi((1))(2)=6.59, p=0.01). No significant difference was observed in the prevalence for IgG antibodies to SQE in females (17.7%) and males (12.5%). We conclude that antibodies to SQE occur naturally in humans; have an increased prevalence in females; are not correlated with vaccination with AVA; and appear to increase in prevalence with age.

Adjuvants, Immunologic↗

PubMedDate not supplied

Safety and immunogenicity of two Haemophilus influenzae type b polysaccharide-tetanus toxoid conjugate vaccines (PRP-T) given with diphtheria-tetanus-pertussis vaccine to young Papua New Guinean children.

BACKGROUND: In view of high mortality and morbidity from Haemophilus influenzae type b (Hib) in young Papua New Guinean children, the incorporation of a Hib conjugate vaccine into a nationwide immunization program would be of major public health benefit. METHODS: We evaluated the safety and immunogenicity of a lyophilized and a liquid form of Hib polysaccharide-tetanus toxoid conjugate vaccines (PRP-T) given in the same syringe as diphtheria-tetanus-pertussis (DTP) vaccine to children in Goroka, Eastern Highlands Province. In Part 1 of the study 209 children were randomized to receive at ages 1, 2 and 3 months either DTP alone or a liquid formulation of DTP/PRP-T or lyophilized PRP-T dissolved in DTP suspension. A further 75 children were given the liquid DTP/PRP-T formulation at ages 2, 3 and 4 months (Part 2). 54 children aged 15-18 months were given a booster of the same preparation of PRP-T/DTP as they had received during Part 1. Blood for antibody assays was collected at enrolment, before (Part 1 only) and one month after the third dose, then just before and 3 weeks after the booster dose. RESULTS: Follow-up to age of 12 months showed that PRP-T was safe with no evidence of impaired response to individual vaccine components when combined with DTP. Geometric mean titres (GMTs) of anti-PRP antibody before vaccination (n = 64, mean age 41 days), after 2 doses (mean age 99 days) and after 3 doses (mean age 132 days) of the lyophilized formulation were 0.21, 1.48 and 5.04 microg/ml, respectively, with 58% and 89% having anti-PRP antibody titres > or = 1.0 microg/ml after 2 and 3 doses, respectively. Anti-PRP antibody responses to the liquid Hib vaccine formulation were lower (GMT post-dose 3 = 0.48 microg/ml) than to the lyophilized formulation, but better responses were elicited from older children (Part 2; GMT post-dose 3 = 0.78 microg/ml, with 79% > or = 0.15 microg/ml). Both PRP-T preparations elicited excellent booster responses suggesting that children are likely to be protected if exposed to Hib infection. CONCLUSIONS: Lyophilized PRP-T given together with DTP is safe and immunogenic when given to young infants. The liquid DTP/PRP-T formulation showed a lower immunogenicity than in earlier studies with this vaccine, which might have been due to exposure to low temperature during shipment or the younger age at immunization.

Administration, Oral↗

PubMed1998

Tetanus surveillance--United States, 1995-1997.

UNLABELLED: PROBLEM/CONDITIONS: Despite widespread availability of a safe and effective vaccine against tetanus, 124 cases of the disease were reported during 1995-1997. Only 13% of patients reported having received a primary series of tetanus toxoid (TT) before disease onset. Of patients with known illness outcome, the case-fatality ratio was 11%. REPORTING PERIOD COVERED: 1995-1997. DESCRIPTION OF SYSTEM: Physician-diagnosed cases of tetanus are reported by state and local health departments to CDC's National Notifiable Diseases Surveillance System. In addition, since 1965, supplemental clinical and epidemiologic information for cases has been provided to CDC's National Immunization Program. RESULTS: From 1995 through 1997, a total of 124 cases of tetanus were reported from 33 states and the District of Columbia, accounting for an average annual incidence of 0.15 cases per 1,000,000 population. Sixty percent of patients were aged 20-59 years; 35% were aged > or =60 years; and 5% were aged <20 years, including one case of neonatal tetanus. For adults aged > or =60 years, the increased risk for tetanus was nearly sevenfold that for persons aged 5-19 years and twofold that for persons aged 20-59 years. The case-fatality ratio varied from 2.3% for persons aged 20-39 years to 16% for persons aged 40-59 years and to 18% for persons aged > or =60 years. Only 13% of patients reported having received a primary series of TT before disease onset. Previous vaccination status was directly related to severity of disease, with the case-fatality ratio ranging from 6% for patients who had received one to two doses to 15% for patients who were unvaccinated. No deaths occurred among the 16 patients who previously had received three or more doses. Tetanus occurred following an acute injury in 77% of patients, but only 41% sought medical care for their injury. All patients who sought care were eligible for TT as part of wound prophylaxis, but only 39% received it. Tetanus in injecting-drug users (IDUs) with no known acute injury comprised 11% of all cases, compared with 3.6% during 1991-1994. None of the IDU-associated tetanus cases occurred among persons who were known to have been vaccinated. Sixty-nine percent of IDU-associated tetanus cases were reported from California, and 77% of these cases occurred in heroin users. INTERPRETATION: Tetanus remains a severe disease that primarily affects unvaccinated or inadequately vaccinated persons. Adults aged > or =60 years continue to be at highest risk for tetanus and for severe disease. However, the overall incidence of tetanus has decreased slightly since the late 1980s and early 1990s, from 0.20 to 0.15, a result primarily of a decreased incidence among persons aged > or =60 and <20 years. ACTIONS TAKEN: Tetanus is preventable through both routine vaccination and appropriate wound management. In addition to decennial booster doses of diphtheria and tetanus toxoids during adult life, the Advisory Committee on Immunization Practices (ACIP) recommends vaccination visits for adolescents at age 11-12 years and for adults at age 50 years to enable health-care providers to review vaccination histories and administer any needed vaccine. Every contact with the health-care system, particularly among older adults and IDUs, should be used to review and update vaccination status as needed.

Adolescent↗

PubMed2005

A new vaccine against tuberculosis shows greater protection in a mouse model with progressive pulmonary tuberculosis.

SETTING: The effectiveness of Bacillus Calmette-Guerin (BCG) vaccination in reducing tuberculosis (TB) prevalence rates is poor, resulting in urgent need for improved immunization programs, with new and more effective vaccines against TB. OBJECTIVE: To develop a recombinant Tice BCG vaccine against TB that overexpresses the 38-kDa antigen of Mycobacterium tuberculosis in order to protect against infection by M. tuberculosis H37Rv and hyper-virulent M. tuberculosis Beijing genotype. DESIGN: M. tuberculosis 38-kDa protein was cloned into a mycobacterial shuttle plasmid, which was used to overexpress the 38 kDa protein in BCG Tice to produce the recombinant vaccine, rBCG38 Tice (rBCG38). RESULTS: Compared with BCG Tice, which conferred little protection against the Beijing strain of M. tuberculosis, vaccination with the rBCG38 increased survival of mice infected with either M. tuberculosis H37Rv or a Beijing strain of M. tuberculosis, isolate 9501000. Vaccination with either BCG Tice or rBCG38 resulted in enhanced protection against mycobacterial growth in lung tissue by reducing the number of colony-forming units (CFU). The vaccine induced a strong and highly significant Th1 response, shown by the high level of IL-2 and IFN-gamma cytokine producer cells found in the lungs of challenged mice, and an increase in the IgG2a:IgG1 ratio found in the pooled sera of the vaccinated mice. CONCLUSIONS: This study showed that rBCG38 vaccine induced a strong Th1 response, demonstrated by the high levels of IL-2 and IFN-gamma producer cells and IgG2a. Protection was mediated for as long as 6 and 4 months after challenge with M. tuberculosis H37Rv and Beijing genotypes, respectively.

Animals↗

PubMed1982

Guillain-Barré syndrome in the US Army.

Using the US Army's operational reporting system, the medical records of soldiers with Guillain-Barré syndrome were retrieved and compared with reported incidence figures from the 1976 national influenza immunization program. Military personnel sustained an incidence of disease approximatley 50% higher than unvaccinated civilians but less than 25% of the rate attributed to civilian vaccinees.

Adult↗

PubMed2001

Nonpoliovirus poliomyelitis simulating Guillain-Barré syndrome.

BACKGROUND: Paralytic poliomyelitis due to the wild-type poliovirus has been eradicated in the United States because of effective immunization programs. In the postvaccination era, most cases are caused by other RNA viruses, such as coxsackievirus or echovirus. The condition usually begins with a fever and upper respiratory tract or gastrointestinal tract symptoms that progress to a "paralytic" phase characterized by limb weakness, areflexia, and, occasionally, respiratory failure that superficially resemble Guillain-Barré syndrome. OBJECTIVE: To describe 2 patients with nonpoliovirus poliomyelitis and highlight the findings on magnetic resonance imaging of the spinal cord to distinguish these cases from variants of Guillain-Barré syndrome. DESIGN AND SETTING: Case series from an academic medical center. PATIENTS: Following a viral illness, the patients, aged 35 and 50 years, had painless, progressive, asymmetrical weakness in the arms followed by respiratory failure in one patient, and generalized limb weakness in the other patient, reaching a nadir in 1 week. Both patients had fevers but no signs of meningitis at onset. Tendon reflexes were absent or reduced in affected regions. The cerebrospinal fluid findings were as follows: mononuclear leukocyte counts of 100 000 cells/mm(3) and 700 000 cells/mm(3), respectively, and the protein level was above 10 g/dL in both patients. Compound muscle action potential amplitudes were reduced in some nerves with active denervation in clinically affected muscles, and F-responses were absent but there were no other demyelinating features. Magnetic resonance imaging showed discrete T2-weighted signal changes of the ventral horns of the spinal cord, and one had elevated coxsackievirus titers in the serum. There was little recovery and significant atrophy in weak muscles after 3 years. CONCLUSIONS: The poliomyelitis syndrome still occurs in adults in developed countries. It has superficial similarities to a motor axonal variant of Guillain-Barré syndrome but can be distinguished by clinical, cerebrospinal fluid, and, perhaps specifically, magnetic resonance imaging characteristics.

Adult↗

PubMed2004

An epidemiological and clinical study of ocular manifestations of congenital rubella syndrome in Omani children.

OBJECTIVE: To conduct a follow-up study in patients with congenital rubella syndrome (CRS) in Oman and analyze the prevalence of ophthalmic disorders and associated systemic problems. METHODS: This historical prospective cohort study included review of 32 surviving patients with CRS reported by the surveillance system in Oman from 1987 through 2002. All patients underwent a complete ophthalmic examination that included visual acuity estimation, refraction and anterior and posterior segment evaluation, and intraocular pressure measurement. Pediatric and otorhinolaryngologic consultations were also performed. RESULTS: The age-adjusted prevalence of CRS in Oman was 73.2 per million in the Omani population younger than 20 years, and the incidence was 0.6 per 1000 live births. Cataract, retinitis, microphthalmos, and glaucoma were observed in 11, 16, 6, and 4 patients, respectively. Keratoconus, corneal hydrops, and spontaneous resorption of lens were found in 1 patient each. Vision testing was possible in 16 children; 4 were bilaterally blind. Patients who had undergone eye surgery had significantly lower visual acuity, as compared with those who had not undergone surgery (relative risk 2.53; 95% confidence interval, 1.07-6.13). Among the 11 patients with CRS with cataract, we found hearing loss, cardiac anomalies, and neuropsychologic anomalies in 7, 4, and 6 children, respectively. CONCLUSIONS: Congenital rubella syndrome has a wide variety of severe ophthalmic and systemic complications. High clinical vigilance for signs of CRS and regular observation of surviving patients with CRS is desirable. In patients with cataract, the functional results of surgery, despite state-of-the-art ophthalmic care, continue to be poor. Because of a high prevalence of visual, audiologic, and neurologic disabilities, surviving patients with CRS pose a burden on the medical and social communities. Emphasis in management ought to be prevention of CRS through effective immunization programs.

Adolescent↗

PubMed1999

Improving immunization rates in private pediatric practices through physician leadership.

OBJECTIVE: To determine whether a physician-led quality improvement initiative can improve immunization rates in participating private practices. DESIGN: Surveys of private pediatric practices at 6-month intervals over an 18-month period. SETTING: Ten private pediatric practices in Norfolk and Virginia Beach, Va. PATIENTS: Children aged 9 to 30 months attending the private practices. INTERVENTIONS: Practice immunization rates were assessed and presented to practices on 4 occasions at 6-month intervals. A physician leader convened an immunization task force meeting following the first 3 assessments to review practice guidelines, examine data, and discuss practice changes. MAIN OUTCOME MEASURES: Practice immunization rates for patients at age 24 months, with 3- and 12-month immunization rates as secondary outcomes. RESULTS: The mean practice immunization rate at age 24 months increased significantly (P<.05) from 50.9% at baseline to 69.7%. Rates also increased at age 3 months, from 75.5% to 88.9%, and at age 12 months, from 72.9% to 84.6%. The median age at administration of the fourth dose of diphtheria toxoid, tetanus toxoid, and pertussis vaccine decreased (P<.05) from 17.6 to 16.8 months. Physicians also reported making additional changes, including improved record keeping and screening for immunizations at every visit. CONCLUSION: A quality improvement initiative enabling physician leadership can improve preschool immunization practices and coverage levels in pediatric practices.

Analysis of Variance↗

PubMed2000

Adolescent hepatitis B vaccination: comparison among 2 high school-based health centers and an adolescent clinic.

OBJECTIVE: To compare the completion rate of hepatitis B vaccination among adolescents who receive primary care at 2 comprehensive high school-based health centers (SBHCs) and a hospital-based adolescent health center (AHC) to assess predictors for successful immunization. METHODS: A retrospective chart review of patients seen for comprehensive history and physical examinations from September 1997 to March 1998 at 2 SBHCs and an AHC was conducted to determine the immunization status for hepatitis B. One SBHC (SBHC-A) had previously implemented an outreach strategy consisting of advertising through the school's loudspeaker, whereas the other SBHC (SBHC-B) and the AHC did not. Completion rates were assessed among all students requesting comprehensive history and physical examinations. A subset analysis among those without prior immunizations was performed. RESULTS: Of 510 records reviewed, 406 had documented data for hepatitis B immunization status, and 191 (37 for SBHC-A, 59 for SBHC-B, 95 for AHC) did not have any prior hepatitis immunizations. The completion rate of hepatitis B vaccination was significantly higher at SBHC-A (76%) compared with the other 2 sites (29% for SBHC-B and 24% for AHC) (P<.001). CONCLUSION: Patients with access to SBHC services that strongly emphasize outreach were more likely to complete the hepatitis B vaccination series.

Adolescent↗