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PubMed1990

Immunity to measles in a large population of varying age. Significance with respect to vaccination.

During a measles outbreak, 660 hospital employees of widely varying ages were screened for immunity to the disease using an automated indirect fluorescent antibody technique. Of these 660 employees, 623 indicated their year of birth; 21 were seronegative and 13 had borderline titers. Of those born before 1957, 7 tested seronegative and 6 were borderline, while 12 of those born between 1959 and 1964 were seronegative and 3 were borderline. There are several possible reasons for these findings. It is concluded that mass immunization of high-risk populations during outbreaks, while effective, is difficult to justify scientifically because only a small percentage of subjects are not immune. If facilities permit, mass screening during outbreaks may be feasible. Preferably, continuous screening and vaccination of susceptible high-risk employees could be performed. Our study also does not validate exclusion from immunization programs those born prior to 1957 in view of the fact that both seronegativity and disease occur in this age group with significant frequency.

Adult↗
PubMed1994

A randomized trial of the effectiveness of computer-generated telephone messages in increasing immunization visits among preschool children.

OBJECTIVE: To assess the effectiveness of computer-generated telephone reminder and recall messages in increasing preschool immunization visits. DESIGN: Randomized, controlled trial. SETTING: Fourteen counties in urban and rural Georgia. STUDY PARTICIPANTS: Children (N = 8002) who were younger than 2 years; had telephone numbers listed in preexisting computerized immunization databases; and were due or late for immunization(s) during the 4-month enrollment period. INTERVENTION: Households of children were randomized to receive or not receive a general or vaccine-specific computer-generated telephone reminder or recall message the day before the child was due, or immediately after randomization if the child was late. MAIN OUTCOME MEASURE: The rates of immunization visits during the 30-day follow-up period. RESULTS: Of the 4636 children whose households were randomized to receive a message, 1684 (36.3%) visited the health department within 30 days compared with 955 (28.4%) of the 3366 children whose households were not contacted (risk ratio [RR] = 1.28; 95% confidence interval [CI] = 1.20 to 1.37; P < .01). Immunization visits were more frequent (41.1%) among the 3257 children whose households actually received the message (RR = 1.45; 95% CI = 1.36 to 1.56; P < .01). Improvement in immunization visits was similar for general and specific messages, greater for recall than reminder messages, and greatest for children who were late for the third dose of the diphtheria-tetanus-pertussis vaccine and the measles-mumps-rubella vaccine. CONCLUSION: These data suggest a simple and effective way to increase preschool immunization visits, particularly for vaccines associated with the lowest immunization rates.

Catchment Area, Health↗
PubMed1999

Health consequences of religious and philosophical exemptions from immunization laws: individual and societal risk of measles.

CONTEXT: All US states require proof of immunization for school entry. Exemptions are generally offered for medical, religious, or philosophical reasons, but the health consequences of claiming such exemptions are poorly documented. OBJECTIVES: To quantify the risk of contracting measles among individuals claiming religious and/or philosophical exemptions from immunization (exemptors) compared with vaccinated persons, and to examine the risk that exemptors pose to the nonexempt population. DESIGN, SETTING, AND PARTICIPANTS: Population-based, retrospective cohort study of data from 1985 through 1992, collected by the Measles Surveillance System of the Centers for Disease Control and Prevention, as well as from annual state immunization program reports on prevalence of exemptors and vaccination coverage. The study group was restricted to individuals aged 5 to 19 years. To empirically determine and quantify community risk, a mathematical model was developed that examines the spread of measles through communities with varying proportions of exemptors and vaccinated children. MAIN OUTCOME MEASURES: Relative risk of contracting measles for exemptors vs vaccinated individuals based on cohort study data. Community risk of contracting measles derived from a mathematical model. RESULTS: On average, exemptors were 35 times more likely to contract measles than were vaccinated persons (95% confidence interval, 34-37). Relative risk varied by age and year. Comparing the incidence among exemptors with that among vaccinated children and adolescents during the years 1985-1992 indicated that the 1989-1991 measles resurgence may have occurred 1 year earlier among exemptors. Mapping of exemptors by county in California indicated that exempt populations tended to be clustered in certain geographic regions. Depending on assumptions of the model about the degree of mixing between exemptors and nonexemptors, an increase or decrease in the number of exemptors would affect the incidence of measles in nonexempt populations. If the number of exemptors doubled, the incidence of measles infection in nonexempt individuals would increase by 5.5%, 18.6%, and 30.8%, respectively, for intergroup mixing ratios of 20%, 40%, and 60%. CONCLUSIONS: These data suggest the need for systematic review of vaccine-preventable incidents to examine the effect of exemptors, increased surveillance of the number of exemptors and cases among them, and research to determine the reasons why individuals claim exemptions.

Adolescent↗
PubMed2003

Variation in public and private supply of pneumococcal conjugate vaccine during a shortage.

CONTEXT: In late August 2001, a serious shortage of the heptavalent pneumococcal conjugate vaccine (PCV7) developed in 34 state immunization programs. In September 2001, the Centers for Disease Control and Prevention published revised recommendations advising physicians to prioritize PCV7 to specific groups of children. The effect of the shortage at the practice level is unknown. OBJECTIVE: To determine the variation between public and private markets in the supply of PCV7 and the nature and extent of the PCV7 shortage at the practice level. DESIGN, SETTING, AND PARTICIPANTS: Semistructured interviews with office staff responsible for ordering vaccines at private practices in 12 states were conducted between October 19 and November 2, 2001. MAIN OUTCOME MEASURES: Variation in supply of PCV7 obtained from public sources and through purchase on the private market. Supply was characterized into 3 categories: "no problem," "problem obtaining a consistent supply," and "out of stock." RESULTS: Interviews were completed at 405 practices, representing a response rate of 74%. Overall, 51% of practices reported at least 1 episode of being out of stock of public PCV7 and 64% of private PCV7, with significant state-to-state variation. Only 2 of 12 study states had a substantially higher proportion of practices experiencing out-of-stock episodes for public compared with private PCV7, while in 6 states public PCV7 was less frequently out of stock than private PCV7. Only 23% of practices in this study altered their administration policy for private PCV7, while 27% altered their policy for public PCV7. CONCLUSIONS: The distribution and supply of PCV7 varied between public and private supplies and between states during the shortage. Few practices changed their administration schedules in response to revised recommendations.

Pneumococcal Vaccines↗
PubMed2004

Vaccine policy changes and epidemiology of poliomyelitis in the United States.

CONTEXT: The last case of poliomyelitis in the United States due to indigenously acquired wild poliovirus occurred in 1979; however, as a consequence of oral poliovirus vaccine (OPV) use that began in 1961, an average of 9 cases of vaccine-associated paralytic poliomyelitis (VAPP) were confirmed each year from 1961 through 1989. To reduce the VAPP burden, national vaccination policy changed in 1997 from reliance on OPV to options for a sequential schedule of inactivated poliovirus vaccine (IPV) followed by OPV. In 2000, an exclusive IPV schedule was adopted. OBJECTIVE: To review the epidemiology of paralytic poliomyelitis and document the association between the vaccine schedule changes and VAPP in the United States. DESIGN AND SETTING: Review of national surveillance data from 1990 through 2003 for cases of confirmed paralytic poliomyelitis. MAIN OUTCOME MEASURES: Number of confirmed paralytic poliomyelitis cases, including VAPP, and ratio of VAPP cases to number of doses of OPV distributed that occurred before, during, and after implementation of policy changes. RESULTS: From 1990 through 1999, 61 cases of paralytic poliomyelitis were reported; 59 (97%) of these were VAPP (1 case per 2.9 million OPV doses distributed), 1 case was imported, and 1 case was indeterminate. Thirteen cases occurred during the 1997-1999 transitional policy period and were associated with the all-OPV schedule; none occurred with the IPV-OPV schedule. No cases occurred after the United States implemented the all-IPV policy in 2000. The last imported poliomyelitis case occurred in 1993 and the last case of VAPP occurred in 1999. CONCLUSION: The change in polio vaccination policy from OPV to exclusive use of IPV was successfully implemented; this change led to the elimination of VAPP in the United States.

Health Policy↗
PubMed2000

Policy analysis of the use of hepatitis B, Haemophilus influenzae type b-, Streptococcus pneumoniae-conjugate and rotavirus vaccines in national immunization schedules.

After the development of national vaccine programmes to deliver six vaccines to infants, new vaccine adoption has been limited. Analysis of the health and economic implications of new vaccination options can help national policy-makers. Country specific quantitative policy analyses were conducted to estimate the impact of vaccination against hepatitis B (HB), Haemophilus influenzae type b (Hib), Streptococcus pneumoniae (SP) and rotavirus. Disease burden, programme costs and the potential reduction of disease from vaccination was assessed for each vaccine. Without vaccination, these four vaccine preventable diseases contribute up to 4.1 million deaths in each successive birth cohort. Routine scheduled use of HB and Hib vaccines could prevent up to 1.7 million deaths; SP and rotavirus vaccines, an additional 1.4 million deaths, annually. The global cost per life-year saved ranged from $29 to $150 with great variation by income and economic groups. With a few exceptions for a few countries, these vaccines would cost a fraction of average per-capita gross domestic product to save a life-year. The addition of HB and Hib vaccines, should be considered for integration in all national immunization programmes. SP and rotavirus vaccines, with the given assumptions, would also be cost-effective. Proactive analysis of the economic and epidemiologic impact of these vaccines can hasten their introduction into national vaccination schedules.

Bacterial Vaccines↗
PubMed2005

Outcome in children with purpura fulminans: report on 16 patients.

Purpura fulminans (PF) is a severe disorder of acute onset with high morbidity and mortality. In children, this rapidly progressive illness is usually associated with severe bacterial or viral infections. However, some other conditions may participate in the development of PF. Our objective was to investigate the underlying and associated disorders and the outcomes of the disease in 16 children, 7 males and 9 females ranging in age from 3.5 months to 12 years (median age, 2 years). Thirteen of the 16 children (81%) were 4 years of age or younger. The remaining 3 patients were 9, 10, and 12 years of age. Among these 13 infants and small children, 7 (43%) had infection, 2 infants had congenital cardiac disorders necessitating minor or major surgical intervention, and 1 infant and 3 children had different miscellaneous disorders. The factor V G1691A mutation was present in six of the 13 small children (46%). None of the 3 older children carried the mutation. Six (37.5%) of the 16 patients had protein C deficiencies, and 9 (56%) had protein S deficiencies. These deficiencies, except one for protein S, were acquired. Ten patients except two who were diagnosed at this center were treated with fresh frozen plasma. They were also given heparin. Nine (69%) of the 13 children 4 years of age or younger and one of the older children (33%) required amputation. Five of the six patients (83%) who had factor V G1691A mutation, and who also exhibited severe infection, required amputation. This study suggests that an age of 4 years or less is a risk factor for the development of PF during severe infections, especially in the presence of factor V G1691A mutation and congenital heart disease, necessitating major or minor surgical interventions. This study also shows that the amputation rate in 10 patients, after excluding the patients who had been referred to our center after development of sequelae, was 60%. The survival rate among these 10 patients may indicate that, with the treatment protocol, PF need not be regarded as a lethal disease any more. It is also suggested that effective immunization programs and better health care have probably resulted in some changes in the etiological profile of PF.

Amputation, Surgical↗
PubMed2004

Monitoring congenital rubella embryopathy.

BACKGROUND: Currently, all developed countries include rubella vaccination in their immunization programs, targeting the complete elimination of congenital rubella syndrome (CRS). In the underdeveloped world, where this severely disabling condition still exists, only a few countries have implemented vaccination policies, and almost no data on their effectiveness or on prevalence rates are available. The aims of the present work were to search for the best phenotype to be used as a sentinel for CRS in a large series of malformed newborns and to propose a CRS surveillance system, based only on clinical data. METHODS: A total of 43 infants diagnosed as having CRS were obtained from 19,184 multimalformed infants, ascertained by the Latin-American Collaborative Study of Congenital Malformations, World Health Organization (WHO) Collaborating Centre for the Prevention of Birth Defects (ECLAMC), over 3,883,165 consecutive births, between 1982 and 2003. They were distributed by country and the most frequent birth defects were identified. From the 19,184 multimalformed infants, all cases presenting the birth defects identified were selected. The sensitivity, specificity, and likelihood ratio (LR) in detecting CRS were determined for these birth defects, alone and in combination. The sample size of multimalformed infants required to detect different levels of increase in the rate of CRS was determined for three sentinel phenotypes. RESULTS: The rate of CRS was highest in Brazil. Based on the best possible combination of sensitivity, specificity, and LR, the dyad comprising eye anomalies and congenital heart defects was shown to be the most appropriate sentinel, with the lowest sample size required, to detect CRS in neonates. CONCLUSIONS: A surveillance system for CRS, based on clinical data in newborns, is being proposed, in an attempt to monitor ongoing vaccination policies, aimed at eliminating CRS in developing countries.

Developing Countries↗
PubMed1999

An economic analysis of different strategies of immunization against hepatitis A virus in developed countries.

Acute hepatitis A is a major public health problem in developed countries, and because a large proportion of patients with acute hepatitis A do not have any identifiable risk factors, current practice of targeting the high-risk groups for vaccination against hepatitis A virus (HAV) is unlikely to have a significant impact on the overall incidence of acute hepatitis A. No economic analysis of strategies of mass immunization against HAV is available. Three different strategies of immunization against HAV using commercially available inactivated vaccine were compared in a Markov model analysis of a cohort of 2-year-old healthy children in a developed country. In strategy I, universal vaccination was pursued. In strategy II, children were initially screened for antibody and, if susceptible, they were vaccinated. In strategy III, no vaccination was offered. Cost per person and quality adjusted life-years (QALY) gained in each strategy were the outcome measures compared. The baseline analysis showed that strategy II is more cost-effective than strategy I, with marginal cost-effectiveness ratios of $7,267. 67 and $12,833.34, respectively, compared with a strategy of no intervention. Sensitivity analysis showed that if the cost of the two-dose vaccine could be reduced to less than $57, the strategy of universal vaccination would be the preferred immunization strategy. Different strategies of mass immunization against HAV in the developed countries are cost-effective by current standards of health care interventions and should be considered for incorporation into current childhood immunization programs.

Adolescent↗
PubMedDate not supplied

Key issues relating to decentralization at the provincial level of health management in Cambodia.

The following study was conducted as part of a review of management systems at a Provincial Health Department (Kampong Cham Province) and a National Health Programme (National Immunization Program) in 2002-2003 in Cambodia. The aim of this paper is to identify, analyse and recommend those management system factors that are critical to the success of health management performance, with a particular focus on provincial management. The review has identified critical success factors associated with health management performance at the sub-national level that include a stronger role for effective human resource management in health sector reform, elevation of the status of planning in senior level management, and the development of a more comprehensive and transparent finance system. These success factors will position the provincial level of health management to respond more effectively to the reform challenges of administrative de-concentration and political decentralization that are currently underway across a range of government sectors in Cambodia.

Cambodia↗
PubMed2003

Molecular epidemiology of measles virus in Kenya.

Measles causes significant morbidity and mortality globally. Many countries have embarked on immunization programs to control and prevent measles outbreaks and eventually to eliminate endemic measles. Kenya is currently in the outbreak control and prevention stage for measles. Measles virus genotyping is important for molecular epidemiological purposes, including the documentation of the elimination of endemic measles virus strains from a country, and mapping of transmission pathways. In this study, we collected clinical specimens from measles outbreak cases in 2002 in Kenya for measles virus genotyping. We were able to isolate and/or detect measles virus in 10 cases from 5 of the 8 provinces in Kenya. All these Kenyan measles strains were determined to be genotype D4 strains when compared to the standard World Health Organization-designated measles virus reference strains. Interestingly, the Kenyan D4 strains clustered into two distinct D4 subgroups. In addition, the inclusion of other published D4 measles strains in this analysis indicated that there are four distinct D4 clusterings, or subgroups: Montreal-like, India-like, Johannesburg-like, and Ethiopia-like. This is the first measles molecular epidemiology study in Kenya and establishes the current endemic measles strain as genotype D4. Importantly, this study shows that the Kenyan D4 strains are distinct from the B3 measles strain found in West Africa and the D4 strains reported in Ethiopia.

Adolescent↗
PubMed2001

Neuroprogressive disease of post-infectious origin: a review of a resurging subacute sclerosing panencephalitis (SSPE).

Subacute sclerosing panencephalitis (SSPE) is a progressive, essentially untreatable, disease of the nervous system. When first described in the 20th Century, it was characterized more for its neuropathological features than for its pathophysiology or cause. It was not until the 1960s that a clear relationship to the measles virus was established. It is now thought that this uncommon infectious encephalopathy is caused by a "slow," altered or persistent form of the wild measles virus which has harbored in the nervous system for years. Then a "breakout" occurs and the more lytic and virulent organisms produce the progressive and spreading inflammatory and destructive lesions which are confined to the nervous system. Epidemiological study of the disease confirms its relationship to measles. In the years since the development of national measles immunization programs, there has been a dramatic decline in the incidence of measles exanthem and until recently a corresponding decline in the incidence of SSPE. In recent years there has been a mild to moderate increase in cases of SSPE as reported to the USA/International SSPE Registry. As yet, there has not been a totally effective treatment. The purpose of this paper is to give an overall review on SSPE and its relationship to measles. This review will include a prospectus of its history, considerations as to its etiology, correlation of clinicopathological features, and thoughts on the past and present epidemiology and treatment.

Adolescent↗
PubMed2001

Factors associated with hepatitis B virus immunization coverage at the beginning of a population campaign in the Lazio region, Italy.

BACKGROUND: The hepatitis B virus (HBV) vaccination was introduced in Italy in 1991 as compulsory among newborns and among 11-year-old children. METHODS: We conducted a retrospective study to evaluate the HBV immunization coverage of the two target populations by the public health services in the Lazio region and to analyze factors associated with starting and completing HBV immunization in the initial period of the campaign. We used data registered in the public health services of 7/51 Health Districts. As a proxy indicator of services' performance we used the "expected immunization period," that is, the 6-month period in which each child should have been started on immunization, according to the calendar. RESULTS: HBV vaccine coverage rates were 63% in the younger cohort and 50% in the older one. The results of univariate and multivariate regression analysis showed that starting HBV immunization was associated with being newborn (crude OR = 3.30; 95%CI 2.17-2.44), with living in a small city (crude OR = 6.81; 95%CI 6.12-7.58), and with being assigned to the second (crude OR = 1.77; 95%CI 1.65-1.90) or to the third 6-month period of the expected immunization period (crude OR = 2.58; 95%CI 2.42-2.76). The probability of completing HBV immunization was higher among children who had had the first dose "age-appropriately" or with "acceptable delay" and among those living in small cities. It was lower among children in the second or the third 6-month period. Size of urban area of residence was associated with both outcomes: the city of Rome showed the lowest probabilities of starting and completing HBV immunization, while the small cities showed the highest ones. CONCLUSIONS: The performance of public health services was the most important determinant of recourse to public health services for vaccinations; it varied according to size of urban area; in towns organization difficulties contributed to the delay of starting vaccination, for at least a year. The expected immunization period was a good proxy indicator of services' performance. The timing of the first dose was the strongest predictor of completing vaccination also at the beginning of the campaign.

Child↗
PubMed1976

The environment of the malnourished child.

The study of the relation of man to his environment in developing countries emphasizes the inevitable need for societies to recognize the true causes of infection, malnutrition, and poverty. The need is for improvement in the quality of human life in less developed nations, a recommendation easy to prescribe but difficult to accomplish. Although our pool of knowledge is incomplete, it is adequate to suggest ways to diminish infection, increase food production, utilize food more efficiently, improve education, and provide systems of justice to protect the classes most in need. The physical environment in tropical and subtropical regions, and the socioeconomic characteristics of the population inhabiting such regions, favor maintenance and transmission of a variety of viruses, bacteria, and parasites that make agricultural progress and social development difficult, and that contribute to poor fetal growth, nutrient wastage, and deficient postnatal physical growth, accounting for most of the childhood morbidity and mortality. In this regard, infections contribute indirectly to the overall food problem in a similar fashion as pests do in terms of food losses and spoilage. The overall effect could be comparable or greater than that resulting from an inadequate capacity to produce or to purchase the food needed. Thus, my objective has been to stress, within the whole environment, the importance of infection and the need to diminish it. Ways to control and prevent infection are readily known. They have to do with education of the population to improve personal and environmental hygiene. Economic investment is necessary to improve housing and water supply systems, waste disposal, and such preventive measures as immunization programs. Although such measures may appear expensive when first implemented, they have long-lasting effects and many require minimal expenditure once they are established. Large segments of the population stand to benefit, and other development interventions can then be introduced. However, these measures should not be implemented singly. They should be accompanied by community development, family planning, social legislation--in other words, the holistic approach to health and welfare. To do otherwise may aggravate the problem by stimulating demographic growth, perpetuating malnutrition and infection, and maintaining underdevelopment.

Agriculture↗
PubMed1995

Two independent outbreaks of measles in partially vaccinated junior high schools in Tottori, Japan.

We analyzed retrospectively a relative risk of measles attacks in vaccinated vs. unvaccinated students using two independent outbreaks in Japan. The first involved 33/328 (10%) students where 64% students and 30% measles cases had been vaccinated. The second involved 27/241 (11%) students where 81% students and 48% measles cases had been vaccinated. The attack rates of vaccinated vs. unvaccinated students were significantly low (p < 0.001), but they accounted 25% in both episodes. The statistically significant clinical features among vaccinated and unvaccinated cases included the average duration of fever, 5.16 +/- 1.71 vs. 6.67 +/- 2.19 days (p = 0.01) and the incidence of complications, 0 vs. 25%, respectively. These results suggested that the measles in vaccinated cases were mostly due to secondary failures.

Adolescent↗