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PubMed2003

Emergency medicine tools to manage smallpox (vaccinia) vaccination complications: clinical practice guideline and policies and procedures.

In December 2002, the federal government began a program to immunize approximately 500000 civilian public health and health care workers with smallpox (vaccinia) vaccine as a part of our pre-event defense against bioterrorism. First responders will likely follow, and the general US population might be offered vaccination in the next 1 to 2 years. Recent reports that suggest the possible association of the vaccine to adverse cardiac events (including deaths), liability concerns for hospitals, and the availability of compensation for workers with vaccine complications have significantly reduced voluntary participation. Vaccinees might experience robust primary takes or serious adverse events, including viral or even bacterial cellulitides, encephalitis, progressive skin destruction, and other life-threatening complications. With the increasing prevalence of immune suppression from both diseases and immunosuppressive medications, complications might be seen in higher frequency than previously reported. Emergency medicine providers and staff must become familiar with clinical presentations and management of vaccine complications. In addition, policies and procedures must be developed to prevent unimmunized providers from inadvertently contacting the active vaccination sites of their patients and, if the providers themselves have active vaccination sites, to protect their patients and their own families.

Antiviral Agents↗
PubMedDate not supplied

[Disease burden due to vaccinable diseases in the Spanish population aged less than 15 years old].

OBJECTIVES: To estimate the burden of disease due to vaccinable diseases and the relative importance of these diseases in the health of the Spanish population aged less than 15 years old. METHODS: Disease burden was measured in disability-adjusted life years (DALYs). DALYs were computed by adding years of life lost (YLL) to years lived with disability (YLD). The DALYs of the Spanish population aged less than 15 years old were estimated for 1999 and were stratified by diseases according to the classification system of the Global Burden of Disease (adapted to the aim of the study), age group and gender. Diseases included in the childhood vaccination schedule, varicella, and pneumococcal disease were targeted for this study. The sources used were: the national mortality register to compute YLL, the Epidemiologic Surveillance National Network, hospital discharge data (CMBD) and the scientific literature to compute YLD due to vaccinable diseases, and World Health Organization estimates (Euro-A) or, when these were lacking, morbidity hospital data (Hospital Morbidity Survey) to compute the YLD due to non-vaccinable diseases. RESULTS: The burden of disease due to vaccinable diseases was 1.2% of global DALYS (the overall DALYs rate was 46,57/1,000 habitants): excluding meningococcal disease (0.5% to 3.3%), diseases included in the vaccination schedule represented 0.00% to 0.03%, depending on age groups, except meningococcal infection (between 0.5% and 3.3%). Pneumococcal meningitis represented 0.06% to 0.65% and varicella 0.00% to 0.15%, also depending on age groups. CONCLUSIONS: Disease burden due to vaccinable diseases is a good indicator of the health of the young population in Spain. This measure summarizes and combines information on mortality, morbidity and disability caused by diseases. The DALYs attributable to diseases included in the vaccination schedule demonstrate that immunization programs have achieved their goals.

Adolescent↗
PubMed1998

[Medicine in Vanuatu: a voyage to the end of the earth to Espiritu Santo Island].

INTRODUCTION: The republic of Vanuatu, which was previously termed the Hebrides, has been independant since 1981. Colonization by both France and England has left its numerous marks on this country over the years. The authors spent the year 1997 on the Espiritu Santo Island and report their experience as practitioners at the northern district hospital. CURRENT KNOWLEDGE AND KEY POINTS: As Vanuatu is a developing country, medical practice is subject to changes in government, development aid provided by foreign countries and socio-economical conditions. Numerous chronic diseases with historical complications and malpractice are encountered. As well, numerous infectious diseases such as tuberculosis and malaria are still endemic. Means of fighting and preventing infections are great problems, with, for example, deficiencies in immunization programs. Though medical structures are well organized, due to its immature governments and assistance rather than cooperation policies of various helping countries, latitudinarianism is important and medical practice is not continuously organized. FUTURE PROSPECTS AND PROJECTS: Several objectives should be considered: epidemiological studies in order to reconstitute diseases profiles in this archipelago and, most of all, cooperation that would aim at training and education.

Adult↗
PubMed2001

Vaccination against hepatitis viruses in Poland.

At present, two etiologic varieties of viral hepatitis (VH) can be directly vaccine-preventable: VH type A and VH type B. In addition, VH type D can be prevented indirectly through vaccination against VH-B. The first commercially available vaccine against VH-B appeared in 1981 and was human plasma-derived. After several years, it has generally been replaced by a recombinant type of vaccines. The obvious benefits of vaccination against VH-B prompted its introduction into the national immunization program in Poland in 1989. At that time, vaccination was offered free of charge to high-risk groups: newborns of HBsAg-carrier mothers, health-care workers, students: at medical schools, nursing schools, medical technology schools, and caretakers at institutions for mentally retarded persons. However, similarly to the experiences of other countries, observations in Poland indicated that such a targeted strategy fails to induce major epidemiological changes. In 1989 and in 1993, the incidence of VH-B per 100000 was 40.3 and 34.6, respectively. In addition, during these years, the incidence of V-B per 100000 children aged 0-4 years was 20.0 and 38.4, respectively. It has been decided that vaccination against VH-B will be obligatory for all newborns beginning from 1993. Due to financial constraints, it has been introduced in three phases, and since 1996, all newborns in Poland have been vaccinated. Already in 1993, three additional risk groups have been offered vaccination: patients with chronic diseases, patients awaiting planned surgery, and persons coming into close contact with acute VH-B or chronically HBV-infected individuals. In 1999, the incidence of VH-B per 100000 was 9.1/100000, and it may be assumed that vaccination helped to decrease the incidence of VH-B in Poland. The country experience with vaccination against VH-A is still limited. At present, it is recommended for children and adolescents and people dealing with food distribution, as well as for several other groups of people, such as travellers or long-term visitors (soldiers, missionaries, diplomats) to the endemic regions of the world. It has also been recommended in connection with natural disasters such as floods occurring in a large area of Poland in 1997.

Cross Infection↗
PubMed2002

Vaccine quality--can a single standard be defined?

To analyze the current global situation with respect to vaccine quality and to monitor progress in attaining it, it is first necessary to define what this means. While acknowledging that manufacturers are responsible for the quality of the vaccines they produce, World Health Organization (WHO) proposes a definition for "vaccines of assured quality" which depends on the existence of a competent and fully functional regulatory authority as assessed by an external expert team using widely agreed indicators to regulate the product. A vaccine of assured quality is defined as one that consistently meets appropriate levels of purity, potency, safety and efficacy as judged through an independent review system competent to take an evidence-based decision on the product for a specified population in a specific context. Such a review system would make use of all available information, such as licensing dossiers, surveillance of field performance, lot-by-lot scrutiny, appropriate laboratory testing, cGMP inspection of manufacturers, and evaluation of clinical trials, generally assumed by a fully functional regulatory authority. This definition implies that, faced with the same risk/benefit, any competent group would come to the same decision. The definition also indicates clear pathways to improve vaccine quality by strengthening national regulatory authorities and WHO is actively engaged in this task. By insisting on competent regulatory oversight, while recognizing the role of risk analysis in the selection of vaccines for use, WHO strongly reiterates the need for a single standard of quality. Only vaccine of assured quality should be considered for use in national immunization programs on the basis of the risk/benefit ratio for the particular population.

Drug and Narcotic Control↗
PubMed2002

Protective efficacy of hepatitis B vaccine without HBIG in infants of HBeAg-positive carrier mothers in Thailand.

The primary objective of this study was to estimate the efficacy of a recombinant hepatitis B vaccine (H-B-VAXII) in preventing chronic hepatitis B infection when given alone without concomitant hepatitis B immune globulin (HBIG) to healthy Thai infants born of HBeAg-positive carrier mothers. The infants received a 0.5 ml (5 micro g HBsAg) intramuscular injection of H-B-VAXII either at birth, 1, and 6 months of age (Schedule A) or at birth, 1, 2, and 12 months of age (Schedule B). Blood drawings for the determination of hepatitis B virus (HBV) serologic markers were scheduled 4, 9, and 13 months following the initial dose of vaccine. At 13 months, 5 (10%) of 50 infants vaccinated on Schedule A and 7 (14.9%) of 47 infants vaccinated on Schedule B had experienced chronic HBV infection. Based on an expected infection rate in unimmunized infants of either 70 or 90%, the overall efficacy for both schedules combined was estimated to be 82.3% (95% CI: 70.6, 90.6) or 86.2% (95% CI: 77.1, 92.7), respectively. Corresponding schedule-specific estimates were for Schedule A: 85.7% (95% CI: 68.8, 95.3) or 88.9% (95% CI: 75.8, 96.3) and for Schedule B: 78.7% (95% CI: 59.6, 91.1) or 83.4% (95% CI: 68.6, 93.1). These results suggest that in areas of high endemicity, where mothers may not always be screened for HBV infection, routine vaccination of infants at birth with a course of hepatitis B vaccine alone should be highly protective, even for very high-risk infants of HBeAg-positive mothers.

Apgar Score↗
PubMed2002

Preadolescent non- and hyporesponders following three doses of hepatitis B vaccine need only one more dose.

A small proportion of healthy children fail to develop antibodies against hepatitis B after three doses of vaccine. Few data are available regarding the optimal re-immunization strategy. We measured the immune response 1 month after a single supplementary dose of recombinant hepatitis B vaccines in 18 young preadolescents who were non- or hyporesponsive after a regular primary course of three doses of recombinant hepatitis B vaccines. Among them, 100% seroconverted and 89% reached the seroprotective titer of 10 milli-International Units (mIU)/ml. Most healthy children, particularly if they are hyporesponders, will have reached the seroprotective level after one dose and will not need further injections.

Child↗
PubMed2002

Enhanced surveillance of primary measles mumps and rubella (MMR) immunisation in Wales.

In England and Wales routinely available data measure uptake of the measles mumps and rubella (MMR) vaccine at 2 years. This results in a delay in detecting change in uptake of the vaccine, which is scheduled at 12 months of age. The predictive value of uptake at 15-17 months is limited by the greater variability in uptake between quarters at the younger age. This can be overcome by presenting the data as a four-quarter annual rolling average. Uptake of the MMR vaccine at 2 years of age in Wales is predicted to stabilise at around 84% in the first three quarters of 2002.

Child, Preschool↗
PubMed2003

Hepatitis B carriers in large vehicle drivers of Iran.

Hepatitis B is a serious cause of mortality and morbidity worldwide. The prevalence of hepatitis B surface antigen in Iran is about 1.7% but little is known about the high-risk occupations. This study was conducted to investigate the prevalence of HBsAg and assess risk factors of infection in Iran's large vehicle drivers as a high-risk group. The population studied included 1113 large vehicle drivers. Study was carried out in 51 police stations in roads of 17 provinces around the country. From each of the sites 20-30 large vehicle drivers were randomly selected. An interview with each of the subjects was performed and a blood sample was taken. The prevalence of HBsAg was 5.9% (confidence interval (CI) 95%: 4.5-7.3%) which was significantly different from the prevalence in general population in the same age group (P<0.0001). Cost-effectiveness studies regarding immunization programs for this high-risk group is suggested.

Adult↗
PubMed2003

Immunity to diphtheria among refugees in southern Italy.

This study assessed the immune status against diphtheria of a sample of refugees (mainly Kosovars and Kurds) in southern Italy (Puglia). The 54.8% of 1128 subjects showed full protection against diphtheria, 30.1% had basic protection and 15.1% resulted seronegative for antitoxin antibody. Only from 45.9 to 73.9% of 0-10 years old refugees were fully protected while from 12.3 to 24.2% were seronegative to diphtheria with the poorest protection rate among Kurdish children from Turkey. Kosovars showed the highest protection rate to diphtheria whereas data suggest a probable endemic level of diphtheria in Iraq. The screening of refugees revealed a low coverage rate for diphtheria, especially in children, probably due to deterioration of the health service infrastructure or intermittent basic health care in the country of provenience. In terms of public health measures, there is the need of administering booster doses to all refugees coming into Italy and into other host countries to increase the coverage rate against diphtheria. The implementation of the immunization programs against diphtheria in the countries of provenience is also strongly recommended.

Adolescent↗
PubMed1997

Suppression of the immune response to diphtheria toxoid in murine schistosomiasis.

Studies in humans and experimental animals indicate that infection with schistosomes results in impaired immune response to a variety of antigens. Since artificial immunization against a number of infections is frequently attempted in populations in which schistosomiasis is endemic, we have attempted to determine whether this impairment could be demonstrated in response to a commonly used immunogen. We have compared the serum antitoxin response to diphtheria toxoid (DTd) in normal, uninfected mice with that in mice bearing schistosome infections of different duration. Animals were infected with 100 Schistosoma mansoni cercariae 16, 12, 8, 4 and 2 weeks prior to, on the same day as, and 4 weeks after the first of three 1 microgram doses of DTd given at 3 week intervals. The antitoxin level of each mouse was taken as the mean of two sera obtained 1 and 2 weeks after the 3rd dose of DTd. The mean antitoxin level in uninfected-immunized control mice was 0.0457 Antitoxin Units (AU) ml-1. 71% of mice in this group developed antitoxin levels > or = 0.01 AU ml-1. Only 28% of the infected-immunized mice achieved antitoxin levels > or = 0.01 AU ml-1. In infected-immunized mice with infections of all durations, both the percentage of mice with > or = 0.01 AU ml-1 (0 to 50%) and mean antitoxin levels (0.003 to 0.016 AU ml-1) were lower than in uninfected-immunized mice. Antitoxin levels in animals infected 16, 12, 8 and 2 weeks prior to, simultaneously with, and 4 weeks after the first dose of DTd were significantly lower (P = < 0.05) than those of controls. Mice infected 4 weeks prior to the first dose of DTd had antitoxin levels 64% below controls but this difference was not significant. If similar immunosuppression occurs in human schistosomiasis, these findings may have implications for childhood immunization programs in areas where schistosomiasis is endemic.

Animals↗
PubMed1997

Intranasal booster vaccination against diphtheria and tetanus in man.

The booster responses of three different formulations of intranasal (i.n.) diphtheria-tetanus (D-T) vaccines were determined in military recruits and compared with a conventional subcutaneous D-T vaccine. The vaccines for mucosal delivery were sprayed into one nostril and contained D and T toxoids in an enhancer mixture of polysorbate and caprylic/capric glycerides. All of the vaccines gave rise mainly to a systemic IgG response. Among 51 persons with anti-D antibody concentrations in serum below a protective level of 0.01 international units (IU ml-1) before vaccination, all except two attained protective antibody concentrations 4 weeks after vaccination. The median increase in anti-D antibody concentration was 113-fold with the most efficient i.n. formulation. The median increase in anti-T antibody level was 2.4-fold, however, the pre-vaccination levels for this antigen were very high. Within the examined levels, the booster response depended mainly on the dose of the antigen in the vaccine rather than on the concentration of the vehicle mixture. Compared with the parenteral D-T vaccine containing aluminium hydroxide as an adjuvant, all of the tested i.n. formulations showed somewhat lower immunogenicity in man as well as in pre-clinical guinea-pig studies. Among 215 persons immunized i.n., 61% preferred this route of administration rather than a parenteral injection, although the formulations were all associated with varying local symptoms, frequently stinging and pronounced, nasal secretion.

Administration, Intranasal↗
PubMed1997

In vivo protection against Androctonus australis hector scorpion toxin and venom by immunization with a synthetic analog of toxin II.

A synthetic peptide mimicking the North African scorpion Androctonus australis hector toxin II was designed and produced by chemical solid-phase synthesis. It contains the entire sequence of toxin II (64 amino acid residues), with each half-cystine being replaced by the isosteric residue a-aminobutyric acid, and was thus devoid of disulfide bridges. This construct was totally nontoxic in mice even if large amounts, equivalent to 1000 times the LD50 of the original toxin, were injected by the intracerebroventricular route. The synthetic peptide, either as a monomer or polymerized by means of glutaraldehyde, induced the production of antitoxin neutralizing antibodies in immunized mice and rabbits. After three injections with either the monomeric or polymerized synthetic peptide, the immunized mice were protected against several lethal doses of the corresponding native toxin or scorpion venom. Six months after immunization, the mice were completely protected against challenge with eight LD50 of the original toxin. The protection was better when the polymerized synthetic peptide was used. One month after the start of the immunization program, it showed a good correlation between antibody titer and protection. However, antibody titer decreased with time but protection remained high. This suggests that additional factors other than circulating antibodies play a role in protective activity.

Animals↗
PubMedDate not supplied

Immunity to mumps before and after MMR vaccination at 12 years of age in the first generation offered the two-dose immunization programme.

Sweden was the first country in the world to introduce a two-dose programme of vaccination against measles, mumps and rubella with a combined vaccine (MMR). It was commenced in 1982 and the vaccination was carried out at the ages of 18 months and 12 years. In 1992-93 the first age-group vaccinated at 18 months reached the age of 12 and accordingly received a second dose of MMR. A total of 382 children participated in the present study. Sero-immunity against mumps was studied by testing neutralizing antibodies using serial dilutions inoculated into cell cultures before and after the 12-year vaccination. Of the 229 children earlier vaccinated (group A), 27% lacked demonstrable antibodies before the booster. Of those without documented vaccination records (group B), 56% were seronegative before vaccination. After vaccination, 93% of group A and 86% of group B were seropositive (titre > or = 2). In the seronegative children, whether vaccinated earlier or not, the seroconversion was ca 75%. Previously unvaccinated children positive before vaccination and thus likely to be naturally immune had a higher mean-titre both before and after vaccination than the seropositive children earlier vaccinated. So far, the two-dose programme has proceeded as expected.

Child↗
PubMed1998

Universal hepatitis B immunization: infant, and infant plus adolescent immunization.

Hepatitis B virus (HBV) is one of the world's most widespread infectious agents and the cause of millions of diseases and deaths each year. Vaccination programmes aimed at risk groups are important for individual protection, but will not eliminate viral transmission in Europe, since 70% of acute hepatitis B cases are either acquired by sexual activity or are of unknown origin. In industrialized countries, HBV infection occurs mainly in young adults, however, when the virus is acquired during infancy it leads to extremely high rates of chronic carriership, contributing disproportionately to the overall pool of HBsAg carriers. This explains why integrating universal HB vaccination into routine infant immunization programmes is the best means for controlling HB in countries with intermediate to high levels of HB endemicity. In countries of low endemicity, universal immunization of adolescents may be considered as an alternative to infant vaccination, as this strategy has a more rapid effect on the epidemiology of the infection. Where feasible, a double strategy (infant plus adolescent) is the optimal solution. With this strategy, adolescent immunization is necessary only for the time required for the first cohort of immunized infants to reach adolescence. After universal vaccination programmes have been implemented, efforts must be made to sustain vaccine procurement, monitor coverage, check the incidence of acute disease, particularly in immunized cohorts and verify by seroepidemiological studies the progression made in the elimination of HBV transmission.

Adolescent↗
PubMed1999

The clinical effectiveness of pneumococcal vaccination: a brief review.

Randomized controlled trials have shown that pneumococcal polysaccharide vaccine is efficacious in preventing pneumococcal bacteraemia and pneumococcal pneumonia in young adults. Clinical trials in older adults, however, have been inconclusive, usually because the studies have been too small. Retrospective studies have shown that pneumococcal vaccination is approximately 50-80% effective in preventing invasive pneumococcal disease among older persons. Vaccination in this age group is also very cost-effective. These findings are the basis for the recent expansion of immunisation policies and the growth in vaccine use in many developed countries. Serologic and clinical studies, however, suggest that vaccine-induced protection declines after 3-5 years, leading to widespread concern about the need for routine revaccination. Because pneumococcal polysaccharide vaccine does not induce immunologic memory, the benefits of revaccination can also be expected to be relatively short-lasting. Alternative strategies of immunological priming of adults with pneumococcal conjugate vaccine followed by boosting with polysaccharide vaccine, or perhaps vaccination with one of the newer protein vaccines, should be considered. Because these new generation pneumococcal vaccines could provide a foundation of life-long protection against pneumococcal infection, their widespread use among adults could have an immense impact on public health worldwide.

Bacterial Vaccines↗
PubMed1999

The additive benefits of influenza and pneumococcal vaccinations during influenza seasons among elderly persons with chronic lung disease.

Uncertainty regarding the benefits of pneumococcal vaccination may contribute to the under use of this vaccine. The present study was conducted to clarify the benefits of influenza and pneumococcal vaccinations during 3 influenza seasons among elderly persons with chronic lung disease. All elderly members of a large managed care organization with a prior diagnosis of chronic lung disease were included in a cohort that was followed over three influenza seasons (1993-1994, 1994-1995, and 1995-1996). Data obtained from the administrative data bases of the health care organization included baseline demographic and health characteristics, influenza vaccination status for each season, date of pneumococcal vaccination, and outcomes for each season including hospitalization for pneumonia and death. Cox proportional hazards regression and Poisson regression with repeated measures were used to compare the risk of outcomes among vaccinated and unvaccinated persons while controlling for covariates and confounders. During the three influenza seasons, influenza vaccination alone was associated with a 52% reduction (95% CI 18-72) in hospitalizations for pneumonia and a 70% reduction (95% CI 57-89) in death. Pneumococcal vaccination alone during the three influenza seasons was associated with a 27% reduction (95% CI 13-52) in hospitalizations for pneumonia and a 34% reduction (95% CI 6-54) in death. Both vaccinations together demonstrated additive benefits. When both vaccinations had been received, there was a 63% reduction (95% CI 29-80) in hospitalizations for pneumonia and an 81% reduction (95% CI 68-88) in death versus when neither had been received. These findings suggest pneumococcal vaccination is associated with substantial benefits for elderly persons with chronic lung disease.

Aged↗