The cost of childhood immunisation in general practice

AIM: To estimate the cost, to general practices in the Wellington Immunisation Network, of the audit process of recalling and immunising children according to the New Zealand Immunisation Schedule. METHOD: Practices recorded all clinical and clerical time spent on immunisation as well as the materials used throughout one audit cycle. Staff time and materials were costed directly. Practice overheads were apportioned to immunisation according to the actual time spent on each of the tasks relating to immunisation relative to the total staff hours at the practice. RESULTS: The average cost of immunising a child who attended a non-capitated practice after a single reminder or recall was $15.15. The cost to the practice after taking the practice nurse subsidy and GMS into account was $8.51. The cost of immunising children who were not immunised at the first recall increased in proportion to the number of recall reminders. The annual average cost of immunisation to practices in the study exceeded the revenue obtained from the Immunisation Benefit. CONCLUSION: Overall, given the frequency of recall reminders, there was a net cost to practices for childhood immunisation after deducting the current immunisation benefit rate of $9.78 excluding GST. Thus, the practices in this study made a "loss" in carrying out childhood immunisations.     

Missed opportunities for immunisation at hospitals in the western Cape--a reappraisal

Immunisation practices were examined at 6 hospitals in the western Cape during the latter half of 1992 to determine whether these practices had improved subsequent to the February 1991 resolution of the Health Matters Committee (HMC) on immunisation in hospitals, and since a similar study was undertaken in 1990. Exit interviews were conducted with the escorts of all children aged 3-59 months who attended the study hospitals on the days designated for the study. In the second study, 88 of the 311 children studied (28.3%) were in need of immunisation on arrival, but only 12 of the 88 (13.6%) were immunised during the hospital visit. There was no evidence of an increase in requests to see children's Road-to-Health cards (37.1% compared with 35.2% previously). The incidence of missed opportunities for measles immunisation in children aged 6-59 months remained unacceptably high (51.4% compared with 63.7% previously, when a strict definition was used; and 15.7% compared with 18.1% previously, when a lenient definition was used). Health authorities at all levels need to take urgent action to address the problem of missed opportunities for immunisation at hospitals.     

Risk factors for osteoporosis in men

Three months after the launch of the MMR programme in the United Kingdom and the Republic of Ireland, a postal questionnaire was sent to all GP scheme trainees in both Northern Ireland and the Republic of Ireland. The response rate was 81%. All trainees were enthusiastic about promoting MMR immunisation; with 27% favouring compulsory immunisation. 9% had never seen a patient with measles. This did not alter their attitude towards the beneficial effects of MMR immunisation. Of pre-practice year trainees 26% felt their level of knowledge of immunisation was inadequate, 59% claimed to have received no education on immunisation during their vocational training to date. This may reflects deficiencies in their medical curriculum to-date. 95% of third-year trainees indicated that their practice experience had been the source of at least some of their education on immunisation. Only 46% of trainees in the Republic of Ireland were aware of their Department of Health's aims in launching the MMR immunisation campaign.     

A peptide derived from a B cell epitope of Plasmodium falciparum rhoptry associated protein 2 specifically raises antibodies to rhoptry associated protein 1

Mice immunised with a recombinant form of malarial antigen rhoptry-associated protein 2 (RAP2) produce antisera which recognise the native protein by indirect immunofluorescence and immunoblotting. Purified IgG components of the antisera partially inhibit erythrocyte invasion in vitro. This response was obtained only if the recombinant immunogen was presented to the mice in the presence of reducing and denaturing agents. An 8-mer epitope in RAP2 was recognised by antibodies in three of the antisera: E25TEFSKLY32. Immunisation with this octapeptide raised antibodies which strongly recognised reduced RAP2 in seven out of eight mice. However, this antisera either failed to recognise (five out of eight mice), or only weakly (three out of eight mice) recognised nonreduced RAP2. Examination of disulphide bonds in native RAP2 showed that the 4 cysteines of RAP2 form two disulphide bridges: Cys24-Cys88, and Cys277-Cys376. One of these (Cys24-Cys88) is adjacent to the octapeptide in the native protein. Surprisingly, seven out of eight mice immunised with the octapeptide also raised antibodies against native rhoptry-associated protein 1 (RAP1). The raising of antibodies which recognise RAP1 was induced specifically by the RAP2 octapeptide rather than the carrier protein used for immunisation. The epitope in RAP1 recognised by the antibodies was identified and shown not to be the result of any shared contiguous homologous sequence between the two proteins, but to shared homologous amino acids in critical positions within the epitope. Purified IgG components from the antisera of mice immunised with the octapeptide gave partial inhibition of erythrocyte invasion in vitro.     

An assessment of mucosal immunisation in protection against Streptococcus equi ('Strangles') infections in horses

The ability of mucosally administered antigen to provide protection against Streptococcus equi ('Strangles') infections in horses was examined. First, an enzyme linked immunosorbent assay (ELISA) was developed to detect the immune status of horses to S. equi. This assay was used to select Strangles-naive horses for the study and also to monitor their response to immunisation. Potential vaccine candidates were: (a) orally administered paraformaldehyde killed S. equi; (b) intraperitoneally (IP) administered paraformaldehyde killed S. equi in a non-inflammatory adjuvant; (c) orally administered live avirulent S. equi; (d) orally administered microencapsulated streptococcal M protein. The latter three preparations were first assessed in a rat model, using rate of lung bacterial clearance following intratracheal inoculation of live virulent bacteria as an indication of efficacy. Candidates (a) and (b) were then assessed in an equine model. IP immunisation of horses was shown to effectively induce production of specific antibody in mucosal and systemic sites. Four weeks after initial immunisation, horses were challenged intranasally with live virulent S. equi. Both groups of immunised horses demonstrated partial protection following vaccination. Of the IP immunised horses, only two out of four developed clinical signs of Strangles following live challenge. The orally immunised horses all developed submandibular abscesses containing S. equi. However, none of the immunised horses became as ill as the control horses in terms of fever, anorexia, loss of condition and general malaise.     

A general practice case-control study of delayed immunisation in under two year old children

AIM: To identify social factors which characterise the household of children with delayed immunisation. METHOD: The study was done in 15 general practices in the Wellington city region with a case-control design where preschool children who were not up to date (cases) for their immunisations were compared with children who were up to date (controls). RESULTS: There were 215 cases where immunisation was delayed among 3723 children at the time of audit in June 1996. Ethnic status was available from general practice records in 33% of cases and 40% of controls. There were more Maori and Pacific Island children among the cases compared to controls (39% versus 21%, odds ratio (OR) = 2.39, 95% confidence interval (CI) 1.12-5.10, p = 0.022. CASE SAMPLE HOUSEHOLDS COMPARED WITH CONTROLS HAD: (1) more children in the households (mean 2.27 versus 1.98, p = 0.01); (2) more households with a female as the only adult (35% versus 24%, OR = 1.61, 95% CI 1.04-2.51, p = 0.034). There was no difference in the proportions of male only adults (0.02% versus 0.01%, p = 0.70); (3) more mothers who were under 30 years of age (38% versus 25%, OR = 1.61, 95% CI 1.04-2.51, p = 0.034); and more fathers under 30 years of age (20% versus 10%, OR = 2.16, 95% CI 0.97-4.84, p = 0.06); (4) fewer mothers who were up to date with their recorded cervical smear status (66% versus 83%, OR = 0.69, 95% CI 0.23-0.63, p < 0.001); (5) more parents with an active community services card (38% versus 25%, OR 1.82, 95% CI 1.17-2.82, p = 0.007); (6) fewer siblings being immunised (70% versus 94%, OR = 0.14, 95% CI 0.07-0.28, p < 0.001). CONCLUSION: There is a distinct group of New Zealand children for whom immunisation is delayed. Such children live in households which can be characterised by various social factors easily obtainable from general practice records. The identified households could be targeted for efficient preventive care by general practices.     

A method and device for measuring force transfers between the deep flexors in the musician''s hand

The efficacy of passive immunisation against tick-transmitted Lyme disease spirochaetal infection was determined in relation to the duration of previous feeding of infected vector ticks. Thus, mice challenged with spirochaete-infected unfed or partially fed nymphal ticks were passively immunised with monoclonal and polyclonal antibodies against the Lyme disease spirochaete (Borrelia burgdorferi) at various intervals after tick attachment. Spirochaetal infection in challenged mice and engorged ticks was verified by xenodiagnosis and indirect immunofluorescent antibody assay, respectively. Although tick-transmitted spirochaetal infection could be aborted by anti-OspA antibodies and hyperimmune antiserum, nearly all immunised mice challenged with infected ticks that had previous 36-h attachment became infected. More than 72% of the nymphal ticks used in this challenge retained their B. burgdorferi infection after engorgement on mice immunised with anti-spirochaete antibodies, and their subsequent infectivity to mice remained effective. It is concluded that a higher efficiency of transmission by partially fed infected nymphs and a lower efficacy of passive immunisation against infection result from an effect of previous feeding of infected ticks that activates antigenic change and enables the spirochaetes to circumvent OspA-based humoral immunity.     

MMR immunisation status among Dublin paediatric A&E attenders

The objectives of this study were to establish the need for opportunistic MMR immunisation among paediatric A&E attenders to the three Dublin paediatric hospitals and to examine the relationship between immunisation status and socioeconomic factors. Design was that of a two month cross sectional study. Survey data was then compared with information on the Eastern Health Board (EHB) records system. Small area and multiple regression analysis of socioeconomic factors derived from participants addresses was also performed. Subjects were 337 children who attended these departments and were aged between fifteen months and five years. For 66% of cases there was a history of MMR immunisation, 30% gave a negative history and 4% did not know. Of those giving a negative history, one third said immunisation had been omitted for no specific reason. EHB records suggested that 39% were immunised, 41% were not and 20% were not on file. Eligibility for the GMS was not associated with failure to immunise. Small area and multiple regression analysis showed little association between immunisation uptake and socioeconomic factors. An opportunistic MMR immunisation policy in A&E Departments would make an important contribution to increasing overall uptake figures. Parental knowledge of the implications of measles and the effectiveness of immunisation needs to be improved. Computerised child health systems must have high data quality standards and access to these systems should be made available in A&E departments.     

Creutzfeldt-Jakob disease in an Iranian: the first clinico-pathologically described case

The rights of children are not enshrined in statute. However, over recent years, a number of organizations such as Action for Sick Children and The Children's Trust, Tadworth, have produced guidelines related to the rights of children and their families in hospital. The voluntary sector has led the way in influencing policy makers. This is exemplified in the publication of the Department of Health's draft Children's Charter. This article explores the strengths, weaknesses, opportunities and threats of this recent innovation.     

Future vaccines and a global perspective

Advances in medical biotechnology mean that vaccines to prevent more than 75 infectious diseases are being or have been developed. Vaccination is unfortunately not reliant purely on biotechnology but also on politics and resources. Countries with the greatest demand for vaccines have the least ability to pay for or produce them. Health-care Infrastructure and diagnostic facilities also hamper immunisation projects in developing countries. Charitable organisations are relied on heavily to support such projects but the challenge to ensure all infants are immunised against the most common infections of childhood is still enormous. Difficulties that present themselves now should not prevent us looking into future possibilities such as immunisation during pregnancy and targeting of children for immunisation against sexually transmitted diseases. Other avenues for research are in administration of vaccines. A move to mucosal immunisation rather than use of the syringe and needle would be positive both economically and from the point of view of risk of needle contamination. Plant science may also provide a new vehicle for vaccines by engineering plants such as the banana tree to be naturally bioencapsulated vaccines. Prospects for control and eradication of infectious disease in the next century are certainly good.     

Resident attrition from family practice residencies: United States versus international medical graduates

BACKGROUND: Attrition of residents from family practice residency programs may cause significant problems for faculty, residents, and patients. The objective of this study was to determine international medical graduates' attrition rate from family practice residencies, compared with US medical school graduates. METHODS: Surveys were sent to all family practice residency program directors asking them to calculate their attrition rate for a 10-year period. RESULTS: The overall response rate was 56.6%, but interpretable responses were received from 45% of all civilian, continental US family practice residencies. Responding programs did not differ from all family practice programs with respect to program overall. Of those residents leaving, 63% did so to enter other specialties. The attrition rate was 18.5% for international graduates, compared with 7.8% for US graduates (P < .0001). International graduates enrolled outside of the National Resident Matching Program (NRMP) were most likely to leave programs before completion. CONCLUSIONS: Attrition rates from family practice residency programs are higher for international medical graduates than for US graduates. International graduates enrolled outside of the NRMP were most likely to leave a program.     

Characterization of hemolytic and cytotoxic Gallysins: a relationship with arylphorins

The efficacy of injecting antibodies raised against turkey prolactin to prevent the expression of incubation behaviour has been investigated in turkey hens. Medium white turkey hens (n = 15 x 2) were injected three times weekly for 4 consecutive weeks starting on week 5 of egg production. The hens were injected im with a volume of 1 mL per injection for the 1st week and 0.5 mL thereafter, of normal rabbit serum or serum containing antibodies raised against turkey prolactin (Guémené et al, 1994a). None of the 15 passively immunised hens expressed incubation behaviour, whereas, more than half (53%) of the control hens did express it. Plasma prolactin concentrations observed in the two groups presented comparable profiles until week 9 and from week 19 of egg production onward. Differences were, therefore, observed from week 10 until week 17 with the non immunised hens showing higher plasma prolactin concentrations than the immunised ones. This difference was related to the presence of incubating hens in the control group. A higher percentage of non immunised hens disrupted egg production during the course of the study and consequently immunised hens laid more eggs than the control ones. No change in plasma LH and oestradiol concentrations can be related to the immunisation procedure. We conclude that prevention of incubation behaviour can be achieved using passive immunisation against prolactin, prevention which resulted in more egg production under our experimental protocol.     

Immunisation timeliness for a birth cohort in Christchurch. Christchurch Immunisation Coordination Study Group

AIMS: To determine whether New Zealand's goals for immunisation coverage are being met in Christchurch and to assess whether scheduled vaccinations are being delivered in a timely fashion. METHODS: A cohort of all infants born in Christchurch during June, July and August 1995 were matched with immunisation benefit claim information for the 6-week, 3-month, 5-month and 15-month immunisation events. Those with incomplete reports were traced for amendment or verification of their immunisation status. RESULTS: The cohort contained 1002 infants. The full complement of scheduled immunisations was delivered to an estimated 95.8% (95% CI: 94.5, 97.2) of infants within the cohort by two years of age. Infants who presented late for their 6-week immunisation visits were significantly more likely to be late for their next visits (chi 2 log rank = 8.2, df = 1, p < 0.01), as were those late for their 3-month visits (chi 2 = 20.9, df = 1, p < 0.01), and their 5-month visits (chi 2 = 52.5, df = 1, p < 0.01). Infants were significantly less likely to receive their full complement of immunisations by two years of age if they presented late for their 6-week (Fisher's exact test, p = 0.01), 3-month (p < 0.01) or 5-month (p = 0.01) immunisation visits. CONCLUSIONS: The Immunisation 2000 target of 95% full immunisation coverage by two years of age was met by this cohort. However, infants who were late for any immunisation visits were more likely to be late for subsequent visits and incompletely vaccinated by two years of age, compared to those infants who presented on time.     

Immunogenicity of purified lipopolysaccharide or protein-oligosaccharide conjugates of Pasteurella multocida type 6:B in mice

Purified lipopolysaccharide (LPS) of Pasteurella multocida type 6:B, while toxic at higher doses, was protective at lower dose levels against experimentally-induced pasteurellosis in mice. However, the observed protection was abrogated if such LPS was digested with proteinase K prior to use in immunisation. The O-antigen polysaccharide side-chain (OS) of LPS did not appear to contribute to the observed protection as judged by the fact that immunisation of mice with purified OS or OS-protein conjugates, all of which were nontoxic, failed to confer protection against challenge with homologous virulent organisms. This was despite generation of significant levels of OS-specific antibodies, predominantly either of the IgM or IgG isotypes, in immunised mice.     

Crisis in training pediatric psychologists.

Examines the shortage in the US of personnel who are trained in child mental health care that results in underservice to children, youth, and families. Doctoral programs offering specialty training are in short supply, as are pediatric psychology training programs. In addition, many clinical psychology programs are ill-equipped to offer curriculae for the development of skills and knowledge bases required by child psychologists. It is concluded that a training conference is needed to communicate the issues involved in this mental health provider crisis if children are to have access to psychological services. (19 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A case of paradoxical brain embolism in a 17-year-old boy

OBJECTIVE: To estimate the proportion of 1-4-year-old New South Wales children immune to measles and compare the documented immunization history with serologically defined immune status. DESIGN: Population based seroprevalence survey piggybacked onto the National Survey of Lead in Children. Immune status was determined by two different enzyme immunoassays on plasma samples from subjects. SETTING: New South Wales, February-March 1995. OUTCOME MEASURES: Documented measles immunization collected by interview survey and serologically defined immunity. RESULTS: Of 689 survey subjects, 430 (62.4%) provided a blood sample. Adequate plasma remained for both assays for 347 children, of whom 279 (80.4%) were immune by both assays. Parents of 330 stated that their children were immunised, of whom 211 (63.9%) were able to produce corroborating records. Of these 211 subjects, 178 (84.4%) were immune compared to 87 (76.3%) of 114 without records (P = 0.07). CONCLUSIONS: We estimate the prevalence of true measles immunity in 1-4-year-old NSW children to be only 80%, a level inadequate to prevent outbreaks of measles in urban populations. Both long term and immediate strategies are required to increase the prevalence of immunity among NSW children; these may include lowering the age of the routine second measles dose and mounting a mass measles immunisation campaign to include preschool aged children.     

Children and youth services: A vanishing species.

Explores the role of psychology in the development of public policy and programs for children and youth services in the US. An examination of the proposed funding cuts and implications of the Reagan policies on these programs for fiscal year 1983 is made, using Public Law 94-142, Head Start, child mental health, clinical training, prevention, adoption assistance, runaway children, and the White House Conference on Children and Youth as examples. (13 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Lateral-trigonal intraventricular tumors. A new operative approach

Three groups of calves aged 6 months were completely protected against oral challenge with Taenia saginata eggs following immunisation by three different methods. These were hyperimmunisation with six serial inoculations of a homogenate of T. saginata strobila in Freund's complete adjuvant, a single intramuscular inoculation with hatched T. saginata eggs or a single oral dose of unhatched T. saginata eggs. The calves immunised with tapeworm homogenate developed the strongest haemagglutinating and precipitating antibody response to the complex of antigens in an extract of tapeworm strobila, cysticercus tissue or cysticercus fluid. The orally infected calves developed a moderate antibody response to these antigens but the calves inoculated with hatched eggs showed only a very weak antibody response. The calves infected orally with eggs developed a peripheral eosinophilia but the other two methods of immunisation did not evoke this response. After challenge infection all groups showed an increase in peripheral eosinophil counts except the group immunised with tapeworm homogenate.     

Impact of anti-vaccine movements on pertussis control: the untold story

To assess the impact of anti-vaccine movements that targeted pertussis whole-cell vaccines, we compared pertussis incidence in countries where high coverage with diphtheria-tetanus-pertussis vaccines (DTP) was maintained (Hungary, the former East Germany, Poland, and the USA) with countries where immunisation was disrupted by anti-vaccine movements (Sweden, Japan, UK, The Russian Federation, Ireland, Italy, the former West Germany, and Australia). Pertussis incidence was 10 to 100 times lower in countries where high vaccine coverage was maintained than in countries where immunisation programs were compromised by anti-vaccine movements. Comparisons of neighbouring countries with high and low vaccine coverage further underscore the efficacy of these vaccines. Given the safety and cost-effectiveness of whole-cell pertussis vaccines, our study shows that, far from being obsolete, these vaccines continue to have an important role in global immunisation.