Management of pregnancy and childbirth in carriers of haemophilia

3 pregnant women, aged 27, 33 and 31 years respectively, were carriers of haemophilia A. The first patient had a caesarean section without prior measurement or substitution of factor VIII. She gave birth to a healthy boy, but developed severe diffuse abdominal bleeding after a few hours. The second patient had a normal level of factor VIII, and lived 100 km away from the nearest haemophilia treatment centre. Ultrasound investigation revealed a female foetus. She gave birth in the local hospital. The third patient was pregnant with a male foetus, but refused further prenatal investigation. Contrary to medical advice she gave birth at home. For carriers of haemophilia, there are several options for prenatal diagnosis and managing labour and delivery. Early referral is advised and the need for adequate counselling is explained. It is important to have an experienced haemophilia treatment centre nearby, where haematologists, gynaecologists, geneticists and paediatricians cooperate in caring for pregnant carriers of haemophilia.     

Hepatitis E in England and Wales

In 2005, 329 cases of hepatitis E virus infection were confirmed in England and Wales; 33 were confirmed indigenous infections, and a further 67 were estimated to be indigenous infections. Hepatitis E should be considered in the investigation of patients with hepatitis even if they have no history of travel.     

Trends in teenage pregnancy in England and Wales: how can we explain them?

Teenage pregnancy is associated with adverse social and physical outcomes for both mother and child. We drew on various sources--birth and abortion statistics from the Office for National Statistics, data from the National Survey of Sexual Attitudes and Lifestyles, and routinely collected data from family planning clinics--to identify trends in England and Wales and their possible determinants. The rate of teenage sexual activity has increased steadily and consistently over the past four decades, whilst the rate of teenage fertility has shown greater variation. When the teenage fertility rate is calculated against the denominator of sexually active women, rather than the total sample of teenage women, the underlying trend in teenage fertility over the past four decades has been downwards, though not consistently so. Fluctuations in the teenage fertility rate seem to track intervention-related factors such as access to, and use of, contraceptive services and the general climate surrounding the sexual health of young people.     

Congenital anomaly surveillance in England and Wales

The National Congenital Anomaly System (NCAS) was set up in 1964, following the thalidomide epidemic, as a monitoring system designed to detect changes in the frequency of reporting of malformations. Its original aim was to detect anomalies reported within 7 days of birth. The NCAS is voluntary at all stages and covers all live- and stillbirths. It has two tiers; a 'passive system' receiving congenital anomaly notifications through a standard paper notification form, known as the SD56, and the congenital anomaly registers that send notifications electronically. Congenital anomalies are classified using the International Classification of Diseases codes and 10 monitoring groups. The Office for National Statistics performs a statistical analysis on a monthly, quarterly and annual basis, using the cumulative sum technique, which is the basis upon which surveillance alerts are raised within the system. The NCAS is now an open database where congenital anomalies can be notified whenever they are detected. The aim of this paper is to describe the current operation and uses of the NCAS based on guidelines for the evaluation of public health surveillance systems published by the Centers for Disease Control and Prevention.     

Health technology assessment in England and Wales

In this study, we describe the current state of the Health Technology Assessment (HTA) system in England and Wales. This system rests on a distinction between assessment and appraisal and has three main strands: researcher-led HTA, the research and development program, and the HTA-NICE (National Institute for Clinical Excellence) process. We outline the pressures for HTA and how it has evolved in the British National Health Service. We discuss how HTA priorities are chosen, how HTA information is collected and assessed, how HTA evidence is used, and we make some observations about its impact. In our discussion, we consider some limitations of the HTA system, its possible divergence from evidence-based health care, its centralization, and some of the key challenges for managing HTA-driven policy. But we remain hopeful that HTA can contribute to better and more explicit decision-making within England and Wales.     

Accelerating control of pertussis in England and Wales

Results of an accelerated pertussis vaccination schedule for infants introduced in 1990 in England and Wales were examined. Earlier scheduling and sustained high vaccine coverage resulted in fewer reported cases of pertussis among infants, reinforcing the World Health Organization drive for on-time completion of the infant vaccination schedule. As determined by using the screening method, the first dose of vaccine was 61.7% effective in infants <6 months of age, and effectiveness increased with subsequent doses. Three doses of a good whole-cell pertussis vaccine were 83.7% effective in children 10-16 years of age; a preschool booster vaccination further reduced pertussis incidence in children <10 years of age. As in other industrialized countries, surveillance data during 1998-2009 showed that pertussis in England and Wales mainly persists in young infants (i.e., <3 months of age), teenagers, and adults. Future vaccine program changes may be beneficial, but additional detail is required to inform such decisions.     

Sero-epidemiology of Bordetella pertussis in England and Wales

The incidence of pertussis infection can be estimated in the population by defining a single high titre of anti pertussis toxin (PT) immunoglobulin G (IgG) antibody predictive of recent infection. Sera samples collected in 1986, 1996 or annually between 1987 and 1998 were tested for anti-PT IgG antibody. In 1996, the age-adjusted prevalence of pertussis infection was 1.2% and was higher in children than in adults. Amongst samples collected annually, older age and female sex, but none of the temporal variables, were associated with a serologically defined pertussis infection. There is an important incidence of infection in the population, which is greater amongst children than adults, but there is only limited evidence of a correlation with epidemic cycles.     

The prevention of tetanus in England and Wales

Today, tetanus is a rare disease in England and Wales although in less developed and less affluent areas of the World it is still a major cause of morbidity and mortality, particularly in neonates and women following childbirth. An estimated 400,000 deaths worldwide occur annually from neonatal tetanus and in 1989 the World Health Organization adopted the goal of eliminating neonatal tetanus as a public health problem by 1995-2000. This goal has not yet been achieved worldwide; however in England and Wales tetanus in neonates and young women has been extremely rare for the last 50 years. We can attribute the success in eliminating tetanus in the UK to the adoption of highly effective preventative measures as we know that the causative organism is still ubiquitous in the environment. This article outlines how we have achieved the elimination of tetanus in the UK through the development and introduction of appropriately targeted immunisation, combined with an appreciation of the importance of adequate wound toilet measures. The discovery of tetanus toxoid and its applicability for vaccination has been of great benefit and the new challenges which we face relate to the introduction of new multi-component vaccines and how we might better protect the elderly. In other parts of the world, for the cost of a few pence, one dose of tetanus toxoid can still mean the difference between life and death.     

The problem of gonorrhoea in England and Wales

In England and Wales, as in a number of other countries, the incidence of gonorrhoea, having lessened appreciably in the immediate post-war period, has in recent years shown a substantial rise. A variety of epidemiological factors are believed to be responsible for this, including immigration from overseas and apparently increased promiscuity among teenagers. Difficulties in laboratory diagnosis of gonorrhoea, particularly in women, and limitations in smear, culture and complement-fixation techniques also contribute to the present failure to control this disease; and the authors review the efforts being made in the United Kingdom to bring about improvements in technique.     

The infant health effects of starting universal child benefits in pregnancy: Evidence from England and Wales

Child benefits are typically paid from birth. This paper asks whether starting universal child benefits in pregnancy leads to improvements in infant health. Leveraging administrative birth registry and hospital microdata from England and Wales, I study the effects of the Health in Pregnancy Grant, a universal conditional cash transfer equivalent to three months of child benefit (190 GBP) as a lump sum to pregnant mothers from 2009 to 2011. I exploit quasi-experimental variation in eligibility with a regression discontinuity design in the date of birth of the baby. I find that the policy increased birth weight by 8–12 grams on average, reduced low birth weight ($<$2500 g) by 3-6 percent and decreased prematurity by 9–11 percent. Younger mothers, particularly those living in deprived areas, benefit the most. I present evidence that the mechanisms are unlikely to be antenatal care, nutrition or smoking, with reductions in stress remaining a possible explanation.     

Respiratory illness and mortality in England and Wales

The possible relationship between the incidence of respiratory diseases as reported to general practitioners and numbers of registered deaths in England and Wales has been examined. Morbidity data from sentinel practices for the period 1986–1990 (population covered increased from 220,000 to 470,000) were used to calculate weekly rates of aggregated respiratory disease for persons of all ages and for elderly persons (aged 65 years and over). The elderly respiratory disease rates and numbers of deaths were aggregated into 4-week periods; secular and seasonal trends were removed from each series and the two sets of residuals were examined graphically and cross correlation coefficients calculated. There was a very strong positive association between the respiratory disease rate and number of deaths in the same 4-weeck period and there was also a significant but less pronounced association between respiratory disease in one 4-week period and deaths in the next. After prior separation of weeks according to temperature into four bands, weekly rates for respiratory disease were also strongly associated with the number of weekly deaths for each temperature band.The synchronisation of peaks and troughs in the two series throughout the year supports the hypothesis that a cause and effect relationship exists between respiratory disease in the elderly and number of deaths. Other climatic and meteorological variables besides temperature may play a part in determining the spread of a respiratory disease. There is a need for further research to identify the micro-organisms responsible for acute respiratory infections in the elderly.Corresponding author.