Measles immunisation rates and the good practice allowance.

The recent discussion document on primary health care proposes that a good practice allowance is paid to general practitioners based in part on the uptake of immunisation by patients. The variation between and the validity of practice immunisation rates for measles as determined by one district health authority''s child health computer are assessed. In areas of low population mobility district health authority rates may be sufficiently accurate to base a good practice allowance on but should not be used until the social environment of each practice can also be characterised. In areas of high mobility intermittent surveys may be a preferable method of auditing performance.     

Measles matters,but do parents know?

Two hundred and one parents attending three child health clinics were questioned about both measles and immunisation against measles. Most parents were unaware of the symptoms and possible complications of measles and did not believe immunisation to be effective in preventing measles. They did not remember having talked to health professionals about immunisation.     

Study of children not immunised for measles.

The results of a survey of the 165 children born in 1980 in a population served by a health centre showed that 42 were not immunised against measles. The reasons for non-immunisation included 18 refusals (usually on the grounds of incorrect contraindications) and 19 defaulters (where the children were not brought for immunisation). Twenty of the children had contracted measles by March 1984. Among the 19 defaulters 12 had been registered with the health centre since age six months or under. Their average number of consultations a year was four. None of the 42 children had Department of Health and Social Security recommended contraindications to measles immunisation.     

Measles immunisation in children with allergy to egg.

OBJECTIVE--To examine the occurrence of adverse reactions to measles vaccine given as a single dose to children with egg allergy, and to determine if the administration of single dose to children with a positive result in an intradermal skin prick test with the vaccine is associated with adverse reactions. DESIGN--Review of results of immunisation and prospective study of 96 consecutively presenting children given intradermal skin testing with the vaccine. SETTING--Children''s allergy centre. SUBJECTS--410 children sensitive to egg referred to the allergy unit for advice about measles immunisation. MAIN OUTCOME MEASURES--Nature and severity of reactions associated with the administration of measles vaccine. RESULTS--All children had a positive result in a skin prick test with egg white, and five had a positive result in a skin prick test with vaccine. Of 96 consecutive children, 46 had a positive result in an intradermal test with vaccine. After immunisation with a full dose (0.5 ml) of vaccine adverse reactions were associated with a mild reaction in four children, none of whom required treatment. Only one of the 46 children with a positive result in an intradermal vaccine skin test had a reaction associated with vaccine administration. None of the children with a positive result in a skin prick test with measles vaccine reacted to the vaccine. The rate of minor reactions to the vaccine not requiring treatment was 0.98% (95% confidence interval 0.27% to 2.48%) and serious reactions requiring treatment was 0% (0% to 0.9%). CONCLUSION--Children with IgE mediated allergic reactions to egg protein should be investigated and managed by practitioners with special knowledge in this subject. Measles immunisation should be performed in a setting where any adverse reactions can be dealt with appropriately. Skin tests and measles vaccine and desensitisation are not necessary.     

Factors affecting uptake of measles,mumps, and rubella immunisation.

OBJECTIVE--To study factors affecting uptake of measles, mumps, and rubella immunisation. DESIGN--Cohort study using data from computerised child health systems. SETTING--10 health districts in North East Thames and North West Thames regions. SUBJECTS--7841 children born in January to March 1990 and resident in the districts up till the end of October 1991. MAIN OUTCOME MEASURES--Overall uptake of measles, mumps, and rubella immunisation, variation of uptake among groups of children, and odds ratio of being vaccinated against measles, mumps, and rubella. RESULTS--The overall uptake rate of measles, mumps, and rubella immunisation for the study cohort in the 10 districts was 82%. Wide variation was identified among children with different demographic characteristics. Lower uptake was associated with absent or incomplete primary immunisation, including omission of pertussis vaccine. Other factors affecting uptake included the type of resident district, birth order, where registered for immunisation (general practitioner or clinic), and one parent family status. CONCLUSIONS--Many districts have difficulties in meeting the 90% target for measles, mumps, and rubella immunisation, mainly because of the characteristics of their local population. To increase overall coverage, the health service should target families with adverse factors, especially those whose children have missed previous immunisations.     

Measles immunisation: results of a local programme to increase vaccine uptake.

Investigations showed that the measles immunisation programme in our health board was a failure. Surveys of health care staff and parents to determine the cause of the problem identified several aspects of concern: the immunisation of children was often left to parental initiative, with only 29% of general practitioners playing an active part in recalling children by the 15th month of age; general practitioners, clinical medical officers, paediatricians, and health visitors all required education on several aspects of measles immunisation; parents also required more information about the importance of preventing this disease. A coordinated effort to remedy these problems was introduced which achieved an increase of 13% in vaccine uptake during 1984. These findings may have implications beyond our own area.     

Reduced childhood mortality after standard measles vaccination at 4-8 months compared with 9-11 months of age.

OBJECTIVE--To evaluate the impact on mortality of standard Schwarz measles immunisation before 9 months of age. DESIGN--Children vaccinated in 1980-3 at 4-5, 6-8, and 9-11 months of age were followed to migration, death, or the age of 5 years. SETTING--One urban district and nine villages in two rural areas of Guinea-Bissau. SUBJECT--307 children vaccinated at 4-8 months and 256 at 9-11 months. MAIN OUTCOME MEASURES--Mortality from 9 months to 5 years of age for children immunised at 4-5, 6-8, and 9-11 months. RESULTS--Mortality was significantly lower in children vaccinated at 6-8 months than at 9-11 months (mortality ratio = 0.63, (95% confidence interval 0.41 to 0.97), p = 0.047). As vaccination was provided in semiannual or annual campaigns it is unlikely that age at vaccination reflected a selection bias. The trend was the same in all three study areas. Improved survival after early immunisation was not related to better protection against measles infection. With a Cox multivariate regression model to adjust for age, sex, season at risk, season at birth, measles infection, and region, children vaccinated at 4-8 months had a mortality ratio of 0.61 (0.40 to 0.92, p = 0.020) compared with children vaccinated at 9-11 months. Reimmunised children tended to have lower mortality than children who received only one vaccine (0.59 (0.28 to 1.27, p = 0.176)). CONCLUSION--Standard measles vaccination before 9 months is not associated with higher childhood mortality than is the currently recommended strategy of immunising from 9 months, and it may reduce mortality. This has implications for measles immunisation strategy in developing countries.     

Preventing iron deficiency in preschool children by implementing an educational and screening programme in an inner city practice.

OBJECTIVE--To assess the feasibility and acceptability of screening young children for iron deficiency in a deprived inner city practice and to assess the effects of a programme of dietary education. DESIGN--Prospective study of children in general practice, comparison with historical controls. SETTING--A deprived inner city practice. PATIENTS--127 Children aged 13-24 months. Findings were compared with those in 110 children of the same age studied previously. INTERVENTIONS--All mothers received dietary education antenatally and in the first year after giving birth. Screening for iron deficiency (defined as mean cell volume less than 75 fl and haemoglobin concentration less than 105 g/l) and haemoglobinopathy (when appropriate) was offered for all children attending for immunisation against measles, mumps, and rubella over 12 months; capillary blood samples were taken after immunisation. MAIN OUTCOME MEASURES--Uptake of the screening programme expressed as the percentage of all children eligible for immunisation who were screened, and the effectiveness of the dietary education as shown by the prevalence of iron deficiency in the two groups. RESULTS--Altogether, 122 of the 127 (96%) children who attended for immunisation had their haemoglobin concentration and mean cell volume measured; 90% of all children aged 13-24 months in the practice were screened. Dietary education, clinical procedures, and counselling were incorporated successfully into the clinic''s work. Ten children (8%) were iron deficient, all of whom responded to iron supplements, and eight had a haemoglobinopathy trait. In the previous study 110 children (70%) had been screened and 28 children (25%) had been iron deficient. The two groups were similar in terms of sex, social class, and ethnic group. CONCLUSIONS--Screening young children for iron deficiency, sickle cell disease, and thalassaemia when they attended for immunisation was acceptable and successful in a socially deprived inner city practice. Dietary education may have accounted for some of the reduction in the prevalence of iron deficiency that occurred over the two years.     

Domiciliary immunisation for preschool child defaulters.

A selective domiciliary immunisation service has been introduced for preschool children living in the Central Manchester Health District. The service is provided for the children of parents who have given written consent for immunisation but have subsequently failed to bring their children to the clinic or their general practitioner''s surgery to start or complete the basic course of immunisation against diphtheria, tetanus, whooping cough, poliomyelitis, and measles. This failure has occurred despite at least two written invitations for each injection and several reminders from the health visitor. Many additional children have been protected by this scheme.     

Decline in measles mortality: nutrition,age at infection,or exposure?

The mortality from measles was studied in an urban area of Guinea-Bissau one year before and five years after the introduction of a vaccination programme. The years after the introduction of immunisation saw a decline in mortality among unvaccinated children with measles. This decline occurred despite a lower age at infection and an increasing prevalence of malnourished children. State of nutrition (weight for age) did not affect the outcome of measles infection. The incidence of isolated cases, however, increased in the period after the introduction of measles vaccination. As mortality was lower among these cases, diminished clustering explained some of the reduction in mortality. Comparison between the urban district and a rural area inhabited by the same ethnic group showed a lower age at infection, less clustering of cases, and lower case fatality ratios in the urban area.Endemic transmission of measles in urban districts leads to less clustering of cases, which may help explain the usually lower case fatality ratios in these areas. As measles vaccination increases herd immunity and diminishes clustering of cases, it may reduce mortality even among unvaccinated children who contract the disease.     

Do interventions that improve immunisation uptake also reduce social inequalities in uptake?

OBJECTIVE--To investigate whether an intervention designed to improve overall immunisation uptake affected social inequalities in uptake. DESIGN--Cross-sectional small area analyses measuring immunisation uptake in cohorts of children before and after intervention. Small areas classified into five groups, from most deprived to most affluent, with Townsend deprivation score of census enumeration districts. SETTING--County of Northumberland. SUBJECTS--All children born in country in four birth cohorts (1981-2, 1985-6, 1987-8, and 1990-1) and still resident at time of analysis. MAIN OUTCOME MEASURES--Overall uptake in each cohort of pertussis, diphtheria, and measles immunisation, difference in uptake between most deprived and most affluent areas, and odds ratio of uptake between deprived and affluent areas. RESULTS--Coverage for pertussis immunisation rose from 53.4% in first cohort to 91.1% in final cohort. Coverage in the most deprived areas was lower than in the most affluent areas by 4.7%, 8.7%, 10.2%, and 7.0% respectively in successive cohorts, corresponding to an increase in odds ratio of uptake between deprived and affluent areas from 1.2 to 1.6 to 1.9 to 2.3. Coverage for diphtheria immunisation rose from 70.0% to 93.8%; differences between deprived and affluent areas changed from 8.6% to 8.3% to 9.0% to 5.5%, corresponding to odds ratios of 1.5, 2.0, 2.5, and 2.6. Coverage for measles immunisation rose from 52.5% to 91.4%; differences between deprived and affluent areas changed from 9.1% to 5.7% to 8.2% to 3.6%, corresponding to odds ratios of 1.4, 1.4, 1.7, and 1.5. CONCLUSION--Despite substantial increase in immunisation uptake, inequalities between deprived and affluent areas persisted or became wider. Any reduction in inequality occurred only after uptake in affluent areas approached 95%. Interventions that improve overall uptake of preventive measures are unlikely to reduce social inequalities in uptake.     

Mortality and morbidity caused by measles in children with malignant disease attending four major treatment centres: a retrospective review.

Measles is a major cause of mortality and morbidity in children receiving treatment for leukaemia. A review was made of all the documented cases of measles in children in first remission from acute lymphoblastic leukaemia at four major treatment centres in 1974-84. Over the 11 years reviewed 1043 children with acute lymphoblastic leukaemia were referred to these centres. Fifty one (4.9%) died while in first remission and 15 (29.4%) of these deaths were due to measles or its complications: 12 cases of pneumonia, 10 of them fatal; and six cases of encephalitis, five of them fatal and the sixth child left severely handicapped. These children would have had at least a 50% chance of long term survival. The severity of measles in the immunocompromised patient reinforces the need to improve the poor uptake of measles immunisation in Britain.     

BCG immunisation in England and Wales: a survey of policy and practice in schoolchildren and neonates.

OBJECTIVE--To determine the policy and practice of district health authorities in England and Wales for BCG immunisation in schoolchildren and neonates. DESIGN--Self completion postal questionnaire survey. PARTICIPANTS--District immunisation coordinators. SETTING--199 district health authorities in England and Wales. RESULTS--Questionnaires were received from 186 districts, a response rate of 94%. Considerable uniformity was observed in many aspects of BCG immunisation policy and practice but some important variations were found. 15 districts no longer carry out a routine schools programme. 148 districts offer BCG to selected groups of neonates and five to all neonates, but 31 districts do not offer BCG to this age group. The recommended action in response to different levels of tuberculin sensitivity in schoolchildren and neonates varied among districts. CONCLUSIONS--Despite the recommendations of the Joint Committee on Vaccination and Immunisation some districts do not offer BCG immunisation to neonates at high risk of tuberculosis and there are important variations in other aspects of BCG policy.     

Immunogenicity of a Recombinant Measles-HIV-1 Clade B Candidate Vaccine

Live attenuated measles virus is one of the most efficient and safest vaccines available, making it an attractive candidate vector for a HIV/AIDS vaccine aimed at eliciting cell-mediated immune responses (CMI). Here we have characterized the potency of CMI responses generated in mice and non-human primates after intramuscular immunisation with a candidate recombinant measles vaccine carrying an HIV-1 insert encoding Clade B Gag, RT and Nef (MV1-F4). Eight Mauritian derived, MHC-typed cynomolgus macaques were immunised with 10⁵ TCID₅₀ of MV1-F4, four of which were boosted 28 days later with the same vaccine. F4 and measles virus (MV)-specific cytokine producing T cell responses were detected in 6 and 7 out of 8 vaccinees, respectively. Vaccinees with either M6 or recombinant MHC haplotypes demonstrated the strongest cytokine responses to F4 peptides. Polyfunctional analysis revealed a pattern of TNFα and IL-2 responses by CD4+ T cells and TNFα and IFNγ responses by CD8+ T cells to F4 peptides. HIV-specific CD4+ and CD8+ T cells expressing cytokines waned in peripheral blood lymphocytes by day 84, but CD8+ T cell responses to F4 peptides could still be detected in lymphoid tissues more than 3 months after vaccination. Anti-F4 and anti-MV antibody responses were detected in 6 and 8 out of 8 vaccinees, respectively. Titres of anti-F4 and MV antibodies were boosted in vaccinees that received a second immunisation. MV1-F4 carrying HIV-1 Clade B inserts induces robust boostable immunity in non-human primates. These results support further exploration of the MV1-F4 vector modality in vaccination strategies that may limit HIV-1 infectivity.     

Vaccine coverage: recent trends and future prospects.

OBJECTIVE--To assess the feasibility of achieving the target of 95% coverage for the childhood immunisation schedule by 1995 and to determine the influence of sociodemographic factors and information systems on recent trends. DESIGN--Analyses of trends in quarterly vaccination data for diphtheria, pertussis, and measles in health districts between February 1988 and February 1991. SETTING--District health authorities in England and Wales, and health and social services boards in Northern Ireland. SUBJECTS--Cohorts of children whose youngest member had reached the target age of 18 months for receiving the third doses of diphtheria and pertussis vaccines and 2 years for receiving measles vaccine. RESULTS--Predicted coverage levels for mid-1995 were in excess of 95% for diphtheria, pertussis, and measles vaccines. In the 118 districts that continuously reported between February 1988 and February 1991 the increase in coverage was 6% for diphtheria and 13% for pertussis and measles vaccines. 1991 coverage depended primarily on 1988 coverage. The additional effects of deprivation, change in computer system, and child population size achieved at most only marginal statistical significance. CONCLUSIONS--The government''s target of 95% coverage by 1995 is realistic, although projections should be viewed with caution. Several national vaccination initiatives are likely to have contributed to the recent steady increase in coverage. Updating and validation exercises are likely to improve recorded coverage.     

Subacute sclerosing panencephalitis in papua new guinean children: the cost of continuing inadequate measles vaccine coverage

Introduction

Subacute sclerosing panencephalitis (SSPE) is a late, rare and usually fatal complication of measles infection. Although a very high incidence of SSPE in Papua New Guinea (PNG) was first recognized 20 years ago, estimated measles vaccine coverage has remained at ≤70% since and a large measles epidemic occurred in 2002. We report a series of 22 SSPE cases presenting between November 2007 and July 2009 in Madang Province, PNG, including localized clusters with the highest ever reported annual incidence.

Methodology/Principal Findings

As part of a prospective observational study of severe childhood illness at Modilon Hospital, the provincial referral center, children presenting with evidence of meningo-encephalitis were assessed in detail including lumbar puncture in most cases. A diagnosis of SSPE was based on clinical features and presence of measles-specific IgG in cerebrospinal fluid and/or plasma. The estimated annual SSPE incidence in Madang province was 54/million population aged <20 years, but four sub-districts had an incidence >100/million/year. The distribution of year of birth of the 22 children with SSPE closely matched the reported annual measles incidence in PNG, including a peak in 2002.

Conclusions/Significance

SSPE follows measles infections in very young PNG children. Because PNG children have known low seroconversion rates to the first measles vaccine given at 6 months of age, efforts such as supplementary measles immunisation programs should continue in order to reduce the pool of non-immune people surrounding the youngest and most vulnerable members of PNG communities.     

Whooping cough after stopping pertussis immunisation.

An epidemic of whooping cough occurred in a rural practice in Shetland, containing 144 children under 16. Before July 1974 all children were immunised against pertussis, but after that date immunisation was stopped. Of the 134 children studied, 93 had been immunised. Sixty-five of the children developed whooping cough. The incidence of infection was similar in those who had and had not been immunised. The incidence was also similar in those born before and after July 1974. There was no evidence to support the routine use of pertussis immunisation in rural Shetland.     

Use of Mobile Information Technology during Planning,Implementation and Evaluation of a Polio Campaign in South Sudan

Background

Use of mobile information technology may aid collection of real-time, standardised data to inform and improve decision-making for polio programming and response. We utilised Android-based smartphones to collect data electronically from more than 8,000 households during a national round of polio immunisation in South Sudan. The results of the household surveys are presented here, together with discussion of the application of mobile information technology for polio campaign planning, implementation and evaluation in a real-time setting.

Methods

Electronic questionnaires were programmed onto Android-based smartphones for mapping, supervision and survey activities during a national round of polio immunisation. National census data were used to determine the sampling frame for each activity and select the payam (district). Individual supervisors, in consultation with the local district health team, selected villages and households within each payam. Data visualisation tools were utilised for analysis and reporting.

Results

Implementation of mobile information technology and local management was feasible during a national round of polio immunisation in South Sudan. Red Cross visits during the polio campaign were equitable according to household wealth index and households who received a Red Cross visit had significantly higher odds of being aware of the polio campaign than those who did not. Nearly 95% of children under five were reported to have received polio immunisation (according to maternal recall) during the immunisation round, which varied by state, county and payam. A total of 11 payams surveyed were identified with less than 90% reported immunisation coverage and the least poor households had significantly higher odds of being vaccinated than the most poor. More than 95% of households were aware of the immunisation round and households had significantly higher odds of being vaccinated if they had prior awareness of the campaign taking place.

Conclusion

Pre-campaign community education and household awareness of polio is important to increase campaign participation and subsequent immunisation coverage in South Sudan. More emphasis should be placed on ensuring immunisation is equitable according to geographic area and household socio-economic index in future rounds. We demonstrate the utility of mobile information technology for household mapping, supervision and survey activities during a national round of polio immunisation and encourage future studies to compare the effectiveness of electronic data collection and its application in polio planning and programming.     

Pertussis: what percentage of children can we immunise?

The immunisation records of 584 children who were born between 1978 and 1982, in a general practice of average social class distribution, were examined: 3.5% of the children would have been excluded from starting a course of vaccination including pertussis using contra-indications established by the Department of Health and Social Security. A further 3.5% had reactions to immunisation that were judged severe enough to prevent completing the course of vaccination. In 1981 and 1982 13% of parents refused pertussis vaccination, considerably fewer than from 1978 to 80. Concomitantly, immunisation against pertussis rose from 51% to 84% over the five year period. Given the incidence of contra-indications and the level of parental refusal, it is concluded that a pertussis uptake of 80% would be a reasonable target for any population.