Effectiveness of 7-valent pneumococcal conjugate vaccine against radiologically diagnosed pneumonia in indigenous infants in Australia.

OBJECTIVE: To evaluate the effectiveness of the 7-valent pneumococcal conjugate vaccine (PCV7) in preventing pneumonia, diagnosed radiologically according to World Health Organization (WHO) criteria, among indigenous infants in the Northern Territory of Australia. METHODS: We conducted a historical cohort study of consecutive indigenous birth cohorts between 1 April 1998 and 28 February 2005. Children were followed up to 18 months of age. The PCV7 programme commenced on 1 June 2001. All chest X-rays taken within 3 days of any hospitalization were assessed. The primary endpoint was a first episode of WHO-defined pneumonia requiring hospitalization. Cox proportional hazards models were used to compare disease incidence. FINDINGS: There were 526 pneumonia events among 10,600 children - an incidence of 3.3 per 1000 child-months; 183 episodes (34.8%) occurred before 5 months of age and 247 (47.0%) by 7 months. Of the children studied, 27% had received 3 doses of vaccine by 7 months of age. Hazard ratios for endpoint pneumonia were 1.01 for 1 versus 0 doses; 1.03 for 2 versus 0 doses; and 0.84 for 3 versus 0 doses. CONCLUSION: There was limited evidence that PCV7 reduced the incidence of radiologically confirmed pneumonia among Northern Territory indigenous infants, although there was a non-significant trend towards an effect after receipt of the third dose. These findings might be explained by lack of timely vaccination and/or occurrence of disease at an early age. Additionally, the relative contribution of vaccine-type pneumococcus to severe pneumonia in a setting where multiple other pathogens are prevalent may differ with respect to other settings where vaccine efficacy has been clearly established.

Sexual disruption in a second species of wild cyprinid fish (the gudgeon, Gobio gobio) in United Kingdom freshwaters.

To establish whether the intersex condition seen in the roach (Rutilus rutilus) in United Kingdom (UK) rivers was species specific or a more general phenomenon in fish, evidence for sexual disruption was sought in a second cyprinid species, the gudgeon (Gobio gobio). Gudgeon were collected from the Rivers Aire and Lea (at locations that receive high-volume discharges of sewage treatment works [STW] effluent and that contain intersex roach) and from two still waters, and their gonads were examined histologically for evidence of intersexuality (the simultaneous presence of oocytes and testicular tissue). Intersex gonads were found at all sites, with the highest incidences occurring at one of the still waters (Lakeside Fisheries: 15%) and at sites on the River Aire (Thwaite Weir, Silsden Bridge, and Knostrop: 14, 13, and 12%, respectively). In the River Lea and Longton Park Lake, the incidence of intersexuality in gudgeon was 6%. In most cases, intersex gonads were characterized by a few primary oocytes/gonad section in an otherwise normal testis. However, at some sites on the River Aire (Thwaite Weir and Knostrop), the intersex condition was more severe. At Thwaite Weir, for example, more than half of the gonad in 40% of the intersex fish was comprised of ovarian tissue. Elevated concentrations of plasma vitellogenin both in male and in intersex fish indicated that fish had been exposed to estrogen(s). Some of the gudgeon were found at sites several kilometers downstream of any point discharge of STW effluent; therefore, the results likely are representative of this species in wild populations found in typical UK river ecosystems. Together with the findings in the roach, these data on the gudgeon confirm that sexual disruption in fish in UK rivers is not species specific.

Hospitalized community-acquired pneumonia in the elderly: an Australian case-cohort study.

This study describes the epidemiology of community-acquired pneumonia (CAP) in elderly Australians for the first time. Using a case-cohort design, cases with CAP were in-patients aged > or = 65 years with ICD-10-AM codes J10-J18 admitted over 2 years to two tertiary hospitals. The cohort sample was randomly selected from all hospital discharges, frequency-matched to cases by month. Logistic regression was used to estimate risk ratios for factors predicting CAP or associated mortality. A total of 4772 in-patients were studied. There were 1952 cases with CAP that represented 4% of all elderly admissions: mean length of stay was 9.0 days and 30-day mortality was 18%. Excluding chest radiograph, 520/1864 (28%) cases had no investigations performed. The strongest predictors of CAP were previous pneumonia, history of other respiratory disease, and aspiration. Intensive-care-unit admission, renal disease and increasing age were the strongest predictors of mortality, while influenza vaccination conferred protection. Hospitalization with CAP in the elderly is common, frequently fatal and a considerable burden to the Australian community. Investigation is ad hoc and management empirical. Influenza vaccination is associated with reduced mortality. Patient characteristics can predict risk of CAP and subsequent mortality.

ICD-10 codes are a valid tool for identification of pneumonia in hospitalized patients aged > or = 65 years.

This study examines the validity of using ICD-10 codes to identify hospitalized pneumonia cases. Using a case-cohort design, subjects were randomly selected from monthly cohorts of patients aged > or = 65 years discharged from April 2000 to March 2002 from two large tertiary Australian hospitals. Cases had ICD-10-AM codes J10-J18 (pneumonia); the cohort sample was randomly selected from all discharges, frequency matched to cases by month. Codes were validated against three comparators: medical record notation of pneumonia, chest radiograph (CXR) report and both. Notation of pneumonia was determined for 5098/5101 eligible patients, and CXR reports reviewed for 3349/3464 (97%) patients with a CXR. Coding performed best against notation of pneumonia: kappa 0.95, sensitivity 97.8% (95% CI 97.1-98.3), specificity 96.9% (95% CI 96.2-97.5), positive predictive value (PPV) 96.2% (95% CI 95.4-97.0) and negative predictive value (NPV) 98.2% (95% CI 97.6-98.6). When medical record notation of pneumonia is used as the standard, ICD-10 codes are a valid method for retrospective ascertainment of hospitalized pneumonia cases and appear superior to use of complexes of symptoms and signs, or radiology reports.

New normal ranges of antistreptolysin O and antideoxyribonuclease B titres for Australian children.

OBJECTIVE: To determine age-specific upper limit of normal (ULN) values of the ASO and ADB titres in children aged 4-14 years in urban Melbourne. Serology is often used to diagnose a preceding Streptococcus pyogenes infection, particularly in potential cases of rheumatic fever and post-streptococcal glomerulonephritis. The most commonly used antigens are antistreptolysin O (ASO) and antideoxyribonuclease B (ADB). Reference ranges used in Australia for these serological markers are usually based on data in adults from other countries. There are no age-specific reference values for Australian children. METHODS: Sixty-six sera from children with no history of recent streptococcal infection were obtained in May-June 2002. The children were divided into three age groups for analysis: 4-5 (n = 20), 6-9 (n = 19) and 10-14 (n = 25) years. The geometric mean titre and ULN (defined as the 80th percentile) for the ASO and ADB titres for each age group were determined in both international and log units. RESULTS: The ULN for ASO titres in each age group was 120 (2.08 log units), 480 (2.68) and 320 (2.51). The ULN for ADB titres in each age group was 100 (2.00 log units), 400 (2.60) and 380 (2.58). CONCLUSION: The ASO and ADB ULN values in school-aged children are higher than the current reference ranges suggest.

Respiratory illness during winter: a cohort study of urban children from temperate Australia.

OBJECTIVE: To examine the epidemiology and burden of respiratory illness during winter in urban children from temperate Australia. METHODS: We conducted a cohort study of healthy Melbourne children, aged from 12 to 71 months. Parents kept a daily respiratory symptom diary and recorded resource use when an influenza-like illness (ILI) occurred. RESULTS: One-hundred and eighteen children had 137 ILI episodes over 12 weeks for a rate of 0.53 ILI episodes per child-month (95% CI 0.44-0.61). Risk factors for ILI included younger age, fewer people residing in the household, structured exposure to other children outside the home, and a higher household income. Episodes had a mean duration of 10.4 days with 64 visits to a general practitioner (46.7 GP visits per 100 episodes), 27 antibiotic courses prescribed (19.7 antibiotic courses per 100 episodes), and three overnight hospitalizations (2.2 admissions per 100 episodes). Parents reported an average of 11.7 h excess time spent caring for a child per episode. CONCLUSIONS: Respiratory illnesses are a common and largely neglected cause of illness in Australian children. Pathogen-specific data are required to better assess the likely impact of available and developing vaccines and other treatment options.

Reactogenicity and immunogenicity profile of a two-dose combined hepatitis A and B vaccine in 1-11-year-old children.

This study was conducted to compare the reactogenicity, immunogenicity and safety of a combined two-dose (0, 6 months) hepatitis A and B vaccine (720ELU HAV, 20 mcg HBsAg) with the established three-dose (0, 1 and 6 months) hepatitis A and B vaccine (360ELU HAV, 10 mcg HBsAg). A total of 511 children aged 1-11 years who had not previously received a hepatitis A or B vaccine were enrolled in the study. Both vaccines were well tolerated, and were shown to be safe and immunogenic. The analysis, stratified according to two age groups (1-5 year and 6-11-year-old children) demonstrated that the reactogenicity profile of the two-dose schedule was at least as good as that of the established schedule. Both vaccines and schedules provided at least 98% seroprotection against hepatitis B and 100% seroconversion against hepatitis A, 1 month after the end of the vaccination course (Month 7).

Conjugate pneumococcal vaccines for non-indigenous children in Australia.

Childhood pneumococcal disease is associated with substantial morbidity and mortality, but total disease burden is more difficult to measure than for invasive disease caused by Haemophilus influenzae type b (Hib). A safe, effective seven-valent conjugate pneumococcal vaccine will be available in Australia by early 2001, and will certainly be indicated for high-risk groups and purchased in the private sector, as was Hib vaccine. The status of this vaccine on the Australian Standard Vaccination Schedule will require more detailed consideration of the burden and serotype distribution of pneumococcal disease in Australian children and the vaccine's likely cost-effectiveness. Postmarketing surveillance will be particularly important.

Radiological services in a hospital emergency department--an evaluation of service delivery and radiograph interpretation.

Radiological services to the Department of Ambulatory Paediatrics were audited over 1 month. Of a total of 782 separate radiographs, more than two-thirds were performed outside hours when radiologists are normally in the hospital. For only 171 of the 782 radiographs (22%) were there immediate reports by a radiologist. To determine whether the absence of immediate radiologist reports affected clinical care, a process was introduced whereby radiologists reviewed interpretation of radiographs made by resident medical officers (RMO) when no report was available. Over a 5 month period 2888 patients had radiographs when there was no immediate radiologist's report. Comparisons were made between RMO interpretation and ultimate radiologist report in 1411 of these patients. In 232 cases (16.4%) there was a discrepancy between RMO interpretation and radiologist report; 70% of these were false positive (the RMO interpreting a normal film as abnormal) while 71 were false negative (the RMO interpreting an abnormal film as normal). This study demonstrates the utility of a relatively simple quality assurance measure in situations where clinical decisions have to be made in the absence of an immediate radiologist report.

Home vaccination for children behind in their immunisation schedule: a randomised controlled trial.

OBJECTIVE: To ascertain the effectiveness of a home vaccination service for children behind in their vaccination schedule. DESIGN: Randomised controlled trial of nurse-administered vaccination at home. Children were allocated at random to the intervention or the control group before any contact with the parents was made. SETTING: 10 council areas in north-west metropolitan Melbourne defined by 56 postcode zones. Six-week intervention period from November 1996. PARTICIPANTS: 405 children--all those in the study area (n = 2610) 90 days late (age 9 months) for their third diphtheria-tetanus-pertussis/poliomyelitis/Haemophilus influenzae type B (DTP/OPV/Hib) vaccination, or 120 days late (age 16 months) for their measles-mumps-rubella (MMR) vaccination, according to the Australia Childhood Immunisation Register. MAIN OUTCOME MEASURES: Number of children completing DTP/OPV/Hib or MMR during the intervention period, and number up to date before intervention. RESULTS: Verification of vaccination status with the parents revealed that 123 (60%) of the children in the intervention group and 113 (56%) of those in the control group were up to date with their vaccinations, leaving a study population of 81 (intervention group) and 88 (control group). Vaccination was achieved in 46 (57%) intervention children and 24 (27%) control children (risk ratio [RR], 2.08; 95% CI, 1.4-3.1; P < 0.001). For DTP/OPV/Hib, 18/32 (56%) intervention children and 12/36 (33%) control children were vaccinated, (P = 0.06). For MMR, 28/49 (57%) and 12/52 (23%) children were vaccinated, respectively (P < 0.001). Home vaccinations were completed with 26 families (including five siblings). The average cost per child vaccinated as a result of the home program was $92.52. CONCLUSION: Home vaccination for children behind in their immunisation schedule is an effective, acceptable and relatively cheap method of completing recommended vaccinations. We recommend that a home vaccination program be widely implemented and made available, particularly for disadvantaged families.

Atopic eczema: its impact on the family and financial cost.

OBJECTIVE: To evaluate the impact of childhood atopic eczema on families and assess the personal financial cost of its management. DESIGN: Cross sectional survey. SETTING: Paediatric dermatology and paediatric diabetology outpatient clinics. PATIENTS: Parents of 48 randomly selected children with atopic eczema and 46 with insulin dependent diabetes mellitus. MAIN OUTCOME MEASURES: The impact on family score, the reported cost of relevant medical treatments, medical consultations, relevant hospitalisation, and income loss. RESULTS: Families of children with moderate or severe atopic eczema had a significantly higher impact on family score than families of diabetic children. A conservative estimate of the annual personal financial cost of managing mild, moderate, and severe eczema was Aus$330, 818, and 1255, respectively. The financial cost to the community for the management of atopic eczema in the study groups was greater. The personal financial cost of managing eczema was greater than for asthma. CONCLUSION: Childhood atopic eczema has a profound impact on the social, personal, emotional, and financial perspectives of families.

Developmental language disorders and epilepsy.

The association of speech and language disorders with epilepsy is well-known in children with acquired epileptic aphasia, involving such entities as Landau-Kleffner syndrome (LKS), continuous spike wave in slow wave sleep (CSWSS) epilepsy and benign partial epilepsy with centro-temporal spikes (BPECTS). The possible association between epilepsy and a subgroup of children with developmental dysphasia is reported less frequently. Lack of controlled prospective studies of sleep electroencephalograms (EEG), and the use of medication, in children with developmental dysphasia, may deny appropriate treatment strategies to children with severe developmental speech and language disorders.

Clinical significance of anismus in encopresis.

Treatments designed to relieve paradoxical contraction of the anal sphincters during defecation (anismus) have had limited success in children with encopresis. This has raised doubts as to the clinical relevance of this diagnosis in childhood as anorectal dysfunction. Our aim was to determine whether, in patients who had treatment-resistant encopresis, the presence of electromyographic anismus was associated with increased faecal retention. Sixty-eight children with soiling (mean age 8.7+/-2.06 years) were assessed by clinical examination, abdominal radiography and then with anorectal manometry. Patients with electromyographic anismus (n=32; 47%) had significantly increased radiographic rectal faecal retention and were significantly less likely to be able to defecate water-filled balloons. There were no significant differences in response to prior therapy, history of primary encopresis, behavioural adjustment or in sociodemographic data. Our results suggest that electromyographic anismus is associated with obstructed defecation and faecal retention.

Antibodies to diphtheria, tetanus and pertussis in infants before and after immunization with DTP (Triple Antigen) vaccine.

OBJECTIVE: To determine antibody levels to the Australian manufactured combined diphtheria, tetanus and pertussis (DTP) vaccine (Triple Antigen, CSL Ltd) in infants before and after their primary immunization course. METHODOLOGY: Serosurvey (antibody prevalence study) in two groups: infants aged 5-9 weeks who had not received any immunizations (n = 25), and infants aged 7-10 months who had received two (n = 25) or three immunizations (n = 57) with DTP, sampled from infants attending the Royal Children's Hospital, Melbourne, either as inpatients or outpatients between February and April 1993. The immunization history for each infant was determined from hospital records, the parent-held child health record, or the local council or family doctor who immunized the infant. RESULTS: Enzyme immunoassay (EIA) of antibodies to diphtheria and tetanus showed all infants to have adequate protective levels after two or three vaccinations (> or = 0.01 IU/mL). All subjects who had received all three DTP vaccinations had detectable antibody to at least one pertussis antigen. Antibodies to the pertussis antigens filamentous haemagglutinin and pertussigen (pertussis toxin) were comparable to levels determined for whole cell pertussis vaccines used elsewhere in the world. EIA-determined antibodies to pertussis agglutinogen type 2 and agglutinogen type 3 showed substantially higher geometric mean titres when results for pre-immunization and post-immunization subjects were compared. CONCLUSIONS: These data show that the Australian manufactured DTP vaccine has immunogenic properties similar to those of vaccines used elsewhere, and that antibody concentrations following immunization are at levels consistent with efficacy.

Wilms' tumor: a rational use of preoperative imaging.

OBJECTIVE: To determine whether a preoperative imaging protocol relying predominantly on a chest X-ray film (CXR) and ultrasound in patients with Wilms' tumor is adequate for patient management and to determine the frequency more sophisticated imaging, in particular, computed tomography (CT), is required. DESIGN AND SETTING: Historical cohort study at a tertiary pediatric hospital. SUBJECTS: 60 consecutive patients with Wilms' tumor treated at our institution between 1980 and 1990. MAIN OUTCOME MEASURE: The preoperative imaging was recorded and 2- and 4-year survival were compared with the National Wilms' Tumor Study. RESULTS: 100% of patients had a preoperative CXR, 95% abdominal ultrasound, 5% abdominal CT, 13% chest CT, 47% abdominal X-ray, 2% aortography, 5% cavography, and 35% intravenous urography. The overall 2- and 4-year survivals of 92% and 90%, respectively, did not statistically differ from the National Wilms' Tumor Study 2- and 4-year survivals of 94% and 91%. CONCLUSIONS: A preoperative imaging protocol relying predominantly on a CXR and abdominal ultrasound does not reduce survival. Other more sophisticated imaging, in particular, CT, is not required in the majority of cases and is warranted only when a CXR or ultrasound is unable to resolve relevant management problems.

Fecal incontinence after the surgical treatment of Hirschsprung disease.

We examined 60 children 8.9 years (+/- 2.6 years) after surgical treatment of Hirschsprung disease to determine the extent of fecal incontinence. Thirty-two children (53%) had significant fecal soiling and 16 (27%) less severe soiling. The prevalence of incontinence did not diminish with increasing age.

Systematic review of rheumatic heart disease prevalence in children in developing countries: the role of environmental factors.

OBJECTIVES: To consider the worldwide prevalence of rheumatic heart disease in children in developing countries using surveys with uniform methodologies, and to consider the effect of environmental factors including socio-economic status, overcrowding, urbanization, nutrition and access to medical services on the distribution of rheumatic heart disease in developing countries. METHODS: Sixty-one surveys of the prevalence of rheumatic heart disease in developing countries were found using a systematic review of MEDLINE from January 1976 to July 1999. Twenty-four studies were selected for comparison based on their uniform methodological and diagnostic techniques. RESULTS: There is a high prevalence of rheumatic heart disease in the Pacific region with a lower prevalence in the Indian subcontinent, Asian, sub-Saharan African, Mediterranean, Latin American and Caribbean regions. However, aside from the Indian subcontinent, these regions have not been well studied, and it may be that the true prevalence is actually higher. CONCLUSIONS: There is a lack of good quality prevalence surveys of rheumatic heart disease in developing countries. It appears that a threshold level where higher socio-economic status is associated with reduced prevalence of rheumatic heart disease is not reached in developing countries. Therefore, differences in prevalence between socio-economic groups in the one area cannot be detected. A similar case can be made for overcrowding. Many regions need well-designed studies of rheumatic heart disease that incorporate assessment of environmental factors as well as the study of the microbiological epidemiology of rheumatic heart disease and group A streptococci.

Prevalence of asthma in regional Victorian schoolchildren.

OBJECTIVE: To determine whether the high prevalence of reported asthma in Melbourne schoolchildren is seen in rural Victoria. DESIGN: A questionnaire on respiratory symptoms was distributed to children to be completed by parents and returned to the school. Results were compared with a previous Melbourne study. SETTING: Two hundred and twenty-seven government and non-government primary schools in five rural regions of Victoria: coast, wheatbelt, riverland, highland and Latrobe valley. SUBJECTS: All children enrolled in grade 2 were invited to join the study. Parents completed questionnaires for 4661 children after 4886 questionnaires were distributed (response rate, 95%). MAIN OUTCOME MEASURE: History of wheeze in the past 12 months. RESULTS: The overall prevalence of wheeze in the last 12 months was 23.6%. There was a significant difference overall in this rate across the five rural areas and Melbourne, with the Latrobe Valley (26.2%) and highland areas (25.0%) having the highest rate, and the wheatbelt the lowest (19.6%). The spectrum of severity of asthma was similarly distributed across rural regions, although severe episodes were significantly more frequently reported by parents from rural areas than by parents in Melbourne. The reported use of bronchodilators and diagnosis of asthma showed a similar pattern of variation to that of the 12-month prevalence of wheeze. CONCLUSION: The prevalence of asthma in 7-year-old children is similar for rural Victoria as a whole compared with Melbourne, but there is variability in asthma prevalence in individual rural areas which is difficult to account for in terms of known environmental precipitants.

Risk factors for adverse outcomes of bacterial meningitis.

OBJECTIVE: To identify risk factors for adverse outcomes from bacterial meningitis. METHODOLOGY: From a cohort of 166 children with bacterial meningitis who were studied prospectively, 130/158 (82%) survivors underwent neurological, neuropsychological, audiological and behaviour assessments 5-9 years following their illness. RESULTS: Major adverse outcomes included B/166 (4.8%) deaths and severe neurological, intellectual or audiological sequelae in 11/130 (8.5%) children followed. Another 24 (18.5%) had cognitive, auditory or behaviour disorders. Bivariate analysis found age < or = 12 months, tertiary referral, symptoms > 24 h before diagnosis, seizures, focal neurological signs, deteriorating conscious state in hospital, Streptococcus pneumoniae infection and serum sodium concentration < 130 mmol/L were associated with adverse outcomes. Multivariate analysis showed age < or = 12 months, symptoms > 24 h, seizures after 72 h in hospital and focal neurological signs as independent risk factors. These were present in 18/19 (95%) children with major sequelae, but absent in 9/24 (37.5%) children with minor disabilities. CONCLUSIONS: As minor disabilities following meningitis cannot be predicted, all survivors require assessment during their early school years.