The medical schools outcomes database project: Australian medical student characteristics.

BACKGROUND: Global medical workforce requirements highlight the need for effective workforce planning, with the overall aims being to alleviate doctor shortages and prevent maldistribution. The Medical Schools Outcomes Database and Longitudinal Tracking (MSOD) Project provides a foundation for evaluating outcomes of medical education programs against specified workforce objectives (including rural and areas of workforce needs), assisting in medical workforce planning, and provision of a national research resource. This paper describes the methodology and baseline results for the MSOD project. METHODS: The MSOD Project is a prospective longitudinal multiple-cohort study. The project invites all commencing and completing Australian medical students to complete short questionnaires. Participants are then asked to participate in four follow-up surveys at 1, 3, 5 and 8 years after graduation. RESULTS: Since 2005, 30,635 responses for medical students (22,126 commencing students and 8,509 completing students) in Australia have been collected. To date, overall eligible cohort response rates are 91% for commencing students, and 83% for completing students. Eighty three percent of completing medical student respondents had also completed a commencing questionnaire.Approximately 80% of medical students at Australian medical schools are Australian citizens. Australian medical schools have only small proportions of Indigenous students. One third of medical students speak a language other than English at home.The top three vocational choices for commencing medical students were surgery, paediatrics and child health and general practice. The top three vocational choices for completing students were surgery, adult medicine/ physician, and general practice. Overall, 75.7% of medical students changed their first career preference from commencement to exit from medical school.Most commencing and completing medical students wish to have their future medical practice in capital cities or in major urban centers. Only 8.1% of commencing students and 4.6% of completing students stated an intention to have their future medical practice in smaller towns and small communities. CONCLUSIONS: The MSOD longitudinal project is now an established national resource that is beginning to generate significant research outputs, along with providing key information for workforce planning and policy makers. The project has now expanded to enrol New Zealand medical students.

Acellular pertussis vaccine at birth and one month induces antibody responses by two months of age.

BACKGROUND: Infants less than 3 months of age are at highest risk of hospitalization and death from pertussis. Several studies have examined antibody responses to pertussis vaccines at birth but no previous study has evaluated 2 doses of monovalent acellular pertussis vaccine (aPV) before 2 months of age. METHODS: Seventy-six newborns were randomized at birth to 3 groups-aPV at birth and 1 month, aPV at birth, and control. All infants received hepatitis B vaccine (HBV) at birth followed at 2, 4, and 6 months by a combination vaccine including aPV, diphtheria, tetanus, Haemophilus influenzae type b (Hib), hepatitis B, polio antigens and 7 valent conjugate pneumococcal vaccine. IgG antibody responses to pertussis toxoid (PT), filamentous hemagglutinin (FHA), and pertactin (PRN) were measured in maternal serum and in infants at 2, 4, 6, and 8 months of age. Antibody responses to hepatitis B, diphtheria, tetanus, and Hib were measured at 8 months only. A parental diary and active telephone follow-up occurred for 7 days after each vaccination. RESULTS: The aPV birth dose was well tolerated. By 2 months of age, 22 of 25 (88%) of 2 dose recipients had detectable IgG antibody to PT (IgG PT) compared with 9 of 21 (43%) who received a birth dose only and 3 of 20 (15%) of controls. Infants in the 2 dose group had a geometric mean concentration (GMC) of IgG PT of 16 ELISA units per mL (EU/mL), 95% CI: 11 to 25, significantly higher than birth dose only (5 EU/mL, 95% CI: 3-8) and controls (3 EU/mL, 95% CI: 2-5). At 8 months of age, following 5, 4, and 3 doses of aP-containing vaccine, respectively, IgG PT had plateaued but IgG to FHA and PRN increased with successive doses. There was a trend to lower antibody responses for hepatitis B and Hib with higher numbers of Pa doses. CONCLUSION: These data suggest that aPV at birth and 1 month induces significantly higher IgG antibody against pertussis antigens by 2 months of age without reducing subsequent pertussis antibody responses. Larger and more detailed studies of aPV from birth are needed to evaluate other antibody responses and the potential of this approach to reduce death and morbidity from Bordetella pertussis infection in the first 3 months of life.

Primary and booster immunization with a diphtheria, tetanus, acellular pertussis, hepatitis B (DTPa-HBV) and Haemophilus influenzae type b (Hib) vaccine administered separately or together is safe and immunogenic.

OBJECTIVES: The aim of this study was to evaluate the safety and immunogenicity of DTPa-HBV and Hib vaccines given mixed or separately to 360 healthy infants at 2, 4, and 6 months of age. METHODS: Immune memory was assessed in lower responders (post-primary anti-PRP <0.545 microg/ml), through administration of plain polyribosylribitol phosphate (PRP) at 12-15 months. All subjects received a DTPa-HBV/Hib booster at 18-19 months. RESULTS: One month after primary vaccination, 98% had seroprotective antibody levels against HBV and 94-97% against Hib (anti-PRP> or =0.15microg/ml). A statistically significant difference between groups was observed in the proportion of subjects who achieved anti-PRP antibodies > or =1.0microg/ml post-primary vaccination; 68.1% for DTPa-HBV/Hib and 84.5% for DTPa-HBV and Hib. PRP administered to lower responders produced a 7-fold increase in anti-PRP antibodies, indicative of immunological memory. After DTPa-HBV/Hib booster vaccination, 96-100% of subjects had seroprotective antibody concentrations against Hib, hepatitis B, tetanus, and diphtheria and high vaccine response rates against pertussis toxoid, filamentous hemagglutinin, and pertactin. CONCLUSION: A robust and protective Hib response was demonstrated following plain PRP and/or a booster conjugate Hib vaccine in both lower and higher Hib responders.

Pandemic influenza and community preparedness.

OBJECTIVES: We aimed to examine community knowledge about and attitudes toward the threat of pandemic influenza and assess the community acceptability of strategies to reduce its effect. METHODS: We conducted computer-aided telephone interviews in 2007 with a cross-sectional sample of rural and metropolitan residents of South Australia. RESULTS: Of 1975 households interviewed, half (50.2%) had never heard of pandemic influenza or were unaware of its meaning. Only 10% of respondents were extremely concerned about the threat of pandemic influenza. Respondents identified children as the highest priority for vaccination, if supplies were limited; they ranked politicians and teachers as the lowest priority. Although only 61.7% of respondents agreed with a policy of home isolation, 98.2% agreed if it was part of a national strategy. Respondents considered television to be the best means of educating the community. CONCLUSION: s. Community knowledge about pandemic influenza is poor despite widespread concern. Public education about pandemic influenza is essential if strategies to reduce the impact of the disease are to be effective.

Varicella immunisation practice: Implications for provision of a recommended, non-funded vaccine.

AIM: In Australia in 2003 a two-tiered immunisation schedule was introduced consisting of funded (National Immunisation Program) and non-funded but recommended vaccines (Best Practice Schedule), including varicella vaccine. The aim of this study was to examine immunisation practice when a vaccine is recommended but not funded by Government. METHODS: A survey was sent to 600 randomly selected general practitioners (GPs) in South Australia between June and August 2005, prior to provision of Federal funding for varicella vaccine. RESULTS: Although varicella was considered an important disease to prevent by 89% of GPs, only 25% of GPs always discussed the non-funded immunisation with parents at the time of a routine immunisation visit. Female GPs were more likely to discuss immunisation with recommended, non-funded vaccines than male GPs. Those who were supportive of varicella prevention were more likely to discuss immunisation with the non-funded vaccine. GPs who always provided information about the disease were more likely to have parents accept their advice about varicella vaccine (62.7%) than those who never provided information (40%). GPs reported parental refusal of varicella vaccine was due to the cost and perception that varicella is a mild disease. CONCLUSIONS: The results of this study showed variability in prescribing practices for a non-funded vaccine. Recommending a vaccine without provision of funding may lead to 'mixed messages' for immunisation providers and parents with resultant low coverage. Funding a vaccine is likely to reduce variability in provision of the vaccine and improve coverage in the community.

A novel combined Haemophilus influenzae type b-Neisseria meningitidis serogroups C and Y-tetanus-toxoid conjugate vaccine is immunogenic and induces immune memory when co-administered with DTPa-HBV-IPV and conjugate pneumococcal vaccines in infants.

Immunogenicity and safety of a novel combined Haemophilus influenzae type b-Neisseria meningitidis serogroups C and Y-tetanus-toxoid conjugate vaccine (Hib-MenCY-TT) candidate was evaluated when co-administered with DTPa-HBV-IPV(Pediarix)+PCV7(Prevnar) at 2-4-6 months of age. Anti-PRP concentrations >or= 1.0 microg/mL were observed in 92.9-98.7%, rSBA-MenC/Y titres >or= 1:8 in >98%, rSBA-MenC/Y titres >or= 1:128 in >95.8 and >89.9% subjects. PRP and MenC responses were similar to respective controls (ActHIB and Menjugate) including for antibody persistence. Response to co-administered vaccines was not impaired. Polysaccharide challenge (PRP, PSC, PSY at 11-14 months of age) evidenced immune memory was induced for Hib, MenC/Y conjugate components. The safety profile of Hib-MenCY-TT was similar to controls. Hib-MenCY-TT administered according to the current US Hib vaccine schedule has the potential to induce protective antibodies against Hib and meningococcal-CY disease in infants and toddlers.

DTPa-HBV-IPV vaccine for primary vaccination of infants.

AIM: Combined vaccines have an increasingly important role to play in delivering these antigens acceptably. We describe the immunogenicity and reactogenicity of a combined DTPa-HBV-IPV vaccine (diphtheria, tetanus, acellular pertussis, hepatitis B, inactivated poliovirus (DTPa-HBV-IPV: Infanrix penta) ) when administered for the primary vaccination of infants resulting from a study where the primary objective was to demonstrate non-inferiority of the immune response induced by DTPa-HBV-IPV using an industrial-scale IPV production process. METHODS: Three hundred and fourteen infants received primary immunisation with DTPa-HBV-IPV at 2, 4 and 6 months of age. Routine Haemophilus influenzae immunisation was performed at 2 and 4 months of age at a separate injection site. Blood samples were taken at 2 and 7 months of age. Reactogenicity was assessed using diary cards for 7 days after each dose. RESULTS: One month after the primary course, at least 98.9% of subjects achieved seroprotective antibody concentrations/titres against diphtheria, tetanus, hepatitis-B and polio types 1, 2 and 3. More than 97% had a vaccine response to pertussis antigens. The incidence of local injection site reactions after DTPa-HBV-IPV was similar to that for the Haemophilus influenzae vaccine site. General reactions of Grade 3 intensity were uncommon. CONCLUSIONS: The DTPa-HBV-IPV vaccine is a new combination of vaccines previously available separately, with established effectiveness and safety profiles. Combined vaccines reduce storage requirements and minimise the number of injections required, thereby reducing distress for infants and parents. DTPa-HBV-IPV was immunogenic with an acceptable safety profile and could replace separate administration of DTPa, HBV and IPV vaccines in infants.

A cross-sectional survey to assess community attitudes to introduction of Human papillomavirus vaccine.

OBJECTIVE: A vaccine to prevent human papilloma virus (HPV) infection has been licensed recently in the United States of America and Australia. The aim of this study was to assess community attitudes to the introduction of HPV vaccine in the State of South Australia. METHODS: A cross-sectional survey was conducted by computer-aided telephone interviews in February 2006. The survey assessed adult and parental attitudes to the introduction of HPV vaccine to provide protection against a sexually transmitted disease caused by HPV and against cervical cancer. Two thousand interviews were conducted in metropolitan and rural households. RESULTS: Two per cent of respondents knew that persistent HPV infection caused cervical cancer and a further 7% were aware that the cause was viral. The majority of adults interviewed (83%) considered that both men and women should receive HPV vaccine and 77% of parents agreed that they would have their child/children immunised. Parents were mainly concerned about possible side effects of the vaccine (66%), with only 0.2% being concerned about discussing a sexually transmitted disease with their children and 5% being concerned that use of the vaccine may lead to promiscuity. IMPLICATIONS: Our findings suggest that public health education campaigns for HPV vaccination will find a majority of parents receptive to their children being vaccinated, but attention must be paid to appropriate explanation about HPV infection as the cause of cervical cancer and education about the safety of the HPV vaccine.

The relationship between health-related quality of life, pain, and coping strategies in juvenile arthritis--a one year prospective study.

The aim of this 12-month prospective study was to compare reports describing the health-related quality of life (HRQL) of children with Juvenile idiopathic arthritis (JIA) obtained from parents and children, to investigate the extent to which the children's HRQL changed over a 12-month period, and to describe the relationship between children's HRQL, and their experience of pain and use of pain coping strategies. Fifty-four children aged 8-18 years with JIA and their parents completed standard questionnaires assessing children's HRQL, pain intensity, and pain coping strategies at baseline, 6 months, and 12 months. In general, children reported that their HRQL was better than was reported by parents. Both informants described children's HRQL as being very stable over the 12 months of the study. Consistent with the Biobehavioural Model of Pain, there was a significant negative relationship between children's HRQL and their experience of pain. However, there was little evidence that pain coping strategies mediated the relationship between children's experience of pain and their HRQL.

Uptake of varicella vaccine--a cross sectional survey of parental attitudes to nationally recommended but unfunded varicella immunisation.

The aim of this study was to assess the uptake of varicella vaccine in South Australian children under circumstances where varicella immunisation is recommended, but is not funded by Government. The study examined the main reasons that determined a parent's decision whether or not to have their child immunised with varicella vaccine. A cross-sectional survey was conducted by Computer Aided Telephone Interviews (CATI) in June 2004. Data were obtained from 613 households containing 1148 children aged from birth to 17 years of age. Statistical analyses were performed using data weighted to the South Australian population. Six hundred and eighty children (55.7%) had a history of varicella infection and 446 children (42.0%) had received varicella vaccine (weighted data). The most common reasons cited for not having children immunised included lack of knowledge about the vaccine and cost. One year after inclusion of varicella vaccine in the Australian Standard Vaccination Schedule there is evidence of incomplete coverage in children in South Australia due to absence of government funding for vaccine provision.

Festschrift for Professor Margaret Burgess AO.

In honour of the retirement of our director Margaret Burgess, National Centre for Immunisation Research and Surveillance (NCIRS) held a Festschrift on 5th to 6th February 2004. The themes of the event were Vaccines for the 21st Century and Congenital and Neonatal Infections. International guests attended the Festschrift, as well as over 180 colleagues and co-workers from across Australia. A summary of the presentations over these two fascinating days is provided herein.

Juvenile arthritis-associated uveitis: visual outcomes and prognosis.

BACKGROUND: The current issues in the management of uveitis associated with juvenile arthritis revolve mainly around the treatment of mild disease and how to treat patients with more severe disease. The aims of this study were to determine the incidence of uveitis in a cohort of patients with juvenile arthritis as well as the nature of treatment and the risk factors for visual loss. METHODS: Review of the charts of 71 patients with juvenile arthritis, as defined by the American Academy of Rheumatology, seen between 1992 and 2001 at a combined rheumatology and ophthalmology clinic. Information collected included the patient's sex, age at diagnosis of arthritis and uveitis, and date of diagnosis of arthritis and uveitis. The rheumatologic diagnosis, results of serologic testing, and details of systemic and topical treatments were also recorded. RESULTS: There were 47 girls and 24 boys ranging in age from 16 months to 13 years. The median age at diagnosis of juvenile arthritis was 4 years and 1 month. Twenty-seven patients (38%) had uveitis. The median age at uveitis onset was 5.9 years, with an average interval of 18 months from the diagnosis of arthritis; 11 patients had uveitis at the time of arthritis diagnosis. There was a positive relation between anti-nuclear antibody positivity and the development of uveitis (p < 0.05). Thirteen (48%) of the 27 patients with uveitis had mild anterior segment inflammation, with fewer than 25 cells in the anterior chamber. This group had spontaneous resolution of uveitis without topical therapy. All the patients without uveitis had a final visual acuity of 6/9 or better. Five of the patients with uveitis had a final visual acuity of 6/36 or worse. Cataract was the most common complication affecting visual outcome. Cataract extraction initially improved the visual acuity, but posterior segment complications and glaucoma compromised the final visual outcome. INTERPRETATION: We found an incidence of uveitis of 38% with long-term follow-up of patients with juvenile arthritis; the uveitis was diagnosed an average of 18 months after the arthritis. Almost half of the patients with uveitis had minor anterior segment inflammation. These patients did not receive topical treatment and had good visual outcomes. Patients with uveitis at the time of diagnosis of arthritis tended to have a worse visual prognosis and experienced persistent uveitis despite treatment. In this series, cataract extraction was beneficial in improving visual acuity immediately postoperatively, but posterior segment changes and glaucoma may compromise final visual outcomes.

Evaluation of combined live, attenuated respiratory syncytial virus and parainfluenza 3 virus vaccines in infants and young children.

We evaluated a combination respiratory syncytial virus (RSV) and parainfluenza 3 virus (PIV3) live, attenuated intranasal vaccine for safety, viral replication, and immunogenicity in doubly seronegative children 6-18 months old. RSV cpts-248/404 and PIV3-cp45 vaccines were combined in a dose of 10(5) plaque-forming units of each per 0.5-mL dose and compared with monovalent vaccines or placebo. The virus shedding pattern of RSV was not different between monovalent RSV cpts-248/404 vaccine and combination vaccine. Modest reductions in the shedding of PIV3-cp45 vaccine virus were found after the administration of RSV cpts-248/404 and PIV3-cp45 vaccine, relative to monovalent PIV3 vaccine; 16 (76%) of 21 children given combination vaccine shed PIV3-cp45 versus 11 (92%) of 12 of those given monovalent PIV3 vaccine. Both vaccines were immunogenic, and antibody responses were similar between the monovalent groups and the combination group. Combined RSV/PV3 vaccine is feasible for simultaneous administration, and further studies are warranted.

The association between maternal ratings of child health interviews and maternal and child characteristics.

BACKGROUND: Doctors develop the skills needed to interview parents and children in paediatric settings by practice and by receiving feedback during their medical training. Interviewed parents are ideally placed to provide evaluations of these skills. If parents, as consumers of health care services, are to be consulted, it is important to determine whether factors other than interview skills affect their evaluations. OBJECTIVES: Our aim was to examine the relationship between maternal satisfaction ratings of student doctor interviews, and maternal and child characteristics. METHODS: Sixty mothers of children attending the paediatric medical out-patient clinic at the Women's and Children's Hospital, South Australia were allocated randomly to rate one of four video-taped final year student doctor interviews (15 mothers per interview). The level of skills displayed by the student doctor differed in each interview. Maternal satisfaction was measured using the Medical Interview Satisfaction Scale (MISS) and the Interpersonal Skills Rating Scale (IPS), and interview ratings were compared for a number of maternal and child characteristics. RESULTS: No significant associations were observed between maternal satisfaction ratings and any maternal or child characteristics other than lower satisfaction associated with previous experience of a real student doctor interview (P <0.01). The interview seen by mothers predicted 53% (MISS) and 65% (IPS) of the variance in maternal satisfaction ratings. After controlling for the interview type, the maternal and child characteristics studied predicted 17% additional variance in MISS scores and 7% in IPS scores. CONCLUSION: The quality of the interview skills demonstrated was the principle determinant of maternal satisfaction ratings.

Generation of murine monoclonal antibodies to Haemophilus influenzae type b capsular polysaccharide by in vivo immunization.

Haemophilus influenzae type b (Hib) is a pathogenic gram-negative bacterium associated with human disease, especially in young children. Protective immune response to Hib results from antibodies developed against the polyribosylribitol phosphate (PRP) capsular polysaccharide of the bacterium. Several investigators in the study of immune response to Hib have produced human monoclonal antibodies to PRP. Only two previous groups have reported the generation of murine anti-PRP monoclonal antibodies using either immunizing mice with inactivated Hib bacteria or a combination of in vivo and in vitro immunization of mice with PRP conjugate antigen (PRP-D). In this present study, we generated murine anti-PRP monoclonal antibody secreting hybridomas for the first time by simple in vivo immunization with PRP conjugate antigen (PRP-T). The anti-PRP antibodies from one hybridoma clone (B10) are further characterized and potential applications are discussed.

Lessons from the Clinical Support Systems Program: facilitating better practice through leadership and team building.

The increasing array of strategies and models for improving clinical practice and patient outcomes can be confusing for clinicians. The Clinical Support Systems (CSS) model has proved to be effective in local environments because it demystifies the design and implementation of evidence-based practice improvement projects. The CSS model is simple and has a wide scope. It provides a broad framework with minimalist specifications, enabling clinicians to design their own systems of care that cut across fragmented organisational structures. Implementing simple rules can be an effective strategy for change in complex care systems. These rules do not impose solutions on clinicians, but rather, help them to find creative solutions that have meaning for them and are contextually relevant.

Medical students taking the role of the mother in paediatric interview evaluation.

BACKGROUND: Medical students develop the skills required to interview parents and children through practice and by receiving feedback. Parental perceptions of medical student skills in child health interviews can be used to enhance student learning. OBJECTIVES: To integrate maternal perspectives of medical student interviews into student learning, and to compare student and maternal evaluations of simulated medical student interviews. METHODS: A sample of 45 medical students viewed 2 standardised videotapes in which a 'medical student' interviewed the mother of a sick child. The videotapes demonstrated contrasting levels of 'student' clinical competence and patient-centeredness. After each interview students were asked to rate their satisfaction and recall of information as if they were the mother in the interview. Student satisfaction was measured using the Interpersonal Skills Rating Scale (IPS). Recall of interview information was assessed by questionnaire, with student answers coded independently before analysis. Following both videotapes, students reviewed transcripts of the interviews and discussed their evaluations. Student responses were compared with maternal satisfaction and recall responses after viewing of the same videotapes. RESULTS: Student IPS ratings were higher following the high clinical competence, high patient-centred interview (P < 0.0001). Student recall of specific information was greater for some items following the high clinical competence, high patient-centred interview, but was lower for others. Maternal and student satisfaction and recall were similar following the 2 interviews. CONCLUSION: Students and mothers agreed on the qualities of a successful interview. Experiencing an interview through the 'eyes' of a mother provided students with valuable insights regarding interview skills.

Phase 2 evaluation of parainfluenza type 3 cold passage mutant 45 live attenuated vaccine in healthy children 6-18 months old.

A phase 2 evaluation of live attenuated parainfluenza type 3 (PIV3)-cold passage mutant 45 (cp45) vaccine was conducted in 380 children 6-18 months old; 226 children (59%) were seronegative for PIV3. Of the 226 seronegative children, 114 received PIV3-cp45 vaccine, and 112 received placebo. No significant difference in the occurrence of adverse events (i.e., runny nose, cough, or temperature > or =38 degrees C) was noted during the 14 days after vaccination. There was no difference between groups in the occurrence of acute otitis media or serous otitis media. Paired serum samples were available for 109 of the seronegative vaccine recipients and for 110 of the seronegative placebo recipients; 84% of seronegative vaccine recipients developed a > or =4-fold increase in antibody titers. The geometric mean antibody titer after vaccination was 1 : 25 in the vaccine group and <1 : 4 in the placebo group. PIV3-cp45 vaccine was safe and immunogenic in seronegative children and should be evaluated for efficacy in a phase 3 field trial.