Influenza and pneumococcal vaccine distribution and use in primary care and hospital settings in Scotland: coverage, practice and policies.

A survey of the coverage, distribution and the factors associated with use of influenza and pneumococcal vaccines among general practitioners (GPs) in primary care and in hospital settings was carried out in 53 general practices in Scotland taking part in the 'Continuous Morbidity Recording' (CMR) programme. The annual vaccine distribution increased substantially among 53 general practices from 1993 to 1999 and in Scotland as a whole from 1984 to 1999. From the questionnaire, overall coverage was 43% (95% CI 38-48) for influenza vaccine in the 2000-1 season and 13% (95% CI 9-16) for pneumococcal vaccine in the last 5 year period, in high-risk patients recommended for these vaccines by the Department of Health (DoH). Influenza vaccine coverage was highest in the elderly (65 years of age and above) at 62% (95% CI 59-74). Although pneumococcal vaccination is not currently recommended for all elderly, coverage of this vaccine was also higher in this group (22%, 95% CI 16-29). In the majority of patients (influenza vaccine, 98% and pneumococcal vaccine, 94%), vaccination was carried out in general practice. Only 2% of patients had received pneumococcal vaccination in a hospital setting. The level of influenza and pneumococcal vaccination varied with the level of deprivation. Most GPs considered that the responsibility for influenza and pneumococcal vaccination lay with them. Forty-five percent of GPs reported having a written policy with set target for influenza vaccination and 11% for pneumococcal vaccination.

A survey of vaccine coverage and antibiotic prophylaxis in splenectomised patients in Scotland.

AIMS: To determine the coverage of vaccine and antibiotic prophylaxis in splenectomised patients in Scotland. METHODS: Patients who had undergone splenectomy between 1 January 1988 and 31 December 1998 were identified. A questionnaire was sent to general practitioners to validate vaccine and antibiotic status for these patients. RESULTS: A total of 974 living splenectomised patients were identified during the study period. Information on vaccine and antibiotic status was available for 708 (73%) and 770 (79%) of living patients, respectively. Coverage of pneumococcal vaccine (88%) was higher than that of Haemophilus influenza type b (Hib) conjugate vaccine (70%) or meningococcal vaccine (51%). Only 47% of patients received all three vaccines. A higher coverage was also documented for pneumococcal vaccine (28%) than Hib (19%) and meningococcal vaccine (14%) before elective splenectomy. Only 13% received all three vaccines before splenectomy. Coverage of influenza vaccine increased significantly, from 76% in the 1997/1998 season to 96% in the 2000/2001 season. Antibiotic prophylaxis was received by 67% of all patients. The current recommendation, comprising pneumococcal and Hib vaccination and antibiotic prophylaxis, was received by only 52% of the patients. There was no association between the coverage of vaccine and socioeconomic status. CONCLUSION: Further improvement in coverage of recommended vaccines and antibiotic prophylaxis is still needed to reduce the risk of serious infection in this high risk group.

Incidence of invasive pneumococcal disease in Scotland, 1988-99.

A review of the epidemiology of invasive pneumococcal disease in Scotland was carried out using data from laboratory-based systems during the period 1988-99. This comprised 5456 (90.8%) isolates of Streptococcus pneumoniae from blood, 467 (7.8%) from cerebrospinal fluid (CSF) and 84 (1.4%) from other sterile sites. The mean annual incidence of invasive disease was 9.8/10(5) population (9.0/10(5) for bacteraemia and 0.8/10(5) for meningitis). Invasive disease was highest in children < 2 years of age and in the elderly > or = 65 years (44.9/10(5) and 28.4/10(5) population in these age groups respectively). The highest incidence of pneumococcal meningitis, 11.8/10(5) persons occurred in children < 2 years of age. Males had a higher incidence of pneumococcal bacteraemia and meningitis than females (male:female = 1.2:1 for bacteraemia (RR = 1.17, 95 % CI 1.11, 1.24) and 1.5:1 for meningitis (RR = 1.41, 95 % CI 1.18, 1.70)). Pneumococcal disease was highest in winter periods and coincided with influenza activity. The proportion of penicillin and erythromycin non-susceptible isolates increased from 4.2% in 1992 to 12.6% in 1999 and from 5.6% in 1994 to 16.3% in 1999 respectively. Our data confirm the substantial and increasing disease burden from pneumococcal disease and rise in prevalence of antibiotic non-susceptibility among pneumococci in Scotland. Continued surveillance of groups at increased risk for pneumococcal disease and the antibiotic susceptibility and serotype distribution of isolates are important to develop appropriate policies for the prevention of pneumococcal disease in Scotland.

Prevalence of moderate penicillin resistant invasive Neisseria meningitidis infection in Scotland, 1994-9.

We examined the serological characteristics of 774 invasive meningococcal isolates collected through an active laboratory-based surveillance system in Scotland from 1994 to 1999. Of these, 72-73% of isolates were tested for susceptibility to several antimicrobial agents. Meningococci with high-level resistance to sulphadiazine had a prevalence of 10% and incidence of 0.22 per 100,000 population. High-level resistance to penicillin and other antibiotics was not detected. The prevalence of moderate penicillin resistant meningococci was 8.3%. There was no increase in moderate penicillin resistant meningococcal isolates during the study period, but there were temporal and geographic variations. The estimated incidence of moderate penicillin resistant meningococci was 0.15 per 100,000 population. High and low incidence of moderate penicillin resistant meningococci appeared to correlate with the number of doses of penicillin prescribed in some geographic locations. The majority of moderate penicillin resistant isolates belonged to serogroups B (52.2%) and C (39.2%). However, the prevalence of moderate penicillin resistance in serogroup W135 was substantially higher (51.7%) than serogroups B (7.8%) and C (7.6%). Serogroup W135 accounted for a higher proportion of moderate penicillin resistance (8.7%) than disease (1%). There was no predominant penicillin resistant serotype/subtype within any serogroup. Constant surveillance is necessary to monitor the emergence and spread of resistance and to guide appropriate public health interventions in preventing drug resistant meningococci.

Non-invasive pneumococcal disease and antimicrobial resistance: vaccine implications.

We reviewed laboratory data on non-invasive pneumococcal isolates reported from all diagnostic laboratories in Scotland during the period 1988-99. Of 4491 isolates from hospitalized patients, 654 (64.7%) were from sputum, 79 (7.8%) from the nasopharynx and 278 (27.5%) from other superficial sites. The serogroups included in the 23-valent polysaccharide vaccine caused 96.9% of all non-invasive disease in all age groups. The 7-, 9-, and 11-valent conjugated vaccine serogroups were responsible for 87-94%, 85-93%, 74-81% and 75-84% of non-invasive disease respectively in age groups < 2 years, < or = 5 years, > or = 65 years and all ages. The coverage of non-susceptible penicillin and erythromycin non-invasive isolates was > 99% and > 95% with the 23-valent polysaccharide and 7-11-valent conjugate vaccines respectively. The eight most common serogroups were 23, 9, 6, 19, 14, 3, 15 and 11 (in descending order). The serogroups associated with antimicrobial resistance in non-invasive disease were similar to those found in invasive disease. The finding of a similar serogroup distribution in both invasive and non-invasive disease (regardless of the site of clinical isolate), is consistent with serogroups colonizing non-sterile sites and having the potential to invade. The availability of conjugated vaccines reinforces the importance of systematic surveillance to determine accurately and regularly the coverage of pneumococcal serogroups and types causing both invasive and non-invasive disease.

Pneumococcal vaccination: opinion of general practitioners and hospital doctors in Scotland, 1999-2000.

A cross sectional survey by postal questionnaire was carried out to examine general practitioners' (GPs) and hospital doctors' (HDs) knowledge, attitudes and practice (KAP) with regard to pneumococcal vaccination in primary and hospital care in Scotland. Most GPs and HDs considered patients with chronic medical conditions, as recommended by the Department of Health (DoH), to be candidates for pneumococcal vaccination. Although the DoH does not currently recommend the vaccine for all the elderly, 47% of GPs and 46% of HDs reported that the vaccine should be given to this group. GPs (61-85%) and HDs (48-55%) indicated that they considered the vaccine to be safe and effective. The acceptance of pneumococcal vaccine was much lower than for influenza vaccine however, and 79% of HDs and 17% of GPs had never used the vaccine. Documented policies (with or without set targets) for pneumococcal vaccine existed in only 14% of general practice and 3% of hospital settings. Over 70% of respondents indicated that GPs should take responsibility for pneumococcal vaccination. The main sources of knowledge about pneumococcal vaccines were stated to be discussion with colleagues, review of medical literature, past experience, and the DoH recommendations. A clear immunisation policy and financial support for vaccination were identified as important strategies to improve pneumococcal vaccine coverage. Strategies directed toward these factors could enhance vaccine delivery and coverage of vaccine in high-risk individuals.

Prevention of pneumococcal disease in children. Pneumococcal conjugate vaccines: their use globally could have a major impact on public health.

UNLABELLED: Pneumococcal disease is a major cause of morbidity and mortality in infants and young children worldwide. New pneumococcal conjugate vaccines include 7 to 11 serotypes, which are the most common cause of paediatric disease in most parts of the world. The efficacy of a 7-valent conjugate vaccine was 97.4% (95% CI, 82.7-99.9) against invasive pneumococcal disease, and 57% (95% CI, 44-67) against otitis media, caused by vaccine serotypes. Evidence shows that the vaccine has the potential to prevent pneumonia. Pneumococcal conjugate vaccination has also been shown to reduce nasopharyngeal carriage of vaccine serotypes (particularly serotypes associated with antibiotic resistance). Thus widespread use of pneumococcal conjugate vaccine could substantially reduce the burden of invasive disease and would have the potential to control the global spread of antibiotic resistance in pneumococci. CONCLUSION: It is important that these highly effective vaccines should be made available to children in the developing countries.

Safety and immunogenicity of three lots of meningococcal serogroup C conjugate vaccine administered at 2, 3 and 4 months of age.

The reactogenicity and immunogenicity of meningococcal serogroup C conjugate (MenC) vaccine was assessed in 322 infants vaccinated at 2, 3, and 4 months of age, with concomitant administration of mixed diphtheria-tetanus-whole-cell pertussis vaccine and Haemophilus influenzae type b conjugate vaccine (DTwP-Hib) and oral polio vaccine. All infants in whom post-vaccination meningococcal C anticapsular IgG levels were assayed (n = 265) attained > or = 2 microg ml(-1). Serum bactericidal titres were assayed for a proportion of subjects (n = 171), 98% of whom obtained a reciprocal titres > or = 8. Local reactions were less frequent at the MenC injection site than at the DTP-Hib site. Systemic events were frequent, but consistent with established DTwP-Hib experience. The study demonstrates that MenC vaccine is immunogenic and well tolerated in infants at manufacturing scale production levels.

ADHII in Aspergillus nidulans is induced by carbon starvation stress.

In Aspergillus nidulans there are three NAD(+)-dependent alcohol dehydrogenases (ADHs) that are capable of utilizing ethanol as a substrate. ADHI is the physiological enzyme of ethanol catabolism and ADHIII is induced under conditions of anaerobiosis. The physiological role of ADHII (structural gene alcB) is unknown. We have measured beta-galactosidase in a transformant with an alcB::lacZ fusion and have shown that alcB is maximally expressed under conditions of carbon starvation. The behavior of the alcB::lacZ transformant suggests a hierarchy of repressing carbon sources characteristic of repression by the general carbon catabolite repressor protein, CreA, but in a creA(d)30 background the transformant shows only partial derepression of beta-galactosidase on 1% glucose compared to the creA+ strain. Our results suggest that, in addition to carbon catabolite repression acting via CreA, a CreA-independent mechanism is involved in induction of alcB on carbon starvation.

Epidemiology of chickenpox in Scotland: 1981 to 1998.

Scotland requires cases of chickenpox to be notified formally and maintains comprehensive data on general practice consultations, hospital admissions, abortions, laboratory reports, and mortality associated with the disease. These were used to investigate the age specific incidence of chickenpox for the years 1981 to 1998. The general trend was towards decreased age at infection: most infections now occur in the 1 to 4 year age group, rather than among schoolchildren. Hospital admissions for which a diagnosis of chickenpox was recorded increased, mainly in the under 5 and 25 to 34 year age groups. These data, which we believe to be among the most comprehensive available on current chickenpox epidemiology, may be used to inform preventative policy, particularly now that a live vaccine for the prevention of primary varicella infection is available. If vaccination against varicella is introduced in the United Kingdom, these data will provide a baseline against which to assess its impact on primary varicella infection.

Serotypes/groups distribution and antimicrobial resistance of invasive pneumococcal isolates: implications for vaccine strategies.

Based on the invasive pneumococcal isolates referred to reference laboratories in Scotland in 1988-99, we identified the distribution of serotypes/groups and their antimicrobial resistance patterns in order to evaluate the coverage of polysaccharide and the new pneumococcal conjugate vaccines. A total of 5659 invasive isolates were included. Of these, 5124 (90.5%) were blood isolates, 308 (5.5%) were CSF isolates, 143 (2.5%) were blood and CSF and 84 (1.5%) were other normally sterile isolates. The most prevalent 11 serotypes/groups were 14, 9, 19, 6, 23, 1, 3, 4, 7, 8 and 18, in numerical order. These accounted for 84% of total serotypes/groups. The serotypes/groups included in the 23 and 14-valent polysaccharide vaccines accounted for 96% and 88% of all isolates. Both vaccines accounted for 98% of penicillin non-susceptible and 100% of erythromycin non-susceptible isolates. The 7, 9, and 11-valent conjugate vaccines covered 61, 68 and 80% of invasive isolates respectively. The coverage of these vaccines was substantially higher in youngest age group with 84, 86 and 93% of invasive isolates in children < 2 years included in the 7, 9 and 11-valent conjugate vaccines compared with 58, 64 and 77% in adults > or = 65 years of age. The serotype/group distribution of invasive isolates in Scotland varied from year to year over the period 1993-9. The coverage of the 23-valent vaccine remained above 95% in each year but the coverage of the 7, 9 and 11-valent conjugate vaccines showed more marked fluctuation with coverage as low as 53, 60 and 75% in some years. Continued surveillance of invasive pneumococcal isolates is required to inform the development of appropriate vaccine strategies to prevent pneumococcal disease in Scotland.

The Scottish Centre for Infection and Environmental Health (SCIEH).

The Scottish Centre for Infection and Environmental Health has four core functions: the monitoring and surveillance of communicable diseases and environmental hazards in Scotland; operational advice and support at national and local level; research; and education and training. Its work is determined by a specification drawn up by the Public Health Policy Unit of the Scottish Office Department of Health. To fulfill its remit it works closely with a wide range of professionals, including those in the Scottish Office Department of Health, the health service, local government, and in organisations concerned with the environment. It also has close relationships with the Communicable Disease Surveillance Centre, Public Health Laboratory Service, London, the World Health Organization and other international bodies.

Randomised controlled trial of combined diphtheria, tetanus, whole-cell pertussis vaccine administered in the same syringe and separately with Haemophilus influenzae type b vaccine at two, three and four months of age.

An open randomised controlled multicentre study compared the immunogenicity and reactogenicity of three vaccines given by injection at two, three and four months of age. Children (89) received Haemophilus influenzae type b (Hib) vaccine (SmithKline Beecham Biologicals [SB]) administered in the same syringe with combined diphtheria-tetanus-whole-cell pertussis (DTPw) vaccine (Evans); 75 received Hib vaccine (SB) administered as a separate injection with DTPw vaccine; 66 received Hib vaccine (Pasteur Merieux [PM]) administered as a separate injection with DTPw vaccine. All subjects in both groups receiving Hib (SB) vaccine had levels of antibodies to the Hib polysaccharide polyribosylribitol phosphate (PRP) greater than 0.15 microgram ml-1 as did 97% of those receiving Hib (PM) vaccine 1 month after administration of the final vaccine dose. Subjects in all three groups demonstrated an immunological response to pertussis, diphtheria and tetanus antigens. The geometric mean titres of the group given Hib (SB) and DTPw vaccine mixed in the same syringe were lower than the other groups. There were no apparent differences between the treatment groups in the incidence of local or systemic reactions, or serious adverse events. This study has confirmed that it is possible to halve the number of injections necessary to offer protection, with advantages to parents, children, doctors and nurses, using a combined DTPwHib vaccine and in accordance with the UK's accelerated primary immunisation schedule at two, three and four months of age.

The centre for the vulnerable child: a new model for the therapeutic provision for abused children and their families.

In the last decade in Scotland there has been a rise in the number of known cases of children and adolescents who have experienced sexual abuse and a rise in the number of cases entering treatment after detection. This is putting a considerable strain on existing child and adult mental health services. As part of the response to this problem a new service was set up in Fife, the Centre for the Vulnerable Child, to provide an integrated focus for therapy, in-service training, consultancy and research into the area of sexual abuse. The Centre has strong links with the local joint police and social work Child Protection Unit with which it shares premises. Early indications are that the service is dealing primarily with more severely abused children. An evaluation is underway to assess both user satisfaction and the impact of this new service on measurable health and social outcomes among sexually abused children and their families. Professionals who have referred patients and clients to the Centre are largely satisfied with its work and an instrument for seeking the views of referred children is under development.

An outbreak of Escherichia coli O157 and campylobacteriosis associated with contamination of a drinking water supply.

Stream water into which treated sewage discharged contaminated the public water supply of a Fife village with a population of about 1100. Of 765 residents and workers who reported illness 711 had gastrointestinal symptoms and 633 were defined as cases. Mains water analysis revealed high faecal coliform counts. An outbreak of Campylobacter and E coli 0157 infection was bacteriologically confirmed in eight and six people respectively. Two of the latter developed haemolytic uraemic syndrome. All affected individuals made full recoveries. Human normal immunoglobulin was offered to those aged between six months and 40 years of age and 618 individuals were immunised. Salivary tests four months after the incident confirmed that no Hepatitis A outbreak had occurred. In a follow-up questionnaire residents generally expressed happiness with the medical response to the incident although many reported that they still had worries. The two major medical issues which emerged from this outbreak were the importance of effective communications and the appropriateness of offering post-exposure human normal immunoglobulin.

The cloning and sequencing of the alcB gene, coding for alcohol dehydrogenase II, in Aspergillus nidulans.

Alcohol dehydrogenase II (ADH II, structural gene alcB) was purified from a strain H1035, biA1; alcE1; alc500 alcD1, which produces 100-times more ADH II activity than the alcAalcR deletion strain (alc500). Antibodies were raised against this ADH, and were used to screen a cDNA library in lambda gt11. We have isolated the gene for an ADH which is over-expressed in H1035, and which we believe to be the alcB gene: cDNA and genomic clones were sequenced. The sequence contains three introns and encodes a protein of 367 amino acids. This protein shows a clear level of identity to a range of alcohol dehydrogenases, but is no more closely related to the ADH I and ADH III previously described in A. nidulans than to the ADHs of S. pombe and S. cerevisiae. The significance of consensus sequences found in the 5' region of the gene is discussed in relation to the regulation of the gene.

A review of Fife's food and health policy.

Fife Health Board published its food and health policy in May 1986, introduced a board-wide food and health strategy in 1987, and carried out a comprehensive review of its implementation in 1990. Other health boards currently considering their strategies may benefit by learning from Fife's experience. A number of base-line studies were carried out between 1987 and 1989 before the policy was implemented. Further surveys have monitored progress. Positive features of the programme included the introduction of a comprehensive food and health policy throughout the health board, the establishment of base-line measurements for future outcome evaluation, and the enthusiastic support of a wide range of people. Negative features included some opposition from a number of health service staff to its introduction, lukewarm support from public leaders for its proposed public launch, and a patchy response from the education sector. Although it is still too early to be confident of the success of policy in terms of outcome measures, there is some evidence that the first phase of its introduction may have had some success within the health service. Alternative strategies are now required to tackle some of the areas where the introduction was less successful.