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Journal Club summaries - 2008

Opportunistic immunisation of infants admitted to hospital: are we doing enough?

Ressler KA, Orr K, Bowdler S, et al.
Journal of Paediatrics and Child Health 2008;44(6):317-20
Link to abstract

With associated editorial: Minimising missed opportunities to vaccinate. Crawford NW, Buttery JP. Journal of Paediatrics and Child Health 2008;44(6):315-6.

Ressler et al compared ward-based assessment of immunisation status with ACIR data to determine the effectiveness of opportunistic immunisation of children in the paediatric unit of a large teaching hospital in South Eastern Sydney. 9% of the children included in the study were reported to be not up-to-date with their immunisations according to their hospital charts and poor agreement was reported between ACIR and hospital charts. A missed opportunity to vaccinate was reported in 24% of those identified on admission as overdue but was less likely in those children given a catch-up plan prior to discharge when assessed at 30 and 90 days post-discharge. The study considered the ACIR to be the gold standard when assessing immunisation status but failed to identify the delay associated with reporting to the ACIR. However, the study highlighted the potential of ward-based access to ACIR to reduce inaccuracies of immunisation status and identified areas of potential improvement and strategies to reduced missed opportunities to vaccinate.

Presented by Anita Heywood, Research Assistant, NCIRS, and PhD candidate, School of Public Health and Community Medicine, The University of New South Wales

Brachial plexus neuritis following HPV vaccination

Debeer P, De Munter P, Bruyninckx F, Devlieger R
Vaccine 2008;26(35):4417-9
Link to abstract

This is a case report from Belgium of brachial plexus neuritis following HPV (Gardasil®) vaccination. A 19-year-old student was referred to the orthopaedic department with a three month history of severe shoulder pain heavily interfering with normal daily activities after the second dose of HPV vaccination. Conservative treatment consisting of adequate analgesia was initiated. Eight months after the onset of the pain, there was marked improvement of strength and mobility of the left shoulder but pain remained present requiring high doses of analgesics.

This first case warrants careful attention in view of the large vaccination campaigns in young adolescents being launched all over the world. The post-vaccination event described in this patient is one of extreme rarity and careful monitoring of unusual complications like this is important. Since the HPV vaccination comprises of three consecutive injections, this could theoretically potentiate the neurological complications observed after the first or second injection.

Presented by Dr Aditi Dey, Epidemiologist, NCIRS

Effects of influenza plus pneumococcal conjugate vaccination versus influenza vaccination alone in preventing respiratory tract infections in children: a randomized, double-blind, placebo-controlled trial

Jansen AG, Sanders EA, Hoes AW, et al.
Journal of Pediatrics 2008;153(6):764-70
Link to abstract

The main objective of this study was to evaluate the effects of influenza vaccination with or without heptavalent pneumococcal conjugate vaccination on respiratory tract infections (RTIs) in children.

This study was a randomised, double-blind, placebo-controlled trial conducted in the Netherlands, comprising 579 children aged 18 to 72 months with a previous history of physician-diagnosed RTI who had not been vaccinated with any of the study vaccines, recruited in the months of September and October in the three years of 2003, 2004 and 2005. Children with specific medical conditions for which the influenza or pneumococcal vaccine were recommended were excluded. The participating children were randomly assigned to one of the three groups, to receive either 2 doses of parenteral inactivated trivalent subunit influenza plus heptavalent pneumococcal conjugate vaccination (TIV+PCV7), influenza plus placebo vaccination (TIV+plac), or control hepatitis B virus vaccination plus placebo (HBV+plac).

Study results showed that during the influenza seasons, febrile RTI were reduced by 24% (95% confidence interval [CI] 1% to 42%) in the TIV+PCV7 group and by 13% (95% CI –12% to 32%) in the TIV+plac group compared with the control group. The occurrence of PCR-confirmed influenza was reduced by 52% (95% CI 7% to 75%) in the TIV+PCV7 group and by 51% (95% CI 3% to 75%) in the TIV+plac group. Episodes of AOM were reduced by 57% (95% CI 6% to 80%) in the TIV+PCV7 group and by 71% (95% CI 30% to 88%) in the TIV+plac group. There were no significant differences in primary care visits and antibiotic prescriptions among the three groups. Outside of the influenza seasons, no significant effects of vaccinations were demonstrated on the studied outcomes. Two of the three influenza seasons were mild seasons, and the influenza vaccine virus strains were suboptimal matches with the dominant circulating influenza strains over all the three seasons.

Results of this study were in agreement with other published non-randomised, unblinded or small studies or the few meta-analyses on the effect of the inactivated influenza vaccine in younger children. This study had limited power to detect a small additional benefit, if any, of the pneumococcal conjugate vaccine against AOM in children of this age group.

Presented by Dr Clayton Chiu, Clinical Research Fellow, NCIRS

Too little but not too late: results of a literature review to improve routine immunization programs in developing countries

Rymen TK, Dietz V, Cairns KL
BMC Health Services Research 2008;8:134
Link to abstract

This review provides a valuable insight into the status of immunisation related health services research in developing countries.

A disproportionately high burden of vaccine preventable diseases is borne by low and middle income countries due to their failure to achieve acceptable levels of vaccine coverage. Against this backdrop, the authors claim that there is a clear need to make national and sub-national level managers of immunisation services in these countries aware of proven strategies designed to strengthen routine immunisation programs at community and facility level to improve vaccine coverage. However, the key message that emerges from this review is that there is a disturbing lack of good quality research based evidence related to immunisation services to inform policy and practice in developing countries.

The authors have conducted a comprehensive search of the published and grey literature. They used a standardised assessment tool, comprising elements considered critical to the scientific quality of a study and the readability to understand adequately an intervention and its impact, to rate papers. The authors compiled four approaches for immunisation service managers to identify effective strategies: bringing immunisation closer to the community, using information dissemination to increase demand for vaccination, changing practices in fixed sites and using innovative management practices. 

Despite an exhaustive search, the authors have been able to identify only 25 papers for the period from 1974 to 2004 that meet the inclusion criteria for the review. They were only from 17 separate countries and 3 were situation specific with limited transferability. Papers were also found to be of moderate scientific quality probably because research was not the primary purpose of the activity described. There were only 4 papers in the last 10 years. Due to this lack of high quality research based evidence to inform policy and practice these countries will continue to struggle to make best use of their limited resources. These countries will continue to be reservoirs of diseases to the rest of the world and their low levels of vaccine coverage will significantly impact the potential to eliminate and eradicate vaccine preventable diseases. 

Presented by Sanjay Jayasinghe, Senior Project Officer, NCIRS

World wide experience with inactivated poliovirus vaccine

Bonnet MC, Dutta A
Vaccine 2008;26(39):4978-83
Link to abstract

This article provides an excellent overview of the development and implementation of poliomyelitis vaccines and will be an extremely useful reference for anyone reviewing the global use of these vaccines. 

The paper provides an overview of the disease and polioviruses and the key milestones in the development of a suitable polio vaccine for global use. The various schedules used by different countries are described with some countries using inactivated poliomyelitis virus vaccine (IPV) alone, others using a combination of oral poliomyelitis virus vaccine (OPV) with some doses of IPV, and some countries continuing to use OPV exclusively. 

The authors suggest that IPV could replace OPV due to the high immunogenicity and safety of IPV and acknowledge the contribution that OPV has made towards the ultimate aim of the global elimination of polio. A move to IPV will be necessary to ensure eradication of both wild-type and vaccine-derived polioviruses as part of the WHO Polio Eradication Initiative. 

However, the authors concede that such a move to IPV will be driven by not only medical but political, ethical, economical and logistical considerations.

Outer membrane vesicles as acellular vaccine against pertussis

Roberts R, Moreno G, Bottero D, et al.
Vaccine 2008;26(36):4639-46
Link to abstract

The authors describe a series of experiments undertaken using the animal mouse-model and an outer membrane vesicle (OMV) vaccine prepared from 2 different B. pertussis strains. Analysis of the proteome of the B. pertussis OMV indicated that at least 43 potential antigens could be used to develop an effective pertussis vaccine although the immune response generated for each antigen was not assessed individually by the authors. The OMV included a number of antigens already used in the currently available acellular pertussis vaccines and the use of surface exposed protein such as those described allow for a preferentially targeted immune response. 

However, this OMV study was limited to use in an animal model at present. OMV vaccines have already been described for other micro-organisms, such as Neisseria

Presented by Dr Jane Jelfs, Immunisation Handbook and Policy Coordinator, NCIRS