Christine Miller

Surveillance of antibody to measles, mumps, and rubella by age.

Before the introduction of measles, mumps, and rubella vaccine a survey was carried out to measure antibody prevalence to the three viruses by age. A total of 8716 samples of serum collected by five public health laboratories in different parts of England during 1986-7 were tested. Despite the current measles vaccination programme 60% of children aged 1-2 years did not have measles antibody and over 80% did not have antibodies to mumps and rubella. In the 3-4 year age group 17% of the children were susceptible to measles, 55% to mumps, and 73% to rubella. The results suggest that vaccinating children early in the second year of life will be necessary to eliminate the three diseases. The survey provides baseline data for continuing surveillance of the immediate and long term effects of the new vaccination strategy.

Rubella susceptibility and the continuing risk of infection in pregnancy.

Dr Neil Smith, FRCP, is consultant dermatologist and honorary senior lecturer in histopathology at the Institute ofDermatology, St Johns Hospital for Diseases ofthe Skin, London WC2H 7BJ, and Dr Margaret Spittle? MSC, FRCR, is consultant radiotherapist and oncologist at St Johns Hospital for Diseases ofthe Skin and the Middlesex Hospital, LondonWIN 8AA. The photograph oflymphoma was reproduced by kind permission ofDr Charles Farthing. lymphoma is difficult. The use ofintravenous multiple agent chemotherapy regimens(CHOP orMBACOP) has resulted in complete initial remission, but there is a high relapse rate with poor response to second line chemotherapy. The commonly found disease ofthe central nervous system dictates that CNS irradiation or intrathecal chemotherapy should be given. Although some long term responses have been noted, median survival of these patients is poor and is usually less than a year. Most patients die from their lymphoma, although others succumb to opportunistic infections. Patients are treated aggressively with cytotoxic regimens ifthe symptoms of lymphoma appear before the opportunistic infections ofAIDS, but ifthe patient has had recurrent infective episodes radical chemotherapy treatment is often curtailed or withheld. The rare cases oflow grade lymphoma should be treated conservatively.

Effect of selective vaccination on rubella susceptibility and infection in pregnancy.

The effect of school and adult vaccination on susceptibility to rubella in women of childbearing age was assessed in the Manchester area, where the population attending antenatal clinics is over 40 000 a year. Between 1979 and 1984 the proportion susceptible fell from 6.4% to 2.7%. In 1984, 4.2% of nulliparous women were susceptible compared with 1.4% of women in their second or subsequent pregnancy. Eighty five per cent of pregnant women screened and found to be non-immune were vaccinated post partum before leaving hospital. Requests for prevaccination screening of non-pregnant women increased in response to a national campaign and at the time of local outbreaks of rubella but only two thirds of those found to be nonimmune were subsequently vaccinated. During 1983 and 1984 infection was confirmed in 57 pregnant women--2% of those non-immune. Selective vaccination has reduced susceptibility to rubella in the childbearing population, but it is suggested that mass vaccination of children of both sexes should be added to the existing policy to control circulation of wild rubella virus and reduce the risk of infection to pregnant women who remain susceptible.

Antibody response and reactions to aqueous influenza vaccine, simple emulsion vaccine and multiple emulsion vaccine. A report to the Medical Research Council Committee on influenza and other respiratory virus vaccines*

Influenza vaccines prepared with a mineral oil adjuvant induce a substantial and durable antibody response. However, vaccines containing mineral oil in simple emulsion (water-in-oil emulsion) sometimes produce persistent local reactions (Medical Research Council, 1964). The development of a redispersed ‘multiple’ emulsion in which antigen is incorporated as an oil-in-water emulsion starting from an original water-in-oil emulsion was described by Herbert (1965). Such multiple emulsion vaccine has a lesser viscosity than simple emulsions and might therefore produce a substantial antibody response with fewer reactions. In this investigation a comparison has been made of the antibody response and short-term vaccination reactions after aqueous influenza vaccine, influenza vaccine containing a mineral oil in simple emulsion, and influenza vaccine containing mineral oil in multiple emulsion.

SURVEYS OF RUBELLA ANTIBODIES IN YOUNG ADULTS AND CHILDREN

22 000 serum samples from university students and young adult blood donors collected between 1969 and 1980 were tested for antibody to rubella virus. Of the women born in 1956 and after (i.e., those eligible for rubella vaccine at school) the proportions seronegative ranged from 3% to 6% in different years, compared with 12-20% in men of the same age groups. Serum samples from schoolchildren were also tested: 40-50% of girls and boys aged 10-11 years were seronegative--percentages similar to those before the introduction of vaccine. However, only 2-6% of 15-year-old girls (who would have been offered vaccine) were seronegative compared with 20-30% of 15-year-old boys. These results indicate that the rubella vaccination programme in the U.K. is having a significant impact on the immunological status of young women of childbearing age but that a large number of women remain potentially susceptible.

Immunisation of preterm infants.

and achieve better results than the officially appointed health professionals. Many of the health targets set for 1990 were achieved without incurring the expense of providing a new water supply, additional food, or new sanitation methods-the total cost of the project being about Rs 6 per head per year. The Mandwa project also showed that the interest of the health professional does not always coincide with the interest ofthe people. The professionals prefer to retain power over the local people and keep medical treatment shrouded inmystery. Moreover, it seems that few trained health workers, however well intentioned, can discriminate between education and intelligence and hence establish a rapport with the local people. Perhaps the reason that the Mandwa experiment and other similar projects remain isolated experiments that have had little impact on the health service of India lies in the opposition from the people who hold the power in rural communities. Resistance to anything that changes the status quo is considerable. This seems the only explanation for the fact that almost four decades after independence half the population in India remain below the poverty line, 30 of every 1000 children who are born die within the first year, and diseases that can be prevented and controlled continue to take their toll. It may also explain why, despite there being a school in every village, about 60% of the population (75% of women) are illiterate. This is profoundly important for the link between female literacy and health is clear: in Bihar and Uttar Pradesh where female literacy is 14%, the infant mortality rate is 177. By comparison, in Kerala female literacy is 65% and the infant mortality rate is 42. -Sadly even well intentioned doctors see health as an isolated problem rather than as a subsystem of the social,economic, and -political structureof the country. Even with the best of intentions most voluntary agencies with their purely humane approach often help to create an even greater dependence among those whom they serve. The Mandwa experiment may either be seen as a failed community health project or as an experiment that shows that simple knowledge and technology can help poor people to overcome their fears and develop selfreliance. Before health can be improved appreciably, however, education, especially of women, must be improved. Furthermore, the economy must be developed and the political will generated to effect change.