Frank Mahoney

Immunogenicity of Hepatitis B Vaccines Implications for Persons at Occupational Risk of Hepatitis B Virus Infection

OBJECTIVE To assess risk factors for decreased immunogenicity among adults vaccinated with hepatitis B vaccine and to determine the importance of differences in immunogenicity between vaccines among health care workers (HCWs). DESIGN Randomized clinical trial and decision analysis. PARTICIPANTS HCSw. MAIN OUTCOME MEASURES Development of seroprotective levels of antibody to hepatitis B surface antigen (anti-HBs) and the number of expected chronic hepatitis B virus (HBV) infections associated with lack of protection. RESULTS Overall, 88% of HCWs developed seroprotection. Risk factors associated with failure to develop seroprotection included increasing age, obesity, smoking and male gender (P < .05). Presence of a chronic disease was associated with lack of seroprotection only among persons > or = 40 years of age (P < .05). The two vaccines studied differed in their overall seroprotection rates (90% vs. 86%; P < .05), however, this difference was restricted to persons > or = 40 years of age (87% vs. 81%; P < .01). Among HCWs > or = 40 years of age, the decision analysis found 44 (0.34/100,000 person-years) excess chronic HBV infections over the working life of the cohort associated with use of the less immunogenic vaccine compared to the other. CONCLUSIONS He patitis B vaccines are highly immunogenic, but have decreased immunogenicity associated with increasing age, obesity, smoking, and male gender; and among older adults, the presence of a chronic disease. One of the two available vaccines is more immunogenic among older adults; however, this finding has little clinical or public health importance. Hepatitis B vaccines should be administered to persons at occupational risk for HBV infection early in their career, preferably while they are still in their training.

Estimating the Incidence of Typhoid Fever and Other Febrile Illnesses in Developing Countries

To measure the incidence of typhoid fever and other febrile illnesses in Bilbeis District, Egypt, we conducted a household survey to determine patterns of health seeking among persons with fever. Then we established surveillance for 4 months among a representative sample of health providers who saw febrile patients. Health providers collected epidemiologic information and blood (for culture and serologic testing) from eligible patients. After adjusting for the provider sampling scheme, test sensitivity, and seasonality, we estimated that the incidence of typhoid fever was 13/100,000 persons per year and the incidence of brucellosis was 18/100,000 persons per year in the district. This surveillance tool could have wide applications for surveillance for febrile illness in developing countries.

Progress toward elimination of hepatitis B virus transmission in the United States

The strategy to eliminate hepatitis B virus (HBV) transmission in the United States is comprised of the following components: (1) preventing perinatal transmission, (2) routine infant vaccination, (3) catch-up vaccination of children in high-risk groups at any age, (4) catch-up vaccination of all children at 11-12 years of age and (5) vaccination of adolescents and adults in high-risk groups. According to recent surveys, > 85% of pregnant women are screened for hepatitis B surface antigen (HBsAg). Of infants born to HBsAg-positive women identified in 1995, 93% received appropriate immunoprophylaxis at birth; however, only 69% were fully vaccinated by 6-8 months of age. From 1991 (when routine infant hepatitis B vaccination was first recommended) to 1996, the proportion of 19-35-month-old children who have received three doses of hepatitis B vaccine has increased from < 10 to 83%. During this time, rates of acute hepatitis B in children 7-10 years of age have declined by 27% and rates among children 3-6 years of age have declined by 62%. Implementation of programmes for catch-up vaccination of all adolescents at 11-12 years of age and for vaccination of adolescents and adults in high-risk groups have only recently begun and no data are available to assess the progress of these programmes. However, 26% (13/50) of states now have laws requiring adolescents to be vaccinated in order to enter school. Current data indicate that substantial progress has been made in implementing a strategy to eliminate HBV transmission in the United States. Future efforts need to be focused on improving complete immunoprophylaxis of infants of HBsAg-positive mothers, increasing vaccine coverage among 11-12 year old children and implementing programmes to vaccine adolescents and adults in high-risk groups.

Etiology, antimicrobial susceptibility profiles, and mortality associated with bacterial meningitis among children in Egypt

PURPOSE Surveillance for patients with meningitis is a high priority in order to determine the etiology of disease and design prevention strategies. This study presents data on the causes of bacterial meningitis among children <6 years of age treated in a network of hospitals throughout Egypt. METHODS Training was provided to standardize the collection of clinical information and optimize recovery of bacterial pathogens. Bacterial isolates were tested for antimicrobial resistance patterns using Kirby Bauer disk diffusion, E-test and/or Beta-lactamase (BL) testing methods. RESULTS Patients with culture-confirmed bacterial meningitis (228 children<6 years) were identified including 89 (39%) patients with H. influenzae (HI), 68 (30%) with Streptococcus pneumoniae (SP), 30 (13%) with N. meningitidis (NM), 18 (8%) with Mycobacterium tuberculosis (MTB) and 23 (10%) with other bacteria. The overall case fatality ratio was high (24%) and increased among children with TB meningitis (56%). The susceptibility for HI to ampicillin (AMP), chloramphenicol (C) and ceftriaxone (CRO) was 21%, 13%, and 100% respectively. The susceptibility for SP to C and CRO was 79% and 100%, respectively. CONCLUSIONS HI and SP are the leading causes of bacterial meningitis among children in Egypt. The majority of HI strains tested were resistant to AMP or C suggesting the need for routine use of CRO as first line therapy. Among older children TB emerges as a significant cause of bacterial meningitis in Egypt.

Trends of Multiple-Drug Resistance among Salmonella Serotype Typhi Isolates during a 14-Year Period in Egypt

A total of 853 isolates of Salmonella serotype Typhi recovered from patients with typhoid fever who were admitted to a major infectious disease hospital in Cairo, Egypt, from 1987 through 2000 underwent antibiotic susceptibility testing to determine multiple-drug resistance. The observed resurgence of chloramphenicol susceptibility (P=.002) may suggest reuse of this drug for the treatment of typhoid fever in Egypt.

Overview of injection practices in two governorates in Egypt

objective  To describe the extent and characteristics of injection use and injection providers in Egypt, given that unsafe injections are associated with blood‐borne pathogen transmission.

Neonatal sepsis in Egypt associated with bacterial contamination of glucose-containing intravenous fluids.

Background: Rates of sepsis exceeding 50% in a neonatal intensive care unit (NICU) in Cairo, Egypt, were not controlled by routine antimicrobial therapy. We investigated these conditions in September 2001. Methods: Case series and retrospective cohort studies were conducted on 2 groups of NICU infants admitted to an academic medical center between February 12 and July 31, 2001. Observation of clinical practices led us to culture in-use intravenous (iv) fluids and medications. We monitored rates of iv fluid contamination, clinical sepsis and mortality after interventions to establish new procedures for handling and disposal of iv fluids, infection control training and improved clinical laboratory capacity. Results: Among infants in the retrospective cohort group, 88 (77%) of 115 had clinical sepsis, and 59 (51%) died. In the case series group, we documented the time of initial positive blood culture; 21 (64%) of 33 were septic <24 hours after birth. Klebsiella pneumoniae accounted for 24 (73%) of 33 isolates; 14 (58%) of 24 were extended spectrum β-lactamase-producing and aminoglycoside-resistant. On admission, all neonates received glucose-containing iv fluids; iv bottles (500 mL) were divided among multiple infants. The iv fluids were prepared at the bedside; poor hand hygiene and poor adherence to aseptic techniques were observed. K. pneumoniae was isolated from 13 (65%) of 20 in-use glucose-containing iv fluids. Fluid contamination, sepsis and mortality rates declined significantly after intervention. Conclusion: Extrinsically contaminated iv fluids resulted in sepsis and deaths. Standard infection control precautions significantly improve mortality and sepsis rates and are prerequisites for safe NICU care.

Progress in measles and rubella elimination in Iran.

Background: Measles is a leading cause of death worldwide because of vaccine preventable diseases. Prevention and control of measles and rubella is a high priority for the Islamic Republic of Iran. In 2002, the Ministry of Health and Medical Education in Iran developed a comprehensive strategy to eliminate measles and rubella. This strategy included recommendations for a mass immunization campaign for all persons between the ages of 5–25 years with measles-rubella (MR) vaccine. This report reviews the results of this campaign and progress in the elimination of measles and rubella in Iran. Methods: Measles vaccination coverage, supplemental immunization activities, surveillance data, and results from a nationwide serosurvey were reviewed. Results: Between 1980 and 2005, vaccination coverage ranged from 38%–99% with sustained high coverage (≥94–99%) for the past decade. Despite high coverage with the first dose of measles vaccine (MCV1) and the introduction of a second dose of measles in 1984, case counts remained high between 1980 and 2005 with a median case count of 4414. In December 2003, a nationwide immunization campaign was conducted targeting 33,579,082 people between the ages of 5 and 25 years with a combined measles and rubella vaccine; 98% of the target population was vaccinated. A postcampaign serosurvey conducted in 2004 revealed >97.4% of the population aged between 5 and 40 years had immunity to measles and rubella. Case-based surveillance for measles identified 3 children with laboratory confirmed disease in 2004, 35 in 2005, and 42 children in 2006. Most confirmed disease occurred in immigrant communities or communities with migrant populations from neighboring counties with ongoing measles outbreaks. Surveillance for rubella was established after the campaign and identified 37 patients with confirmed disease in the follow-up period. Conclusions: Implementation of a comprehensive strategy for measles elimination in Iran has remarkably reduced the incidence of measles and rubella to <1 case per 1,000,000. Sporadic transmission continues to occur, particularly in areas with immigrant and nomadic populations.

A hepatitis B vaccination program targeting adolescents

PURPOSE To determine the effectiveness of using a middle school for hepatitis B vaccination of adolescents. METHODS An immunization program was designed to educate parents and students about hepatitis B virus (HBV) infection and hepatitis B vaccination using science class presentations and mailings. Students were given at each visit and on vaccination series completion. Costs were calculated and divided by the number of students completing the series to obtain per student cost. RESULTS Of the 654 students, 519 (79%) received at least one dose of hepatitis B vaccine, 497 (76%) two doses, and 425 (65%) three doses. Student participation did not vary by grade level, gender, or income. Per student vaccination cost was

Hepatitis B vaccination in sexually transmitted disease (STD) clinics: a survey of STD programs.

77.23 for those receiving three doses of hepatitis B vaccine and