Vaccine-preventable Illnesses Research Articles

Patients with systemic inflammatory and autoimmune diseases are at risk of vaccine-preventable illnesses

To evaluate vaccine coverage and humoral immunity to tetanus, diphtheria and poliomyelitis in adults followed for systemic inflammatory and/or autoimmune diseases (SIADs). A cross-sectional study was conducted between June and August 2006 in a monocentric cohort of adults with SIAD. A standardized questionnaire was administered to collect medical, therapeutic and vaccine coverage data. Blood samples were collected in order to measure antibody titres against diphtheria, tetanus and poliomyelitis (DTP). One hundred and eighty-six patients, 32% males, mean (s.d.) age 51 (16) years, 79% receiving CSs and/or immunosuppressants, were included. The vaccine coverage was 29% for diphtheria, 48% for tetanus and 33% for poliomyelitis. The percentages of patients with no humoral immunity against DTP were 44, 21 and 12%, respectively, decreasing to 37.5, 10 and 0%, respectively, for those who had received a vaccine booster in the last 10 years. In a multivariate analysis, age and CS treatment were associated with the absence of humoral immunity against diphtheria and female sex, CD4(+) T cell <200/mm(3) and an absence of tetanus vaccine booster in the last 10 years with the absence of humoral immunity to tetanus. Vaccine coverage against tetanus, diphtheria and poliomyelitis is low in patients with SIAD despite the risk in this population of severe infection, especially when receiving immunosuppressants. A significant proportion of them had no humoral immunity against diphtheria or tetanus. Specific immunization schedules need to be optimized in these patients.

Immunosuppression Impairs Response to Pneumococcal Polysaccharide Vaccination in Patients With Inflammatory Bowel Disease

The treatment of inflammatory bowel disease (IBD) often includes immunosuppressive medications, which may increase the risk of vaccine-preventable illnesses. We aimed to assess the impact of immunosuppression on immune responses to pneumococcal vaccination in patients with IBD. The study design consists of a prospective controlled clinical trial. This study was carried out at a tertiary-care IBD clinic. The subjects for the study belonged to one of the following three groups: adult patients with IBD on combination TNF-blockers and immunomodulators (Group A), those without immunosuppressive therapy (Group B), and age-matched healthy controls (Group C). The treatment consisted of immunization with 23-valent pneumococcal polysaccharide vaccines (PSVs). The main outcome was immune response for five serotypes defined as a twofold or greater increase from pre-vaccination titers and > or =1 microg post-vaccination titer. Sixty-four subjects participated in the study: 20 in Group A, 25 in Group B, and 19 in Group C. Pre-vaccination titers were similar among the three groups. Vaccine responses were lower in Group A than in Group B (P< or =0.01 for four out of five antigens) and Group C (P<0.01 for all five antigens). Overall vaccine response was seen in 45, 80, and 85% of Groups A, B, and C (P=0.01), respectively. Immune response to PSV-23 is impaired in Crohn's disease (CD) patients on combination immunosuppressive therapy but is normal among non-immunosuppressed patients. Given the unpredictable likelihood for immunosuppressive therapy, newly diagnosed patients with IBD should undergo vaccination before the initiation of immunosuppressive therapy.

Not Just for Kids: New Paradigms for Vaccine Delivery in Pediatrics

Protecting children and adolescents from vaccine-preventable illnesses is a central goal of pediatric medicine. Educating family members, a willingness to vaccinate at all visits, and implementing recall-reminder systems are some of the classic strategies used to enhance pediatric vaccination rates. However, 2 recent expansions to the currently recommended vaccine schedule create new challenges for primary care—vaccinating adolescents and vaccinating adults who have close contact with infants. The adolescent population has been challenging to vaccinate because they have more sporadic primary care visits than younger children.

Routine immunization of adults in Canada: Review of the epidemiology of vaccine-preventable diseases and current recommendations for primary prevention.

Vaccination is one of the greatest achievements in public health of the 20th century. However, the success of vaccine uptake and adherence to immunization guidelines seen in pediatric populations has not been observed among adult Canadians. As a result of the disparity in susceptibility to vaccine-preventable disease, there has been an increasing shift of vaccine-preventable childhood diseases into adult populations. Accordingly, morbidity and mortality due to vaccine-preventable illnesses now occur disproportionately in adults. All Canadians, irrespective of age, should have immunity to measles, mumps, rubella, tetanus, diphtheria, pertussis and varicella. All adult Canadians with significant medical comorbidities or those older than 65 years of age should receive the pneumococcal polysaccharide vaccine and yearly trivalent inactivate influenza vaccines. The present review summarizes the burden of illness of these vaccine-preventable diseases in the Canadian adult population and reviews the current immunization recommendations. Vaccination of all Canadians to these common agents remains a vital tool to decrease individual morbidity and mortality and reduce the overall burden of preventable disease in Canada.

Emerging Viruses in Transplantation: There Is More to Infection After Transplant Than CMV and EBV

Transplant physicians and surgeons are familiar with the risks, clinical behavior, and management of cytomegalovirus in transplant recipients. Donor-transmitted viral infections are uncommon but in recent years have brought to light the clinical manifestations of rabies, West Nile virus, and lymphocytic choriomeningitis virus in the early posttransplant period. Later posttransplant, infection with viruses circulating in the community can occur with a number of pathogens, including some vaccine-preventable illnesses such as measles and mumps. Recent advances in molecular microbiology have made it possible to diagnose a growing number of community-acquired viral pathogens infecting transplant recipients. This article reviews some of the emerging and reemerging viral pathogens infecting solid organ and hematopoietic stem-cell recipients, including adenovirus, bocavirus, coronavirus, human herpesvirus-6, lymphocytic choriomeningitis virus, measles, mumps, metapneumovirus, parainfluenza, rotavirus, respiratory syncytial virus, and West Nile virus.

Programme activities: a major burden for district health systems?

The dual nature of dealing with health problems has been recognized since antiquity. Asklepios, the god of medicine in ancient Greece, had two daughters: Panacea – the goddess of healing and cures, and Hygeia – the goddess of welfare and hygiene, symbolizing curative and preventive medicine respectively. It is well understood nowadays that these two approaches blend: the range from primary and secondary prevention over curative to rehabilitative and promotive action is a continuum rather than a series of neatly separated concepts and activities. Nevertheless, there is a fundamental difference in the people the two approaches are dealing with: curative medicine deals with people who are ill, often acutely so, whereas preventive activities are largely directed at people who are not (yet) ill or only slightly so. Therefore, preventive activities can be organized in a periodic fashion, but curative activities are timely only when carried out at the moment people are ill and thus need to be permanently available – ideally. In present day health services, certainly in developing countries, both approaches are combined, most often in the same health structure and by the same health personnel (WHO 2006). Over the last decades an increasing number of health problems have been identified as priorities, based on their estimated contribution to the overall burden of disease and the availability of cost-effective measures, many of which are related to secondary prevention (Hotez et al. 2007, Johns & Tan Torres Edejer 2003). In a typical West-African country, a list of such problems and measures may (and often does) include Guinea worm, tuberculosis, vitamin A supplementation, schistosomiasis, soil transmitted helminthiasis, trachoma, vaccine preventable child illnesses, reproductive health and malaria, with variable importance given to HIV. All these health priorities are implemented at regional and district level through various strategies such as punctuated mass campaigns or regular outreach activities, each of which requires specific training and temporary mobilization of health workers, and thus valuable time and attention. In Douentza, a rural health district in Mali, we determined the relative importance of the time spent by qualified staff in charge of first line health services on activities requiring their absence from the health centre. We distinguished activities related to their general duties, and specific programme activities, including district mass campaigns. Data for the year 2006 were collected from district reports and administrative district and regional documents. The information concerned first line health care structures (a total of 15 health centres, with 14 situated in rural areas and one in the district’s central town) and their nurses in charge. Table 1 shows that in 2006 the nurse in charge of the health centre was absent during 81 working days in the case of the district central town health centre, and during 118 working days in the case of rural centres. This difference in days of absence is related to the time needed for the nurses in rural areas to reach the district’s central town, where training activities generally take place. In the ‘worst case’ scenario, which applies to the majority of health centres situated outside the district’s central town, the total annual nurse’s absence (118 working days) represents more than half (52%) of the annual total number of working days (225 days per year). Of these 118 days, 69 (58%) were directly attributable to specific programme activities, with mass campaigns being the principal component (Table 1). Mass drug distributions to control and eliminate trachoma, schistosomiasis and soil-transmitted helminthiasis as well as vitamin A distribution campaigns were carried out in the district in 2006. The nurses in charge were instructed to participate in Tropical Medicine and International Health doi:10.1111/j.1365-3156.2008.02174.x

Epidemiology and public health in primary care: looking back and forward - 30 years after Alma Ata.

Epidemiology is the basic science of public health, and an epidemiologist has been described as someone with a brilliant mind but dirty hands! The dirty hands come from the essential ability to count, collate and analyse raw data in order to give meaning to it. This ability to synthesise research evidence and transform health service activity data into simple and clear information for health service managers is what makes epidemiology an essential link between research and health policy. One of the key aims of the London Journal of Primary Care is to facilitate the transfer of good research evidence and best practice into London primary care, as well as helping to build up the evidence base to support clinical practice from a variety of sources including local audits and experiential learning. As the Epidemiology Editor, I look forward to reviewing articles that are grounded in both qualitative and quantitative research methodology, but will also encourage articles with simpler methodologies where the focus is on improving clinical quality and systems. London is a unique city – not only in the financial, arts and multi-cultural realms, but in its contribution to the history and development of epidemiology and public health in the United Kingdom and rest of the world. It is not surprising therefore that London is home to some ‘national treasures’ ranging from great medical and social science institutions, research centres, health observatories, prisons, air and sea ports to unique and prestigious government departments. These have one thing in common – they are a rich source of routine data which could be used to improve the health of Londoners in various ways ranging from infectious disease surveillance, to monitoring trends in patterns and distribution of morbidity, mortality and health inequalities across the capital. The epidemiology team will seek to build collaborations between the journal and these London institutions so that the journal becomes an important vehicle for disseminating information relevant to the health of Londoners. We will also welcome articles from other metropolitan cities across the world with similar demographic profiles to that of London. This year marks the 30th anniversary of the WHO declaration of the Alma Ata principles which emphasised the central role of primary health care (PHC) in any given health system. Many of the issues specifically addressed in that declaration such as the need for appropriate social and cultural systems to support health care, involving individuals and communities in health care decisions, the need for affordable health care, health inequalities, the link between poverty and health and the menace from vaccine preventable childhood illnesses are still very much important health issues in London today. The next issue of the London Journal of Primary Care will focus on the Alma Ata declaration and I would like to invite articles that demonstrate relevant lessons learnt across primary care from different perspectives. That includes articles that look forward using these lessons, derived from the familiar research methods to case studies and relevant experiences over the past 30 years in settings relevant to a metropolitan city.

Perceived Vaccination Status in Ecotourists and Risks of Anthropozoonoses

Anthropozoonotic (human to nonhuman animal) transmission of infectious disease poses a significant threat to wildlife. A large proportion of travelers to tropical regions are not protected against vaccine-preventable illnesses, and a majority of these travelers demonstrate poor recall of actual vaccination status. Here we characterize self-perceived vaccination status among a large sample of ecotourists at the Sepilok Orangutan Rehabilitation Centre, Sabah, Malaysia. Despite their recognized travel itinerary to view endangered animals, tourists at wildlife sanctuaries are not adequately protected against vaccine-preventable illnesses. Of 633 surveys, over half reported being currently vaccinated against tuberculosis, hepatitis A, hepatitis B, polio, and measles. Fewer participants reported current vaccination status for influenza, rabies, and chickenpox. Despite the fact that the majority of visitors to Sepilok are from temperate regions where influenza is relatively more prevalent, 67.1% of those surveyed with medical-related occupations reported not being currently vaccinated for influenza. Ecotourists concerned about environmental protection are themselves largely unaware of their potential contribution to the spread of diseases to animals. The risks of negatively affecting animal populations must be communicated to all concerned parties, and this may begin by urging travelers to examine their actual vaccination status, particularly as the ecotourism industry continues its rapid expansion, and is seen increasingly as a possible tool to save great ape populations from extinction.

Displacement and disease: The Shan exodus and infectious disease implications for Thailand

Decades of neglect and abuses by the Burmese government have decimated the health of the peoples of Burma, particularly along her eastern frontiers, overwhelmingly populated by ethnic minorities such as the Shan. Vast areas of traditional Shan homelands have been systematically depopulated by the Burmese military regime as part of its counter-insurgency policy, which also employs widespread abuses of civilians by Burmese soldiers, including rape, torture, and extrajudicial executions. These abuses, coupled with Burmese government economic mismanagement which has further entrenched already pervasive poverty in rural Burma, have spawned a humanitarian catastrophe, forcing hundreds of thousands of ethnic Shan villagers to flee their homes for Thailand. In Thailand, they are denied refugee status and its legal protections, living at constant risk for arrest and deportation. Classified as "economic migrants," many are forced to work in exploitative conditions, including in the Thai sex industry, and Shan migrants often lack access to basic health services in Thailand. Available health data on Shan migrants in Thailand already indicates that this population bears a disproportionately high burden of infectious diseases, particularly HIV, tuberculosis, lymphatic filariasis, and some vaccine-preventable illnesses, undermining progress made by Thailand's public health system in controlling such entities. The ongoing failure to address the root political causes of migration and poor health in eastern Burma, coupled with the many barriers to accessing health programs in Thailand by undocumented migrants, particularly the Shan, virtually guarantees Thailand's inability to sustainably control many infectious disease entities, especially along her borders with Burma.

Immunization for Vaccine-Preventable Illnesses in Patients with Inflammatory Bowel Disease

Purpose: Vaccines are underutilized in immunocompromised patients including those with Inflammatory bowel disease (IBD) on immunosuppressive therapy, despite published guideline recommendations. IBD patients on immunosuppressive therapy are at higher risk for infections. A recent study suggests that immunization against vaccine-preventable illnesses is uncommon in IBD patients and efforts are needed to improve vaccine administration. Aim of our study was to determine the rate of immunization among patients with Inflammatory bowel disease (IBD) on immunosuppressive therapies, identify patients at risk for infection, and review reasons for non-immunization. This study was undertaken to improve performance at our institution. Methods: Electronic medical records of all outpatients with IBD seen at Ochsner Clinic Foundation between September 2005 and August 2006 were retrieved based on ICD-9 codes between September 2005 to August 2006. Patients on immunosuppressive therapy were administered a 25-point phone survey questionnaire encompassing basic medical history, IBD related medication exposure, vaccination history, previous infections with vaccine preventable diseases. Electronic medical records were assessed for hepatitis B serology and varicella titers (IgG; ELISA). Information was collected on exposure to known risk factors for acquiring selected vaccine preventable diseases. Results: 798 patients were coded as having IBD during the study period. A phone survey questionnaire was administered to 189 patients on immunosuppressive therapies. Our final study population included 118 patients after excluding 71. 95 (81%) patients recalled tetanus immunization within the past 10 yrs, 53 (45%) reported annual flu shots, and 32 (27%) reported pneumococcal vaccination. One of the more common reasons for nonimmunization for influenza included lack of awareness (31%). 47 patients (40%) were at risk for HBV but only 28 (24%) were vaccinated. 27 patients could not recall a history of chicken pox; of these, 13 reported varicella immunization. Conclusion: Immunization against vaccine-preventable illnesses is underutilized in IBD patients on immunosuppressive therapies. Efforts are necessary to improve immunization efforts in this at risk population.

Patients with Inflammatory Bowel Disease Are at Risk for Vaccine-Preventable Illnesses

Patients with chronic, immune-mediated conditions such as inflammatory bowel disease (IBD) are often treated with long-term immunosuppressive therapies, potentially increasing their risk of developing an infection. Empiric data suggest that vaccines are underutilized in immunocompromised patients, despite published guidelines recommending their use. We aimed to assess exposure risk and immunization status among patients receiving care in an IBD specialty clinic. Patients completed a self-administered, pretested, structured questionnaire during a routine visit for the management of IBD. Survey questions related to medical and immunization histories, and exposures to known risk factors for influenza, pneumococcus, viral hepatitis, and varicella. Additionally, in a subgroup of patients who agreed to donate a sample of blood, immune status to hepatitis A (HAV), hepatitis B (HBV), and varicella was determined. Two hundred four patients were asked to participate in the study; 169 completed surveys and comprised the study population. Mean age was 35 yr (range 13-75 yr). One hundred forty-six respondents (86%) reported current or prior use of immunosuppressive medications. Only 45% of respondents recalled tetanus immunization within the past 10 yr, 41 (28%) reported regularly receiving flu shots, and 13 (9%) reported having received pneumococcal vaccine. The most common reasons for nonimmunization with influenza included lack of awareness (49%) and concern for side effects (18%). Responses indicated that 75 (44%) patients were at risk for HBV but only 47 (28%) had been vaccinated against the infection; of patients with previous HBV vaccination, only three of nine (33%) had measurable antibodies against hepatitis B surface antigen. Immunization against selected vaccine-preventable illnesses was uncommon in patients with IBD, despite the presence of significant risk factors. Efforts to improve immunization status among patients with IBD and other chronic, immune-mediated conditions are needed.

Prospects for prevention of childhood infections by maternal immunization

To review the literature on using maternal immunization as a strategy to prevent infections in young infants aged below 6 months Maternal immunization continues to reduce the incidence of neonatal tetanus worldwide. Despite increased influenza-related morbidity and mortality in pregnant women and in infants aged less than 6 months, compliance with US recommendations for immunization against influenza in pregnancy is poor. Polysaccharide vaccines against Haemophilus influenzae type b, Streptococcus pneumoniae and Neisseria meningitidis are safe and immunogenic in pregnancy. Protein conjugate vaccines against these infections would be likely to induce higher maternal antibody levels and improve placental transport, thereby further reducing the maternal and infant disease burden. Further studies of acellular pertussis vaccines for use in adolescents and adults should evaluate if maternal immunization could prevent life-threatening pertussis in young infants. Maternal immunization against group B streptococcus is projected to be superior to screening and/or chemoprophylaxis strategies in decreasing infant disease. Maternal immunization, with the passage of protective antibody to infants, is a potential strategy to prevent infection in infants who have not completed their primary immunization series from both specific infections of infancy and vaccine-preventable illnesses. Further evaluation of this strategy is supported by medical literature, but liability and educational barriers exist.

Commentary: The epidemiology of neurodevelopmental disorders in Sub-Saharan Africa—moving forward to understand the health and psychosocial needs of children, families, and communities

vaccine preventable childhood illnesses, bacterial and acute viral infections, parasitic infestations, toxic exposures, nutritional deficiencies, and injuries have accounted for the vast majority of infant and childhood mortality; childhood disability was barely ever measured. Addressing neurodevelopmental disabilities has become increasingly important with the decrease in infant mortality seen in recent decades. Disability in children can lead to lower health status and also increase the risk of death resulting from a range of potential mechanisms; children with developmental disabilities may be less likely to receive appropriate preventive and therapeutic

Economics of Rotavirus Gastroenteritis and Vaccination in Europe

Rotavirus is a major cause of gastroenteritis in children throughout Europe and the world. In addition to causing morbidity and mortality in children, rotavirus gastroenteritis (RVGE) creates a major economic burden on health care systems and families in Europe. The costs of hospital admissions for RVGE and nosocomial infections generate significant medical treatment costs throughout the region. Less information is available on the costs associated with less severe episodes and the costs borne by families, including lost time from work. The availability of rotavirus vaccines presents an effective opportunity to prevent RVGE and these associated economic costs, as well as providing protection to each child and hence benefiting the child's family. The adoption of rotavirus vaccine by health authorities in Europe will require a comparison of the costs and benefits. Economic evaluations that compare the costs of vaccination to the economic benefits of rotavirus vaccination will provide an estimate of its financial impact on health care systems and society. However, to provide a complete picture, economic evaluations of rotavirus vaccines will need to account for both the reduced costs and the reduced morbidity from prevented RVGE. Cost-effectiveness analyses based on quality-adjusted life years (QALYs) provide a systematic approach for assessing vaccination as a health investment, comparing the incremental costs associated with rotavirus vaccination and the reduced morbidity and mortality. QALYs provide a standardized approach for quantifying and comparing reductions in health-related quality of life and premature mortality. Although methodologic limitations exist in applying the QALY approach to childhood vaccines, their use in cost effectiveness analyses allows decision makers to consider the full health benefits of rotavirus and other vaccines.

Patients with Inflammatory Bowel Disease Are at Risk for Vaccine-Preventable Illnesses

Patients with Inflammatory Bowel Disease Are at Risk for Vaccine-Preventable Illnesses

Illnesses among recently immigrated children

The number of children immigrating to the United States has increased steadily during the last decade. American families are adopting a significant portion of these children, more than 20,000. Recently immigrated children face many different health risks when compared to children born in the United States. They are subject to many infectious diseases no longer seen commonly in the United States such as malaria, tuberculosis, and HIV. They are more likely to have inadequate immunity to vaccine-preventable illnesses. Recent immigrants have a higher likelihood of having malnutrition and developmental delay. Finally, many will have suffered psychological trauma in either institutions or refugee camps. These children require specialized testing, care, and treatment in the pediatric office.

Health Disparities among Travelers Visiting Friends and Relatives Abroad

For an estimated 10 million trips abroad by U.S. residents in 2002, "visiting friends and relatives" (VFR) was a purpose for travel. Made up largely of foreign-born U.S. residents and their children, this population shows disparities in the number of reported cases of many preventable travel-related illnesses compared with people who travel for other purposes, such as tourism. High-risk illnesses in VFR travelers include childhood vaccine-preventable illnesses, hepatitis A and B, tuberculosis, malaria, and typhoid fever. Gaps in the prevalence of disease and access to care both between countries and within the United States uniquely influence disease risk in this population of travelers. We describe this population, a framework for understanding travel-related health disparities, and recommendations for improving the effective delivery of preventive travel-related care to VFR travelers. In addition to transnational efforts to control and eradicate disease, preventing illness in U.S. resident VFR travelers requires focused efforts to remove barriers to their care. In the United States, barriers exist at the systems level (for example, low insurance coverage), patient level (for example, misperception of disease risk), and provider level (for example, inadequate knowledge of travel medicine).

Economic value to parents of reducing the pain and emotional distress of childhood vaccine injections.

One reason that recommended childhood immunizations due at child health visits are deferred is to avoid the pain and emotional distress associated with the increasing number of injections required. This deferral leads to additional visits and costs and reduced immunoprotection against vaccine-preventable illnesses. To assess the economic value of combination vaccines that address this problem, we surveyed parents to determine the amount they would be willing to pay to avoid the pain and emotional distress experienced by their infants from injections. A self-administered questionnaire was completed within 24 h of the vaccinations by 294 parents of children ages 11/2 to 7 months receiving vaccine injections at 26 outpatient child health centers. The willingness-to-pay (WTP) method was used to estimate the intangible cost of the pain and emotional distress of the 1 to 4 injections their child had received. Parents were asked how much of their own money they would have paid to avoid these injections, without any compromise in the safety and efficacy of the vaccinations. Wide variations in WTP amounts were observed, ranging from median values of $10 to $25 and average values of $57.06 to $79.28 to avoid the pain and emotional distress associated with eliminating all injections at visits in which one to four injections were administered. Parents placed greater value on reductions that avoided all injections than on reductions that avoided only some injections. Overall the median cost per injection avoided was $8.14, and the mean was $30.28. Parents have strong preferences for limiting vaccine injections. The economic cost of the pain and distress associated with such injections, reflected in the amounts they report they would be willing to pay to avoid them, represents a substantial component of the cost of disease control through immunization.

Emergency medicine in Ukraine: Challenges in the post-Soviet era

The practice of emergency medicine in Ukraine is markedly different from the practice in North America. The emergency physician counterpart in Ukraine attends 6 years of medical school then 18 months of prehospital physician training at an EMS base station. Once trained, prehospital physicians work 160 hours/month in 24-hour shifts at the base station as part of a physician-nurse team which answers ambulance requests. Most patients are seen and treated on site of the ambulance call. Patients are transported to the hospital only 20% of the time. Prehospital physicians can expect to earn $35 to $65 per month. Nearly all prehospital physicians are government employees. Since becoming an independent democratic republic, Ukraine's turbulent economy has negatively affected health care. Deaths from infectious diseases, including vaccine-preventable illnesses are 10-fold to that of Western countries. A 90% income tax discourages the private practice of medicine. Medical care is provided free of charge, however, if a patient wants a higher standard of care, they may have to pay an attending physician up to $200. Most medications used to treat emergencies are free, but if thrombolytics are required, the patient will have to pay for them before they are administered. Budgetary constraints limit equipment and technology. The disparity between urban and rural resources is striking as even the most basic equipment is antiquated and in need of repair. Despite the economic challenges facing Ukranian physicians, they are enthusiastic about the care and services they provide. EMS is well organized and offers services not seen in the United States. Prehospital physicians in Ukraine are viewed as an integral part of the health care system by their hospital-based colleagues. (Am J Emerg Med 2000;18:828-832.

Humoral immunity against diphtheria, tetanus and poliomyelitis after antineoplastic therapy in children and adolescents — a retrospective analysis

Serum antibodies against diphtheria- and tetanus-toxin were measured in 71 children and against poliomyelitis viruses 1–3 in 65 children and adolescents 0–18 months after cessation of antineoplastic therapy. Non or marginally protective serum titers were found in 62% of patients against diphtheria, in 18% of patients against tetanus and in 72% of patients against one or more poliomyelitis virus serotypes. Of these patients, 55%, 46% and 75% were immunized adequately according to age against diphtheria, tetanus and poliomyelitis, respectively. In 50% or more of patients a lack of protective immunity against diphtheria, tetanus and poliomyelitis was found which could not be explained by an inadequate immunization status. This suggests that other factors (e.g. influence of underlying illness, antineoplastic therapy or both on lymphocytes) might be responsible for these findings and this deserves further investigation. Measurement of serum antibodies against vaccine-preventable illnesses and consecutive booster immunizations are an essential part of long-term follow up in pediatric patients after antineoplastic therapy.