- Email: [email protected]
EXPANDED IMMUNISATION
438
specimen taken later was reported normal. DNA probes are now becoming available for HPV and it will be interesting to examine such tissue for presence of virus.’ I The Bristol and Aberdeen papers give us interesting information on the association of HPV and arthralgia, but without the more rigorous scientific assessment that would be provided by a prospective epidemiological study with carefully selected control groups we cannot draw any conclusions about the relative importance of rubella and HPV in arthralgia. Nor can we definitively exclude HPV as a cause of
progressive joint disease, though it seems very unlikely to be associated with progressive rheumatoid arthritis. On existing evidence, HPV arthralgia is real but, like rubella, mild and self-limiting, mainly affecting young women. Occasionally patients may be so badly affected to present at rheumatology clinics. Now that serological testing is available, HPV, like rubella, should be excluded in newly presenting patients with unexplained arthropathies with a view to identifying those in whom arthritis is likely to be shortsevere or
lived and not associated with more sinister disease. 12
EXPANDED IMMUNISATION OF every 1000 children born into the world, 5 will grow up
crippled by poliomyelitis, 10 die of neonatal tetanus, 20 die of whooping-cough, and 30 or more die of measles or its complications. These diseases, along with diphtheria and tuberculosis,
are
the
targets
of the
World
Health
Organisation’s Expanded Programme on Immunisation (EPI), and between a quarter and a third of the world’s children are now protected against them. Clearly there is much to be done if, as the 1978 World Health Assembly proposed, immunisation is to be brought to all the world’s children by 1990. At the meeting of the EPI’s Global Advisory Group last year in Alexandria, some great success stories were heard. Brazil discovered
the potential for immunisation the success of smallpox eradication programmes through between 1966 and 1971. This led to national immunisation programmes particularly against poliomyelitis. By the end of the 1970s polio vaccine was reaching half of the population but the incidence of poliomyelitis did not show much of a decline. The Ministry of Health therefore initiated a fresh policy whereby a national programme was conducted on two single Saturdays, one in June and one in August. 90 000 vaccination sites were set up-ten times the number of permanent health service stations. 20 million doses of trivalent oral poliomyelitis vaccine were delivered and were believed to reach 90% of the target population. The results were impressive (see figure). Since 1980 there have been, apart from single cases, only four outbreaks, all in the north east of Brazil, involving 17, 7, 12, and 8 cases. In 1982 there was a total of 69 cases, and in 1983 only 43. Before 1981 there were 1-2 cases per 100 000 population each year. Since 1981, measles and diphtheria/pertussis/tetanus (DPT) vaccination 1 1 Anderson MJ, Minson AC. Diagnosis of PHV infection by dot-blot
hybridisation using
cloned viral DNA J Med Virol 1985; 15: 163-72. 12 Editorial The viral aetiology of rheumatoid arthritis Lancet 1984;
i:
772-74.
has also been available on these days for children whose immunisation has not been completed, and all immunisations have been recorded. During the campaign on June 16, 1984, vaccine. 2’1 million children measles received of measles been surveillance has inadequate Unfortunately, and only some 10% of measles cases are notified. The immunisation programme stimulated interest in the disease and, as might be expected, there was no great decline in notifications. There was, however, an increase in the proportion of cases in older age-groups and this probably denotes the effect of the measles immunisation programme. Previously the Global Advisory Group has had strong reservations about such national campaigns, largely because they were limited to poliomyelitis and there was little or no record-keeping. National immunisation days in some countries meet these objections by offering vaccination against all six target diseases according to the child’s needs, each dose being entered on the child’s record card; these oneday campaigns have strong backing from political and religious leaders and there is much community involvement. They are likely to contribute greatly in the efforts to bring vaccine to all children by the year 1990. Existing knowledge suggests that retiming of vaccinations could save lives, particularly in those countries where the six target diseases cause many deaths in the first year of life. A new recommendation is that polio vaccine in these countries should now be given at birth. Although the serological response is less than in later age groups, 70-100% of newborn babies acquire local immunity in the intestinal tract. 30-50% will gain antibodies against one or more poliovirus types, and the remainder will be immunologically primed for the additional later doses. There is also evidence that DPT injections can usefully be offered earlier in life. The suggested immunisation schedule for countries where the six target diseases are frequent in the first year of life is now likely to be: Birth—Trivalent oral polio vaccine and BCG. 6, 10, and 14 weeks-Trivalent oral polio vaccine and DPT. 9 months-Measles vaccine. Vaccines not given at these ages should be given as soon as possible afterwards. Where contact with children is inadequate and there is a longer interval between doses there is no need to restart the series; the next injection due can be given. There is no contraindication to including measles vaccine with the final dose of trivalent oral polio vaccine if this has not been given at 9 months. If measles vaccine has been given before 9 months, a second dose should be given in the second year of life.
Poliomyelitis by 4-week periods, Arrows indicate
Brazil 1975 - 83.
Saturdays on which polio vaccine was given to all children
age 0-4 yr. Modified from Risl JB, J Nationwide Brazil. Assignment Children 1984; 65/68: 137-57.
mass
polio immunisationin
439 The WHO group reaffirmed its 1983 recommendation, also adopted by the Twelfth International Congress of Paediatrics, to exploit every opportunity to immunise eligible children and particularly those with malnutrition. Low-grade fever, mild respiratory infection, or diarrhoea and other minor illnesses should not be regarded as contraindications to immunisation. (When a child is so ill as to require hospital admission, immunisation should be left to the hospital authorities.) Unfortunately, the deferring of immunisations because children are unwell is still one of the main reasons for lack of protection against the six target diseases. Logistic and managerial dilemmas continue to arise. At the Alexandria meeting a Government Minister from India pointed out that the plan for a dose of polio vaccine at birth would require production of a further 24 million doses of vaccine. Immunisation of all children by 1990 will clearly demand additional both national and resources, and will external have to be assistance international, coordinated. At an important conference in Bellagio last year the participants committed themselves to improving collaboration between countries, UN and bilateral agencies, and other concerned groups. The result should be an acceleration of the programme, which has much work to do in the next five years.
EMPLOYMENT IN PREGNANCY THE divisions of labour consequent upon the decline of and increasing automation in Britain have resulted in women becoming an increasing proportion of the population doing paid work outside of the home. In particular, the young mother of today is more likely than her own mother will have been to have a job; and the job is likely to be part-time, classified (often unjustly) as unskilled, and paid accordingly.’ Inevitably, some of the members of this female workforce will be pregnant and considerable effort has been expended on determining whether paid work outside of the home has any adverse effect upon pregnancy outcome. The epidemiological problems are enormous. The factors that influence pregnancy outcome-such as age, parity, general health, and social class-may also influence motivation and employability. The work may be heavy or light, worrying or relaxing, boring or stimulating. It may be more or less fatiguing than that done by the non-working woman at home. The remuneration may be generous or derisory. Outside of the home may be next door or involve a stressful journey, and may be in a factory, office, laboratory, hospital, or field. In a perfect study, all these variables and others would have to be controlled for. The interrelated pregnancy outcomes-congenital abnormality, immaturity, growth retardation, and perinatal loss-would also require
heavy industry
separation. Nothing daunted, Murphy et al2 used data from the Cardiff Births Survey (1975-79) to analyse the relation between employment and perinatal outcome. Gainful employment pregnancy was one of the items about which information was routinely collected. Work was recorded as being sedentary or non-sedentary according to the amount of physical energy expended, but no distinction was made between part-time and full-time work. The analysis was essentially confined to primigravidas who were married, who
had a singleton pregnancy, and whose husbands were not students or in the armed forces. The major conclusion, aptly expressed by Williams3 after reworking the data with a different statistical method, was "that married women can safely continue in employment during their first pregnancy (if it is singleton)". Whether the work is sedentary or nonsedentary does not seem to matter. The National Epidemiology Unit at Oxford was involved in the Cardiff study, and the Royal Society of Medicine has also been promoting the study of pregnant women at work; the 1983 Anglo-American Conference was devoted to this subject and the society has now published the edited proceedings.4 Emphasis was on possible adverse effects of work on pregnancy outcome, and items on current legislation and recent court rulings, the work of different advisory commissions, European Economic Community directives, occupational health programmes, and trade union and management positions all testify to the amount of official concern there is to protect the pregnant woman and her child from harm. Perhaps it is because of this concern and protection that the epidemiology and teratology sections are generally reassuring, suggesting a benefit from work outside the home unless it is particularly arduous or involves undue exposure to chemical or other teratogens, In the Cardiff study about 80% of primigravidas had a job during pregnancy. This figure had not changed in 10 years. The number of working multigravidas, however, had increased 50% from 15.1% to 22.1%. These are the women identified by Pahl’ as likely to be working part-time in "unskilled" jobs for little remuneration and whose work is little controlled or protected. Perhaps this subgroup of working gravidas and their families deserve special consideration.
FISSURE SEALANTS FOR TEETH ONEmeans of preventing dental caries is the application of adhesive plastic to pits and fissures. Rock’’ has suggested that there is now sufficient evidence to support the use of fissure sealants in the General Dental Service (GDS) of the National Health Service. His proposal comes at a time when the prevalence of dental caries is rapidly falling in Britain. In 12 surfaces has dropped year-olds the number of affected tooth from 9’ 3 to 4 - 4 in the past decade.6 The question is, with this reduced level of caries, is the introduction of fissure sealants appropriate and can the cost be justified? This major change in the incidence of dental caries has coincided with a shift in its pattern of attack; now up to 80% of caries lesions occur in the pits and fissures, which are amenable to sealing.’ However, the US National Preventive Dentistry Demonstration Program has shown that, although sealants are the most effective preventive method tried (apart from water fluoridation), they are also the most expensive.8 The most widely adopted strategy has been
during
1. Pahl RE. Divisions of labour. Oxford Blackwell, 1984 2 Murphy JF, Dauncey M, Newcombe R, et al Employment
maternal
characteristics, perinatal
outcome.
3. Williams JH. Employment in pregnancy. Lancet 1984; ii: 103-04. 4. Chamberlain G, ed Pregnant women at work. London: Royal Society of Medicine/
Macmillan. 1984.
7
8
in pregnancy: prevalence,
Lancet 1984;
i:
1163-66
Pp
302. £32 hard cover, £15
paperback.
of fissure sealants in the NHS. Br Dent J1984; 157: 445-48. 6 Anderson RJ, et al The reduction of dental caries prevalence in English schoolchildren J Dent Res 1982; 61 (special issue). 1311-16. 5. Rock WP Potential
use
Miller AM, Brunelle JA, Carlos JP, Scott DB The prevalence of dental caries in United States children 1979-1980 Washington DC US Department of Health and Human Services, 1981 NIH publication no 82-2245 The National Preventive Dentistry Demonstration Program Robert Wood Johnson Foundation special report no. 2 The Rand Corporation, Santa Monica, California, 1983
specimen taken later was reported normal. DNA probes are now becoming available for HPV and it will be interesting to examine such tissue for presence of virus.’ I The Bristol and Aberdeen papers give us interesting information on the association of HPV and arthralgia, but without the more rigorous scientific assessment that would be provided by a prospective epidemiological study with carefully selected control groups we cannot draw any conclusions about the relative importance of rubella and HPV in arthralgia. Nor can we definitively exclude HPV as a cause of
progressive joint disease, though it seems very unlikely to be associated with progressive rheumatoid arthritis. On existing evidence, HPV arthralgia is real but, like rubella, mild and self-limiting, mainly affecting young women. Occasionally patients may be so badly affected to present at rheumatology clinics. Now that serological testing is available, HPV, like rubella, should be excluded in newly presenting patients with unexplained arthropathies with a view to identifying those in whom arthritis is likely to be shortsevere or
lived and not associated with more sinister disease. 12
EXPANDED IMMUNISATION OF every 1000 children born into the world, 5 will grow up
crippled by poliomyelitis, 10 die of neonatal tetanus, 20 die of whooping-cough, and 30 or more die of measles or its complications. These diseases, along with diphtheria and tuberculosis,
are
the
targets
of the
World
Health
Organisation’s Expanded Programme on Immunisation (EPI), and between a quarter and a third of the world’s children are now protected against them. Clearly there is much to be done if, as the 1978 World Health Assembly proposed, immunisation is to be brought to all the world’s children by 1990. At the meeting of the EPI’s Global Advisory Group last year in Alexandria, some great success stories were heard. Brazil discovered
the potential for immunisation the success of smallpox eradication programmes through between 1966 and 1971. This led to national immunisation programmes particularly against poliomyelitis. By the end of the 1970s polio vaccine was reaching half of the population but the incidence of poliomyelitis did not show much of a decline. The Ministry of Health therefore initiated a fresh policy whereby a national programme was conducted on two single Saturdays, one in June and one in August. 90 000 vaccination sites were set up-ten times the number of permanent health service stations. 20 million doses of trivalent oral poliomyelitis vaccine were delivered and were believed to reach 90% of the target population. The results were impressive (see figure). Since 1980 there have been, apart from single cases, only four outbreaks, all in the north east of Brazil, involving 17, 7, 12, and 8 cases. In 1982 there was a total of 69 cases, and in 1983 only 43. Before 1981 there were 1-2 cases per 100 000 population each year. Since 1981, measles and diphtheria/pertussis/tetanus (DPT) vaccination 1 1 Anderson MJ, Minson AC. Diagnosis of PHV infection by dot-blot
hybridisation using
cloned viral DNA J Med Virol 1985; 15: 163-72. 12 Editorial The viral aetiology of rheumatoid arthritis Lancet 1984;
i:
772-74.
has also been available on these days for children whose immunisation has not been completed, and all immunisations have been recorded. During the campaign on June 16, 1984, vaccine. 2’1 million children measles received of measles been surveillance has inadequate Unfortunately, and only some 10% of measles cases are notified. The immunisation programme stimulated interest in the disease and, as might be expected, there was no great decline in notifications. There was, however, an increase in the proportion of cases in older age-groups and this probably denotes the effect of the measles immunisation programme. Previously the Global Advisory Group has had strong reservations about such national campaigns, largely because they were limited to poliomyelitis and there was little or no record-keeping. National immunisation days in some countries meet these objections by offering vaccination against all six target diseases according to the child’s needs, each dose being entered on the child’s record card; these oneday campaigns have strong backing from political and religious leaders and there is much community involvement. They are likely to contribute greatly in the efforts to bring vaccine to all children by the year 1990. Existing knowledge suggests that retiming of vaccinations could save lives, particularly in those countries where the six target diseases cause many deaths in the first year of life. A new recommendation is that polio vaccine in these countries should now be given at birth. Although the serological response is less than in later age groups, 70-100% of newborn babies acquire local immunity in the intestinal tract. 30-50% will gain antibodies against one or more poliovirus types, and the remainder will be immunologically primed for the additional later doses. There is also evidence that DPT injections can usefully be offered earlier in life. The suggested immunisation schedule for countries where the six target diseases are frequent in the first year of life is now likely to be: Birth—Trivalent oral polio vaccine and BCG. 6, 10, and 14 weeks-Trivalent oral polio vaccine and DPT. 9 months-Measles vaccine. Vaccines not given at these ages should be given as soon as possible afterwards. Where contact with children is inadequate and there is a longer interval between doses there is no need to restart the series; the next injection due can be given. There is no contraindication to including measles vaccine with the final dose of trivalent oral polio vaccine if this has not been given at 9 months. If measles vaccine has been given before 9 months, a second dose should be given in the second year of life.
Poliomyelitis by 4-week periods, Arrows indicate
Brazil 1975 - 83.
Saturdays on which polio vaccine was given to all children
age 0-4 yr. Modified from Risl JB, J Nationwide Brazil. Assignment Children 1984; 65/68: 137-57.
mass
polio immunisationin
439 The WHO group reaffirmed its 1983 recommendation, also adopted by the Twelfth International Congress of Paediatrics, to exploit every opportunity to immunise eligible children and particularly those with malnutrition. Low-grade fever, mild respiratory infection, or diarrhoea and other minor illnesses should not be regarded as contraindications to immunisation. (When a child is so ill as to require hospital admission, immunisation should be left to the hospital authorities.) Unfortunately, the deferring of immunisations because children are unwell is still one of the main reasons for lack of protection against the six target diseases. Logistic and managerial dilemmas continue to arise. At the Alexandria meeting a Government Minister from India pointed out that the plan for a dose of polio vaccine at birth would require production of a further 24 million doses of vaccine. Immunisation of all children by 1990 will clearly demand additional both national and resources, and will external have to be assistance international, coordinated. At an important conference in Bellagio last year the participants committed themselves to improving collaboration between countries, UN and bilateral agencies, and other concerned groups. The result should be an acceleration of the programme, which has much work to do in the next five years.
EMPLOYMENT IN PREGNANCY THE divisions of labour consequent upon the decline of and increasing automation in Britain have resulted in women becoming an increasing proportion of the population doing paid work outside of the home. In particular, the young mother of today is more likely than her own mother will have been to have a job; and the job is likely to be part-time, classified (often unjustly) as unskilled, and paid accordingly.’ Inevitably, some of the members of this female workforce will be pregnant and considerable effort has been expended on determining whether paid work outside of the home has any adverse effect upon pregnancy outcome. The epidemiological problems are enormous. The factors that influence pregnancy outcome-such as age, parity, general health, and social class-may also influence motivation and employability. The work may be heavy or light, worrying or relaxing, boring or stimulating. It may be more or less fatiguing than that done by the non-working woman at home. The remuneration may be generous or derisory. Outside of the home may be next door or involve a stressful journey, and may be in a factory, office, laboratory, hospital, or field. In a perfect study, all these variables and others would have to be controlled for. The interrelated pregnancy outcomes-congenital abnormality, immaturity, growth retardation, and perinatal loss-would also require
heavy industry
separation. Nothing daunted, Murphy et al2 used data from the Cardiff Births Survey (1975-79) to analyse the relation between employment and perinatal outcome. Gainful employment pregnancy was one of the items about which information was routinely collected. Work was recorded as being sedentary or non-sedentary according to the amount of physical energy expended, but no distinction was made between part-time and full-time work. The analysis was essentially confined to primigravidas who were married, who
had a singleton pregnancy, and whose husbands were not students or in the armed forces. The major conclusion, aptly expressed by Williams3 after reworking the data with a different statistical method, was "that married women can safely continue in employment during their first pregnancy (if it is singleton)". Whether the work is sedentary or nonsedentary does not seem to matter. The National Epidemiology Unit at Oxford was involved in the Cardiff study, and the Royal Society of Medicine has also been promoting the study of pregnant women at work; the 1983 Anglo-American Conference was devoted to this subject and the society has now published the edited proceedings.4 Emphasis was on possible adverse effects of work on pregnancy outcome, and items on current legislation and recent court rulings, the work of different advisory commissions, European Economic Community directives, occupational health programmes, and trade union and management positions all testify to the amount of official concern there is to protect the pregnant woman and her child from harm. Perhaps it is because of this concern and protection that the epidemiology and teratology sections are generally reassuring, suggesting a benefit from work outside the home unless it is particularly arduous or involves undue exposure to chemical or other teratogens, In the Cardiff study about 80% of primigravidas had a job during pregnancy. This figure had not changed in 10 years. The number of working multigravidas, however, had increased 50% from 15.1% to 22.1%. These are the women identified by Pahl’ as likely to be working part-time in "unskilled" jobs for little remuneration and whose work is little controlled or protected. Perhaps this subgroup of working gravidas and their families deserve special consideration.
FISSURE SEALANTS FOR TEETH ONEmeans of preventing dental caries is the application of adhesive plastic to pits and fissures. Rock’’ has suggested that there is now sufficient evidence to support the use of fissure sealants in the General Dental Service (GDS) of the National Health Service. His proposal comes at a time when the prevalence of dental caries is rapidly falling in Britain. In 12 surfaces has dropped year-olds the number of affected tooth from 9’ 3 to 4 - 4 in the past decade.6 The question is, with this reduced level of caries, is the introduction of fissure sealants appropriate and can the cost be justified? This major change in the incidence of dental caries has coincided with a shift in its pattern of attack; now up to 80% of caries lesions occur in the pits and fissures, which are amenable to sealing.’ However, the US National Preventive Dentistry Demonstration Program has shown that, although sealants are the most effective preventive method tried (apart from water fluoridation), they are also the most expensive.8 The most widely adopted strategy has been
during
1. Pahl RE. Divisions of labour. Oxford Blackwell, 1984 2 Murphy JF, Dauncey M, Newcombe R, et al Employment
maternal
characteristics, perinatal
outcome.
3. Williams JH. Employment in pregnancy. Lancet 1984; ii: 103-04. 4. Chamberlain G, ed Pregnant women at work. London: Royal Society of Medicine/
Macmillan. 1984.
7
8
in pregnancy: prevalence,
Lancet 1984;
i:
1163-66
Pp
302. £32 hard cover, £15
paperback.
of fissure sealants in the NHS. Br Dent J1984; 157: 445-48. 6 Anderson RJ, et al The reduction of dental caries prevalence in English schoolchildren J Dent Res 1982; 61 (special issue). 1311-16. 5. Rock WP Potential
use
Miller AM, Brunelle JA, Carlos JP, Scott DB The prevalence of dental caries in United States children 1979-1980 Washington DC US Department of Health and Human Services, 1981 NIH publication no 82-2245 The National Preventive Dentistry Demonstration Program Robert Wood Johnson Foundation special report no. 2 The Rand Corporation, Santa Monica, California, 1983