- Email: [email protected]
Meningococcal vaccine coverage in Hajj pilgrims
identifying haemorrhagic stroke; and (d) its use in the emergency setting should be assessed on the basis of pretest probability. The latter deserves a few additional remarks. The proportion of patients with a definite stroke seen by Chalela and colleagues (61%) is much lower than that reported from comparable settings,2,3 where emergency department physicians correctly identified 89–91% of acute stroke patients before doing brain imaging. A high pretest probability is likely to offset the expected advantage of MRI over CT.4 Moreover, CT is as helpful as MRI in identifying bleeding, which cannot be clinically detected. Therefore, when a patient’s referral for brain imaging is based on a good-quality clinical examination, MRI is no better than a standard CT scan. In our post-evaluation survey, all participants agreed that MRI should replace CT if a low pretest probability of acute stroke (eg, 60–70%) is expected. Students who assessed the paper were: Flavia Angelucci, Sabrina Anticoli, Flavio Arciprete, Rita Bella, Marcella Caggiula, Roberto Frediani, Rosathea Giugliano, Antongiulio Guadagno, Domenica Le Pera, Alessandra Martignoni, Giordana Pelone, Francesca R Pezzella, Sebastiano Uselli. We declare that we have no conflict of interest.
*Alfonso Ciccone, Roberto Sterzi, Luca Munari, on behalf of the students assessing the paper [email protected] Neurology - Stroke Unit (AC, RS) and Chief Medical Officer (LM), Azienda Ospedaliera Niguarda Ca’ Granda, Milan, Italy 1
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Chalela JA, Kidwell CS, Nentwich LM, et al. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet 2007; 369: 293–98. Ferro JM, Pinto AN, Falcao I, et al. Diagnosis of stroke by the non-neurologist: a validation study. Stroke 1998; 29: 1106–09. Morgenstern LB, Lisabeth LD, Mecozzi AC, et al. A population-based study of acute stroke and TIA diagnosis. Neurology 2004; 62: 895–900. Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Can you apply this valid, important evidence about a diagnostic test in caring for your patient? In: Sackett DL, Richardson WS, Rosenberg W, Haynes RB, eds. Evidence-based medicine: how to practice & teach EBM, 1st edn. London: Churchill Livingstone, 1997: 159–63.
www.thelancet.com Vol 369 April 21, 2007
Meningococcal vaccine coverage in Hajj pilgrims As one us (ZAM) wrote with Qanta A Ahmed and Yaseen M Arabi,1 Saudi residents undertaking the Hajj pilgrimage must be immunised, and non-immunised local inhabitants of Mecca are offered the vaccine free of charge, whether or not they undertake the pilgrimage. After the 2000 and 2001 outbreaks of Hajjassociated meningococcal infections, meningococcal quadrivalent polysaccharide vaccine became a mandatory requirement for pilgrims.2 Despite this rule, coverage is still too low in local pilgrims. During the 2006 Hajj, we surveyed 134 male British and 109 male Saudi pilgrims (including resident nonSaudis) who attended Mecca’s British Hajj Delegation and the National Guard Clinics, respectively, to compare meningococcal vaccine coverage between the groups. Questionnaires in English and Arabic were completed to record the pilgrims’ demographics and vaccination histories. The British pilgrims, aged 14–81 years, all said they had been vaccinated. Of the 109 pilgrims from Saudi Arabia (aged 16–85 years), 70 (64%) reported being vaccinated, 35 (32%) stated they had not, and four (4%) were unsure. Fewer expatriates (43%) had been immunised than native Saudis (78%), but only 50% of pilgrims from Mecca and Jeddah had been immunised compared with 71% of those from the rest of the country. The lower vaccine coverage in Saudi Arabia pilgrims overall, and Mecca’s native residents in particular, is worrying and could lead to further meningococcal outbreaks. It also indicates the need for regular audit of the immunisation programme, and an investigation into why uptake is so low. Chemoprophylaxis (eg, with oral ciprofloxacin) might need to be reintroduced to clear infection from those carrying the bacteria and interrupt its spread.3–5
We declare that we have no conflict of interest. We also thank Elizabeth Haworth and Robert Booy, members of the Health at Hajj and Umra Research Group, for their contribution to this manuscript.
*Haitham El Bashir, Harunor Rashid, Ziad A Memish, Shuja Shafi, on behalf of the Health at Hajj and Umra Research Group [email protected]
The printed journal includes an image merely for illustration
General and Adolescent Paediatric Unit, Institute of Child Health, University College London, 250 Euston Road, London NW1 2PG, UK (HEB); Research Centre for Child Health, St Bartholomew’s and The London Queen Mary’s School of Medicine and Dentistry, University of London, UK (HR); Department of Medicine, Infection Prevention and Control King, Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia (ZAM); and Health Protection Agency London, HPA Collaborating Laboratory, Northwick Park Hospital, Harrow, Middlesex, UK (SS) 1 2 3
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5
Ahmed QA, Arabi YM, Memish ZA. Health risks at the Hajj. Lancet 2006; 367: 1008–15. WHO. Meningococcal disease, serogroup W135. Wkly Epidemiol Rec 2001; 76: 141–42. El Bashir H, Coen PG, Haworth E, et al. Meningococcal W135 carriage; enhanced surveillance amongst east London Muslim pilgrims and their household contacts before and after attending the 2002 Hajj. Travel Med Infect Dis 2004; 2: 13–15. Balkhy HH, Memish ZA, Almuneef MA, Osoba AO. Neisseria meningitidis W-135 carriage during the Hajj season 2003. Scand J Infect Dis 2004; 36: 264–68. Wilder-Smith A, Barkham TM, Chew SK, Paton NI. Absence of Neisseria meningitidis W-135 electrophoretic Type 37 during the Hajj, 2002. Emerg Infect Dis 2003; 9: 734–37.
Gastrointestinal safety of NSAIDs versus COX-2 inhibitors Loren Laine and colleagues (Feb 10, p 465)1 compare the upper gastrointestinal safety of the traditional non-steroidal anti-inflammatory drug (NSAID) diclofenac with that of the new cyclo-oxygenase-2 (COX-2) inhibitor etoricoxib. While matching the baseline characteristics of the two groups, certain factors have been overlooked. Alcohol consumption has been associated with the risk of upper gastrointestinal bleeding in previous studies,2 as have commonly prescribed antidepressants (serotonin-selective reuptake inhibitors), especially when used in combination with aspirin.3 1343
Still Pictures
Correspondence
*Alfonso Ciccone, Roberto Sterzi, Luca Munari, on behalf of the students assessing the paper [email protected] Neurology - Stroke Unit (AC, RS) and Chief Medical Officer (LM), Azienda Ospedaliera Niguarda Ca’ Granda, Milan, Italy 1
2
3
4
Chalela JA, Kidwell CS, Nentwich LM, et al. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet 2007; 369: 293–98. Ferro JM, Pinto AN, Falcao I, et al. Diagnosis of stroke by the non-neurologist: a validation study. Stroke 1998; 29: 1106–09. Morgenstern LB, Lisabeth LD, Mecozzi AC, et al. A population-based study of acute stroke and TIA diagnosis. Neurology 2004; 62: 895–900. Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Can you apply this valid, important evidence about a diagnostic test in caring for your patient? In: Sackett DL, Richardson WS, Rosenberg W, Haynes RB, eds. Evidence-based medicine: how to practice & teach EBM, 1st edn. London: Churchill Livingstone, 1997: 159–63.
www.thelancet.com Vol 369 April 21, 2007
Meningococcal vaccine coverage in Hajj pilgrims As one us (ZAM) wrote with Qanta A Ahmed and Yaseen M Arabi,1 Saudi residents undertaking the Hajj pilgrimage must be immunised, and non-immunised local inhabitants of Mecca are offered the vaccine free of charge, whether or not they undertake the pilgrimage. After the 2000 and 2001 outbreaks of Hajjassociated meningococcal infections, meningococcal quadrivalent polysaccharide vaccine became a mandatory requirement for pilgrims.2 Despite this rule, coverage is still too low in local pilgrims. During the 2006 Hajj, we surveyed 134 male British and 109 male Saudi pilgrims (including resident nonSaudis) who attended Mecca’s British Hajj Delegation and the National Guard Clinics, respectively, to compare meningococcal vaccine coverage between the groups. Questionnaires in English and Arabic were completed to record the pilgrims’ demographics and vaccination histories. The British pilgrims, aged 14–81 years, all said they had been vaccinated. Of the 109 pilgrims from Saudi Arabia (aged 16–85 years), 70 (64%) reported being vaccinated, 35 (32%) stated they had not, and four (4%) were unsure. Fewer expatriates (43%) had been immunised than native Saudis (78%), but only 50% of pilgrims from Mecca and Jeddah had been immunised compared with 71% of those from the rest of the country. The lower vaccine coverage in Saudi Arabia pilgrims overall, and Mecca’s native residents in particular, is worrying and could lead to further meningococcal outbreaks. It also indicates the need for regular audit of the immunisation programme, and an investigation into why uptake is so low. Chemoprophylaxis (eg, with oral ciprofloxacin) might need to be reintroduced to clear infection from those carrying the bacteria and interrupt its spread.3–5
We declare that we have no conflict of interest. We also thank Elizabeth Haworth and Robert Booy, members of the Health at Hajj and Umra Research Group, for their contribution to this manuscript.
*Haitham El Bashir, Harunor Rashid, Ziad A Memish, Shuja Shafi, on behalf of the Health at Hajj and Umra Research Group [email protected]
The printed journal includes an image merely for illustration
General and Adolescent Paediatric Unit, Institute of Child Health, University College London, 250 Euston Road, London NW1 2PG, UK (HEB); Research Centre for Child Health, St Bartholomew’s and The London Queen Mary’s School of Medicine and Dentistry, University of London, UK (HR); Department of Medicine, Infection Prevention and Control King, Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia (ZAM); and Health Protection Agency London, HPA Collaborating Laboratory, Northwick Park Hospital, Harrow, Middlesex, UK (SS) 1 2 3
4
5
Ahmed QA, Arabi YM, Memish ZA. Health risks at the Hajj. Lancet 2006; 367: 1008–15. WHO. Meningococcal disease, serogroup W135. Wkly Epidemiol Rec 2001; 76: 141–42. El Bashir H, Coen PG, Haworth E, et al. Meningococcal W135 carriage; enhanced surveillance amongst east London Muslim pilgrims and their household contacts before and after attending the 2002 Hajj. Travel Med Infect Dis 2004; 2: 13–15. Balkhy HH, Memish ZA, Almuneef MA, Osoba AO. Neisseria meningitidis W-135 carriage during the Hajj season 2003. Scand J Infect Dis 2004; 36: 264–68. Wilder-Smith A, Barkham TM, Chew SK, Paton NI. Absence of Neisseria meningitidis W-135 electrophoretic Type 37 during the Hajj, 2002. Emerg Infect Dis 2003; 9: 734–37.
Gastrointestinal safety of NSAIDs versus COX-2 inhibitors Loren Laine and colleagues (Feb 10, p 465)1 compare the upper gastrointestinal safety of the traditional non-steroidal anti-inflammatory drug (NSAID) diclofenac with that of the new cyclo-oxygenase-2 (COX-2) inhibitor etoricoxib. While matching the baseline characteristics of the two groups, certain factors have been overlooked. Alcohol consumption has been associated with the risk of upper gastrointestinal bleeding in previous studies,2 as have commonly prescribed antidepressants (serotonin-selective reuptake inhibitors), especially when used in combination with aspirin.3 1343
Still Pictures
Correspondence