Comparison of the safety and immunogenicity of the lyophilized Mérieux seed and the World Health Organization working reference BCG vaccines in school-aged children in Senegal

In order to validate two new lots of Mérieux BCG vaccine (Mérieux seed derived from strain 1072), a calibration study was performed to compare their safety and immunogenicity to a full dose of the WHO-reference BCG vaccine (Tokyo strain 172) as well as the WHO-reference vaccine given at 1/10 of its normal concentration, in an open, randomized, four-arm, multicenter study in Senegal. A total of 1041 healthy Senegalese children aged 8-10 years were screened for participation in this study, of whom 548 had a negative Mantoux test and complied with inclusion and exclusion criteria. These children were randomly allocated a single dose of one of the following vaccines: full-dose Mérieux BCG vaccine (lot E0650); full-dose Mérieux BCG vaccine (lot E0624); full-dose WHO-reference vaccine (Tokyo strain 172); or 1/10 dose WHO-reference vaccine. A follow-up examination, including a tuberculin test, was performed 10-12 weeks after BCG vaccination for 465 (85%) children: 236 Mérieux BCG vaccine (117 lot E0650; 119 lot E0624); 115 full-dose WHO; 114 1/10 dose WHO. The percentage of subjects with a positive tuberculin test after vaccination was significantly lower (P < 0.001) in the 1/10 dose group (81.5%) compared to the other three groups (> 96%). The mean induration diameter was significantly smaller in subjects who received the low-dose of WHO vaccine compared to the others, according to analyses considering all subjects vaccinated, as well as only those subjects with a positive tuberculin test after vaccination. More children in the low-dose group did not have a vaccination scar, and the mean diameter of scars was smaller in this group. The rate of tuberculin reactions, the classification of reactions (Palmer and Edwards), and the characteristics of the vaccinal lesion were similar for the Mérieux BCG vaccines and the full-dose WHO-reference vaccine. All vaccines were safe, as evidenced by the absence of adenitis or suppurative adenitis during the course of the study. Results from this trial show that the two lots of Mérieux BCG vaccine behave equally as well as the full-dose WHO-reference BCG vaccine. The WHO-reference vaccine, given at 1/10 of its normal concentration was significantly less immunogenic, according to all parameters evaluated.

Myringoplasty in children: predictive factors of outcome

OBJECTIVES

To assess the results of myringoplasty in children and to determine which factors independently influence the postoperative results.

STUDY DESIGN

Retrospective study of the anatomic and functional results of 231 consecutive myringoplasties performed in 188 children between 1988 and 1992. Multivariate analysis of poor prognostic factors by cross-sectional comparison 1 year after surgery.

METHODS

Myringoplasties were performed via an endaural approach with a fascia temporalis underlay graft.

RESULTS

In 216 of 231 ears (93.5%) the tympanic membrane was closed. A good anatomic outcome was considered to have been achieved in 188 ears (81.6%), although in 18 ears (7.8%) seromucous otitis media occurred, in 8 ears (3.5%) a progressive retraction pocket was encountered, and in 2 ears significant lateralization was present. One hundred thirty-nine (67.5%) of the 206 ears tested in the postoperative period had a postoperative air-bone gap of 10 dB or less. On average, mean bone conduction remained unaltered. The age of the patient and the size and the location of the perforation did not affect the outcome. Three prognostic factors for an abnormal postoperative tympanic membrane were found, with 95% confidence intervals: inflammatory changes in the middle ear mucosa (P < .05), contralateral tympanic perforation (P < .05), and contralateral cholesteatoma (P < .01).

CONCLUSIONS

Myringoplasty with underlay grafting of the fascia temporalis in children gives good anatomic and functional results. Inflammatory changes within the middle ear mucosa, contralateral tympanic perforation, and contralateral cholesteatoma independently influence the risk of an abnormal postoperative tympanic membrane. The presence of one of these factors preoperatively should lead to the consideration of alternative, more durable graft material, such as autologous cartilage.

Persistence of susceptibility to measles in France despite routine immunization: a cohort analysis

OBJECTIVES

This study examined the impact of French routine programs urging the combined measles-mumps-rubella immunization of 15-month-old children.

METHODS

We applied a cohort analysis to surveillance data collected by general practitioners to estimate the cumulative incidence rate per 1000 unvaccinated children and the proportion of susceptible children, by age and for each birth cohort between 1985 and 1995.

RESULTS

More than 70% of unvaccinated children born in 1985 and 1986 had measles by the age of 10. This incidence rate dramatically decreased after implementation of the routine measles-mumps-rubella immunization program in 1989, but the proportion of 5-year-olds susceptible to measles has not decreased appreciably. In 1996, more than 15% of the children born between 1990 and 1995 were susceptible.

CONCLUSIONS

The measles vaccine coverage achieved by the French routine immunization program remains insufficient as regards reducing the number of susceptible children.

[Access to social coverage of uninsured patients attending a hospital clinic: a historical cohort study at the Baudelaire outpatient clinic in Paris]

BACKGROUND

In France health insurance coverage is universal (see note at the end of the text), nevertheless some people remain uninsured. In this high-risk population, the lack of insurance coverage contributes to the aggravation of health, by reducing access to medical care. In 1992, the Baudelaire consultation was incorporated into the outpatient clinic of Saint-Antoine hospital (Paris, France), to provide the uninsured with the same access as any other patient--but free of charge--to medical care. Social care was also provided in particular by assisting the uninsured in applying for insurance coverage. Our objectives were to quantify the delay in obtaining insurance coverage and to study whether the sociodemographic characteristics of these patients were associated with inequalities in terms of delays.

METHODS

All patients attending the consultation for the first time in 1994 were included (n = 623). Because of differences linked to the French social security system, analysis was performed into two groups according to the existence of a prior insurance coverage. Delay in obtaining or recovering insurance coverage was considered as the key variable. The socio-demographic factors linked to the rates of access to insurance coverage were determined using Cox proportional hazards regression models. We also examined the factors linked with the existence of a prior insurance coverage by logistic regression modeling.

RESULTS

Within one year 96% of the patients who had had insurance coverage in the past, and 63% of the patients who had not, were insured. No factor, whether nationality, educational level, socio-professional category, family situation, type of housing, made of income was found to be linked with obtaining or recovering insurance coverage. However, nearly all these factors were related with the existence of prior insurance coverage.

CONCLUSIONS

Our approach of systematically providing social care allows 70% of uninsured patients to obtain insurance coverage within one year. This approach probably contributes to an improvement by facilitating access to mainstream health care. Moreover, no difference in delay in obtaining insurance coverage was found associated with sociodemographic characteristics.

Circulating endotoxin during initial antibiotic treatment of severe gram-negative bacteremic infections

The impact of antibiotics on total endotoxemia and circulating tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, and IL-8 in 18 patients with severe bacteremic sepsis or septic shock due to gram-negative species was investigated. Endotoxemia, TNF-alpha, IL-6, and IL-8 were assayed before (H0) and 1 h (H1) and 4 h (H4) after the first antibiotic infusion. Endotoxemia decreased from H0 (median, 0.4 EU/mL; interquartile interval, 0.09-1.23) to H1 (median, 0.19 EU/mL; interquartile interval, 0.07-0.75; P = .03) and remained stable between H1 and H4 (median, 0.12 EU/mL; interquartile interval, 0.09-0.30; P = .4). IL-6 levels fell between H0 and H4 (P = .01) and between H1 and H4 (P = .03). IL-8 was higher at H0 than at H1 (P = .04) and at H4 (P = .01). These results suggest that endotoxemia is not increased by antibiotherapy of severe gram-negative bacteremia.

Participation of French general practitioners in public health surveillance: a multidisciplinary approach

STUDY OBJECTIVES

To evaluate the feasibility of a novel approach to measure compliance of sentinel general practitioners (SGPs) in sentinel public health surveillance and to determine the characteristics in the SGP's profile that can be objectively associated with their perseverance in public health surveillance.

DESIGN

Prospective study of the compliance of the SGPs (compliance being defined as the length of time during which an SGP complies with a given theoretical surveillance protocol) and qualitative study of the determinants of their initial motivations (using group and face to face interviews).

SETTING

The 1970 SGPs who have participated in the Sentinel system since 1984.

PARTICIPANTS

Among them, the 502 SGPs recruited since 1 July 1992 have been questioned by mailed questionnaire and 20 SGPs have been questioned during face to face semistructured interviews.

MAIN RESULTS

According to the maximum number of silences allowed by the given theoretical protocol, median compliances varied between 1.9 months (95% CI = (1.8, 2.0)) and 14.3 months (95% CI = (13.8, 15.2)). In multivariate analysis, long compliances for SGPs with a < or = 5 or > or = 20 years seniority was seen and an interest in using multimedia home servers. On the other hand, interest in local epidemiological surveys and previous experience with other surveillance networks or clinical trials were associated with short compliances. No statistical association was found between compliance and computing experience, having a medical secretary, a particular feeling of being a "public health actor", or the desire to belong to a GPs' network. A thematic analysis of interview records showed that the main motivation of the SGPs was their need to share their experiences and to self evaluate by comparison with colleagues by the means of a surveillance system that would be used as a health information system.

CONCLUSIONS

The longitudinal method used in this study was shown to be an efficient tool to monitor non-compliant SGPs with respect to given surveillance protocols. Furthermore, this approach allows the selection out of the SGPs' profile the characteristics that are associated with a longer compliance. The additional variables to be taken into account in this profile could be identified among the topics, attitudes, and experiences collected during the semistructured interviews. This work considers the question of understanding what determines the motivation of GPs to participate in public health surveillance and what are their expectations of feed back. This question is essential if information systems in general practice are to be implemented.

High doses of hydroxyethyl starch and human albumin have similar effects on monocyte function and oncotic pressure

The accumulation of hydroxyethyl starches (HES) in monocytes/macrophages has raised concern over their potential detrimental effects on host defences. We assessed prospectively the function of circulating monocytes isolated from patients treated with plasma exchange (PE) using HES. The study was carried out in the medical intensive care unit of a university hospital. Eight patients underwent PE for neurological disorders. Each patient underwent three PEs, 48 h apart. The total exchange volume was 4 L per PE. Only 4% human albumin was used for the first PE. In the second and third PEs, the plasma substitute was 2 L of HES (200,000/6%/0.62) and 2 L of albumin. Mononuclear cells were collected before and immediately after each PE and 48 h after the last PE. They were placed in suspension culture and incubated with lipopolysaccharide (LPS). Monocyte function was assessed in terms of procoagulant activity (PCA) and tumour necrosis factor alpha (TNF-alpha) production. LPS-stimulated PCA increased after the first PE (P < 0.05). Stimulated TNF-alpha production increased, but not significantly so. Similar effects were observed after the second and third PE (P < 0.05 for stimulated TNF-alpha). Values 48 h after the last PE were similar to those obtained before the second PE, suggesting that repeated infusions of HES had no detrimental effect on monocyte function. Furthermore, plasma oncotic pressure was preserved after PE with HES. These results support the partial replacement of costly human albumin with HES during repetitive PE, and suggest that HES might be a safe plasma expander in septic patients.

Predictive risk factors of residual cholesteatoma in children: a study of 256 cases

OBJECTIVE

This study aimed to determine which children are at risk of having residual cholesteatoma develop after initial surgery for either cholesteatoma or severe retraction pocket. This study aimed to identify the characteristics of each patient and assessing whether predictive factors exist to propose a well-guided therapeutic approach.

DESIGN

This was a retrospective study. Mean follow-up period (after the last eradication intervention) was 42 months.

PATIENTS

Two hundred thirty-one children (256 ears) with either cholesteatoma (n = 157) or severe retraction pockets (n = 99), both treated surgically, composed the patient group.

METHODS

STATISTICAL ANALYSIS

univariate analysis of event-free survivals (using log-rank test and Kaplan-Meier estimate) and multivariate analysis (using Cox regression model) of clinical history, surgical observations, residuals occurrence (using Kaplan-Meier's statistical method) were used.

RESULTS

Posterior mesotympanum involvement, ossicular chain interruption after disease excision (and moreover combination of both), relative lack of experience of the surgeon, and presumed incomplete removal were identified as independent risk factors highly correlated with residuals' development (relative risks ranging from 2.02-4.84). Disease extension, type of process (cholesteatoma vs. retraction pocket), eventual surgical history, and surgical method initially used (closed or open) showed no such correlation.

CONCLUSION

The identification of any of these factors should instigate a mandatory second-look procedure regardless of other initial surgical findings and of technique used. The authors propose to advance this procedure from 12 to 9 months when all these factors are found in one child.

A new out-patient care facility for HIV-infected destitute populations in Paris, France

In France, the entire population theoretically has access to health coverage, but in fact a section of the poorest population does not. Institutions have therefore been set up to provide medical care for the destitute. The objectives of this study were to describe the social characteristics of the HIV-positive destitute population attending an out-patient clinic providing free health care for the destitute in a Paris University Hospital, to compare their clinical-epidemiological characteristics with those of non-destitute HIV-positive patients, and to evaluate the quality of their care. We performed a historical prospective study wherein a cohort of 115 HIV-positive destitute patients (defined as having no health coverage at their first consultation) was compared with a control cohort of 183 HIV-positive non-destitute patients attending the same clinic. Ninety-five per cent of the destitute patients had no stable employment, 32% had no source of income, 75% had no permanent residence and 27% were i.v. drug abusers. Fifty-nine per cent were foreigners, most of whom had legal residence papers and had been in France for more than 3 years. When comparing the control and the destitute groups, the latter had a three times greater risk of developing tuberculosis (RH = 3.2, CI 95% = [1.1-9.4]). Medical compliance, access to antiretroviral treatment and hospitalization were identical in both groups. No difference was observed in terms of occurrence of a new AIDS-related disease during follow-up when full-blown AIDS before entry, CD4 count at entry and transmission group were taken into account in multivariate analysis. From the moment that destitute patients attended this adapted medico-social facility, their access to care was the same as, if not better than, that of the other patients. The development of out-patient medico-social facilities for HIV-positive destitute patients must be a public health priority even for those countries theoretically providing generalized health coverage.

Monitoring the compliance of sentinel general practitioners in public health surveillance: which GPs persevere?

OBJECTIVES

This study was undertaken to develop a novel approach to measure compliance of general practitioners (GPs) in sentinel public health surveillance. More specifically, its purpose was to determine the characteristics in the SGP's profile which can be objectively associated with perseverance.

METHODS

Since 1984, the French sentinel network has collected weekly data on eight communicable diseases, involving volunteer SGPs. In this study, 'compliance' was defined as the length of time during which a SGP complies with a given theoretical surveillance protocol. This left-censored variable was computed from individual SGP's connection time series. Kaplan-Meier method was used to estimate the compliances survival distribution for all the SGPs (1824 SGPs who have been part of the network, at one point, or another, since 1984). Using Cox regression model, a prospective survey on the 376 most recent recruits allowed us to select the characteristics associated with a longer compliance. Sensitivity analyses were carried out using the bootstrap method.

RESULTS

According to the maximum number of silences allowed by the given theoretical protocol, median compliances varied between 11.7 (95% CI: 11.1-12.3) and 38.8 (95% CI: 35.7-40.7) months. In multivariate analyses we observed long compliances for SGPs whose main motivation for being involved in the network was an interest in epidemiology and SGPs with < or = 5 or > or = 20 years seniority. On the other hand, interest in local epidemiological surveys and previous experience with other surveillance networks were associated with short compliances. We found no statistical association between compliance and computing experience, having a medical secretary, a particular feeling of being a 'public health actor', or the desire to belong to a GPs' network.

CONCLUSION

We have shown our longitudinal method to be an efficient tool for monitoring non-compliant SGPs with respect to given surveillance protocols. Furthermore, this approach allows us to select out of the SGPs' profile the characteristics which are associated with a longer compliance. This regression model could be further refined by extending the SGPs' profile. The additional variables to be taken into account in this profile could be identified through a complementary sociological approach. Our work addresses the question of understanding what determines the motivation of GPs to participate in public health surveillance. This question is essential if we hope to turn general practice information systems into genuine public health surveillance tools.

Correlation between polysialic-neural cell adhesion molecule levels in CSF and medulloblastoma outcomes

PURPOSE

To quantify CSF levels of polysialic-neural cell adhesion molecule (PSA-NCAM) in patients with medulloblastoma (MB) metastasis, to assess the correlation with other diagnostic techniques (imaging and cytology) and clinical features, and to determine whether it is a suitable marker to monitor response to treatment and subsequent follow-up data.

PATIENTS AND METHODS

PSA-NCAM levels were measured using a double-site enzyme-linked immunoadsorbant assay (ELISA) in 145 samples from 14 controls and 29 patients with MB. Clinical status of patients, imaging, and cytologic data were available at the time of each lumbar puncture. Medians and ranges for the 131 pooled PSA-NCAM concentrations were calculated for the MB versus the control groups, and for MB patients for normal versus abnormal groups at cytology or imaging, and for four clinical subgroups, respectively. For patients with MB, three PSA-NCAM measurements that corresponded to punctures performed during three time periods following surgery were selected. The kappa measure of agreement was calculated between normal and abnormal groups at cytology or imaging, and between groups of patients in remission and refractory, respectively. For the same phases, sensitivity and specificity of PSA-NCAM and cytology tests and their 95% confidence intervals (95% CIs) were computed.

RESULTS

PSA-NCAM was never detected in control CSF. PSA-NCAM concentration medians were higher in CSF with metastatic cells or that corresponded to abnormal imaging than in the corresponding normal groups (P < .05). The PSA-NCAM concentration median was significantly higher (P < .05) in CSF from patients refractory to treatment or who relapsed than from patients in remission. Agreements between PSA-NCAM and clinical status and between PSA-NCAM and cytology were excellent during and after treatment. The sensitivity of PSA-NCAM test was always better than that of cytology, whereas its specificity was lower for phases that corresponded to more than 1 month following surgery. However, specificity was 100% for patients refractory to treatment or with relapse.

CONCLUSION

PSA-NCAM measurement appears to be a new biologic marker of possible use in the management of patients with MB.

Early results of conventional versus two-portal endoscopic carpal tunnel release. A prospective study

The authors compare in a prospective, randomized study the early outcome of carpal tunnel release using either a conventional palmar open release (n = 40) or a two-portal endoscopic release (n = 56). Both groups were similar. No statistically significant differences were found regarding pain, disappearing of paraesthesiae or time to return to work. However, better recovery of grip strength was observed in the endoscopic group at 1 and 3 months. No surgical complications were observed in either group.

Attitude of French general practitioners to the public health surveillance of communicable diseases

BACKGROUND

The attitude of general practitioners (GPs) to public health surveillance is not well documented, even though they furnish essential information, in particular for sentinel surveillance among the general population.

METHODS

The attitude of 560 French GPs to the surveillance of 17 communicable diseases was researched. Half the GPs had previous experience in public health surveillance and the other half did not. Their motivation for belonging to a public health surveillance network and some of their demographic characteristics were also investigated. Their attitude was compared with an objective evaluation of public health surveillance priorities, based on 10 criteria.

RESULTS

Primarily, GPs are interested in the surveillance of uncommon and serious diseases (HIV infection, tuberculosis, meningitis), and/or preventable ones (viral hepatitis, flu' syndrome, measles, sexually transmitted diseases), which coincides with the choices made by public health decision makers. The age of the GPs, their type of practice (urban/rural), and their participation (or not) in a surveillance network modify their priorities: in general the GPs' perception of the risks to which their patients may be exposed influences their choice of which diseases should be subject to surveillance in general medicine.

Constitution and monitoring of an epidemiological surveillance network with sentinel general practitioners

The Réseau National Télé-informatique de surveillance et d'information sur les Maladies Transmissibles (RNTMT) (French communicable diseases computerised surveillance network) comprises a network of sentinel general practitioners (SGP). These benevolent volunteers are responsible for the weekly epidemiological surveillance. Since its creation, 1,700 SGPs have participated in the RNTMT, representing a total of more than 120,000 connections to the RNTMT telematic service center. The principal motivation of these benevolent SGPs was to 'actively participate in public health', although only a minority of them (17.6%) had any training in this field. Such a system, based on the benevolent and voluntary activity of SGPs, requires a good understanding of SGPs' attitudes towards epidemiological surveillance in general and the tool used, in order to quantitatively and qualitatively follow their participation and to provide regular and useful feedback to the surveillance actors.

[An outbreak of Heliotrope food poisoning, Tadjikistan, November 1992-March 1993]

The seeds and roots of Heliotropium lasocarpium, contain a pyrrolizidine alkaloid which causes toxic liver injury and veno-occlusive disease (VOD), characterised by an occlusive lesion of the centrolobular veins of the liver, when consumed by humans. The Farkhar region of Southern Tadjikistan, was blockaded from May to November 1992. This led to a famine and a delay of two months in the wheat harvest. Heliotropium lasocarpium had time to grow in the fields and their seeds were therefore collected with the wheat. The contaminated wheat was distributed to the population, who milled it and made bread. The first case of liver toxicity was six weeks after the first consumption of the contaminated bread. By March 1993, 3,906 cases had been recorded (attack rate = 4%). The attack rate were 0.4%, 5.4%, 4.0%, 2.8% and 1.5% for the less than 1 year, 1-14 years, 15-30 years, 31-50 years and over 50 years age groups respectively. The overall case fatality ratio (CFR) was 1.3% and increased with age from 0 to 5.9% in the same age groups. Two of the ten collective farms represented 83.3% of the cases attack rate of 16.9% and 23.6%. Four stages of illness were defined. Stage I corresponds to abdominal pain, nausea or vomiting, and asthenia. All stage I patients (55.5%) recovered rapidly. Stage II is an association of Stage I and hepatomegalia (29.9%). Stage III includes ascites in addition to these symptoms (13.7%) and stage IV alteration of consciousness (0.9%). The last case was reported on March 4th 1993.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ten years of measles epidemiological surveillance in France through a network of sentinel physicians]

In France, the sentinel general practitioners of the French Communicable Diseases Network (FCDN) monitor the epidemiological surveillance of eight communicable diseases, including measles. For the last 10 years, this surveillance has shown a seasonality of the annual incidence of measles (with peaks in late spring) and a decrease in incidence since the last outbreaks in 1986 and 1987. This decrease, the increasing mean age of the cases and an increase in the percentage of appropriately vaccinated cases are due to the increasing vaccination coverage of children due to the national immunization programme was reinforced in 1989. However, with 75,000 cases in 1993, measles is far from being a rare disease in France; epidemiological surveillance and improved vaccination coverage are still necessary.

[Immediate hypersensitivity to latex: a new problem. Future perspectives]

From a series of 30 cases of immediate allergy to the latex of Hevea Brasiliensis, the authors recall the principal clinical aspects of these allergies, specially contact urticaria (during the use of surgical or cleaning gloves) and systemic anaphylactic accidents, essentially the anaphylactic shock during surgical procedures. They mention the diagnostic procedures; skin tests and measurement of specific IgE (RAST). They show the interest of biological research, yielding to the identification of the allergens of the latex in order to obtain non allergenic latex. Such a result would be of interest to limit the number of the accidents in a period where the use of rubber protective material is much larger/gloves and condoms).

Conditioned taste aversion and conditioned drinking: two independent and opposing effects of 5-hydroxytryptophan?

Four experiments were carried out to examine the effects of 5-HTP in a conditioned taste aversion (CTA) paradigm. Using two-choice tests to measure the CTA, administration of 5-HTP following consumption of a novel flavour caused aversions to saline and saccharin solutions. In single-choice tests 5-HTP reduced consumption of saccharin, sugar cubes and beef-flavoured stock cubes, but only reduced saline consumption if animals had been pretreated with the 5-HTP decarboxylase inhibitor benserazide or the 5-HT receptor antagonist xylamidine, both of which act peripherally. Benserazide did not attenuate the CTA in any experiment. The results are interpreted in terms of two competing behavioural effects of 5-HTP: a centrally-mediated CTA and a peripherally-mediated conditioned drinking response.