Communication of children's weight status: what is effective and what are the children's and parents' experiences and preferences? A mixed methods systematic review

BACKGROUND

Early intervention and conversation about a child's weight may offer an important chance of success in reducing weight and implementing a healthier lifestyle. This review explores the most effective ways to notify parents and children about the child's weight as well as their preferences and experiences around weight notification.

METHODS

We systematically searched nine databases for relevant primary research. Records were independently screened by two authors. We extracted data into a form designed for this review. Effect data was analysed using narrative synthesis and qualitative data using a best-fit framework synthesis. We assessed our confidence in the evidence using GRADE and GRADE-CERQual.

RESULTS

Studies of effect found that the format of feedback made little or no difference in parents attending further treatment, recognising their child as overweight or obese, reactions to the way the weight notification is given, motivation for lifestyle change, understanding how to reduce the risk of overweight, or taking any action. However, parents receiving feedback with motivational interviewing have somewhat greater satisfaction with the way the healthcare provider supports them. Qualitative studies found that parents had clear preferences for the format, timing, content and amount of information they wanted to receive in relation to both the weighing process and weight notification. They also had clear preferences for how they wanted health care providers to interact and communicate with them and their children. Both parents and children often felt that they were not receiving enough information and worried about how their results would be kept private. Many parents experienced an emotional response when told about their child's weight ranging from positive, disbelief and negative feelings. Those who reacted with disbelief or negatively were less likely to accept their child's weight status and/or act upon the notification letter. No studies reported results for children who were underweight.

CONCLUSIONS

Based on these qualitative results people working with weight assessment and notification programs should consider parents' preferences when developing feedback formats, considering the mode of feedback they are going to use and provide parents and children with tailored feedback and personalized follow up once a child is identified as overweight or obese.

Safety review: two outer membrane vesicle (OMV) vaccines against systemic Neisseria meningitidis serogroup B disease

MenBvac is an OMV vaccine against systemic serogroup B Neisseria meningitidis disease. MenBvac was developed for control of a B:15:P1.7,16 subtype epidemic in Norway and administered to 180,000 subjects in 28 clinical studies. MeNZB, a daughter vaccine of MenBvac, was developed for a clonal B:4:P1.7b,4 epidemic in New Zealand and administered to 1 million people <20 years. The vaccines were similar regarding reactogenicity profile. Serious adverse events (SAEs) in general and particularly neurologic SAEs were very rare. Despite frequently reported local reactions and fever in those under 5 years, these OMV-based vaccines containing 25 microg antigen can be considered safe for use in all age groups.

Serum bactericidal activity correlates with the vaccine efficacy of outer membrane vesicle vaccines against Neisseria meningitidis serogroup B disease

For evaluation of serum bactericidal activity (SBA) as surrogate for the efficacy of outer membrane vesicle (OMV) vaccines against Neisseria meningitidis serogroup B disease, we have reanalyzed data from a randomized double blind placebo-controlled efficacy trial involving 172000 secondary school students (aged 13-14 years) in Norway (1988-1991). A cohort of the efficacy trial consisting of 880 individuals was selected for immunogenicity studies. An efficacy of 87% was calculated for a 10-month observation period. However, after an observation period of 29 months, the estimated efficacy against group B disease induced by vaccination was 57%. The immunogenicity study showed that the SBA geometric mean titer (GMT) for the vaccinees was 2.4 before vaccination and 19.0 six weeks after the second vaccine dose. One year after vaccination the GMT was reduced to 2.8. A separate three-dose study with 304 adolescents showed that with a third dose at 10 months after the second dose (i.e. when cases of disease started to appear) a strong booster response was induced. Ten months after the second dose the SBA was reduced to near pre-immunization level. Following the third dose the SBA geometric mean titer of 2.7 increased to 62.3. One year after the third dose, the GMT was markedly higher than 6 weeks after the second dose (12.6 versus 8.8). Thus, protection after vaccination corresponds with the level of SBA. In order to reach lasting protective levels of SBA in a population, three vaccine doses are probably required. Measurements of SBA are likely to be useful for evaluating various upcoming formulations and improvements of immunization regimens for OMV vaccines.

[Should school children receive pertussis vaccine?]

BACKGROUND

A study comparing diphtheria immunity in Norwegian and Russian schoolchildren indicated low immunity against diphtheria in Norwegian children before the booster dose given at age 11 years. The pertussis epidemic in Norway 1997-98 demonstrated decreasing vaccine immunity from age 5-6 years. The possibility of improving immunity against both diseases by a booster dose during early school age is therefore under consideration.

MATERIAL AND METHODS

Immune response and adverse events were studied after a combined vaccine against diphtheria, tetanus, pertussis (acellular) and poliomyelitis (DTPa-IPV) given at seven years of age, and a combined vaccine against diphtheria, tetanus and pertussis (acellular) (DTPa) at 11 years of age, in two parallel trials including 124 and 83 participants respectively.

RESULTS

The trials confirmed that the diphtheria immunity is lower than it ideally should be in more than 40% of children before the booster dose at age 11. Pertussis immunity is difficult to assess because there is no clear relationship between antibody levels and protection. All study participants responded well to all vaccine components. The 11-year-old children reported higher occurrence of adverse events than the 7-year-olds. All adverse events were brief and none were serious.

INTERPRETATION

The results indicate that a booster dose of DTPa-IPV in early school age would give better protection against diphtheria and pertussis in Norwegian schoolchildren, without unacceptable side effects.

Immunogenicity of 2 serogroup B outer-membrane protein meningococcal vaccines: a randomized controlled trial in Chile

CONTEXT

Meningococcal disease occurs worldwide, and serogroup B disease accounts for a large proportion of cases. Although persons younger than 4 years are at greatest risk for serogroup B meningococcal disease, vaccine efficacy has not been demonstrated in this age group.

OBJECTIVE

To evaluate serum bactericidal activity (SBA) against homologous vaccine type strains and a heterologous Chilean epidemic strain of Neisseria meningitidis as a potential correlate for vaccine efficacy.

DESIGN

Double-blind, randomized controlled trial conducted between March 14 and July 20, 1994. All blood samples were taken by December 1994.

SETTING

Santiago, Chile, where a clonal serogroup B meningococcal disease epidemic began in 1993.

PARTICIPANTS

Infants younger than 1 year (n = 187), children aged 2 to 4 years (n = 183), and adults aged 17 to 30 years (n = 173).

INTERVENTION

Participants received 3 doses of outer-membrane protein (OMP) meningococcal vaccine developed in either Cuba or Norway or a control vaccine, with each dose given 2 months apart. Blood samples were obtained at baseline, prior to dose 3, and at 4 to 6 weeks after dose 3.

MAIN OUTCOME MEASURE

Immune response, defined as a 4-fold or greater rise in SBA titer 4 to 6 weeks after dose 3 compared with prevaccination titer.

RESULTS

Children and adult recipients of either meningococcal vaccine were more likely than controls to develop an immune response to the heterologous epidemic strain. After 3 doses of vaccine, 31% to 35% of children responded to the vaccine vs 5% to placebo; 37% to 60% of adults responded to vaccine vs 4% to placebo (P<.05 vs control for all). Infants, however, did not respond. In contrast, against homologous vaccine type strains, the response rate was 67% or higher among children and adults and 90% or higher among infants (P<.001 vs control for all). Subsequent SBA against 7 isogenic homologous target strains identified class 1 OMP as the immunodominant antigen.

CONCLUSIONS

These data suggest that neither serogroup B OMP meningococcal vaccine would confer protection during a heterologous epidemic. However, epidemic strain-specific vaccines homologous for class 1 OMP are promising candidates for the control of epidemic serogroup B meningococcal disease.

Perspective: a five-country analysis of the impact of four different Haemophilus influenzae type b conjugates and vaccination strategies in Scandinavia

Prior to vaccinations against invasive Haemophilus influenzae type b (Hib) diseases in Scandinavia, first initiated in Finland in 1986, the incidence of cases in those five countries was 49/100,000/year in 0- to 4-year-olds and 3.5/100,000 overall. During the following decade, Hib conjugates administered to young children had approximately 95% effectiveness, regardless of which conjugate was used, whether two or three primary doses were administered, and at what age in early infancy the first vaccination was given. The herd immunity effect has extended protection to older age groups. A similar effectiveness of different conjugates in five countries despite considerable diversity in approach suggests that the same impact would occur in other regions with comparable epidemiology. The Scandinavian experience supports the view that three primary vaccine doses are not imperative, thus suggesting that reducing doses of costly Hib vaccines would be one way to facilitate their usage in regions with limited resources.

Effect of aluminium hydroxide and meningococcal serogroup C capsular polysaccharide on the immunogenicity and reactogenicity of a group B Neisseria meningitidis outer membrane vesicle vaccine

Three different formulations of an outer membrane vesicle (OMV) vaccine against group B meningococcal disease have been prepared and tested for immunogenicity and reactogenicity in adult volunteers. The vaccines were prepared with or without aluminium hydroxide and serogroup C-polysaccharide (C-ps). Doses from 12.5 to 100 micrograms protein were given twice at a six weeks' interval. All three formulations were well tolerated and highly immunogenic, inducing bactericidal and opsonizing antibodies in humans. Adsorption of OMVs to aluminium hydroxide reduced the pyrogenicity in rabbits. The differences in immunogenicity between the formulations were relatively small, but after the second dose a stronger booster response was observed when the vaccines were adsorbed. Thus, a formulation with OMVs and C-ps represents a safe and highly immunogenic vaccine, even without aluminium hydroxide.

Influenza vaccination in 22 developed countries: an update to 1995

This study expands and updates through 1995 our earlier report on influenza vaccine use in 18 developed countries. Five of the six countries with high levels of vaccine use in 1992 (> or = 130 doses/1000 population) showed little change or slight declines over the subsequent 3 years. The exception was the United States, where a new federal program for vaccination reimbursement for the elderly helped to increase vaccine distribution from 144 to 239 doses/1000 population. The six countries with medium levels of vaccine use in 1992 (76-96 doses/1000 population) increased to > or = 100 doses/1000 population by 1995. Among the six low-use countries in 1992 (< or = 65 doses/1000 population), only Finland showed substantial improvement (96 doses/1000 population) in 1995. Four new countries were added to the study. In Germany, vaccine use increased to 80 doses/1000 population in 1995, but in Ireland it remained at a low level (48 doses/1000 population). In Korea, vaccine use increased from 17 to 95 doses/ 1000 population during the period 1987-1995. In Japan, very high levels of vaccine use (approximately 280 doses/1000 population) in the early 1980s were associated with vaccination programs for school children. However, vaccine use fell precipitously when these programs were discontinued, and only 2 and 8 doses/1000 population were used in 1994 and 1995, respectively. In all 22 countries, higher levels of vaccine use were associated with vaccination reimbursement programs under national or social health insurance and were not correlated with different levels of economic development. Excluding Japan, in 1995 there was still a greater than fourfold difference between the highest and lowest levels of vaccine use among the other 21 countries in the study. Given its well established clinical effectiveness and cost-effectiveness, none of these countries has yet achieved the full benefits of its programs for influenza vaccination.

[Influenza vaccination--socially beneficial prevention or a prick without effect?]

Every winter we are assailed by influenza epidemics. International collaboration would enable us to be forearmed with the appropriate virus-specific vaccines, for influenza viruses and strains are characterised by constant variation. In most cases influenza is an innocuous disease, but in certain risk groups-e.g., people with heart disease or the elderly with diminished immune defence, influenza may have serious consequences. The Nordic countries differ from each other in the free provision of their recommendations as to influenza vaccination.

Human antibody responses to meningococcal outer membrane antigens after three doses of the Norwegian group B meningococcal vaccine

The antibody kinetics in sera from 27 adults after three doses of the Norwegian group B meningococcal outer membrane vesicle (OMV) vaccine was studied. The vaccinees received the third dose 4 to 5 years after the first two. Antibody responses against outer membrane proteins (OMPs) and lipopolysaccharides were studied by enzyme-linked immunosorbent assay and immunoblotting and with serum bactericidal assays (SBA) with three variants of the vaccine strain, 44/76. Six weeks after the second injection, the geometric mean (GM) of the levels of immunoglobulin G (IgG) against OMVs was about sevenfold higher than that of prevaccination levels, and 74% of the vaccinees developed a greater-than-twofold rise in SBA titer. After 6 months, the GM of IgG levels declined to about threefold higher, and after 4 to 5 years it declined to about twofold higher, than that before vaccination. The third dose induced a rapid increase in SBA titers in 96% of the vaccinees, and the GM of levels of IgG against OMVs rose to about 14-fold the prevaccination level. One year later, the IgG antibody levels had dropped to 4.6-fold the prevaccination level, but 88% of the vaccinees still showed bactericidal activity. The response after the two first doses was higher in individuals with prevaccination antibodies, but no such effect was found after three doses. The use of defined mutants in SBA and linear multiple regression analyses indicated that among the major OMPs, antibodies to the Opc and class 1 proteins made the most important single contributions to the bactericidal activity against the vaccine strain, but it also demonstrated the importance of antibodies against other antigens. After three doses, 68% of the vaccinees showed a significant SBA response against a strain lacking both the Opc and the class 1 proteins. Three doses converted almost all subjects to SBA responders and gave higher antibody levels and relatively less serosubtype-specific bactericidal activity than did two doses, probably indicating a broader cross-protection against heterologous strains.

[Vaccine against Haemophilus influenzae type b--antibody response and adverse effects]

In 1992 it was decided to implement vaccination against Haemophilus influenzae type b (Hib) in the Norwegian vaccination programme. The chosen vaccine consists of Hib-polysaccharide conjugated to tetanus toxoid. To suit the Norwegian vaccination schedule, Hib-vaccine was given together with vaccine against diphtheria, tetanus and pertussis (DTP) at three, five and ten months of age. Since all earlier studies with the Hib-vaccine have used other time schedules, a pilot study was conducted to test antibody response and side effects when using the Norwegian schedule. 44 infants were vaccinated with Hib-vaccine and DTP at three, five and ten months of age. Blood samples showed that 95% had protective antibody titer against Hib after two doses, 100% after three. The response to the other antigens was adequate. There were only minor side effects. After introduction of the Hib-vaccine the incidence of invasive Hib-infection in children below three years of age has decreased considerably.

[All persons without spleen should be given pneumococcal vaccine]

Splenectomized individuals run increased risk of developing overwhelming septicemia from encapsulated bacteria, especially Streptococcus pneumoniae. Polyvalent pneumococcal polysaccharide vaccine should be given to all splenectomized individuals above two years of age. Antipneumococcal antibody levels should be measured three to five years after the first vaccination, and persons with low antibody levels should be revaccinated. Splenectomized persons may be given a supply of penicillin V to enable them to start therapy while avaiting medical attention.

The Norwegian meningococcal group B outer membrane vesicle vaccine: side effects in phase II trials

In order to establish the safety of the Norwegian meningococcus B vaccine we have focused on detailed reporting of side effects in several phase II trials. We report here the results of the largest single phase II study, (step II-6) including 877 school children. The incidence of local side effects was significantly higher in the vaccine than in the placebo group, but most of them were mild and short-lasting. Mild systemic side effects were commonly reported in both groups, but more severe side effects were rare and almost equally distributed between the groups.

Bactericidal antibodies after vaccination with the Norwegian meningococcal serogroup B outer membrane vesicle vaccine: a brief survey

Results from the serum bactericidal assay (BA) after immunization of human volunteers with the Norwegian serogroup B meningococcal outer membrane vesicle vaccine are surveyed. In the phase II trials with adults we found very high seroconversion rates (greater than 98%) against the vaccine strain in the BA. Details in the antigenic composition of the inoculum used in the BA seem very important as shown here by finding lower bactericidal titres with teenager sera when tested with a variant of the standard inoculum. The present preliminary report corresponds to the presentation given at the Report Meeting on the Norwegian Meningococcal Vaccine Trial, Oslo, 12 September, 1991.

Design of clinical trials with an outer membrane vesicle vaccine against systemic serogroup B meningococcal disease in Norway

An outer membrane vesicle vaccine against acute, systemic disease caused by meningococci of serogroup B has been developed. The vaccine has been tested consecutively in phase I and phase II clinical trials including more than 5000 volunteers. These trials provided data on safety, immunogenicity and reactogenicity and possible effect on carriage of meningococci in the throat, and consequently formed the basis for two major protection trials; one in secondary school students and one among military recruits. The aims, design and major results of phase I and phase II studies are described as well as the design and organization of the protection trials.

Human antibody responses after vaccination with the Norwegian group B meningococcal outer membrane vesicle vaccine: results from ELISA studies

Antibody responses after vaccination with three different formulations of a new meningococcal group B outer membrane vesicle (OMV) vaccine have been studied with the ELISA technique using four different antigens. Sera from about 1200 vaccinees participating in steps 1, 2, 3 and 6 of the phase II clinical trials in Norway were analysed. The effects of non-covalently complexing the OMV antigen to group C polysaccharide (C-PS) and of adsorbing OMV (with and without C-PS) to aluminium hydroxide (AH) were studied. All three vaccine formulations were highly immunogenic in humans. Adsorption of the vaccine to AH had a relatively small effect on the immune response, but the results indicated that the booster response was stronger with the adsorbed than with the unadsorbed vaccines. Some increase in the immune response against OMV was also observed by non-covalent complexing OMV with C-PS, particularly after the second dose. In most of the vaccinees the antibody levels were significantly reduced 6 to 12 months after vaccination. Adsorption of the vaccine to AH had no effect on the antibody response against C-PS. Comparison with bactericidal activity of the same sera was done. A highly significant correlation was observed between the bactericidal titres and the levels of IgG antibodies against OMV and class 5C protein, whereas the correlation between antibody levels against lipopolysaccharide and the bactericidal activity was poor.

Results of an efficacy trial with an outer membrane vesicle vaccine against systemic serogroup B meningococcal disease in Norway

A placebo controlled, double blind efficacy trial with a new outer membrane vesicle vaccine against systemic meningococcal disease of serogroup B, has been conducted in Norwegian secondary schools. The study was randomized at school level (1335 schools) and 171,800 students volunteered. The study started in October 1988 and the code was opened in June 1991. Out of the thirty-six proven cases of acute, severe, systemic disease caused by serogroup B meningococci among the participants, twelve occurred in eleven schools given vaccine, twenty-four in twenty-four schools given placebo. twenty-four cases were recorded among secondary school students who did not participate in the study. The protection rate was calculated to 57.4% with a p-value of 1.2% and lower limit of confidence (95%) to 27.7%. The results have initiated research towards an improved outer membrane vesicle vaccine against this disease.

Effect of outer membrane vesicle vaccine against group B meningococcal disease in Norway

For more than 15 years, Norway has had the highest incidence of meningococcal disease in northern Europe, with 80% of cases being due to serogroup B meningococci. The case-fatality has remained high, at about 10%. In this study, an outer membrane vaccine, which had previously been shown to induce an increase in bactericidal antibodies to the parent strain, was assessed in a large-scale, randomised, double-blind trial. From October, 1988, 171,800 students in secondary schools volunteered to take part in a double-blind, placebo-controlled, efficacy trial with school as the randomisation unit. Hospitals and clinics that routinely receive patients with infectious disease were asked to report urgently all cases of suspected meningitis and/or septicaemia in 13-21-year-old students in Norway. These cases were registered and further investigated according to a detailed protocol. 89 out of the 221 cases investigated by June 3, 1991, were shown to be severe systemic disease due to group B meningococci. 36 cases in 35 schools took part in the trial (11 schools with vaccinated students and 24 with students given placebo). The calculated rate of protection was thus 57.2% (p = 0.012, one-sided test). The findings suggest that, although the vaccine conferred protection against group B meningococcal disease, the effect was insufficient to justify a public vaccination programme.

[Vaccination of premature infants]

Until now premature infants in Norway have not been vaccinated as early as full term infants. Recent studies prove that premature infants show adequate responses to vaccination. Therefore premature infants should be vaccinated at the same age as full term infants.

[Clinical trials of the new Norwegian vaccine against diseases caused by Meningococcus B]

Since 1974 Norway has experienced an epidemic of meningococcal disease. In October 1986 the National Institute of Public Health decided to develop and test out a vaccine against group B meningococci. This paper describes how the vaccine was tested through phase I and II trials, and how problems of safety and informed consent were handled. Two major protection trials are currently in progress. 130,000 secondary school students have volunteered for a study simulating the use of a vaccine in the long-term protection of an age group at risk. Military recruits are involved in a study where instant protection is important, as in a situation where the vaccine is used in the vicinity of an outbreak of the disease. 20,000 soldiers are included so far, and the study will ultimately include 70,000.