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Craiu D, Rener Primec Z, Lagae L, Vigevano F, Trinka E, Specchio N, Bakhtadze S, Cazacu C, Golli T, Zuberi SM. Vaccination and childhood epilepsies. Eur J Paediatr Neurol 2022; 36:57-68. [PMID: 34922162 DOI: 10.1016/j.ejpn.2021.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 11/08/2021] [Accepted: 11/24/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The evidence relating vaccination to febrile seizures and epilepsy is evaluated with an emphasis on febrile seizures (FS), Dravet syndrome (DS), West syndrome, and other developmental and epileptic encephalopathies. METHODS A systematic literature review using search words vaccination/immunization AND febrile seizures/epilepsy/Dravet/epileptic encephalopathy/developmental encephalopathy was performed. The role of vaccination as the cause/trigger/aggravation factor for FS or epilepsies and preventive measures were analyzed. RESULTS From 1428 results, 846 duplicates and 447 irrelevant articles were eliminated; 120 were analyzed. CONCLUSIONS There is no evidence that vaccinations cause epilepsy in healthy populations. Vaccinations do not cause epileptic encephalopathies but may be non-specific triggers to seizures in underlying structural or genetic etiologies. The first seizure in DS may be earlier in vaccinated versus non-vaccinated patients, but developmental outcome is similar in both groups. Children with a personal or family history of FS or epilepsy should receive all routine vaccinations. This recommendation includes DS. The known risks of the infectious diseases prevented by immunization are well established. Vaccination should be deferred in case of acute illness. Acellular pertussis DTaP (diphtheria-tetanus-pertussis) is recommended. The combination of certain vaccine types may increase the risk of febrile seizures however the public health benefit of separating immunizations has not been proven. Measles-containing vaccine should be administered at age 12-15 months. Routine prophylactic antipyretics are not indicated, as there is no evidence of decreased FS risk and they can attenuate the antibody response following vaccination. Prophylactic measures (preventive antipyretic medication) are recommended in DS due to the increased risk of prolonged seizures with fever.
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Affiliation(s)
- Dana Craiu
- Carol Davila University of Medicine and Pharmacy, Faculty of Medicine, Department of Neurosciences, Pediatric Neurology Discipline II, Strada Dionisie Lupu No. 37, postal code: 020021, Bucharest/S2, Romania; Pediatric Neurology Clinic, Center of Expertise for Rare Disorders in Pediatric Neurology, EpiCARE member, Sos. Berceni 10, Bucharest/S4, Romania.
| | - Zvonka Rener Primec
- Department of Child, Adolescent and Developmental Neurology, Children's Hospital, University Medical Center Ljubljana Bohoričeva 20, 1000, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia.
| | - Lieven Lagae
- University of Leuven, Department of Development and Regeneration, Section Paediatric Neurology, Herestraat 49, 3000, Leuven, Belgium.
| | - Federico Vigevano
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network EpiCARE, Piazza S. Onofrio, 4, 00151, Rome, Italy.
| | - Eugen Trinka
- Department of Neurology, Christian-Doppler Medical Centre, Paracelsus Medical University, Affiliated Member of the European Reference Network, EpiCARE, 5020, Salzburg, Austria; Neuroscience Institute, Christian-Doppler Medical Centre, Paracelsus Medical University Salzburg, Austria.
| | - Nicola Specchio
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network EpiCARE, Piazza S. Onofrio, 4, 00151, Rome, Italy.
| | - Sophia Bakhtadze
- Department of Paediatric Neurology, Tbilisi State Medical University, 0160, Tbilisi, Georgia.
| | - Cristina Cazacu
- Pediatric Neurology Clinic, Center of Expertise for Rare Disorders in Pediatric Neurology, EpiCARE member, Sos. Berceni 10, Bucharest/S4, Romania.
| | - Tanja Golli
- Department of Child, Adolescent and Developmental Neurology, Children's Hospital, University Medical Center Ljubljana Bohoričeva 20, 1000, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia.
| | - Sameer M Zuberi
- Paediatric Neurosciences, Royal Hospital for Children, Glasgow, UK; Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK.
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Lewnard JA, Reingold AL. Emerging Challenges and Opportunities in Infectious Disease Epidemiology. Am J Epidemiol 2019; 188:873-882. [PMID: 30877295 PMCID: PMC7109842 DOI: 10.1093/aje/kwy264] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 11/28/2018] [Accepted: 11/29/2018] [Indexed: 12/12/2022] Open
Abstract
Much of the intellectual tradition of modern epidemiology stems from efforts to understand and combat chronic diseases persisting through the 20th century epidemiologic transition of countries such as the United States and United Kingdom. After decades of relative obscurity, infectious disease epidemiology has undergone an intellectual rebirth in recent years amid increasing recognition of the threat posed by both new and familiar pathogens. Here, we review the emerging coalescence of infectious disease epidemiology around a core set of study designs and statistical methods bearing little resemblance to the chronic disease epidemiology toolkit. We offer our outlook on challenges and opportunities facing the field, including the integration of novel molecular and digital information sources into disease surveillance, the assimilation of such data into models of pathogen spread, and the increasing contribution of models to public health practice. We next consider emerging paradigms in causal inference for infectious diseases, ranging from approaches to evaluating vaccines and antimicrobial therapies to the task of ascribing clinical syndromes to etiologic microorganisms, an age-old problem transformed by our increasing ability to characterize human-associated microbiota. These areas represent an increasingly important component of epidemiology training programs for future generations of researchers and practitioners.
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Affiliation(s)
- Joseph A Lewnard
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, California
- Correspondence to Dr. Joseph A. Lewnard, Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, 2121 Berkeley Way, Berkeley, CA 94720 (e-mail: )
| | - Arthur L Reingold
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, California
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Jia JL, Chen S, Sivarajah V, Stephens D, Cortez MA. Latitudinal differences on the global epidemiology of infantile spasms: systematic review and meta-analysis. Orphanet J Rare Dis 2018; 13:216. [PMID: 30486850 PMCID: PMC6262963 DOI: 10.1186/s13023-018-0952-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 11/14/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Infantile spasms represent the catastrophic, age-specific seizure type associated with acute and long-term neurological morbidity. However, due to rarity and heterogenous determination, there is persistent uncertainty of its pathophysiological and epidemiological characteristics. The purpose of the current study was to address a historically suspected latitudinal basis of infantile spasms incidence, and to interrogate a geographical basis of epidemiology, including the roles of latitude and other environmental factors, using meta-analytic and -regression methods. METHODS A systematic search was performed in Ovid MEDLINE and Embase for primary reports on infantile spasms incidence and prevalence epidemiology. RESULTS One thousand fifteen studies were screened to yield 54 eligible publications, from which 39 incidence figures and 18 prevalence figures were extracted. The pooled incidence was 0.249 cases/1000 live births. The pooled prevalence was 0.015 cases/1000 population. Univariate meta-regression determined a continental effect, with Europe demonstrating the highest onset compared from Asia (OR = 0.51, p = 0.004) and from North America (OR = 0.50, p = 0.004). Latitude was also positively correlated with incidence globally (OR = 1.02, p < 0.001). Sub-analyses determined a particularly elevated Scandinavian incidence compared to the rest of world (OR = 1.88, p < 0.001), and lack of latitudinal effect with Scandinavian exclusion (p = 0.10). Metrics of healthcare quality did not predict incidence. Multiple meta-regression determined that latitude was the key predictor of incidence (OR = 1.02, p = 0.001). CONCLUSIONS This is the first systematic epidemiological study of infantile spasms. Limitations included lack of Southern hemispheric representation, insufficient study selection and size to support some sub-continental analyses, and lack of accessible ethnic and healthcare quality data. Meta-analyses determined a novel, true geographical difference in incidence which is consistent with a latitudinal and/or ethnic contribution to epileptogenesis. These findings justify the establishment of a global registry of infantile spasms epidemiology to promote future systematic studies, clarify risk factors, and expand understanding of the pathophysiology.
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Affiliation(s)
- Jason L. Jia
- Department of Medicine, University of Toronto, 190 Elizabeth Street R. Fraser Elliott Wing, Toronto, M5G 2C4 Canada
| | - Shiyi Chen
- Child Health Evaluative Sciences Research Program, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Vishalini Sivarajah
- Department of Medicine, University of Toronto, 190 Elizabeth Street R. Fraser Elliott Wing, Toronto, M5G 2C4 Canada
| | - Derek Stephens
- Child Health Evaluative Sciences Research Program, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Miguel A. Cortez
- Department of Pediatrics, Division of Neurology, University of Toronto, Toronto, Canada
- Neurosciences & Mental Health Program, Peter Gilgan Centre for Research and Learning, SickKids Research Institute, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8 Canada
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Incidence rates of narcolepsy diagnoses in Taiwan, Canada, and Europe: The use of statistical simulation to evaluate methods for the rapid assessment of potential safety issues on a population level in the SOMNIA study. PLoS One 2018; 13:e0204799. [PMID: 30332477 PMCID: PMC6192586 DOI: 10.1371/journal.pone.0204799] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 09/07/2018] [Indexed: 12/21/2022] Open
Abstract
Background & objectives Vaccine safety signals require investigation, which may be done rapidly at the population level using ecological studies, before embarking on hypothesis-testing studies. Incidence rates were used to assess a signal of narcolepsy following AS03-adjuvanted monovalent pandemic H1N1 (pH1N1) influenza vaccination among children and adolescents in Sweden and Finland in 2010. We explored the utility of ecological data to assess incidence of narcolepsy following exposure to pandemic H1N1 virus or vaccination in 10 sites that used different vaccines, adjuvants, and had varying vaccine coverage. Methods We calculated incidence rates of diagnosed narcolepsy for periods defined by influenza virus circulation and vaccination campaign dates, and used Poisson regression to estimate incidence rate ratios (IRRs) comparing the periods during which wild-type virus circulated and after the start of vaccination campaigns vs. the period prior to pH1N1 virus circulation. We used electronic health care data from Sweden, Denmark, the United Kingdom, Canada (3 provinces), Taiwan, Netherlands, and Spain (2 regions) from 2003 to 2013. We investigated interactions between age group and adjuvant in European sites and conducted a simulation study to investigate how vaccine coverage, age, and the interval from onset to diagnosis may impact the ability to detect safety signals. Results Incidence rates of narcolepsy varied by age, continent, and period. Only in Taiwan and Sweden were significant time-period-by-age-group interactions observed. Associations were found for children in Taiwan (following pH1N1 virus circulation) and Sweden (following vaccination). Simulations showed that the individual-level relative risk of narcolepsy was underestimated using ecological methods comparing post- vs. pre-vaccination periods; this effect was attenuated with higher vaccine coverage and a shorter interval from disease onset to diagnosis. Conclusions Ecological methods can be useful for vaccine safety assessment but the results are influenced by diagnostic delay and vaccine coverage. Because ecological methods assess risk at the population level, these methods should be treated as signal-generating methods and drawing conclusions regarding individual-level risk should be avoided.
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de St Maurice A, Edwards KM. Post-licensure monitoring to evaluate vaccine safety. J Pediatr 2015; 166:513-5. [PMID: 25722262 DOI: 10.1016/j.jpeds.2014.12.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 12/12/2014] [Indexed: 10/23/2022]
Affiliation(s)
- Annabelle de St Maurice
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt Vaccine Research Program, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Kathryn M Edwards
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt Vaccine Research Program, Vanderbilt University School of Medicine, Nashville, Tennessee.
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7
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Evans G, Levine EM, Jacobs AL. Legal issues. Vaccines (Basel) 2013. [DOI: 10.1016/b978-1-4557-0090-5.00077-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Pertussis vaccines. Vaccines (Basel) 2013. [DOI: 10.1016/b978-1-4557-0090-5.00030-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] Open
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Affiliation(s)
- John Snyder
- Tufts University School of Medicine, Boston, and Pediatric Residency Program, Baystate Children’s Hospital, Springfield, MA, USA
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Neuropathology of vaccination in infants and children. Vaccine 2011; 29:8754-9. [DOI: 10.1016/j.vaccine.2011.07.122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 07/25/2011] [Accepted: 07/26/2011] [Indexed: 11/19/2022]
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Abstract
Despite a well documented efficacy and a generally good adhesion of a large majority of the lay population and health care professionals as well, immunization is still the object of controversies. It affects several vaccines against hepatitis B, influenza, BCG, pertussis and measles. In most cases, polemics on vaccination result from a temporal association between a vaccination and the revelation of a serious disease, when the immunization is performed at the peak of incidence of the disease. Controversies can also be initiated by scientific publications, even though these are often biased, by a misinterpretation or the absence of official positions from the health care authorities, or by justice decisions, whose criteria differ from the scientists' ones and are therefore difficult to understand for the lay public. Furthermore, the scientific demonstration of the exclusion of a risk is difficult to obtain. In the past, it appeared to be very difficult to stop controversies. Improving the communication is the main issue, towards lay public as well as health care professionals. This implies to learn how to better use the media, to motivate and educate professionals who administer vaccine, and anticipate the eventuality of a temporal relationship between vaccination and occurrence of a serious disease by an improved management of the pharmacovigilance system.
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Affiliation(s)
- Daniel Floret
- Comité technique des vaccinations, Université Claude Bernard Lyon 1, Hôpital Femme-mère-enfant, 59, boulevard Pinel, 69500 Bron, France.
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15
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Pertussis vaccines. Vaccines (Basel) 2008. [DOI: 10.1016/b978-1-4160-3611-1.50025-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] Open
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Abstract
PURPOSE OF REVIEW Concerns about the safety of vaccination have plagued the community, with reduction in vaccine uptake resulting in increased risk of epidemics. Vaccination has been implicated in the cause of febrile seizures, 'vaccine encephalopathy' and autistic spectrum disorders. Evaluation of alleged associations is complicated by evolution in the vaccination field. This review focuses on the risk of seizures following vaccination and the alleged associations of vaccination with vaccine encephalopathy and also with autism spectrum disorders. RECENT FINDINGS Over the last decade the introduction of new vaccines such as the acellular pertussis vaccine has produced a reduction in seizures following vaccination, the outcome of which was benign even with older vaccines. New evidence emerged in 2006 showing that cases of alleged 'vaccine encephalopathy' are due to mutations within a sodium channel gene. The weight of epidemiological evidence does not support a relationship between vaccination and childhood epileptic encephalopathies or autism spectrum disorders. SUMMARY Vaccines are safer than ever before, but the challenge remains to convey this message to society in such a way that produces change in attitudes to vaccination and subsequent increase in vaccine coverage.
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Affiliation(s)
- Natasha J Brown
- Epilepsy Research Centre and Department of Medicine, University of Melbourne, Austin Health, Heidelberg West, Victoria, Australia
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Gitiaux C, Poeyo S, Demazes S, Pedespan L, Pillet P, Husson M, Pedespan JM. Statut vaccinal d'enfants ayant un antécédent de convulsion ou d'épilepsie débutante : étude rétrospective comparative réalisée au CHU de Bordeaux. Arch Pediatr 2006; 13:1102-6. [PMID: 16697162 DOI: 10.1016/j.arcped.2006.04.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2005] [Accepted: 04/03/2006] [Indexed: 11/26/2022]
Abstract
UNLABELLED Vaccination is a common act in medicine. Some serious side effects are always feared in a preventive action, mainly among high-risk patients such as epileptic children or children having already experienced a seizure. OBJECTIVES To study consequences of such background on the vaccine medical practice. POPULATION AND METHODS A retrospective study comparing the vaccine statute of children with or without case history of seizures was carried out by the neurologic and paediatric emergencies departments. The study compared 55 with seizures versus 109 without. RESULTS On the whole, the 2 groups were insufficiently vaccinated. A statistically significant difference was highlighted between the 2 groups for the vaccination coverage by vaccine DTP (diphtheria-tetanus-pertussis) (P=0.017) and MMR (measles-mumps-rubella) (P=0.004). However, concerning the vaccination against hepatitis B, no difference was found. CONCLUSION The usual contra-indications of these vaccines do not explain this difference and progress must be made to improve the vaccination coverage of epileptic children.
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Affiliation(s)
- C Gitiaux
- Service de neurologie pédiatrique, département de pédiatrie, CHU de Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France.
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Floret D, Bonmarin I, Deutsch P, Gaudelus J, Grimprel E, Guérin N, Guiso N, Morer I. Conduite à tenir devant un ou plusieurs cas de coqueluche. Arch Pediatr 2005; 12:1281-91. [PMID: 15961299 DOI: 10.1016/j.arcped.2005.01.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2004] [Accepted: 01/31/2005] [Indexed: 10/25/2022]
Abstract
The evolution of the epidemiology of pertussis, new licensed macrolides and vaccines, new recommendations for vaccination among adolescents and adults need an update of the French guidelines for prevention of the disease around one or grouped cases of the disease. A particular attention should be raised to the diagnosis of whooping cough in adults who are presently the main reservoir of Bordetella pertussis. Whooping cough in adults presents as an unexplained prolonged cough with nocturnal exacerbation witch accounts for most of the contaminations of young infants. A bacteriological confirmation of pertussis should be provided before implementation of preventive measures: culture and PCR are presently the gold standard for the diagnosis of pertussis in infants, children and even adults who have been coughing for less than 20 days. Later on, serology (Elisa, immuno-empreinte) is the only technique available, but cannot be interpreted if the patient has been vaccinated less than one year ago. Infants under three months should be admitted to hospital and every case submitted to respiratory isolation. Eviction from the community should be pronounced within the five first days following the onset of an effective antibiotic treatment. New macrolides should be favoured: clarithromycin for seven days or azithromycin for five days. Household contacts should be given the same prophylactic antibiotic treatment: children and adolescent not correctly immunized, parents of the index case as adults parents of not or not completely immunized infants. The vaccination program of the household should be updated. The same measures should be applied in case of grouped cases (at least two contemporary or consecutive cases in the same area). In that case, the Public Health System doctors should be involved in the investigation and the classification of the cases. The close contacts not or not completely immunized should be prescribed and antibiotic prophylaxis and an update of their vaccination program. Among the occasional contacts, high-risk people only should be treated. In the day care centres an antibiotic prophylaxis should be given to children who have received less than four vaccine shots against pertussis and to the personnel contact to the cases as well. In the schools, the antibiotic prophylaxis should be prescribed to all children of the classroom(s) not completely vaccinated and to the teacher(s) as well. In the boarding schools and institutions with handicapped children, antibiotic prophylaxis could be applied to every member if the pertussis vaccine coverage is at less than 50%. In hospitals, coughing personnel should wear masks and investigations towards pertussis should be performed in people with a more than seven day unexplained cough. Preventive measures should be applied in case of confirmation of pertussis.
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Affiliation(s)
- D Floret
- Service d'urgence et de réanimation pédiatrique, hôpital Edouard-Herriot, place d'Arsonval, 69437 Lyon cedex 03, France.
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Mattoo S, Cherry JD. Molecular pathogenesis, epidemiology, and clinical manifestations of respiratory infections due to Bordetella pertussis and other Bordetella subspecies. Clin Microbiol Rev 2005; 18:326-82. [PMID: 15831828 PMCID: PMC1082800 DOI: 10.1128/cmr.18.2.326-382.2005] [Citation(s) in RCA: 775] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Bordetella respiratory infections are common in people (B. pertussis) and in animals (B. bronchiseptica). During the last two decades, much has been learned about the virulence determinants, pathogenesis, and immunity of Bordetella. Clinically, the full spectrum of disease due to B. pertussis infection is now understood, and infections in adolescents and adults are recognized as the reservoir for cyclic outbreaks of disease. DTaP vaccines, which are less reactogenic than DTP vaccines, are now in general use in many developed countries, and it is expected that the expansion of their use to adolescents and adults will have a significant impact on reducing pertussis and perhaps decrease the circulation of B. pertussis. Future studies should seek to determine the cause of the unique cough which is associated with Bordetella respiratory infections. It is also hoped that data gathered from molecular Bordetella research will lead to a new generation of DTaP vaccines which provide greater efficacy than is provided by today's vaccines.
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Affiliation(s)
- Seema Mattoo
- Department of Microbiology, Immunology, and Molecular Genetics, David Geffen School of Medicine, University of California, Los Angeles, California 90095-1752, USA
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Abstract
Epidemiological methods involving only cases are reviewed in the context of vaccine safety studies. These methods include some ecological methods, case-coverage methods, case-crossover and self-controlled case series methods. The properties of the methods are described using examples from the literature. It is argued that such methods, and in particular the self-controlled case series method, are powerful epidemiologic tools meriting the same attention as more traditional cohort and case-control methods.
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Affiliation(s)
- C P Farrington
- Department of Statistics, The Open University, Walton Hall, Milton Keynes MK7 6AA, UK.
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Abstract
Media attention and consequent public concerns about vaccine safety followed publication of a small case-series of children who developed autism after receipt of the measles-mumps-rubella (MMR) vaccine. Many well-controlled studies performed subsequently found no evidence that MMR vaccine causes autism. However, despite these studies, some parents remain concerned that the MMR vaccine is not safe. We will discuss the origins of the hypothesis that the MMR vaccine causes autism, studies performed to test the hypothesis, how these studies have been communicated to the public, and some suggested strategies for how this communication can be improved.
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Affiliation(s)
- Paul A Offit
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, The University of Pennsylvania School of Medicine, 34th St. and Civic Center Blvd., Philadelphia, PA 19104, USA.
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Hrachovy RA, Frost JD. Infantile Epileptic Encephalopathy with Hypsarrhythmia (Infantile Spasms/West Syndrome). J Clin Neurophysiol 2003; 20:408-25. [PMID: 14734931 DOI: 10.1097/00004691-200311000-00004] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Infantile spasms is a unique disorder peculiar to infancy and early childhood. In this article, the clinical manifestations and electroencephalographic features of the disorder are described. The possible pathophysiologic mechanisms underlying infantile spasms and the relation of this disorder to other childhood encephalopathies are discussed. Finally, the treatment of patients with infantile spasms and their long-term outcome are briefly reviewed.
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Affiliation(s)
- Richard A Hrachovy
- Peter Kellaway Section of Neurophysiology, Department of Neurology and Division of Neuroscience, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, U.S.A.
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Abstract
Infantile spasm is a catastrophic form of epilepsy found only in infants and young toddlers. Onset is before one year of age, with a peak incidence occurring between 4 to 7 months of age. The prevalence is difficult to calculate, but previous reviews have estimated between 1 per 2000 to 6000 live births. There are many causes of infantile spasms, including tuberous sclerosis, malformations of cortical development, hypoxic-ischemic injury, congenital infectious diseases, inborn errors of metabolism, genetic syndromes such as Aicardi's syndrome, and chromosomal abnormalities. A small percentage of patients have idiopathic infantile spasms, with no identifiable cause and premorbid normal growth and development. In order to prevent an ongoing epileptic encephalopathy with its concomitant consequences of cognitive impairment and intractable seizures, treatment should be aggressive and immediate. It is not enough to control the clinical infantile spasms. The underlying "interictal" hypsarrhythmia pattern must also be abolished if the prognosis is to be improved. Otherwise, the immature brain appears to remain hyperexcitable.
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Affiliation(s)
- Mary L. Zupanc
- Department of Clinical Neurology and Pediatrics, Babies and Children's Hospital, 3959 Broadway, Suite 11N-#8, New York, NY 10032, USA.
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Affiliation(s)
- H McPhillips
- Child Health Institute, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
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DuVernoy TS, Braun MM. Hypotonic-hyporesponsive episodes reported to the Vaccine Adverse Event Reporting System (VAERS), 1996-1998. Pediatrics 2000; 106:E52. [PMID: 11015547 DOI: 10.1542/peds.106.4.e52] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND A hypotonic-hyporesponsive episode (HHE) is the sudden onset of hypotonia, hyporesponsiveness, and pallor or cyanosis that occurs within 48 hours after childhood immunizations. This syndrome has been primarily associated with pertussis-containing vaccines administered to children <2 years of age, and has been estimated to occur once every 1750 diphtheria-tetanus-pertussis (DTwP) vaccinations. Previous studies of HHE were limited by small numbers of cases and, sometimes, by limited details of the event. OBJECTIVES To characterize a large number of HHE cases reported to the Vaccine Adverse Event Reporting System (VAERS), to assist clinicians in identifying HHE, and to assist researchers in investigating the risk factors, cause, and pathogenesis of this syndrome. METHODS More than 40,000 VAERS reports received between 1996 and 1998 were screened for HHE by a computer algorithm and reviewed, and a telephone follow-up questionnaire was administered to the witness of HHE. RESULTS There were 215 HHE cases, all nonfatal. The median age of onset of HHE was 4.0 months (range: 1.1-107 months). Over half of the reports (53%) concerned females. The median birth weight was 3. 36 kg (range: 1.27-4.96 kg); 4.7% had a birth weight <2500 g. The median interval between vaccination and HHE was 210 minutes (range: 1 minute-2 days). Among children with HHE who were <24 months of age, the episode occurred within 5 minutes in only 8.5%, compared with 66.7% of children with HHE >24 months of age. There were no relevant findings regarding family medical history or the mothers' gestational history. Nearly all of the children (98.6%) returned to their prevaccination state according to the telephone questionnaire; median time to return was 6 hours (range: 1 minute- 4 months). The 3 children reported as not returning to their prevaccination state all had VAERS reports submitted after they developed conditions (autism, complex partial epilepsy, and developmental delays with infantile spasms) that are not known to be causally associated with immunization. The vast majority of children (93%) with HHE received a pertussis-containing vaccine, either diphtheria-tetanus-acellular pertussis (DTaP, 28%), DTwP (11%), or diphtheria-tetanus-pertussis-Haemophilus influenzae type b (DTwP-HIB, 61%). During the HHE episode, 90.1% of the children had pallor and 49% had cyanosis. Because of the HHE event, 6.8% of children had had all vaccines withheld as of the date of the interview. Of the remainder, 66.5% of children have had 1 or more subsequent vaccinations or vaccine components withheld, and 26.7% have not had any subsequent vaccinations withheld. Only 1 child was reported to have had a repeat episode of HHE, occurring after hepatitis B vaccination. From 1996 to 1998, the number of HHE reports decreased from 99 to 38, when the predominant pertussis vaccine administered to infants changed from whole-cell to acellular. CONCLUSION This study represents the largest published case series of children with HHE and supports the generally benign, self-limited, nonrecurrent nature of this syndrome. Although HHE has been less frequently reported to VAERS after increased use of DTaP, HHE does occur after the administration of DTaP and other nonpertussis-containing vaccines. Although most parents and pediatricians withheld the pertussis component of subsequent vaccinations, many did not, with no reported adverse events occurring in the children after the subsequent immunizations. Restricting the definition of HHE to a more narrow age range (eg, <2 years of age) is also proposed because most of the older children probably experienced vasovagal syncope rather than HHE within 5 minutes of immunization.
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Affiliation(s)
- T S DuVernoy
- Division of Epidemiology, Office of Biostatistics and Epidemiology, Center for Biologics Evaluation and Research, Food and Drug Administration, Rockville, Maryland 20852-1428, USA
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Abstract
Immunisations have been one of the most cost-effective public health interventions in human history. Despite remarkable progress, several challenges face immunisation programs worldwide. Paradoxically, despite vaccines' clear effectiveness in reducing risks of diseases that were previously widely prevalent and caused substantial morbidity and mortality, current vaccination policies have become increasingly controversial due to concerns about vaccine safety. Vaccines, like other pharmaceutical products, are not entirely risk-free. While most known adverse effects are minor and self-limited, some vaccines have been associated with very rare but serious adverse effects. Because such rare effects are often not evident until vaccines come into widespread use, ongoing surveillance programs to monitor vaccine safety are needed. Such monitoring will be essential if the public is to accept the increasing number of new vaccines made possible by biotechnology. The interpretation of data from vaccine safety research is complex and is associated with some uncertainty. Effectively communicating this uncertainty and continuing to improve understanding of rare risks and risk factors are essential for "mature" immunisation programs to maintain public confidence in immunisations.
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Affiliation(s)
- R T Chen
- Vaccine Safety and Development Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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28
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Goodman M, Lamm SH, Bellman MH. Temporal relationship modeling: DTP or DT immunizations and infantile spasms. Vaccine 1998; 16:225-31. [PMID: 9607034 DOI: 10.1016/s0264-410x(97)00191-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The time relationship between DTP immunization and infantile spasms (IS) onset was examined using three models--association, temporal shift, and no-effect--and the case/control data from the National Childhood Encephalopathy Study (NCES). Infantile spasms cases classified as being previously abnormal (e.g., tuberous sclerosis complex patients) showed a no-effect relationship, whereas those classified as previously normal suggested a fit to the temporal shift model, i.e. no increase in number of cases but a shortening of time to onset of seizure. No data fit the association model. Analyses for vaccine complications should examine for temporal changes (i.e. temporal shift) in addition to increased risks.
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Affiliation(s)
- M Goodman
- Johns Hopkins University School of Public Health, Washington, DC 20007, USA
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Rantala H, Shields WD, Christenson PD, Nielsen C, Buch D, Jacobsen V, Zachau-Christiansen B, Uhari M, Cherry JD. Risk factors of infantile spasms compared with other seizures in children under 2 years of age. Epilepsia 1996; 37:362-6. [PMID: 8603641 DOI: 10.1111/j.1528-1157.1996.tb00572.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
To analyze the magnitude of the risk factors for infantile spasms, we evaluated the records of 80 children with infantile spasms, 474 children with other types of epilepsy, 2,196 children with febrile seizures, and 262 children with CNS infections. There was a family history of seizures in 13.8% of children with infaNtile spasms, 28.5% of children with other forms of epilepsy, 25.5% of children with febrile seizures, and 5.3% of children with CNS infections. Children with a family history of seizures were 2.82 times more likely to have infantile spasms, 7.05 time more likely to have other epilepsy, and 6.08 time more likely to have febrile seizures than controls (children with CNS infections). However, a family history of seizures increased the risk for infantile spasms only in the cryptogenic group. Children with infantile spasms were significantly more likely to have cerebral palsy, microcephaly, hydrocephaly, CNS malformations, neonatal hypoxia, or neonatal seizures than children with other types of epilepsy, febrile seizures, or CNS infections. There was a modest genetic predisposition to seizures in children with infantile spasms. However, our data suggest a much stronger association with underlying neurologic abnormalities, mainly neonatal seizures, neonatal hypoxia, and CNS malformations.
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Affiliation(s)
- H Rantala
- Department of Neurology, University of california at Los Angeles School of Medicine, California, U.S.A
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Renfroe B, Sirbaugh P. Febrile seizures: A review of the literature and a systematic approach to the evaluation and management of simple febrile seizures. ACTA ACUST UNITED AC 1995; 6:218-22. [PMID: 16731351 DOI: 10.1016/s1045-1870(05)80005-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- B Renfroe
- Section of Pediatric Emergenqy Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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31
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Kobayashi RH. VACCINATIONS. Immunol Allergy Clin North Am 1995. [DOI: 10.1016/s0889-8561(22)00761-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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32
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Cowan LD, Griffin MR, Howson CP, Katz M, Johnston RB, Shaywitz BA, Fineberg HV. Acute encephalopathy and chronic neurological damage after pertussis vaccine. Vaccine 1993; 11:1371-9. [PMID: 7906066 DOI: 10.1016/0264-410x(93)90163-r] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
In August 1991, the Institute of Medicine released a report entitled Adverse Effects of Pertussis and Rubella Vaccines, which examined, among others, the relation between immunization with whole-cell diphtheria-tetanus-pertussis (DTP) vaccine and both acute encephalopathy and chronic neurological damage. The committee reviewed information from a wide range of both professional and lay sources and found that the evidence is consistent with a possible causal relation between DTP vaccine and acute encephalopathy, although it is insufficient to establish causality. The range of excess risk of acute encephalopathy following DTP immunization is consistent with that estimated from the National Childhood Encephalopathy Study: 0.0 to 10.5 cases per million immunizations. The committee concluded that the evidence is insufficient to indicate either the presence or absence of a causal relationship between DTP vaccine and permanent neurological damage. The evaluative methods used by the committee are briefly described and the evidence underlying its conclusions presented.
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Affiliation(s)
- L D Cowan
- Institute of Medicine, National Academy of Sciences, Washington, DC
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33
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Cherry JD, Holtzman AE, Shields WD, Buch D, Nielsen C, Jacobsen V, Christenson PD, Zachau-Christiansen B. Pertussis immunization and characteristics related to first seizures in infants and children. J Pediatr 1993; 122:900-3. [PMID: 8501566 DOI: 10.1016/s0022-3476(09)90014-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In a previous study in which we examined the relationship of pertussis immunization to the onset of neurologic disorders during 1967 and 1968 and during 1972 and 1973 in Denmark, there were 554 children with initial onset of epilepsy and 2158 children with first febrile convulsions. In the study population there were 112 children with epilepsy and 229 children with febrile convulsions for whom the exact date of pertussis immunization and the exact date of the onset of illness were known. We analyzed selected clinical variables by specific time intervals between pertussis immunization and the first seizure. In the children with epilepsy, no relationship was found between time of pertussis immunization and the specific variables that were examined. In contrast, the following characteristics in children with febrile seizures were significantly more common when pertussis immunization had occurred within 3 days, compared with more than 7 days of the event: first seizure more than 10 minutes in duration, the occurrence of more than one seizure, the longest seizure (when there was more than one) more than 10 minutes in duration, and the occurrence of a seizure described as focal. The lack of specific characteristics in epilepsy that had its onset in a temporal relationship to pertussis immunization is further evidence that pertussis vaccine does not cause this disorder. The cause of increased severity of febrile seizures apparently associated with pertussis immunization is unknown.
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Affiliation(s)
- J D Cherry
- Department of Pediatrics, University of California Los Angeles School of Medicine
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34
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Poon CY. Childhood immunization. Part I. J Pediatr Health Care 1992; 6:370-6. [PMID: 1491322 DOI: 10.1016/0891-5245(92)90044-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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35
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Abstract
The mortality from pertussis in unvaccinated infants is significantly greater than that reported. Most present day whole-cell pertussis vaccines are efficacious. Although they cause frequent reactions, studies during the last 15 years reveal no evidence that they cause brain damage. Acellular pertussis vaccines have been used successfully in Japan since 1981. In spite of this, five vaccine efficacy trials in three countries are presently in progress. Of the six vaccines being studied, three seem to be less than optimal choices for study because they are similar to the two vaccines evaluated in the original Swedish efficacy trial which had disappointing efficacy. The lessened reactions associated with acellular pertussis vaccines make routine adult booster immunization possible. A future immunization programme with vaccines that elicit antibodies which completely block bacterial attachment to ciliary epithelial cells, and which includes universal childhood immunization and adult booster doses can be expected to have a dramatic effect upon disease incidence and the circulation of Bordetella pertussis in the community.
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Affiliation(s)
- J D Cherry
- Department of Pediatrics, UCLA School of Medicine 90024-1752
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36
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Golden GS. Medical-legal aspects of neurologic problems. CURRENT PROBLEMS IN PEDIATRICS 1991; 21:259-81; discussion 282-3. [PMID: 1833128 DOI: 10.1016/0045-9380(91)90018-g] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- G S Golden
- Boling Center for Developmental Disabilities, University of Tennessee, College of Medicine, Memphis
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37
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Pertussis immunization and the central nervous system. Ad Hoc Committee for the Child Neurology Society Consensus Statement on Pertussis Immunization and the Central Nervous System. Ann Neurol 1991; 29:458-60. [PMID: 1929219 DOI: 10.1002/ana.410290426] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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38
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The Australian College of Paediatrics. Policy Statement. Report of the Immunization Subcommittee on Pertussis Immunization. J Paediatr Child Health 1991; 27:16-20. [PMID: 2043385 DOI: 10.1111/j.1440-1754.1991.tb00339.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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39
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Affiliation(s)
- R Gold
- Faculty of Medicine, University of Toronto, Ontario, Canada
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40
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Abstract
It has been suggested that one of the major advances in medicine, and for society at large, has been the development of vaccines and the adoption of routine immunization by the vast majority of responsible health care practitioners in the developed nations. Thankfully, there continue to be rapid advances in our ability to diagnose and treat infectious diseases. However, with these rapid advances come necessary changes in the dogma of medical practice, including changes in the routine immunization procedures recommended by various authoritative bodies in the United States. New immunizing agents will be developed and will achieve routine use. Unexpected adverse reactions and complications of our immunization reagents must constantly be sought and described. Previously unrecognized subgroups of hosts at special susceptibility to adverse and untoward vaccine effects will be recognized; the pathogenesis of their special susceptibility needs to be understood and then will have to be appropriately addressed. Individual health care practitioners will need to keep abreast of routine immunization recommendations and the application of these recommendations in an organized and thorough fashion to infants, children, adolescents, and adults. A crucial link in the chain of optimal preventive health care will continue to involve those who prescribe, order, and administer vaccines.
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Affiliation(s)
- L D Frenkel
- Department of Pediatrics, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick
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41
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Abstract
Concern over adverse reactions temporally associated with whole cell pertussis vaccine and advances in the understanding of the Bordetella pertussis organism have led to a new generation of more purified acellular vaccines. The biology of the pertussis organism, epidemiology of disease, vaccine development over the decades, and vaccine efficacy and adverse reaction data from whole cell and acellular vaccine trials are presented. Questions that remain to be answered before acellular vaccine replaces conventional vaccine are defined, and future studies addressing these questions are proposed.
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Affiliation(s)
- K M Edwards
- Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee
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42
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Abstract
A syndrome of pertussis vaccine encephalopathy was first reported 56 years ago. Analysis of the recent literature, however, does not support the existence of such a syndrome and suggests that neurologic events after immunization are chance temporal associations of neurologic conditions that occur in the target age group, even in the absence of immunization. Population-based studies do not prove a causal relationship with acute encephalopathy. There are no consistent neuropathologic findings suggesting a specific pathophysiologic process, and hypotheses concerning possible mechanisms of damage are not supported by reproducible studies in children. No acceptable animal model exists. There clearly is an increased risk of a convulsion after diphtheria-tetanus-pertussis immunization but no evidence that this produces brain injury or is a forerunner of epilepsy. Studies have also not linked immunization with either sudden infant death syndrome or infantile spasms.
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Affiliation(s)
- G S Golden
- Department of Pediatrics, University of Tennessee, Memphis 38105
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