Clinical efficacy of seasonal influenza vaccination: characteristics of two outbreaks of influenza A(H1N1) in immunocompromised patients

BACKGROUND

Influenza A(H1N1) causes serious complications in immunocompromised patients. The efficacy of seasonal vaccination in these patients has been questioned.

AIM

To describe two outbreaks of influenza A(H1N1) in immunocompromised patients.

METHODS

Two outbreaks of influenza A(H1N1) occurred in our institution: on the kidney transplant ward in 2014 including patients early after kidney or simultaneous pancreas-kidney transplantation, and on the oncology ward in 2016 including patients receiving chemotherapy for malignant tumours. Factors leading to these outbreaks and the clinical efficacy of seasonal influenza vaccination were analysed.

FINDINGS

Altogether 86 patients were exposed to influenza A(H1N1) during the outbreaks, among whom the seasonal influenza vaccination status was unknown in 10. Only three out of 38 vaccinated patients were infected with influenza A(H1N1), compared with 20 out of 38 unvaccinated patients (P = 0.02). The death of one out of 38 vaccinated patients was associated with influenza, compared with seven out of 38 unvaccinated patients (P = 0.06). Shared factors behind the two outbreaks included outdated facilities not designed for the treatment of immunosuppressed patients. Vaccination coverage among patients was low, between 40% and 70% despite vaccination being offered to all patients free of charge. Vaccination coverage of healthcare workers on the transplant ward was low (46%), but, despite high coverage on the oncology ward (92%), the outbreak occurred.

CONCLUSION

Seasonal influenza vaccination was clinically effective with both a reduced risk of influenza infection and a trend towards reduced mortality in these immunocompromised patients. Several possible causes were identified behind these two outbreaks, requiring continuous awareness in healthcare professionals to prevent further outbreaks.

New Zealand rural general practitioners 1999 survey--part 1: an overview of the rural doctor workforce and their concerns

AIMS

To obtain current information about New Zealand rural general practitioners (GPs) and their localitites.

METHODS

An anonymous postal questionnaire was mailed out to 559 rural and semi-rural GPs in November 1999, and non-responders were sent three reminders.

RESULTS

Of the 417 completed questionnaires returned (response rate 75%), 338 were from rural GPs(Rural Ranking Scale score > or = 35 points) and these formed the study group. The mean age was 44 years, 72% were male, and 93% were of New Zealand European ethnicity. Less than 50%had graduated from a New Zealand medical school with Britain (30%) and South Africa (11%) providing most of the foreign- trained rural GPs. Only 59% had received vocational training in general practice. The majority worked fulltime (79%) and owned their practice (78%), while 133 (39%) worked part time as rural hospital doctors and 72 (21%) provided intra-partum obstetric care. Over two thirds rated lack of locum relief, onerous oncall,and rural GP shortages as 'important' or 'very important' problems, with one third stating that more rural GPswere needed in their locality.

CONCLUSIONS

This, only the second national survey of rural GPs, provides a comprehensive overview of New Zealand rural general practice in November 1999. It confirms that the major current problem is an under supply of rural GPs, causing overwork and stress in those remaining.

Complement activation in circulation and central nervous system after rituximab (anti-CD20) treatment of B-cell lymphoma

Rituximab (IDEC-C2B8, Mabthera, Rituxan), a chimeric monoclonal antibody against the B-cell specific CD20-antigen, has been demonstrated to be effective in the treatment of non-Hodgkin's B-cell lymphoma (B-NHL). Previous in vitro studies have shown that direct complement-dependent cytotoxicity (CDC), ADCC and apoptosis are important in the rituximab-induced killing of lymphoma cells. It is, however, unknown whether rituximab penetrates the blood-brain barrier. Therefore, we studied rituximab levels and complement (C) activation in blood and cerebrospinal fluid (CSF) following intravenous rituximab therapy in a patient with relapsing non-Hodgkin's lymphoma with central nervous system (CNS) involvement. Longitudinal samples from blood and CSF were taken at 13 time-points during the treatment period. The results show that the C cascade becomes activated in blood during the first mAb infusion (C3a-desArg concentration rose from 55 to 138 microg/ml during the first 2 hours). After the first infusion the proportions of lymphocytes positive for the CD19- and CD20-antigens in the peripheral blood were reduced from 41% and 35%, respectively, to a level of 2% (for both). In CSF the rituximab concentration increased after successive infusions, but remained below 0.55 microg/ml (compared to a Cmax of 400 microg/ml in peripheral blood). Although a minor and delayed C activation response was seen in the CSF the treatment did not clear CD20-positive cells away from the CNS. Thus, it appears that an intact blood-brain barrier restricts the entry of rituximab into the CNS. Possible options to circumvent this would be dose escalation or intrathecal rituximab treatment.

Rural hospital amniotomy induction for women at or past term with a healthy pregnancy and a favourable cervix: is it a safe option?

AIM

To assess the safety and efficacy of amniotomy induction of labour for women at or past term with a healthy pregnancy and a favourable cervix.

METHODS

Retrospective chart review of nine cases involving amniotrophy induction managed by the author since 1991, combined with a literature search for randomised controlled clinical trials of the use of amniotomy inducton.

RESULTS

All nine women delivered within fourteen hours of amniotomy. The only serious complication was group B streptcoccal septicaemia in one newborn that developed four hours after birth. No randomised controlled clinical trials was found that examined the use of amniotomy alone in a rural setting to induce women at or past term with a healthy pregnancy and a favourable cervix. However, studies from secondary care institutions of women at or past term with a favourable cervix, being induced for a variety of reasons, demonstrate that amniotomy is both safe and effective.

CONCLUSION

In appropriately selected women, the use of amniotomy induction in a rural maternity unit is both safe and effective.

Rural hospitals in New Zealand

AIM

To produce a list of New Zealand rural hospitals, including information on acute bed numbers, population served, average driving time to base hospital, and number and payment of rural hospital doctors.

METHODS

Information about rural hospitals was obtained from local doctors and/or administrators, and reflected conditions at June 15, 1998. A 'rural hospital' was defined as a facility with no resident medical specialists, where acutely ill patients are admitted and cared for solely by generalist doctors, either general practitioners or medical officers of special scale.

RESULTS

Varying definitions for acute 'facilities' and 'beds' made analysis difficult. There were a total of 36 'rural hospitals' in New Zealand at June 15, 1998 containing 293 acute beds and serving a population of about 340000. Patient care was provided by a total of 131 generalists (general practitioners or medical officers of special scale) equivalent to 40 full-time rural hospital doctors.

CONCLUSIONS

Approximately 10% of the New Zealand population are served by rural hospitals. Discrepancies exist between the list of rural hospitals provided in this study and that provided by the Government's recent 'Hospital Services Plan'.

Assessment of rubella immunity in women born in 1959-74 in a solo rural general practice

AIM

To evaluate the rubella immunity of all women in the practice born 1959-74.

METHOD

A chart audit followed by offering testing to all women whose rubella status was unknown.

RESULTS

According to their records, of 203 female patients born 1959-74, 149 (73%) were immune to rubella and 54 were not. All of the 54 nonimmune women agreed to rubella testing and only three were found to be susceptible. These three women had never been pregnant before, none were from the higher risk cohort born 1965-7 and all accepted vaccination.

CONCLUSION

For general practitioners it is important to assess the rubella immunity of all women of childbearing age in their practice, especially those who have never been pregnant and not just the high risk cohort born 1965-7.

Reactive arthritis associated with Shigella sonnei infection

Several studies have failed to show an association between Shigella sonnei dysentery and reactive arthritis. We describe 3 patients who had reactive arthritis and a recent or concurrent S sonnei infection. To our knowledge, this is only the second study to suggest this association. We propose that S sonnei should be considered as a triggering agent for reactive arthritis.

Tuberculous Empyema

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