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This week in BMJ Saturday 1 February 1997

New recombinant vaccine improves protection against hepatitis B

Hepatitis B vaccines containing the S component have been available since the early 1980s. However, 5-10% of healthy people do not mount an antibody response to them and therefore remain susceptible to infection. Several factors, including immunogenetic profiles, seem to affect the immune response. On p 329 Zuckerman et al evaluate a new recombinant hepatitis B vaccine containing three antigenic regions of the surface antigen (S, pre-S1, and pre-S2) in 100 healthcare workers who had not previously responded to standard vaccine. Sixty nine of them seroconverted after a single dose of the new vaccine. This signifies a welcome advance in the development of new third generation vaccines against hepatitis B.

Prophylactic antibiotics for children with measles seem to have little effect on mortality

Many of the million deaths a year from measles in children aged under 5 years are caused by bacterial pneumonia. Thus, where there is high case mortality it might be sensible to give antibiotics to all children with measles. However, there has been no systematic evaluation of such a policy. Shann (p 334) performed a meta-analysis of randomised controlled trials of prophylactic antibiotics given to children with measles. He found six trials: all were poorly designed and preceded the introduction of vitamin A treatment for measles. Prophylactic antibiotics had little or no effect on mortality from measles, and an apparent reduction in the incidence of pneumonia disappeared when two studies with usually high complication rates in the control groups were removed. Shann concludes that in communities with a high mortality from measles all children with measles should be treated with vitamin A but antibiotics be given only if a child has clinical signs of pneumonia or sepsis.

Respiratory disease persists in survivors of the Bhopal gas leak

In 1984 an accident at the Union Carbide pesticide plant in Bhopal released intensely irritant fumes across the city. About 250 000 people were exposed and about 2500 died within a week, most as a direct result of respiratory tract damage. On p 338 Cullinan et al report a study of respiratory disease 10 years after the disaster. Respiratory symptoms were reported with increasing frequency across six strata of estimated exposure, and a relation was found between exposure and reduced lung function. The findings were consistent with irreversible obstruction of the small airways.

Patients with Hodgkin's disease have too many follow up visits

Detection of relapse is the most important function of follow up after treatment for Hodgkin's disease. Radford et al (p 343) studied the efficiency of current follow up policy in a cohort of 210 patients after treatment for Hodgkin's disease. Over the period of observation 2512 clinic visits took place and 37 relapses were identified. Thirty of these were diagnosed as a result of the investigation of symptoms and only four by routine physical examination or investigation of patients who did not have symptoms. Furthermore, half of the patients with symptoms were prompted either to make an earlier appointment themselves or to see a local doctor. Radford et al propose that routine follow up visits should be reduced in frequency and far greater emphasis placed on patient education.

Children susceptible to glue ear have more rather than longer episodes of effusion

Otitis media with effusion is the most common reason for children to visit the doctor in the developed world, but the pattern and duration of episodes remains unclear. On p 350 Hogan et al prospectively assessed 95 children every month from birth to 3 years with otoscopy and tympanometry. The duration of episodes of otitis media with effusion was calculated using a stochastic (Markov) model, and the model was tested using Monte Carlo simulations. Analysis of the model showed that the mean duration of an episode was 5-10 weeks and that susceptible children tended to have more separate episodes of effusion. The mean duration of individual episodes of bilateral effusion in susceptible children was 1.7 times longer than in children who were less susceptible, while the duration of unilateral effusions did not differ. However, susceptible children were most notable for the likelihood with which they acquired the disease rather than for their ability to recover from it. Six months of "watchful waiting" should be effective in releasing children who are less susceptible from surgical waiting lists.