Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Dogs chasing tails
- Jayne LM Donegan (23 September 2004)
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Low Haemophilus Influenzae type b and pneumococcal antibodies among adults with chronic respiratory disease
- Harmesh Moudgil, Rana Rabbani (14 October 2004)
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Re: Low Haemophilus Influenzae type b and pneumococcal antibodies among adults with chronic respiratory disease
- Denise L. Rogers (12 February 2005)
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Jayne LM Donegan, GP & Homoeopath 121 Sunny Gardens Road, London NW4 1SH
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Haemophilus influenza has six encapsulated forms that can cause human disease, type B does so most commonly. The incidence of invasive disease caused by these encapsulated forms has been rising since the 1950s, which is, coincidentally, the time that mass vaccination was introduced and antibiotics started to be prescibed so liberally. Before vaccination against HiB was introduced, 90% of individuals carried Haemophilus influenza in their noses, approximately 5% being type B. Antibodies form against the encapsulated forms either as a result of such symptomless nasal carriage or of disease.(1) As the vaccine is only targeted at type B, it is possible that a drift will occur towards more disease being caused by other types. For example, meningitis caused by Haemophilus influenza A when there has been vaccination against HiB. A similar drift has been seen pertussis infection and possibly mumps. When the HiB vaccine was introduced in 1992, it was not given to children over the age of four years or adults because they were regarded as already immune. However, once the vaccine was introduced children were less likely to carry it in their nose and gain natural immunity. This would be expected to increase the likelihood of their contracting severe forms of the disease at a later age as has, in fact, been the case. After the introduction of the vaccine in 1992, cases of Hib disease were dramatically reduced, although some of this was thought to be due to significant underreporting of cases after introduction of the vaccine combined with more rigorous case definition with “consequent overestimation of the effectiveness of the immunisation programme”(2). However, after this initial decline, cases in children aged five to eleven months rose in England and Wales from 0.15 per 100,000 in 1998 to 0.76 in 2000 and in 2001, a similar rise was seen in one to two year olds; 0.45 in 1998 to 3.97 per 100,000 in 2001 (figures presented by Dr J McVernon at the International Network of Paediatric Surveillance Units in York April 2002). It was thought to be due to possible problems with vaccine efficacy but was difficult to test because of lack of information on antibody levels in these children after their primary course (3)due to lack of long term studies. In 1992 before the vaccine was introduced, carriage of Hib was found in 4% of 1,500 children tested, this had dropped to 0.7% by 1994 and in 1997 none of 500 children were carrying it (unpublished results of Public Health Laboratory Service study)(4). Such reduced carriage rates left children without natural immunity to Hib and invasive disease is occurring in older children who would previously have been expected to be immune. Rather than giving serious thought to removing this vaccine from the schedule, a campaign to give a ‘catch up’ dose to all under four year olds took place in 2003 and the decision has now been made to add HiB to the preschool booster. A booster dose given to four to five year olds is likely to push invasive disease into adulthood as is already being shown by McVernon et al in this study. No doubt we shall soon start offering HiB vaccination to school leavers, along with diphtheria and the soon-to-be-added pertussis vaccines, plus perhaps a bit of influenza vaccine for good measure and mumps and measles and rubella (the rubella antibodies from MMR given to preschoolers will definitely have worn off by the time these children are of an age to reproduce) - as we add booster after booster rather like a dog trying to catch its tail. Perhaps it is time to stop injecting the population with these toxins and return to real ways of promoting health:- good food, clean water and air, well ventilated housing, exercise and emotional harmony. The only people that benefit by such imprudent public 'health' measures are the vaccine manufacturers and their share holders. References (1) Harrison’s Principles of Internal Medicine 11th Ed, McGraw-Hill Inc 1987 (2) Decrease in effectiveness of routine surveillance of H. influenza disease after introduction of the conjugate vaccine, Olowokure B,HawkerJ,Blair I,Spencer N,BMJ;2000;321:731-732 (3) Vaccine experts to debate need for booster Hib jab, Pulse, 15 April 2000 (4) Hib vaccine boosts herd immunity, Pulse, 27 May 2002 Competing interests: None declared |
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Harmesh Moudgil, Consultant Physician Princess Royal Hospital, Telford, Shropshire TF1 6TF, Rana Rabbani
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Editor, It is with much interest we read the recent article by McVernon et al [1] reporting a recent resurgence among the adult population in reported cases of invasive Haemophilus influenzae type b (Hib). Although proposing surveillance strategies targeted for entire populations, whether there is an additional at high risk adult population who may benefit from vaccination is still to be determined. In a recent study to date only reported provisionally [2] we too have indirectly noted similar findings to the above study in a more targeted population while investigating humoral immunodeficiency in patients with defined chronic respiratory disease who specifically also reported recurrent respiratory tract infections. 66% of the patients had asthma, chronic bronchitis/emphysema or bronchiectasis and none had diagnosed immunoglobulin deficiency. Investigating primary antibody deficiency using anti-pneumococcal and Hib vaccines to invoke thymic dependent and independent responses using methods proposed by Rodrigo et al [3] we collected baseline and follow up data on functional antibodies on 252 patients. Mean (SD, range) age of these patients was 53.4 (14.5, 17-80) years. Baseline values were compared with published reference data and categorized graded for risk of infection or levels of protection. Relevant Hib antibody levels were 0.15 mic/ml (minimum protective level) and 1 mic/ml (optimum protective level). For strep pneumonae the reference values for whole IgG, IgG1, and IgG2 were at the middle of the normal range of values taken from a serum pool obtained from a health unimmunised adult population. Interestingly 63 (25%) had Hib antibody levels below those defining invasive sepsis , 120 (48%) had minimum protective levels, and only 65 (25%) had optimum protective levels. Similarly, with respect to pneumococcal antibody levels, 133 (53%) had poor levels, 85 (26%) adequate levels, and 51 (20 %) good levels. After vaccination only 3 remained at low levels for Hib and 9 for pneumococcus meriting further investigation. A targeted rather than generalized population makes it difficult to conclude for the purposes of surveillance strategies. A diversity of the antibody responses in healthy adults to Hib and pneumococcus further leads to a difficulty in publishing acceptable reference values. We were, however, surprised at the low baselines values in this adult population for both Hib (which supposedly is acquired through sub-clinical infections rather than through vaccination as for young children) and pneumococcal antibodies. References: 1 McVernon J, Trotter CL, Slack MP, Ramsay ME. Trends in Haemophilus influenzae type b infections in adults in England and Wales: surveillance study. BMJ 2004;329:655-8 2 Rabbani R, Moss A, Pandya L, Moudgil H. Investigating immunodeficiency in patients with recurrent respiratory tract infections. Eur Resp J 2002 (Stockholm conference report) 3 Rodrigo MJ, Vendrell M, Cruz MJ, Miravitlles M, Pascual C, Morell F, De Gracia J. Utility of the antibody response to conjugated Haemophilus influenzae type B vaccine for diagnosis of primary humoral immunodeficiency. Am J Respir Crit Care Med 2000;162:1462-5. Competing interests: None declared |
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Denise L. Rogers, Reverend U.S.A 59715
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I live in the north western part of the United States. 4 years ago I came down with hib (b), it was very dibilitating and painful as it attacked all of my joints. The diagnosis was confirmed through a culture. I was 49 years old at the time, I am an insulin dependant diabetic, who also suffers with chronic bronchitis. Because of my age it took a while for my doctor to recognize that I had hib. It was about 3 weeks before the correct diagnosis was made. I spent 3 months in bed recovering. I encourage all doctors to continue to alert doctors of the possibility of this disease in older adults, particularly those of us with suppressed immune systems. Competing interests: None declared |
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