A researcher has suggested a link between the vaccine and AUTISM, but massive studies of children with and without this condition in several countries have failed to ?nd any evidence to back the claim. Nonetheless, the publicity war has been largely lost by the UK health departments so that vaccine rates have dropped to a worryingly low level.
(See IMMUNISATION.)... mmr vaccine
Pathology There are three types of virus, infection spreading by the stools-contaminated hands-mouth route. Children are most susceptible.
One attack usually produces permanent immunity, and second attacks are rare. The virus typically affects the anterior horn cells of the spinal cord, especially those in the lumbar region; the grey matter of the brain stem and cortex may also be damaged.
Vaccination is given to infants at two, three and four months: a booster dose is given at around the age of ?ve. The vaccine contains all three types of polio virus. Two types of vaccine are available: inactivated polio virus (IPV) contains dead virus and is administered by injections; oral polio vaccine (OPV) contains live, harmless strains. The latter is used in the United Kingdom.
Symptoms The incubation period is around 7–14 days, the onset being marked by a mild fever and headache which improves after a few days. In around 85 per cent of infected children there is no further progression, but in some – after approximately one week – the symptoms recur, together with neck sti?ness and signs of meningeal irritation (see MENINGES). Weakness of individual muscle groups is common, and may progress – to a variable extent, depending on the distribution of the virus – to widespread PARALYSIS. Involvement of the diaphragm and intercostal muscles may lead to respiratory failure and rapid death unless arti?cial respiration is provided. Involvement of the cranial nerves and brain may lead to nystagmus (see under EYE, DISORDERS OF), hoarseness and di?culty in swallowing, and CONVULSIONS may occur in young children. The CEREBROSPINAL FLUID shows an early increase in lymphocytes, followed by a rise in protein concentration.
Treatment There is no e?ective drug treatment for the infection. Treatment involves early bed rest, followed by PHYSIOTHERAPY and orthopaedic measures as required. At the onset of respiratory diffculties a TRACHEOSTOMY and arti?cial ventilation should be started. (In the 1950s, when polio epidemics were occurring, respiratory diffculties were treated by placing patients in an ‘iron lung’ – a large, airtight, cylindrical container in which the air pressure was raised and lowered to simulate normal breathing.) In cases of severe paralysis with persistent wasting of the limbs, surgery may be necessary to minimise the resulting disability.... poliomyelitis
Causes The disease is caused by the bacillus Clostridium tetani, found generally in earth and dust and especially in places where animal manure is collected. Infection usually follows a wound, especially a deeply punctured or gunshot wound, with the presence of some foreign body. It is a hazard in war and also among farmers, gardeners and those in the construction industry. The bacillus develops a toxin in the wound, which is absorbed through the motor nerves into the spinal cord where it renders the nerves excitable and acutely sensitive to mild stimuli.
Symptoms Most commonly appearing within four to ?ve days of the wound, the patient’s symptoms may be delayed for several weeks – by which time the wound may have healed. Initially there is muscle sti?ness around the wound followed by sti?ness around the jaw, leading to lockjaw, or trismus. This extends to the muscles of the neck, back, chest, abdomen, and limbs, leading to strange, often changing, contorted postures, accompanied by frequent seizures – often provoked by quite minor stimuli such as a sudden noise. The patient’s breathing may be seriously affected, in severe cases leading to ASPHYXIA; the temperature may rise sharply, often with sweating; and severe pain is common. Mental clarity is characteristic adding to the patient’s anxiety. In severe infections death may be from asphyxia, PNEUMONIA, or general exhaustion. More commonly, the disease takes a chronic course, leading to gradual recovery. Outcome depends on several factors, chie?y the patient’s immune status and age, and early administration of appropriate treatment.
Tetanus may occur in newborn babies, particularly when birth takes place in an unhygienic environment. It is particularly common in the tropics and developing countries, with a high mortality rate. Local tetanus is a rare manifestation, in which only muscles around the wound are affected, though sti?ness may last for several months. STRYCHNINE poisoning and RABIES, although similar in some respects to tetanus, may be easily distinguished by taking a good history.
Prevention and treatment The incidence of tetanus in the United Kingdom has been almost abolished by the introduction of tetanus vaccine (see IMMUNISATION). Children are routinely immunised at two, three and four months of age, and boosters are given later in life to at-risk workers, or those travelling to tropical parts.
Treatment should be started as soon as possible after sustaining a potentially dangerous wound. An intravenous injection of antitoxin should be given immediately, the wound thoroughly cleaned and PENICILLIN administered. Expert nursing is most important. Spasms may be minimised by reducing unexpected stimuli, and diazepam (see BENZODIAZEPINES; TRANQUILLISERS) is helpful. Intravenous feeding should be started immediately if the patient cannot swallow. Aspiration of bronchial secretions and antibiotic treatment of pneumonia may be necessary.... tetanus
Mild fever, rash, and malaise may occur after vaccination. In 1 per cent of cases, mild, noninfectious swelling of the parotid glands develops 3–4 weeks after vaccination. There is no evidence for a link between and Crohn’s disease or autism.... mmr vaccination
History Child health services were originally designed, before the NHS came into being, to ?nd or prevent physical illness by regular inspections. In the UK these were carried out by clinical medical o?cers (CMOs) working in infant welfare clinics (later, child health clinics) set up to ?ll the gap between general practice and hospital care. The services expanded greatly from the mid 1970s; ‘inspections’ have evolved into a regular screening and surveillance system by general practitioners and health visitors, while CMOs have mostly been replaced by consultant paediatricians in community child health (CPCCH).
Screening Screening begins at birth, when every baby is examined for congenital conditions such as dislocated hips, heart malformations, cataract and undescended testicles. Blood is taken to ?nd those babies with potentially brain-damaging conditions such as HYPOTHYROIDISM and PHENYLKETONURIA. Some NHS trusts screen for the life-threatening disease CYSTIC FIBROSIS, although in future it is more likely that ?nding this disease will be part of prenatal screening, along with DOWN’S (DOWN) SYNDROME and SPINA BIFIDA. A programme to detect hearing impairment in newborn babies has been piloted from 2001 in selected districts to ?nd out whether it would be a useful addition to the national screening programme. Children from ethnic groups at risk of inherited abnormalities of HAEMOGLOBIN (sickle cell disease; thalassaemia – see under ANAEMIA) have blood tested at some time between birth and six months of age.
Illness prevention At two months, GPs screen babies again for these abnormalities and start the process of primary IMMUNISATION. The routine immunisation programme has been dramatically successful in preventing illness, handicap and deaths: as such it is the cornerstone of the public health aspect of child health, with more potential vaccines being made available every year. Currently, infants are immunised against pertussis (see WHOOPING COUGH), DIPHTHERIA, TETANUS, POLIOMYELITIS, haemophilus (a cause of MENINGITIS, SEPTICAEMIA, ARTHRITIS and epiglottitis) and meningococcus C (SEPTICAEMIA and meningitis – see NEISSERIACEAE) at two, three and four months. Selected children from high-risk groups are o?ered BCG VACCINE against tuberculosis and hepatitis vaccine. At about 13 months all are o?ered MMR VACCINE (measles, mumps and rubella) and there are pre-school entry ‘boosters’ of diphtheria, tetanus, polio, meningococcus C and MMR. Pneumococcal vaccine is available for particular cases but is not yet part of the routine schedule.
Health promotion and education Throughout the UK, parents are given their child’s personal health record to keep with them. It contains advice on health promotion, including immunisation, developmental milestones (when did he or she ?rst smile, sit up, walk and so on), and graphs – called centile charts – on which to record height, weight and head circumference. There is space for midwives, doctors, practice nurses, health visitors and parents to make notes about the child.
Throughout at least the ?rst year of life, both parents and health-care providers set great store by regular weighing, designed to pick up children who are ‘failing to thrive’. Measuring length is not quite so easy, but height measurements are recommended from about two or three years of age in order to detect children with disorders such as growth-hormone de?ciency, malabsorption (e.g. COELIAC DISEASE) and psychosocial dwar?sm (see below).
All babies have their head circumference measured at birth, and again at the eight-week check. A too rapidly growing head implies that the infant might have HYDROCEPHALUS – excess ?uid in the hollow spaces within the brain. A too slowly growing head may mean failure of brain growth, which may go hand in hand with physically or intellectually delayed development.
At about eight months, babies receive a surveillance examination, usually by a health visitor. Parents are asked if they have any concerns about their child’s hearing, vision or physical ability. The examiner conducts a screening test for hearing impairment – the so-called distraction test; he or she stands behind the infant, who is on the mother’s lap, and activates a standardised sound at a set distance from each ear, noting whether or not the child turns his or her head or eyes towards the sound. If the child shows no reaction, the test is repeated a few weeks later; if still negative then referral is made to an audiologist for more formal testing.
The doctor or health visitor will also go through the child’s developmental progress (see above) noting any signi?cant deviation from normal which merits more detailed examination. Doctors are also recommended to examine infants developmentally at some time between 18 and 24 months. At this time they will be looking particularly for late walking or failure to develop appropriate language skills.... child health
Age Disease and mode of administration
3 days BCG (Bacille Calmette-Guerin) by injection if tuberculosis in family in past 6 months.
2 months Poliomyelitis (oral); adsorbed diphtheria, whooping-cough (pertussis)1 and tetanus2 (triple vaccine given by injection); HiB injection.3
3 months Poliomyelitis (oral); diphtheria, whooping-cough (pertussis)1 and tetanus2 (triple vaccine given by injection); HiB injection.3
4 months Poliomyelitis (oral); diphtheria, whooping-cough (pertussis)1 and tetanus2 (triple vaccine given by injection); HiB injection.3
12–18 months Measles, mumps, and rubella (German measles)4 (given together live by injection).
(SCHOOL ENTRY)
4–5 years Poliomyelitis (oral); adsorbed diphtheria and tetanus (given together by injection); give MMR vaccine if not already given at 12–18 months.
10–14 females Rubella (by injection) if they have missed MMR.
10–14 BCG (Bacille Calmette-Guerin) by injection to tuberculin-negative children to prevent tuberculosis.
15–18 Poliomyelitis single booster dose (oral); tetanus (by injection).
1 Pertussis may be excluded in certain susceptible individuals.
2 Known as DPT or triple vaccine.
3 Haemophilus in?uenzae immunisation (type B) is being introduced to be given at same time, but di?erent limb.
4 Known as MMR vaccine. (Some parents are asking to have their infants immunised with single-constituent vaccines because of controversy over possible side-effects – yet to be con?rmed scienti?cally – of the combined MMR vaccine.)
Recommended immunisation schedules in the United Kingdom... immune system
Deficiency. Sun sensitivity; exposure inducing itching, burning and swelling of the skin. Kidney, bladder, and gut infections. Severe earache in young children. Strokes, heart attacks.
It is claimed that those who eat a diet rich in beta-carotene are less likely to develop certain types of cancer.
Smokers usually have low levels of beta-carotene in the blood. Statistics suggest that people who eat a lot of beta-carotene foods are less likely to develop lung, mouth or stomach cancer. In existing cases a slow-down of the disease is possible.
Daily dose. Up to 300mg. Excess may manifest as yellow discoloration of the skin, giving appearance of sun-tan.
Sources. Mature ripe carrots of good colour. A Finland study suggests that four small carrots contain sufficient beta-carotene to satisfy the recommended daily amount of Vitamin A. Orange and dark green fruits and vegetables. Broccoli, Brussels sprouts, spinach, pumpkin, apricots, peaches, oranges, tomatoes. Harvard Medical School study. Among 333 subjects with a history of heart disease, those who received beta-carotene supplements of 50 milligrams every other day suffered half as many heart attacks as those taking placebos. (Dr Charles Hennekens, Harvard Medical School) ... beta-carotene
It seems that this common bacteria, in some unknown way, receives a booster by taking on viral DNA. Lungs, liver and stomach may be attacked, while red blood cells are disrupted and their haemoglobin released. Among other conditions caused by streptococcus is the bright red rash of scarlet fever, sinusitis, meningitis and rheumatic fever. Flesh-eater disease may take just twenty hours to kill a man (“galloping gangrene”).
Symptoms. High temperature – body hot, hands and feet freezing cold. ‘Strep’ sore throat (pharyngitis). Bright red skin rash. Pains in arms and legs as if straining a muscle.
Treatment. The disease is resistant to penicillin. Frequent hot lemon drinks well-laced with honey. Tinctures. Echinacea 2; Goldenseal 1; Myrrh half. Dose: 10-20 drops in dessertspoon water or honey, hourly, acute cases.
Treatment by or in liaison with medical practitioner or infectious diseases specialist. ... flesh-eating disease
Protection against pertussis and tetanus gradually wanes. In adults, pertussis is mild but can be transmitted to children. Since tetanus is serious at any age, boosters are recommended at the time of any dirty, penetrating injury if there has not been a vaccination in the past 10 years.
Reactions to the diphtheria and tetanus parts of the vaccine are rare.
The pertussis vaccine often causes slight fever and irritability for a day or so.
More serious reactions are extremely rare and include seizures and an allergic reaction, which may lead to sudden breathing difficulty and shock.
Permanent damage from the vaccine is even rarer.
Doctors are now agreed that for most children, the benefits of outweigh the minimal risk from the vaccine.
The pertussis element of the vaccine should not be given to children who have reacted severely to a preceding dose of the vaccine, or who have a progressing brain abnormality.... dpt vaccination
The most common complications are ear and chest infections, which usually occur 2–3 days after the rash appears. Diarrhoea, vomiting, and abdominal pain also occur. Febrile convulsions (see convulsion, febrile) are also common, but these are not usually serious. Encephalitis occurs in about 1 in 1000 cases, causing headache, drowsiness, and vomiting. Seizures and coma may follow, sometimes leading to brain damage or even death. In very rare cases, a progressive brain disorder known as subacute sclerosing panencephalitis develops years later. If measles occurs during pregnancy, the fetus dies in about a fifth of cases. However, there is no evidence that measles causes birth defects. There is no specific treatment for measles. Plenty of fluids and paracetamol are given for fever, and antibiotic drugs may be given to treat bacterial infections that occur as complications.
To help prevent measles, immunization with the MMR vaccination is recommended at 12–15 months of age.
This produces immunity in about 90 per cent of cases, with a booster shot given before school or nursery school entry.... measles
Healthy people are inoculated with vaccine as a protection against a particular disease; this produces ANTIBODIES which will confer immunity against a subsequent attack of the disease. (See IMMUNISATION for programme of immunisation during childhood.)
Vaccines may be divided into two classes: stock vaccines, prepared from micro-organisms known to cause a particular disease and kept in readiness for use against that disease; and autogenous vaccines, prepared from microorganisms which are already in the patient’s body and to which the disease is due. Vaccines intended to protect against the onset of disease are of the former variety.
Autogenous vaccines are prepared by cultivating bacteria found in SPUTUM, URINE and FAECES, and in areas of in?ammation such as BOILS (FURUNCULOSIS). This type of vaccine was introduced by Wright about 1903.
Anthrax vaccine was introduced in 1882 for the protection of sheep and cattle against this disease. A safe and e?ective vaccine for use in human beings has now been evolved. (See ANTHRAX.)
BCG vaccine is used to provide protection against TUBERCULOSIS. (See also separate entry on BCG VACCINE.)
Cholera vaccine was introduced in India about 1894. Two injections are given at an interval of at least a week; this gives a varying degree of immunity for six months. (See CHOLERA.)
Diphtheria vaccine is available in several forms. It is usually given along with tetanus and pertussis vaccine (see below) in what is known as TRIPLE VACCINE. This is given in three doses: the ?rst at the age of two months; the second at three months; and the third at four months, with a booster dose at the age of ?ve years. (See DIPHTHERIA.)
Hay fever vaccine is a vaccine prepared from the pollen of various grasses. It is used in gradually increasing doses for prevention of HAY FEVER in those susceptible to this condition.
In?uenza vaccine A vaccine is now available for protection against INFLUENZA due to the in?uenza viruses A and B. Its use in Britain is customarily based on advice from the health departments according to the type of in?uenza expected in a particular year.
Measles, mumps and rubella (MMR) vaccines are given in combination early in the second year of life. A booster dose may prove necessary, as there is some interference between this vaccine and the most recent form of pertussis vaccine (see below) o?ered to children. Uptake has declined a little because of media reports suggesting a link with AUTISM – for which no reliable medical evidence (and much to the contrary) has been found by investigating epidemiologists. (See also separate entry for each disease, and for MMR VACCINE.)
Pertussis (whooping-cough) vaccine is prepared from Bordetella pertussis, and is usually given along with diphtheria and tetanus in what is known as triple vaccine. (See also WHOOPING-COUGH.)
Plague vaccine was introduced by Ha?kine, and appears to give useful protection, but the duration of protection is relatively short: from two to 20 months. Two injections are given at an interval of four weeks. A reinforcing dose should be given annually to anyone exposed to PLAGUE.
Poliomyelitis vaccine gives a high degree of protection against the disease. This is given in the form of attenuated Sabin vaccine which is taken by mouth – a few drops on a lump of sugar. Reinforcing doses of polio vaccine are recommended on school entry, on leaving school, and on travel abroad to countries where POLIOMYELITIS is ENDEMIC.
Rabies vaccine was introduced by Pasteur in 1885 for administration, during the long incubation period, to people bitten by a mad dog, in order to prevent the disease from developing. (See RABIES.)
Rubella vaccine, usually given with mumps and measles vaccine in one dose – called MMR VACCINE, see also above – now provides protection against RUBELLA (German measles). It also provides immunity for adolescent girls who have not had the disease in childhood and so ensures that they will not acquire the disease during any subsequent pregnancy – thus reducing the number of congenitally abnormal children whose abnormality is the result of their being infected with rubella via their mothers before they were born.
Smallpox vaccine was the ?rst introduced. As a result of the World Health Organisation’s successful smallpox eradication campaign – it declared the disease eradicated in 1980 – there is now no medical justi?cation for smallpox vaccination. Recently, however, there has been increased interest in the subject because of the potential threat from bioterrorism. (See also VACCINATION.)
Tetanus vaccine is given in two forms: (1) In the so-called triple vaccine, combined with diphtheria and pertussis (whooping-cough) vaccine for the routine immunisation of children (see above). (2) By itself to adults who have not been immunised in childhood and who are particularly exposed to the risk of TETANUS, such as soldiers and agricultural workers.
Typhoid vaccine was introduced by Wright and Semple for the protection of troops in the South African War and in India. TAB vaccine, containing Salmonella typhi (the causative organism of typhoid fever – see ENTERIC FEVER) and Salmonella paratyphi A and B (the organisms of paratyphoid fever – see ENTERIC FEVER) has now been replaced by typhoid monovalent vaccine, containing only S. typhi. The change has been made because the monovalent vaccine is less likely to produce painful arms and general malaise, and there is no evidence that the TAB vaccine gave any protection against paratyphoid fever. Two doses are given at an interval of 4–6 weeks, and give protection for 1–3 years.... vaccine
The rubella virus is spread by motherto-baby transmission and in airborne droplets; it has an incubation period of 2–3 weeks. Infection usually occurs in children aged 6–12. A rash appears on the face, spreads to the trunk and limbs, then disappears after a few days. There may be slight fever and enlarged lymph nodes at the back of the neck.
The virus may be transmitted from a few days before symptoms appear until one day after they disappear. An unborn baby is at risk if the mother is infected during the first 4 months of pregnancy. The earlier the infection occurs, the more likely the infant is to be affected, and the more serious the abnormalities tend to be. The most common abnormalities are deafness, congenital heart disease, learning difficulties, cataracts, purpura, cerebral palsy, and bone abnormalities. About 1 in 5 affected babies dies in early infancy.
There is no specific treatment, apart from paracetamol for fever.
Treatment of rubella syndrome depends on the defects.
Rubella vaccine provides longlasting immunity to the disease; it is given in the MMR vaccine to babies aged 12–15 months, with a booster at school entry.
Rubella infection also provides immunity.
If a nonimmune pregnant woman comes into contact with a person who has rubella, passive immunization by immunoglobulin injection may help prevent infection of the fetus.... rubella