Letters
6
7
8
9
10
11
12
13
Advances m Btotechnologlcal Processes Vol 13, Wfley-bss New York 1990 pp 169 199 Gupta R K Saxena S N , Sharma, S B and Ahu)a S Production of a safe potent and immunogemc partially purified acellular pertuss~s vaccine using s~mple indigenous techtuques Paper presented at the International Symposium on Pertuss~s Evaluation and Research on Acellular Pertussts Veccmes Japan 14 15September 1990 Dev Biol Stand m press Relyveld E H Preparation de vaccins antitoxiques et anttmtcrobiens a I aide de glutaraldehyde C R Acad Scl Parts SertesD 1973 277 613 Relyveld E H Detoxfflcatlon of microbial toxins with glutaraldehyde and their use tn the preparation of vaccines In Toxins Animal Plant and Microbial (Ed Rosenberg P) Pergamon Press Oxford 1978 pp 1049-1065 Gupta R K Sharma S B Ahula S andSaxena S N The effects ot different reactivating agents on the potency toxicity and stabdfly of pertuss~s vaccine J Biol Stand 1987 18 87 hda T and Hortuch~ Y The detoxfftcat~on of Bordetella pertussm w*th glutaraldehyde J B~ol Stand 1987 15 17 Gupta R K Saxena S N Sharma S B and Ahuja S The potency toxicity and tmmunogemc~ty of g[utaraldehyde mact~vated pertussis vaccine Natl Med J India 1989 2 163 Gupta R K Saxena S N Sharma S B and Ahuja S Immunogemc~ty of glutaraldehyde inactivated pertussls vaccine Vaccine 1990 8 563 Gupta R K Use of glutaraldehyde for the preparation of pertussls vaccine Vaccine t990 8 409
14
Munoz J J Aral, H, Bergman, R K and Sadowskl P L Biological actiwt0es of crystalline pertusstgen from Bordetella pertussls Infect Immun 1981, 33 820 15 Cowell J L Sato, Y Sato, H, Lan, B A D and Manclark C R Separabon, purification and properties of the filamentous hemagglubnm and the leukocytosls promoting factor-hemagglutmm from Bordetella pertussts In Seminars in Infectious Diseases Vol IV Bacterial Vaccines (Eds Robbms J B Hdl J C and Sadofl J C ) , Thleme-Stratton Inc, NewYork 1982, pp 371 379 16 Robinson A and Hawkins D C Structure and biological properties of solubihzed envelope oroteins of Bordetella pertussls Infect Immun 1983 39 590 17 Robinson A and Ashworth L A E Acellular and defined-component vaccines against pertussls In Pathogenesm and Immunity in Pertussls (Eds Wardlaw, A C and Parton, R) John Wiley Chlchester, 1988 pp 399-417 18 Quentin-Millet M J Armtnjon F Danve B Cadoz M and Armand, J Acellular pertussts vaccines evaluahon of reversion m a nude mouse model J Biol Stand 1988 16 99
Rajesh K. Gupta Laholatol I o/Developmental and Mole~ ulal Immumtv, NICHD, National hlstttt~te~ o[ Health, BId,q 6, Room IA06, Bethesda, MD 20892, USA
Influenza vaccination acceptance among health care professionals Health care professionals (HCP) in close contact with hospltahzed high rtsk pattents, Including the elderly, are recommended for influenza tmmuntzatton m the United States ~, but their acceptance of the vaccine remains alarmingly low In the hope that knowledge of factors mhtbltlng HCP partlc~paUon m vaccine programmes could help to improve these rates, we conducted a survey among 62 randomly chosen medical personnel at the James A Haley Veterans' Hospttal Tampa, FL A written questionnaire was developed to determine influenza vaccination behavtour and reasons that influence its poslttve outcome Followup techniques were employed to obtain a 100% response rate Data were analysed 2 to tdentlfy the most common factors contributing to non-vacclnatton behavlour Only 12 out of 62 subjects (194%) indicated that they had received vacclnatron during the last year while 23 subjects (37 1%) had received the vaccme 1-5 years previously and 27 subjects (43 5%) had never recetved influenza vaccine Among the last group 13 subjects 148%) were physicians, nine subjects (33%) were nurses, two subjects (7%) chntcal laboratory and three subjects (11%) other support personnel The majority of the HCP (36 subjects 63%) surveyed lndtcated that they had close
contact with patients (a higher percentage among physicians and nurses) There was no difference m vaccination rates between the HCP with close patient contacts (19 4%) and those without (20%) (Table I) The most frequently ctted reason for lack of Immunization was that the HCP did not want the vaccine This amotlvatton was due to a multitude of factors lack of time in making the effort to get vaccinated, fear of side effects from vaccination, misconception about the vaccme efficacy and target groups, lack of mformation regardmg the easy availability of the vaccine at the VA chine free of charge, and perceived low risk of contacting influenza m medical settings Overall, fear of side effects and needle prick played a major role for non-
Table 1
compliance with influenza vaccine recommendation m less than one quarter (242%) of the non-comphant HCP When asked if the HCP knew somebody who suffered from influenza vaccine side reactions, 25 out of 58 HCP who responded said that they d]d (43%) Vaccine comphance rates between those that knew somebody who suffered from side effects of the vaccine and those that did not was not stattstlcally s~gmficant Nearly all physicians (17/18, 89%) and most of the clinical laboratory personnel (12/15, 80%) beheved that the vaccine benefits outweigh the side effects (Table 2a) The nurses were split almost equally on this issue (8/17 47% in favour) When risks of nosocomtal transmission or infection were considered, overwhelmmgly all categories of HCP indicated that thetr risk of mfectlon/transmisslon was no more than the general pubhc (67 7%) (Table 2b) Yet, over 74% of the HCP mdtcated that they had suffered from mfluenza-hke illness in the past (Table 2c) When asked if the flu shot should be taken yearly by the HCP, over half of the physlcmns and nurses were m favour of annual vaccination Physicians and nurses indicated also that they recommended influenza vaccination for their high risk pattents more physlctans (14/18 physicians) said they did (78%) than did the nurses (11/17 nurses, 65%) Results of this study reveal some dtsturbmg facts that prevent prophylactic comphance among the health care providers Amotlvatton is the most prevalent which reflects a discordance between knowledge and experience of the HCP and their personal preventive health practices This situation may be remedied by repeated dissemination of Information on vaccine efficacy and safety, reminders that the HCP in contact w~th htgh risk patients can transmit/ contact influenza and that easily accessible opportunity to be vaccmated, free of charge, ts avatlable at the VA hospitals Since most of the HCP think that the benefit of the vaccine outweighs risks from immunization and that it should be recommended for patients, these data indicate that the subjects do not act according to thetr knowledge/behefs when their own immunization behaviour ts concerned The HCP intellectually accept the influenza vaccine, but they do
Vaccination compliance among the health care professionals (HCP) and patient contacts Close patient contact
No close patient contact
HCP category
Comphant e
Non-comphant
Compliant
Physicians Nurses Clinical laboratory Other
2 1 2 2
8 14 2 5
0 0 4 0
Total
7 (19 4%) °
29
4 (20%)
Non-comphant 3 1 6 6 16
56 HCP responded to this question aVacclnated in previous year a% Compliant tn respective groups
Vaccine, Vol 9, September 1991 691
Book Rewew not practise what they learn Our results are, m part, similar to those previously reported by Pachuckl et al 3 The most &sturbmg feature of the findings of the present study is that nearly three quarters of the HC P (74 2%) had suffered from mfluenza-hke mfectmn in the past and yet beheve that their risks
of lnfectmn or transmission of mfluenza to patients are no more than average This complacency among the H CP is not only counterproductive for the medmal professmnals, but is potentially dangerous for the high risk patients who they are assigned to protect Health education mterventlon measures are necessary to
correct this present trend of amot~vatlon in vaccine comphance which is widely prevalent in this country'* 5
Acknowledgement This study was supported m part by a VA Medmal Research Fund on Aging References
Table 2
An analysis of the r e s p o n s e s of health care profess)onals to three questions f r o m the questionnaire
Phymclans
Nurses
Chmcal laboratory
Other*
Total (%)
1
2 3
a Does influenza vaccine produce side reachons wh)ch outweigh its benefits9 Yes No No answer
1 16 1
9 8 0
3 12 0
4 6 2
17 (27 4) 42 (67 8) 3 (4 8)
b What is your risk of catchmg/transmRtmg influenza9 H)gh Average Low No response
4 10 2 2
3 10 4 0
3 12 0 0
0 10 0 2
13 1 1
9 3 0
10 42 6 4
(16 1) (67 7) (9 7) (6 5)
c Have you ever suffered from influenza? Yes No No answer
11 4 3
13 3 1
46 (74 2) 11 (177) 5 (8 1)
4 5
Center for D~sease Control Prevention and control of influenza epldemlolOglC notes and reports Morbtd Mortal Week Rep 1985 34 633 Johnson R Elementary Statistics 1976 p 206 PachuckJ C T Lentmo J R and Jackson G G Altitude and behawor of health care personnel regarding the use and efficacy of influenza vaccine J Infect Dis 1985 151 1170 Schoenbaum Sc Vaccination for influenza any aRernatwes9 N Engl J Med 1978, 298 621 Ganguly R and Cameron D J Factors affecting )mmumzatlon rate )n a cohort of elderly veterans a retrospectwe p=lot study of influenza vaccine comphance Vaccine 1989 7, 462
b.W. Russell, D.J. Cameron, R.F. Lockey, R.H. Behnke, J.T. Sinnott and R. Ganguly UHIUe/sit t' Of Sotllh FlorMa, Colleqe o/ Medicine and James A Haler Veterans Hospital Tampa, FL 33612, USA
Book Review Immunochemistry of viruses II. The basis for serodiagnosis and vaccines Editors M H V Van Regenmortel Amsterdam, New York, London,
and A R Neurath, Elsevier, 544 pages, 385 Dutch florins
This book is a worthy successor to the first volume of lmmunochemtstry of Viruses and provides a useful update on recent developments m viral antlgemclty and immune responses to viral refections, sero&agnosls and the new trends and ideas currently permeating work on virus vaccmes The book represents an invaluable overview of the field for postgraduate and postdoctoral workers coming to grips with research m this highly technological area, and should also find a place on the desk of thmr more senior colleagues In both the academm and industrial worlds as a useful point of reference and as a gmdehne to developing areas of Interest m the highly important field of viral vaccines The book consists essentially of two halves, eight chapters are concerned with an update and overview of topics such as antigen processing and presentatmn, glycosylanon and antlgenlclty, expression 0264-410)(/91/090692-02 © 1991 B u t t e r w o r t h - H e m e m a n n Ltd
692
Vaccine, Vol 9, S e p t e m b e r 1991
systems for viral antigens, viral epltope structures and live recombinant viral vaccines The remaining chapters are devoted to aspects of the antlgemclty and immunology of selected virus groups, including the plcornawruses the Arenavmdae and Bunyavmdae, lentlvlruses, rhabdovlruses, reovlruses and the Herpes simplex virus There are also chapters, one on plant viruses and one on bacteriophages, with the object as stated by the e&tors, of spreading informatmn across normally widely divergent virological worlds Although in general the chapters on the distinct virus famdles are pnmardy devoted to aspects of viral antlgemoty, the detailed immune response to viral antigens, and the impact these may have on vaccine strategy, there is nevertheless a tendency to follow a more basra, conventmnal approach, with sections on wral morphology, viral replication, classtfi-
cat]on and, in some chapters, even the diseases for whmh the viral agents are responsible These sections sit somewhat uncomfortably amongst the considerable volume of more technologmally based mformatlon on viral epltope mapping, neutrahzatlon escape mutants and the interaction of the ~mmune response network with isolated viral glycoprotems, protective epltopes or synthetic peptldes In addition, it seems to be taking a somewhat narrow vmwpolnt to include a chapter solely on Herpes simplex virus antigens without cons~deratmn of the advances being made in defining the antigenic structure and the vaccine strategy to be adopted for other members of the Herpetovlrldae In spite of these minor reservations the lnformatlon In these chapters on the progress being made towards unravelling the detailed antigenic structure of individual viruses within different viral
6
7
8
9
10
11
12
13
Advances m Btotechnologlcal Processes Vol 13, Wfley-bss New York 1990 pp 169 199 Gupta R K Saxena S N , Sharma, S B and Ahu)a S Production of a safe potent and immunogemc partially purified acellular pertuss~s vaccine using s~mple indigenous techtuques Paper presented at the International Symposium on Pertuss~s Evaluation and Research on Acellular Pertussts Veccmes Japan 14 15September 1990 Dev Biol Stand m press Relyveld E H Preparation de vaccins antitoxiques et anttmtcrobiens a I aide de glutaraldehyde C R Acad Scl Parts SertesD 1973 277 613 Relyveld E H Detoxfflcatlon of microbial toxins with glutaraldehyde and their use tn the preparation of vaccines In Toxins Animal Plant and Microbial (Ed Rosenberg P) Pergamon Press Oxford 1978 pp 1049-1065 Gupta R K Sharma S B Ahula S andSaxena S N The effects ot different reactivating agents on the potency toxicity and stabdfly of pertuss~s vaccine J Biol Stand 1987 18 87 hda T and Hortuch~ Y The detoxfftcat~on of Bordetella pertussm w*th glutaraldehyde J B~ol Stand 1987 15 17 Gupta R K Saxena S N Sharma S B and Ahuja S The potency toxicity and tmmunogemc~ty of g[utaraldehyde mact~vated pertussis vaccine Natl Med J India 1989 2 163 Gupta R K Saxena S N Sharma S B and Ahuja S Immunogemc~ty of glutaraldehyde inactivated pertussls vaccine Vaccine 1990 8 563 Gupta R K Use of glutaraldehyde for the preparation of pertussls vaccine Vaccine t990 8 409
14
Munoz J J Aral, H, Bergman, R K and Sadowskl P L Biological actiwt0es of crystalline pertusstgen from Bordetella pertussls Infect Immun 1981, 33 820 15 Cowell J L Sato, Y Sato, H, Lan, B A D and Manclark C R Separabon, purification and properties of the filamentous hemagglubnm and the leukocytosls promoting factor-hemagglutmm from Bordetella pertussts In Seminars in Infectious Diseases Vol IV Bacterial Vaccines (Eds Robbms J B Hdl J C and Sadofl J C ) , Thleme-Stratton Inc, NewYork 1982, pp 371 379 16 Robinson A and Hawkins D C Structure and biological properties of solubihzed envelope oroteins of Bordetella pertussls Infect Immun 1983 39 590 17 Robinson A and Ashworth L A E Acellular and defined-component vaccines against pertussls In Pathogenesm and Immunity in Pertussls (Eds Wardlaw, A C and Parton, R) John Wiley Chlchester, 1988 pp 399-417 18 Quentin-Millet M J Armtnjon F Danve B Cadoz M and Armand, J Acellular pertussts vaccines evaluahon of reversion m a nude mouse model J Biol Stand 1988 16 99
Rajesh K. Gupta Laholatol I o/Developmental and Mole~ ulal Immumtv, NICHD, National hlstttt~te~ o[ Health, BId,q 6, Room IA06, Bethesda, MD 20892, USA
Influenza vaccination acceptance among health care professionals Health care professionals (HCP) in close contact with hospltahzed high rtsk pattents, Including the elderly, are recommended for influenza tmmuntzatton m the United States ~, but their acceptance of the vaccine remains alarmingly low In the hope that knowledge of factors mhtbltlng HCP partlc~paUon m vaccine programmes could help to improve these rates, we conducted a survey among 62 randomly chosen medical personnel at the James A Haley Veterans' Hospttal Tampa, FL A written questionnaire was developed to determine influenza vaccination behavtour and reasons that influence its poslttve outcome Followup techniques were employed to obtain a 100% response rate Data were analysed 2 to tdentlfy the most common factors contributing to non-vacclnatton behavlour Only 12 out of 62 subjects (194%) indicated that they had received vacclnatron during the last year while 23 subjects (37 1%) had received the vaccme 1-5 years previously and 27 subjects (43 5%) had never recetved influenza vaccine Among the last group 13 subjects 148%) were physicians, nine subjects (33%) were nurses, two subjects (7%) chntcal laboratory and three subjects (11%) other support personnel The majority of the HCP (36 subjects 63%) surveyed lndtcated that they had close
contact with patients (a higher percentage among physicians and nurses) There was no difference m vaccination rates between the HCP with close patient contacts (19 4%) and those without (20%) (Table I) The most frequently ctted reason for lack of Immunization was that the HCP did not want the vaccine This amotlvatton was due to a multitude of factors lack of time in making the effort to get vaccinated, fear of side effects from vaccination, misconception about the vaccme efficacy and target groups, lack of mformation regardmg the easy availability of the vaccine at the VA chine free of charge, and perceived low risk of contacting influenza m medical settings Overall, fear of side effects and needle prick played a major role for non-
Table 1
compliance with influenza vaccine recommendation m less than one quarter (242%) of the non-comphant HCP When asked if the HCP knew somebody who suffered from influenza vaccine side reactions, 25 out of 58 HCP who responded said that they d]d (43%) Vaccine comphance rates between those that knew somebody who suffered from side effects of the vaccine and those that did not was not stattstlcally s~gmficant Nearly all physicians (17/18, 89%) and most of the clinical laboratory personnel (12/15, 80%) beheved that the vaccine benefits outweigh the side effects (Table 2a) The nurses were split almost equally on this issue (8/17 47% in favour) When risks of nosocomtal transmission or infection were considered, overwhelmmgly all categories of HCP indicated that thetr risk of mfectlon/transmisslon was no more than the general pubhc (67 7%) (Table 2b) Yet, over 74% of the HCP mdtcated that they had suffered from mfluenza-hke illness in the past (Table 2c) When asked if the flu shot should be taken yearly by the HCP, over half of the physlcmns and nurses were m favour of annual vaccination Physicians and nurses indicated also that they recommended influenza vaccination for their high risk pattents more physlctans (14/18 physicians) said they did (78%) than did the nurses (11/17 nurses, 65%) Results of this study reveal some dtsturbmg facts that prevent prophylactic comphance among the health care providers Amotlvatton is the most prevalent which reflects a discordance between knowledge and experience of the HCP and their personal preventive health practices This situation may be remedied by repeated dissemination of Information on vaccine efficacy and safety, reminders that the HCP in contact w~th htgh risk patients can transmit/ contact influenza and that easily accessible opportunity to be vaccmated, free of charge, ts avatlable at the VA hospitals Since most of the HCP think that the benefit of the vaccine outweighs risks from immunization and that it should be recommended for patients, these data indicate that the subjects do not act according to thetr knowledge/behefs when their own immunization behaviour ts concerned The HCP intellectually accept the influenza vaccine, but they do
Vaccination compliance among the health care professionals (HCP) and patient contacts Close patient contact
No close patient contact
HCP category
Comphant e
Non-comphant
Compliant
Physicians Nurses Clinical laboratory Other
2 1 2 2
8 14 2 5
0 0 4 0
Total
7 (19 4%) °
29
4 (20%)
Non-comphant 3 1 6 6 16
56 HCP responded to this question aVacclnated in previous year a% Compliant tn respective groups
Vaccine, Vol 9, September 1991 691
Book Rewew not practise what they learn Our results are, m part, similar to those previously reported by Pachuckl et al 3 The most &sturbmg feature of the findings of the present study is that nearly three quarters of the HC P (74 2%) had suffered from mfluenza-hke mfectmn in the past and yet beheve that their risks
of lnfectmn or transmission of mfluenza to patients are no more than average This complacency among the H CP is not only counterproductive for the medmal professmnals, but is potentially dangerous for the high risk patients who they are assigned to protect Health education mterventlon measures are necessary to
correct this present trend of amot~vatlon in vaccine comphance which is widely prevalent in this country'* 5
Acknowledgement This study was supported m part by a VA Medmal Research Fund on Aging References
Table 2
An analysis of the r e s p o n s e s of health care profess)onals to three questions f r o m the questionnaire
Phymclans
Nurses
Chmcal laboratory
Other*
Total (%)
1
2 3
a Does influenza vaccine produce side reachons wh)ch outweigh its benefits9 Yes No No answer
1 16 1
9 8 0
3 12 0
4 6 2
17 (27 4) 42 (67 8) 3 (4 8)
b What is your risk of catchmg/transmRtmg influenza9 H)gh Average Low No response
4 10 2 2
3 10 4 0
3 12 0 0
0 10 0 2
13 1 1
9 3 0
10 42 6 4
(16 1) (67 7) (9 7) (6 5)
c Have you ever suffered from influenza? Yes No No answer
11 4 3
13 3 1
46 (74 2) 11 (177) 5 (8 1)
4 5
Center for D~sease Control Prevention and control of influenza epldemlolOglC notes and reports Morbtd Mortal Week Rep 1985 34 633 Johnson R Elementary Statistics 1976 p 206 PachuckJ C T Lentmo J R and Jackson G G Altitude and behawor of health care personnel regarding the use and efficacy of influenza vaccine J Infect Dis 1985 151 1170 Schoenbaum Sc Vaccination for influenza any aRernatwes9 N Engl J Med 1978, 298 621 Ganguly R and Cameron D J Factors affecting )mmumzatlon rate )n a cohort of elderly veterans a retrospectwe p=lot study of influenza vaccine comphance Vaccine 1989 7, 462
b.W. Russell, D.J. Cameron, R.F. Lockey, R.H. Behnke, J.T. Sinnott and R. Ganguly UHIUe/sit t' Of Sotllh FlorMa, Colleqe o/ Medicine and James A Haler Veterans Hospital Tampa, FL 33612, USA
Book Review Immunochemistry of viruses II. The basis for serodiagnosis and vaccines Editors M H V Van Regenmortel Amsterdam, New York, London,
and A R Neurath, Elsevier, 544 pages, 385 Dutch florins
This book is a worthy successor to the first volume of lmmunochemtstry of Viruses and provides a useful update on recent developments m viral antlgemclty and immune responses to viral refections, sero&agnosls and the new trends and ideas currently permeating work on virus vaccmes The book represents an invaluable overview of the field for postgraduate and postdoctoral workers coming to grips with research m this highly technological area, and should also find a place on the desk of thmr more senior colleagues In both the academm and industrial worlds as a useful point of reference and as a gmdehne to developing areas of Interest m the highly important field of viral vaccines The book consists essentially of two halves, eight chapters are concerned with an update and overview of topics such as antigen processing and presentatmn, glycosylanon and antlgenlclty, expression 0264-410)(/91/090692-02 © 1991 B u t t e r w o r t h - H e m e m a n n Ltd
692
Vaccine, Vol 9, S e p t e m b e r 1991
systems for viral antigens, viral epltope structures and live recombinant viral vaccines The remaining chapters are devoted to aspects of the antlgemclty and immunology of selected virus groups, including the plcornawruses the Arenavmdae and Bunyavmdae, lentlvlruses, rhabdovlruses, reovlruses and the Herpes simplex virus There are also chapters, one on plant viruses and one on bacteriophages, with the object as stated by the e&tors, of spreading informatmn across normally widely divergent virological worlds Although in general the chapters on the distinct virus famdles are pnmardy devoted to aspects of viral antlgemoty, the detailed immune response to viral antigens, and the impact these may have on vaccine strategy, there is nevertheless a tendency to follow a more basra, conventmnal approach, with sections on wral morphology, viral replication, classtfi-
cat]on and, in some chapters, even the diseases for whmh the viral agents are responsible These sections sit somewhat uncomfortably amongst the considerable volume of more technologmally based mformatlon on viral epltope mapping, neutrahzatlon escape mutants and the interaction of the ~mmune response network with isolated viral glycoprotems, protective epltopes or synthetic peptldes In addition, it seems to be taking a somewhat narrow vmwpolnt to include a chapter solely on Herpes simplex virus antigens without cons~deratmn of the advances being made in defining the antigenic structure and the vaccine strategy to be adopted for other members of the Herpetovlrldae In spite of these minor reservations the lnformatlon In these chapters on the progress being made towards unravelling the detailed antigenic structure of individual viruses within different viral
