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ObjectiveTo compare the occurrence of chickenpox in children with cancer who received varicella immunoglobulin (VZIG) or aciclovir as postexposure prophylaxis (PEP).DesignProspective multicentre service evaluation of children with cancer who received either VZIG or aciclovir as PEP following significant exposure to varicella zoster virus (VZV) over a 24-month period from May 2018.SettingData were collected from 9 UK Paediatric Oncology Primary Treatment Centres.PatientsChildren under 16 years old with a diagnosis of cancer and/or previous haematopoietic stem cell transplant who were VZV seronegative at exposure and/or diagnosis and received PEP following significant VZV exposure.Main outcome measuresThe primary outcome was the incidence of breakthrough varicella within 6 weeks of VZV exposure and treatment with PEP.ResultsA total of 105 eligible patients were registered with a median age of 4.9 years (range 1.1–10.5 years). Underlying diagnoses were acute leukaemia (64), solid tumours (22), Langerhans cell histiocytosis (9), central nervous system (CNS) tumours (8) and other (2). Aciclovir was received by 86 patients (81.9%), 18 received VZIG (17.1%) and 1 valaciclovir (0.9%). There were seven reported break-through VZV infections in 103 patients at follow-up (7/103, 6.8%). Clinical VZV developed in 5/84 of the aciclovir group (6.0%, 95% CI 2.0 to 13.3) and 2/18 of VZIG group (11.1%, 95% CI 1.4 to 34.7). All breakthrough infections were either mild (5/7) or moderate (2/7) in severity.ConclusionAciclovir is a safe and effective alternative to VZIG as VZV PEP in children with cancer and should be considered as standard of care.

Introduction Understanding the effectiveness and durability of protection against SARS-CoV-2 infection conferred by previous infection and COVID-19 is essential to inform ongoing management of the pandemic. This study aims to determine whether prior SARS-CoV-2 infection or COVID-19 vaccination in healthcare workers protects against future infection. Methods and analysis This is a prospective cohort study design in staff members working in hospitals in the UK. At enrolment, participants are allocated into cohorts, positive or naïve, dependent on their prior SARS-CoV-2 infection status, as measured by standardised SARS-CoV-2 antibody testing on all baseline serum samples and previous SARS-CoV-2 test results. Participants undergo monthly antibody testing and fortnightly viral RNA testing during follow-up and based on these results may move between cohorts. Any results from testing undertaken for other reasons (eg, symptoms, contact tracing) or prior to study entry will also be captured. Individuals complete enrolment and fortnightly questionnaires on exposures, symptoms and vaccination. Follow-up is 12 months from study entry, with an option to extend follow-up to 24 months. The primary outcome of interest is infection with SARS-CoV-2 after previous SARS-CoV-2 infection or COVID-19 vaccination during the study period. Secondary outcomes include incidence and prevalence (both RNA and antibody) of SARS-CoV-2, viral genomics, viral culture, symptom history and antibody/neutralising antibody titres. Ethics and dissemination The study was approved by the Berkshire Research Ethics Committee, Health Research Authority (IRAS ID 284460, REC reference 20/SC/0230) on 22 May 2020; the vaccine amendment was approved on 12 January 2021. Participants gave informed consent before taking part in the study. Regular reports to national and international expert advisory groups and peer-reviewed publications ensure timely dissemination of findings to inform decision making. Trial registration number NCT11041050.

ObjectiveTo understand community seroprevalence of SARS-CoV-2 in children and adolescents. This is vital to understanding the susceptibility of this cohort to COVID-19 and to inform public health policy for disease control such as immunisation.DesignWe conducted a community-based cross-sectional seroprevalence study in participants aged 0–18 years old recruiting from seven regions in England between October 2019 and June 2021 and collecting extensive demographic and symptom data. Serum samples were tested for antibodies against SARS-CoV-2 spike and nucleocapsid proteins using Roche assays processed at UK Health Security Agency laboratories. Prevalence estimates were calculated for six time periods and were standardised by age group, ethnicity and National Health Service region.ResultsPost-first wave (June–August 2020), the (anti-spike IgG) adjusted seroprevalence was 5.2%, varying from 0.9% (participants 10–14 years old) to 9.5% (participants 5–9 years old). By April–June 2021, this had increased to 19.9%, varying from 13.9% (participants 0–4 years old) to 32.7% (participants 15–18 years old). Minority ethnic groups had higher risk of SARS-CoV-2 seropositivity than white participants (OR 1.4, 95% CI 1.0 to 2.0), after adjusting for sex, age, region, time period, deprivation and urban/rural geography. In children ConclusionsApproximately one-third of participants aged 15–18 years old had evidence of antibodies against SARS-CoV-2 prior to the introduction of widespread vaccination. These data demonstrate that ethnic background is independently associated with risk of SARS-CoV-2 infection in children.Trial registration numberNCT04061382.

ObjectivesTo investigate the safety of live attenuated varicella zoster vaccination when administered to immunosuppressed individuals.DesignProspective observational cohort study.SettingThe study used anonymised data from the Clinical Practice Research Datalink (CPRD), comprising a representative sample of routinely collected primary care data in England between 2013 and 2017 and and linked Hospital Episode Statistics data.Participants168 767 individuals age-eligible for varicella zoster vaccination registered at a general practice in England contributing data to CPRD.Main outcome measuresElectronic health records indicating immunosuppression, zoster vaccination, diagnoses of specific varicella-zoster virus (VZV)-related disease and non-specific rash/encephalitis compatible with VZV-related disease.ResultsBetween 1 September 2013 and 31 August 2017, a period of immunosuppression was identified for 9093/168 767 (5.4%; 95% CI: 5.3%–5.5%) individuals age-eligible for zoster vaccination. The overall rate of vaccination while immunosuppressed was 1742/5251 (33.2 per 100 adjusted person years at risk; 95% CI: 31.9%–34.5%). Follow-up of the 1742 individuals who were inadvertently vaccinated while immunosuppressed identified only two cases of VZV-related disease within 8 weeks of vaccination (0.1%; 95% CI: 0.01%–0.4%), both primary care diagnoses of ‘shingles’, neither with a related hospital admission.ConclusionsDespite evidence of inadvertent vaccination of immunosuppressed individuals with live zoster vaccination, there is a lack of evidence of severe consequences including hospitalisation. This should reassure primary care staff and encourage vaccination of mildly immunosuppressed individuals who do not meet current thresholds for contraindication. These findings support a review of the extent to which live zoster vaccination is contraindicated among the immunosuppressed.

ObjectivesTo assess the impact of herpes zoster vaccination in the 5 years after introduction for 70- to 79-year-olds in England in September 2013.DesignPopulation based ecological impact assessment.SettingHospitals covering the whole English population for the period 2008 to 2018 and 293 general practices (GP) for the period 2005 to 2018, in England.ParticipantsOver the period the population contributed 117·5 million person-years for hospitalisation events and 6.96 million person-years for GP events in individuals aged 60 to 89.InterventionsLive attenuated herpes zoster vaccination (Zostavax), first used on 1st September 2013, in 70- and 79-year-olds with continued use in new 70 year-olds and with a staged catch-up of those aged 71 to 78 years in 2013.Outcome measuresHerpes zoster and postherpetic neuralgia (PHN) consultation and hospitalisation rates in age-cohorts according to vaccine eligibility. Incidence rate ratios in age-cohorts eligible for vaccination compared with those non-eligible were calculated by Poisson regression. This was used to estimate prevented cases and, along with vaccine coverage, to estimate vaccine effectiveness.ResultsLarge and prolonged reductions in herpes zoster and PHN consultations and hospitalisations were observed in the 5 years post-implementation. For example, in 79 year-olds first eligible in 2013, the incidence rate ratio for consultations 5 years later was 0·65 (95% CI: 0·52 to 0·81). Over the whole period an estimated 40 500 fewer zoster consultations and 1840 fewer zoster hospitalisations occurred because of the vaccination programme. These reductions were consistent with effectiveness in the routine cohorts (vaccinated aged 70) of between 37% (for hospitalised zoster) and 75% (for PHN consultations) and, in catch up cohorts (vaccinated aged 78 to 79) of between 49% (for hospitalised PHN) and 66% (for PHN consultations).ConclusionGiven the clear and sustained impact of herpes zoster vaccination over the 5-year period since introduction, optimising vaccination coverage is important to attain maximum benefit.

Objective To record clinical findings in all new cases of Guillain–Barre syndrome (GBS) or Fisher syndrome (FS) in UK children in the 2 years following September 2009 and determine the proportion temporally associated with recent infections, pandemic H1N1 (2009) strain influenza vaccination or seasonal influenza vaccination. Design A prospective UK-wide epidemiological study using the British Paediatric Surveillance Unit system. Patients Children aged 16 years or less meeting the Brighton Collaboration criteria for GBS or FS. Results 112 children with GBS (66 boys and 46 girls) and 3 boys with FS were identified in 2 years. All but one recovered sufficiently to go home. The annual UK incidence rate of GBS in patients less than 15 years old was 0.45/100 000, similar to other countries. There was evidence of infection in the 3 months preceding onset in 92/112 GBS and 3/3 FS cases. Of those living in England, 7 cases received pandemic A/H1N1 2009 influenza vaccination before GBS symptom onset (3/7 were within 6 months including 1 within 3 months); 2 children received 2010/2011 seasonal influenza vaccination within 6 months of GBS onset. The numbers vaccinated were not significantly greater than expected by chance. Conclusions The outcome for childhood GBS and FS after 6 months was better than reported in adults. Most UK GBS and FS cases had infections in the preceding 3 months. When considering the children living in England, there was no significantly increased risk of GBS after pandemic A/H1N1 2009 influenza vaccination or 2010/2011 seasonal influenza vaccination.

BackgroundRapidly undertaken age-stratified serology studies can produce valuable data about a new emerging infection including background population immunity and seroincidence during an influenza pandemic. Traditionally seroepidemiology studies have used surplus laboratory sera with little or no clinical information or have been expensive detailed population based studies. We propose collecting population based sera from the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC), a sentinel network with extensive clinical data.AimTo pilot a mechanism to undertake population based surveys that collect serological specimens and associated patient data to measure seropositivity and seroincidence due to seasonal influenza, and create a population based serology bank.Methods and analysisSetting and Participants: We will recruit 6 RCGP RSC practices already taking nasopharyngeal virology swabs. Patients who attend a scheduled blood test will be consented to donate additional blood samples. Approximately 100–150 blood samples will be collected from each of the following age bands – 18– 29, 30– 39, 40– 49, 50– 59, 60– 69 and 70+ years.MethodsWe will send the samples to the Public Health England (PHE) Seroepidemiology Unit for processing and storage. These samples will be tested for influenza antibodies, using haemagglutination inhibition assays. Serology results will be pseudonymised, sent to the RCGP RSC and combined using existing processes at the RCGP RSC secure hub. The influenza seroprevalence results from the RCGP cohort will be compared against those from the annual PHE influenza residual serosurvey.Ethics and disseminationEthical approval was granted by the Proportionate Review Sub- Committee of the London – Camden & Kings Cross on 6 February 2018. This study received approval from Health Research Authority on 7 February 2018. On completion the results will be made available via peer-reviewed journals.

Objectives To assess childhood vaccination coverage at first, second and fifth birthdays by ethnicity in London between 2006/2007 and 2010/2011 and identify factors relating to lower coverage. Design Data concerning receipt of diphtheria-containing vaccines were extracted from child health information systems (CHISs) and sent to the Health Protection Agency. Setting Nine London Primary Care Trusts (PCTs). Participants Records for 315 381 children born April 2001–March 2010. Main outcome measures Receipt of a full primary course of diphtheria-containing vaccines at first and second birthdays, and a primary course and preschool booster at fifth birthday. Results Consistently good vaccine coverage of the primary course (>88% at first birthday, >89% at second birthday) was achieved across the five largest ethnic groups. Coverage of the preschool booster at fifth birthday was >65% across the five largest ethnic groups. Lowest coverage was observed in smaller ethnic groups. Deprivation was not a strong indicator of coverage overall, and for most ethnic groups there was no relationship between deprivation and coverage. Coverage was significantly lower in children not assigned to a general practitioner practice in the CHIS. Conclusions Smaller, less well-established ethnic groups within a PCT may require specific targeting to ensure children are fully immunised and to improve record keeping. Unregistered children need particular attention and may be missed by current scheduling processes in London. In order to monitor the impact of the current National Health Service (NHS) reorganisation on inequalities in access to healthcare data on country of birth, in addition to ethnicity, should be available for analysis.

Estimation of influenza vaccine effectiveness (V/E) is needed early during influenza outbreaks in order to optimise management of influenza--a need which will be even greater in a pandemic situation.Examine the potential of routinely collected virological surveillance data to generate estimates of V/E in real-time during winter seasons.Integrated clinical and virological community influenza surveillance data collected over three winters 2004/5-2006/7 were used. We calculated the odds of vaccination in persons that were influenza-virus-positive and the odds in those that were negative and provided a crude estimate of V/E. Logistic regression was used to obtain V/E estimates adjusted for confounding variables such as age.Multivariable analysis suggested that adjustments to the crude V/E estimate were necessary for patient age and month of sampling. The annual adjusted V/E was 2005/6, 67% (95% CI 41% to 82%); 2006/7 55% (26% to 73%) and 2007/8 67% (41% to 82%). The adjusted V/E in persons65 years was 70% (57% to 78%) and 65 years and over 46% (-17% to 75%). Estimates differed by small insignificant amounts when calculated separately for influenza A and B; by interval between illness onset and swab sample; by analysis for the period November to January in each year compared with February to April and according to viral load.We have demonstrated the potential of using routine virological and clinical surveillance data to provide estimates of V/E early in season and conclude that it is feasible to introduce this approach to V/E measurement into evaluation of national influenza vaccination programs.

Background: Declining effectiveness of the UK’s Hib vaccine programme was observed between 1998 and 2002. Objective: To provide insight into non-vaccine factors contributing to ongoing Hib disease in England after immunisation. Design: Postal questionnaire study, matched case–control design. Setting: Health Protection Agency Centre for Infections, England. Patients: Cases were children born after 1 January 1993 presenting with confirmed Hib infection in England between the start of 1998 and end of 2002, regardless of vaccination status. Controls were matched by date of birth and region. Main outcome measures: Odds ratios were calculated to assess the impact of host and environmental variables on disease risk. Results: Increased disease risk was noted among children with frequent antibiotic use (adjusted OR (AOR) (trend) 1.51 (95% CI 1.06 to 2.13); p = 0.02) and from sole-parent households (AOR 2.56 (95% CI 1.24 to 5.29); p = 0.01). These two risk factors were further related to each other, consistent with previously reported associations between infection and social deprivation. In fully immunised children, receipt of all three doses of the primary course as an acellular pertussis-containing combination vaccine (DTaP-Hib) increased the risk of vaccine failure (OR 2.88 (95% CI 0.99 to 8.37), p = 0.01). Day care attendance between 2 and 5 years of age was linked with a dose-dependent reduction in risk (AOR (trend) 0.79 (95% CI 0.66 to 0.93); p = 0.01), possibly because of natural boosting of immunity. Conclusions: The association noted between invasive infection and social deprivation in this and other studies is concerning and merits further investigation. The importance of ongoing surveillance of vaccine-preventable diseases to allow nested studies of this kind was reinforced.

Background: MMR vaccine has been reported to cause gait disturbance, and this possible association has been claimed to support the MMR-causes-autism theory. Aims: To determine whether any association between gait disturbance and MMR vaccination exceeds the age related background rate of gait disturbance, using record linkage and self control case series analyses. Methods: MMR vaccination records were linked to hospital admission and general practitioner attendance data. An increased rate of gait problems with onset in various intervals in the 60 day period after MMR vaccination was looked for in children aged 12 to

Objectives: To describe the seroepidemiology of herpes simplex virus (HSV) types 1 and 2 in the general populations of eight European countries to better understand recent reported changes in disease epidemiology. Methods: Belgium, Bulgaria, Czech Republic, England and Wales, Finland, Germany, Netherlands, and Slovenia conducted national cross sectional serological surveys for HSV-1 and HSV-2 between 1989 and 2000. Survey sizes ranged from 3000 to 7166 sera. External quality control was ensured through reference panel testing. Results: Large intercountry and intracountry differences in HSV-1 and HSV-2 seroprevalence were observed. Age standardised HSV-1 seroprevalence ranged from 52% in Finland, to 57% in the Netherlands, 67% in Belgium, 81% in Czech Republic, and 84% in Bulgaria. Age standardised (>12 years) HSV-2 seroprevalence ranged from 24% in Bulgaria, to 14% in Germany, 13% in Finland, 11% in Belgium, 9% in Netherlands, 6% in Czech Republic, and 4% in England and Wales. In all countries, probability of seropositivity for both infections increased with age. A large proportion of teenagers and young adults remain HSV-1 susceptible particularly in northern Europe. Women were significantly more likely to be HSV-2 seropositive in six of seven (p

Aims: To assess the risk of further cases in educational settings in order to inform policy on managing cases and clusters of meningococcal disease. Methods: Between 1 April 1995 and 31 March 2001, surveillance in preschool and school settings in England and Wales identified 114 clusters of meningococcal disease. Twenty clusters were reported in preschool settings, 43 in primary, 46 in secondary, and five in independent schools. Seventy three clusters (64%) consisted of two or more confirmed cases, of which 30 had two or more serogroup C cases. Following the introduction of the national meningococcal serogroup C vaccination programme in 1999, no serogroup C clusters were observed between April 2000 and March 2001. Results: The relative risk of further cases in the four weeks after a single case compared with the background rate was raised in all settings, ranging from RR 27.6 (95% CI 15.2 to 39.9) in preschool settings to RR 3.6 (95% CI 2.5 to 4.6) in secondary schools. Absolute risk estimates ranged from 70/100 000 in preschool settings to 3.0/100 000 in secondary schools. The relative risk of clustering was similar for serogroup B and C strains. Most (68%) second cases occurred within seven days of the first case. Conclusions: Although there was a higher risk of further cases of meningococcal disease in schools and especially in preschool settings, it is not known whether widespread antibiotic use after single cases reduces risk of further cases and if there is a real risk of harm. Evidence of risk reduction is needed to inform public health policy.

Objective: To determine the prevalence and genetic diversity of hepatitis C virus in genitourinary medicine clinic attenders and to assess the extent of sexual transmission of the virus. Methods: A cross sectional, unlinked, anonymous survey in 14 genitourinary medicine clinics situated in England, Wales, and Northern Ireland. Serum specimens from genitourinary medicine clinic attenders, retained as part of the Unlinked Anonymous Prevalence Monitoring Programme (UAPMP) serum archive, were tested in small pools, for the presence of antibody to hepatitis C virus (anti-HCV). The main outcome measures were prevalence of antibodies to hepatitis C virus and identification of hepatitis C virus genotypes. Results: Testing of 17 586 specimens from 1995 showed an adjusted prevalence of anti-HCV in genitourinary medicine clinic attenders of 1.03% (95% CI: 0.89 to 1.16) overall and 0.65% (95% CI: 0.51 to 0.78) among those who did not report injecting drug use. Prevalence in injecting drug users attending genitourinary medicine clinics was 36.9% in both 1995 and 1996. Heterosexual injecting drug users had a higher prevalence of anti-HCV than homosexual/bisexual injectors. The most common hepatitis C genotypes were types 3a and 1a. There was a high degree of concordance between genotype and serotype. Conclusions: The low prevalence of anti-HCV in genitourinary medicine clinic attenders who deny injecting drugs suggests that the majority of hepatitis C infections have been acquired in adult life, mostly by injecting drug use, and that the hepatitis C virus is rarely transmitted sexually. The use of needle exchanges may explain the relatively low prevalence observed in the injecting drug users.

BackgroundA Heat-Health Watch system has been established in England and Wales since 2004 as part of the national heatwave plan following the 2003 European-wide heatwave. One important element of this plan has been the development of a timely mortality surveillance system. This article reports the findings and timeliness of a daily mortality model used to ‘nowcast’ excess mortality (utilising incomplete surveillance data to estimate the number of deaths in near-real time) during a heatwave alert issued by the Met Office for regions in South and East England on 24 June 2011.MethodsDaily death registrations were corrected for reporting delays with historical data supplied by the General Registry Office. These corrected counts were compared with expected counts from an age-specific linear regression model to ascertain if any excess had occurred during the heatwave.ResultsExcess mortality of 367 deaths was detected across England and Wales in ≥85-year-olds on 26 and 27 June 2011, coinciding with the period of elevated temperature. This excess was localised to the east of England and London. It was detected 3 days after the heatwave.ConclusionA daily mortality model was sensitive and timely enough to rapidly detect a small excess, both, at national and regional levels. This tool will be useful when future events of public health significance occur.

Objectives: To investigate whether meningococcal C conjugate vaccine (MCCV) caused relapse in children with steroid-responsive nephrotic syndrome. Design: A population-based study was conducted using an active surveillance system, developed to assess adverse events following vaccination, which linked hospital record information on relapses of nephrotic syndrome to community child health population MCCV data. An ecological study looking at hospital admissions for nephrotic syndrome in different age cohorts of children before and after the MCCV introductory campaign was also carried out. Settings: South East England, and England and Wales. Patients: 52 children having 162 relapses of nephrotic syndrome. Also, all hospital admissions of children aged 2–18 years with steroid-responsive nephrotic syndrome in England and Wales between 1995 and 2003, relating admissions to when MCCV was introduced in specific age cohorts. Main outcome measures and analysis method: Self-controlled case series analysis looking for increased risk of relapse following MCCV and changes in admission rates for nephrotic syndrome (incidence ratio) following the introduction of MCCV to different age cohorts of children. Results: There was no increased risk of relapse following MCCV in the self-control case series, where a relative incidence of 0.95 (95% confidence interval (CI) 0.61–1.47) was found in the 6-month post-vaccination period, or in the ecological study, which gave an incidence rate ratio of 1.05 (95% CI 0.95 to 1.15) for the quarter when MCCV was introduced and the following two quarters. Conclusions: We found no association between MCCV and nephrotic syndrome, which is therefore not a contraindication to meningococcal vaccination.

Introduction and aims The 7-valent (PCV7) and 13-valent (PCV13) pneumococcal conjugate vaccines (PCVs) are highly effective in preventing invasive pneumococcal disease (IPD) caused by vaccine serotypes and vaccine failure (vaccine-type IPD after age-appropriate immunisation) is rare. Although a number of studies have described children with PCV7 failure, little is known about PCV13 failure. Here, we describe the vaccination status, serotype distribution, risk factors, clinical characteristics and outcomes of children younger than 5 years with PCV7 and PCV13 failure over an eight-year period. Methods Public Health England conducts enhanced surveillance for IPD and provides a national reference service for serotyping pneumococcal isolates in England and Wales. General practitioners are routinely contacted to complete surveillance questionnaires for children aged Results A total of 163 episodes of PCV failure were confirmed in 161 children aged Conclusions PCV failure is rare in young children and, compared to PCV7 serotypes, the additional PCV13 serotypes are more likely to cause LRTI and empyema in healthy vaccinated children, but most children recover without sequelae. Given that most IPD cases in countries with established PCV13 programmes are currently due to non-PCV13 serotypes, there is an urgent need for serotype-independent subunit or whole-cell vaccines to control this devastating disease.

Aims: To improve estimates of deaths from pertussis in England and to identify reasons for under ascertainment. Methods: Comparison of deaths identified from enhanced laboratory pertussis surveillance, hospital episode statistics (HES), and Office for National Statistics (ONS) death registrations in England, 1994 to 1999. Results: A total of 33 deaths were identified, 88% of infants less than 4 months old. There was overlap between all sources; 22 deaths were identified in the enhanced pertussis surveillance system, 18 in ONS mortality data, and nine in HES. Children who had died from pertussis without mention of pertussis on the death certificate were more likely to have been certified by coroners than those with mention of pertussis (p = 0.0005). Using capture–recapture analysis, the total number of deaths from pertussis in the five and a half year period is estimated to be 46 (95% CI 37 to 71), or around nine deaths per year. Conclusions: National mortality statistics significantly under estimate deaths from pertussis in England and are inadequate for monitoring the national immunisation programme. The largest number of deaths is identified through enhanced laboratory surveillance. Death registration systems should take into account available microbiological information to ensure that cause of death is accurately assigned.

A CAUSAL ASSOCIATION BETWEEN MEASLES: mumps-rubella (MMR) vaccine and idiopathic thrombocytopenic purpura (ITP) was confirmed using immunisation/hospital admission record linkage. The absolute risk within six weeks of immunisation was 1 in 22 300 doses, with two of every three cases occurring in the six week post-immunisation period being caused by MMR. Children with ITP before MMR had no vaccine associated recurrences.

Aims To report results after 13 months of prospective UK surveillance for Guillain-Barre/Fisher (GBS/FS) syndrome via the British Paediatric Surveillance Unit (BPSU) system. Methods ‘Fast-track’ surveillance commenced in September 2009 using the BPSU monthly surveillance card. Consent was obtained to share identifying information about cases with the Health Protection Agency (HPA), thus obtaining vaccination details (type, batch number etc.) and laboratory results from General Practitioners and other sources. Results Data from notifying paediatricians is corroborated by the HPA. There were 115 notifications between September 2009 and the end of October 2010 with 16 duplications. So far information is available for 59 cases that meet the case definitions; 57 had GBS and 2 FS. There was a peak of confirmed cases developing symptoms in December 2009. In 43 of the 59 cases there was a suspected or proven infection in the previous 3 months – 4 laboratory proven H1N1, 2 suspected H1N1, 19 upper respiratory tract infection, 12 gastroenteritis (1 campylobacter, 2 norovirus), 1 chickenpox contact, 1 impetigo, 1 infectious mononucleosis, 3 nonspecific systemic illnesses. In eight cases there was a reported vaccination in the 3 months before symptoms as follows: 2 HPV (human papillomavirus), 2 Travel, 1 MMR, 1 MMR and MenC and pneumococcal, 1 diphtheria/tetanus/pertussis/polio/Hib and MenC and pneumococcal, 1 Baxter H1N1 (two doses) and varicella. Conclusion Despite the concern that swine ‘flu vaccination might cause GBS we have so far detected a temporal association with H1N1 vaccination in only one case. There is a clear temporal association between preceding infections (including H1N1) and the onset of illness in the GBS/FS cases, with a peak of onset in December 2009. The response from paediatricians is encouraging – in a previous BPSU study of acute flaccid paralysis just 20 cases of GBS were identified per year, probably because of under-reporting. These results are preliminary, as in some cases we await confirmation of the vaccination details from General Practitioners via the HPA. Acknowledgement Thanks to the Department of Health for our funding [PRP: 0190047], to Richard Lynn, Scientific Co-ordinator of the BPSU, and the paediatricians who report cases.

An increase in idiopathic thrombocytopenic purpura (ITP) cases in the 6 weeks following the first dose of the measles, mumps and rubella (MMR) vaccine has been established, with absolute risks estimated as 1 in 22 3001 and 1 in 21 000 vaccine doses,2 with two in every three cases attributable to the vaccine. However, the risk after a second dose of MMR vaccine has not been investigated. Hospital admissions for children aged from 3 to

Combined measles, mumps, and rubella (MMR) vaccine did not increase the risk of hospitalisation with invasive bacterial infection in the three months after vaccination; rather there was a protective effect. These results provide no support for the concept of "immunological overload" induced by multiple antigen vaccinations, nor calls for single antigen vaccines.

Parents of autistic children with regressive symptoms who were diagnosed after the publicity alleging a link with measles, mumps, and rubella (MMR) vaccine tended to recall the onset as shortly after MMR more often than parents of similar children who were diagnosed prior to the publicity. This is consistent with the recall bias expected under such circumstances.

Snape et al recommend that a booster dose of meningococcal group C glycoconjugate vaccine (MenC) be administered to children entering adolescence in the UK in the next five years.1 However, their study did not look for, or provide, any evidence of increasing nasopharyngeal carriage in pre-adolescents, and underestimates the protective effect of herd …

Objective: To determine the clinical course of hepatitis C virus in the first decade of infection in a group of patients who acquired their infections on a known date. Design: Cohort study. Setting: Clinical centres throughout the United Kingdom. Participants: 924 transfusion recipients infected with the hepatitis C virus (HCV) traced during the HCV lookback programme and 475 transfusion recipients who tested negative for antibodies to HCV (controls). Main outcome measures: Clinical evidence of liver disease and survival after 10 years of infection. Results: All cause mortality was not significantly different between patients and controls (Cox9s hazards ratio 1.41, 95% confidence interval 0.95 to 2.08). Patients were more likely to be certified with a death related to liver disease than were controls (12.84, 1.73 to 95.44), but although the risk of death directly from liver disease was higher in patients than controls this difference was not significant (5.78, 0.72 to 46.70). Forty per cent of the patients who died directly from liver disease were known to have consumed excess alcohol. Clinical follow up of 826 patients showed that liver function was abnormal in 307 (37.2%), and 115 (13.9%) reported physical signs or symptoms of liver disease. Factors associated with developing liver disease were testing positive for HCV ribonucleic acid (odds ratio 6.44, 2.67 to 15.48), having acquired infection when older (at age ≥ 40 years; 1.80, 1.14 to 2.85), and years since transfusion (odds ratio 1.096 per year, 1.00 to 1.20). For patients with severe disease, sex was also significant (odds ratio for women 0.38, 0.17 to 0.88). Of the 362 patients who had undergone liver biopsy, 328 (91%) had abnormal histological results and 35 (10%) of these were cirrhotic. Conclusions: Hepatitis C virus infection did not have a great impact on all cause mortality in the first decade of infection. Infected patients were at increased risk of dying directly from liver disease, particularly if they consumed excess alcohol, but this difference was not statistically significant. What is already known on this topic The clinical course of HCV infection is unclear because most information has come from studies of patients with established chronic liver disease Studies that follow patients from disease onset are rare because most HCV infections are asymptomatic What this study adds HCV infection does not have a great impact on all cause mortality in the first decade of infection Infected patients have an increased risk of dying from a liver related cause, particularly if they consumed excess alcohol