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Vaccines against childhood diseases represent some of the most important applications of 20th-century pediatric research. This survey examines how the components of the current U.S. immunization schedule emerged in three phases during the course of the century. The first phase, after the development of bacterial culture techniques, witnessed numerous efforts in the early 1900s to develop bacterial vaccines. It proved most fruitful with respect to diphtheria, tetanus, and pertussis. The rise of viral tissue culture techniques in the 1950s brought about a second phase of innovation resulting in vaccines against polio, measles, mumps, rubella, and varicella. A third wave of innovation, still very much alive, has drawn on a variety of new technologies and led to vaccines against hepatitis B, Haemophilus influenzae type b, pneumococcus, and still other organisms. Although basic science research has thus been a primary factor shaping the history of vaccine development, the collaboration between the academic, private, and public sectors critical to its application has not always proceeded smoothly. The history of vaccine research and development has important implications for today, as a variety of factors threaten to fragment this network.

A second dose of varicella vaccine is routinely recommended. We report 2 cases of large local reactions after receipt of a second dose of varicella vaccine administered in the thigh. The reactions resolved with symptomatic therapy. Clinicians should continue to administer the second dose of varicella vaccine, but should use the preferred site in the arm.

We evaluated the responses of HIV-infected children to a single dose of split-virus influenza vaccine and the relationship to viral load and other characteristics.Fifty-three HIV-infected children ages 1.8 to 13.2 years were given influenza vaccine for the 1994 to 1995 influenza season (Wyeth-Ayerst: A/Texas H1N1, A/Shangdong H3N2 and B/Panama). Immunologic and virologic factors were assessed at the time of and 2 to 10 weeks after immunization.The differences between pre- and postimmunization CD4+ counts, CD4+:CD8+ ratios and viral load were not significant. Thirty-one of 53 children (58.4%) had a2-fold increase and 16 of 53 (30%) had a 4-fold rise in their postimmunization antibody titers for at least one component of the vaccine. Influenza immunization in the 1993 to 1994 flu season and administration of intravenous immunoglobulin around the time of immunization was not associated with immune response to the vaccine. Factors that were negatively associated with antibody response included increased time between samples (P = 0.004) and decreased preimmunization CD4+:CD8+ ratio (P = 0.02).Influenza immunization in this population is safe, and a positive antibody response to influenza immunization is not associated with significant clinical events or change in HIV-1 plasma viral burden.

The authors reviewed the means by which human immunodeficiency virus (HIV) seropositivity was acquired for the 134 seropositive children seen at Duke University Medical Center prior to September 1990. Perinatal transmission occurred in 111 (83%) and blood product transmission in 15 (11%). Of the 108 mothers (there were three sets of siblings) responsible for perinatal transmission, 44 (41%) had acquired their infection while residing in North Carolina. Intravenous (IV) drug use by the mother or her sexual partner was the significant risk factor for maternal infection in 91 (84%) of the total cases and in 38 (86%) of the 44 women infected in North Carolina. The proportion of women who acquired their HIV infection from a sexual partner who was an IV drug user was significantly greater for mothers who were resident in North Carolina when infected compared with mothers infected elsewhere (P < .001). On the basis of admissions to drug treatment programs during the 1990 fiscal year, cocaine is the predominant IV drug used in North Carolina. Admissions to cocaine abuse programs occurred throughout the state, and mothers who acquired HIV infection from IV drug use were more likely to live in counties with a higher frequency of cocaine abuse treatment.

Public trust in the safety and efficacy of vaccines is one key to the remarkable success of immunization programs within the United States and globally. Allegations of harm from vaccination have raised parental, political, and clinical anxiety to a level that now threatens the ability of children to receive timely, full immunization. Multiple factors have contributed to current concerns, including the interdependent issues of an evolving communications environment and shortfalls in structure and resources that constrain research on immunization safety (immunization-safety science). Prompt attention by public health leadership to spreading concern about the safety of immunization is essential for protecting deserved public trust in immunization.

Infants 1 to 3 months of age were immunized with a vaccine combining diphtheria and tetanus toxoids with pertussis organisms. The combination product was adjuvanted with alum. Infants were injected at four-week intervals between 1–3 months of age and boosted at 7–9 months of age. Serum antibody determinations were done 3 months after completion of the initial three administrations; again at 7–9 months of age, 6 months after completion of the original course; and a booster injection was given and final determinations obtained on serum collected at eight to ten months of age. Utilizing a variety of antitoxin and agglutination techniques, more than 90% of infants had effective antitoxin levels against diphtheria and tetanus on all three laboratory determinations whereas only 53% at 3 months, 51% at 6 months and 80% at 10 months had titers judged protective vs pertussis. It was therefore demonstrated that infants at this young age could respond satisfactorily with humoral antibodies against both diphtheria and tetanus toxoids but less so against pertussis.

* Abbreviations: AAP — : American Academy of Pediatrics FDA — : Food and Drug Administration TCV — : thimerosal-containing vaccine USPHS — : US Public Health Service A draft treaty under consideration by the United Nations Environmental Program has been prepared to greatly reduce global health hazards from environmental mercury.1 In response to the draft treaty, the World Health Organization urges removal of a provision in the treaty that calls for a ban on thimerosal (which contains ethyl mercury) in vaccines, a position recently endorsed by the American Academy of Pediatrics (AAP) and the US Public Health Service (USPHS). Removal of the ban on thimerosal-containing vaccines (TCVs) represents a significant reversal of the position expressed in an AAP/USPHS joint statement in 1999 that called for elimination of mercury in vaccines and the subsequent actions taken in the United States.2 Understanding the circumstances that led 14 years ago to the 1999 statement and the knowledge accumulated in these subsequent years can reinforce the importance of the 2012 AAP/USPHS position. AAP representatives and other members of national pediatric societies within the International Pediatric Association advocating for deletion of the provision banning TCVs need to know why the elimination of thimerosal was initially called for in 1999 but is no longer indicated. This commentary … Correspondence to Louis Z. Cooper, MD, 80 Central Park W, Apt 11F, New York, NY 10023. E-mail: lzcooper{at}verizon.net

Paralytic poliomyelitis was once endemic in the United States; however, because of high vaccination levels, the last case of wild disease occurred in 1979. Although worldwide polio eradication may be achieved in the near future, the presence of undervaccinated children in urban areas and among groups who refuse vaccination creates an outbreak risk, should importation of wild virus occur. In 1999, the Advisory Committee on Immunization Practices (ACIP) recommended that inactivated poliovirus vaccine (IPV) be used for routine immunization of the US population and that oral poliovirus vaccine (OPV) be reserved for "mass vaccination campaigns to control outbreaks of paralytic polio." Subsequently, the sole US manufacturer of OPV withdrew from the market. In 2003, a joint National Vaccine Advisory Committee (NVAC)/ACIP working group was charged with reporting to its parent bodies concerning the need for a poliovirus vaccine stockpile. Based on that working group's report, the NVAC and ACIP have concluded that stockpiles of both IPV and OPV should be maintained. In the event of an outbreak in which OPV continues not to be available, IPV should be used for control, and a stockpile of 8 million doses seems to be sufficient. Should IPV be manufactured only in combination with other vaccines, appropriate procurement actions should be taken to ensure that uncombined IPV continues to be stockpiled. Under circumstances of diminished population immunity, OPV may offer outbreak control advantages. The NVAC and ACIP recommend that the United States collaborate with international agencies to provide guaranteed and rapid access to at least 8 million doses of trivalent OPV or 8 million doses of each of the 3 types of monovalent OPV. The regulatory and practical obstacles to implementation of this recommendation will require assertive facilitation at high levels of the federal government and careful planning at the state and local levels.

Effective immunization programs have markedly diminished the incidence of vaccine-preventable diseases. As a result, there now exists in society a lower awareness of the actual risks associated with the diseases themselves and a greater prominence of the potential risks of adverse effects associated with vaccines. Concern regarding public reactions to new vaccine safety issues may place pressure on policymakers and/or health care providers to act quickly in response to new information. However, this concern must be tempered by the necessary caution required to assess the intended and unintended risks and benefits of any action undertaken. The interplay of these potentially competing demands is well illustrated by the recent safety concern involving the use of thimerosal in vaccines. Thimerosal is a mercury-containing compound that has been widely used as an antimicrobial agent in vaccines for over 60 years. Human exposure to mercury may have potentially significant health consequences. By mid-1999, the Food and Drug Administration (FDA) had discovered that children could be exposed to an amount of mercury from vaccines that exceeded 1 of 3 existing federal safety thresholds. After this realization, the organized medical and public health communities in the United States became involved in a series of urgent and intense discussions to determine an appropriate response to the issue. This manuscript describes and analyzes the process that led to the July 7, 1999, joint American Academy of Pediatrics (AAP)/US Public Health Service (PHS) statement on thimerosal,1 with the goal of suggesting improvements for managing similar vaccine safety concerns in the future. We conducted structured interviews with over 15 individuals involved in the discussions and negotiations leading to the joint AAP/PHS statement on thimerosal. The individuals represented both the governmental agencies and nongovernmental organizations involved, including the FDA, the Environmental Protection Agency (EPA), the Centers for Disease Control and …

To evaluate the prognostic value of surrogate markers (HIV RNA copy number, CD4 counts and CDC clinical and immunologic categories) in HIV-infected children through a 2-year period.Eighty-six HIV-infected children followed by the Duke Pediatric HIV Clinic in the fall of 1994 were evaluated for plasma HIV RNA concentration (viral load), CD4 lymphocyte percentage, age, antiretroviral treatment status and CDC clinical and immunologic categories. Follow-up evaluations were performed for approximately 2 years, and the time to progression to a new CDC category C diagnosis or death was noted.Of 86 children 22 had progression to new Category C diagnosis or death. Seven children died, 17 had a new Category C diagnosis and 2 had both. Among children who progressed, the median CD4 percentage at entry was 3% (absolute count, 75 cells/mm3), whereas children who had no disease progression entered with a median of 29% (868 cells/mm3). The overall median viral load at study entry was 4.58 log10 copies/ml (38,019 copies/ml, with a range of 1.7 to 6.78 logs). Children who had no disease progression had a median log copy number of 4.43, whereas 5.18 was the median for children whose disease progressed. Log copy number declined over time in children3 years of age, whereas it remained fairly consistent for children 3 years or older. Progression rates were determined by entry plasma HIV RNA concentration quartiles [quartile boundaries4.18, 4.58,5.08 log RNA copy/ml (15,136, 38,019 and120,226 copies/ml, respectively)]. Progression rates by quartile were 0 of 21, 4 of 22, 5 of 21 and 13 of 22. Kaplan-Meier survival curves defined by CD4% less than or greater than 15 and log RNA less than or greater than 5.0 (100,000) revealed that patients with CD4% less than 15 and plasma HIV RNA concentration5 log10 copies/ml did least well: 11 of 12 (92%) had a progression event at a median of 179 days. Patients with a high CD4 percentage and high viral load, or a low CD4 percentage and low viral load did similarly; 5 of 14 (36%) and 4 of 12 (33%) had progression events, respectively. Patients with high CD4 percentage and low viral load did best: only 2 of 48 (4%) had a progression event.The two most significant prognostic indicators of disease progression were the initial CD4 percentage and the plasma HIV RNA concentration, and a combination of CD4 percentage and virus load best predicted which children had progression events. Progression was less common in children who had100,000 HIV RNA copies/ml initially (6 of 60 vs. 16 of 26; P0.001; relative risk 0.16). Therefore it seems reasonable that in a child for whom complete suppression is not possible, a threshold of 100,000 (5 log10 copies/ml) can be used to mandate a change in therapy.

Initiated by a report in 1998 by Wakefield et al1 that the onset of a syndrome of ileal-lymphoid-nodular hyperplasia and nonspecific colitis accompanied by pervasive developmental disorder had appeared shortly after receipt of measles-mumps-rubella (MMR) vaccine by 8 children, the vaccine was soon indicted as the etiology of autism spectrum disorders (ASDs). Subsequent reports elaborated on this theory, and several laboratories claimed to have detected measles virus or its genome in intestinal biopsies as well as peripheral blood mononuclear cells from such autistic children.2–4 Other reports described elevated levels of measles antibodies in children with autism.5 In this issue of Pediatrics , D’Souza et al6 present their detailed, careful laboratory studies that refute these claims and explain the errors that led to them. Within a short time after the initial report by Wakefield et al, many parents in the United Kingdom and the United States opted to refuse the MMR vaccine for their infants and children. One explanation offered by the original reporters was that simultaneous MMR vaccination might lead to an aberrant immune response resulting in persistent infection and increased permeability of an inflamed gastrointestinal tract. Such conditions permitted the transport of opiate-like peptides to the central nervous system resulting in the autism syndromes.7 These claims occurred at a time of recognition that reports … Address correspondence to Samuel L. Katz, MD, Duke University Medical Center, Division of Pediatric Infectious Disease, Box 2925, Durham NC 27710. E-mail: katz0004{at}mc.duke.edu

Since 1989 the disparate recommendations of the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics' (AAP) Committee on Infectious Diseases (COID), “The Redbook Committee,” regarding the age at which the second dose of measles vaccine (usually measles, mumps, rubella [MMR]) should be given has posed a dilemma for pediatricians. Although the goals of each group were identical, the pragmatic aspects considered by the respective committees differed. The ACIP, focusing primarily on the public health community, knew that immunizing the “captive audience” at school entry would be the most efficient way of assuring administration of a second dose. The COID, focusing primarily on the practicing clinician, judged that the second dose at 10 to 12 years would more rapidly provide protection for those youngsters who …

Prospects for vaccine research, development, and use over the next decade are extraordinarily optimistic. Innovative investigative programs promise new vaccines with reduced numbers of injections, combinations of multiple antigens, and confinement of administration to the early weeks or months of life. Enhanced attention to the infrastructure and support of immunization programs should rapidly augment coverage to more than 90% of the US infant population in the first 2 years of life with all the recommended vaccines. Programs of the WHO and CVI should extend protection from morbidity and mortality of diseases preventable with vaccine to children of all nations. Adjustments and realignments of the Vaccine Injury Compensation Program should reduce to realistic dimensions the finances of benefits for children who suffer the rare, true adverse responses to required immunizations. In order to maintain familiarity and leadership in childhood immunization, pediatricians will need to maintain careful attention to and familiarity with all these emerging developments.

The history of the elimination of polio from the United States began in 1949 with the landmark achievement by Enders, Robbins, and Weller of the isolation and growth of polioviruses in cell culture systems. Within 5 years, Jonas Salk had developed and successfully tested his inactivated polio virus vaccine (IPV) incorporating all three serotypes in a formalin-heat inactivated preparation. After the successful Francis Field trial in April 1955, widespread programs for immunization were begun throughout the United States. Over the succeeding 4 years the success in marked reduction of polio each summer and autumn resulted in annual totals of fewer than 2000 paralytic patients in contrast to the previous tolls of 25 000 each year.

Virologic and CD4 Response to Treatment with Nelfinavir in Therapy Experienced, Protease Inhibitor Naive HIV-Infected Children: 48 Week Follow-Up

Plasma virus load measurements, CD4 counts, and clinical evaluations were performed on 63 HIV infected children in the Fall of 1994, and follow-up assessments were performed in the Fall,1996. At baseline, the median age was 5.54 years [Range 0.36 to 13.4 years], median log RNA copy number: 4.78(60,256 copies/ml) [1.7-6.34], median CD4 percent: 23% [0-50]. At the time of follow-up, the medians were: Age 7.58 years, CD4 18%, and log viral RNA copy number 4.32 (20,892). 8 Patients died during the period of follow-up, 13 others developed a new CDC Category C diagnosis, 42 had neither. A comparison of the median baseline values for those who died /had a new category C Dx/ neither showed: Age [5.10 / 4.25 / 6.08 years] CD4% [2 / 7 / 27.5%] Log RNA[5.63 / 5.07 / 4.46]. 17 of the 21 children with a new category C or death had an initial RNA PCR >4.6 logs (50,000 copies/ml). Three of the 4 with bad outcomes and

Drs Terry and Schneider raise legitimate questions regarding changes in polio immunization recommendations. In response to the former, although two doses of inactivated polio vaccine provide humoral immunity that will protect an individual against central nervous system invasion by wild or revertant attenuated polioviruses, they do not provide intestinal immunity, a valued asset of oral polio vaccine (OPV). Because we live in a global community where jet transportation enables one to move from a polio-endemic area to a polio-free area in less than one day, the introduction of wild polio viruses from sub-Saharan Africa or Southeast Asia poses a legitimate threat and concern to those who wish to maintain community protection, in addition to individual protection, against possible reintroduction of wild virus to the United States.

In the August 1995 issue of theArchives, Woodin et al 1 presented an interesting survey of physicians and parents regarding multiple immunizations given by separate injections at health visits. This is interesting information and should be used accordingly by those who are working on the technology to combine many antigens, so that a single injection would be polyvalent. Until that time, however, if one uses the already available diphtheria-tetanuspertussis toxoids (DTP) plus Haemophilus influenzae type b (Hib) conjugate combination, there is no need for more than two injections per visit, with the sole exception of that after the first birthday, when one might administer the combination of DTP and Hib conjugate vaccine (DTP-Hib) with measles-mumps-rubella (MMR) and varicella-zoster vaccine (VZV). Our neighbors in Canada already have available to them a combined vaccine that includes DTP, Hib conjugate, and inactivated polio (IPV). With the demonstrated success in overseas trials of

In Reply.— The immediate problem of cost is certainly a barrier to the acceptability of the hepatitis B universal infant and adolescent immunization program. Whereas I agree that the mechanism of sole purchase may result in the detrimental and devastating effects you suggest, is it not possible to suggest that various groups of physicians or clinics combine to seek bulk purchase rates from all manufacturers? Could we encourage the various manufacturers to offer lowered bulk purchase rates, concurrently encouraging and sustaining commercial competitiveness? My assumption would be that the lowered bulk purchase price would not be detrimental to the manufacturer and their needed resources for production and research, as costs could be saved in distribution, sales, and greater use of the vaccines.

In Reply .—Dr Slater writes of the unending debate between the proponents of OPV and those favoring the addition or substitution of the new E-IPV. The exchange of commentaries by Drs Marcuse and me was not such a debate but a presentation of positions both favoring the addition of E-IPV. The question was a matter of timing; whether to make the addition now for the private sector only or to introduce it later when all infants and children would benefit, and when E-IPV could be integrated into our immunization schedule to include DTP and conjugate Haemophilus influenza B for infants. We agree with his conclusion that the need exists for "harnessing the special virtues of both of these excellent products." The combined schedule that eventually will be used in the United States will probably differ from that initiated in Israel (E-IPV at 2, 4, and 12 months; trivalent OPV at

In Reply .—Dr Bader's thoughtful comments merit consideration now and for the future. If, indeed, the state of Washington has a vaccine-associated paralytic polio rate of 1 per 100 000, it differs markedly from the rest of the nation where careful surveillance and annual review of reported alleged cases by an expert committee have consistently disclosed an overall rate of 1 per 2.7 million poliovirus vaccine live oral trivalent (TOPV) doses or 1 per 560 000 first doses of TOPV. From 1975 to 1986, 107 cases were labeled vaccine-associated paralytic disease, of which 37 were in recipients and 48 in contacts. If Washington has a higher rate, it may resemble the unexplained geographic (or possibly genetic) aberrations observed in some other infectious diseases studies such as the unusual results in Minnesota with the initial studies of Haemophilus influenzae type B polyribose phosphate vaccines in contrast to the efficacy studies in

During the first half of this decade, much new information about the acquired immunodeficiency syndrome (AIDS) became available, including landmark reports of the syndrome in children from Oleske et al, Rubinstein et al, and Scott et al; descriptions of AIDS in pregnancy by Wetli et al, Rawlinson et al, and Minkoff et al; and discovery of the agent that causes AIDS, the human immunodeficiency virus (HIV, formerly called HTLV-III/LAV). The first sets of health guidelines pertaining to HIV-infected children and adolescents in school, day-care and foster care settings were published by the American Academy of Pediatrics' Committee on Infectious Diseases in March 1986 and 1987. In 1987, the Surgeon General's Workshop on Children With HIV Infection and Their Families provided the first comprehensive set of recommendations relevant to the provision of pediatric and obstetrical care to infected mothers, infants, children, and adolescents. Most recently, during February 1988, the Secretary of Health and Human Services formed the Secretary's Work Group on Pediatric HIV Infection and Disease that consisted of members from each of the health and human services agencies, including the Social Security Administration and the Health Care Financing Administration. The broad mandate of this group was to make recommendations to facilitate the removal of barriers to care, treatment, and financial burdens of children and adolescents with HIV infection and their families. In contrast, HIV infection has not received sufficiently widespread attention from the obstetric, pediatric, or adolescent research communities. The uneven geographic distribution of the disease; its associated social, legal, and ethical complexities; and the lack of sufficient research monies all have contributed to this problem.

Varicella is usually a well-tolerated disease in normal children. Pyogenic infections involving the skin are the commonest complications and their potential severity is emphasized by our recent experience with two children who suffered from gangrene as a result of cutaneous superinfection with group A β-hemolytic streptococci. We present the recognition and management of these patients in an effort to reacquaint physicians with this potentially fatal infection.

Sixteen patients who fit the diagnostic criteria of endocardial fibroelastosis were investigated by means of mumps skin tests and serum assays of mumps hemagglutination-inhibiting antibodies. No relationship was found between the clinical entity, endocardial fibroelastosis, and either mumps-specific antibodies or delayed cutaneous hypersensitivity to the mumps virus.

A retrospective study of 280 nephrotic admissions from 1963 through 1967 at Children's Hospital Medical Center in Boston revealed that gram-negative bacilli have caused the majority of infections in hospitalized nephrotic children. The organisms isolated during this period included pneumococci, E. coli, proteus, klebsiella-enterobacter species, pseudomonas, and Serratia marcescens. This information is recorded to aid physicians in the selection of initial antibiotic therapy in the septic nephrotic patient.

Consent must be obtained prior to the institution of medical or surgical treatment. Pediatricians should keep informed concerning court decisions and statutes relative to consent and minors.

Preceding reports at this conference have already considered many aspects of the question of markers for the measles virus. Table 1 recapitulates some of these markers that have already been discussed. Two more will have to be added in the light of the report by Dr. Buynak, Dr. Hilleman, and co-workers 1 describing the plaques produced by the attenuated Edmonston strain in cultures of chick embryo and grivet kidney cells and the neuropathology produced by the virulent Edmonston strain after thalamic inoculation in the monkey. Virulent early kidney-cell-passage virus does not seem to grow in chick cells, where as the attenuated does. In one stable amnion cell line, developed at the Sterling-Winthrop Company laboratories, the 20th passage of the human kidney line induces few or no cytopathic effects. Virus from the 30th passage level in this medium does, however, cause extensive changes. The attenuated agent grows well in this line

Cystic fibrosis of the pancreas is a generalized disease of genetic nature chiefly affecting young infants and children. Many mucus secreting glands are involved and characteristically produce a viscid secretion, hence the name mucoviscidosis. In addition, the eccrine sweat glands show a marked functional disturbance with the elaboration of a concentrated electrolyte secretion without affecting the concentration of the other normal constituents of sweat. The name cystic fibrosis, therefore, is a misnomer for this disease because it does not primarily affect the pancreas, nor is it a disease characterized by cyst formation. The survival of patients with this disease depends primarily upon the extent and progression of the pulmonary involvement. In recent years a small number of mild cases have been observed, i.e., children who reach adolescence or young adulthood without having had serious complaints. However, prior to 1948, the outlook for these patients was grave, and the majority of

Introduction That measles and its complications are of major importance as causes of morbidity and mortality in Nigeria has been emphasized by recent studies. 1 Those factors which seem to underlie the unusual severity of the disease are the occurrence of annual epidemics with a resultant lowering of the mean age incidence to 15 months, the extremely high rate of pyogenic complications involving the skin and respiratory tract, and the frequency of stomatitis and diarrhea inducing dehydration. In Nigeria, measles is the acute infection most likely to precipitate acute kwashiorkor. Over the last 5 years an investigation into the morbidity and mortality among children under the age of 5 years has been conducted at the Wesley Guild Hospital in Ilesha, Western Nigeria. Of the acute infective fevers, measles was found to be outstanding as a cause of death. Because of this experience, a trial of attenuated measles-virus vaccine seemed highly

For the third consecutive year October has been designated as Immunization Action Month (IAM). This is the effort of a coalition of governmental, professional, and private groups to highlight the need for continued attention to the immunization programs of all American children, particularly the pre-school group. The American Academy of Pediatrics since the inception of IAM has been among the leaders in its activities. Once again this year, the members of the Academy are urged to participate actively on the local scene in generating information about the goals of IAM and in implementing them. The justification for continued efforts of this sort must be found in the data on the utilization of vaccines and on the reported cases of those diseases which can be prevented.

The passage of 20 years since the first International Conference on Measles Immunization in November 1961 has been accompanied by very significant advances in our understanding of the impact of measles among different groups, in the development and the utilization of measles vaccines, and in the control of the disease. Throughout all these considerations, there remains great variability. This is manifest in the surveillance data on morbidity and mortality, the extent of vaccine utilization, and the attitudes about measles as a serious public health problem. Because of these variations it is obvious that any recommendations must be evaluated carefully and adapted appropriately to meet the needs of a given nation, a population group, a geographic locale, or an environmental setting.

The success of initial pertussis immunization programs resulted not only in a sharp decrease in the incidence of the disease but also in a diminution of interest in and research on the organism, and complacency with regard to the vaccine itself. Concern and apprehension about both the efficacy and the safety of pertussis vaccine have recently stimulated a renewed investigative interest in the biology of Bordetella pertussis. This occurs at a time. when cases of pertussis reported in the United States are at an all-time low (less than 2,000 in 1978 contrasted with more than 150,000 in 1950). This infrequency of clinical whooping cough contributes to our desire for a more critical examination of the rare serious complications attributed to the immunizing procedure.

Thank you for the opportunity to reply to Dr. Marder's letter concerning the therapy of H. influenzae meningitis. The Red Book recommendations to which he refers were written in 1968 (published 1970) and list chloramphenicol or ampicillin as satisfactory. The use of ampicillin in the therapy of childhood meningitis has become the initial treatment of choice for several reasons. First, this drug offers the advantage of a single effective antibiotic to initiate therapy before the cause of the meningitis has been definitely identified.

For the Academys' Committee on Infectious Diseases, Dr. Katz writes as follows: Dr. Lewak has underlined a troublesome confusion in names which has plagued physicians, patients, and parents. The single letter substitution which barely distinguishes rubella from rubeola is too subtle. The use of a national modifier ("German") which implies that rubella is merely another type of measles, is biologically, historically, and semantically unsound. Would that the confusion were limited to laymen alone! Many an obstetrician has telephoned or written to inquire about a pregnant woman with "measles," when his concern was obviously about rubella.

In vitro studies of post mortem neural tissue in subacute selerosing panecephalitis (SSPE)