Rates and predictors for influenza vaccine prescriptions among HIV-infected clinic patients in Singapore

<p><b>INTRODUCTION</b>Although Singapore national guidelines recommend influenza vaccination for individuals with comorbidities, the vaccine uptake remains relatively low. This study examines the rates of influenza vaccine prescriptions in a clinic population, and patient, doctor and clinic factors that could affect the vaccine prescribing rates.</p><p><b>MATERIALS AND METHODS</b>This retrospective review utilised electronic medical records from HIV-infected patients seen in an infectious disease (ID) specialist clinic. Data from 40 randomly selected patients per physician were analysed for the outcome of influenza vaccine prescriptions from 1 January to 31 December 2007. All 7 consultants and the 6 ID registrars who had spent at least 4 months in the Department during 2007 were included. Data analysed included patient, physician, and clinic characteristics, and clinically relevant outcomes of admission within a year, and the length of hospital stay.</p><p><b>RESULTS</b>Of the 461 HIV-infected patients analysed for this study, only 107 (23%) were prescribed influenza vaccine in 2007. Vaccine prescribing rates by individual physicians ranged from 0% to 77%. The outcome of vaccine prescribing was analysed by patient demographics (age >40 years, gender, race), physician characteristics (doctor grade, gender and training), and clinic volumes (number of patients per clinic session). Multivariate analysis demonstrated that patients with female doctors (OR 1.8, 95% CI, 1.1 to 3.0, P = 0.017), and doctors with overseas medical training (OR 11.6, 95% CI, 6.0 to 22.2, P <0.001) were significantly more likely to have influenza vaccine prescribed. On univariate analysis, patients were more likely to be admitted if they were male (OR 2.1, 95% CI, 1.0 to 5.1, P = 0.041), and over 40 years old (OR 2.1, 95% CI, 1.1 to 4.5, P = 0.024). Patients prescribed influenza vaccine showed a non-significant trend for protection against admission (OR 0.7, P = 0.288), and shorter length of stay (median 5 vs 9 days, P = 0.344).</p><p><b>CONCLUSION</b>Influenza vaccine prescribing for HIV-infected outpatients in 2007 was only 23%, even in an ID specialist clinic. There was substantial variability in prescribing rates by individual physicians. Neither patient demographics nor patient volumes per clinic session had an impact on the prescribing rates, but significant predictors included physician gender and medical school training. Patients prescribed influenza vaccine had fewer admissions and shorter hospital lengths of stay, although these trends were non-significant.</p>

Causes of death and factors associated with early death among human immunodeficiency virus (HIV)-infected persons in Singapore: pre-highly active antiretroviral therapy (HAART) and Peri-HAART

<p><b>INTRODUCTION</b>Highly active antiretroviral therapy (HAART) has greatly changed the epidemiology of human immunodefi ciency virus (HIV) mortality. The aim of this study is to compare the causes of death and factors associated with early death in HIV-infected persons in the pre- and peri-highly active antiretroviral therapy (HAART) periods.</p><p><b>MATERIALS AND METHODS</b>We conducted a retrospective review of 483 HIV-infected persons who were diagnosed with HIV from 1985 to 2000, and had died within 5 years of the diagnosis. We examined the temporal change in the primary causes of death between those who were diagnosed in the pre-HAART (1985 to 1995) and peri-HAART (1996 to 2000) periods, and compared the demographic and clinical characteristics of the 2 groups.</p><p><b>RESULTS</b>During the peri-HAART period, HIV encephalopathy, cryptococcal meningitis, and lymphoma were no longer the leading causes of death. Opportunistic infections remained important causes of death. Early deaths from the peri-HAART period were older (60 years and above) at diagnosis (Adj OR 7.50; 95% CI, 1.78 to 31.58), more likely to be divorced (Adj OR 5.05, 95% CI, 1.96 to 13.02) and tended to have a low baseline CD4 cell count of <50 cells/ uL (Adj OR 2.18, 95% CI, 1.14 to 4.16) , and were more likely to have received HAART (Adj OR 5.19; 95% CI, 2.22 to 12.12) than early deaths from the pre-HAART period.</p><p><b>CONCLUSION</b>In the peri-HAART era, HIV-infected persons who died within 5 years of diagnosis were those who were older (≥60 years), divorced, or who presented with very late-stage disease (CD4 <50) at diagnosis. More targeted public health interventions, such as targeted public health messages and outreach to increase access to HIV testing and treatment should be developed for these subpopulations.</p>

Influenza B outbreak among influenza-vaccinated welfare home residents in Singapore

<p><b>INTRODUCTION</b>Outbreaks of acute respiratory illness occur commonly in long-term care facilities (LTCF), due to the close proximity of residents. Most influenza outbreak reports have been from temperate countries. This study reports an outbreak of influenza B among a highly immunised resident population in a welfare home in tropical Singapore, and discusses vaccine efficacy and the role of acute respiratory illness surveillance for outbreak prevention and control.</p><p><b>MATERIALS AND METHODS</b>During the period from 16 to 21 March 2007, outbreak investigations and active case finding were carried out among residents and nursing staff at the welfare home. Interviews and medical notes review were conducted to obtain epidemiological and clinical data. Hospitalised patients were tested for respiratory pathogens. Further genetic studies were also carried out on positive respiratory samples.</p><p><b>RESULTS</b>The overall clinical attack rate was 9.4% (17/180) in residents and 6.7% (2/30) in staff. All infected residents and staff had received influenza immunisation. Fifteen residents were hospitalised, with 2 developing severe complications. Genetic sequencing revealed that the outbreak strain had an 8.2% amino acid difference from B/Malaysia/2506/2004, the 2006 southern hemisphere influenza vaccine strain, which the residents and staff had earlier received.</p><p><b>CONCLUSIONS</b>A mismatch between the vaccine and circulating influenza virus strains can result in an outbreak in a highly immunised LTCF resident population. Active surveillance for acute respiratory illness in LTCFs could be implemented for rapid detection of antigenic drift. Enhanced infection control and other preventive measures can then be deployed in a timely manner to mitigate the effect of any outbreaks.</p>

Effectiveness of health education methods displayed at the selected health centres, Yangon Division

A clinic-based cross-sectional survey was conducted at outpatient departments of Hlegu and kungyangone Township Hospitals to explore the existing situation of effectiveness of health education (HE) methods displayed at health centres. two types of study population were involved: clinic attendants and health care providers and face-to-face interviewing method was performed by using separate questionnaires. Clinic attenders who were 13 years old and above and who have been visiting more than once were considered to be involved. During the study period of 2 weeks each at respective health centre, 99 clinic attenders (74.7 per cent) patients and 25.3 per cent their companions) were observed. Only 32.3 per cent of total attenders were aware of and noticed HE posters displayed at health centres and read them. Only 26.3 per cent said that they had seen HE activities done at health centres during their presence. Regarding the HE activities performed at health centres, 19.2 per cent were satisfied with the works of health centres and staff, whereas, about 71 per cent had no idea due to their unawareness. apart from HE talk and poster display, other HE activities were rarely observed. Due to availability during the study period, 12 health care providers could respond to our questionnaire. Their mean service year at the study place was 2.2 years. All respondents were aware of the HE activities performing at their health centres. All of them were found to be satisfied with their own performance, and only 3 (25 per cent) satisfied with their health centre's job.

Comparing the efficacy of mefloquine-artesunate combination with that of mefloquine and artesunate as single agents in uncomplicated falciparum malaria

To find out whether the combination regimen of mefloquine and artesunate tablets improves the cure rate in uncomplicated falciparum malaria compared to the use of mefloquine and artesunate as single agents, a prospective, randomised, uniblind controlled study was done between May and November 1991, on one hundred and eighty cases of acute uncomplicated falciparum malaria. The patients were randomised to the following three frug regimens: - (1) Mefloquine - 1000 mg stat, (2) Tab Artesunate 600 mg over 48 hours, (3) Mefloquine 1000 mg plus tab Artesunate 600 mg over 48 hours. The regimen of mefloquine as a single agent gave a cure rate of 83.3 percent (with R1 = 15 percent and R2 = 1.7 percent), PCT = 52.15 + 55.2 hours and FCT = 23.98 + 59.87 hours. Tab artesunate gave a cure rate of 75 percent (with R1 = 25 percent), PCT = 33.16 + 5.15 and FCT = 23.4 + 22.7 hours. The combination regimen gave a cure rate of 98.27 percent with only one patient recrudescing at R1 level, PCT = 35.11 + 29.16 and FCT = 8.15 + 10.34 hours. The side effects were not much increased by using the combination. No cardiovascular effects were noted. The combination is superior to that of the single agents.

Effect of insight meditation practice on drug addicts

Drawing upon the principles of human behaviour, this study suggests the positive use of insight meditation as an alternative to drug abuse and prevention of relapse. Randomized experimental trial involving (31) Myanmar Buddhist male drug addicts from DDTC, YPH are studied, using psychotic rating scale, anxiety, depression and psychopathic personality scores (Ohn Kyaw and Ohn Hlaing). The results showed that there is a significant reduction in anxiety and depressive scores in drug addicts, and they have a sense of psychological well being after meditation practice. However, the effects on relapse of these patients should be continued in later research studies.

Different dosage regimens of artemisinin and its derivatives as single agents and in combination with mefloquine in uncomplicated falciparum malaria

To compare the efficacy of Artemisinin tablet, Artesunate tablet and Artemether capsule, randomized uniblind clinical trials using 9 different dosage regimens of the drugs as single agents and also in combination with mefloquine was carried out between January 1991 and December 1993. A total of 480 patients suffering from acute uncomplicated falciparum malaria with asexual parasitaemia ranging from 500-100,000 per microlitre were tried on the various drug regimens. The response rates (according to the WHO in vivo extended 28 days trial) showed that all 3 forms of the drug used as single agents had rapid initial parasite clearance but had high recrudescence rates. Combining either artesunate or Artemether with mefloquine gave cure rates above 95 percent. Artemisinin in combination with Mefloquine had better cure rates than Artemisinin alone too. Hence artemisinin or its derivatives need to be combined with a synergistic drug like mefloquine to achieve satisfactory cure rates.

The drug sensitivity patterns of Plasmodium falciparum in Myanmar (1990)

During 1990, sensitivity of P. falciparum to antimalarials was conducted in Mawlamyaing, Lashio and Seik Phyu townships. There were 40 successful in vitro test in Mawlamyaing, 39 in Lashio, 26 in Seik Phyu township. Chloroquine was found to be highly resistant (95 to 100 Percent) in Mawlamyaing and Lashio areas but 31 Percent sensitivity was detected in Seik Phyu township. Amodiaquine was found to be much more sensitive (38 to 67 Percent) than chloroquine. Effective concentration (EC99) for chloroquine varies from 7.4 to 8.4 U mol/L and EC99 for amodiaquine varies from 0.58 to 1.6 U mol/L. In all the areas studied sulfadoxine/pyrimethamine sensitivity was seen in 65 to 80 Percent. All the isolates from the three areas were 100 Percent sensitive to mefloquine and were also highly sensitive (93 to 100 Percent) to quinine. EC99 of quinine varies from 1.35 to 2.7 U mol/L and EC99 of mefloquine varies from 1.5 to 2.2 U mol/L in the areas.

The effect of chloroquine chemoprophylaxis on workers in Kazunma area

The study was conducted in November 1990 in the Kazunma village area of the Seikphyu Township. The study included 300 villagers of the Kazunma village as the control and the 315 workers of the Kazunma camps. The workers were on chloroquine chemoprophylaxis for more than three months. Among the villagers of the Kazunma village 16

were infected with malaria, P. falciparum 64.8

and P. vivax 31.3

. The malaria infection rate of the workers from the northern and the base camps were similar to the villagers. The workers from the southern camps have higher level of parasitaemia (26

) inspite of the chemoprophylaxis. Though the chemoprophylaxis has no effect on the parasite rate, it seems to have some effect on the parasite density of the workers of the northern and the base camps. The in vitro sensitivity of P. falciparum isolates were 30,8

sensitive to chloroquine and 55.6

sensitive to amodiaquine.

Thalassemia in the outpatient department of the Yangon Children's Hospital in Myanmar: basic hematological values of thalassemia traits.

The present study was conducted in the Outpatient Department (OPD) of Yangon Children's Hospital (YCH) during June to November 1990 to determine the hematological data of 133 Myanmar patients with thalassemia trait who were the parents of patients with known beta-thalassemia major or hemoglobin E (Hb E)/beta-thalassemia. The mean values of hemoglobin (Hb) concentration, packed cell volume (PCV), mean cell hemoglobin (MCH) and mean cell volume (MCV) were significantly lower than normal controls but the mean cell hemoglobin concentration (MCHC) was the same as controls. Increased osmotic resistance tested in 0.36% buffered saline was detected in 81-97% of cases depending on the cut-off point. High levels of Hb A2 (> 3.5%) were found in 93% of cases whereas Hb F was increased (> 0.8%) only in 23% of cases. Although the mean red cell count (RBC) was significantly higher than normal, only 79% of thalassemia traits were detected if the RBC count of > 5.0 x 10(12)/1 was taken as the discrimination limit. Other discrimination functions such as MCH/RBC, MCV/RBC, (MCV)2 x MCH x 0.01 and MCV-(RBC/10(12)/1)-(5 x Hb) - 3.4 or - 8.4 were tested for their utility in diagnosing thalassemia traits. All of them were found not to be superior to each of the simple tests (MCV, MCH, Hb A2 or osmotic fragility) in diagnosing thalassemia traits. The one tube osmotic fragility test is a the suitable test to be used in future thalassemia screening programs in Myanmar.