Paradoxical response to a novel influenza virus vaccine strain: the effect of prior immunization.

BACKGROUND: repeated influenza immunization does not appear to adversely affect the serum antibody response to new influenza strains. OBJECTIVE: to determine whether the immune response to a new influenza strain was inferior in persons previously vaccinated compared with persons not previously vaccinated. DESIGN: randomized, double-blind clinical trial. SETTING: university affiliated community teaching hospital. PATIENTS: 139 healthy adult men and women, mean age 38 years. INTERVENTION: subjects were vaccinated as part of another study. They received influenza vaccines containing influenza strains A/Texas/36/91 (H1N1), A/Nanchang/933/95 (H3N2) and B/Beijing/184/93. One group received a licensed influenza vaccine while the other group received a similar vaccine except the A/Nanchang strain had a diminished potency. MEASUREMENTS: serum hemagglutination inhibition (HAI) antibody titers were determined prior to vaccination and two weeks afterward. If patients had a low postvaccination titer, they were revaccinated and HAI titers were determined two weeks later. RESULTS: 68 adults received the licensed vaccine and 70 received the subpotent vaccine. The groups were similar with regards to baseline characteristics. Those previously vaccinated had significantly lower postvaccination HAI geometric mean titers (GMTs) for all three vaccine strains (A/Texas--127 vs. 359, p < 0.001, A/Nanchang--31 vs. 93, p < 0.001 and B/Beijing--140 vs. 205, p < 0.05). The percentage of subjects with a presumed protective HAI titer of > or =40 was significantly lower among the previously vaccinated groups only for the new influenza strain, A/Nanchang (55% vs. 80%, p < 0.05). For the other two vaccine strains, the percentage with an HAI titer > or =40 was greater than 90% for both groups. CONCLUSIONS: the decrease in serologic response to influenza vaccine among healthy, young adults who were previously vaccinated appears to be unique for this year's influenza vaccine. Further studies are required to determine the frequency and clinical significance of this phenomenon observed in younger healthy adults, and whether it is a general one. Based on its proven efficacy, influenza vaccine should continue to be given on an annual basis to high risk children and adults and to all those 65 years or older.

Interview with Avedis Donabedian, M.D. Interview by Gordon Brown.

Avedis Donabedian was born in Beirut, Lebanon, grew up in a small town north of Jerusalem, and returned to Beirut to obtain his B.A. and M.D. degrees from the American University. After the receipt of his M.P.H. degree from the Harvard School of Public Health, and a period as a research assistant in Boston, he became a teacher of preventive medicine at New York Medical College. Dr. Donabedian subsequently joined the faculty of the University of Michigan, Ann Arbor, where he is now the Nathan Sinai Distinguished Professor of Public Health, Emeritus. His lifetime's work has focused on systematizing knowledge in health care organization-especially quality assessment and monitoring-but also assessments of health care needs and resources, and the design of program benefits. The quality and contribution of his writings, including six books and many other publications, have been acknowledged throughout the world, and he has received recognition from numerous organizations such as the Institute of Medicine of the National Academy of Sciences, the American College of Healthcare Executives, and the American College of Medical Quality. In addition to his many prestigious awards, Dr. Donabedian was honored in 1990 by the creation-in Barcelona, Spain-of the Avedis Donabedian Foundation for the Improvement of Health Care.

Preparation and characterization of a purified influenza virus neuraminidase vaccine.

Influenza virus neuraminidase (NA) has been shown to induce protective but infection-permissive immunity in experimental animals. Challenge infection following such immunization is attended by decreased viral replication and disease manifestations but is sufficient to provide antigenic stimulation and definitive immunity to the virus. The present report describes the preparation and characterization of a purified NA vaccine (NAV) used in Phase 1 (immunogenicity and toxicity) trials in humans. In essence, virion NA was isolated from detergent-disrupted virus by affinity chromatography on oxamic acid-agarose, treated with formalin and tested for its enzymatic activity and for its immunogenicity in Balb/c mice and New Zealand rabbits. The preparation was essentially free of viral hemagglutinin but contained residual NP and M1 proteins. Both dispersed and aggregated NA tetrameric heads were seen in electron micrographs. Enzymatic activity was preserved, and minimal immunogenic doses in mice and rabbits, respectively, were 3.7 and 0.027 micrograms per kg.

Effectiveness of computer-aided learning in community health nursing.

The authors report an evaluation of one experience in computer-aided learning, with an attempt to ascertain its effectiveness in adding to knowledge or changing attitudes about selected aspects of the diagnosis and management of breast cancer in women. The authors also discuss how much a selected group of senior nursing students knew about the subject before embarking on the exercise in computer-aided learning.

[Priorities of progress in evaluating and monitoring quality of care]. / Prioridades para el progreso en la evaluación y monitoreo de la calidad de la atención.

This paper discusses the following priorities: redefining and widening the scope of assessment, redefining assessment methods, redesigning and evaluating quality assurance systems, promoting consumer participation, professionalizing quality assurance, and creating a supportive culture. The article proposes empirical assessment of quality assurance methods as the highest priority. It concludes with the idea that seeking quality is the ethical dimension of professional life. Therefore, all reasonable efforts towards monitoring quality will be successful. Without this, the cleverest monitoring systems will fact.