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Bringing cutting-edge science into the classroom and beyond

Jemima Hodkinson looks at Jenner, vaccines and Blossom the cow

In the library of St George’s, University of London, a large brown and white cowhide is proudly displayed inside a glass case. The hide belonged to Blossom – a rare-breed Gloucester cow who played an important part in the history of medicine.

Blossom’s hide was donated to St George’s by the family of Edward Jenner, the family doctor who developed Womens Ponte Jersey Pleated Dress 1416 BLACK Lands End Cheap Pre Order akAGoAcwNQ
a s amethod of protecting people from deadly diseases.

Jenner was born in 1749 in a village in Gloucestershire, where his father worked as the local vicar. He started his medical training at the age of 14 when he became the apprentice of a local surgeon, then moved to London to complete his education at St George’s. In 1772, he returned to his home town to work as a country doctor.

Throughout Jenner’s life, epidemics of smallpox – nicknamed ‘the speckled monster’ – were common in Europe. The disease is caused by the variola
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, which can spread through close contact with an infected person or object. Abouttwo weeks after the virus infects a person a high fever takes hold, followed by a rash, which appears in the mouth before spreading across the whole body over the course of a day.

Over the next few weeks, the rash develops into pus-filled sores which crust over and form scabs. When the scabs fall off, they leave deep scars behind. An infected person is contagious from the day the rash appears until the last scab falls off, which is usually about three weeks. During the 18th and 19th centuries as many as 98 per cent of children who caught the disease died from it; those who survived suffered from disfiguring scars, and up to a third became blind.

Although there was no way of treating smallpox once the infection had taken hold, 18th-century doctors did attempt to protect individuals from infection. The most common method they used was called variolation. This involved taking material from a fresh human smallpox sore and inserting it under the skin of an uninfected person. The hope was that the person would go on to develop a less serious form of smallpox disease, then once fully recovered would have lasting immunity.

However, many people treated this way developed serious, life-threatening smallpox infections that could then be easily passed on to other people. The crude method of variolation also carried a risk of transferring other blood-borne infections such as syphilis. Although many doctors were concerned about these risks, by the mid-18th century thousands of children were variolated each year – including an eight-year-old Edward Jenner. Luckily, he survived the procedure.

There are no vaccination requirements for travelers. More specific measures to prevent importation of diphtheria from countries where it is endemic would be difficult to enforce, especially in time of lower risk. Surveillance for communicable diseases, including diphtheria, needs to be increased when circumstances conducive for an outbreak (e.g., international sporting events) exist.

In the event of an outbreak of diphtheria, health care providers would be a group at risk of contracting the disease. However because the current risk is low, there is no special vaccination requirement related to diphtheria for health care workers. Health care providers need to be appropriately immunized according to age, as recommended by the ACIP for all adults. If diphtheria is suspected in a patient, it is recommended that he or she receive a booster dose of Td if >5 years have elapsed since the last dose [ 26 ].

During the NIS diphtheria epidemic, the US Department of Health and Human Services released advisory memoranda that recommended that travelers to areas where diphtheria was occurring should be appropriately immunized, and the recommendations were widely distributed to travel agencies [ 27 , 28 ]. In late 1994, 2 cases of diphtheria were reported among US citizens working in or visiting countries of the former Soviet Union [ 29 ].

Currently, travelers may still be at risk for exposure to strains of C. diphtheriae in countries where it is endemic, especially with prolonged travel, extensive contact with children, or exposure to poor hygiene, and they should be appropriately immunized (according to age) against diphtheria (i.e., completion of a primary series and receipt of a diphtheria toxoid booster within the previous 10 years).

In 1999, one lot of a licensed diphtheria-tetanus toxoids-acellular pertussis (DTaP) vaccine was found to have subpotent diphtheria toxoid by the manufacturer and consequently was recalled from use. Children who were vaccinated with this lot and who were traveling to a country where the risk of diphtheria was high before their scheduled fourth dose of DTaP were recommended to get an additional dose of vaccine on an accelerated schedule [ 30 ].

Until 1996, antitoxin was manufactured in the United States; however, because of low demand for equine diphtheria antitoxin, domestic pharmaceutical manufacturers no longer produce and distribute it in the United States. Since 1997, a French product manufactured by Pasteur Mérieux Connaught has been made available to suspected diphtheria cases in the United States through an investigational new drug protocol administered by the CDC [ 31 ]. Although there are few reported diphtheria cases in the United States, there are ∼20–30 suspected cases per year for which antitoxin is released; only a minority of the cases are actually treated with antitoxin. An adequate supply of diphtheria antitoxin and diphtheria toxoid–containing vaccines should be assured.

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reveals the differences in baseline characteristics between patients dying while hospitalised and those surviving to discharge. Those who died were older but there were no other differences in demographics. Patients dying were more severely ill based on all measures used to assess this. Specifically, survivors had lower CURB-65 scores as compared with decedents (median CURB-65 class 4 vs 2, p=0.025). More than a quarter of those dying received MV while fewer than 5% of those discharged alive required MV (p=0.001). The distribution of criteria defining HCAP did not differ between groups. Approximately 11% of all patients resided in nursing homes prior to admission and the rate of admission from nursing homes did not correlate with hospital mortality. Immunosuppression was prevalent in the study population, but this also did not differ between those dying and those surviving.

View this table:
Table1

Baseline characteristics

With respect to infection-related characteristics, the frequency of bacteraemia was similar between the two groups. Compared with those who survived, however, those who died were more likely to have been given delayed antibiotic therapy (38.1% vs 9.0%, p=0.001). In all instances, inappropriate therapy occurred not because of the use of an in vitro inactive agent but because of a delay in the initiation of antibiotics. All isolates were susceptible to the agents actually administered.

Hospital death rates were significantly lower in persons treated with azithromycin. Of patients given the macrolide, only 5.4% expired in the hospital as opposed to 23.8% of persons not treated with such an agent ( Majestic Filatures Woman Mélange Jersey Top Anthracite Size 1 Majestic Filatures Pay With Paypal Sale Online Buy Cheap Lowest Price Really Cheap Shoes Online Buy Cheap Big Sale bQuxSJz
). The OR for death with a macrolide was 0.20 (94% CI 0.08 to 0.52).

Figure1

Hospital mortality and azithromycin treatment. OR for death with azithromycin: 0.20 (94% CI 0.08 to 0.52).

In the logistic regression, four variables remained independently associated with mortality ( Striped Pleated Short in Beige size XS also in LMS Bcbgmaxazria Discount Cheap ATMzvEZ
). Mortality increased with increasing age (AOR 1.05, 95% CI 1.01 to 1.09, p=0.018) and with the need for MV (AOR 8.82, 95% CI 2.74 to 28.46, <0.001). Timely antibiotic therapy resulted in lower in-hospital death rates (AOR, 0.13, 95% CI 0.03 to 0.46, p=0.002). Finally, treatment with azithromycin correlated with enhanced survival. Azithromycin exposure was independently associated with reduced risk for death by nearly 75% (AOR 0.26, 95% CI 0.08 to 0.90, p=0.018). Neither being classified as HCAP nor any of the individual criteria defining HCAP stayed in the final model. The model had an excellent fit with an R 2 value of 0.42 and a C-statistic of 0.991. In a sensitivity analysis ( Outlet Discounts Womens Cherie Sneezing Bikini Briefs Stella McCartney Low Price Sale Largest Supplier Cheap Very Cheap Great Deals PjHtT
) where the CURB 65 score was employed as a marker for severity of illness rather than either need for MV or ICU admission, treatment with azithromycin remained associated with a lower probability for mortality (AOR 0.34, 95% CI 0.11 to 0.88).