(1) WHOOPING COUGH “ENDEMIC” AMONG UK SCHOOL CHILDREN, SAY EXPERTS

(2) POOREST CHILDREN FACE HIGHEST RISK OF DEATH FROM INJURY

(3) TUBERCULOSIS MUST BE TACKLED AMONG SOCIALLY EXCLUDED GROUPS

(4) DRUG APPROVAL PROCESSES MAY HAVE DELAYED SAFETY WARNINGS FOR ANTIDEPRESSANTS

(1) WHOOPING COUGH “ENDEMIC” AMONG UK SCHOOL CHILDREN, SAY EXPERTS

Online First
(Whooping cough in school age children with persistent cough: prospective cohort study in primary care)
http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.38870.655405.AE

Nearly 40% of school age children in the United Kingdom who visit their family doctor with a persistent cough have evidence of whooping cough infection, even though they have been fully immunised, finds a study published on bmj.com today.

These startling results suggest that whooping cough is endemic among young children in the UK, with important implications for clinical practice and immunisation policy, say the authors.

Previous research in several countries has shown that Bordetella pertussis (whooping cough) infection is an endemic disease among adolescents and adults. Data also shows that neither infection nor immunisation results in lifelong immunity. Yet general practitioners in the UK seldom diagnose or even consider pertussis in older children. It is perceived as a disease of very young children who have not been immunised and who have classic features such as whoop.

So researchers set out to estimate the proportion of school age children in Oxfordshire with a persistent cough who have evidence of a recent pertussis infection.

They identified 172 children aged 5-16 years who visited their family doctor with a cough lasting 14 days or more. Details on the duration and severity of cough were recorded and immunisation records were checked. Blood samples were taken to test for pertussis infection and parents and children also completed a cough diary.

A total of 64 (37.2%) children had evidence of a recent pertussis infection; 55 (85.9%) of these children had been fully immunised.

Children with pertussis were more likely than others to have whooping, vomiting, and sputum production. They were also more likely to still be coughing two months after the start of their illness, continue to have more than five coughing episodes per day, and cause sleep disturbance for their parents.

These results show that a substantial proportion of immunised school age children presenting to UK primary care with a persistent cough have evidence of a recent infection with Bordetella pertussis, say the authors.

They urge general practitioners to be alert to a potential diagnosis of pertussis in any child who presents with a persistent cough. A clear diagnosis will allow general practitioners to give parents an indication of the likely length of cough and prevent them prescribing unnecessary drugs for asthma or referring children for further investigations, they conclude.

Contact:

Anthony Harnden, University Lecturer, Department of Primary Care, University of Oxford, Oxford, UK
Email: anthony.harnden{at}dphpc.ox.ac.uk

(2) POOREST CHILDREN FACE HIGHEST RISK OF DEATH FROM INJURY

Online First
(Fewer child injury deaths but only for families in paid employment: analysis of trends in class-specific death rates)
http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.38875.757488.4F

(Editorial: Death and injury on roads)
http://bmj.com/cgi/content/full/333/7558/53

Children from the poorest families in England and Wales face greater risks of dying from injury than children in all other social groups, finds a study published on bmj.com today.

This suggests that serious inequalities in injury death rates still exist, despite a government strategy to target ‘particular areas of health inequality’ say the researchers.

A decade ago, the death rate from injury and poisoning for children in the lowest social class was five times greater than that for children in the highest social class. Inequalities were greatest for house fire and pedestrian deaths.

Ten years on, researchers examined child injury death rates by social class to test whether these inequalities persist. They analysed all child (0-15 years) deaths due to injury and poisoning in England and Wales using population data from the 1981, 1991 and 2001 censuses. Each record included the year of death, the underlying cause of death, and the parents’ socio-economic class.

They found that injury death rates for children have declined from 11 deaths per 100,000 children per year around the 1981 census to 4 deaths per 100,000 children per year around the 2001 census.

But socio-economic inequalities remain: the death rate for children of parents classified as never worked or long-term unemployed (social class 8) was 13 times that for children of parents in higher managerial and professional occupations (social class 1).

And inequalities were again greatest for house fire and pedestrian deaths. Compared to children of parents in social class 1, the death rate in children of parents in social class 8 was 20 times higher for pedestrian deaths and nearly 40 times higher for deaths due to fires. Serious inequalities also existed for cyclists and deaths of undetermined intent.

Child death rates from injury and poisoning have fallen in England and Wales over the last 20 years, say the authors. However, children in families where no adult is in paid employment are a notable exception.

Children in these families face greater risks of dying in road traffic accidents, in fires and from undetermined causes than children in all other social groups. In short, these children have been excluded from the reductions in injury mortality made over this period.

Explanations are speculative, but probably lie in different exposure to risk, they add. For example, the higher risk of dying in house fires may reflect the quality and type of housing, with the greatest fire risks for those in temporary and poor housing.

At the beginning of the 21st century, there is evidence that the economic exclusion of the poorest families is reflected in significantly increased death rates from injury in childhood, they conclude.

An editorial, published in this week’s print BMJ, argues that approaches to reduce these inequalities must tackle economic and transport policy as well as interventions affecting the environment, vehicles, and road users, rather than relying solely on changing the behaviour of victims.

Contact:

Phil Edwards, Lecturer in Statistics, Department of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
Email: phil.edwards{at}lshtm.ac.uk

(3) TUBERCULOSIS MUST BE TACKLED AMONG SOCIALLY EXCLUDED GROUPS

(Editorial: Tuberculosis and social exclusion)
http://bmj.com/cgi/content/full/333/7558/57

Tuberculosis cannot be controlled unless the disease is tackled effectively among socially excluded groups, warn experts in this week’s BMJ.

Tuberculosis can infect anyone, but predominantly affects the poor, write Alistair Story and colleagues. In London, where over 40% of all cases in the UK in 2004 were reported, rates of tuberculosis have more than doubled since 1987 and are now the highest among homeless people, problem drug users, people living with HIV, prisoners and new entrants, particularly those from countries experiencing chronic civil conflict.

Recently published guidance from the National Institute of Health and Clinical Excellence (NICE) recommends chest x-ray screening for homeless people and entry screening for prisoners. Mobile x-ray units targeted at high risk groups are also being evaluated in London.

The guidance also suggests hospital admission for homeless people and those with clear socioeconomic need, allocation of a named key worker for all patients, and risk assessment to identify those patients unlikely to adhere to treatment. Directly Observed Therapy (DOT – where a health worker or other responsible adult observes the patients taking their medication) is also recommended to improve adherence to treatment.

Most tuberculosis patients are not infectious, readily access health services, and complete treatment successfully without DOT, say the authors. As a result, they make only limited demands on services and pose little public health risk.

By contrast, many socially excluded patients are at risk of delayed presentation, poor adherence and loss to follow-up. A major and persistent outbreak including over 200 linked drug resistant cases disproportionately affecting homeless people, prisoners and problem drug users in London clearly illustrates the urgent need to strengthen tuberculosis control among socially excluded groups.

The occurrence of tuberculosis in England closely reflects indices of poverty and overcrowding, they add. If the major determinants of a disease are social, so must be the remedies.

Tuberculosis cannot be controlled unless the disease is tackled effectively among socially excluded groups. This demands co-ordinated action beyond established control strategies that will require significant and sustained investment, they conclude.

Contact:

Contact authors via Health Protection Agency Press Office, London, UK 

(4) DRUG APPROVAL PROCESSES MAY HAVE DELAYED SAFETY WARNINGS FOR ANTIDEPRESSANTS

(Did regulators fail over selective serotonin reuptake inhibitors?)
http://bmj.com/cgi/content/full/333/7558/92

(Can we tame the monster?)
http://bmj.com/cgi/content/full/333/7558/0-f

Drug approval processes may have delayed warnings about the safety of antidepressants, argues a senior doctor in this week’s BMJ.

Following GlaxoSmithKline’s recent letter to doctors pointing to a sixfold increase in the risk of suicidal behaviour in adults taking paroxetine, Professor David Healy examines the regulation of selective serotonin reuptake inhibitors (SSRIs) and asks were mistakes made and could they have been avoided?

In February 1990 an article raised concerns that the recently licensed fluoxetine might trigger suicide acts in depressed patients. Subsequent trials showed a doubling of rates of suicidal acts between active treatment and placebo, but it was only in a recent study reviewing over 700 trials that this difference became significant.

This trend should have been seen by both companies and regulators as something that required investigation, writes the author.

Trials in children conducted from the mid-1990s also show a doubling of the risks of suicidal acts with SSRIs. These results have recently formed the basis of warnings about the use of SSRIs in children. Trials in adults show a similar risk ratio yet, until May 2006, no warnings were issued for adults.

“Although data submitted to the FDA show an excess of suicides with every antidepressant licensed since 1987 compared with placebo, this simple but crucial finding continues to be obscured,” he says.

He also examines the way in which the data were presented to regulators by manufacturers, and suggests that inappropriate inclusion of suicidal acts in the placebo group biased estimates of suicide risk. Subsequent “rigid interpretation” of these data by the regulators “may have delayed warnings of dangers of suicidal acts,” he adds.

Having re-analysed the evidence, he suggests that the best estimate for the likely risk of suicide on SSRIs over placebo is 2.6 (more than double the risk) and he calls for suitably powered studies to settle the issue.

He also believes that greater data transparency and statistical sophistication might lead to earlier research to discriminate between those who do well on new drugs and those who do not.

“The regulators seem stuck in a world where balancing evidence of potential benefit against actual risk causes real problems,” he writes. “The SSRI and rofecoxib disasters have harmed public confidence in drugs. We urgently need to learn how to regulate both the risks and benefits of new treatments more effectively.”

BMJ Editor, Fiona Godlee also touches on this issue in her Editor's choice column. She talks of "an overpowerful under-regulated drug industry and a research establishment and publishing industry in its thrall." A radical solution would be to stop allowing drug companies to evaluate their own products. Is this feasible? Is it the answer? she asks.

Contact:

David Healy, Professor of Psychiatry, North Wales Department of Psychological Medicine, Cardiff University, Bangor, Wales
Email: healy_hergest{at}compuserve.com

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