739

TABLE II-DISTRIBUTION OF AF MUTATION IN PANCREATIC SUFFICIENT AND INSUFFICIENT CF PATIENTS

assertion, however, that the presence of at least one mild allele is necessary for the manifestation of the PS phenotype, we have observed homozygosity for the "severe" ,1,F 508 mutation in 5 of 30 CF-PS patients (table 11). Patients were classified clinically on the basis of pancreatic function or dysfunction (eg, pancreatic enzyme substitute requirement, growth retardation, steatorrhoea). The 5 CF-PS patients were aged 1, 3h 16, 22, and 23 years at the time of the last clinical assessment. We conclude that the clinical course of the disease may be determined by other environmental and/or genetic factors within or outside the CFTR gene. Our fmdings also have implications for genetic counselling in that homozygosity for the ,1,F 508 mutation does not necessarily indicate a severe course of the disease. This work was supported by grants from Deutsche Forschungsgemeinschaft (J. S.) and Kali-Chemie, West Germany (M. M., Jr). Institute of Human Genetics,

FU-Berlin, D-1000 Berlin 19, West Germany

Department of Biophysical Chemistry, Medizinische Hochschule, Hannover, West Germany Institute for Child Development Research, Charles University, Prague, Czechoslovakia

Prick tests to ovalbumin, checked after 20 minutes, were positive in 18 (78%) children. Total IgE levels (’Phadebas’ paper radioimmunosorbent test, Pharmacia, Uppsala) were higher than 2 SD above the mean in 18 children and specific IgE (phadebas RAST) to egg (judged positive if higher than 0 35 UI/ml) was present in 15. To confirm egg allergy, an-open challenge test was done under observation and with emergency equipment to hand. A drop of beaten raw egg was placed on the inner border of the lower lip, and a further 1 ml was applied after 5 minutes. Part-cooked egg was given after 30 minutes. Reactions were defmed as immediate if the first symptoms occurred within 4 h of egg ingestion and delayed if these occurred after 4 h. After the last administration of egg the children were observed for at least 4 h before discharge. After the challenge test, 11 (48%) children showed immediate allergic reactions: asthma in 3, urticaria in 3, asthma and rash in 2, rash and rhinitis in 1, lipoedema and urticaria in 1, oculorhinitis in 1; and 12 had worsening of atopic dermatitis. These 23 children received subcutaneously 0-5 ml of Morbilvax vaccine and were checked within 4 h for any immediate allergic reactions. In addition, the parents recorded possible reactions such as fever or rash at home. No allergic reactions were noted after immunisation. The usual reactions to vaccine, including fever and attenuated rash, were recorded in 7 (fever in 4, attenuated rash in 2, and attenuated rash and fever in 1). We conclude that measles immunisation seems to be safe even in children with documented egg

allergy.

MANFRED STUHRMANN MILAN MACEK, JR ANDRÉ REIS JORG SCHMIDTKE

Allergy and Clinical Immunology Division, Department of Paediatrics, University of Rome La Sapienza, 00161 Rome, Italy

BURKHARD TÜMMLER THILO DORK

Rome

M. E. GRANDOLFO

Allergy and Clinical Immunology Division, University of Rome La Sapienza

O. MILITA L. BUSINCO

G. BRUNO P. G. GIAMPIETRO

Department of Epidemiology and Biostatistics, Istituto Superiore Di Sanita,

VERA VAVROVA 1. Herman JJ, Radin R, Schneiderman R.

Centre for Medical Genetics, Charles University, Prague Institute of Human

MILAN MACEK

Genetics,

University of Gottingen, West Germany

Allergic reactions to measles (rubeola) vaccine patients hypersensitive to egg protein. J Pediatr 1983; 196: 102. Pickford R, Taylor B. Natural history of egg hypersensitivity. Arch Dis Child 1982; 57: in

MICHAEL KRAWCZAK

2.

649-52. 3. Dannaeus A,

Johansoon SGO, Foucard T, Ohman S. Clinical and immunological allergy in childhood. Acta Paediatr Scand 1977; 66: 31-77.

aspects of food

Sampson HA. The role of food allergy and mediator release in atopic dermatitis. J Allergy Clin Immunol 1988; 81: 635-45. 5. Businco L, Ziruolo MG, Benincori N, Ferrara M, Muraro A, Giampietro PG. Natural history of atopic dermatitis in childhood: an updated review and personal experience of a five years follow-up. Allergy 1989; 70 (suppl 9): 70. 6. Expanded Programme on Immunisation. Contraindications for vaccines used in EPI. Wkly Epidemiol Rec 1988, 37: 279-81. 7. Pollok TM, Moms JA. Seven years survey of disorders attributed to vaccination in 4.

JM, Iannuzzi MC, Kerem B-S, et al. Identification of the cystic fibrosis walking and jumping. Science 1989; 245: 1059-65. Kerem B-S, Rommens JM, Buchanan JA, et al Identification of the cystic fibrosis gene: genetic analysis. Science 1989; 245: 1073-80.

1 Rommens

gene: chromosome

2.

Safety of measles immunisation in children with IgE-mediated egg allergy SIR,--0n the basis of

Herman and colleagues’ study of measles immunisation in 2 following anaphylactoid children with egg allergy, there is general agreement that such vaccination should not be recommended for children with IgEmediated egg allergy. Such allergy affects 0-5% of healthy children, 5% of atopic babies, and 50% of children with atopic dermatitis.2-S However, we would emphasise that allergic reactions to egg were not well documented by Herman et al.l Two viral attenuated strains of measles vaccine (Schwatz and Moraten) are passaged in a chick embryo fibroblast culture, the fibroblasts being antigenically different from egg proteins.6 Herman et all suggested that crossreactivity between chick embryo fibroblast and egg proteins could be operating. Allergic reactions have, however, been observed in non-atopic children,.7,11 The anaphylactoid reactions reported by

North West Thames region Lancet 1983; i 753-57. 8. Thurston A. Anaphylactic shock reaction to measles vaccine. J R Coll Gen Pract 1987; Jan; 41. 9. Kamin PB, Fein BT, Brittan HA. Live attenuated measles vaccine. its administration to children allergic to egg protein. JAMA 1965; 193: 1125.

reactions

Herman

et al may result from another constituent of the vaccine, such as neomycin and kanamycin. Kamin et a19 reported that children with documented IgE-mediated egg allergy had no anaphylactoid reactions following measles vaccination. To ascertain whether measles immunisation does induce allergic reactions in egg-allergic children, we have investigated 23 children (median age 2 years 5 months) with a positive challenge test to egg and a positive skin test and/or radioallergosorbent test (RAST) to egg.

Mass immunisation campaigns and of immunisation services

quality

SIR,- The goal of the WHO Expanded Program on Immunisation is to provide immunisation to all children. However, the strategy for achieving this remains controversial. Mass campaigns have to be repeated regularly if high coverage is to be sustained, and some suggest that such campaigns conflict with the principle of primary health care.1 Although there is anecdotal evidence of the adverse effects of campaigns on routine health care, few systematic evaluations have been reported. We describe here the quality of immunisation services during mass campaigns in Niger State, Nigeria. Niger State conducted mass immunisation days during September to December, 1989. These days were organised after orientation sessions for health workers and entailed mobilising the population to visit health centres and "outreach posts" to obtain immunisations. In some areas the days coincided with an assessment in October, 1989, by the State ministry of health (in

740

QUALITY OF CARE INDICATORS AT ELEVEN IMMUNISATION CENTRES IN NIGER STATE, NIGERIA

data excluded, resulting in varying denominators. †Criteria of epidemiological unit, Niger State Ministry of Health.

*Mlsslng

conjunction with the African Child Survival Initiative/Combatting Childhood Communicable Diseases project of the US Agency for International Development) of how far health workers complied with standards of care in maternal and child health activities. The assessment was by on-site observation using standard forms, interviews with staff, reviews of registers and equipment, and interviews with mothers. A random sample of thirty government health facilities was visited (50% of the total) but the results presented here refer to the eleven facilities which were providing childhood immunisation services on the day of the assessment. Three were implementing mass immunisation days and eight were providing routine immunisation services. The mass immunisation drug centres performed significantly less well than the routine service centres on several indicators of quality of care (table). The study identified problems during mass immunisation activities that could offset some of the advantage gained by serving larger numbers of children. For example, the mass immunisation centres were less likely to maintain vaccines at correct temperatures or to use sterile needles and syringes and were more likely not to ensure that all children had immunisation records and that mothers were told about return dates for future immunisations. Health workers reported that immunisation services had been interrupted for up to two weeks when health workers, equipment, or transport were redistributed for mass immunisation day activities in other areas. The Niger State Ministry of Health is strongly committed to the immunisation programme and has tried to interest coverage through the use of immunisation days at local level. This strategy cannot be judged adequately by observations on only 59 immunisations. However, the results do suggest that more attention should be paid to difficulties with service delivery during mass immunisation activities. The increased intensity of activities during mass campaigns may be at the cost of quality, maternal knowledge, and compliance with the recommended immunisation schedules. During a campaign, there is often little time and few resources to evaluate activities. However, the assessment procedures used here were simple, quick, and can be conducted by local staff. As 1990 begins, many countries may be encouraged to embark on mass campaigns. A reassessment of performance standards during such campaigns is warranted. International Health Program Office, Centers for Disease Control, Atlanta, Georgia 30333, USA

J. W. BRYCE

Division of Immunization, Centers for Disease Control

F. T. CUTTS

Niger State Ministry of Health, Minna, Nigeria

S. SABA

Hair analysis for

drugs of abuse

SIR,- Traces of many drugs are laid down in hair during keratinisation and remain embedded throughout its life. The absence of drug metabolism in hair and the fairly uniform hair growth rate of about 1 cm per month may provide a historical account of drug use from analyses on hair samples. In a court case our opinion was sought about whether a former heroin addict had been heroin-free two years previously, no medical examination or laboratory tests having been done at that time. Physical examination and urine testing for drug abuse’ merely confirmed that the man had been drug-free during the previous few days. A sample of hair (full length) was divided into 2 cm sections from the scalp end. The sections were weighed and incubated overnight at 55°C in hydrochloric acid to extract any free morphine from the hair. After neutralisation the extracts were analysed for morphine by solid phase radioimmunoassay (Coat-a-Count; D. P. C., Los Angeles). 12sI-labelled morphine competes for a fixed time with morphine in the sample for morphine-specific antibody sites. The isolated antibody-bound fraction is then measured in a gammacounter. A calibration curve is used to give a measure of morphine present in the sample, from which the morphine concentration in the hair can be calculated. Hair from three known heroin addicts and from three drug-free volunteers was tested in the same way. There was a striking difference between morphine concentrations in hair from the heroin addicts and those from drug-free volunteers and from the man whose heroin status was at issue: Subjects

Distance of hair sample from

scalp (cm)

Morphine In sample (ng/mg)

0-2 2-4 4-6 0-2 2-4 4-6 0-2 2-4

300 23-0 219 7-8 11-3 15-0 8-8 99

Morphine positive A

B

C

Morphine-free D E F Unknown

Random 2 Random 2 Random 2

0-2 0-2 0-4

cm cm cm

drug status 0-2 2-4 4-7

0-8 0-8 0-6

We gave our confident opinion that the man had not been a heroin addict over the previous 6 months. Although there have been reports of hair analysis for drugs of abusez-4 this is the first time to our knowledge that such information has been used in the courts. It is not yet clear whether such tests have a future in diagnosis or in monitoring treatment compliance: however, there would seem to be considerable potential in forensic work and research (eg, in follow-up studies which have hitherto relied upon self-reporting). Clinical Research and Treatment Unit. Bethlem Royal Hospital, Beckenham, Kent BR3 3BX,UK, and Maudsley Hospital

JOHN STRANG

Pathology Laboratory, Bethlem Royal Hospital

ANDREW MARSH NEVILLE DESOUZA

Drug Dependence

1. Editorial. Screening for drugs of abuse. Lancet 1987; i: 365-66. 2. Baumgartner AM, Jones PF, Baumgartner WA, Black CT. Radioimmunoassay of hair

for

determining opiate-abuse histories. J Nucl Med 1979; 20: 748-52. D, Cassani M, Pigliapochi M, Vanzetti G. Hair as a sample m

3. Valente

morphine and cocaine addiction. Clin Chem 1981; 27: 1952-53. 4. Puschel K, Thomasch P, Arnold W. Opiate levels in hair. Forensic 1. Seaman J, Poore P. Good intentions, unfortunate consequences. Lancet

1987; i: 1334.

181-86.

assessing

Sci Int 1983, 21: