(Aust Prescr 1995;18:56-7)
Letters, which may not necessarily be published in full, should be restricted to not more than 250 words. When relevant, comment on the letter is sought from the author. Due to production schedules, it is normally not possible to publish letters received in response to material appearing in a particular issue earlier than the second or third subsequent issue.
Editor, Dr McIntyre provides an informative guide to childhood immunisations in his recent article 'Update on childhood immunisations' (Aust Prescr 1994;17:91-5) and helpfully provides a more restricted guide to contraindications. He lists contraindications as a concurrent moderate to severe illness, previous anaphylactic reaction to the vaccine (or severe reaction to a vaccine constituent), attenuated live vaccines in immunocompromised patients, and neurological handicap as regards pertussis.Previously, a fever over 39.5oC, induration and redness around most of the arm and prolonged inconsolable screaming after pertussis vaccine have been considered a contraindication to repeating it.
Are these still considered contraindications (or were such reactions included as an anaphylactic reaction) and what is the risk of subsequent vaccination in a child who has had such a reaction previously?
Brendon Smith
General Practitioner
Surry Hills, N.S.W.
Dr P. McIntyre, the author of the article, comments:
Dr Smith has raised some important points of clarification regarding contraindications to pertussis immunisations which were not addressed in the original article due to reasons of space. The list of contraindications to active immunisation was intended to apply generally to children presenting for immunisation. With regard to pertussis vaccine specifically, contraindications may be divided into absolute and relative contraindications. Both the new edition of immunisation procedures1 and the report of the Committee on Infectious Diseases of the American College of Peadiatrics2 define absolute contraindications to further pertussis vaccine as an immediate severe allergic or anaphylactic reaction or encephalopathy within 7 days. Other reactions such as protracted, inconsolable crying and severe local reactions are considered to be relative contraindications which may preclude further doses, depending upon the clinical status of the patient and their risk both of acquiring pertussis and of having significant complications should this occur. The level of fever considered significant is now generally quoted as more than 40.5oC rather than 39.5oC.3 Unfortunately, there are no available data to evaluate the risk of a subsequent adverse reaction following the occurrence of one such reaction. Anecdotal experience certainly indicates that the occurrence of one of these reactions by no means indicates that it will invariably occur if the vaccine is administered again. Very severe local reactions, high fever and inconsolable crying for more than 3 hours would each be expected to affect less than 1% of DTP recipients.4 Thus, if contraindications to further pertussis vaccine are limited to the absolute and relative contraindications, there should be very few children receiving CDT rather than DTP, certainly many less than appear to be receiving it currently. These issues have been summarised in a recent statement of the Australian College of Paediatrics.4
References
1. National Health and Medical Research Council. The Australian immunisation procedures handbook. 5th ed. Canberra: Australian Government Publishing Service, 1994.
2. Peter G, editor. 1994 Red Book. Report of the Committee on Infectious Diseases. 23rd ed. Illinois:American Academy of Pediatrics,1994: 364-5.
3. Cody CL, Baraff LJ, Cherry JD, Marcy SM, Manclark CR. Nature and rates of adverse reactions associated with DTP and DT immunizations in infants and children. Pediatrics 1981;68:650-60.
4. The Australian College of Paediatrics Policy Statement. Contraindications to immunization against pertussis. J Paediatr Child Health 1994;30:310-1.
With benzodiazepines now known to worsen the very symptoms for which they are most commonly prescribed, their routine use in anxiety and insomnia is no longer justified. The propensity to induce tolerance within two weeks and the association with hip fractures in the elderly 1 are further reasons not to use them. However, I do agree with the suggestion that they be available only on authority. Of course, the commonest indication will be addiction to benzodiazepines.
Andrew Byrne
General Practice Drug and Alcohol
Redfern, N.S.W.
Reference
1. Cumming RG, Klineberg RJ. Psychotropics, thiazide diuretics and hip fractures in the elderly. Med J Aust 1993;158:414-7.
There are some situations where medical practitioners, for sound therapeutic reasons, need to prescribe a banned substance. Examples would be oral corticosteroids in asthma or colitis, testosterone replacement in agonadism and methylphenidate use in attention deficit disorder.
The role of the MAP is to examine such cases and assist doctors and athletes who would otherwise be disadvantaged by the avoidance of a therapeutic, but sport-banned, substance.
Doctors can contact the MAP by writing to:
Dr R. Smith
Australian Institute of Sport
PO Box 176
Belconnen ACT 2616
Peter Harcourt
Medical Consultant
Victorian Institute of Sport
South Melbourne, Vic.
Editor, I read with interest the editorial by ProfessorP.Baume on 'Drugs in sport'. I am very concerned about the matter, of course, as are all sports administrators.
However, I have become concerned over another related matter, i.e. the introduction of drug testing to veteran sports and its implication for menopausal women taking hormone replacement therapy which includes testosterone. I believe that this is an important matter which should be brought to the attention of your readers. The current situation is that a doctor's certificate produced for verification will enable women who could test positive to be cleared.
However, the authorities have yet to take a position on the issue and because of the abuse of testosterone by young elite athletes and the current situation of the Chinese female swimmers, I am concerned that they may prohibit it entirely.
I have received advice and support from the Australian Menopause Society which endorses the legitimate use of testosterone, particularly in cases of loss of libido, loss of energy, depression and headaches which do not respond to oestrogen alone.
The full text of my paper 'Drug testing in veteran women athletes with special reference to hormone replacement therapy' appears in Sport Health (the official journal of Sports Medicine Australia) Vol. 12 No. 3, 1994.
Wendy Ey
Executive Director
Women's Sport Foundation of Western Australia Inc.
Floreat, W.A.
Management of anaphylactic reactions
Editor, Australian Prescriber Vol. 17 No. 4 1994 includes as an insert, the wall chart 'Medical management of severe anaphylactoid and anaphylactic reactions'. Step 4 advises that one, or preferably two, widebore intravenous lines be established. It is regrettable that wide bore is followed by '(16 gauge or larger)'. Many practitioners would not need to be told what widebore means; those who do are presumably also likely to be less skilled in inserting such cannulae. The flow of a watery solution and even of the colloid Haemaccel through an 18 gauge cannula is only a little slower than through a 16 gauge cannula under the same circumstances, but this might be compensated for by raising the infusion flask as much as possible. In any case, an 18 gauge cannula is much easier to insert and the subsequent infusion is far superior to failing to insert a larger cannula, often involving several attempts and the destruction of invaluable venous sites! For many years in anaesthetic practice, I have stressed to my trainees that 16 gauge or larger cannulae need not be used unless there is a significant risk that rapid transfusion of blood or packed cells might be required.Herbert C. Newman
Anaesthetist
Camberwell, Vic.
