PROCEEDINGS OF THE SECTION OF EPIDEMIOLOGY AND PREVENTIVE MEDICINE Registrar's Prize Meeting held on 3rd March, 1988 TUBERCULOSIS QUESTIONNAIRE John C. Stinson. Peamount Hospital, Newcastle, Co. Dublin. A national postal questionnaire survey was used to ascertain the current spectrum of tuberculosis in Ireland, especially with regard to B.C.G. policies, contact tracing, chemoprophylaxis and also to the actual management of patients with tuberculosis. The survey applied to 1986 only. Of 617 questionnaires sent out we received 451 (74%) as eventual total response rate. All Directors of Community Care replied, 744 cases of T.B. were notified in 1986; one third of these patients were under the age of 35. There was no uniformity amongst community care areas with regard to contact tracing, method of tuberculin skin testing and B.C.G. policies. Whilst the tendency was to prolong treatment some community care areas would appear to undertreat tuberculosis. Only a minority of hospital consultants had actually diagnosed or treated T.B. in 1986 and of those treating pulmonary tuberculosis only 38% used a recognized regimen. In total, 43 different drug regimens were used and 29% of hospital consultant clinicians used potentially inadequate chemotherapy. In conclusion there is an urgent need for consensus on management of tuberculosis in Ireland. This is especially apparent as we have one of the highest mortality and morbidity rates from the disease in the E.E.C. MEASLES IMMUNISATION - WHY IS THE UPTAKE SO LOW? Ailis Quinlan. Community Care Area 5, BaUyfermot, Dublin 10. Sustained uptake levels of measles immunisation in excess of 90% are required for eradication of measles. Uptake levels, though initially highly satisfactory, have dropped to 42% in Community Care Area 5. A representative sample of 352 mothers was interviewed to determine reasons for non-uptake of vaccine. The actual uptake was 59% indicating underreporting by G.P.s Uptake was low among children of lower socio-economic groups and of large families. Marital status of mothers did not affect uptake. 84% were well informed about measles and measles vaccine. The main reason given for non-uptake of vaccine was delay in completion of primary immunisation. 30% of mothers would prefer to have their children immunised at a health centre clinic rather than by their G.P. 79% did not object to the concept of compulsory immunisation by school entry. Recommendations for increasing uptake include installation of computer recall systems in each Community Care Area, closer liaision between Community Care staff and G.P.s, regular feed-back re. uptake to G.P.s and Public Health Nurses, measles immunisation to be available at health centres and regular media promotions. KILKENNY POST PRIMARY SCItOOL SURVEY Orlaith O'Reilly. Community Care Centre, Athy Road, Carlow. The study was carried out on a stratified

random sample of 445 Kilkenny post primary school children. A self administered questionnaire was used to collect information on health related knowledge, attitudes and behaviours. The questionnaire was modelled on one used by the W.H.O. collaborative study, to allow for comparison The results showed that physical activity levels were high overall, but decreased throughout the teenage years. 22% of all pupils currently smoke; this increased with age to a peak of 32% of 17 year olds being smokers. 22% of pupils currently drink alcohol, this also increased with age to a peak of 38% of 17 year olds currently drinking. Health related knowledge levels were high but were not associated with behaviour. Behaviours were related to attitudes. The study will provide information for the formulation of health education programmes and provide a baseline for evaluation of these programmes

a) lack of availability of list of susceptibles from the computerised child record. b) lack of targetting of schools most likely to prevent further spread of the epidemic, c) failure to follow up school children for whom consent forms were not returned, d) local public and professional resistance to measles vaccination. The problems described serve to emphasise the need to refine the organisation and delivery of mass vaccination in establishing and maintaining measles eradication.

A STUDY OF INAPPROPRIATE HOSPITAL UTILISATION

M. Hynes. Eastern Health Board, Community Care Area, 8, Dublin 5.

100 patients who had a postero anterior chest x-ray within the previous 24 hours were examined by 2 observers blinded to the x-ray appearance. Position of the apex with reference to the fifth intercostal space and midclavicular line, and horizontal distance from the midLine was recorded. The x-rays were read blindly by a consultant radiologist. Using apex displacement beyond the fifth intercostal space and midclavicular line as the test, and cardiomegaly defined as cardiothoracic ratio greater than 50% as the gold standard, combined specificity was 76%, sensitivity 57%, positive predictive value 59.4%, negative predictive value 76.9%. There was no statistical difference between the distance of the apex from the midline in those with and without radiologic cardiomegaly. The apex beat is insensitive in the detection of cardiomegaly. It has higher specificity but overall is a poor test. Horizontal distance of the apex from the midline is of no value in clinical examination.

The aim of the study was to 'determine what proportion of hospital patients could have been dealt with in a less costly lower-level institutional setting, or at home. Using objective predetermined criteria, 211 medical, surgical and geriatric patients in a Dublin General Hospital were reviewed. Almost 1 in 5 patients (19.5%) were found to have an inappropriate day of care. Such patients were significantly more likely to have been reviewed at the week-end, to have lengths of stay over 21 days, to have been admitted for convalescence, observation or social reasons, and to have a diagnosis of cerebrovascular accident, central nervous system or locomotor disorder, or multiple diagnoses. The single most important factor contributing to misutilisation was the lack of longterm care facilities for the elderly and young chronic sick. However, problems with hospital scheduling of investigations, with availability of consultant second opinions and with discharge arrangements for patients at the weekend also emerged. The study highlights the scarcity of extended care and respite accommodation both for the young chronically disabled and the elderly. It also indicates difficulties within the control of the hospital which, if remedied, would lead to a decrease in hospital misutilisation.

MANAGEMENT OF MEASLES OUTBREAK BY ACTIVE MEASLES VACCINATION.

FISH AND CORONARY ARTERY DISEASE : AN EXPLORATION OF YI'S PROTECTIVE MECHANISM

S. Jennings, N. Begg, & J. White. Communicable Disease Surveillance Centre, Colindale, London, England.

R.J. Clarke, I. Graham, G. Tomkin, C. O'Morain.

THE APEX BEAT. EVALUATION OF A CLINICAL TEST. T. O'Neill, M. Barry, M. Smith, I. Graham. Dept. of Cardiology, Meath Hospital, Dublin.

Measles eradication, as a national and international policy, requires a commitment to high vaccination uptake, surveillance of the disease and active outbreak management. An outbreak of measles was investigated in a Welsh community and a strategy of prevention proposed. The objectives were to prevent secondary cases and to raise awareness of the need of measles vaccination. The overall number vaccinated during the campaign was disappointing; factors contributing to the poor uptake included:

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The low death rate from coronary heart disease among Greenland Eskimos has been ascribed to their high fish consumption. Kromhout reported an inverse relationship between fish consumption and death from coronary heart disease (C.H.D.). He showed that the mortality from C.H.D. was 50% lower among those who consumed fish (30 gm/day) than those who did not eat fish. These observations and similar data from the Western electric study prompted us to study this hypothesis. The beneficial effects offish are due to its characteristic omega three series fatty acid

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eicosapentaenoic acid and its direct effect on lipoproteins or eicosanoids (prostaglandin, thromboxane, prostacyclin and leucotriene) in a way that might afford protection form C.H.D. In a six month study of 30 hyperlipidaemic patients (cholesterol 7 mmol/L on three consecutive occasions) we examined the effect of dietary fish intervention (4 main courses/week) and fish oil therapy (maxEPA seven seas 20 capsules/day 3.6 g m EPA/day) and placebo (20 capsules/day) in a single blind placebo controlled study in three groups of ten patients. The effect of the intervention on serum lipids, white cell function, blood pressure, and blood coagulation indices was measured. Allpatients were on a fat restricted diet with 35% total energy as fat. In the fish oil treated group serum cholesterol fell by 7%, triglycerides fell by 23% and HDL rose by 2% unlike dietary fish which produced no beneficial effect on lipids. Nentrophil chemiluminescence which is an indirect marker of leukot-

Section of Epidemiology and Preventive Medicine riene production fell by 21% in the fish oil treated group 14% in the dietary fish intervention and only 2% in the placebo treated group. This data would support the epidemiologieal evidence that the beneficial effect of eicosapentaenoic acid is not due to its effect on traditional risk factors but more likely to its effect on the mediators of atherosderosis such as leucotrienes and thromboxane.

THE APPLICATION OF A COMPUTERISED BIRTH REGISTER TO CHILDHOOD IMMUNISATION. Chris Buttanshaw. Midland Health Board, County Clinic, Mullingar, Co. Westmeath. A register of children born since 1st January,

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1987 in the Longford/Westmeath Community Care Area of the Midland Health Board has been maintained on a microcomputer. The register is accurate and complete. The records of a three month birth cohort were examined to determine whatimmunisations they had commenced. 92.3% of children had commenced immunisation and 78.7% had started a course of pertussis vaccine. There were significant differences in uptake of pertussis vaccine in different areas, but the number of children with no immunisations was similar. Area medical officers (AMOs) achieved a higher uptake of pertussis vaccine than did general practitioners and during 1987 the uptake of pertussis vaccine at AMO clinics increased from 73% to 94%. These are the first accurate cohort figures produced in this country and uptake is higher than expected. The register identifies those with no immunisations for subsequent action, and is being used to schedule appointments for measles vaccine.