CHILDHOOD IMMUNIZATION 2 has been confused by anecdotal information, inadequate epidemiological studies and mass media speculation. Typical examples i

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1 September 2001 MONTHLY SELF-STUDY SERIES CHILDHOOD IMMUNIZATION Please read the following article and complete the self-assessment questions. Participants in the HKMA CME Programme will be awarded 1 credit point under the Programme for returning completed answer sheet on P. 15 via fax ( ) or by mail to the HKMA Secretariat on or before 1 October Answers to questions will be provided in the next issue of the HKMA CME Bulletin. The Hong Kong Medical Association is dedicated to provide a coordinated CME programme for all members of the medical profession. Under the HKMA CME Programme, a CME register is installed to document the CME efforts of doctors and special CME avenues are provided. The Association strives to foster a vibrant environment of CME throughout the medical profession. Both members as well as non-members of the Association are welcome to join us. You may contact the HKMA Secretariat for details of the programme. Dr. Tse Hung Hing M.B.,B.S.(H.K.), M.R.C.P.(U.K.), D.C.H.(London), D.C.H.(Glasgow), D.C.H.(Ireland), F.H.K A.M.(Paediatrics) Specialist in Paediatrics, HKMA Conuncil Member The CME Co-ordinator wishes to thank Dr. Tse for producing this article in a short period of time. Active immunization is the deliberate stimulation of an immune response in a person by giving a specific vaccine to protect against an infectious disease. The vaccine is usually a protein similar to part of a virulent infectious organism that can be recognized by the individual s immune system which then produces antibiotics and cell-mediated immunity against the antigen in the vaccine. A vaccine is a protein antigen, originally derived from or similar to a bacterium, virus or protozoon, used for active immunization. Vaccines may be live, killed, toxoids or genetically engineered. A live-attenuated vaccine is one which produces active immunity by causing a mild infection. A virulent organism is weakened, usually by multiple subcultures in unfavorable conditions, so that it produces an antigenic response without the serious consequences of a wild organism infection. Cross-reacting organisms are another type of livevaccine which causes the body to produce a defense against the virulent strain, e.g. the BCG (bacillus Calmette- Guerin) vaccine. Killed, or inactivated vaccine is prepared from virulent organisms or preformed antigen inactivated by heat, phenol, formaldehyde or other means, e.g. classical pertussis vaccine. Such vaccines usually require a series of spaced injections to produce an immune response. Component vaccines use parts of pathogens as antigens and the newer pertussis vaccines are examples of this. Meningococcal and pneumococcal vaccines are derived from the mucopolysaccharide coat of specific bacteria. The response to polysaccharide vaccines is incomplete and unreliable and consequently these have sometimes been conjugated with other antigens in an attempt to improve the immunological response, e.g. the linkage of H. influenzae polysaccharide with pertussis antigen of DPT vaccine and diphtheria toxoid. Toxoids also induce active immunity. A toxoid is an inactivated toxin preparation. The serious consequences of some diseases are due to toxins released by the organisms when they infect the patient, e.g. diphtheria and tetanus toxins. Toxoids from these produce antibodies which inactivate the toxins but do not kill the bacteria. ADVERSE REACTIONS AND CONTRAINDICATIONS TO IMMUNIZATION There are many false contraindications to immunization (Table 1) as opposed to true contraindications (Table 2). Adverse reactions may be due to faulty administration, e.g. abscess due to unsterile needles or syringes, or the inherent properties of the vaccine. Both minor and major side-effects of vaccination cause parental anxiety and undermine professional confidence in the benefit of immunization. The situation 1

2 CHILDHOOD IMMUNIZATION 2 has been confused by anecdotal information, inadequate epidemiological studies and mass media speculation. Typical examples include the pertussis component of the DPT vaccine and the measles vaccine. Evidence indicates that the serious side-effects of both pertussis and measles vaccine are much less than the risks and morbidity of the clinical diseases in the first years of life. However, when the risk from a disease becomes very small, as with paralytic poliomyelitis in the Unites States, the small risk of vaccine associated paralytic poliomyelitis (VAPP) from live OPV becomes relatively more important and may warrant a reconsideration of vaccination policy. Table 1: FALSE contraindications to immunization Illnesses or treatments Minor illnesses, e.g. mild upper respiratory infection Chronic diseases of heart, lung and kidneys Treatment with antibiotics or locally-acting corticosteroids, i.e. by topical application or inhalation Stable neurological condition such as Down syndrome, cerebral palsy, spina bifida. Malnutrition or under a particular weight Dermatoses, eczema or localized skin infection Recent or imminent surgery Personal or family medical history Personal or family history of allergy, asthma, eczema, hay fever, etc. Previous history or measles, pertussis, rubella, mumps, Haemophilus influenza, polio or other specific infection Family history of adverse reaction to immunization Family history of convulsions Jaundice at birth or prematurity: do not postpone immunization Contact with an infectious disease Older than the usual age for immunization Note: Some of these conditions constitute priority or high risk groups for immunization, e.g. low birthweight infants, Down syndrome, asthma, congenital heart disease, chronic lung disease and infants with HIV-1 antibody positive mothers. Table 2: TRUE contraindications to immunization Summary of contraindications 1. Acute illness 2. Previous severe reaction to immunization 3. Immune deficiency or suppression, acquired or induced 4. Progressive or uncontrolled CNS disease 5. Specific situations with whole cell pertussis or some live vaccines Definite contraindications general Severe febrile illness. Immunization might superimpose adverse effects on the illness, or manifestations of the disease may wrongly be attributed to immunization. Postpone immunization Definite contraindications pertussis Definite history of severe adverse reactions from previous dose of the vaccine, usually DTP General reactions include fever above 39.5ºC, anaphylaxis, bronchospasm, laryngeal edema, collapse, prolonged unresponsiveness or inconsolable screaming within 72 h Severe local reaction, implies extensive induration or imflammation around the injection site Definite convulsion within 72 h of administration of a previous dose of DPT Progressive neurological disease, e.g. uncontrolled epilepsy or tuberous sclerosis Definite contraindications live vaccines Patients with immune deficiency or those with impaired response due to leukemia, malignant disease and those with AIDS. Those who are HIV Ab positive with symptoms may be given killed vaccines Those being treated with large doses of corticosteroids or other immuno-suppressive treatments, e.g. following organ transplantation Within 3 weeks of another live vaccine (but OPV, measles, rubella or BCG vaccine may be given simultaneously with another live viral vaccine) Within 3 weeks before or 3 months after a dose of normal immunoglobulin Allergy to hens eggs if severe, e.g. anaphylaxis or generalized urticaria (these are relatively rare) BCG should not be given to those with: generalized specific skin conditions; if eczema exists, vaccination should be in the area of healthy skin positive skin sensitivity test to tuberculin protein; an interval of at least 3 weeks should be allowed between BCG and any live vaccine Patients with tuberculosis should not receive measles vaccine unless on full treatment for TB Circumstances requiring individual consideration Children with a personal history of convulsions or febrile convulsions (they can usually be immunized) Children with first degree relatives with epilepsy may have a fit after measles or MMR vaccine. However, the possibility of a fit is 10 times as great with an infection or measles. In these circumstances the matter should be discussed with parents, the vaccine should be given and they should be supplied with a paediatric dose of rectal diazepam and instructions about what to do if a convulsion occurs

3 CHILDHOOD IMMUNIZATION Documental evidence of cerebral damage in neonatal period including twitching and clonic episodes Stable abnormality of the CNS, including spina bifida and cerebral palsy IMMUNIZATION PROGRAMME OF HONG KONG There are some minor differences in the immunization programs in different parts of the world and none is applicable to all. Indeed, programs are changing all the time in response to local scenarios. The timing of the first immunizations is a compromise between the developing maturity of the infant s immune system and the risk of infection from virulent organisms. Maternal transplacental IgG protects infants against many infections for the first few months of life. It is an incomplete protection, particularly against pertussis, but is satisfactory against measles and rubella. Table 3: Immunization Programme of Hong Kong AGE IMMUNIZATION RECOMMENDED New born B.C.G. Vaccine Polio Type I Hepatitis B Vaccine First Dose 1 month Hepatitis B Vaccine Second Dose 2-4 months DPT Vaccine (Diphtheria, Pertussis & Tetanus) First Dose Polio Trivalent First Dose 3-5 months DPT Vaccine (Diphtheria, Pertussis & Tetanus) Second Dose 4-6 months DPT Vaccine (Diphtheria, pertussis & Tetanus) Third Dose Polio Trivalent Second Dose 6 months Hepatitis B Vaccine Third Dose 1 year MMR Vaccine (Measles, Mumps & Rubella) First Dose 1 1/2 year DPT Vaccine (Diphtheria, Pertussis & Tetanus) Booster Dose Polio Trivalent Booster Dose Primary 1 DT Vaccine (Diphtheria & Tetanus) Booster Dose Polio Trivalent Booster Dose MMR Vaccine (Measles, Mumps & Rubella) Second Dose Primary 6 DT Vaccine (Diphtheria & Tetanus) Booster Dose Polio Trivalent Booster Dose SPECIFIC IMMUNIZATIONS Bacille Calmette-Guerin vaccine (BCG) Full term neonates can respond well to BCG vaccine. Indeed, a meta-analysis found that neonatal BCG was as effective as BCG given later in infancy. BCG vaccine is a live, attenuated strain of Mycobacterium bovis. It is only moderately protective against tuberculosis, with an efficacy of 50%. However, it has a 64% efficacy against meningeal tuberculosis, and a 71% efficacy against dying from tuberculosis, so it is well worth giving to babies at risk of contracting tuberculosis. The vaccine is intended to be injected via the intradermal route, avoiding the subcutaneous route. The dose is 0.05 ml for children under 1 year and 0.1 ml for adults and children over 1 year. This injection, usually carried out in the deltoid region of the left arm, should produce an orange-skin papule with a diameter of about 6 to 8 mm, and the injection site should not be covered. A superficial ulceration which heals spontaneously sometimes appears 4 to 6 weeks after the intradermal injection of vaccine. Only dry dressings are recommended. Hepatitis B Vaccine Two standard, similar HBV vaccines are available: (1) H-B-VAX II (Merck) and (2) Engerix-B (GlaxoSmithKline). Both are made from recombinant yeast producing the surface antigen of HBV (HBsAg) adsorbed to alum as an adjuvant. Although the dosages are different, they are interchangeable. The primary series for HBV is three doses given over 6 months time at 0, 1, and 6 months. The most common side effect was injection-site soreness. Acute allergic reactions to the HBV vaccine have been rarely reported. The seroconversion rate among children using the HBV vaccine is almost 100% and is approximately 95% among adolescents. The protection against HBV seems to last longer than detectable anti-hbs, but how long this protection lasts is unknown. How long vaccineinduced immunologic memory lasts and when (or if) routine boosters will be recommended remain to be determined. Poliovirus Vaccines Since 1965, oral poliovirus vaccine (OPV) has been the recommended vaccine in routine use to prevent poliomyelitis. It is a live-attenuated vaccine. Full term neonates respond well when given at birth. OPV stimulates both systemic and local gut mucosal immunity. Preterm babies respond normally to OPV commences at 2 months postnatal age. Vaccine-associated paralytic poliomyelitis (VAPP) is a rare complication of OPV use, occurring at a rate of approximately 1 case per 2.4 million dose of OPV. With the eradiation of wild-type poliomyelitis from the western hemisphere in 1991, VAPP became a more significant cause of acute flaccid paralysis in children. For this reason, the United States has changed to giving killed vaccine (enhanced potency injectable polio vaccine), 3

4 CHILDHOOD IMMUNIZATION which is considered safer than the oral vaccine, for the first two doses, followed by OPV for subsequent doses. However this injectable polio vaccine is much more expensive than the oral vaccine. Acellular Pertussis Vaccines Whole-cell pertussis vaccine, combined with diphtheria and tetanus toxoids (DTP), had been used worldwide since it became available in Despite nearly eliminating pertussis mortality and morbidity, the wholecell vaccines have been among the least satisfactory vaccines because of the adverse reactions they cause. They commonly cause reactions that are minor but burdensome (i.e., pain, redness, and swelling at the injection site; fever, fussiness; drowsiness; and anorexia), occasionally cause reactions that are transient but frightening (i.e., persistent inconsolable crying, high fever, hypotonic-hypo-responsive episodes), and uncommonly cause some more severely adverse effects (i.e., febrile convulsions and acute encephalopathy). The identification and isolation of important constituents of B. pertussis led to the development in Japan of several purified component (acellular) vaccines. These vaccines have been used extensively in japan since 1981 and clearly have been efficacious. According to the American Advisory Committee on Immunization Practices, the American Academy of Family Physicians, and the American Academy of Pediatrics, diphtheria and tetanus toxoids and acellular pertussis vaccine adsorbed (DTaP) is the preferred vaccine formulation for all doses in the vaccination series; DTP is acceptable only if no DTaP is available. At the moment, there are at least two acellular vaccines available locally: Infanrix (GlaxoSmithKline) and Tripacel (Aventia pasteur [Zuellig]). Both contain acellular pertussis vaccine combined with diphtheria and tetanus toxoids. Measles-Mumps-Rubella Vaccine (MMR) Individual, live attenuated vaccines for measles, mumps, and rubella were available since the 1960s. The triple combination product, though available in the United States since 1971, was not provided by the Department of Health until the 1980s. The schedules of vaccination have changed. Initially, the vaccine was given as a single dose by subcutaneous injection at the age of 12 months. But the recognition of as much as 5% primary measles vaccine failure rate in the 1990s led to the use of a two dose regime for MMR. Currently, two doses of MMR are recommended at 12 months of age and at primary 1. Varicella Vaccine It is a live-attenuated vaccine. The virus for the vaccine (Oka strain) was first isolated by Takahasi from the vesicular fluid of a Japanese child in The virus was then attenuated by passage in human embryonic lung cells, subsequently in guinea pig embryo fibroblasts and finally in human diploid cells. The vaccine is administered by subcutaneous injection. It produces both humoral and cell-mediated immune response (CMI), which occurs earlier than the humoral response. This early induction of CMI probably explains the protection conferred by vaccinating susceptible household contacts exposed to varicella. The humoral and CMI response to varicella vaccine among adolescents and adults is less than half of that in children less than 12 years of age. Responses after the second dose were equivalent to the response of children after one dose, indicating that the two-dose regiment is effective for people 13 years of age. It is recommended that all healthy children aged 12 months to 13 years could be routinely immunized with one dose of varicella vaccine. All other routine childhood vaccinations may be safely administered together with varicella vaccine, but not in the same syringe. Healthy adolescents and young adults who have not had chickenpox should receive two doses of varicella vaccine 4 to 8 weeks apart. Routine serologic testing after vaccination is not recommended. Postexposure vaccination was effective. There is no harm from intercurrent administration of varicella vaccine to individuals incubating wild-type varicella. Adverse events associated with vaccine administration include fever (10% to 14%), vaccine-associated rash (4%-6%), and injection site reactions (19.3%). No CNS complications have been linked to the Oka strain, which is the origin for all the currently available licensed varicella vaccine preparations. The incidence of zoster in healthy vaccinees is less than following natural infection, and most cases of zoster were shown to be secondary to wild-type virus. There is no evidence to date that vaccine virus can cross the placenta to cause fetal damage, and inadvertent inoculation of pregnant women with varicella vaccine is not an indication for termination of pregnancy. Patients who are allergic to neomycin or who are suffering moderate to severe intercurrent illness should not receive varicella vaccine. Varicella vaccine should not be administered for 5 months after a dose of immune globulin. Because of the theoretic risk for Reye s syndrome following varicella vaccine (no cases have been reported to date), salicylates should be withheld for 6 weeks after receipt of the vaccine. Children receiving high doses of systemic corticosteroids (µ2 mg/kg prednisone or 20 mg/day prednisone) form more than 1 month should not receive varicella vaccine until the steroid has been discontinued for 3 months. 5

5 CHILDHOOD IMMUNIZATION Haemophilus Influenzae Serotype b Vaccine Haemophilus influenzae serotype b (Hib) is a gramnegative coccobaccilus that can cause meningitis and many other invasive illnesses such as epiglottitis and pneumonia in children. Vaccination against Hib is not routinely recommended by the Department of Health in Hong Kong but is part of the immunization schedule in some countries like Canada and the United States. It is not uncommon for doctors to be questioned by parents concerning the vaccination against Hib. The vaccines were composed of the capsular polysaccharide of Hib conjugated to a carrier protein, changing it to a T-cell dependent antigen. In the United States, 3 doses of Hib vaccine were given in the first year of life, at the same time as DTaP vaccine. A booster injection would be given between 12 to 15 months. New combined vaccines, which contain conjugated Hib vaccine and DTaP vaccine were available to decrease the number of injections. Hib conjugate vaccines not only demonstrated immunogenicity and clinical protection against invasive disease but also reduced nasopharyngeal carriage of Hib among vaccinated children, resulting in decreased transmission of the organism and herd immunity. Hepatitis A Vaccine The vaccine preparations available now are all inactivated vaccines. They are prepared by using a tissue cultureadapted virus propagated in human fibroblasts, purified, formalin inactivated and alum adsorbed as an adjuvant. There are two preparations available: HAVRIX (GlaxoSmithKline), and VAQTA (Merck). They are given in 2 doses with the second dose given 6-12 months after the first dose. They are not recommended for use in children less than 2 years of age because maternal antibody may blunt the active response. In fact these vaccines are not routinely recommended for children but may be considered for children traveling to endemic areas like mainland China. In children, the most frequently reported effects from the vaccines were pain at the injection site (15-19%), headache (4%), and injection-site induration (4%). The incidence of these effects seems to be lower than those in adults. The short-term protective efficacy of the vaccines seems to be almost 100%. Evidence also shows that the vaccine has a postexposure protective effect. The level of antibody needed for protection is not known but is typically believed to be low. No studies provide data from longer than 7 or 8 years of follow-up, but antibody titres have persisted for that time interval. Based on the half-life of the antibody, calculated persistence of the antibody could be as long as 24 to 47 years based on the initial height of the antibody response. Influenza Vaccine Inactivated influenza vaccines are the major preventive measure available to combat influenza. Each year s influenza vaccine is a trivalent composition, containing three viral strains (two influenza type A strains H1N1 and H3N2, and one influenza type B strain), representing the influenza viruses that are likely to circulate in the upcoming season. The composition of the vaccine is changed yearly based on the recommendations of the WHO influenza surveillance program. The strains to be included are selected the year before, based on the circulating strains arising out of the epicenter in Southeast Asia. The virus is cultivated in egg, purified and concentrated and subsequently inactivated with formalin. The currently used vaccine is a split-virus vaccine which tends to cause less adverse effects in children than the whole-virus vaccines. The recommended strains for the 2001/2002 year season (northern hemisphere) consist of: A/NEW CALEDONIA/20/99 (H1N1) A/MOSCOW/10/99 (H3N2) B/SICHUAN/379/99 In previously unvaccinated children between 6 months and 8 years of age, two doses of vaccine 4 or more weeks apart are needed to achieve adequately protective levels. In infants less than 6 months of age, inactivated vaccines are less immunogenic and may not be protective, so vaccination is not recommended in this age group. Annual vaccination is recommended because of the decreasing immunity in the year following vaccination. The following high-risk groups are recommended to receive the vaccination: Healthy individuals 65 years of age or older Children or adults with underlying chronic pulmonary or cardiac disease, especially asthma, chronic obstructive pulmonary disease, broncho-pulmonary dysplasia, and cancer Residents of nursing homes and other long-term care facilities Children or adults with chronic metabolic diseases, including diabetes mellitus; chronic renal disease; haemoglobinopathies; and immunosuppres-sive disorders, including HIV Children or teenagers receiving long-term aspirin therapy Pregnant women in their second or third trimesters Persons capable of transmitting influenza to individuals at high risk for influenza, including physicians, nurses, other health care workers, employees of nursing homes or long-term care facilities, providers of home care to high-risk individuals, and household members of persons at high risk 7

6 CHILDHOOD IMMUNIZATION The most common adverse effect of the vaccine is soreness at the vaccination site. Influenza vaccination carries a minimal risk for inducing the Guillain-Barre syndrome, estimated at 1 or 2 cases per 1 million vaccinated. The vaccine should be administered in the fall, before the start of the influenza season. It should be administered intramuscularly in the deltoid area in the adult and older children and in the anterolateral aspect of the thigh in infants and toddlers. SELF-ASSESSEMENT QUESTIONS (Please indicate T or F for each question) 1. The followings are contraindications to immunization: a. High fever. b. Childhood asthma. c. URTI. d. Down syndrome. e. Family history of convulsion. 2. The following vaccines are recommended for childhood immunization in Hong Kong: a. B.C.G. b. Hemophilus influenza serotype b vaccine. c. Trivalent Polio vaccine. d. Varicella vaccine. e. Influenza vaccine. 3. The followings are true for B.C.G. vaccine: a. It is a live-attenuated vaccine. b. It is given intramuscularly. c. It is indicated for patient who has a positive skin test to tuberculin. d. It is routinely given to newborn babies in Hong Kong. e. It is routinely given to primary 1 students. 4. The followings are true for Hepatitis B vaccine: a. The two Hepatitis B vaccines available in Hong Kong (H-B-Vax II and Engerix-B) are interchangeable. b. They are live-attenuated vaccines. c. The primary series is three doses given over 6 months. d. The seroconversion rate for HBV vaccine is high. e. Fever is one of the side effects of HBV vaccination. 5. The followings are true for Poliovirus vaccine: a. Oral polio vaccine is a live-attenuated vaccine. b. Oral polio vaccine can cause paralytic poliomyelitis. c. Oral polio vaccine is no longer used in Hong Kong. d. Injectable polio vaccine is safer than oral vaccine. e. Injectable polio vaccine is a live-attenuated vaccine. 6. The followings are true for Pertussis Vaccine: a. Febrile convulsion is one of the reactions to whole-cell Pertussis vaccination. b. History of convulsion within 72 hr after a previous dose is a contraindication to give subsequent doses. c. Acellular pertussis vaccine is better than Pertussis vaccine as far as adverse reactions are concerned. d. It is usually given together with Diphtheria and Tetanus toxoids. e. It should not be given in the first year of life. 7. The followings are true for Measles-Mumps- Rubella Vaccine (MMR): a. It is a live-attenuated vaccine. b. It is usually given at the age of 6 months. c. It should not be given to patients with tuberculosis. d. A booster dose is required. e. It should be given intramuscularly. 8. The followings are true for Varicella Vaccine: a. It induces both humoral and cell mediated immune response. b. Fever is one of the reactions to Varicella vaccination. c. The incidence of zoster after vaccination is just the same as that following natural infection. d. It is useless to vaccinate contacts of chickenpox. e. Salicylate should be withheld for 6 weeks after receipt of the vaccine. 9. The followings are true for Hapatitis A Vaccine: a. It is a live-attenuated vaccine. b. It is recommended in the routine immunization programme in Hong Kong. c. Fever is a common reaction to the vaccine. d. It can offer protection to patients who just contacted the virus. e. It is given in a two doses regime. 10. The followings are true for Influenza Vaccine: a. It should be given annually for protection against infection. b. It contains three strains of influenza virus. c. It is recommended for children or adults with chronic pulmonary diseases. d. It is contraindicated in pregnancy. e. Children below the age of 8 years require 2 doses for adequate protection. 9

7 LECTURE NOTES / SHEP, Sys-Eur HOT 83 mmhg <80 mmhg <90 mmhg 30% 2000 : 140/90 : /90 38% perindopril indapamide4 28% ALLHAT Doxazosin 13% (0.87) ( ) 144/82 154/87 44% HOT 75 mg 0.4% 60 g pravastatin, simvastatin LovastatinHMG-CoA 28% 23% 19, atorvastatin 6% 31% (gemfibrozil) 59% 25% 65% 11

8 LECTURE NOTES >190 mg/dl<160 mg/dl >160 mg/dl<130 mg/dl >130 mg/dl <100 mg/dl >16 mol/l B6 (INR) % 325 mg (INR2-3) ( mg) 22% (2-38%) 12% 4% 300 mg 75 INR3 INR INR HOT75 mg 36% Hart ( mg) ,95% ? 75 mg Ticlopidine, clopidogril 12% dipyridamole 15 ESP mg 50 mg 50 mg >70% 8.8% 60% 2.2% 3-10%<60% 1.6%60-90% 3.2% 13

9 LECTURE NOTES OR 29% 218 >60% 12.1% 4.5%(p<0.049) 12.1% 3.6% CAVITAS <6% >70% 1 Alberts MJ: results of a multicenter prospective randomized trial of carotid artery stenting vs. carotid endarterectomy Stroke :325 HKMA CME PROGRAMME MONTHLY SELF-STUDY SERIES Childhood Immunization (Please indicate T or F in each box) a b c d e CME IN NORTH DISTRICT Current Management of Chronic Hepatitis B Infection Speaker Dr. Hsu Yau Que Date 7 September 2001 (Friday) Time Lunch : 1:15 p.m. 2:00 p.m. Lecture : 2:00 p.m. 3:00 p.m. Venue Lunch : Maxim Chinese Restaurant, 5/F, Landmark North, Sheung Shui Lecture : Meeting Room, Super e-management Centre, Unit Landmark North, Sheung Shui Sponsor GlaxoSmithKline Registration (Ms. Candy Choi) ANSWERS TO AUGUST 2001 ISSUE Office Nephrology for the GPs (Part II) a b c d 1. F T F 2. F T F F 3. F F T F 4. F F T F 5. F F T F 6. F T F F 7. F T F F 8. T F F F 9. T F F F Name: HKMA Membership No. or HKMA CME No.: HKID No.: Signature: Contact Tel. No.: Answer Sheet for September 2001 XX(X) Please return completed answer sheet to the HKMA Secretariat on or before 1 October 2001 for documentation. 1 CME point will be awarded. (Fax: ) :

10 9 October 2001 (Tuesday) Management of Infertility Speaker: HKMA CME Programme CME Lectures in October 2001 Dr. Ho Pak Chung, M.B.B.S., M.D., F.R.C.O.G., F.H.K.A.M.(O&G), F.H.K.C.O.G. Chair in Obstetrics & Gynaecology, Department of Obstetrics & Gynaecology, Faculty of Medicine, The University of Hong Kong This symposium is sponsored by CME Event Organon (HK) Ltd. 16 October 2001 (Tuesday) Latest Development in the Management of Acid-Related Diseases Speaker: Dr. Wong Chun Yu, Benjamin, M.B.B.S.(H.K.), M.D. (H.K.), M.R.C.P. (U.K.), F.H.K.C.P. (Medicine) Associate Professor, Department of Medicine, The University of Hong Kong This symposium is sponsored by Hong Kong Ltd. 23 October 2001 (Tuesday) Is it Possible to Diagnose Asthma in Younger Children? Speaker: Dr. Wong Wing Kin, Gary, B.M.Sc., M.D.(Alta.), M.D.(C.U.H.K.), D.A.B.P., F.H.K.A.M.(Paed.), F.R.C.P.C. Associate Professor, Department of Paediatrics, Prince of Wales Hospital This symposium is sponsored by Merck Sharp & Dohme (Asia) Ltd. Venue & Time Crystal Ballroom, B3 Holiday Inn Golden Mile HK 50 Nathan Road, TST Lunch : 1:00-2:00 p.m. Lecture : 2:00-3:00 p.m. The Ballroom, Level 3 Sheraton Hotel 20 Nathan Road, Kln Lunch : 1:00-2:00 p.m. Lecture : 2:00-3:00 p.m. : : Crystal Ballroom, B3 Holiday Inn Golden Mile HK 50 Nathan Road, TST Lunch : 1:00-2:00 p.m. Lecture : 2:00-3:00 p.m. : : 1. Applicants will be registered to lectures according to their choice and preference and the Association will try its best to accommodate as many doctors as possible in lectures. However, registrations to lectures selected are not guaranteed. 2. To facilitate the necessary arrangements, please send registration forms either by fax or by mail to the Association on or before 22 September Registrants will be confirmed individually , Please register for participation. First come first served. Accreditation: HKMA CME Programme (1 pt per CME hour); Accreditation from various colleges pending Reply Slip To: The Hong Kong Medical Association [Fax: ] [: ] I would like to register for the following CME lecture to be held in October 2001: (Please "tick" the lecture(s) interested and indicate your priority.) 1,2,3 pls. and write down 1, 2, 3 9 Oct (Tue) : Management of Infertility 16 Oct (Tue) : Latest Development in the Management of Acid-Related Diseases 23 Oct (Tue) : Is it Possible to Diagnose Asthma in Younger Children? Name : Tel No. : Fax No. : HKMA Membership No. or HKMA CME No. : Signature : Data collected will be used and processed for the purposes related to the HKMA CME Programme only.

11 CME CALENDAR 18 CME CALENDAR CME Accreditation Date/Time Function Remarks/Contact Info / 1 Sep 2001 Merck Sharp Dohme (Asia) Ltd (Sat) Osteoporosis: Underdiagnosed, Underterated, How the Front Line 12:30-3:30 pm Physician Can Help 1 1 Sep 2001 Department of Medicine & Therapeutics, CUHK (Sat) CUHK Certificate Course in Liver Disease 2001 (IX) - Viral Hepatitis C Clinical Skill Laboratory, 2/F, Clinical Science Building, 2 Sep 2001 (Sun) 1:30-5:00 pm Sep 2001 (Tue) Sep 2001 (Tue - Wed) Sep 2001 (Wed) Sep 2001 (Thu) Sep 2001 HKMA North District Study Group (Fri) Current Management of Chronic Hepatitis B Infection 1 1 Maxim s Chinese Restaurant, 5/F, Landmark North, Sheung Shui, NT 7 Sep 2001 Union Hospital, HKCFP, CU (Fri) Video Viewing Session: Paediatrics - Examination of the Child Seminar Room, 2/F, Medical Centre, Union Hospital, Tai Wai, NT 8 Sep 2001 Our Lady of Maryknoll Hospital, HKMA, (Sat) Kowloon Central District Health Committee 2:30-4:30 pm Refresher Course for Health Care Providers 2001/2002 (I) - 8 Sep 2001 Hong Kong College of Physicians (Sat) Update Lecture - Clinical Trials 2:30-4:30 pm Seminar Room 1, HA Building, 147B Argyle Street, Kln Sep 2001 Hong Kong Baptist Hospital (Mon) Treatment of Cardiovascular & Renal Diseases in Diabetes Mellitus & * 8:00-10:00 pm Use of Insulin 2 2 The Chapel, 9/F, HK Baptist Hospital, Kln Training Room 2, 1/F, OPD Block, Our Lady of Maryknoll Hospital, Kln Common Dermatology Problems in General Practice Prince of Wales Hospital, Shatin, NT Sun Yat Sen University of Medical Sciences HK Alumni Association Common Gynaecological Tumors & Advanced Technology in Artificial Fertilization Flat 1, 11/F Alhambra Building, 385 Nathan Road, Kln Hong Kong Mood Disorders Centre, CUHK Training Course on Mood Disorders in Primary Care (III) - Physicians Heal Thyself: A Practicum on Hypnotherapy Ching Room, Sheraton Hotel, TST, Kln University of HK Medical Centre, QMH & American College of Surgeons (HK Chapter) Pre-Hospital Trauma Life Support Program - Provider Course Jockey Club Skills Developments Centre, Dept of Surgery, University of HK Medical Centre, Queen Mary Hospital, HK Breast Care Centre, Hong Kong Sanatorium & Hospital Who is at Risk for Breast Cancer, How to Manage These Individuals Rm 502, Nursing School, Li Shu Pui Block, Hong Kong Sanatorium & Hospital, HK Hong Kong Baptist Hospital Breast Nursing School Lecture Room, 2/F, Au Shue Hung Health Center, Hong Kong Baptist Hospital, Kln Ming & Ching Room, Sheraton Hotel, TST, Kln 1:30-3:00 pm 1:30-3:00 pm 8:00-9:30 am 8:30-9:30 am 1:00-4:00 pm 2:30-5:30 pm Tel: Tel: Ms. Patti Lam Tel: Dr. Nancy Leung Tel: Mr. Chow Tel: Tel: * Course Fee: $2,000 Tel: Ms. Gloria Hung Tel: Ms. Connie Lok Tel: * Ms.Candy Choi Tel: Tel: Ms. Clara Tsang Tel: Fee: $200 Registration for HKMA Members 1.5 * College accreditation pending HKMA HKDU HKCA HKCCM HKCEM HKCFP HKCOG COHK HKCOS HKCORL HKCPaed HKCPath HKCP HKCPsy HKCR CSHK

12 CME CALENDAR 19 CME Accreditation Date/Time Function Remarks/Contact Info / 11 Sep 2001 Department of Psychiatry, HKU (Tue) Certificate Course on Psychological Medicine (V) - Somatoform Disorders $3,000 per person 12:45-3:15 pm Sheraton Hotel, TST, Kln 11 Sep 2001 Hong Kong Mood Disorders Centre, CUHK (Tue) Training Course on Mood Disorders in Primary Care (IV) - * 1:00-4:00 pm What Really Matters: Doctor-Patient Communication and Psychoeducation 2 12 Sep 2001 (Wed) :30-1:30 pm 12 Sep 2001 (Wed) Sep 2001 (Fri) 1 16 Sep 2001 (Sun) Sep 2001 (Tue) 1:00-4:00 pm Sep 2001 Dept of Medicine & Geriatrics, Our Lady of Maryknoll Hospital (Wed) Journal Club :30-1:30 pm Conference Room A, G/F, North Wing, Our Lady of Maryknoll Hospital, Kln 19 Sep 2001 HKMA CME Programme (Wed) Practical Issues in NSAID and COXIB Usage Crystal Ballroom, Holiday Inn Golden Mile, TST, Kln 19 Sep 2001 Tuen Mun Hospital, DH, HKCFP, HKMA, HKDU, GDA (Wed) Recognition and Management of First Episode Psychosis 1 1 Discussion Room, 1/F, Main Block, Tuen Mun Hospital, NT 19 Sep 2001 Pamela Youde Nethersole E Hospital, HKCFP, HKDU (Wed) Management of Radiotherapy & Chemotherapy Side Effects 1:15-3:00 pm Lecture Hall, 1/F, Pathology Block, Sep 2001 Union Hospital, HKCFP, CU (Fri) Video Viewing Session: Cardiovascular Examination Seminar Room, 2/F, Medical Centre, Union Hospital, Tai Wai, NT Sep 2001 University of HK Medical Centre, QMH & American College (Fri - Sun) of Surgeons (HK Chapter) Advanced Trauma Life Support Program - Student Course University of HK Medical Centre, Queen Mary Hospital, HK Jockey Club Skills Developments Centre, Dept of Surgery, Pamela Youde Nethersole E Hospital, HK Sung Room, Sheraton Hotel, TST, Kln Dept of Medicine & Geriatrics, Our Lady of Maryknoll Hospital Grand Round: Practical Tips in Prescribing Dietary Formulation Conference Room A, G/F, North Wing, Our Lady of Maryknoll Hospital, Kln HKMA CME Programme Clinical Approach in Patients with Respiratory Allergies Crystal Ballroom, Holiday Inn Golden Mile, TST, Kln Union Hospital, HKCFP, CU Video Viewing Session: Paediatrics - Developmental Assessment Seminar Room, 2/F, Medical Centre, Union Hospital, Tai Wai, NT Hong Kong Mood Disorders Centre, CUHK Training Course on Mood Disorders in Primary Care (V) - Hand in Hand: Working with HMDC in Helping Patients with Mood Disorders in Hong Kong Sung Room, Sheraton Hotel, TST, Kln 1:30-3:00 pm 1:00-3:00 pm 1:00-3:00 pm 1:30-4:00 pm 1:30-3:00 pm 1:00-3:00 pm Ms. Elsa Ip Tel: * Fax reply to F: Tel: Tel: Tel: * Ms. Elsa Ip Tel: * Fax reply to F: Ms. Emily Cheuk Tel: Ms. Michelle Lam Tel: * Tel: Course Fee: $5,000 Tel: Tel: Tel: Ms. Kandy Wan $500 per session Course fee: * College accreditation pending HKMA HKDU HKCA HKCCM HKCEM HKCFP HKCOG COHK HKCOS HKCORL HKCPaed HKCPath HKCP HKCPsy HKCR CSHK

13 CME CALENDAR 20 CME Accreditation Date/Time Function Remarks/Contact Info / 22 Sep 2001 Hong Kong Society of Rheumatology Ms. Michelle Chan (Sat) Rheumatology Course for Family Physicians Tel: :00-5:00 pm Sheraton Hotel, TST, Kln 23 Sep 2001 Sun Yat-sen University of Medical Sciences HK Alumni Association Tel: (Sun) Facial Dermatosis 2 2 2:00-5:00 pm Ballroom, Sheraton Hotel, TST, Kln 25 Sep 2001 Department of Psychiatry, HKU Course fee: (Tue) Certificate Course on Psychological Medicine (VI) - $3,000 per person 12:45-3:15 pm Anxiety Disorders 1: Panic & Phobic Disorders $500 per session Sheraton Hotel, TST, Kln Ms. Kandy Wan Tel: Sep 2001 Tseung Kwan O Hospital Ms. Michelle Li (Tue) Resuscitation and Pre-hospital Care 1 1 Tel: :30-3:00 pm G/F, Auditorium, Tseung Kwan O Hospital, Kln 25 Sep 2001 Hong Kong Mood Disorders Centre, CUHK Tel: (Tue) Training Course on Mood Disorders in Primary Care (VI) - * 1:00-4:00 pm Depression and Dementia in the Elderly 2 2 Sung Room, Sheraton Hotel, TST, Kln Sep 2001 University of HK Medical Centre, QMH & American College Course Fee: $5,000 (Tue - Thu) of Surgeons (HK Chapter) Tel: Advanced Trauma Life Support Program - Student Course Jockey Club Skills Developments Centre, Dept of Surgery, University of HK Medical Centre, Queen Mary Hospital, HK 26 Sep 2001 Dept of Medicine & Geriatrics, Our Lady of Maryknoll Hospital Ms. Elsa Ip (Wed) Grand Round: Case Presentation Tel: :30-1:30 pm Conference Room A, G/F, North Wing, Our Lady of Maryknoll Hospital, Kln 1 1 * 27 Sep 2001 HKMA CME Programme Fax reply to (Thu) Office Dermatology for Me (III) F: :00-3:00 pm Crystal Ballroom, Holiday Inn Golden Mile, TST, Kln Sep 2001 Department of Surgery, University of Hong Kong Medical Centre, Ms. Edith Tong (Thu - Fri) Queen Mary Hospital Tel: th Hong Kong International Cancer Congress HKAM Building, HK 28 Sep 2001 Union Hospital Tel: (Fri) Management of Patients with Bleeding per Rectum :30-3:00 pm Seminar Room, 2/F, Medical Centre, Union Hospital, Tai Wai, NT 3 Oct 2001 Breast Care Centre, Hong Kong Sanatorium & Hospital Ms. Gloria Hung (Wed) MRI Scan in Breast Cancer Tel: :30-9:30 am Rm 502, Nursing School, Li Shu Pui Block, 1 1 Hong Kong Sanatorium & Hospital, HK 4 Oct 2001 Hong Kong Baptist Hospital Ms. Connie Lok (Thu) Haemorrhoidal Disease - Current Concepts and Treatment Tel: :00-9:30 am Nursing School Lecture Room, 2/F, Au Shue Hung Health Center, 1 1 Hong Kong Baptist Hospital, Kln 4-7 Oct 2001 Royal College of Pathologist of Australasia, Hong Kong College Ms. Louisa Chiu (Thu - Sun) of Pathologists and the Hong Kong Division of Tel: the International Academy of Pathology International Joint Congress - Challenges and Opportunities in Pathology HKAM Building, Wong Chuk Hang, HK * College accreditation pending Note: For each issue of the CME Bulletin, we shall try our best to include all the CME activities for the month, which are made known to the Association Secretariat. The Credit points awarded by each college are herein indicated for members' reference only. While we try our best to ensure the information to be most accurate and up-to-date, members interested in any of these functions are advised to check with the respective organizers for confirmation of the details. Pharmaceutical advertisements are welcome. For advertising rates and placement details, please contact Ms Samantha Wong, Executive Officer at Tel: , Fax: or samantha@hkma.org HKMA HKDU HKCA HKCCM HKCEM HKCFP HKCOG COHK HKCOS HKCORL HKCPaed HKCPath HKCP HKCPsy HKCR CSHK