Objective: To compare the effectiveness and cost-effectiveness of three methods of inviting women with a long history of non-attendance to undergo cervical screening. Methods: Randomized controlled trial and cost-effectiveness analysis. In all, 1140 women were identified from routine NHS screening records as having no smear for at least 15 years and randomly allocated to receive a telephone call from a nurse, a letter from a well-known celebrity (Claire Rayner) or letter from the local NHS Cervical Screening Commissioner. Uptake of screening was measured using routine data and attributed to interventions if occurring within three months. Uptake was compared with a control group. Costs of carrying out the interventions were noted from the perspective of the NHS and cost-effectiveness, as cost per additional attender, calculated. Results: Uptake following all interventions was low: telephone call (1.4, 95% confidence interval [CI] 0.38-3.6%); celebrity letter (1.8, 95% CI 0.57-4.0%); commissioner letter (4.6, 95% CI 2.5-7.7%); control group (1.8, 95% CI 0.57-4.0%). There were no significant differences between groups. Telephone intervention was not possible in a quarter of women whose numbers were unlisted. Telephone intervention was the most expensive and least effective of the interventions. The commissioner letter yielded an additional attender within three months at an incremental cost of £23.21 compared with taking no action. Conclusions: Neither a telephone call from a nurse nor a letter from a celebrity to encourage attendance for cervical screening were effective or cost-effective in women with a prolonged history of non-participation in the screening programme. A letter from the local cervical screening programme commissioner resulted in a small, non-significant increase in uptake. The low cost and ease of implementation of this intervention supports further research into its use in routine practice.

Aim-To test the hypothesis that children with behavioural and/or developmental problems have significantly higher blood lead concentrations than the general childhood population. Methods-Blood samples were taken from 69 children with behavioural and/or developmental problems and 136 controls (children admitted for elective day case surgery under general anaesthetic). Blood lead estimations were carried out using graphite furnace atomic absorption Results-Children with behavioural and/or developmental problems had higher lead concentrations than controls, both in terms of their distribution across the group (mean geometric lead concentrations: 40.7 (cases), 29.2 (controls), ratio of the means geometric 1.35 (95% CI 1.17, 1.58)) and the proportion of children with lead concentrations above those commonly defined as "toxic"-that is, 100 µg/l (12% (cases), 0.7% (controls); p < 0.001). Multiple linear regression suggested that this diVerence was not explained by diVerences in age, sex, or socioeconomic status of the two comparison groups. Conclusions-Children with behavioural and/or developmental problems are more likely to have significantly higher blood lead concentrations than the general childhood population. Lead, a known and more importantly, a treatable neurotoxin, would further contribute to the impairment suVered by these children. We argue that this group of children should be routinely screened for lead. (Arch Dis Child 2001;85:286-288)

Objective To determine the levels of concern about risks associated with childhood immunisations among principal immunisers in general practice. Design Self-administered postal questionnaire survey. Setting South & West Devon Health Authority. Participants Eighty-eight/102 general practices: 78 practice nurses, 7 general practitioners, 3 health visitors. Of these, 73 (83 per cent) were the principal immuniser for the general practice and comprise the study sample. Results A third of the principal immunisers (34.2 per cent) were concerned about at least one of the immunisations given to children. Most of the concern reported focused on the measles, mumps and rubella vaccinations. Issues mentioned in the reasons given for concern included concerns about safety (risks, reactions and side effects), about parents, about adverse media and publicity, about research evidence, doubts about the need for the second MMR and personal experiences. Conclusion The role of principal immunisers is crucial especially when many parents are undecided about immunisation when they attend a clinic. Addressing their concerns may contribute to improving overall confidence in the immunisation programme.

Culturing of pharyngeal swabs for Neisseria meningitidis is an important clinical and epidemiological tool. Routine methods include direct plating onto solid medium or later plating in the laboratory. A comparison of these methods used with 490 high school students found a significantly higher carriage rate with direct plating (11.8 versus 6.1%; P < 0.001).Pharyngeal carriage of Neisseria meningitidis is common in the general population, with rates of 20 to 30% in young adults (2, 3). Immediate plating of cotton swabs onto solid culture medium at the site of swabbing (direct plating) is commonly used in epidemiological studies to measure carriage rates (2). An accepted alternative method is to place the swabs in transport medium and send them to the laboratory for plating (3). In clinical practice in the United Kingdom, laboratory plating is usual, as reflected in the Public Health Laboratory Service standard operating procedure for culture of pharyngeal swabs. The assumption is that prompt (i.e., often overnight) transport under appropriate conditions will not significantly affect the rate of isolation of N. meningitidis.Nasopharyngeal swabs were collected in autumn 1999 from sixth-form students in the Plymouth area of southwest England as part of a United Kingdom multicenter study of meningococcal carriage. Other study centers were in Manchester, Oxford, Nottingham, London, Glasgow, Cardiff, and Bangor. The study protocol allowed either direct plating or transport in Amies medium for laboratory plating, with the latter method being used in Plymouth. The estimated interval between specimen collection and inoculation of plates ranged between 5 and 7 h. An interim analysis, after swabs were taken from 906 students, showed an unexpectedly low meningococcal carriage rate of 6.1% (55 of 906). This contrasted sharply with results from other centers, where direct plating was mostly used and where carriage rates ranged from 10 to 23%. The culture medium used was GCVCAT. This is a modified New York City medium, containing vancomycin, trimethoprim, and amphotericin B. Quality control of the medium revealed no inhibition of meningococcal growth, and the swab collection technique was satisfactory.We set out to compare meningococcal isolation rates obtained with direct and laboratory plating. Pharyngeal swabs from 490 students were plated on-site and then placed in transport medium for plating at the laboratory. The carriage rate from direct plating was 11.8% (58 of 490), whereas the rate obtained from laboratory plating was 6.1% (30 of 490) ( Table 1). This difference was highly statistically significant using McNemar's test (P Ͻ 0.001). The carriage rate from laboratory plating during the comparative study (6.1%) was the same as the rate before the study (6.1%), suggesting that the difference was unlikely to be due to loss of organisms from the plate. Swabs were taken from students in many of the same schools for direct plating a year later. For schools in which swabs were laboratory plated in the first year and directly...

Objective To compare the health outcomes in sheltered and evacuated populations after a chemical incident in a plastics factory. Design Cross sectional survey. Setting Urban area in southwest England. Participants 1750 residents from the area exposed to the chemical smoke, of which 472 were evacuated and the remaining 1278 were advised to shelter indoors. Main outcome measure Number of adverse health symptoms. A case was defined by the presence of four or more symptoms. Main results 1096 residents (63%; 299 evacuated, 797 sheltered) provided data for analyses. The mean symptom score and proportion of cases were higher in evacuated people than in the sheltered population (evacuated: symptom score 1.9, cases 19.7% (n = 59); sheltered: symptom score 1.0, cases 9.5% (n = 76); P < 0.001 for both). The difference between the two groups attenuated markedly at the end of two weeks from the start of the incident. The two main modifiable risk factors for the odds of becoming a case were evacuation (odds ratio 2.5, 95% confidence interval 1.7 to 3.8) and direct exposure to smoke for more than two hours on the first day of the incident (2.0, 1.7 to 2.3). The distance of residence from the factory or level of exposure before intervention (first six hours) had little effect on the odds of a person becoming a case. Conclusions Sheltering may have been a better protective action than evacuation in this chemical incident, which is consistent with the prevailing expert view. Although this study has limitations, it is based on a real event. Evacuations carry their own risks and resource implications; increased awareness may help to reduce unnecessary evacuations in the future.