2011 Journals

Vol.12 No.1 Jan-June 2011
THE CLINICAL AND EPIDEMIOLOGIC PROFILE OF COMMUNITY-ASSOCIATED METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS INFECTION AMONG PEDIATRIC PATIENTS ADMITTED AT THE PHILIPPINE GENERAL HOSPITAL
Mercy Jeane Uy Aragon, M.D. *, Ma. Liza Gonzales, M.D.*, Anna Ong-Lim, M.D. *Philippine General Hospital
Keywords: Methicillin Resistant Staphylococcus aureus, Community-Associated MRSA, CA-MRSA
Abstract:
Background: Several studies have reported increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA) infection among patients with no predisposing factors. This paper aims to determine the clinical and epidemiologic profile of community-associated MRSA (CA-MRSA) infection among children admitted at UP-PGH.
Methodology: A retrospective review of the medical records of patients 0-to-18 years old with S. aureus isolate admitted at University of the Philippines-Philippine General Hospital (UP PGH) from January 1, 2007 to December 31, 2008 was conducted. S. aureus isolates were classified as methicillin-susceptible S. aureus (MSSA), CA-MRSA or healthcare-associated MRSA (HA-MRSA). Risk factors for MRSA acquisition were identified. Demographic data, site of infection, outcome, and antibiotic susceptibility patterns were compared.
Results: S. aureus was isolated in 382 children. Medical records of 219 (57.33%) patients were available for review. Of the 219 patients, 40.64% had MSSA, 15.07% had CA-MRSA, and 44.3% had HA-MRSA isolates. The prevalence of CA-MRSA is seven per 1000 admissions. There was no statistical difference between the age, sex, outcome and the site of infection among the three groups. The most common source of isolates was exudates, followed by blood. There were statistically significant differences in the resistance patterns of S. aureus isolates, with MSSA and CA-MRSA having lower resistance rates (<10%) as compared to HAMRSA (>40%) and non-beta lactam antibiotics such as tetracycline, clindamycin, cotrimoxazole, gentamicin and vancomycin.
Conclusion: This study showed that MRSA infection is no longer limited to patients with predisposing factors. The type of S. aureus infection cannot be predicted based on clinical and demographic profile of patients. Based on the susceptibility patterns in this study, CA-MRSA may be treated with tetracycline, clindamycin, cotrimoxazole, gentamicin and vancomycin.
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INFECTIONS IN FEBRILE NEUTROPENIC CANCER PATIENTS WHO WERE UNDERGOING CHEMOTHERAPY AT THE MAKATI MEDICAL CENTER
Claire Ann B. Celiz-Pascual, M.D.*, Robert Dennis Garcia, MD.. * *Makati Medical Center
Keywords: Febrile neutropenia, malignancies, chemotherapy
Abstract:
The immune system of children with malignancies is compromised by chemotherapy and by the cancer itself. In addition, frequent intravenous cannulation, indwelling catheters, malnutrition, prolonged exposure to antibiotics and frequent hospitalizations increase the risk for infection. Neutropenia may lead to an inappropriately low inflammatory response so that fever may be the only manifestation of infection. Management of this complication can vary widely, relating to different geographic patterns of infections and antimicrobial resistance, as well as, issues of treatment availability and cost attainment. The objective of this study was to determine the etiology of infections in febrile neutropenic cancer patients aged 18 years and below who were undergoing chemotherapy at the Makati Medical Center. Inpatient charts of 21 episodes of febrile neutropenia in 19 cancer patients undergoing chemotherapy were reviewed. The primary diseases were mostly acute leukemias (94.7%). Sites of documented infections were the respiratory tract (26.1%), skin and soft tissues (21.7%) oral cavity, ear and sinuses (19.6%), gastrointestinal tract (17.4%), bloodstream (8.7%) and the genitourinary tract (6.5%). Cultures from different sites of infection yielded Escherichia coli (36.4%) and Staphylococcus species (27.3%) to be the most common isolates. The overall mortality was 4.8%. Although broad spectrum antibiotics were used as empiric therapy, the number of isolates obtained was too few to allow a standard recommendation on an appropriate antibiotic regimen.
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A CROSS-SECTIONAL ANALYSIS OF NEONATAL BACTEREMIA IN THE NEONATAL INTENSIVE CARE UNIT OF THE PHILIPPINE GENERAL HOSPITAL FROM JULY TO DECEMBER 2006
Cecille Y. Aguilar, M.D.*, Cecilia C. Maramba-Lazarte, M.D.* University of the Philippines College of Medicine – Philippine General Hospital
Keywords: neonates, neonatal factors, maternal factors, bacteremia, sepsis, SIRS.
Abstract:
The Philippine General Hospital (PGH) has the most number of high-risk infant admissions locally. Neonatal bacteremia and sepsis are the perennial problems encountered. Previous researches may not be reflective of the current situation in the Neonatal Intensive Care Unit (NICU) of PGH, thus an updated study on neonatal bacteremia becomes important.
Objectives: This study was performed to describe the clinical profile of neonates born with positive blood cultures together with the new criteria for sepsis as defined by the 2001 International Pediatric Consensus Conference at PGH from July to December 2006.
Methods: A prospective chart review of all neonates born with positive blood cultures at UP-PGH from July 1 to December 31, 2006 was performed. Demographic, clinical, and laboratory data were then analyzed. Results: Out of 3,870 live births, 103 (2.6%) patients with positive blood cultures fulfilled the criteria of sepsis. Mothers were around 20 to 25 years of age comprising 35 (34%), less than half had prenatal checkups and more than 2/3 had not maternal immunizations. Fifty-eight (56%) of the neonates were males, 68 were premature (66%), 76 were appropriate for gestational age (74%), and 37 were of low birth weight (36%). Most patients (62 or 60%) developed sepsis within the first 3 days of admission, while 65 (63%) patients had pneumonia. The most common organisms isolated were Pseudomonas putida (50 or 49%), Burkholderia mallei (15 or 15%) and Burkholderia cepacia (8 or 8%). The organisms were sensitive Ceftazidime, Cefepime and Piperacillin-Tazobactam. Of 103 subjects, 58 or 56% fulfilled the criteria for systemic inflammatory response syndrome (SIRS) for sepsis. Multivariate analysis showed that those with SIRS were 4.89 times more likely to die than those without SIRS.
Conclusion: Sepsis usually develops among neonates in less than 72 hours after their delivery at PGH. The neonates who were prone to develop sepsis were those who are male, premature, appropriate for gestational age, and of low birth weight. The organisms that predominate in PGH are usually gram-negative pathogens. The number of hospital-acquired infection is significant. SIRS could be an important prognostic factor in affecting outcome and may aid significantly in the proper diagnosis of sepsis in newborns.
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VARICELLA IN IMMUNOCOMPROMISED CHILDREN AT THE PHILIPPINE GENERAL HOSPITAL : A SIX-YEAR REVIEW
Elizabeth T. Escaño-Gallardo, M.D.*, Lulu C. Bravo, M.D.* *Philippine General Hospital
Keywords: Varicella, Chickenpox, Immunocompromised, Pediatric Cancer, Acyclovir
Abstract:
Objective: This research aims to describe the profile, clinical course, treatment and outcome of varicella in immunocompromised children at the Philippine General Hospital from January 1999 to December 2004 Study Population: All immunocompromised patients less than 19 years of age with a clinical diagnosis of varicella admitted at the Philippine General Hospital during the study period were included.
Method: A review of medical records and monthly census reports of the Pediatric Infectious Disease and Hematology-Oncology Services was conducted.
Results: Out of 26 immunocompromised patients who developed varicella during the study period, only 22 charts were available for review. Of these patients, 13 were male and 9 were female. The highest incidence occurred from 0 to 5 years old (41%). Twenty patients had an underlying malignancy in the form of leukemia (14%) and solid organ tumors (6%). Two patients were on chronic steroid therapy (Prednisone) for more than a month due to Nephrotic Syndrome and Myelodysplastic Syndrome with Stevens-Johnson Syndrome. The most common presenting symptom was a rash (68%), with an associated fever seen in 54% of the cases. Majority were treated with acyclovir for an average of 7 days with good response. Nine patients developed complications: mainly, pneumonia and sepsis. Recovery rate was 82%; however, fatality rate was 13.6%.
Conclusion: Varicella in immunocompromised children is associated with increased morbidity and mortality. Our patients responded well to sequential intravenous and oral acyclovir. Vaccination of targeted populations such as close household contacts of immunocompromised patients, as well as, healthcare workers may be a good strategy to protect high-risk children from developing the disease and its complications.
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AN IN-VITRO STUDY ON THE ANTIBACTERIAL EFFECT OF NEEM (AZADIRACHTA INDICA) LEAF EXTRACT ON METHICILLIN-SENSITIVE AND METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS
Wendy C. Sarmiento, M.D.*, Cecilia C. Maramba, M.D.*, Ma. Liza M. Gonzales, M.D.* University of the Philippines College of Medicine- Philippine General Hospital
keywords: Staphylococcus aureus, MRSA, Neem, Azadirachta indica, antibacterial
Abstract:
The most common cause of pyogenic infection of the skin and soft tissues in children is Staphylococcus aureus, a fast-emerging problem due to its accompanying significant cost and morbidity. The popularity of herbal medications has increased due to the search for cheaper and more accessible alternatives. However, data is still lacking to back up these claims. Although a few in vitro studies have tested Neem leaf extract on S. aureus, there are none done on Methicillin-resistant Staphylococcus aureus (MRSA) despite the fact that it is being marketed for such purposes.
Objectives: This study aims to determine if Neem leaf extract (Azadirachta indica) has antibacterial properties against Methicillin-sensitive and Methicillin-resistant Staphylococcus aureus and to compare the antistaphylococcal properties of Neem leaf extract with oxacillin, vancomycin, mupirocin, and povidone iodine.
Methods: An in vitro experimental study was performed using Neem leaf, properly identified and verified, was subjected to ethanol extraction of its active ingredients then diluted to produce 25%, 50%, 75%, and 100% concentrations. Standard strains of Staphylococcus aureus and clinical isolates of MRSA where inoculated on blood agar plates and subjected to the standardized disc susceptibility testing method. Zones of inhibition were measured for each test extract and compared to currently used medications, namely oxacillin, vancomycin, mupirocin, and povidone iodine with the pure diluent as negative control. The data was analyzed using difference of means hypothesis testing; it utilized the student’s t-test to determine significance. Results: A trend of increasing antibacterial activity was noted with increasing concentration of the extract. Zones of inhibition started to appear at 50% concentration for S. aureus and 75% for MRSA. The antibiotics were able to produce greater zones of inhibition than the Neem extracts.
Conclusion: Data from this study strongly suggest that the ethanol extract from Neem leaves exhibits in vitro antibacterial activity against both Staphylococcus aureus and MRSA with greatest zones of inhibition noted at 100% concentration.
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SURVEY ON THE KNOWLEDGE, ATTITUDES AND PRACTICES OF PARENTS IN BARANGAY 8A, DISTRICT 1, DAVAO CITY REGARDING THEIR CHILDREN’S IMMUNIZATION
Sylvia E. Caingles, M.D.*, Joanne J. Lobo, M.D.* *Davao Doctors Hospital
Keywords: EPI, immunization, childhood immunizations
Abstract:
Background: Despite the success of the Expanded Program of Immunization, many vaccine-preventable diseases remain prevalent in developing countries.
Objective: This study aims to determine the knowledge, attitudes, and practices of parents regarding immunization of their children.
Methods: This is a descriptive study using a pre-tested, self-administered questionnaire pertaining to knowledge, attitudes, and practices of parents regarding immunization. The questionnaire was given to parents whose children were being immunized at a barangay health center within a one month period.
Results: Twenty-nine (93%) out of 31 mothers claimed they knew what vaccines were to be given, but only 22 (75.86%) were correct. Twenty-one (68.75%) learned of the immunization through barangay health workers. With regard to adverse reactions: giving of appropriate medication was applied by 18 (69.2%) respondents. Six mothers (23%) preferred going to a physician; 29 (93.5%) were aware of the next scheduled dates of visit. Major reasons for missed vaccinations were sickness and long waiting time before vaccine was given: accounting for 9 (29.03%) each. During the times when vaccines were not available at the health center, 19 (61.29%) preferred to wait for it to become available. 20 respondents (64.5%) knew of other recommended vaccines which were not included in the EPI (Non-EPI) vaccines, but only 3 (9.7%) availed of it from private physicians. Of this group, 14 (70%) were willing to avail of the vaccines; 17 (85%) were thought of these vaccines as expensive; 12 (71%) were willing to have their children vaccinated; and 3 (17.64%) opted to save money first prior to vaccination.
Conclusion: Parents still lacked knowledge with regards to their children’s vaccination. The outcome of the child being fully immunized depends on the availability and affordability of vaccine, as well as, the willingness and effort of their parents.
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Vol.12 No.2 July-Dec 2011
A PAIRED COMPARISON OF TUBERCULIN SKIN TEST RESULTS IN CHILDREN WITH CLINICAL MANIFESTATIONS OF TUBERCULOSIS USING 2 TU AND 5 TU TUBERCULINS
Carmina M. Arriola-delos Reyes, M.D., Leilanie Sanchez, M.D., Anna Lisa Ong-Lim, M.D., Ma. Liza M. Gonzales, M.D. University of the Philippines College of Medicine – Philippine General Hospital
Keywords: tuberculin skin test, purified protein derivative, childhood tuberculosis
Abstract:
Rationale: A paired comparison of reactivity to purified protein derivative 2 TU PPD RT-23 and 5 TU PPD-S in children with clinical manifestations of tuberculosis was done to assess if 2 TU PPD RT-23 can be used instead of 5 TU PPD-S in routine Mantoux testing in the country.
Objective: To determine the correlation of skin test reactivity to 2 TU PPD RT-23 and 5 TU PPD-S.
Study Design: Cross Sectional Study.
Methods: Two simultaneous skin tests using 2 TU PPD RT-23 and 5 TU PPD-S were performed. Each dose was randomly assigned in a blinded manner to the right or left forearm and read after 72 hours. Correlation between the size of induration obtained with 2 TU PPD RT-23 and with 5 TU PPD-S was done, as well as, correlation between tuberculin reactivity and age, gender, nutritional status, presence of BCG vaccination, exposure, and clinical manifestations. A p-value Results: Sixty five patients were included in the study. The overall mean difference in paired reaction sizes for the two doses was -1.02 + 2.8 mm (range of -11 to 3 mm). Using the present guidelines in the country to determine a positive tuberculin skin test, 27 (41.5 %) patients were positive when tested with 2 TU PPD RT-23 and 33 (50.8 %) patients were positive when tested with 5 TU PPD. The mean PPD size with 2 TU was 4.7 mm + 6.1 mm compared to 5.8 mm + 6.1 mm with 5 TU. PPD skin test reactivity with the two reagents was highly correlated (intraclass correlation 0.88; 95% CI 0.83-0.94). There was no significant association between age, gender, nutritional status, presence of BCG vaccination, TB exposure, and clinical manifestations to tuberculin reactivity. .
Conclusion: Tuberculin skin test reactivity among children, who were with clinical manifestations of tuberculosis and tested with 2 TU PPD RT-23 and 5 TU PPD-S, were found to be comparable. Age, gender, nutritional status, presence of BCG vaccination, TB exposure, and clinical manifestations were not factors influencing the size of the PPD reaction. 2 TU PPD RT-23 can be used instead of 5 TU PPD-S in routine Mantoux testing.
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WRITE TO PRACTICE
Rea Uy-Epistola
Abstract:
Dr. Jacob Kracier, who is the author of the “Art of Grantsmanship”, aptly puts it: “Good writing will not save bad ideas, but bad writing can kill good ones.” Nowadays, good science and medical researches are often set aside because they are poorly written. Thus, when the Pediatric Infectious Disease Society of the Philippines (PIDSP) announced the conduct of the 1st Medical Writing Skills Workshop here in the Philippines, the sponsored slots of the workshop were filled up straight away. It was held last 2 September at the Hyatt Hotel and Casino, Manila.
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POSITION PAPER OF THE PEDIATRIC INFECTIOUS DISEASES SOCIETY OF THE PHILIPPINES ON PRESERVING THE USEFULNESS OF FLUOROQUINOLONES
Abstract:
At present, there are limited indications for the use of fluoroquinolones in children. Present safety data suggest the possibility of increased musculoskeletal adverse events in this age group. Current indications for use among children include (1) treatment of infections by multi-drug resistant gram negative pathogens, such as shigella dysentery, where there are no safe and effective alternatives and (2) as part of a treatment regimen for multi-drug resistant tuberculosis. Thus it is still an important chemotherapeutic agent in the armamentarium of pediatricians.
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CLINICAL PROFILE AND HISTOPATHOLOGIC DIAGNOSES OF CHILDHOOD PERIPHERAL LYMPHADENOPATHY: AN MMC EXPERIENCE
Maria Christine Joy B. Tanteo, M.D.*, Robert Dennis Garcia, M.D. * Makati Medical Center
Keywords: Lymphadenopathy, Lymph node biopsy, Malignancy, TB Adenitis
Abstract:
Peripheral lymphadenopathy is a common clinical problem wherein surgery is performed, especially, when malignancy cannot be eliminated as a differential diagnosis. In the Philippine setting, there is a paucity of data on the incidence of lymphadenopathy in children.
Objectives: This descriptive study aims to describe the clinical profile and histopathologic diagnoses of peripheral lymphadenopathy requiring biopsy in children aged one-to-eighteen years seen at the Makati Medical Center (MMC) from 1998 to 2008.
Methods: Patients’ charts were reviewed and 22 patients were included in the study; 17 were male and 5 were female. All patients underwent excision biopsy, except for one who had fine needle aspiration biopsy.
Results: The most common sites of peripheral lymphadenopathy were cervical (78%) and inguinal (14%). The most common histopathologic diagnoses were benign etiology (46%), tuberculous (TB) adenitis (32%), and malignancy (23%). Of the malignant cases, three were Hodgkin’s lymphoma and two were non- Hodgkin’s lymphoma. Clinical profile included the findings that patients with benign etiology were younger, presented more frequently with fever; and males were more commonly affected; whereas children with malignant etiology were older, had a shorter duration of lymphadenopathy, which were of a larger size, and with accompanying weight loss.
Conclusion: The following occurred more often in patients with malignancy: children more than 12 years old, cervical location of lymph nodes, shorter duration of lymph node enlargement, the lack of response to initial antibiotic treatment, and the presence of certain signs and symptoms such as fever and weight loss. Excision biopsy was the predominant surgical procedure used despite extensive invasiveness and the requirement of general anesthesia.
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ETIOLOGY OF NEONATAL SEPSIS IN FIVE URBAN HOSPITALS IN THE PHILIPPINES
Cecilia C. Maramba-Lazarte, MD1, Mary Ann C. Bunyi, MD2, Elizabeth E. Gallardo, MD3, Jonathan G. Lim, MD4, Joanne J. Lobo, MD5, Cecille Y. Aguilar, MD1 University of the Philippine- Philippine General Hospital1, Philippine Children`s Medical Center 2, St. Louis University- Hospital of the Sacred Heart3, Chong Hua Hospital4, Davao Doctor’s Hospital5
Keywords: neonatal sepsis, neonatal infection
Abstract:
The most frequent cause of mortality in neonates is infections which include sepsis, meningitis, pneumonia, diarrhea and tetanus. Approximately 1.6 million deaths due to neonatal infections occur annually in developing countries. The causes of sepsis vary from one geographic area to another. Thus, it is important to create a database for the Philippines regarding the etiologies of neonatal sepsis.
Objectives: The study was undertaken to determine the most common bacterial pathogens of neonatal sepsis in the Philippines and the antibiotic sensitivity patterns of these pathogens.
Methods: A multicenter surveillance and chart review was conducted in five hospital sites for a period of six months- from July to December 2006. All neonates less than or equal to 28 days who had positive cultures from a sterile site and or had fulfilled the SIRS criteria as defined by the International Pediatric Sepsis Consensus Conference in the presence of suspected or proven infection were included in the study.
Results: A total of 289 neonates fulfilled the criteria of sepsis. More than 61% of the patients had early onset neonatal sepsis. The most common site of infection was the lungs, (57%), followed by sepsis without an obvious site of infection (35%). In 50% of patients, an organism was identified; gram-negative bacteria were the dominant bacteria found (Pseudomonas, Burkholderia, Klebsiella) which comprised 94% of the bacteria isolated. Resistance patterns varied among the different urban study centers. The Pseudomonas and Burkholderia isolates from the Philippine General Hospital (PGH) were sensitive to ceftazidime. All Klebsiella isolates from St. Louis University (SLU) were resistant to third generation cephalosporins. In contrast, Klebsiella isolates from PGH and Davao were sensitive to third generation cephalosporins but resistant to piperacillin-tazobactam. The overall mortality rate was 11%. Ampicillin and an aminoglycoside were the most common regimens used but were only successful in less than 50% of cases.
Conclusion: Gram-negative organisms comprised the majority of the neonatal infections, with Pseudomonas and Burkholderia being the most prevalent. Resistance patterns differed among the different centers. Continuing surveillance of infections is still needed in order choose the most appropriate empiric therapy for each center.
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THE CLINICAL EFFICACY OF MULTI- STRAIN PROBIOTICS (PROTEXIN) IN THE MANAGEMENT OF ACUTE GASTROENTERITIS IN CHILDREN TWO MONTHS TO TWO YEARS OLD
Expedito T. Yala, M.D.* Department of Pediatrics, Baguio General Hospital and Medical Center
Keywords: Protexin, probiotics, acute gastroenteritis
Abstract:
Acute gastroenteritis is considered as one of the most common causes of morbidity and mortality worldwide. In the Philippines, the World Health Organization (WHO) noted that acute gastroenteritis is the most common cause of morbidity and it ranks among the top 20 causes of mortality. The standard treatment as provided by WHO is the use of oral rehydration solution, intravenous fluid if indicated, and zinc supplement. Recently, the use of probiotics has been introduced as an adjunct to the treatment of acute gastroenteritis; however, its role in the management of the disease has not yet been fully established.
Objective: This study aims to determine the clinical efficacy of multi-strain probiotics (Protexin) as adjunct treatment of acute gastroenteritis.
Methodology: This is a randomized, single-blinded, clinical trial of patients with acute gastroenteritis from age two months to two years old and who were assigned to either Standard Treatment only (Control Group) and Standard treatment plus Protexin (Protexin Group). Both study groups were treated in accordance to the WHO standard regimen of treatment for diarrheal diseases with the addition of a Protexin given to Group B. The frequency of purging, character or texture of stool, length of hospital stay, and adverse reaction to the drug were noted.
Results: A total of 51 patients were eligible for the study. No untoward event was noted from both groups and no adverse reaction was observed when Protexin was used during the study. The Protexin group had a significant decline in purging rate—as early as the second day —which is almost half the purging rate in the control group. Although both groups showed improvement in stool consistency, the experimental group showed significant improvement on the second hospital day. The experimental group had a significantly shorter course of hospitalization of at least one day. The analysis of variance showed a significant difference between the two study groups regarding purging rate, stool consistency, and duration of hospital stay.
Conclusion: Protexin is both efficacious and safe in patients 2 months to 2 years old with acute gastroenteritis. Thus Protexin is beneficial and provides an additional therapeutic modality in the treatment of acute gastroenteritis.
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MMR TRIVALENT VACCINE BASED ON SAFETY, REACTOGENICITY AND IMMUNOGENICITY OBSERVED IN 12–24 MONTH-OLD HEALTHY FILIPINO CHILDREN: EVALUATION OF LOT-TO-LOT CONSISTENCY OF A LIVEATTENUATED MEASLES-MUMPS-RUBELLA
Salvacion Gatchalian, MD.1, 2, 7, Margaret Lu-Fong, MD.3, Leticia Cordero-Yap, MD.4, Jossie Rogacion, MD, MSc (Clin. Epid).5, Josefina Cadorna-Carlos, MD.6, Htay Htay Han, MBBS.7, Hans L Bock, MD.7 1Research Institute for Tropical Medicine, Alabang, Munti
Keywords: MMR, vaccination, immunogenicity, reactogenicity, Priorix™
Abstract:
In this double-blind, randomized single-dose study, 194 healthy Filipino children aged 12–24 months were randomized into three groups (1:1:1) to receive one of the three lots of live-attenuated measles-mumpsrubella (MMR) vaccine to assess lot-to-lot consistency in safety and immunogenicity. Adverse events were recorded during 43-day post-vaccination follow-up period. Antibody levels were measured using ELISA pre-vaccination and on Day-60. No statistically significant differences were observed across groups for overall incidences of local and general symptoms (p>0.05) or immune response rates against the three antigens (p=0.835, 0.458 and 0.222 for anti-measles, anti-mumps and anti-rubella, respectively). The three lots demonstrated consistency in their reactogenicity and immunogenicity profile.
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