either near or distant vision in the best eye was abnormal.

Global educational ability was measured with a combination of scores attained on intelligence, vocabulary, spelling, reading, and arithmetic tests. A score of less than the fifth percentile of control children was categorized as an indication of dysfunction. The Rutter A(2) Parent Questionnaire and the B(2) Teacher Questionnaire were used to measure behavior. Behavioral dysfunction was indicated if the child had problem behavior, hyperactive behavior, unsociable behavior, or any combination of the three behaviors and if that same behavior occurred both at home and at school. Self-care ability was based on whether the child lost control of his or her bladder or bowels at least once a week.

Case children (i.e., children who had experienced a serious acute neurologic illness between ages 2 and 35 months) were more likely than controls to have died or shown some form of dysfunction. This is analyzed in great detail in the report by Madge et al. (1993). The proportion of children who had any dysfunction or died was highest for those with a diagnosis of infantile spasms as the acute event (90 percent); this was followed by nonfebrile severe convulsions (85 percent), encephalopathy (77 percent), and severe febrile convulsions (44 percent). In contrast, only 24 percent of control children had any dysfunction or had died at follow-up.

The authors then investigated the relation between DPT vaccination 7 days prior to the acute illness and long-term outcome in the original study children (Miller et al., 1993). Unfortunately, that analysis excluded the case children with the initial diagnosis of infantile spasms on the basis of a post hoc analysis showing no association between infantile spasms and earlier DPT immunization. The analysis also excluded case children with recognized neurologic defects prior to the acute neurologic illness, although the neurologic status of very young children is difficult to assess and therefore such assessments might not have been done in a rigorous manner. Of the 770 case children reported to have had no apparent neurologic illness prior to the initial illness, 594 were traced and assessed. Of those 594 case children, 367 had died (n = 117) or had some dysfunction (n = 250) at follow-up; 12 of those 367 children had been immunized with DPT within 7 days prior to the acute illness (Miller et al., 1993). This rate was significantly higher than expected by comparison with matched controls (RR, 5.5; 95 percent CI, 1.6 to 23.7). Restriction of the comparison to children who had more serious dysfunctions at follow-up (i.e., children who had neurologic, educational, or behavioral dysfunction or who had died) yielded a higher RR (RR, 7.3; 95 percent CI, 1.9 to 40.9).

Case children who had received DPT within 7 days prior to the acute event were no more or no less likely to have died or experienced dysfunction at the 10-year follow-up (66.7%) than case children who had not been vaccinated with DPT within 7 days prior to the acute event (61.6%).



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