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To study the duration of antibody persistence and protection provided by the hepatitis B vaccine, we followed 773 homosexual men for five years after completion of vaccination. Among the 635 participants in whom antibody levels above 9.9 sample ratio units (SRU) developed after vaccination, 15 percent lost antibody altogether, and in another 27 percent, antibody levels declined below 10 SRU within five years. The extent of the maximal antibody response strongly predicted the persistence of protective antibody. Hepatitis B infection occurred in 55 men; 8 of these infections were clinically important (characterized by the presence of the hepatitis B surface antigen and elevation of liver-enzyme levels), and two of the patients became hepatitis B virus carriers. The long-term risk of hepatitis B infection was inversely related to the maximal antibody response to vaccine. Most severe infections occurred among those who responded poorly or had no response to the vaccination. The risk of late infection with hepatitis B in those with an initially adequate vaccine response increased markedly when antibody levels decreased below 10 SRU, but only 1 of 34 late infections resulted in viremia and liver inflammation. A second series of vaccinations induced a moderate antibody response in 50 percent of the subjects who initially had no response or a poor response; however, the persistence of antibody was poor. Both antibody loss and the risk of severe disease should be considered when booster-dose strategies for the hepatitis B vaccine are being designed.

Strong correlations between the use of CAM and gross socio-economic indicators are demonstrated in the survey. Repeated national surveys of this type could provide a useful vehicle for collecting information about changing patterns of CAM use on a routine basis.

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Objectives-To estimate the potential of general practice, minor injury units, walk in centres and NHS Direct to reduce nonurgent demands on accident and emergency (A&E) departments taking into account the patient's reasons for attending A&E. Methods-A questionnaire survey and notes review of 267 adults presenting to the A&E department of a large teaching hospital in SheYeld, England, triaged to the two lowest priority treatment streams, was conducted over seven weeks. Using defined criteria, patients were classified by the suitability of the presenting health problem to be managed by alternative immediate care services or only by A&E, and also by the likelihood, in similar circumstances, of patients presenting to other services given their reasons for seeking A&E care. Results-Full data were obtained for 96% of participants (255 of 267). Using objective criteria, it is estimated that 55% (95% CI 50%, 62%) of the health problems presented by a non-urgent population attending A&E are suitable for treatment in either general practice, or a minor injury unit, or a walk in centre or by self care after advice from NHS Direct. However, in almost one quarter (24%) of low priority patients who self referred, A&E was not the first contact with the health services for the presenting health problem. The reason for attending A&E cited most frequently by the patients was a belief that radiography was necessary. The reason given least often was seeking advice from a nurse practitioner. Taking into account the objective suitability of the health problem to be treated elsewhere, and the reasons for attending A&E given by the patients, it is estimated that, with similar health problems, as few as 7% (95% CI 3%, 10%) of the non-urgent A&E population may be expected to present to providers other than A&E in the future. Conclusions-The increasing availability of alternative services oVering first contact care for non-urgent health problems, is likely to have little impact on the demand for A&E services. (Emerg Med J 2001;18:482-487) Keywords: immediate care services; NHS Direct Against the background of increasing demands on accident and emergency (A&E) departments, 1 the debate on how to deliver health care appropriately to attenders who are neither accidents nor emergencies has focused on initiatives to encourage patients to present to their general practitioner (GP), 2 or employing GPs in A&E departments to manage the primary care component eVectively and at more or less cost than hospital doctors. [3][4][5][6][7] Recently, the debate has widened to include service models involving extended nursing roles such as minor injury units, 8 nurse practitioners, 9 walk in centres, 10 and the telephone health advice line NHS Direct. 11We studied a sample of non-urgent A&E attenders to improve understanding of why patients present to A&E despite the availability of alternative services. We provide estimates of the potential that other models of health care have to alleviate demands for A&E services taking into account both the s...