Role of Barriers and Technology in Globalization Essay

Role of Barriers and Technology in Globalization - Essay Example The gradual reduction of these barriers has helped lead to the process of globalization by allowing for a more free flow goods & services across boundaries. However, according to Micklethwait and Wooldridge (2003) the reduction of barriers is not an easy process. Often times it requires the passing of serious legislation and laws over long periods of time. From this perspective one could argue that globalization does not occur in leaps and bounds, rather it is a slow and arduous process insofar as there is not one moment that could be pinpointed as the catalyst for globalization. Moreover, the process requires a great deal of goodwill from nations to help ensure that nations remain in good standing with each other, such as the U.S. passing of the Mashall plan to help build Europe as a strong trading partner. Another major contributing factor of globalization is the role of technology. Much like the reduction of trade barriers there is no one single source of technological innovation that is the sole contributor of globalization. Rather it is a series of several new technologies that contribute to globalization. One of the major new technologies is improved communication channels. By having access to telephones, fax machines, email, the internet, instant messaging, mobile telephone devices etc., there comes an increased transparency.

Sec accredited investor for hedge funds PowerPoint Presentation

Sec accredited investor for hedge funds - PowerPoint Presentation Example According to this regulation, accredited investors are those individuals or group of investors who possess financial might and autonomy. These investors are legalized to invest in a higher risk investment such as hedge funds, limited partnerships, seed money, and private placements networks. It also refers generally to wealthy individuals and organizations such as insurance firms, banks, big charities, and some corporations who are allowed to invest in securities markets. These investors require very little protection offered by particular government filings. (Jaffer p. 134) As explained earlier, accredited investors are investors who are financially powerful and very rich individuals and to qualify as accredited investor, one must have at least one of the following: as an individual or together with his or her spouse must have a net worth more than $1 million. He or she must have stable financial income of more than $200,001 annually or a steady joint income of more than $300,000. One must be a director, general partner, or executive officer for the hedge fund . An employee benefit plan or a trust can qualify as accredited investors if the total asset exceeds $5 million. An American financial journalist known as Alfred W. Jones, in 1949, created the first Hedge fund. By then the funds were known to manage the investment risk due to dynamics in the financial markets. The number of hedge fund grew to over 200 by 1968. Hedge funds refer to privately managed accredited investment funds or securities markets. These are investments made in wide range of markets and large schemes and are bound by regulatory restrictions of a given country. In some countries like in U.S, the regulations restrict hedge fund involvement to certain group of accredited investors. These investments are quite flexible and often permit withdrawals or

Effect of Taxation on the Investment Decision in Firms Research Paper

Effect of Taxation on the Investment Decision in Firms - Research Paper Example The government dishes out sops to specific sectors and fulfills its task of generating enough growth in high risk sectors. The investment decision of firms depends upon various factors like the political will and stability, the infrastructure and the tax regime. The taxes levied on corporate investments also have a direct bearing on the profitability of these firms; hence they become a vital factor while taking any investment decisions. This therefore makes tax rates an important instrument with governments who manipulate it to ensure economic growth of a country. This paper examines the effect of taxes on investment decisions of the firms. It explains the various factors that affect firms functioning in the high risk taking sectors and the various instruments available with the government by which they can assist these firms to attain a better economic growth both for the firms and the country. In the end a case study of the steps taken to promote investments in the European Union amplifies the points made in the paper. The profits that a firm earns are directly affected by the rate of taxes that are levied on its produce. This has a bearing on its investment capacity. The poor infrastructure and institutional facilities combined with high tax rates can make any country a poor investment destination for firms. The tax system is an effective tool in the hands of the government to encourage those sectors which require investments of long gestational periods or poorly developed sectors where there is a need of capital investment. By altering the tax rates governments can shift the investments from more lucrative to high risk sectors by giving cuts in corporate tax and accelerated depreciation so as to increase the post tax profitability of the firm. This will lead to long run growth of the business as well as the economy. The effects of the proposed tax cuts like the capital gain tax, import duty exemption or local indirect taxes should be measured in relation to the expenditure change that they can offset. Such reductions in tax rates increase the firm's investment capability. Lower taxes help to reap a higher profit by the firms. The role of the government The government hands out large incentives to firms that are keen to invest in high risk sectors but which are good for the overall growth of the country. These sops can be in the form of tax holidays, import duty exemptions, exemption from custom duties etc. The firm's investment decision is greatly influenced by these tax exemptions. Other major factors that also affect the investments are the political and economic stability of the nation, infrastructure facilities, transport system, roads etc. These factors have an important bearing as they make the environment more conducive for investment, tax rebates are important but cannot be the sole incentive for investment. Especially in the case of MNC and FDI, studies reveal that the investors are mostly influenced by the market, political factors and tax rebates which are being offered. The government attracts foreign investment in targeted high risk

Any topic of your choosing from the study of law enforcement Research Paper

Any topic of your choosing from the study of law enforcement - Research Paper Example As such, they often apprehend criminals who are a menace to innocent citizens (Goldstein 12). This sparks hatred between the criminal gangs and police officers. In this situation, criminal gangs decree that police officers will be vulnerable when they are off work. This is partially owing to the protection from other officers while at work. Similarly, police officers are vulnerable when they are off work since they are not armed (Stering 33). This makes them an easy target. A number of cases have been reports where police officers are attacked at their place of residence. This is a challenge they face owing to their involvement in law enforcement. They are targeted since they limit the activities of criminal gangs. Police officers are considered one of the most stressed government officers. The stress levels in police officers increase owing to the indulgence in their work. They are required to work for long hours since they have to protect the nation throughout day and night (Forbes , 54). This leads to limited hours of sleep. This affects their lives, even when they are off duty. For example, their sleeping pattern is frequently distracted owing to the scope of their work. At times, the police officers are required to report on duty at night. As such, they often feel fatigued and tired. This could affect their family life. In most cases, police officers have families, which need their support and care. Consequentially, with such working conditions, the family support and care is jeopardized. The families have to persevere with such conditions, as it is almost impossible to rectify such a situation. In bizarre instances, it leads to neglect of the family since they do not have ample time with the family. The family could feel neglected since the police officer, who has a family is hardly present for the family. This will increase the stress levels of the police officers as they could have a guilty conscience. Police officers will often have stress concerning th eir job. As such, they would like to relieve their stress with the easiest possible means. Apparently, controlling stress to manageable levels is an indulging activity that needs time and dedication (Stering 19). For example, visiting a therapist will consume time and finances. As such, they revert to using alcohol and drugs. This behavior starts as a genuine solution to an incumbent problem. However, it exceeds to become a problem in itself. When the officers are drunk or high on drugs, they will have ease as they have solved some of their problems. Unfortunately, they get used to the behavior of using drugs and abusing alcohol most of the times they are stressed. This leads to addiction. This further deteriorates the situation as they depend on alcohols and drugs in solving and relieving their stress. As a fact, solving such a situation will require intervention from concerned parties. Bizarrely, some of the concerned parties do not have the time to reflect on the problems of the police officers (Raymond, 41). As such, they will continue with such behaviors. This ruins their life especially when they are off duty. For example, they will have to look for additional finances to sustain their alcohol and drug consumption. This will lead to uncouth behavior including corruption. Police officers are often dispatched to places marred with chaos, war and fighting between members of a society (Goldstein 23). At times, this is not a welcoming scene. Police

Green Washing and Its Effects on Consumer Perspectives Essay Example for Free

Green Washing and Its Effects on Consumer Perspectives Essay The term green washing denotes the use of false or misleading information concerning green marketing by companies to compel consumers to buy their products on the perception that the company is environmentally friendly. It involves the misleading use of green marketing to endorse a false perception that the company products or policies are environmentally friendly. Green washing has been growing in the recent years mainly due to the increasing demand for green products. Due to increasing concerns about global warming, consumers are increasingly demanding for economically responsible products (Hart, 1997). Companies that seek to survive have no option but to either provide these products or to fake them. Another reason why green washing is growing is due to the fact that the sales of green oriented products have increased. A study carried out in the United States showed that in 2007, 328 products labelled â€Å"environmentally friendly† were launched by major manufacturers. This was a significant increase as in 2002 only 5 products were labelled the same (Bansal Roth, 2000). The rise of green products in the market has forced companies to undertake green washing in order to compete effectively. Another reason why green washing is growing is that the communication of environmental messages is still not controlled by any industrial wide standards. Companies are free to disseminate information about their environmental policies without any restrictions hence they can provide misleading information at will. The final reason why green washing is common is that government action and regulation is still pending. An analysis by HSBC on passed and pending economic stimulus packages of 15 countries reported that over US $3 trillion is intended to stimulate economies for the next ten years (Bazzillier Vauday, 2009). A large percentage of this money will support environmental objectives. This situation has resulted in the increase of lobbying which in turn has resulted in a situation whereby companies have to hunt tactical opportunities that do not conform to their messages on environmental friendliness. Ways of Carrying out Green Washing There are several techniques of green washing employed by companies. Although only a few literatures exist on the subject, the basis of identifying these techniques is that proposed by the TerraChoice Environmental Group. The group did research on the manners with which companies mislead consumers about their environmental friendliness and came up with six ways which they dubbed â€Å"the six sins of green washing. † The first sin is â€Å"the sinof hidden trade off†. This involves the attempt by companies to promote a product as green by using only one environmental attribute or an intolerable narrow set of attributes disregarding other more important environmental issues. Although the claims are not false, they portray a â€Å"greener† picture of the product which cannot be supported by a full environmental analysis. The second sin is â€Å"the sin of no proof. † This involves all information disseminated by a company about environmental friendliness but cannot be validated by easily accessible supporting information. According to a study by Bazillier and Vauday (2009), communication of full CSR activities by companies to customers is impossible. As a result, two types of information communicated to consumers exist, hard and soft information. Hard information is that which can be verified by customers but tends to be costly while soft information is that which is readily available to consumers but cannot be verified.

Comparison of Cousin Kate and The Seduction Essay Example for Free

Comparison of Cousin Kate and The Seduction Essay After she has taken the decision about what to do about the lord, she hints that she regrets her relationship with the lord by asking questions. The girl in The Seduction also admits that she regrets her fling with the boy by asking questions, the tenth, eleventh and twelfth stanzas are all asking questions for example how did she feel betrayed? . Both of the poems make the reader feel sorry for the girls featured in them. The Seduction makes you feel sorry for the girl by using phrases such as and he muttered little slag and she sobbed in the cool locked, darkness of her room. From these phrases you learn that the girl is unaware of what the boy is really thinking about her. She also seems to be unaware that she could get pregnant. Cousin Kate makes you feel sorry for the maid by using phrases such as Not mindful I was fair and now I moan an unclean thing that might have been a dove. These phrases tell the reader that she was innocent and unaware of the consequences when she met the lord. I feel more sorry for the maid in Cousin Kate than the girl in The Seduction. This is because I feel that although the girl in The Seduction knew what she was doing was wrong, she did it anyway. She didnt have to have sex with him and although she liked him and it appeared that he liked her she should have known better. I feel more sorry for the maid because she says O cousin Kate my love was true, your love was writ in sand. She truly loved the lord, more than she believes Kate does. The maid also seems innocent. Another reason I feel sorry for the maid is even when she was with the lord, they didnt have a proper relationship, he didnt treat her very well. She felt like his plaything. She didnt mean anything to him. In The Seduction the atmosphere is conveyed well. In the beginning of the poem there is a sense that something will go wrong. Descriptive phrases such as the quiet bricks, far past the silver stream of traffic and far from the blind windows are a sign that things do not all go well. The adjectives are used to show that no one will be around to see whats going on. Another sign that something is going to go wrong is that the poem keeps reminding the reader that the girl is very drunk. We are twice reminded about the number of drinks shes had, these are he handed her the vodka and she knocked it back like water and as he bought her more drinks. The poem says she sat her head rolling forward. This shows that the girl is not in control of what she is doing. The imagery used in the poem is not very positive. The girl is said to be facing the frightening scum on the water. The use of frightening scum gives a very unpleasant image of the water. In the beginning of the poem the scum she faces is only on the top of that water, in the later stages of the poem, she feels the scum facing her is the rest of her life. The Mersey, green as a septic wound is also a negative simile. It gives a bad image of the setting, which gives an image of bad things to come. After the girl has discovered she is pregnant, the atmosphere is very powerful. Using strong verbs such as ripped and flung, cheated, creates this. At the end of the poem the girl is very depressed. She says: Better to starve yourself like a sick precocious child- Than to walk through town with a belly huge and ripe. We anticipate what will happen in the future. The atmosphere also changed in Cousin Kate. In the beginning of the poem the atmosphere is good. The maids says contented with my cottage mates which tells me that she is happy with her life before she met the lord. After this point she becomes angry and depressed. This is because the lord has left her for Kate. She becomes enraged and jealous. I believe that The Seduction is aimed at a younger audience than Cousin Kate. The Seduction uses much simpler language, although this could be because The Seduction was written much later. Both poems warn about pregnancy but The Seduction is easier to understand for people my age. I found The Seduction easier to understand and relate to because the language is more modern. In Cousin Kate the maid says the neighbours call you good and pure, call me an outcast thing. In The Seduction it says: And better now, to turn away, move away, fade away, Than to have the neighbours whisper that you always looked the type. In both examples the girls are worried about what other people (the neighbours) think of them. The mood of both poems is quite angry. In Cousin Kate, the mood changes from excitement to anger and jealousy. The maid is excited because about her future with the lord and their relationship. She is then angry about the lord leaving her to be with Kate. She is jealous of Kate because she took the lord away from her. However, the maid also feels quite proud because she has a son and Kate does not, she is smug. In The Seduction the mood also changes from excitement to anger. She too is excited about her relationship with the man. She is angry because the man left her, instead of feeling proud or smug at the end of the poem, she is depressed. The tones of the two poems are very different. In Cousin Kate, the writer (Rosetti) seems to be very sympathetic to the maid. She says that the maid has sex with the lord because she loves him and does not criticize her behaviour or suggest that she has done anything wrong by doing this. The tone of The Seduction however, does seem to criticize the girl. The writer (McAuley) seems to criticise the girls behaviour, she makes out that the girl deserves what happens. The phrase and he muttered little slag suggests this. I have found The Seduction easier to understand, mainly because the language is simpler and the images described are more modern. However I prefer the imagery used in Cousin Kate because I feel it is more original and interesting. I prefer phrases such as his plaything and his love and he wore me like a silken knot to his eyes as blue as iodine and green as a septic wound. On the other hand, I think the symbolism used in The Seduction is very effective, i. e. the confetti and the high white shoes. I feel that the main reason I prefer The Seduction is its easier to relate to for my age group. It is very hard to imagine what it would be like to be singled out by a great lord and then to be left for her cousin and having the lords baby on the way. I find it much easier to relate to The Seduction as I can understand how it must feel to have a one night stand and then become pregnant. 1 Show preview only The above preview is unformatted text This student written piece of work is one of many that can be found in our GCSE JRR Tolkien section.

Nurse-led Respiratory Syncytial Virus Immunisation

Nurse-led Respiratory Syncytial Virus Immunisation Respiratory syncyital virus in pre-term babies. Setting up a nurse led clinic to give Synagis (immunisation) with implications for nursing practice. From the neonatal nurses view point. Introduction The respiratory syncytial virus is identified as a labile paramyxovirus which produces a histologically characteristic effect of causing fusion of human cells in tissue culture – hence the term â€Å"syncytial†. It is commonly sub-classified into types A and B. The B strain is generally asymptomatic in the majority of the population whereas the A subtype tends to produce the more severe illnesses which tend to predominate in the majority of clinically significant outbreaks (Bar-on ME et al 1996). It has an incubation period of 4-6 days and the infection typically lasts from 7-14 days, but does occasionally last up to three weeks. If it becomes necessary to hospitalise a child with respiratory syncytial virus infection, the admission period is typically 5-7 days.(Hentschel J et al 2005) Contagion in the form of virus shedding is its highest levels during days 2-4 of the illness but the active viral particles will continue to be shed for up to 14 days after the clinical onset of symptoms. The respiratory syncytial virus is known to affect both upper and lower respiratory tracts although the most clinically significant manifestations arise in lower respiratory tract infections, bronchiolitis and pneumonia being perhaps the most significant. Bronchiolitis is a particularly severe illness in the pre-term infant by virtue of the fact that it causes very significant small airways obstruction. (Sigurs N et al 1995) The respiratory syncytial virus is currently the commonest identified cause of lower respiratory tract infections in children under the age of three world-wide. Serological studies have identified that, at least in the UK, that virtually all children will have had at least one episode of infection by the age of three. In the infant and neonate age groups, it is currently the numerically largest cause of both pneumonia and bronchiolitis (Krilov L R et al 1997), and is also thought to play a role (as yet not fully understood), in the aetiology of both asthma and chronic obstructive airways disease.(Pullan C R et al 1998) For those patients who have concurrent immunodeficiency states it is a very significant cause of both morbidity and mortality (Long C E et al 1995) Clinical presentation In our considerations here we shall confine our discussion to those clinical manifestations common in the neonatal group and accept that the comments made do not necessarily apply to those older children and adults who may also contract the virus. The respiratory syncytial virus is currently the commonest cause of pneumonia in young children with the greatest preponderance in the under three age range. (Jeng M-J et al 1997) The initial phases of an infection are generally characterised by symptoms of a transient upper respiratory tract infection such as runny nose, watery eyes and mild pyrexia. This typically progresses to produce symptoms of cough, wheeze (although this may be absent in the neonate), high pyrexia, dyspnoea, central cyanosis – characterised by a bluish tinge to the skin, lips and fingernails, increased respiratory rate and occasionally visible utilisation of the accessory muscles of respiration and sub-costal retraction, all of which indicate lower respiratory tract involvement. (Brunell P A 1997). In severe cases it can progress to the point of respiratory failure. In the context of our discussion here, these developments can be extremely dangerous in the pre-term infant who has significantly smaller airways than older children or adults, and also less in the way of respiratory reserve, so that any embarrassment of the respiratory function is of proportionally greater clinical significance. (Graham S M et al 2002) Particular risk factors for a severe bout of the disease are: Prematurity Young age (especially those less than six weeks old) Pre-existing heart conditions (congenital malformations) Pre-existing lung conditions (bronchopulmonary dysplasia and cystic fibrosis ) Immune system malfunction Low socio-economic status and especially those who live in Overcrowded housing conditions Passive exposure to cigarette smoke Day care or childcare attendance Presence of older children in the same household Lack of innate immunity from failure to breast feed. (after Thompson et al. 2003) Mode of infection After each bout of infection the body develops a degree of immunity to the virus. This is less of a factor in the neonate, whose immune system has not developed to the same degree as in the older child. In the pre-term infant , the immune response is (in practical terms) almost non-existent. In any event the immunity is never complete as the virus is capable of subtle mutations of its protein coat which allows it to partially evade the immune system. Re-infections are common but they do tend to be less severe than the original attack. (Panicar J, et al 2004) The mode of spread is through droplet spread and from direct contact with infected nasal or oral fluids. It can enter the body most easily through the epithelial surfaces of the eyes and nose. Epidimiology The respiratory syncytial virus produces characteristic patterns of infection which are epidemics of up to five months duration. They typically occur in the winter months and records show (since 1990) that they typically begin in the time span between October to mid-December with a marked peak in January and February. In the UK, the respiratory syncytial virus is responsible for about 125,000 episodes of hospitalisation (Leader S et al 2002).and about 2,500 deaths (NCHS 2002). These factors are of particular importance in our considerations when we are considering the timing of any protection programme. These figures translate into the fact that 20% of all hospital admissions for lower respiratory tract infections are due to respiratory syncytial virus infections, and if looked at as an annual incidence rate, admission for respiratory syncytial virus infection is currently 28.3 per 1,000 infants and 1.3 per 1,000 for children under the age of 4 years. (Muller-Pebody B et al 2002) The highest rate of clinically significant infection occurs at ages between 2 and 6 months with a significant peak in the 2-3 month age range. Respiratory syncytial virus is typically brought into the home by an older (school age) child who then passes it onto the younger child in the family. In child care and crà ¨che facilities it is quite common to observe 100% infection rates in both children and staff. On a practical note, respiratory syncytial virus infection has also been seen to spread throughout a hospital environment infecting patients and staff alike. (Shay, D K et al 2001), We shall specifically consider the implications of vaccination later in this essay, but there are other issues of prevention that require examination. We have already discussed the mode of common infection through the respiratory and ocular epithelial surfaces. It follows that there are certain measures which, while not eradicating the possibility of spread, will certainly help to reduce it. In the home environment, it is sensible to frequently wash hands after coming into contact with nasal or oral secretions and before handling a young child. Frequent handwashing will reduce the risk of contamination by direct spread. School age children should be kept as separate as practically possible from a neonate if they have symptoms of a â€Å"cold†. Sneezing into a handkerchief will also help to reduce the possibility of droplet transmission. In its droplet form, the virus will live on household surfaces for many hours and is therefore still capable of transmission. In terms of the work of the neonatal community nurse, such patient education should be seen both as part of an empowerment and education programme every bit as much as a prophylactic measure for the neonate. (Hogston, R et al 2002). In the more controlled environment of a hospital, it is possible to institute barrier measures if there is significant risk such as the immuno-compromised patient or the child at risk with congenital heart disease. Frequent pre-touching hand washing is essential to help prevent cross transmission (Ng D K et al 2000). Specific preventative treatments Palivizumab ( or Synagis – Trade name) is a medication that is commonly given to infants at highest risk of complications of respiratory syncytial virus infection, for example those who were born prematurely or those with chronic heart and lung disease. It is given by monthly injection through the at-risk winter months and provides significant levels of protection. This protection however, is comparatively short lived and has to be repeated on a yearly basis until the child is judged to be no longer at high risk of significant sequelae of infection. (PPTI 2005). It is also extremely expensive. (see on). Palivizumab is the first of what may become a series, of monoclonal antibodies, which have been developed to specifically target and combat one specific infection. Its current indications include prevention of serious lower respiratory tract disease caused specifically by the respiratory syncytial virus. There are currently a number of papers that have studied its safety and efficacy in a number of situations such as bronchopulmonary dysplasia (BPD), infants with a history of premature birth (≠¤35 weeks gestational age), and children with hemodynamically significant CHD. (Meissner H C et al 1999), Technically it is a humanised monoclonal antibody of IgG1k type which is produced by recombinant DNA methods. It targets an A antigenic site of the F-protein covering of the virus. It is primarily derived from human antibody sequences and has two light and two heavy chains with a molecular weight of about 148,000 Daltons. The viability of nurse-led respiratory syncytial virus immunisation programme. >From the literature and the evidence that we have presented so far we can point to the fact that the respiratory syncytial virus is a significant risk to neonates, especially those who have significant risk factors for the development of lower respiratory tract complications. (Berwick D 2005) Although we specifically have not considered treatment in this essay, we should note that, in the context of a discussion on the role of prophylaxis, that the treatments available for neonate infection with respiratory syncytial virus are severely limited. In the words of Jon Friedland, an eminent professor of infectious diseases in London: Treating respiratory syncytial virus bronchiolitis remains a good example of therapeutic nihilism — nothing works except oxygen. Adrenaline, bronchodilators, steroids, and ribavirin all confer no real benefit. (quoted in Handforth J et al 2004) If we accept that this is the case and we also accept the significant morbidity and mortality rates quoted earlier in this essay, then it clearly makes sense to consider the role of prophylaxis in respiratory syncytial virus infections. It clearly therefore also makes sense to consider what active measures can be taken in order to try to reduce the possibility of infection or prevent the damaging and serious sequelae of infection. Sadly, this is far from straightforward. One could reasonably hope that a immunologically based vaccine would have been developed to help with this problem. Despite the fact that the first formalin inactivated respiratory syncytial virus vaccine was developed over forty years ago, progress in this field appears to have been painfully slow. Recently published literature on the subject of the effect of vaccines against respiratory syncytial virus found that there was no significant benefit conferred in terms of preventing either the infection or the complications. (Simoes E A et al 2001). We should note that this was not a small study but a meta-analysis of five major studies on the subject and therefore has considerable weight if we are considering an evidence base for our findings. (Green J et al 1998). If we accept the premise that a successful respiratory syncytial virus vaccine should be able to prevent severe lower respiratory tract disease and the morbidity consequent upon it, and should also ideally protect against both A and B strains of the virus, we would also have to postulate that it would have to be given directly after birth in order to prevent immediate primary infection form the environment. In general terms, this presents the nub of the problem as neonates have very poorly developed immune response mechanisms and the bulk of their immunity is passively derived form the trans-placental maternal antibody production and the immunoglobulins present in the maternal milk. (Kim H W et al 1969). Active immunisation in very early life proves to be fruitless, as the immature neonatal immune system cannot generally produce either an adequate T-cell response or effective antibody levels. It is also the case that the maternal antibodies themselves, also interfere with the infant’s ability to mount an antibody response of its own. (Clements M L et al 1996) In order to combat these problems there are a number of immunological strategies currently under investigation. One strategy is to vaccinate the mother during the third trimester in order to try to boost the naturally occurring antibodies and thereby increase the natural passive immunity. This is unlikely to give significant immunity beyond the first six weeks of birth unless the child is breast fed, in which case the immunity would last for longer (see below). It would however, have the advantage of protecting the most vulnerable individuals at a critical time. Initial trials of this method using a purified F protein subunit vaccine was found to be safe in a trial of 35 third trimester vaccinations. (Munoz FM et al 2003). The trial showed a disappointing, but detectable, response and the infants had increased IgG against respiratory syncytial virus up until 9 months of age. Clearly this strategy would be ineffective against children born with a significant degree of prematurity and who therefore, are at greatest risk A second approach was tried with live attenuated genetically modified vaccine. This approach was found to work in adults and older children but could not be sufficiently attenuated to produce a safe and sufficient response in neonates. (Piedra P A 2003). The third approach was to try live recombinant viral vectors which expressed respiratory syncytial virus proteins. Thus far, the results have been disappointing both in terms of immunogenicity and there are also safety concerns with iatrogenic oncogene activation. (Haller A A et al 2003) In terms of our potential nurse run clinic, all of these options have very significant drawbacks and none are therefore likely to represent a realistic immunisation option. Clarke (S J et al 2000) suggest that although huge strides have been taken with a number of vaccine products – especially the live attenuated vaccines, it will probably be a minimum of another decade before routine effective vaccination becomes widely available. It is perhaps because of this failure to present a solution of a vaccine that has caused researchers to examine other avenues of investigation for workable prophylactics. A line of investigation into passive immunity with IV hyperimmune globulins against respiratory syncytial virus has shown positive results in initial trials against preventing severe forms of respiratory complications in high risk children (Groothuis J R et al 1999). This particular formulation can only be given intravenously and therefore is of limited use outside of a hospital environment. It is clearly of no use in a community setting. The other line of passive immunity has developed into the intramuscular form of IgG humanised monoclonal antibody described above (palivizumab). Clinical trials already published have already shown that monthly injections of palivizumab in high risk infants have been able to reduce the hospital admissions for respiratory syncytial virus-related disease by more than 50% (IRSVSG 1998). This was a well designed double-blind placebo controlled randomised study and, in addition to apparently demonstrating its efficacy, it also showed an impressive safety record. This particular formulation appears to have a very good side-effect profile and clinical experience appears to confirm the initial trial results. Given the fact that respiratory syncytial virus places a heavy financial and economic burden on the NHS, a 50 % reduction in these levels is quite substantial. Cost-effectiveness is clearly a major question in any consideration of a national vaccination programme and studies elsewhere in Europe, (Roeckl-Wiedmann I et al 2003) have called into question the costings and have therefore also called into question the need for further evaluation. These considerations are given further credence if we consider the fact that if we take as a marker the number of hospital laboratory reports of respiratory syncytial virus, there appears to be a marked downward trend in the UK between 1990 and 2003. (Fleming D M et al 2003). It may be that there are other active factors here such as changes in clinical or laboratory practice, but it would appear to reflect a definite downward trend. This comment is actually given further credence when one considers the epidemiological data from the primary health care sources which also show a fall in acute respiratory infections over the same period. (Neuzil K M et al 2000) Passive immunisation is currently considered to be the best option in terms of providing immunity in the community although many authorities consider that it is currently only an option for the high risk infant. In the terms of our consideration here for a nurse run immunisation clinic, we should consider a set of guidelines, (that were actually produced in the USA), which could be adopted as they are based on the current best evidence available. (AAP 2003) The guidelines suggest that passive immunisation (palivizumab ) should be currently considered for premature infants born at less than 32-35 weeks gestation or for infants younger than 2 years with chronic lung disease. Although this is clearly a rational view, we have to note that it is based upon American statistics and American costings and is applicable primarily to American culture. It does not imply that the recommendations are necessarily transferable to the UK situation. The NHS has been more cautious. The current NHS guidelines were considered and formulated by the joint committee on vaccination and immunisation of the Department of Health. (JCVI 2002). Their report notes that: Palivizumab seems safe, well tolerated, and effective in reducing admissions to hospital, but it remains very expensive, at a cost of around  £2500 for five doses over the season for respiratory syncytial virus. In the UK, the statistics seem to suggest that readmission rates associated with respiratory syncytial virus infection-related bronchioliitis show that palivizumab is only cost effective if it is used in infants born prematurely with chronic lung disease and receiving oxygen at home (which is actually a very expensive undertaking in any event). (Feltes T F et al 2003). If this opinion is taken in conjunction with the suspicion that the rates of respiratory syncytial virus infection are actually falling, this will actually weight the cost-effectiveness argument further against the use of palivizumab. It is noted that a more recent study of palivizumab in infants who have congenital heart disease has been completed, but the information collected is insufficient in terms of readmission rates, morbidity and cost-benefit analysis, to allow a confident recommendation for use in this population. (Feltes T F et al 2003) The neonatal nurse’s viewpoint. In this essay we have considered much of the current literature on the subject of community immunisation for respiratory syncytial virus. There is little doubt that the virus represents a significant threat to a small proportion of neonates and a minor threat to the rest. (Crowe JE Jr 1995). It is also clear from the evidence that the prospect of active immunisation of the at risk groups has been aggressively pursued over a time scale of about four decades with very little in the way of positive practical results. In essence, this means that the only realistic prospect of giving the at-risk neonate a degree of protection against the respiratory syncytial virus, is by means of increasing the levels of passive immunity. We have considered the role of the only viable therapeutic agent in this area (palivizumab), and have come to the conclusion that the evidence base for its use is sound if it is given on a monthly basis through the winter months when the at risk populations are at greatest risk of significant morbidity, and indeed mortality. Against this statement we have to weight the cost-effectiveness of what is a very expensive agent. (Handforth J et al 2000). The neonatal community nurse therefore finds herself ideally placed to act as the gatekeeper in this role. By virtue of her position of having direct contact with each of the neonates in her community, she is probably the most optimally places member of the primary healthcare team to assess and oversee the administration of palivizumab to those at greatest risk. (Scally G et al 1998) The mechanics of the enterprise will inevitably vary from practice to practice, but the elements of any recall system will be an up to date age/sex register, a forward planning facility and good communications with the antenatal services so that prospective candidates can be assessed at the earliest opportunity. The multidisciplinary nature of the modern primary healthcare team is ideal for communication of this nature and the neonatal nurse should be able to optimally utilise the recall facilities of the practice in order to ensure maximal compliance once the decision to treat has been made. (Yura H et al 1998) On the positive side there is the fact that Nurse led clinics, in general terms, have been proven to work both effectively and efficiently in many other areas. On the negative side we have the practical situation that the current recommendations from the Joint Committee on Vaccination and Immunisation that the current evidence base supports the view that palivizumab should only be offered to babies in the Group I classification, which currently includes babies under the age of two years with severe chronic lung disease, on home oxygen during the RSV season. This represents about 500 babies a year nationally. Common sense would indicate that there is absolutely no practical rationale for setting up any form of clinic in primary care for this number of babies on a national basis. Even if this recommendation was extended to include those babies in Group II (those with chronic lung disease but not on home oxygen), this would only add another 1000 to the national total and again, clearly there would be absolutely no rationale for setting up a local clinic base for this type of work load. (Netten A et al. 2000) The Committee’s reasoning for offering palivizumab to the Group I babies was on the evidence that it would be likely to reduce hospitalisation by a factor of 40% and thereby be cost effective. The Committee also suggested that these guidelines should be reviewed if a more effective and cheaper vaccine became available. If we consider, for the sake of argument, that such a vaccine has become available and that it is both practical and National policy to set up such vaccination clinics, we can consider the leads given by papers that report experiences in other areas of childhood vaccination. Nesbitt (A et al. 1997) give a very informative overview of the practical difficulties involved in setting up a Hepatitis B vaccination clinic. They point to the problems of trying to reach the most vulnerable and potentially isolated individuals in the community and highlight the need for specific nurse initiated home visits to the persistent absentees to the clinic. (Nesbitt A et al. 1995) They also highlight the difficulties in trying to get a level of immunity in a population that is constantly turning over. It requires a very high degree of vigilance on the part of the nurse running the clinic to ensure that all new arrivals are incorporated into the recall system with complete efficiency and without delay. On a slightly tangential subject, the whole issue of the nurse-led clinic was reviewed and assessed for overall effectiveness and cost effectiveness by Raftery (J et al. 2005). This paper demonstrated, beyond doubt that nurse led clinics could be both effective and very cost effective. This particular paper looked at the role of the clinic in the prevention of heart disease in the adult population, which is clearly not directly applicable to our considerations here, but the important relevant considerations are that the autonomous nurse led clinic can work very effectively with auditable results that can demonstrate both positive health benefits and an efficient and cost-effective use of a nurse’s time. (Polsky D et al. 1997) One of the interesting points raised in this paper which was also directly transferable to a nurse led immunisation clinic was that the increased costs noted also included an element for increased prescribing for intercurrent morbidity that was discovered at the time of the assessment. This is a factor that is likely to be translated into increased costings for the vaccination clinic, as many mothers are likely to save up questions and minor degrees of pathology if they know that they are having an appointment with the practice nurse. (Lancaster T 2003). This may well be translated into increased prescribing costs. Taking a holistic view however, one would hope that these costs would not be incurred without good reason and therefore one could conclude that it would be for the greater good of the patient in the long run and therefore presumably justified. (Benger J R et al. 2005) Considering all of these issues one can see that the viability of the nurse led clinic, certainly in the areas of RSV vaccination, is totally dependant on the development of an effective and cheaper vaccine. At this point in time, the recommendations do not support the logistics of a nurse led clinic for palivizumab although it is clear that the neonatal nurse should be the prime source of the palivizumab vaccination, the numbers involved support the specific identification and targeting of the Group I babies. References AAP 2003 American Academy of Pediatrics. Respiratory syncytial virus. In: Pickering LK, ed. Red Book: 2003 Report of the committee on infectious diseases. 26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003: 523-8. Bar-on ME, Zanga JR. 1996 Bronchiolitis. Prim Care. 1996;23:805-819. Benger J R, Hoskins R 2005 Nurse led care: Nurses are autonomous professionals delivering expert care BMJ 2005 330: 1084. Berwick D 2005 Broadening the view of evidence-based medicine Qual. Saf. Health Care, Oct 2005; 14: 315 316. Brunell PA. 1997 The respiratory season is upon us. Infectious Diseases in Children. Thorofare, NJ: Slack Inc; 1997;10(1):5. Clark SJ, Beresford MW, Subhedar NV, Shaw NJ. 2000 Respiratory syncytial virus infection in high risk infants and the potential impact of prophylaxis in a United Kingdom cohort. Arch Dis Child 2000;83: 313-6 Clements ML, Makhene MK, Karron RA, Murphy BR, Steinhoff MC, Subbarao K, et al. 1996 Effective immunisation with live attenuated influenza A virus can be achieved in early infancy. J Infect Dis 1996;173: 44-51. Crowe JE Jr. 1995 Current approaches to the development of vaccines against disease caused by respiratory syncytial virus (RSV) and parainfluenza virus (PIV): a meeting report of the WHO Programme for Vaccine Development. Vaccine 1995;13: 415-21. Feltes TF, Cabalka AK, Meissner HC, Piazza FM, Carlin DA, Top FH, et al for the Cardiac Synagis Study Group.2003 Palivizumab reduces hospitalisation due to respiratory syncytial virus in young children with haemodynamically significant congenital heart disease. J Pediatrics 2003;143: 532-40 Fleming DM, Ross AM, Cross KW, Kendall H. 2003 The reducing influence of respiratory tract infection and its relation to antibiotic prescribing. Br J Gen Pract 2003;53: 778-83. Graham SM, Gibb DM. 002 HIV disease and respiratory infection in children. Br Med Bull 2002;61: 133-50 Green J, Britten N. 1998 Qualitative research and evidence based medicine. BMJ 1998; 316: 1230-1233 Groothuis JR, Simoes EAE, Levin MJ, Hall CB, Long CE, Rodriguez WJ. 1999 Prophylactic administration of respiratory syncytial virus immune globulin to high-risk infants and young children. N Engl J Med 1999;329: 1524-30 Haller AA, Mitiku M, Macphail M. 2003 Bovine parainfluenza virus type 3 (PIV3) expressing the respiratory syncytial virus (RSV) attachment and fusion proteins protects hamsters from challenge with human PIV3 and RSV. J Gen Virol 2003;84(Pt 8): 2153-62 Handforth J, Friedland JS, Sharland M. 2000 Basic epidemiology and immunopathology of RSV in children. Paediatr Respir Rev 2000;1: 210-4 Handforth J, Mike Sharland, and Jon S Friedland 2004 Prevention of respiratory syncytial virus infection in infants BMJ, May 2004; 328: 1026 – 1027 Hentschel J Berger T M Tschopp A et al 2005 Population-based study of bronchopulmonary dysplasia in very low birth weight infants in Switzerland. Eur J Pediatr 2005 May;164(5):292-7. Hogston, R. Simpson, P. M. (2002) Foundations in nursing practice 2nd Edition, London: Palgrave Macmillian. 2002 IRSVSG 1998 The Impact-RSV Study Group. Palivizumab, a humanized respiratory syncytial virus monoclonal antibody, reduces hospitalization from respiratory syncytial virus infection in high-risk infants. Pediatrics 1998;102: 531-7 Jeng M-J, Lemen RJ. 1997 Respiratory syncytial virus bronciolitis. Am Fam Physician. 1997;55:1139-1146. JCVI 2002 Joint Committee on Vaccination and Immunisation. Minutes of the meeting held on 1 November 2002. www.doh.gov.uk/jcvimins01nov02.htm (accessed 31.3.06) Kim HW, Canchola JG, Brandt CD, Pyles G, Chanock RM, Jensen K, et al. 1969 Respiratory syncytial virus disease in infants despite prior administration of antigenic inactivated vaccine. Am J Epidemiol 1969;89: 422-34 Krilov LR, Mandel FS, Barone SR, Fagin JC and The Bronchiolitis Study Group. 1997 Follow-up of the children with respiratory syncytial virus bronchiolitis in 1986 and 1987: potential effect of ribavirin on long term pulmonary function. Pediatr Infect Dis J. 1997;16:273-6. Lancaster T. 2003 The benefits of nurse led secondary prevention clinics continued after 4 years. Evid Based Med 2003;8: 158 Leader S. Kohlhase K. 2002 Respiratory syncytial virus-coded pediatric h