Service evaluation of selected risk factors for extended-spectrum beta-lactamase Escherichia coli urinary tract infections: a case-control study

In the context of the increasing incidence of extended-spectrum beta-lactamase (ESBL) Escherichia coli infection, this prospective frequency-matched case-control study aimed to identify risk factors that would provide information and guidance for local clinical practice. One hundred and twelve participants were recruited: 54 cases and 58 controls. Univariate analysis indicated that isolation of an ESBL-producing E. coli in the previous 12 months and diabetes were significantly associated with the outcome. This study demonstrates the utility of service evaluation studies for producing epidemiological information to inform clinical practice.

Norovirus outbreak associated with canteen salad in Suffolk, United Kingdom

An outbreak of diarrhoea and vomiting among employees of an office in Suffolk, in the United Kingdom, was reported to the district council on 11 June 2007. An outbreak investigation was initiated immediately and a case control study was conducted to investigate the possibility of the outbreak being caused by contaminated food.

Monitoring tuberculosis treatment outcome: analysis of national surveillance data from a clinical perspective

BACKGROUND

In 1998, the World Health Organization (WHO) and the International Union Against Tuberculosis and Lung Disease (IUATLD) published recommendations standardising the evaluation of tuberculosis treatment outcome in Europe. These guidelines fail to account for clinically appropriate alterations in the management of patients.

OBJECTIVES

To evaluate tuberculosis treatment outcome in England, Wales and Northern Ireland by redefining the outcome criteria and investigate factors associated with unsuccessful treatment outcome 12 months after notification.

METHODS

This was a prospective analysis of a cohort of patients diagnosed in England, Wales and Northern Ireland and reported to the Enhanced Tuberculosis Surveillance system in 2001 and 2002. Proportions of success and failure were calculated based on a new set of criteria following discussion with clinicians treating tuberculosis cases. Logistic regression was used to study risk factors for unsuccessful treatment outcome.

RESULTS

13 048 cases were notified in the study period. Of the 2676 that were identified as new sputum smear positive pulmonary cases, 2209 (82.5%) had treatment outcome data reported. Using the WHO/IUATLD criteria, 76.8% were classified as successful. In contrast, applying the new criteria, the success rate was 87.5%. This rate exceeds the 85% success target set by the WHO. Risk factors for unsuccessful treatment outcome included male sex (OR 1.27; 95% CI 1.08 to 1.49), being elderly (p trend < 0.001), having pulmonary tuberculosis (OR 1.28; 95% CI 1.08 to 1.53) and having resistance to any antituberculosis drug (OR 1.90; 95% CI 1.44 to 2.52).

CONCLUSION

The proportion of tuberculosis cases with a successful treatment outcome exceeded the target of 85% success rate based on the modified outcome categories. Although the tuberculosis treatment outcome criteria set by WHO/IUATLD appear to be clear, they mix measures of process and outcome. Further refinement may be necessary in low incidence high income countries, especially those with a high mortality among the elderly.

Legionnaires' disease: when an 'outbreak' is not an outbreak

During August 2006, there was a large increase in non-travel related legionella cases throughout England and in the Netherlands.

Outbreaks of waterborne infectious intestinal disease in England and Wales, 1992-2003

We reviewed the epidemiological and microbiological characteristics of 89 reported outbreaks of waterborne infectious intestinal disease affecting 4321 people in England and Wales over the period 1992-2003. Public water supplies were implicated in 24 outbreaks (27%), private water supplies in 25 (28%), swimming pools in 35 (39%) and other sources in five outbreaks (6%). Cryptosporidium was implicated in 69% of outbreaks, Campylobacter sp. in 14%, Giardia in 2%, E. coli O157 in 3% and Astrovirus in 1%. From 2000, there was a consistent decline in the number of outbreaks of waterborne disease associated with public water supplies. The incidence rate of outbreaks in recipients of private water supplies may be as high as 35 times the rate in those receiving public water supplies (1830 vs. 53 per million population). Private water suppliers need to be aware of the importance of adequate treatment and the prevention of faecal contamination of storage water. Swimming-pool operators need to ensure chlorination and in particular adequate filtration measures are in place.

Health impacts of flooding in Lewes: a comparison of reported gastrointestinal and other illness and mental health in flooded and non-flooded households

Severe flooding may become more frequent due to global warming. A historical cohort study was conducted by telephone interview for new episodes of illness in all age groups, and for psychological distress in adults, following severe river flooding on 12 October 2000 in the town of Lewes in Southern England. Two hundred and twenty-seven residents of 103 flooded households and 240 residents of 104 non-flooded households in the same postal district were recruited by random selection of addresses from a post flooding survey and a commercial database respectively. Having been flooded was associated with earache (RR 2.2 [1.1,4.1] p = 0.02), and a significant increase in risk of gastroenteritis with depth of flooding (RR 1.7 [0.9,3.0] p = 0.09, p for trend by flood depth = 0.04). Adults had a four-times higher risk of psychological distress defined as a score of > or = 4 in response to the 12-item General Health Questionnaire (GHQ-12) (RR 4.1 [2.6, 6.4] p < 0.0005, p for trend by flood depth = 0.01). Associations between flooding and new episodes of physical illness in adults diminished after adjustment for psychological distress. Flooding remained highly significantly associated with psychological distress after adjustment for physical illnesses. Psychological distress may explain some of the excess physical illness reported by flooded adults and possibly by children as well. Policies to promote population resilience to flooding where flood prevention has failed must include practical support for flood victims and provision of appropriate psychological support. Associations with physical illnesses affirm the need for advice and assistance with individual, household and environmental hygiene and access to medical services.

Outbreaks of infectious disease associated with private drinking water supplies in England and Wales 1970-2000

In England and Wales over the last 30 years there have been 25 reported outbreaks of infection, associated with private water supplies (PWS). The majority (16 outbreaks) were reported after the introduction of enhanced surveillance. Although PWS only serve 0.5% of the population, 36% of drinking water outbreaks are associated with PWS. The main pathogen, campylobacter, was implicated in 13 (52%) outbreaks. Most reported outbreaks (88%) occurred in commercial or Category Two supplies, which potentially affect larger populations. The main factors implicated in these outbreaks are temporary or transient populations, treatment (lack or failure), the presence of animals and heavy rains. The public health problem associated with PWS could be prevented by the identification and understanding of risk factors, by the proper protection of water sources and adequate treatment and maintenance. This could be facilitated through the introduction of a risk assessment as part of a scheme for PWS.

Causes of morbilliform rash in a highly immunised English population

AIMS

To determine the causes of morbilliform rash and fever in a population with high vaccination coverage for measles and rubella.

METHODS

Comprehensive laboratory investigation additional to routine oral fluid testing of children presenting to primary care physicians in East Anglia, England.

RESULTS

Laboratory confirmation of infection was obtained in 93 (48%) of 195 children: parvovirus B19 in 34 (17%); group A streptococcus in 30 (15%); human herpesvirus type 6 in 11 (6%); enterovirus in nine (5%); adenovirus in seven (4%); and group C streptococcus in six (3%) (four individuals tested positive for two agents). None had measles or rubella.

CONCLUSIONS

Oral fluid testing to cover infections additional to measles and rubella aids clinical management and is likely to maintain uptake of testing, which is essential for measles and rubella surveillance in highly immunised low incidence populations.

Enhancing surveillance of cryptosporidiosis: test all faecal specimens from children

The heightened risk of waterborne cryptosporidiosis, associated with heavy rainfall in autumn 2000, prompted us to survey laboratory practice in the South East Region of England in testing faecal specimens for Cryptosporidium spp. oocysts and reporting to the Public Health Laboratory Service Communicable Disease Surveillance Centre (PHLS CDSC). Varied practices were found. Ideally, all faecal specimens should be tested, but where laboratories are unable to do so, screening all faecal specimens from children age 15 years or younger would improve surveillance and could probably be accomplished with minimal additional resources.

Laboratory capability in Europe for foodborne viruses

This report describes a survey of national laboratory capabilities of diagnostics and surveillance databases for foodborne viruses among the "Foodborne Viruses in Europe" consortium. All the countries have laboratories that can test for HAV antibody in human serum. Eight of the ten surveyed European countries maintain a national database of HAV cases. Food can be tested for the presence of HAV in Finland, Italy, Spain, France and Denmark. All surveyed countries have at least one laboratory that tests for Norwalk-like virus (NLV) by reverse transcriptase-polymerase chain reaction and all also have the capability to use electron microscopy. Five countries maintain a national database of NLV cases and nine maintain a national database of NLV outbreaks. Almost all participant countries have laboratories that can test for NLV in food items including shellfish.

General outbreaks of infectious intestinal disease linked with red meat, England and Wales, 1992-1999

Between 1992 and 1999, 1,426 foodborne general outbreaks of infectious intestinal disease (IID) were reported to the Public Health Laboratory Service (PHLS) Communicable Disease Surveillance Centre (CDSC). Sixteen percent were linked with the consumption of red meat. Over 5,000 people were affected, with 186 hospital admissions and nine deaths. Beef (34%) and pig meat (32%) were the most frequently implicated meat types, with lamb implicated in 11% of outbreaks. The organisms most frequently reported were Clostridium perfringens (43.4%) and salmonellas (34.3%). During the summer, outbreaks were mainly of Salmonella spp. and attributed to the consumption of pig meat. In December, outbreaks of C. perfringens linked with beef predominated. Most outbreaks occurred as a result of food cooked on commercial catering premises (46%). The highlight of this surveillance period is a fall in the number of outbreaks linked with foods containing red meat. This corresponds with a steady decline in red meat consumption over the last two decades, as well as a transient though marked decline in the purchase and consumption of red meat in the UK during the BSE crisis in the early to mid 1990s. As cited in the Pennington Report, further reducing the morbidity and mortality from red meat outbreaks means targeting meat production at various points along the food chain from abattoir and butchering, to cooking and holding of cooked food, especially on commercial catering premises.

Deliberate releases of biological agents: initial lessons for Europe from events in the United States

The experience of autumn 2001, when anthrax spores were released in the postal system, had considerable consequences in the United States and in Europe. The threat of covert deliberate releases against civilians has become a reality. In Europe, despite the growing number of criminal hoaxes, no cases of anthrax linked to deliberate releases have been reported, and the only contaminated letters were addressed to American embassies abroad. Nevertheless, the time has come for Europe to set up efficient and timely plans to respond to bioterrorism, under the coordination of the European Commission.

Surveillance of listeriosis in England and Wales, 1995-1999

A total of 543 cases of listerIosis were ascertained by the Public Health Laboratory Service Communicable Disease Surveillance Centre (PHLS CDSC) in residents of England and Wales with onset of illness between 1st January 1995 and 31st December 1999. Of 452 non-pregnancy associated cases, 326 (72%) had major medical conditions, 140 (31%) had received immuno-suppressive therapy and 97 (21%) were aged 60 years or over. Serovar 4b predominated in both pregnancy and non-pregnancy associated cases. Of ninety-one pregnancy associated cases, five had underlying medical conditions. Foetal death or early neonatal death was reported in 24 (26%) of the cases giving a mean perinatal mortality rate of 7.5 per million conceptions per year. Two episodes of neonatal cross infection occurred. Two non-pregnancy associated cases in 1999 were linked by a common food; all other cases were unlinked. No trend was observed from 1995 to 1999.

Visual acuity measurements in a national sample of British elderly people

BACKGROUND

Despite the fact that visual function has an important role in the quality of life in later years, very few studies have measured visual acuity in population based nationwide samples of British elderly people. Such measurements were carried out in the context of the national diet and nutrition survey of people aged 65 years or over (NDNS).

METHODS

NDNS participants, who were living in 80 different randomly selected postcode areas of mainland Britain, were visited at their home by a nurse who measured visual acuity at 3 metres, using the Glasgow acuity card (GAC) method. In addition, a brief questionnaire related to ocular health was administered.

RESULTS

Visual acuity was measured in 1362 NDNS participants who were not classified as mentally impaired. Visual impairment (using the WHO low vision criteria) was measured in 195 (14.3%) subjects. Prevalence of visual impairment increased significantly with age (65-74 years 3.1%; 75-84 years 11.6%; 85+ years 35.5%, p<0.001 for trend). Impaired vision was more common in subjects living in a nursing home (odds ratio adjusted for age 2.59 (95% CI 2.23 to 2. 96)) and in women (odds ratio adjusted for age 1.55 (95% CI 1.21 to 1.89)). 132 (9.7%) subjects had previously undergone cataract surgery and another 157 (11.5%) had been told that they currently had cataract. Vision improved 0.2 log units or more (at least one Snellen line) with the aid of a pinhole occluder in 289 subjects (21. 2%).

CONCLUSION

Results of this nationwide, community based study confirm that problems with poor distance visual acuity exist in a substantial part of the elderly community, particularly in women and people living in nursing homes.

Nontoxigenic corynebacterium diphtheriae: an emerging pathogen in England and Wales?

Confirmed isolates of nontoxigenic Corynebacterium diphtheriae in England and Wales increased substantially from 1986 to 1994. Ribotyping of 121 isolates confirmed in 1995 showed that 90 were of a single strain isolated exclusively from the throat; none had previously been identified in toxigenic strains from U.K. or non-U.K. residents. The upward trend in nontoxigenic C. diphtheriae probably represented increased ascertainment, although dissemination of a particular strain or clone may have been a factor.

Outbreak of gastroenteritis associated with contamination of a private borehole water supply

An outbreak of gastroenteritis affected 58 of 700 people served by a private water supply at a biological research institute located in a village. No cases were detected in 250 residents of the same village served by a public water supply over the same period. Consumer complaints of tainting and laboratory evidence of bacterial and chemical contamination were obtained for the private water supply, but not for the public water supply. The outbreak was probably caused by contamination from a nearby sewer of a borehole used for the private supply. The outbreak showed how a large, private water supply posed a substantial risk to public health. The regulatory framework for such water supplies should be modified to ensure their safer design and operation.

Quantitative grading of nerve fiber layer photographs

PURPOSE

The authors have developed a simple method for semi-quantitative grading of atrophy of the peripapillary nerve fiber layer (NFL) in black and white photographs.

METHODS

An experienced observer read sets of NFL photographs using a four-level grading system. Five observers with varying levels of experience at ophthalmic examination were taught the grading system in approximately 4 hours, and their readings were compared with those of the expert.

RESULTS

The reproducibility of readings by an experienced observer was excellent. The validity of the grading system was confirmed by comparisons to visual field findings, as well as to cup-to-disc ratios in the same eyes. The agreement with the expert by the five trained graders was good.

CONCLUSIONS

Grading of the NFL could be useful both to monitor development of early glaucoma damage clinically and to measure progression of glaucoma damage in clinical trials research. The grading system can be taught readily to other observers.

Inapparent ocular infection by Chlamydia trachomatis in experimental and human trachoma

There is substantial indirect evidence which suggests that Chlamydia trachomatis can generate inapparent, persistent infections in human. To confirm this directly, we examined ocular chlamydial infection in both the cynomolgus monkey model of trachoma and in patient samples from a trachoma-endemic area. In monkeys, ocular infection was studied over time using direct immunofluorescence cytology (DFA) and a molecular hybridization screening system which targets chlamydial ribosomal RNA. In eleven animals infected once with B serovar, DFA and probe screening of parallel conjunctival swabs gave congruent results through day 42 post-infection. Thereafter, DFA showed clearing of chlamydia and was negative by day 70, as in previous studies. In contrast, hybridization analysis indicated a continuing presence of chlamydial RNA in all samples from all animals through the end of the experiment at day 84 post-infection. Similarly, analysis of swabs from trachoma patients showed that a number of DFA-negative samples gave clear positive signal for chlamydial RNA. Taken together these data indicate that ocular chlamydial infection persists for longer periods than previously thought, judging solely on the basis of DFA, and they support the idea that inapparent ocular chlamydial infection occurs in vivo.

Drug therapy for Plasmodium falciparum malaria resistant to pyrimethamine-sulfadoxine (Fansidar). A study of alternate regimens in Eastern Thailand, 1980

A trial of drug regimens for treating Plasmodium falciparum malaria was conducted in a refugee camp in eastern Thailand where extensive 'Fansidar' (pyrimethamine-sulfadoxine) resistance had been demonstrated. The efficacy of quinine alone was compared to that of quinine combined with either fansidar or tetracycline. Quinine alone cleared the parasitaemia in 57 of 59 patients but failed to cure approximately one-third of these patients after 7 or 10 days of therapy. The addition of fansidar to quinine therapy did not significantly improve the overall cure rate. Tetracycline given for 10 days in combination with quinine cured all patients, suggesting that tetracycline should be considered in treating patients with falciparum malaria contracted in the area of the Thai-Kampuchean border.