Hepatitis E virus (HEV) in Scotland: evidence of recent increase in viral circulation in humans.

BackgroundPrevious studies showed low levels of circulating hepatitis E virus (HEV) in Scotland. We aimed to reassess current Scottish HEV epidemiology. Methods: Blood donor samples from five Scottish blood centres, the minipools for routine HEV screening and liver transplant recipients were tested for HEV antibodies and RNA to determine seroprevalence and viraemia. Blood donor data were compared with results from previous studies covering 2004-08. Notified laboratory-confirmed hepatitis E cases (2009-16) were extracted from national surveillance data. Viraemic samples from blood donors (2016) and chronic hepatitis E transplant patients (2014-16) were sequenced. Results: Anti-HEV IgG seroprevalence varied geographically and was highest in Edinburgh where it increased from 4.5% in 2004-08) to 9.3% in 2014-15 (p = 0.001). It was most marked in donors < 35 years. HEV RNA was found in 1:2,481 donors, compared with 1:14,520 in 2011. Notified laboratory-confirmed cases increased by a factor of 15 between 2011 and 2016, from 13 to 206. In 2011-13, 1 of 329 transplant recipients tested positive for acute HEV, compared with six cases of chronic infection during 2014-16. Of 10 sequenced viraemic donors eight and all six patients were infected with genotype 3 clade 1 virus, common in European pigs. Conclusions: The seroprevalence, number of viraemic donors and numbers of notified laboratory-confirmed cases of HEV in Scotland have all recently increased. The causes of this change are unknown, but need further investigation. Clinicians in Scotland, particularly those caring for immunocompromised patients, should have a low threshold for testing for HEV.

Not just a matter of size: a hospital-level risk factor analysis of MRSA bacteraemia in Scotland.

BACKGROUND: Worldwide, there is a wealth of literature examining patient-level risk factors for methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia. At the hospital-level it is generally accepted that MRSA bacteraemia is more common in larger hospitals. In Scotland, size does not fully explain all the observed variation among hospitals. The aim of this study was to identify risk factors for the presence and rate of MRSA bacteraemia cases in Scottish mainland hospitals. Specific hypotheses regarding hospital size, type and connectivity were examined. METHODS: Data from 198 mainland Scottish hospitals (defined as having at least one inpatient per year) were analysed for financial year 2007-08 using logistic regression (Model 1: presence/absence of MRSA bacteraemia) and Poisson regression (Model 2: rate of MRSA bacteraemia). The significance of risk factors representing various measures of hospital size, type and connectivity were investigated. RESULTS: In Scotland, size was not the only significant risk factor identified for the presence and rate of MRSA bacteraemia. The probability of a hospital having at least one case of MRSA bacteraemia increased with hospital size only if the hospital exceeded a certain level of connectivity. Higher levels of MRSA bacteraemia were associated with the large, highly connected teaching hospitals with high ratios of patients to domestic staff. CONCLUSIONS: A hospital's level of connectedness within a network may be a better measure of a hospital's risk of MRSA bacteraemia than size. This result could be used to identify high risk hospitals which would benefit from intensified infection control measures.

Upper gastrointestinal bleeding in Scotland 2000-2010: Improved outcomes but a significant weekend effect.

AIM: To assess numbers and case fatality of patients with upper gastrointestinal bleeding (UGIB), effects of deprivation and whether weekend presentation affected outcomes. METHODS: Data was obtained from Information Services Division (ISD) Scotland and National Records of Scotland (NRS) death records for a ten year period between 2000-2001 and 2009-2010. We obtained data from the ISD Scottish Morbidity Records (SMR01) database which holds data on inpatient and day-case hospital discharges from non-obstetric and non-psychiatric hospitals in Scotland. The mortality data was obtained from NRS and linked with the ISD SMR01 database to obtain 30-d case fatality. We used 23 ICD-10 (International Classification of diseases) codes which identify UGIB to interrogate database. We analysed these data for trends in number of hospital admissions with UGIB, 30-d mortality over time and assessed effects of social deprivation. We compared weekend and weekday admissions for differences in 30-d mortality and length of hospital stay. We determined comorbidities for each admission to establish if comorbidities contributed to patient outcome. RESULTS: A total of 60643 Scottish residents were admitted with UGIH during January, 2000 and October, 2009. There was no significant change in annual number of admissions over time, but there was a statistically significant reduction in 30-d case fatality from 10.3% to 8.8% (P < 0.001) over these 10 years. Number of admissions with UGIB was higher for the patients from most deprived category (P < 0.05), although case fatality was higher for the patients from the least deprived category (P < 0.05). There was no statistically significant change in this trend between 2000/01-2009/10. Patients admitted with UGIB at weekends had higher 30-d case fatality compared with those admitted on weekdays (P < 0.001). Thirty day mortality remained significantly higher for patients admitted with UGIB at weekends after adjusting for comorbidities. Length of hospital stay was also higher overall for patients admitted at the weekend when compared to weekdays, although only reached statistical significance for the last year of study 2009/10 (P < 0.0005). CONCLUSION: Despite reduction in mortality for UGIB in Scotland during 2000-2010, weekend admissions show a consistently higher mortality and greater lengths of stay compared with weekdays.

Performance of new thresholds of the Glasgow Blatchford score in managing patients with upper gastrointestinal bleeding.

BACKGROUND & AIMS: Upper gastrointestinal hemorrhage (UGIH) is a common cause of hospital admission. The Glasgow Blatchford score (GBS) is an accurate determinant of patients' risk for hospital-based intervention or death. Patients with a GBS of 0 are at low risk for poor outcome and could be managed as outpatients. Some investigators therefore have proposed extending the definition of low-risk patients by using a higher GBS cut-off value, possibly with an age adjustment. We compared 3 thresholds of the GBS and 2 age-adjusted modifications to identify the optimal cut-off value or modification. METHODS: We performed an observational study of 2305 consecutive patients presenting with UGIH at 4 centers (Scotland, England, Denmark, and New Zealand). The performance of each threshold and modification was evaluated based on sensitivity and specificity analyses, the proportion of low-risk patients identified, and outcomes of patients classified as low risk. RESULTS: There were differences in age (P = .0001), need for intervention (P < .0001), mortality (P < .015), and GBS (P = .0001) among sites. All systems identified low-risk patients with high levels of sensitivity (>97%). The GBS at cut-off values of ≤1 and ≤2, and both modifications, identified low-risk patients with higher levels of specificity (40%-49%) than the GBS with a cut-off value of 0 (22% specificity; P < .001). The GBS at a cut-off value of ≤2 had the highest specificity, but 3% of patients classified as low-risk patients had adverse outcomes. All GBS cut-off values, and score modifications, had low levels of specificity when tested in New Zealand (2.5%-11%). CONCLUSIONS: A GBS cut-off value of ≤1 and both GBS modifications identify almost twice as many low-risk patients with UGIH as a GBS at a cut-off value of 0. Implementing a protocol for outpatient management, based on one of these scores, could reduce hospital admissions by 15% to 20%.

Is the Glasgow Blatchford score useful in the risk assessment of patients presenting with variceal haemorrhage?

BACKGROUND: The Glasgow Blatchford score (GBS) is a pre-endoscopic risk assessment tool for patients presenting with upper gastrointestinal haemorrhage. There are few data regarding use in patients with variceal bleeding, who are generally accepted as being at high risk. AIM: The aim of the study was to assess GBS in correctly identifying patients with subsequently proven variceal bleeding as 'high risk' and to compare GBS, admission and full Rockall scores in predicting clinical endpoints in this group. PATIENTS AND METHODS: Data on consecutive patients with upper gastrointestinal haemorrhage presenting to four UK hospitals were collected. The GBS, admission and full Rockall scores were calculated and compared for the subgroup subsequently shown to have variceal bleeding. Area under the receiver operating curve (AUROC) was used to assess the scores ability to predict clinical endpoints within this variceal bleeding subgroup. RESULTS: A total of 1432 patients presented during the study period. Seventy-one (5%) had a final diagnosis of variceal bleeding. At presentation, none of this group had GBS less than 2, but six had an admission Rockall score of 0. In predicting need for blood transfusion, AUROC scores for GBS, full and admission Rockall scores were 0.68, 0.65 and 0.68, respectively. For endoscopic/surgical intervention the scores were 0.34, 0.51 and 0.55, respectively, and for predicting death the scores were 0.56, 0.72 and 0.70, respectively. None of these AUROC score comparisons were significant. CONCLUSION: At presentation, GBS correctly identifies patients with variceal bleeding as high risk and appears superior to the admission Rockall score. However, GBS and both Rockall scores are poor at predicting clinical outcome within this group.

Contact tracing for influenza A(H1N1)pdm09 virus-infected passenger on international flight.

In April 2009, influenza A(H1N1)pdm09 virus infection was confirmed in a person who had been symptomatic while traveling on a commercial flight from Mexico to the United Kingdom. Retrospective public health investigation and contact tracing led to the identification of 8 additional confirmed cases among passengers and community contacts of passengers.

Investigating transmission of Mycobacterium bovis in the United Kingdom in 2005 to 2008.

Due to an increase in bovine tuberculosis in cattle in the United Kingdom, we investigated the characteristics of Mycobacterium bovis infection in humans and assessed whether extensive transmission of M. bovis between humans has occurred. A cross-sectional study linking demographic, clinical, and DNA fingerprinting (using 15-locus mycobacterial interspersed repetitive-unit-variable-number tandem-repeat [MIRU-VNTR] typing) data on cases reported between 2005 and 2008 was undertaken. A total of 129 cases of M. bovis infection in humans were reported over the period, with a decrease in annual incidence from 0.065 to 0.047 cases per 100,000 persons. Most patients were born pre-1960, before widespread pasteurization was introduced (73%), were of white ethnicity (83%), and were born in the United Kingdom (76%). A total of 102 patients (79%) had MIRU-VNTR typing data. A total of 31 of 69 complete MIRU-VNTR profiles formed eight distinct clusters. The overall clustering proportion determined using the n - 1 method was 33%. The largest cluster, comprising 12 cases, was indistinguishable from a previously reported West Midlands outbreak strain cluster and included those cases. This cluster was heterogeneous, having characteristics supporting recent zoonotic and human-to-human transmission as well as reactivation of latent disease. Seven other, smaller clusters identified had demographics supporting recrudescence rather than recent infection. A total of 33 patients had incomplete MIRU-VNTR profiles, of which 11 may have yielded 2 to 6 further small clusters if typed to completion. The incidence of M. bovis in humans in the United Kingdom remains low, and the epidemiology is predominantly that of reactivated disease.