An outbreak of legionnaire s disease among visitors to a fair in Belgium, 1999.

Ninety-three cases of legionnaires disease (43 confirmed, 12 presumptive, and 38 possible/ clinical) were identified in an outbreak associated with a trade fair in Kapellen, Belgium in November 1999. Five cases died. Epidemiological investigation showed

What is the role of quality circles in strategies to optimise antibiotic prescribing? A pragmatic cluster-randomised controlled trial in primary care.

OBJECTIVE: To evaluate the effect on antibiotic prescribing of an intervention in existing local quality circles promoting an evidence-based guideline for acute rhinosinusitis. DESIGN: A pragmatic cluster-randomised controlled trial comparing standard dissemination of the guideline by mail with an additional strategy using quality circles. SETTING: General practice in Flanders, Belgium. PARTICIPANTS: General practitioners (GPs) in 18 local quality circles were randomly allocated to two study arms. All GPs received the guideline by mail. GPs in the nine quality circles allocated to the intervention arm received an additional group intervention, which consisted of one self-led meeting using material introduced to the group moderator by a member of the research team. MAIN OUTCOME MEASURES: Adherence to the guideline was measured as differences in the proportion of antibiotic prescriptions, including the choice of antibiotic, between the two study arms after the intervention period. GPs registered their encounters with patients presenting with signs and symptoms of acute rhinosinusitis in a booklet designed for the study. RESULTS: A total of 75 doctors (29% of GPs in the participating quality circles) registered 408 consultations. In the intervention group, 56.9% of patients received an antibiotic compared with 58.3% in the control group. First-choice antibiotics were issued in 34.5% of antibiotic prescriptions in the intervention group compared with 29.4% in the control group. After adjusting for patient and GP characteristics, the ORadj for antibiotics prescribed in the intervention arm compared with the control arm was 0.63 (95% CI 0.29 to 1.37). There was no effect on the choice of antibiotic (ORadj 1.07, 95% CI 0.34 to 3.37). CONCLUSION: A single intervention in quality circles of GPs integrated in the group's normal working procedure did not have a significant effect on the quality of antibiotic prescribing. More attention to the context and structure of primary care practice, and insight into the process of self-reflective learning may provide clues to optimise the effectiveness of quality circles.

An outbreak of Legionnaire's disease among visitors to a fair in Belgium in 1999.

This paper describes an outbreak of Legionnaire's disease at Kapellen in Belgium among visitors of the annual fair. The investigation started on 13th November 1999 after a respiratory physician notified the health authorities of the province of Antwerp of presumptive cases of legionellosis. The annual commercial fair at Kapellen, a small town in northern Belgium, was held 10 days previously and attracted 50,000 visitors. Stand employees (professionals or volunteers), technical staff of the hall and visitors at the fair were affected cases. An exploratory case-control study was conducted to trace the source of the epidemic. To complete the inventory study and to evaluate other risk factors, a cohort study of exhibitors and staff was conducted. Ninety-three people met the case definition, 41 of whom were considered as confirmed, 14 as presumptive cases and 38 as possible/clinical cases. Five people died. Further testing at the reference laboratory confirmed all strains to be Legionella pneumophila serogroup 1. The sensitivity for culture was low (29.2%), and sensitivity for seroconversion was high (90.9%). For urinary antigen test, a sensitivity with Biotest EIA of 65.6% was found, and the sensitivity of polymerase chain reaction (PCR) was 85.7%. In all cases, the individual had visited the fair. Those individuals working in the central areas of the tent, near the aerosol-producing devices, were at higher risk of disease. Legionella was detected by PCR on swabs of the surfaces of the whirlpool. Although not fully proven, an aerosol-producing device was the most probable source of the outbreak.