CTX-M ESBL-producing Enterobacteriaceae: estimated prevalence in adults in England in 2014.

Background: ESBL-producing Enterobacteriaceae (ESBLPE) are increasing in prevalence worldwide and are more difficult to treat than non-ESBLPE. Their prevalence in the UK general population is unknown, as the only previous UK ESBLPE faecal colonization study involved patients with diarrhoea. Objectives: To estimate the prevalence of CTX-M ESBLPE faecal colonization in the general adult population of England in 2014, and investigate risk factors. Methods: A stratified random sample of 58 337 registered patients from 16 general practices within four areas of England were invited to participate by returning faeces specimens and self-completed questionnaires. Specimens were tested for ESBLPE and carbapenemase-producing Enterobacteriaceae (CPE). Results: 2430 individuals participated (4% of those invited). The estimated prevalence of colonization with CTX-M ESBLPE in England was 7.3% (95% CI 5.6%-9.4%) (Shropshire 774 participants, 4.9% colonization; Southampton City 740 participants, 9.2%; Newham 612 participants, 12.7%; Heart of Birmingham 234 individuals, 16.0%) and was particularly high in: those born in Afghanistan (10 participants, 60.0% colonization, 95% CI 29.7%-84.2%); those born on the Indian subcontinent (India, Pakistan, Bangladesh or Sri Lanka) (259 participants, 25.0% colonization, 95% CI 18.5%-32.9%); travellers to South Asia (India, Pakistan, Bangladesh, Sri Lanka or Nepal) in the last year (140 participants, 38.5% colonization, 95% CI 27.8%-50.5%); and healthcare domestics (8 participants, unweighted 37.5% colonization, 95% CI 8.5%-75.5%). Risk factors identified included: being born in the Indian subcontinent (aOR 5.4, 95% CI 3.0-9.7); travel to South Asia (aOR 2.9, 95% CI 1.8-4.8) or to Africa, China, South or Central America, South East or Pacific Asia or Afghanistan (aOR 2.6, 95% CI 1.7-4.1) in the last year; and working as a healthcare domestic (aOR 6.2, 95% CI 1.3-31). None of the 48 participants who took co-amoxiclav in the last year was colonized with CTX-M ESBLPE. blaCTX-M-15 accounted for 66% of CTX-M ESBLPE positives. 0.1% (two participants) were colonized with CPE. Conclusions: CTX-M ESBLPE are established in the general population in England and prevalence is particularly high in people from certain countries of birth or with recent travel. We recommend that these findings be taken into account in guidance on the empirical management of patients presenting with a likely Enterobacteriaceae infection.

Can we use postal surveys with anonymous testing to monitor chlamydia prevalence in young women in England? Pilot study incorporating randomised controlled trial of recruitment methods.

OBJECTIVES: Chlamydia prevalence in the general population is a potential outcome measure for the evaluation of chlamydia control programmes. We carried out a pilot study to determine the feasibility of using a postal survey for population-based chlamydia prevalence monitoring. METHODS: Postal invitations were sent to a random sample of 2000 17-year-old to 18-year-old women registered with a general practitioner in two pilot areas in England. Recipients were randomised to receive either a self-sampling kit (n=1000), a self-sampling kit and offer of £5 voucher on return of sample (n=500) or a self-sampling kit on request (n=500). Participants returned a questionnaire and self-taken vulvovaginal swab sample for unlinked anonymous Chlamydia trachomatis testing. Non-responders were sent a reminder letter 3 weeks after initial invitation. We calculated the participation rate (number of samples returned/number of invitations sent) and cost per sample returned (including cost of consumables and postage) in each group. RESULTS: A total of 155/2000 (7.8%) samples were returned with consent for testing. Participation rates varied by invitation group: 7.8% in the group who were provided with a self-sampling kit, 14% in the group who were also offered a voucher and 1.0% in the group who were not sent a kit. The cost per sample received was lowest (£36) in the group who were offered both a kit and a voucher. CONCLUSIONS: The piloted survey methodology achieved low participation rates. This approach is not suitable for population-based monitoring of chlamydia prevalence among young women in England. STUDY REGISTRATION NUMBER: (UKCRN ID 10913).

Repeat infection with gonorrhoea in Sheffield, UK: predictable and preventable?

BACKGROUND: Repeat infection with gonorrhoea may contribute significantly to infection persistence and health service workload. The authors investigated whether repeat infection is associated with particular subgroups who may benefit from tailored interventions. METHODS: Data on gonorrhoea diagnoses between 2004 and 2008 were obtained from Sheffield sexually transmitted infection clinic. Kaplan-Meier survival curves were used to estimate the percentage of patients with repeat diagnoses within a year, and a Cox proportional hazard model was used to investigate associated risk factors. RESULTS: Of 1650 patients diagnosed with gonorrhoea, 7.7% (95% CI 6.5% to 9.1%) had a repeat diagnosis within 1 year. Men who have sex with men under 30, teenage heterosexuals, black Caribbeans, people living in deprived areas and those diagnosed in 2004 were most likely to re-present. Of those patients (53%) providing additional behavioural data, repeat diagnosis was more common in those reporting prior history of gonorrhoea, any previous sexually transmitted infection diagnoses, two or more partners in the past 3 months and a high-risk partner in the past year. In an adjusted analysis, repeat diagnosis was independently associated with being a young man who has sex with men, living in a deprived area, a history of gonorrhoea and being diagnosed in 2004 but was most strongly associated with non-completion of behavioural data forms. CONCLUSIONS: Groups most at risk of repeat infection with gonorrhoea are highly predictable but are disinclined to provide detailed information on their sexual behaviour. Care pathways including targeted and intensive one-to-one risk reduction counselling, effective partner notification and offers of re-testing could deliver considerable public health benefit.

Pathways to interoperable electronic patient records for health and social care: Part 1: for those involved directly in care.

Here, we illustrate the clinical and technical implementation of interoperable health data for direct care from the viewpoint of practicing clinicians using examples from primary care. Interoperability allows people involved in the provision and receipt of care to seamlessly exchange and use the coded, free text and documentary data they need to inform care decisions. The pathway toward NHS interoperability to support direct care has been long, but substantial progress has been made. GP computer systems and data-recording standards, national infrastructure and hospital trusts have come a long way on the journey to fully interoperable records. GPs can now receive and utilise laboratory data; via GP2GP, they can transfer full electronic patient records when patients move practice; share health data with other health organisations through GP Connect to support patient care; and provide patients with online access to their full GP record, a cornerstone of person-centred care. Here, we describe the effective technical assets and standards that have been developed to enable electronic patient record data to be shared reliably and securely.

Should young people be paid for getting tested? A national comparative study to evaluate patient financial incentives for chlamydia screening.

BACKGROUND: Patient financial incentives ("incentives") have been widely used to promote chlamydia screening uptake amongst 15-24 year olds in England, but there is scarce evidence of their effectiveness. The objectives of the study were to describe incentives used to promote chlamydia screening in Primary Care Trusts (PCTs) in England and to evaluate their impact on coverage and positivity rate. METHODS: PCTs that had used incentives between 1/1/2007 and 30/6/2009 (exposed) were matched by socio-demographic profile and initial screening coverage with PCTs that had not (unexposed). For each PCT, percentage point change in chlamydia screening coverage and positivity for the period before and during the incentive was calculated. Differences in average change of coverage and positivity rate between exposed and unexposed PCTs were compared using linear regression to adjust for matching and potential confounders. RESULTS: Incentives had a significant effect in increasing average coverage in exposed PCTs (0.43%, CI 0.04%-0.82%). The effect for voucher schemes (2.35%) was larger than for prize draws (0.16%). The difference was greater in females (0.73%) than males (0.14%). The effect on positivity rates was not significant (0.07%, CI -1.53% to 1.67%). CONCLUSIONS: Vouchers, but not prize draws, led to a small absolute but large relative increase in chlamydia screening coverage. Incentives increased coverage more in females than males but had no impact on reported positivity rates. These findings support recommendations not to use prize draws to promote chlamydia screening and contribute to the evidence base of the operational effectiveness of using patient incentives in encouraging public health action.

Emergence of a Neisseria gonorrhoeae clone showing decreased susceptibility to cefixime in England and Wales.

OBJECTIVES: The third-generation cephalosporins recommended in national guidelines are amongst the last remaining effective agents for treatment of gonorrhoea. This study characterizes gonococcal isolates with decreased cefixime susceptibility from England and Wales. METHODS: A total of 96 isolates of Neisseria gonorrhoeae exhibiting cefixime MICs of ≥0.125 mg/L, either collected as part of the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) between 2005 and 2008 (54 from a total of 4649 isolates) or referred to the national reference laboratory in 2008 and 2009 (42 isolates), were tested for susceptibility to a range of antimicrobial agents and were typed using N. gonorrhoeae multiantigen sequence typing (NG-MAST). RESULTS: All 96 isolates were also resistant to tetracycline (MIC ≥2 mg/L) and ciprofloxacin (MIC ≥16 mg/L) and 56% showed low-level chromosomal resistance to penicillin. Where data were available, the mean patient age was 31 years, and 88% (83/94) of patients were men. Isolates referred through GRASP were predominantly from men who have sex with men (MSM; 29/44, 66%) and from patients of white British ethnicity (25/43, 58%). The majority of isolates belonged either to sequence type (ST) 1407 (71/96, 74%) or to a highly related ST that shares the tpbB allele (allele 110), but with a different por allele (20/96, 21%). ST1407 was found in both MSM (22/29, 76%) and heterosexual patients (12/15, 80%) and among all eight isolates from patients reporting sex abroad. CONCLUSIONS: The emergence of a clonal group of gonococci showing decreased susceptibility to cefixime in England and Wales highlights the need for continued surveillance.

Estimating the prevalence of gonococcal resistance to antimicrobials in England and Wales.

BACKGROUND: Gonorrhoea can rapidly develop resistance to antimicrobials and treatment options are becoming depleted. Treatment guidelines require robust estimates of the prevalence of resistance but sentinel surveillance systems may not be representative nationally. OBJECTIVE: To investigate the effectiveness of the sentinel Gonococcal Resistance to Antimicrobials Surveillance System (GRASP) at estimating resistance prevalence in England and Wales. METHODS: Annual cross-sectional data on reported gonorrhoea diagnoses between 2000 and 2008 were compared between GRASP (26 clinics) and national mandatory (KC60) reporting (229 clinics). Resistance prevalence estimates in GRASP were weighted according to the national distribution of relevant PATIENT CHARACTERISTICS: age group, gender, sexual orientation and geographical region. Trends in actual and weighted estimates were plotted. Results Gonorrhoea cases reported through GRASP were more likely to be from London and to be men who have sex with men (MSM) and were less likely to be women and heterosexual men than those reported through KC60. Weighting for national distributions of demographic characteristics reduced estimates of resistance prevalence, particularly ciprofloxacin in 2006 (27% to 21%). Emerging resistance to cefixime in 2008 was reduced from 1.5% to 1.0%. Weighting did not adjust resistance prevalence above or below the 5% threshold for any antimicrobial. CONCLUSIONS: Although over-representing MSM and under-representing women and heterosexual men, GRASP has provided reliable estimates of resistance prevalence in England and Wales. However, weighting for the national distribution of patient characteristics should be considered in future. As resistance usually emerges in MSM, enhanced surveillance of high-risk populations could enable development of more tailored (and therefore optimal) treatment strategies.

Prevalence of human papillomavirus antibodies in males and females in England.

BACKGROUND: Most studies of human papillomavirus (HPV) epidemiology have employed DNA testing, which measures current infections. Serum antibodies offer a longer-term marker of infection in individuals who seroconvert and can therefore provide additional information about the exposure of populations to HPV. METHODS: Sera from a population-based sample of males and females aged 10 to 49 years, in England, were tested for type-specific HPV antibodies using a multiplexed competitive Luminex assay and previously defined cutoffs of 20, 16, 20, and 24 mMU mL for HPV 6, 11, 16, and 18, respectively. Seropositivity and geometric mean titers of seropositives were analyzed by HPV type, gender, and age. Catalytic models were developed to explore potential effects of antibody waning over time and changing risk of infection by age-cohort. RESULTS: Seroprevalence for HPV 6, 11, 16, and 18 was 16.4%, 5.7%, 14.7%, and 6.3%, respectively, among females and 7.6%, 2.2%, 5.0%, and 2.0%, respectively, among males. Seroprevalence in females was significantly higher than males (P < 0.001 for all types) and showed a decline in older ages that was not seen in males. There was no evidence of declining antibody titers with increasing age. Model results suggest that cohort effects mediated through changes in sexual behavior better explain the observed trend in seroprevalence than waning antibodies over time. CONCLUSIONS: Preimmunization HPV seroprevalence in England shows similar trends to reports from other developed countries. We find the lower seroprevalence in older females probably reflects changes in sexual behavior over the last few decades. This study provides baseline data to monitor the impact of the immunization programme.

The English antibiotic awareness campaigns: did they change the public's knowledge of and attitudes to antibiotic use?

OBJECTIVES: To determine the effect of the 2008 English public antibiotic campaigns. METHODS: English and Scottish (acting as controls) adults aged > or = 15 years were questioned face to face about their attitudes to and use of antibiotics, in January 2008 (1888) before and in January 2009 (1830) after the antibiotic campaigns. RESULTS: Among English respondents, there was a small increase in recollection of campaign posters (2009 23.7% versus 2008 19.2%; P = 0.03), but this increase was only 2.3% higher in England than in Scotland. We did not detect any improvement in either England or Scotland, or any differences between England and Scotland in the understanding of the lack of benefit of antibiotics for coughs and colds, and we found no improvement in antibiotic use. We detected a significant increase in respondents retaining leftover antibiotics. Over 20% reported discussing antibiotics with their general practitioner (GP) or nurse in the year to January 2009. The offer of a delayed antibiotic prescription was reported significantly more often by English respondents (19% versus 8% Scottish in 2009; P = 0.01), and English respondents were advised to use other remedies for coughs and colds significantly more often in the year to January 2009 (12.7% in 2009 versus 7.4% in 2008; P < 0.001). CONCLUSIONS: There is little evidence that the 2008 public antibiotic campaigns were effective. The use and visibility of future campaign materials needs auditing. A carefully planned approach that targets the public in GP waiting rooms and through clinicians in consultations may be a more effective way of improving prudent antibiotic use.

Cephalosporin MIC creep among gonococci: time for a pharmacodynamic rethink?

BACKGROUND: Gonorrhoea has been among the easiest infections to cure with antibiotics. Nevertheless, emerging resistance has driven repeated treatment shifts. Decreased cephalosporin susceptibility is now being reported. We examined cephalosporin MIC trends for Neisseria gonorrhoeae in the UK and undertook pharmacodynamic analyses to predict efficacy against strains with raised MICs. METHODS: Neisseria gonorrhoeae isolates were collected annually in a structured surveillance from 26 genitourinary medicine clinics in England and Wales. MICs were determined by agar dilution and confirmed by Etests. Pharmacodynamic modelling was performed for cefixime and ceftriaxone with Monte Carlo simulations. RESULTS: There was a progressive emergence of small numbers of gonococci with cephalosporin MICs of 0.125-0.25 mg/L; these were not seen before 2005 but, for ceftriaxone and cefixime, respectively, accounted for 0.4% (95% confidence interval 0.2%-1.1%) and 2.8% (1.6%-4.8%) of the 1253 isolates collected in 2008; such MICs are 16-64 times the modal values for the species. Pharmacodynamic analysis was complicated by evidence that cephalosporins need a longer period with the free drug level above MIC than the 7-10 h required for penicillin G; nevertheless, pharmacodynamic analyses predict that failures with the standard 400 mg cefixime po and 250 mg ceftriaxone im regimens become likely around the present MIC maxima. CONCLUSIONS: Gonococci with ceftriaxone and cefixime MICs of 0.125-0.25 mg/L are accumulating in the UK. These MICs lie on the edge of likely responsiveness to current regimens, which need review. Possible responses include: (i) higher cephalosporin doses; (ii) multidose cephalosporin regimens; (iii) multidrug regimens; (iv) microbiologically directed treatment; or, in the future, (v) drug cycling. The practicalities of these approaches are discussed.

Cerebral Venous Sinus Thrombosis as a Presentation of COVID-19.

Coronavirus disease 19 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We describe the case of a 59-year-old man who presented with headache, hypertension and a single episode of fever with no other symptoms. He subsequently developed unilateral weakness. Computer tomography identified a cerebral venous sinus thrombosis (CVST). A subsequent test for COVID-19 was positive. This is the first report of CVST as a presenting symptom of COVID-19 infection. LEARNING POINTS: Thrombotic events may be the initial presenting symptom of COVID-19.These thrombotic events include stroke, venous thromboembolism, pulmonary embolism and cardiac complications.Clinicians should carefully consider the risk of thrombosis in patients positive for COVID-19, including prophylaxis and treatment beyond discharge.

Unravelling the GSK3ß-related genotypic interaction network influencing hippocampal volume in recurrent major depressive disorder.

OBJECTIVE: Glycogen synthase kinase 3ß (GSK3ß) has been implicated in mood disorders. We previously reported associations between a GSK3ß polymorphism and hippocampal volume in major depressive disorder (MDD). We then reported similar associations for a subset of GSK3ß-regulated genes. We now investigate an algorithm-derived comprehensive list of genes encoding proteins that directly interact with GSK3ß to identify a genotypic network influencing hippocampal volume in MDD. PARTICIPANTS AND METHODS: We used discovery (N=141) and replication (N=77) recurrent MDD samples. Our gene list was generated from the NetworKIN database. Hippocampal measures were derived using an optimized Freesurfer protocol. We identified interacting single nucleotide polymorphisms using the machine learning algorithm Random Forest and verified interactions using likelihood ratio tests between nested linear regression models. RESULTS: The discovery sample showed multiple two-single nucleotide polymorphism interactions with hippocampal volume. The replication sample showed a replicable interaction (likelihood ratio test: P=0.0088, replication sample; P=0.017, discovery sample; Stouffer's combined P=0.0007) between genes associated previously with endoplasmic reticulum stress, calcium regulation and histone modifications. CONCLUSION: Our results provide genetic evidence supporting associations between hippocampal volume and MDD, which may reflect underlying cellular stress responses. Our study provides evidence of biological mechanisms that should be further explored in the search for disease-modifying therapeutic targets for depression.

Informing future research for carriage of multiresistant Gram-negative bacteria: problems with recruiting to an English stool sample community prevalence study.

OBJECTIVES: This study aims to highlight problems with recruiting to an English stool sample community prevalence study. It was part of a larger cross-sectional research to determine the risk factors for the presence of extended-spectrum beta-lactamase and carbapenemase-producing coliforms in stool samples of the asymptomatic general English population. SETTING: Four National Health Service primary care trusts (PCTs) of England representing a different section of the population of England: Newham PCT; Heart of Birmingham Teaching PCT; Shropshire County PCT; and Southampton City PCT. PARTICIPANTS: Sixteen general practices across the four PCTs were purposefully selected. After stratification of GP lists by age, ethnicity and antibiotic use, 58 337 randomly selected patients were sent a postal invitation.Patients who had died, moved to a different surgery, were deemed too ill by their General Practitioner or hospitalised at the time of mailing were excluded. RESULTS: Stool and questionnaire returns varied by area, age, gender and ethnicity; the highest return rate of 27.3% was in Shropshire in the age group of over 60 years; the lowest, 0.6%, was in Birmingham in the age group of 18-39 years. Whereas only 3.9%(2296) returned a completed questionnaire and stool sample, 94.9% of participants gave permission for their sample and data to be used in future research. CONCLUSION: Researchers should consider the low stool specimen return rate and wide variation by ethnicity and age when planning future studies involving stool specimen collection. This is particularly pertinent if the study has no health benefit to participants. Further research is needed to explore how to improve recruitment in multicultural communities and in younger people.

Evaluation of the measles, mumps and rubella vaccination catch-up campaign in England in 2013.

In January-March 2013 in England, confirmed measles cases increased in children aged 10-16 years. In April-September 2013, the National Health System and Public Health England launched a national measles-mumps-rubella (MMR) campaign based on data from Child Health Information Systems (CHIS) estimating that approximately 8% in this age group were unvaccinated. We estimated coverage at baseline, and, of those unvaccinated (target), the proportion vaccinated up to 20/08/2013 (mid-point) to inform further public health action. We selected a sample of 6644 children aged 10-16 years using multistage sampling from those reported unvaccinated in CHIS at baseline and validated their records against GP records. We adjusted the CHIS MMR vaccine coverage estimates correcting by the proportion of vaccinated children obtained through sample validation. We validated 5179/6644 (78%) of the sample records. Coverage at baseline was estimated as 94.7% (95% confidence intervals, CI: 93.5-96.0%), lower in London (86.9%, 95%CI: 83.0-90.9%) than outside (96.1%, 95%CI 95.5-96.8%). The campaign reached 10.8% (95%CI: 7.0-14.6%) of the target population, lower in London (7.1%, 95%CI: 4.9-9.3) than in the rest of England (11.4%, 95%CI: 7.0-15.9%). Coverage increased by 0.5% up to 95.3% (95% CI: 94.1-96.4%) but an estimated 210,000 10-16 year old children remained unvaccinated nationally. Baseline MMR coverage was higher than previously reported and was estimated to have reached the 95% campaign objective at midpoint. Eleven per cent of the target population were vaccinated during the campaign, and may be underestimated, especially in London. No further national campaigns are needed but targeted local vaccination activities should be considered.

Expectations for consultations and antibiotics for respiratory tract infection in primary care: the RTI clinical iceberg.

BACKGROUND: Respiratory tract infection (RTI) is the commonest indication for community antibiotic prescriptions. Prescribing is rising and is influenced by patients' consulting behaviour and beliefs. AIM: To build up a profile of the 'RTI clinical iceberg' by exploring how the general public manage RTI, visit GPs and why. DESIGN AND SETTING: Two-phase qualitative and quantitative study in England. METHOD: Qualitative interviews with 17 participants with acute RTI visiting pharmacies in England, and face-to-face questionnaire survey of 1767 adults ≥15 years in households in England during January 2011. RESULTS: Qualitative interviews: interviewees with RTI visited GPs if they considered their symptoms were prolonged, or severe enough to cause pain, or interfered with daily activities or sleep. Questionnaire: 58% reported having had an RTI in the previous 6 months, and 19.7% (95% CI = 16.8 to 22.9%) of these contacted or visited their GP surgery for this, most commonly because 'the symptoms were severe'; or 'after several days the symptoms hadn't improved'; 10.3% of those experiencing an RTI (or 53.1% of those contacting their GP about it) expected an antibiotic prescription. Responders were more likely to believe antibiotics would be effective for a cough with green rather than clear phlegm. Perceptions of side effects of antibiotics did not influence expectations for antibiotics. Almost all who reported asking for an antibiotic were prescribed one, but 25% did not finish them. CONCLUSION: One-fifth of those with an RTI contact their GP and most who ask for antibiotics are prescribed them. A better public understanding about the lack of benefit of antibiotics for most RTIs and addressing concerns about illness duration and severity, could reduce GP consultations and antibiotic prescriptions for RTI.

Have the public's expectations for antibiotics for acute uncomplicated respiratory tract infections changed since the H1N1 influenza pandemic? A qualitative interview and quantitative questionnaire study.

OBJECTIVE: To investigate the effect of the H1N1 influenza pandemic on the public's expectations for a general practice consultation and antibiotic for acute respiratory illness. DESIGN: Mixed methods. PARTICIPANTS: Qualitative interviews: 17 participants with acute respiratory tract infection (RTI) visiting English pharmacies. Face-to-face survey: about 1700 adults aged 15 years and older were recruited from households in England in January 2008, 2009 and 2011. RESULTS: The qualitative data indicated that the general public had either forgotten about the 'swine flu' (H1N1 influenza) pandemic or it did not concern them as it had not affected them directly or affected their management of their current RTI illness. Between 2009 and 2011, we found that there was little or no change in people's expectations for antibiotics for runny nose, colds, sore throat or cough, but people's expectations for antibiotics for flu increased (26%-32%, p=0.004). Of the 1000 respondents in 2011 with an RTI in the previous 6 months, 13% reported that they took care of themselves without contacting their general practitioners and would not have done so before the pandemic, 9% reported that they had contacted their doctor's surgery and would not have done so before the pandemic and 0.6% stated that they had asked for antibiotics and would not have done so before the pandemic. In 2011, of 123 respondents with a young child (0-4 years) having an RTI in the previous 6 months, 7.4% requested antibiotics and would not have done so before the pandemic. Unprompted, 20% of respondents thought Tamiflu© (oseltamivir) was a vaccine. CONCLUSIONS: Expectations of the general public for a consultation or antibiotics with an RTI are similar now to before the H1N1 influenza pandemic; therefore, public antibiotic campaign messages and general practice advice to patients can remain unchanged. Parents with young children and those with personal experience of the H1N1 influenza are more likely to consult and will need more reassurance. The public need more education about Tamiflu©.

Body piercing in England: a survey of piercing at sites other than earlobe.

OBJECTIVES: To estimate the prevalence of body piercing, other than of earlobes, in the general adult population in England, and to describe the distribution of body piercing by age group, sex, social class, anatomical site, and who performed the piercings. To estimate the proportion of piercings that resulted in complications and the proportion of piercings that resulted in professional help being sought after the piercing. DESIGN: Cross sectional household survey. SETTING: All regions of England 2005. PARTICIPANTS: 10,503 adults aged 16 and over identified with a two stage selection process: random selection of geographical areas and filling predefined quotas of individuals. Results weighted to reflect the national demographic profile of adults aged 16 and over. MAIN OUTCOME MEASURES: Estimates of the prevalence of body piercing overall and by age group, sex, and anatomical site. Estimates, in those aged 16-24, of the proportion of piercings associated with complications and the seeking of professional help. RESULTS: The prevalence of body piercing was 1049/10,503 (10%, 95% confidence interval 9.4% to 10.6%). Body piercing was more common in women than in men and in younger age groups. Nearly half the women aged 16-24 reported having had a piercing (305/659, 46.2%, 42.0% to 50.5%). Of the 754 piercings in those aged 16-24, complications were reported with 233 (31.0%, 26.8% to 35.5%); professional help was sought with 115 (15.2%, 11.8% to 19.5%); and hospital admission was required with seven (0.9%, 0.3% to 3.2%). CONCLUSIONS: Body piercing is common in adults in England, particularly in young women. Problems are common and the assistance of health services is often required. Though serious complications requiring admission to hospital seem uncommon, the popularity of the practice might place a substantial burden on health services.

The public's attitudes to and compliance with antibiotics.

Although a third of the public still believe that antibiotics work against coughs and colds, simply getting the public to believe otherwise may not be enough to reduce the level of prescribing. The large Department of Health sponsored household survey demonstrated that those with a greater knowledge about antibiotics were no less likely to be prescribed an antibiotic, and although those with increased knowledge about antibiotics were more likely to complete a course they were also more likely to self-medicate and to keep left-over antibiotics. Future campaigns that are aimed at reducing the level of prescribing should be focused towards those more likely to be prescribed antibiotics at present: younger women and those with a lower level of education. They should also examine and consider modifying consultation behaviour and other behavioural components involved in patient' expectations for antibiotics. This should include delayed antibiotic prescriptions. The easiest way to reduce the use of leftovers may be to shorten the course of antibiotics prescribed to 3 or 5 days. We should also promote a 'Do not recycle antibiotics' message towards the more highly educated, young women who are more likely to store, take and share antibiotics without advice.

Don't wear me out--the public's knowledge of and attitudes to antibiotic use.

OBJECTIVES: To assess the public's knowledge and attitudes to antibiotics, their reported antibiotic use and the relationship between them. PATIENTS AND METHODS: A questionnaire was included in the face-to-face Office for National Statistics Omnibus Household Survey in Britain in 2003. Of 10 981 randomly selected adults from England, Scotland and Wales, 7120 (65%) completed the questionnaire. RESULTS: Although 79% of respondents were aware that 'antibiotic resistance is a problem in British hospitals', 38% of respondents did not know that antibiotics do not work against most coughs or colds and 43% did not know that 'antibiotics can kill the bacteria that normally live on the skin and in the gut'. Respondents with lower educational qualifications were less knowledgeable about antibiotics. In a multivariable analysis, better knowledge of antibiotics was not associated with being less likely to be prescribed any in the last year, but was independently associated with being more likely to finish a course of antibiotic as prescribed. Knowledge was also associated with being more likely to take antibiotics without being told to do so. In women, better knowledge was associated with being more likely to give an antibiotic to someone else that was not prescribed for them. CONCLUSIONS: We have shown that there is no simple relationship between increased knowledge and more prudent antibiotic use. Future national antibiotic campaigns should have a defined audience and aims in order to facilitate prudent antibiotic use by clinicians and public.

Changes in histamine and microbiological analyses in fresh and frozen tuna muscle during temperature abuse.

Temperature abuse of tuna (Thunnus alalunga) was carried out in order to assess the histamine buildup in fish-processing facilities where fish can be exposed to high temperatures for short periods of time. Histamine production was studied in tuna loins under different storage and abuse conditions. Tuna was stored at 0-2 degrees C, 3-4 degrees C, and 6-7 degrees C, and abused for 2 h daily at 20 degrees C and 30 degrees C for 7-12 days. Loins abused at 30 degrees C for 2 h daily contained potentially toxic histamine concentrations (67-382 mg kg(-1)) when stored at a low refrigeration temperature (0-2 degrees C), whereas when stored at 6-7 degrees C, the loins contained highly toxic histamine concentrations (544.5-4156.6 mg kg(-1)). Lower histamine concentrations (23-48 mg kg(-1) in loins stored at 0-2 degrees C and 124.7-2435.8 mg kg(-1) in loins stored at 6-7 degrees C) were observed in temperature-abused loins that were initially frozen. An increase over time was observed in most microbial counts tested. Bacteria isolated from the temperature-abused loins showed a varied ability of histamine production, with Morganella morganii, Klebsiella oxytoca, Staphylococcus hominis, and Enterococcus hirae being the most active histamine-producing bacteria.