An outbreak of food-borne botulism in Scotland, United Kingdom, November 2011.

An investigation is currently underway to explain an outbreak of food-borne botulism in Scotland. Three children in the same family were confirmed as having botulism following consumption of a meal made with a jar of korma sauce. Residual sauce from the jar, the jar lid and a remnant of the meal, all tested positive for Clostridium botulinum type A toxin. The children are recovering, although two remain ventilated and in intensive care unit.

Temperature-dependent transmission of rotavirus in Great Britain and The Netherlands.

In Europe, rotavirus gastroenteritis peaks in late winter or early spring suggesting a role for weather factors in transmission of the virus. In this study, multivariate regression models adapted for time-series data were used to investigate effects of temperature, humidity and rainfall on reported rotavirus infections and the infection-rate parameter, a derived measure of infection transmission that takes into account population immunity, in England, Wales, Scotland and The Netherlands. Delayed effects of weather were investigated by introducing lagged weather terms into the model. Meta-regression was used to pool together country-specific estimates. There was a 13 per cent (95% confidence interval (CI), 11-15%) decrease in reported infections per 1 degrees C increase in temperature above a threshold of 5 degrees C and a 4 per cent (95% CI, 3-5%) decrease in the infection-rate parameter per 1 degrees C increase in temperature across the whole temperature range. The effect of temperature was immediate for the infection-rate parameter but delayed by up to four weeks for reported infections. There was no overall effect of humidity or rainfall. There is a direct and simple relationship between cold weather and rotavirus transmission in Great Britain and The Netherlands. The more complex and delayed temperature effect on disease incidence is likely to be mediated through the effects of weather on transmission.

Campylobacter immunity and coinfection following a large outbreak in a farming community.

An outbreak of campylobacteriosis affected approximately one-half of 165 people attending an annual farmers' dance in Montrose, Scotland, in November 2005. Epidemiological investigations, including a cohort study (n = 164), identified chicken liver paté as the most likely vehicle of infection. Paté preparation involved deliberate undercooking of chicken livers by flash-frying, followed by mechanical homogenization. Typing of 32 Campylobacter strains (isolated from submitted stools) by multilocus sequence typing identified four distinct clades of Campylobacter jejuni. There was good agreement when isolates were typed by Penner serotyping, pulsed-field gel electrophoresis, and flaA short variable region sequencing but poorer agreement with phage and antibiotic susceptibility testing. At least three attendees were coinfected with two Campylobacter strains each. The outbreak was probably due to several livers contributing Campylobacter strains that survived undercooking and were dispersed throughout the paté. The study highlights improper culinary procedures as a potential human health risk and provides a striking counterexample to the "dominant outbreak strain" view of point source outbreaks of food-borne infections. It also demonstrates that previous exposure to biologically plausible sources of Campylobacter may confer protection against subsequent infection.

Clinical management of children with suspected or confirmed E. coli O157 infection.

Scotland continues to report higher rates of infection with Escherichia coli O157 than elsewhere in the UK. Infection with E. coli O157 usually manifests as acute, afebrile, painful, bloody diarrhoea and is the commonest cause of Haemolytic Uraemic Syndrome (HUS), an important cause of childhood renal failure. In 1996 an outbreak of E. coli O157 infection in Central Scotland, resulted in over 500 cases and 17 deaths. Ten years on, high-profile outbreaks of E. coli O157 infection in Scotland still result in cases of HUS and fatalities. We sought to identify outcomes and describe pre-hospital clinical management strategies using prospective, national surveillance of paediatric HUS cases, from 2003 to 2006 inclusive. We recommend that children who present with acute, afebrile, and painful bloody diarrhoea be referred to hospital as early as possible for appropriate clinical management.

A European outbreak of Salmonella enterica serotype Typhimurium definitive phage type 204b in 2000.

OBJECTIVE: To describe the clinical, epidemiologic and microbiological features of a large outbreak of infection with a multiresistant Salmonella enterica serotype Typhimurium definitive type DT204b infection involving at least 392 people in five European countries. METHODS: Icelandic public-health doctors responded to a report on an Internet news site of an outbreak of infection with a multiresistant strain of Typhimurium DT104 in England by contacting the Public Health Laboratory Service (PHLS) Communicable Disease Surveillance Centre (CDSC). An international alert was sent out through Enter-net. All strains from England & Wales, The Netherlands, Scotland and Germany, and 17 of the outbreak isolates from Iceland, were phage-typed, screened for antimicrobial resistance, and subjected to molecular typing. Hypothesis-generating interviews were conducted, followed by case-control studies performed in Iceland and England. RESULTS: Isolates from cases in Iceland, England and Wales, The Netherlands, Scotland and Germany were identified as Typhimurium DT204b. The antimicrobial resistance pattern was ACGNeKSSuTTmNxCpL. All strains tested displayed an identical plasmid profile. Strains from five cases in England & Wales and five cases in Iceland possessed identical pulsed-field profiles. Although a common source was suspected, only Iceland implicated imported lettuce as a vehicle, with an analytic epidemiologic study (OR = 40.8; P = 0.005; 95% CI 2.7-3175). CONCLUSION: The identification of international outbreaks, necessary for investigation and control, can be facilitated by standardized phage-typing techniques, the electronic transfer of molecular typing patterns, formal and informal links established through international surveillance networks, and the early reporting of national outbreaks to such networks.

Outbreaks of infectious intestinal disease in residential institutions in England and Wales 1992-1994.

Data from the surveillance scheme of all general outbreaks of infectious intestinal disease in England and Wales reported to or otherwise identified, by the Public Health Laboratory Service Communicable Disease Surveillance Centre (CDSC) in 1992 and 1994 were used to describe the epidemiology of outbreaks of infectious intestinal disease in residential institutions. Outbreaks in residential institutions accounted for 22% (282/1275) of all outbreaks with most, 95% (268/282), occurring in homes for the elderly. The commonest pathogens in these 282 outbreaks were small round structured viruses 48% (132), salmonellas 17% (49). Clostridium perfringens 8% (23), rotavirus 5% (15) and Shigella sonnei 2% (6). The mode of transmission was described as mainly person to person in 71% (200 outbreaks) and mainly foodborne in 21% (58 outbreaks). The mean duration of outbreaks was 9 days. Duration of outbreaks varied with both the mode of transmission and the pathogen involved. The mean attack rate was 37%. Illness was reported in 5872 people. One or more individuals were admitted to hospital in 22% of outbreaks. Twenty-six deaths were reported, of which 18 were attributed to salmonellosis. Outbreaks in residential institutions are common. Attack rates are high and outbreaks are often prolonged, with high morbidity and mortality. There is a need for effective infection control policies which include appropriate training of staff, simple surveillance systems and readily available expert advice to ensure outbreaks are rapidly controlled.

Scottish outbreak of Escherichia coli O157, November-December 1996.

On the afternoon of Friday 22 November 1996, Lanarkshire Health Board s Public Health Department became aware of 15 cases of possible Escherichia coli O157 infection (five of which had been confirmed microbiologically) in residents of the town of Wishaw i

Epidemiology of Salmonella enterica serovars enteritidis and Typhimurium in animals and people in Scotland between 1990 and 2001.

Two serovars of salmonella which are currently of particular importance in both human and animal infections are Salmonella enterica serovars Enteritidis phage type 4 (PT4) and Typhimurium definitive type 104 (DT104). This paper describes the trends in the relationships between the levels of infection of people and a range of farm animal species with these two serovars and explores some of the reasons behind them. In 1996, there was a peak of 520 reports of S Typhimurium DT104 infection in people in Scotland, but the number has decreased every year since, to 96 in 2001. In cattle the incidence of S Typhimurium DT104 also peaked in 1996, with 138 incidents, and it has similarly decreased every year to 2001 when there were 10 reported incidents. Similar declines have been observed in its incidence in sheep and pigs. In people the number of reports of S Enteritidis PT4 peaked in 1997 at 1684 and then declined to 457 in 2001. In chickens, the number of reports of S Enteritidis PT4 peaked in 1998 at 34 incidents, but no incidents were reported in the following three years.

Foodborne infectious risks: do we need a wide system of data collection and survey? The lessons learned from the study of infectious intestinal disease in England.

In 2000, the United Kingdom Government's Food Standards Agency published "A report of the study of infectious intestinal disease in England". This report was the result of over a decade's endeavour and cost well in excess of 2 million pound sterling (approximately 3.3 million euros). The study originated in 1989. In response to national epidemics of foodborne infection with Salmonella enteritidis phage type 4 and Listeria monocytogenes, the Government set up the Committee on the Microbiological Safety of Food (the Richmond Committee). This committee wished to know the actual level of clinical disease in the population giving rise to the laboratory reports of gastro-intestinal pathogens in national surveillance data and recommended studies to achieve this objective. In addition, successors to the to Richmond Committee decided that it would be of value to collect information from both cases and controls, including documenting exposure to biologically plausible risk factors so that differences between the ill and the well could be identified. Enquiries were also made about the clinical course of disease, so that long term sequelae and socio-economic costs could be estimated. A full description of this enormous study is beyond the scope of this paper, which defends the personal view that resources might have been better spent on a less ambitious enquiry.

Case-control study of infections with Salmonella enteritidis phage type 4 in England.

OBJECTIVE: To determine the source of indigenous sporadic infection with Salmonella enteritidis phage type 4. DESIGN: Case-control study of primary sporadic cases identified by the Public Health Laboratory Service between 1 August and 30 September 1988. SETTING: PHLS Communicable Disease Surveillance Centre, Division of Enteric Pathogens, 11 PHLS laboratories, and 42 local authority environmental health departments in England. SUBJECTS: 232 Patients (cases) with confirmed primary sporadic infection, for 160 of whom (88 female) (median age 30 years, age range 4 months to 85 years) data were obtained by questionnaire about consumption of fresh eggs, egg products, precooked chicken, and minced meat in the three days and one week before onset of the symptoms. Up to three controls, matched for neighbourhood, age, and sex (if aged greater than 11 years), were asked the same questions for the same calendar period. MAIN OUTCOME MEASURE: Association of primary sporadic infection with consumption of suspected food items. RESULTS: Illness due to S enteritidis phage type 4 was significantly associated with consumption of raw shell egg products (homemade mayonnaise, ice cream, and milk drinks containing eggs) (matched p = 0.02) and shop bought sandwiches containing mayonnaise (matched p = 0.00004) or eggs (matched p = 0.02). Illness was also significantly associated with eating lightly cooked eggs (unmatched p = 0.02), but not soft boiled eggs, and precooked hot chicken (matched p = 0.006). Reported consumption of eggs was not appreciably different between cases and controls before or after the median date of interview. CONCLUSIONS: Fresh shell eggs, egg products, and precooked hot chicken are vehicles of S enteritidis phage type 4 infection in indigenous sporadic cases. Public health education and reduction in contamination of eggs and infection of poultry with S enteritidis are needed to reduce the incidence of human infection.

Study of infectious intestinal disease in England: rates in the community, presenting to general practice, and reported to national surveillance. The Infectious Intestinal Disease Study Executive.

OBJECTIVE: To establish the incidence and aetiology of infectious intestinal disease in the community and presenting to general practitioners. Comparison with incidence and aetiology of cases reaching national laboratory based surveillance. DESIGN: Population based community cohort incidence study, general practice based incidence studies, and case linkage to national laboratory surveillance. SETTING: 70 general practices throughout England. PARTICIPANTS: 459 975 patients served by the practices. Community surveillance of 9776 randomly selected patients. MAIN OUTCOME MEASURES: Incidence of infectious intestinal disease in community and reported to general practice. RESULTS: 781 cases were identified in the community cohort, giving an incidence of 19.4/100 person years (95% confidence interval 18.1 to 20.8). 8770 cases presented to general practice (3.3/100 person years (2.94 to 3.75)). One case was reported to national surveillance for every 1.4 laboratory identifications, 6.2 stools sent for laboratory investigation, 23 cases presenting to general practice, and 136 community cases. The ratio of cases in the community to cases reaching national surveillance was lower for bacterial pathogens (salmonella 3.2:1, campylobacter 7.6:1) than for viruses (rotavirus 35:1, small round structured viruses 1562:1). There were many cases for which no organism was identified. CONCLUSIONS: Infectious intestinal disease occurs in 1 in 5 people each year, of whom 1 in 6 presents to a general practitioner. The proportion of cases not recorded by national laboratory surveillance is large and varies widely by microorganism. Ways of supplementing the national laboratory surveillance system for infectious intestinal diseases should be considered.

How protective is breast feeding against diarrhoeal disease in infants in 1990s England? A case-control study.

AIMS: To assess the effect of several measures of infant feeding on diarrhoeal disease, and whether these effects vary according to markers of social deprivation. METHODS: Case-control study of diarrhoeal disease cases presenting to 34 general practices in England. Controls were stratified on age group, area deprivation index for the practice, and whether or not the practice was in London. Data were available on 304 infants (167 cases and 137 controls). RESULTS: After adjustment for confounders, breast feeding was associated with significantly less diarrhoeal disease. Associations were striking even in infants aged > or = 6 months. They did not vary by social class, but were greater in those living in rented council accommodation and in more crowded households. The effect of receiving no breast milk was stronger in more deprived areas than in less deprived areas. The effect of not receiving exclusive breast milk was stronger in more deprived areas than in less deprived areas. In formula fed infants, there was significantly more diarrhoeal disease in those not sterilising bottles/teats with steam or chemicals. The protective effect of breast feeding did not persist beyond two months after breast feeding had stopped. CONCLUSIONS: Breast feeding protects against diarrhoeal disease in infants in England although the degree of protection may vary across infants and wear off after breast feeding cessation. Education about the benefits of breast feeding and the risks of inadequate sterilisation should be targeted at carers in deprived areas or households.

Food poisoning notification: time for a rethink.

The notification of food poisoning is a statutory obligation of medical practitioners in the United Kingdom. Its objectives and methods are vague and ill documented, and the value of its output doubtful. Statutory notification of food poisoning is poor at identifying outbreaks, or single cases of severe disease, or as a measure of longer term trends. It should be fundamentally reformed.

Infection with small round structured viruses: England and Wales 1981-1990.

Infection with small round structured viruses (SRSV) usually causes an acute, but short-lived, attack of gastroenteritis in which vomiting is a prominent feature. Most documented outbreaks have occurred in institutional and catering establishments and infected food handlers are often implicated. Reports of SRSV infection have risen substantially during the last decade partly due to an increase in the number of laboratories able to examine samples for this organism. Ascertainment is likely to remain low, however, until a sensitive, simple, reliable and economical method of detection becomes routinely available.

The measles/rubella immunisation campaign in Scotland.

This report describes why the 1994 measles/rubella immunisation campaign was necessary, reviews its implementation, and provides information on its impact in Scotland where 60,504 children were immunised. Data on suspected adverse reactions to the measles/rubella vaccine are also presented. A large UK measles epidemic was predicted by independent researchers, and action in response was planned in accordance with the recommendations of the Joint Committee on Vaccination and Immunisation. As a result, the epidemic predicted for England and Wales was averted and the epidemic which had occurred in the West of Scotland was prevented from spreading to the East. Laboratory-confirmed cases of measles and rubella are now rare in all parts of the UK, especially in the age group targeted by the campaign. Most reported adverse reactions were mild and self-limiting: only one child per 6,700 vaccinated in the UK was reported to have suffered any adverse reaction. Immediate, serious reactions were either allergic or were described as convulsions (most associated with immediate syncope); all of these children recovered fully. Later onset neurological problems were reported at rates no higher than expected from normal population incidence.

Epidemiological investigation of the central Scotland outbreak of Escherichia coli O157 infection, November to December 1996.

On Friday, 22 November 1996, the microbiologist at a hospital in Lanarkshire, Scotland, identified presumptive Escherichia coli O157 in faecal specimens submitted by three patients with bloody diarrhoea, and confirmed its presence in one. Over the next 6 h, 12 more potential cases were identified. Investigations first indicated then confirmed a single food premises as the source of infection. Effective control measures were applied promptly. The outbreak was declared over on 20 January 1997, by which time 512 cases had been identified, and infection with the outbreak strain confirmed in 279. Twenty deaths occurred in cases during the outbreak and there were two more in cases during 1997. Seventeen of these deaths resulted from the outbreak. This paper describes the outbreak's epidemiological investigation, referring to other investigations, and control measures, where appropriate.

Investigation and management of sporadic gastrointestinal infections with potentially Vero cytotoxin producing Escherichia coli in Scotland.

Recognition of the potential of Escherichia coli O157 and other Vero cytotoxin producing E. coli (VTEC) organisms to cause serious disease led to the recommendation that all diarrhoeal stool specimens be examined for E. coli O157. National guidelines exist for the testing and exclusion of cases and contacts of VTEC infection. A survey was conducted to discover the extent to which these recommendations are followed in Scotland by asking about current practices for public health management of identified cases and laboratory investigation of E. coli infection. About two thirds of Scottish health boards followed national guidelines for testing and exclusion of cases and contacts of VTEC O157 infection. Most laboratories tested all diarrhoeal stools for E. coli O157 but detection methods varied and a minority tested selected stools for non-O157 E. coli serogroups. Standardisation of policies for laboratory testing of VTEC infection would improve national surveillance. Adherence to evidence based guidelines would standardise public health management of VTEC infections in Scotland.

The Public Health Laboratory Service national case-control study of primary indigenous sporadic cases of campylobacter infection.

The aetiology of sporadic campylobacter infection was investigated by means of a multicentre case-control study. During the course of the study 598 cases and their controls were interviewed. Conditional logistic regressional analysis of the data collected showed that occupational exposure to raw meat (odds ratio [OR] 9.37; 95% confidence intervals [CI] 2.03, 43.3), having a household with a pet with diarrhoea (OR 2.39; CI 1.09, 5.25), and ingesting untreated water from lakes, rivers and streams (OR 4.16; CI 1.45, 11.9) were significant independent risk factors for becoming ill with campylobacter. Handling any whole chicken in the domestic kitchen that had been bought raw with giblets, or eating any dish cooked from chicken of this type in the home (OR 0.41-0.44; CI 0.24, 0.79) and occupational contact with livestock or their faeces (OR 0.44; CI 0.21, 0.92) were significantly associated with a decrease in the risk of becoming ill with campylobacter.