Optimal staffing for a good quality inpatient diabetes service.

INTRODUCTION: Increasing numbers of people admitted to hospital have diabetes and need specialist support. To date, there is no mechanism which can help teams estimate the number of health care professionals they need to provide optimal care for people with diabetes in hospitals. METHODS: The Joint British Diabetes Societies (JBDS) for Inpatient Care Group organised a survey of specialist inpatient diabetes teams in the UK for current staffing and the perception of optimal staffing using mailing lists available through their representative organisations. The results were verified and confirmed by one-to-one conversations with individual respondents and discussed in multiple expert-group meetings to agree on the results. RESULTS: Responses were received from 17 Trusts covering 30 hospital sites. Current diabetes specialist staffing level per 100 people with diabetes in hospital (Median, IQR) for consultants was 0.24 (0.22-0.37), diabetes inpatient specialist nurses was 1.94 (1.22-2.6), dieticians was 0.00 (0.00-0.00), podiatrists was 0.19 (0.00-0.62), pharmacists was 0.00 (0.00-0.37), psychologists was 0.00 (0.00-0.00). The teams also reported that for optimal care the total staff needed for each group (Median, IQR) was much higher; consultants 0.65 (0.50-0.88), specialist nurses 3.38 (2.78-4.59), dieticians 0.48 (0.33-0.72), podiatrists, 0.93 (0.65-1.24), pharmacists, 0.65 (0.40-0.79) and psychologists 0.33 (0.27-0.58). Based on the results of the survey, the JBDS expert group produced an Excel calculator to estimate staffing needs of any hospital site in question just by populating a few of the cells. CONCLUSION: Current inpatient diabetes staffing is much lower than needed in most Trusts who responded to the survey. The JBDS calculator can provide an estimate of the staffing needs of any hospital.

Is increased screening and early antiretroviral treatment for HIV-1 worth the investment? An analysis of the public health and economic impact of improvement in the UK.

OBJECTIVES: Early treatment of HIV-1 infection at all CD4 levels has demonstrated clinical and public health benefits. This analysis examined the costs, health outcomes, and cost-effectiveness of increased HIV-1 screening and early treatment initiation in the UK. METHODS: A Markov model followed theoretical cohorts of men who have sex with men (MSM), heterosexuals, and people who inject drugs (PWID) with initially undiagnosed HIV-1 infection over their remaining lifetimes. The analysis examined increased HIV-1 screening (resulting in 10-50% improvements in diagnosis rates) versus current screening in sexual health services (SHS) and other settings, with all individuals initiating treatment within 3 months of diagnosis. Health status was modelled by viral load and CD4 cell count as individuals progressed to diagnosis and treatment. Individuals accrued quality-adjusted life-years (QALYs), incurred costs for screening and HIV-related clinical management, and were at risk of transmitting HIV-1 infection to their partners. Input parameter data were taken primarily from UK-specific published sources. All outcomes were discounted at 3.5% annually. RESULTS: The model estimated that increased screening and early treatment resulted in fewer onward HIV transmissions, more QALYs, and higher total costs. For SHS, incremental cost-effectiveness ratios (ICERs) for heterosexuals (~£22 000/QALY gained) were within typical UK willingness-to-pay thresholds and were well below these thresholds for MSM (~£9500/QALY gained) and PWID (~£6500/QALY gained). Sensitivity analysis showed that model results were robust. CONCLUSIONS: Increased HIV-1 screening and early treatment initiation may be a cost-effective strategy to reduce HIV transmission and improve health for MSM, heterosexuals, and PWID in the UK.

Is It Time To Review The Vaccination Strategy To Protect Adults Against Invasive Pneumococcal Disease?

Pneumococcal conjugate vaccines (PCVs) have reduced the predominant serotypes causing invasive pneumococcal disease (IPD). We assessed the impact of the paediatric 7- and 13-valent pneumococcal conjugate vaccines (PCV7 and PCV13) among older adults. We compared serotype-specific incidence rates from 2007/08 to 2016/17, expressed as incidence rate ratios (IRR). Introducing PCV7 and PCV13 into the childhood immunisation programme resulted in a decline in these serotypes in adults ≥65 years of age, with PCV7 serotypes decreasing by 85% (IRR=0.11, 95%CI: 0.05-0.22, p<0.0001) and PCV13 serotypes not included in PCV7 (PCV13-7), decreasing by 9% (IRR=0.68, 95%CI: 0.40-1.16, p=0.134). However, there was a significant increase in serotypes only found in the 23-valent polysaccharide vaccine, PPV23-PCV13: IRR=2.57, 95%CI: 1.68-4.03, p<0.0001, and non-vaccine types (NVTs), IRR=3.33, 95%CI: 1.75-6.84, p=0.0001. The decline of IPD associated with PCV7/13 serotypes and the increase in PPV23-PCV13 serotypes indicates clear serotype replacement. Increasing PPV23 uptake could still reduce the burden of disease for this population.

Self-management of diabetes in hospital: a guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care group.

The aims of these guidelines are to improve the inpatient experience and safety for people with diabetes through effective self-management. The guidelines are aimed primarily at healthcare professionals working in hospitals, although some aspects are relevant to staff involved in pre-admission preparation. The guidelines suggest an approach to providing patient information, the circumstances in which self-management is appropriate, the development of care plans and the elements needed for effective self-management. This document is an abridged and modified version of 'Self-management of diabetes in hospital' adapted specifically for Diabetic Medicine. The full version can be found online at: www.diabetes.org.uk/joint-british-diabetes-society or https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group.

A retrospective assessment of the completeness and timeliness of meningococcal disease notifications in the Republic of Ireland over a 16-year period, 1999-2015.

OBJECTIVES: To assess how invasive meningococcal disease (IMD) records held by the Irish Meningitis & Sepsis Reference Laboratory (IMSRL) compare to records of IMD notifications reported on the national integrated electronic Computerised Infectious Disease Reporting (CIDR) system. STUDY DESIGN: We assessed the completeness, data quality and timeliness of IMD notifications and reference laboratory records for the period between 01 July 1999 and 30 June 2015 by identifying discrepant and/or missing data items in a matched case data set and by measuring the timeliness of case reporting. METHODS: We matched anonymised cases notified to CIDR to records based at the IMSRL using birth, reporting and onset dates with gender and laboratory parameters of meningococcal strain characteristics and method of confirmation. Completeness, data quality and the timeliness of notifications were assessed by a stratified sensitivity-based technique and by calculating the average difference between IMSRL and CIDR reporting dates. RESULTS: CIDR recorded a total of 3163 notifications, of which 2759 (87.2%) were matched to IMSRL records. Completeness of IMD case classification as confirmed was estimated to be >99%. Examining the levels of discrepant or missing data in both matched CIDR and IMSRL records as a measure of data quality, recording of demographic items and meningococcal group showed least differences, recording of laboratory case confirmation method and meningococcal strain characteristics were less well recorded, with detail on clinical presentation/diagnosis least well recorded. Overall average annual difference between CIDR and IMSRL recording dates was 3.2 days (95% confidence interval 2.6-3.8). CONCLUSIONS: A high quality of IMD surveillance in Ireland was demonstrated, but scope for improvements in timeliness and capture of enhanced surveillance data regarding date of onset and strain-specific characteristics were identified.

The epidemiology of invasive pneumococcal disease in older adults in the post-PCV era. Has there been a herd effect?

The 7 and 13-valent pneumococcal conjugate vaccines (PCVs) have reduced the incidence of invasive pneumococcal disease (IPD) in children in many countries. The objective of this work was to assess the impact of PCVs and potential herd-protection in older adults in Ireland. IPD notification and typing data from adults ⩾65 years of age from July 2007 to June 2016 was assessed using national surveillance data. There was a 94% reduction in PCV7 serotypes from 2007-2008 to 2015-2016, incidence rate ratio (IRR 0·05, P < 0·0001). However, there was no decline in the additional PCV13 (PCV13-7) serotypes over the same period (IRR 0·90) nor in comparison with the pre-PCV13 period 2009-2010 (IRR 0·92). The incidence of serotypes in the 23-valent pneumococcal polysaccharide vaccine only (PPV23-PCV13) and non-vaccine types (NVTs) increased significantly (IRR 2·17, P = 0·0002 and IRR 3·43, P = 0·0001 respectively). Consequently, the overall IPD incidence rate in adults has remained relatively unchanged (from 28·66/100 000 to 28·88/100 000, IRR 1·01, P = 0·9477). Serotype 19A and NVTs were mainly responsible for penicillin resistance in recent years. The decline of PCV7 serotypes indicate that the introduction of PCV7 resulted in herd-protection for adults. However, increases in PPV23-PCV13 and NVTs suggest that changes in vaccination strategy amongst older adults are needed to build on the success of PCVs in children.

Reporting of Acute Flaccid Paralysis in Children under 15 years of age: Improving Surveillance, January 2009 - December 2014.

Acute Flaccid Paralysis (AFP) surveillance, including case investigation and specimen collection is a gold standard method for poliomyelitis surveillance. The expected annual non-polio AFP rate <15 years of age in Ireland is = 1/100 000 population. This study reviewed all cases of AFP reported to the Irish Paediatric Surveillance Unit and the Health Protection Surveillance Centre between January 2009 and December 2014 and compared reporting rates with the expected incidence rate annually. We assessed quality of surveillance data in terms of completeness of investigation for each case reported. Forty-three AFP cases in children <15 years were notified; 35 of which were confirmed. Guillain-Barre Syndrome (GBS) accounted for 48.6% (n=17) of AFP notifications. In 2014, the expected annual AFP target rate was reached. This study identified possible under-reporting of AFP paediatric cases in Ireland between 2009-2013. Completeness of investigations has improved over time, but requires further work.

Tuberculosis incidence in the Irish Traveller population in Ireland from 2002 to 2013.

The health status of the Irish Traveller ethnic minority is low compared to the general population in Ireland in terms of infant mortality rates and life expectancies. Respiratory disease is an area of health disparity manifested as excess mortalities in Traveller males and females. In this study, we examined the available data with regard to tuberculosis (TB) notifications in Ireland from 2002 to 2013. We found an increase in TB notifications in Irish Travellers from 2010 onwards. This resulted in a crude incidence rate for TB in Irish Travellers that was approximately threefold higher than that of the white Irish-born population in 2011 and 2012. An outbreak of TB in Irish Travellers in 2013 increased this differential further, but when outbreak-linked cases were excluded, a higher incidence rate was still observed in Irish Travellers relative to the general population and to white Irish-born. The mean age of a TB patient was 26 years in Irish Travellers compared to 43 years in the general population, and 49 years in white Irish-born. Based on available data, Irish Travellers exhibit a higher incidence rate and younger age distribution of TB compared to white Irish-born and the general population. These observations emphasize the importance of routine use of ethnicity identifiers in the management of TB and other notifiable communicable illnesses in Ireland. They also have implications for the orientation of preventive services to address health disparities in Irish Travellers and other ethnic minority groups.

A prolonged outbreak of invasive meningococcal disease in an extended Irish Traveller family across three Health Service Executive (HSE) areas in Ireland, 2010 to 2013.

Between March 2010 and November 2013 eight laboratory-confirmed cases of serogroup B, invasive meningococcal disease (IMD) were identified in an extended Irish Traveller family across three Health Service Executive (HSE) areas of Ireland. Cases were aged between 5 and 46 months, and were either a cousin or sibling of another case. All eight cases survived. Chemoprophylaxis was given to relevant nuclear family members and close contacts on each occasion, but failed to prevent further cases. Neisseria meningitidis isolates from six cases were highly related, belonging to the ST-41/44 clonal complex, and shared the porA designation 7­2,4. In November 2013, the outbreak control team recommended that directly observed ciprofloxacin chemoprophylaxis be administered simultaneously to the extended family, and that the four component meningococcal B (4CMenB) vaccine be administered to family members aged 2 months to 23 years inclusive and relevant close contacts of the eighth case. Subsequently these recommendations were implemented at three regional clinics. Additionally pharyngeal swabs (n=112) were collected to assess carriage rates of N. meningitidis in this extended family. Pharyngeal carriage of N. meningitidis was detected in 15 (13%) family members. From the epidemiological investigation and carriage study overcrowding was the most likely risk factor identified in this outbreak. To date, the combination of directly observed ciprofloxacin chemoprophylaxis and use of 4CMenB vaccine have controlled the outbreak with no further cases diagnosed.

Patients Accessing Ambulatory Care for HIV-infection: Epidemiology and Prevalence Assessment.

This study describes the demographics and treatment status of HIV-infected adults accessing ambulatory care in the Republic of Ireland and estimates diagnosed HIV prevalence rates. 3254 HIV-infected adults attended 1 of the 6 specialist HIV centres in the 12- month period 1st July 2009 to 30th June 2010. 2023/3254 (62%) were male, 1761/3133 (56%) Irish and 1048/3133 (34%) African. 1924/3098 (62%) resided in the Dublin area. The mean age was 39.8 years (SD 9.3); probable route of acquisition was available for 2898/3254 (89%); heterosexual acquisition accounted for 1442 (50%), MSM 777 (27%) and IDU 598 (21%). 2574/3202 (80%) were on highly active antiretroviral therapy (HAART). Of these 87% had HIV-RNA levels < 50cpm and 94% < 500cpm. The HIV diagnosed prevalence rate is estimated at 1.09/1000 nationally and at 2.25/1000 in the Dublin area for 15-59 year olds.

Severe hypoglycaemia in type 1 diabetes mellitus: underlying drivers and potential strategies for successful prevention.

Hypoglycaemia remains an over-riding factor limiting optimal glycaemic control in type 1 diabetes. Severe hypoglycaemia is prevalent in almost half of those with long-duration diabetes and is one of the most feared diabetes-related complications. In this review, we present an overview of the increasing body of literature seeking to elucidate the underlying pathophysiology of severe hypoglycaemia and the limited evidence behind the strategies employed to prevent episodes. Drivers of severe hypoglycaemia including impaired counter-regulation, hypoglycaemia-associated autonomic failure, psychosocial and behavioural factors and neuroimaging correlates are discussed. Treatment strategies encompassing structured education, insulin analogue regimens, continuous subcutaneous insulin infusion pumps, continuous glucose sensing and beta-cell replacement therapies have been employed, yet there is little randomized controlled trial evidence demonstrating effectiveness of new technologies in reducing severe hypoglycaemia. Optimally designed interventional trials evaluating these existing technologies and using modern methods of teaching patients flexible insulin use within structured education programmes with the specific goal of preventing severe hypoglycaemia are required. Individuals at high risk need to be monitored with meticulous collection of data on awareness, as well as frequency and severity of all hypoglycaemic episodes.

Leptospirosis in Ireland: annual incidence and exposures associated with infection.

Human leptospirosis is found throughout the world, albeit with a higher incidence in tropical regions. In temperate regions it is associated with certain occupational and recreational activities. This paper reports both on the incidence of human leptospirosis in Ireland and on possible associated exposures, using leptospirosis case notification, enhanced surveillance, hospital discharge data and death registrations. Based on official notification data, there was a threefold increase in the reported incidence of leptospirosis in Ireland between 1995-1999 and 2004-2009, which appears partially to be due to improved reporting. The exposures most associated with infection were those involving contact with livestock or water-based recreational sports, in particular kayaking. Advice on prevention should continue to be targeted in the first instance at these groups. The variety of potential transmission routes reported should inform clinicians to consider leptospirosis in individuals with a compatible clinical profile who were not from occupational groups historically considered at risk.

Influenza in hospitalized children in Ireland in the pandemic period and the 2010/2011 season: risk factors for paediatric intensive-care-unit admission.

Influenza causes significant morbidity and mortality in children. This study's objectives were to describe influenza A(H1N1)pdm09 during the pandemic, to compare it with circulating influenza in 2010/2011, and to identify risk factors for severe influenza defined as requiring admission to a paediatric intensive care unit (PICU). Children hospitalized with influenza during the pandemic were older, and more likely to have received antiviral therapy than children hospitalized during the 2010/2011 season. In 2010/2011, only one child admitted to a PICU with underlying medical conditions had been vaccinated. The risk of severe illness in the pandemic was higher in females and those with underlying conditions. In 2010/2011, infection with influenza A(H1N1)pdm09 compared to other influenza viruses was a significant risk factor for severe disease. An incremental relationship was found between the number of underlying conditions and PICU admission. These findings highlight the importance of improving low vaccination uptake and increasing the use of antivirals in vulnerable children.

Seasonal influenza immunisation in Europe. Overview of recommendations and vaccination coverage for three seasons: pre-pandemic (2008/09), pandemic (2009/10) and post-pandemic (2010/11).

Since 2008, annual surveys of influenza vaccination policies, practices and coverage have been undertaken in 29 European Union (EU)/ European Economic Area (EEA) countries. After 2009, this monitored the impact of European Council recommendation to increase vaccination coverage to 75% among risk groups. This paper summarises the results of three seasonal influenza seasons: 2008/09, 2009/10 and 2010/11. In 2008/09, 27/29 countries completed the survey; in 2009/10 and 2010/11, 28/29 completed it. All or almost all countries recommended vaccination of older people (defined as those aged ≥50, ≥55, ≥59, ≥60 or ≥65 years), and people aged ≥6 months with clinical risk and healthcare workers. A total of 23 countries provided vaccination coverage data for older people, but only 7 and 10 had data for the clinical risk groups and healthcare workers, respectively. The number of countries recommending vaccination for some or all pregnant women increased from 10 in 2008/09 to 22 in 2010/11. Only three countries could report coverage among pregnant women. Seasonal influenza vaccination coverage during and after the pandemic season in older people and clinical groups remained unchanged in countries with higher coverage. However, small decreases were seen in most countries during this period. The results of the surveys indicate that most EU/EEA countries recommend influenza vaccination for the main target groups; however, only a few countries have achieved the target of 75% coverage among risk groups. Coverage among healthcare workers remained low.

Investigation of an association between onset of narcolepsy and vaccination with pandemic influenza vaccine, Ireland April 2009-December 2010.

In 2011, the Irish Medicines Board received reports of onset of narcolepsy following vaccination against influenza A(H1N1)pdm09 with Pandemrix. A national steering committee was convened to examine the association between narcolepsy and pandemic vaccination. We conducted a retrospective population-based cohort study. Narcolepsy cases with onset from 1 April 2009 to 31 December 2010 were identified through active case finding. Narcolepsy history was gathered from medical records. Pandemic vaccination status was obtained from vaccination databases. Two independent experts classified cases using the Brighton case definition. Date of onset was defined as date of first healthcare contact for narcolepsy symptoms. Incidence of narcolepsy in vaccinated and non-vaccinated individuals was compared. Of 32 narcolepsy cases identified, 28 occurred in children/adolescents and for 24 first healthcare contact was between April 2009 and December 2010. Narcolepsy incidence was 5.7 (95% confidence interval (CI): 3.4­8.9) per 100,000 children/adolescents vaccinated with Pandemrix and 0.4 (95% CI: 0.1­1.0) per 100,000 unvaccinated children/adolescents (relative risk: 13.9; absolute attributable risk: 5.3 cases per 100,000 vaccinated children/adolescents). This study confirms the crude association between Pandemrix vaccination and narcolepsy as observed in Finland and Sweden. The vaccine is no longer in use in Ireland. Further studies are needed to explore the immunogenetic mechanism of narcolepsy.

Outbreak of hepatitis A infection associated with the consumption of frozen berries, Ireland, 2013--linked to an international outbreak.

In May 2013, a European alert was issued regarding a hepatitis A virus (HAV) outbreak in Italy. In June 2013, HAV subgenotype IA with an identical sequence was identified in Ireland in three cases who had not travelled to Italy. The investigation consisted of descriptive epidemiology, a case-control study, microbiological testing of human and food specimens, molecular typing of positive specimens and food traceback. We identified 21 outbreak cases (14 confirmed primary cases) with symptom onset between 31 January and 11 October 2013. For the case-control study, we recruited 11 confirmed primary cases and 42 matched controls. Cases were more likely than controls to have eaten berry cheesecake (matched odds ratio (mOR): 12; 95% confidence interval (CI): 1.3-114), whole frozen berries (mOR: 9.5; 95% CI: 1.0-89), yoghurt containing frozen berries (mOR: 6.6, 95% CI: 1.2-37) or raw celery (mOR: 4; 95% CI: 1.2-16). Among cases, 91% had consumed at least one of four products containing frozen berries (mOR: 12; 95% CI: 1.5-94). Sixteen food samples tested were all negative for HAV. As products containing frozen berries were implicated in the outbreak, the public were advised to heat-treat frozen berries before consumption.

Seasonal influenza vaccine uptake in HSE-funded hospitals and nursing homes during the 2011/2012 influenza season.

Annual seasonal influenza vaccine is recommended for all health care workers (HCWs) in Ireland. For the 2011/2012 influenza season, information was collected on influenza vaccination uptake among HCWs employed in Health Service Executive (HSE)-funded hospitals (primarily acute) and of nursing homes (NHs) and also among NH long-term and short-term respite care residents. Forty-five hospitals (80%) and 120 NHs (75%) provided uptake data. Nationally, influenza vaccine uptake among hospital employed HCWs was estimated to be 18% and 14% among HCWs in NHs; in NHs vaccine uptake among long-term care residents was estimated to 88%. These findings highlight the continued low uptake among HCWs of all categories and demonstrate the need for sustained measures to improve uptake rates.

Exercise combined with Acceptance and Commitment Therapy for chronic pain: One-year follow-up from a randomized controlled trial.

BACKGROUND: Acceptance and Commitment Therapy (ACT) is a type of Cognitive Behavioural Therapy, which has demonstrated positive outcomes in individuals with chronic pain. The purpose of this study was to compare the effect of an 8-week programme combining Exercise with Acceptance and Commitment Therapy (ExACT) with a standalone supervised exercise programme at 1-year follow-up. METHODS: One hundred and seventy-five people with chronic pain were randomly assigned to ExACT or supervised exercise only. The primary outcome was pain interference measured with the Brief Pain Inventory-Interference Scale. Secondary and treatment process outcomes included pain severity, depression, anxiety, pain catastrophizing, pain self-efficacy, fear avoidance, pain acceptance, committed action, healthcare utilization, patient satisfaction, and global impression of change. Estimates of treatment effects at 1-year follow-up were based on intention-to-treat analyses, implemented using a linear mixed-effects model. RESULTS: Eighty-three participants (47.4%) returned the outcome measures at 1-year follow-up. No significant difference was observed between the groups for the primary outcome, pain interference. There was a statistically significant difference between the groups, in favour of ExACT for pain catastrophizing. Within group improvements that were observed within both groups at earlier timepoints were maintained at 1-year follow-up for many of the secondary and treatment process outcomes. ExACT group participants reported higher levels of satisfaction with treatment and global perceived change. CONCLUSIONS: The study results showed no significant difference between the two groups for the primary outcome pain interference at 1-year follow-up. Future research could investigate factors that may predict and optimize outcomes from these types of intervention for people living with chronic pain. SIGNIFICANCE: Few previous randomized controlled trials investigating ACT for chronic pain have included long-term follow-up. This study found that Exercise combined with ACT was not superior to supervised exercise alone for reducing pain interference at 1-year follow-up. Further research is necessary to identify key processes of therapeutic change and to explore how interventions may be modified to enhance clinical outcomes for people with chronic pain.

The impact of hypoglycaemia on patients admitted to hospital with medical emergencies.

AIMS: To quantify the frequency of biochemical hypoglycaemia in acutely unwell patients in the medical assessment unit and relate this to their subsequent outcomes. METHODS: A retrospective audit was conducted on all emergency medical patients attending the medical assessment unit between November 2010 and April 2011. Capillary blood glucose measurements were obtained and electronically stored for all patients. Admission details, presence of diabetes, type of diabetes and treatment, length of stay in hospital and death in hospital were obtained from the hospital clinical coding data and electronic discharge summary. The incidence of hypoglycaemia in patients with and without diabetes was quantified. The mean age, length of stay and percentage of death in hospital were compared between groups with and without hypoglycaemia. RESULTS: One hundred and thirty-eight (9.5%) patients with diabetes and 70 (2.7%) patients without diabetes had an episode of hypoglycaemia in the medical assessment unit. Patients with diabetes and hypoglycaemia on admission had a significantly longer length of stay (mean ± sd) (10.3 ± 11.2 vs. 7.3 ± 9.5 days, P = 0.001) and higher rate of hospital mortality (14.5 vs. 5.2%, P < 0.001) compared with those without hypoglycaemia. Patients without diabetes with hypoglycaemia had a longer length of stay (mean ± sd) (9.1 ± 10.5 vs. 6.7 ± 9.9 days, P = 0.05) and a higher rate of hospital mortality (24.3 vs. 5.4%, P < 0.001) compared with those without hypoglycaemia. CONCLUSION: Hypoglycaemia is associated with an increased length of stay in hospital and an increased in-hospital mortality rate. Hypoglycaemia may have contributed to the poorer outcome, but would also appear to be a marker of disease severity in unwell patients, especially patients with sepsis.

Seroepidemiology of mumps in Europe (1996-2008): why do outbreaks occur in highly vaccinated populations?

Mumps outbreaks have recently been recorded in a number of highly vaccinated populations. We related seroprevalence, epidemiological and vaccination data from 18 European countries participating in The European Sero-Epidemiology Network (ESEN) to their risk of mumps outbreaks in order to inform vaccination strategies. Samples from national population serum banks were collected, tested for mumps IgG antibodies and standardized for international comparisons. A comparative analysis between countries was undertaken using age-specific mumps seroprevalence data and information on reported mumps incidence, vaccine strains, vaccination programmes and vaccine coverage 5-12 years after sera collection. Mean geometric mumps antibody titres were lower in mumps outbreak countries [odds ratio (OR) 0·09, 95% confidence interval (CI) 0·01-0·71)]. MMR1 vaccine coverage ⩾95% remained protective in a multivariable model (P < 0·001), as did an interval of 4-8 years between doses (OR 0·08, 95% CI 0·01-0·85). Preventing outbreaks and controlling mumps probably requires several elements, including high-coverage vaccination programmes with MMR vaccine with 4-8 years between doses.