Influence of socio-economic status on Shiga toxin-producing Escherichia coli (STEC) infection incidence, risk factors and clinical features.

Shiga toxin-producing Escherichia coli (STEC) infection can cause serious illness including haemolytic uraemic syndrome. The role of socio-economic status (SES) in differential clinical presentation and exposure to potential risk factors amongst STEC cases has not previously been reported in England. We conducted an observational study using a dataset of all STEC cases identified in England, 2010-2015. Odds ratios for clinical characteristics of cases and foodborne, waterborne and environmental risk factors were estimated using logistic regression, stratified by SES, adjusting for baseline demographic factors. Incidence was higher in the highest SES group compared to the lowest (RR 1.54, 95% CI 1.19-2.00). Odds of Accident and Emergency attendance (OR 1.35, 95% CI 1.10-1.75) and hospitalisation (OR 1.71, 95% CI 1.36-2.15) because of illness were higher in the most disadvantaged compared to the least, suggesting potential lower ascertainment of milder cases or delayed care-seeking behaviour in disadvantaged groups. Advantaged individuals were significantly more likely to report salad/fruit/vegetable/herb consumption (OR 1.59, 95% CI 1.16-2.17), non-UK or UK travel (OR 1.76, 95% CI 1.40-2.27; OR 1.85, 95% CI 1.35-2.56) and environmental exposures (walking in a paddock, OR 1.82, 95% CI 1.22-2.70; soil contact, OR 1.52, 95% CI 2.13-1.09) suggesting other unmeasured risks, such as person-to-person transmission, could be more important in the most disadvantaged group.

Estimating the incubation period of acute Q fever, a systematic review.

Estimates of the incubation period for Q fever vary substantially between different reviews and expert advice documents. We systematically reviewed and quality appraised the literature to provide an evidence-based estimate of the incubation period of the Q fever by the aerosolised infection route. Medline (OVIDSP) and EMBASE were searched with the search limited to human studies and English language. Eligible studies included persons with symptomatic, acute Q fever, and defined exposure to Coxiella burnetti. After review of 7115 titles and abstracts, 320 records were screened at full-text level. Of these, 23 studies contained potentially useful data and were quality assessed, with eight studies (with 403 individual cases where the derivation of incubation period was possible) being of sufficient quality and providing individual-level data to produce a pooled summary. We found a median incubation period of 18 days, with 95% of cases expected to occur between 7 and 32 days after exposure.

An outbreak of Shiga toxin-producing Escherichia coli O157:H7 associated with contaminated salad leaves: epidemiological, genomic and food trace back investigations.

In August 2015, Public Health England detected an outbreak of Shiga toxin-producing Escherichia coli (STEC) serotype O157:H7 caused by contaminated salad leaves in a mixed leaf prepacked salad product from a national retailer. The implicated leaves were cultivated at five different farms and the zoonotic source of the outbreak strain was not determined. In March 2016, additional isolates from new cases were identified that shared a recent common ancestor with the outbreak strain. A case-case study involving the cases identified in 2016 revealed that ovine exposures were associated with illness (n = 16; AOR 8·24; 95% CI 1·55-39·74). By mapping the recent movement of sheep and lambs across the United Kingdom, epidemiological links were established between the cases reporting ovine exposures. Given the close phylogenetic relationship between the outbreak strain and the isolates from cases with ovine exposures, it is plausible that ovine faeces may have contaminated the salad leaves via untreated irrigation water or run-off from fields nearby. Timely and targeted veterinary and environmental sampling should be considered during foodborne outbreaks of STEC, particularly where ready to eat vegetables and salads are implicated.

Online market research panel members as controls in case-control studies to investigate gastrointestinal disease outbreaks: early experiences and lessons learnt from the UK.

Established methods of recruiting population controls for case-control studies to investigate gastrointestinal disease outbreaks can be time consuming, resulting in delays in identifying the source or vehicle of infection. After an initial evaluation of using online market research panel members as controls in a case-control study to investigate a Salmonella outbreak in 2013, this method was applied in four further studies in the UK between 2014 and 2016. We used data from all five studies and interviews with members of each outbreak control team and market research panel provider to review operational issues, evaluate risk of bias in this approach and consider methods to reduce confounding and bias. The investigators of each outbreak reported likely time and cost savings from using market research controls. There were systematic differences between case and control groups in some studies but no evidence that conclusions on the likely source or vehicle of infection were incorrect. Potential selection biases introduced by using this sampling frame and the low response rate are unclear. Methods that might reduce confounding and some bias should be balanced with concerns for overmatching. Further evaluation of this approach using comparisons with traditional methods and population-based exposure survey data is recommended.

A systematic review and meta-analysis on the incubation period of Campylobacteriosis.

Accurate knowledge of pathogen incubation period is essential to inform public health policies and implement interventions that contribute to the reduction of burden of disease. The incubation period distribution of campylobacteriosis is currently unknown with several sources reporting different times. Variation in the distribution could be expected due to host, transmission vehicle, and organism characteristics, however, the extent of this variation and influencing factors are unclear. The authors have undertaken a systematic review of published literature of outbreak studies with well-defined point source exposures and human experimental studies to estimate the distribution of incubation period and also identify and explain the variation in the distribution between studies. We tested for heterogeneity using I 2 and Kolmogorov-Smirnov tests, regressed incubation period against possible explanatory factors, and used hierarchical clustering analysis to define subgroups of studies without evidence of heterogeneity. The mean incubation period of subgroups ranged from 2·5 to 4·3 days. We observed variation in the distribution of incubation period between studies that was not due to chance. A significant association between the mean incubation period and age distribution was observed with outbreaks involving only children reporting an incubation of 1·29 days longer when compared with outbreaks involving other age groups.

Outbreak of Salmonella enteritidis PT14b gastroenteritis at a restaurant in England: the use of molecular typing to achieve a successful prosecution.

OBJECTIVES: To describe an outbreak of Salmonella enteritidis phage type (PT) 14b in people who had eaten at a restaurant, and the investigation and subsequent prosecution of the food business operator (FBO). STUDY DESIGN: The local health protection team and environmental health department formed an outbreak control team to investigate the outbreak. METHODS: Epidemiological, microbiological, and environmental investigations were undertaken. Epidemiological investigations involved case finding and interviews. Microbiological investigation: stool samples from the suspected cases and environmental samples from the implicated food business were investigated. Salmonella isolates obtained were subjected to multiple locus variable-number tandem repeat analysis (MLVA) profiling and whole genome sequencing. In addition, adenosine triphosphate (ATP) hygiene swab tests were used to verify the quality of cleaning procedures and data loggers were used to determine the water temperature of the mechanical dishwasher. RESULTS: Fifteen cases of illness where the causative agent was shown to be S. enteritidis PT14b were identified, all of whom had eaten at the same restaurant. S. enteritidis PT14b was also identified from three of the 11 food and environmental samples taken at the restaurant and found to have the same MLVA profile as the cases. A case for prosecution was built and the FBO was successfully prosecuted in July 2015. CONCLUSIONS: This investigation highlighted that the use of molecular typing as part of thorough epidemiological, microbiological, and environmental investigations can present a robust case for prosecution against restaurants which pose a risk to public health.

What is the utility of using syndromic surveillance systems during large subnational infectious gastrointestinal disease outbreaks? An observational study using case studies from the past 5 years in England.

Syndromic surveillance systems in England have demonstrated utility in the early identification of seasonal gastrointestinal illness (GI) tracking its spatio-temporal distribution and enabling early public health action. There would be additional public health utility if syndromic surveillance systems could detect or track subnational infectious disease outbreaks. To investigate using syndromic surveillance for this purpose we retrospectively identified eight large GI outbreaks between 2009 and 2014 (four randomly and four purposively sampled). We then examined syndromic surveillance information prospectively collected by the Real-time Syndromic Surveillance team within Public Health England for evidence of possible outbreak-related changes. None of the outbreaks were identified contemporaneously and no alerts were made to relevant public health teams. Retrospectively, two of the outbreaks - which happened at similar times and in proximal geographical locations - demonstrated changes in the local trends of relevant syndromic indicators and exhibited a clustering of statistical alarms, but did not warrant alerting local health protection teams. Our suite of syndromic surveillance systems may be more suited to their original purposes than as means of detecting or monitoring localized, subnational GI outbreaks. This should, however, be considered in the context of this study's limitations; further prospective work is needed to fully explore the use of syndromic surveillance for this purpose. Provided geographical coverage is sufficient, syndromic surveillance systems could be able to provide reassurance of no or minor excess healthcare systems usage during localized GI incidents.

A multi-country Salmonella Enteritidis phage type 14b outbreak associated with eggs from a German producer: 'near real-time' application of whole genome sequencing and food chain investigations, United Kingdom, May to September 2014.

We report an outbreak of Salmonella Enteritidis phage type 14b (PT14b) in the United Kingdom (UK) between May and September 2014 where Public Health England launched an investigation to identify the source of infection and implement control measures. During the same period, outbreaks caused by a Salmonella Enteritidis strain with a specific multilocus variable-number tandem repeat analysis (MLVA) profile occurred in other European Union Member States. Isolates from a number of persons affected by the UK outbreak, who had initially been tested by MLVA also shared this particular profile. Cases were defined as any person infected with S. Enteritidis PT14b, resident in England or Wales and without history of travel outside of this geographical area during the incubation period, reported from 1 June 2014 onwards, with a MLVA profile of 2­11­9-7­4-3­2-8­9 or a single locus variant thereof. In total, 287 cases met the definition. Food traceback investigations in the UK and other affected European countries linked the outbreaks to chicken eggs from a German company. We undertook whole genome sequencing of isolates from UK and European cases, implicated UK premises, and German eggs: isolates were highly similar. Combined with food traceback information, this confirmed that the UK outbreak was also linked to a German producer.

Four-month outbreak of invasive meningococcal disease caused by a rare serogroup B strain, identified through the use of molecular PorA subtyping, England, 2013.

Molecular PorA subtyping provides information that increasingly requires the adaptation of standard public health approaches to outbreak management. We report an outbreak of a rare subtype of meningococcal infection not previously identified in the United Kingdom (UK). The outbreak occurred in the Warwickshire area in England between February and June 2013. Molecular subtyping allowed the identification of additional cases, prompting an enhanced public health response that included efforts to identify potential social networks that might benefit from chemoprophylaxis. It also prompted swabbing to define nasopharyngeal carriage in the focal nursery and helped explain the unusual epidemiological pattern. Without subtyping to identify a link, the additional cases would have been managed as sporadic cases in accordance with current UK guidance.

An outbreak of Legionnaires' disease associated with a display spa pool in retail premises, Stoke-on-Trent, United Kingdom, July 2012.

Twenty-one confirmed cases of Legionnaires' disease (Legionella pneumophila serogroup 1) were identified in the Stoke-on-Trent area of England with onsets since 2 July 2012. Sequence-based typing results are available for nine cases; all are a unique type (ST1268). Initial interviews highlighted a number of possible environmental sources. Inspection of premises of interest revealed an operating spa pool on display, from which the outbreak strain was identified. All cases had visited the retail premise with this spa pool.

Don't forget the fragment! An unusual case of occult fragment embolisation following penetrating neck injury.

Fragment embolisation following vascular injury is uncommon. The case of a 31 year old soldier, who sustained a penetrating fragment injury to the neck with distal arterial embolisation, is presented and the discussion illustrates both the importance of expedient assessment and management of cervical vascular injuries and of thorough correlation of clinical and radiological findings to avoid missed emboli.

Measuring the success of an objective structured clinical examination for dietetic students.

BACKGROUND: Growing requirements to train more dietetic students greatly increase the teaching burden on clinical supervisors. This may be reduced if students can develop basic nutrition assessment skills before they commence clinical placement. To test achievement of these skills by Australian dietetic students, a preclinical objective structured clinical examination (OSCE) was developed. Performance at this OSCE was then compared with the performance at first clinical placement. METHODS: An OSCE was developed to test preclinical skills during the third year of a 4-year dietetic degree. Learning outcomes relating to nutritional assessment skills were assessed via a 1-h preclinical examination. Student application of these skills was then assessed after the first clinical placement, when performance was compared with the results at the preclinical OSCE. RESULTS: One hundred and ninety-three students completed the preclinical OSCE and first clinical placement during the period 2002-2007. A strong relationship was observed for individual student scores at the OSCE and the score achieved at the end of clinical placement (beta = 0.66; 95% confidence interval = 0.46-0.86; P < 0.0001). This relationship was maintained even when outliers were removed. No specific year effect was apparent. CONCLUSIONS: A third-year preclinical dietetic OSCE was found to be a valuable method of formative assessment for assisting dietetic students with the preparation for their first clinical placement. It aided the early identification of those students who are likely to do less well on their first clinical placement.

Marine vessels as substitutes for heavy-duty trucks in Great Lakes freight transportation.

This paper applies a geospatial network optimization model to explore environmental, economic, and time-of-delivery tradeoffs associated with the application of marine vessels as substitutes for heavy-duty trucks operating in the Great Lakes region. The geospatial model integrates U.S. and Canadian highway, rail, and waterway networks to create an intermodal network and characterizes this network using temporal, economic, and environmental attributes (including emissions of carbon dioxide, particulate matter, carbon monoxide, sulfur oxides, volatile organic compounds, and nitrogen oxides). A case study evaluates tradeoffs associated with containerized traffic flow in the Great Lakes region, demonstrating how choice of freight mode affects the environmental performance of movement of goods. These results suggest opportunities to improve the environmental performance of freight transport through infrastructure development, technology implementation, and economic incentives.

Farnesyltransferase and geranylgeranyltransferase I inhibitors upregulate RhoB expression by HDAC1 dissociation, HAT association and histone acetylation of the RhoB promoter.

Recently, we have shown that RhoB suppresses EGFR-, ErbB2-, Ras- and Akt-mediated malignant transformation and metastasis. In this paper, we demonstrate that the novel antitumor agents farnesyltransferase inhibitors (FTIs) and geranylgeranyltransferase I inhibitors (GGTIs) upregulate RhoB expression in a wide spectrum of human cancer cells including those from pancreatic, breast, lung, colon, bladder and brain cancers. RhoB induction by FTI-277 and GGTI-298 occurs at the transcriptional level and is blocked by actinomycin D. Reverse transcription-PCR experiments documented that the increase in RhoB protein levels is due to an increase in RhoB transcription. Furthermore, treatment with FTIs and GGTIs of cancer cells results in HDAC1 dissociation, HAT association and histone acetylation of the RhoB promoter. Thus, promoter acetylation is a novel mechanism by which RhoB expression levels are regulated following treatment with the anticancer agents FTIs and GGTIs.

Assessing energy, environmental, and economic tradeoffs in intermodal freight transportation.

This paper presents an energy and environmental network analysis model to explore tradeoffs associated with freight transport. The geospatial model uses an intermodal network built by the authors to connect various modes (rail, road, water) via intermodal terminals. Routes along the network are characterized not only by temporal and distance attributes, but also by cost, energy, and emissions attributes (including emissions of carbon dioxide, particulate matter, sulfur oxides, volatile organic compounds, and oxides of nitrogen). Decision-makers can use the model to explore tradeoffs among alternative route selection across different modal combinations, and to identify optimal routes for objectives that feature energy and environmental parameters (e.g., minimize carbon dioxide emissions). The model is demonstrated with three case studies of freight transport along the U.S. eastern seaboard.

Shiga toxin-producing Escherichia coli (STEC) O157 outbreak associated with likely transmission in an inflatable home paddling pool in England, June 2017.

In June 2017, an outbreak of Shiga toxin-producing Escherichia coli (STEC) O157 infection with phage type 21/28 and identical genotypic profiles involving three children from Staffordshire was reported. Two cases developed haemolytic uraemic syndrome (HUS). Person-to-person transmission via a shared inflatable home paddling pool was the most likely route of infection, following contamination by the first case. The source of infection in the first case was not identified. We recommend that individuals experiencing gastroenteritis should not bathe in paddling pools and that water should be changed at frequent intervals throughout the day to minimise the spread of infection.

Interventions to increase influenza vaccination rates in children with high-risk conditions--a systematic review.

BACKGROUND: Influenza is a common cause of morbidity and mortality, especially among the elderly and those with certain chronic diseases. Annual influenza vaccination is recommended for individuals in at-risk groups, but rates of vaccination are particularly low in children with high-risk conditions (HRCs). OBJECTIVE: To conduct a systematic review of studies that have examined interventions aimed at improving influenza vaccination in children with HRCs. METHODS: Two databases - PubMed and SCOPUS - were searched (with no time or language restrictions) using a combination of keywords - Influenza AND vaccination OR immunization OR children AND asthma OR malignancy OR high-risk AND reminder. Duplicates were removed, and abstracts of relevant articles were screened using specific inclusion/exclusion criteria. Thirteen articles were selected, and five additional studies were identified following a review of the reference lists of the initial thirteen articles, bringing the total number to eighteen. RESULTS: Most studies were conducted in the United States. Among the 18 studies, there was one systematic review of a specific intervention in asthmatic children, seven randomized controlled trials (RCTs), six before-and-after studies, one non-randomized controlled trial, one retrospective cohort study, one quasi-experimental post-test study, and one letter to editors. Interventions reported include multi-component strategies, letter reminders, telephone recall, letters plus telephone calls, an asthma education tool and year-round scheduling for influenza vaccination, amongst others. CONCLUSION: There is good evidence that reminder letters will improve influenza vaccination uptake in children with HRCs, but the evidence that telephone recall or a combination of letter reminder and telephone recall will improve uptake is weak. It is not known if multiple reminder letters are more effective than single letters or if multi-component strategies are more effective than single or dual component strategies. There is a need for further research of these interventions, possibly outside the United States.