A protracted outbreak of Salmonella Hessarek infection associated with one brand of eggs­South Australia, March 2017 - July 2018

Salmonella Hessarek is an uncommon serotype in Australia. We report on the investigation of a protracted outbreak of 25 cases of S. Hessarek gastroenteritis in which cases were defined as any laboratory confirmed case of Salmonella Hessarek notified to the South Australian Communicable Disease Control Branch from 1st March 2017 to 3 July 2018. We conducted a descriptive case series investigation interviewing all cases and 17 (68%) reported consuming brand X free-range eggs. Four samples of one-dozen brand X eggs were cultured for the presence of Salmonella spp. One out of the four samples returned positive for S. Hessarek in the contents of the eggs; Salmonella was not present in any of the whole egg rinses of the four samples. The high proportion of cases reporting the consumption of brand X free-range eggs and the isolation of S. Hessarek from sampling four dozen brand X eggs is an unusually strong signal implicating brand X eggs as the source of this outbreak. From a public health perspective, it is important to understand the behaviour of S. Hessarek including its ability to be present in the content of eggs and further research is recommended. The findings in this investigation into a rare Salmonella serotype highlight the need for continuous monitoring of the epidemiology of Salmonella in Australia including the epidemiology of egg-associated Salmonella outbreaks of human disease.

Benchmarking epidemiological characteristics of cervical cancer in advance of change in screening practice and commencement of vaccination.

OBJECTIVES: To investigate trends in cervical cancer incidence, mortality and survival by histology for benchmarking purposes ahead of practice change and the introduction of Human Papilloma Virus (HPV) vaccine. METHODS: Using data from the South Australian Cancer Registry, age-standardised rates are presented for four-year periods from 1977 to 2004. Socio-demographic and secular predictors of glandular as opposed to squamous cancers are investigated, using multivariable logistic regression. Disease-specific survivals are analysed using Kaplan-Meier product-limit estimates and Cox proportional hazards regression. RESULTS: Incidence and mortality rates reduced by 55.1% and 59.3% respectively between 1977-80 and 2001-04, with larger reductions for squamous than glandular cancers. The ratio of squamous to glandular cancer incidence reduced from 5.4:1 in 1977-88 to 2.8:1 in 1993-2004, with a corresponding reduction from 5.2:1 to 3.0:1 for mortality. Compared with squamous cancers, glandular lesions were more common in patients from higher socio-economic areas, but less common in those over 70 years of age, Aboriginal patients, and those born in Southern Europe. CONCLUSION: The proportion of cancers comprising glandular lesions has increased, possibly reflecting prevention of squamous cancers through treatment of screen-detected preinvasive lesions. Additional mortality reductions from screening may be limited where the proportion of glandular lesions is high, with vaccination offering the best prospects for gains in the long term. Priority should be given to Aboriginal and Torres Strait Islander women in vaccination programs in view of their high death rate from cervical cancer.

Once-daily opioids for chronic dyspnea: a dose increment and pharmacovigilance study.

CONTEXT: Randomized controlled trials can answer questions of efficacy, but long-term pharmacovigilance studies generate complementary safety data. OBJECTIVES: Level I evidence supports short-term efficacy of opioids in reducing chronic refractory dyspnea. This study aimed to determine the minimum effective once-daily dose of sustained-release morphine, and whether net clinical benefits are sustained safely. METHODS: In a Phase II dose increment study, 10mg daily of sustained-release morphine was administered, and increased in nonresponders by 10mg daily each week to a maximum of 30 mg daily. The participant was withdrawn if there were unacceptable side effects or no response to maximum dose. If participants had a 10% improvement in dyspnea over their own baseline, they joined a long-term Phase IV effectiveness/safety study at that dose. Complying with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines, response and side effects are described, with demographic and clinical characteristics of responders. RESULTS: Eighty-three participants (53 males, mean age 75 years, 54% with chronic obstructive pulmonary disease) provided more than 30 patient-years of data. Fifty-two participants derived ≥ 10% benefit (on average 35% improvement over baseline), giving a response rate of 62% (number needed to treat of 1.6: number needed to harm 4.6); for 70%, this dose was 10mg/24h. Benefit was maintained at three months for 28 (33%) people. Ranking of breathlessness was reduced significantly (P<0.001), but constipation increased (P<0.001) despite laxatives. There were no episodes of respiratory depression or hospitalizations as a result of the sustained-release morphine. Overall, one in three people continued to derive benefit at three months. CONCLUSION: Ten milligrams of sustained-release oral morphine once daily is safe and effective for most people who respond.

Endometrial cells as a predictor of uterine cancer.

BACKGROUND: With the recent cervix screening national guidelines recommending against reporting of benign endometrial cells, we examined South Australian data to see what impact this would have on detecting uterine cancers. AIMS: To test whether benign endometrial cells detected in cervical cytology testing confer an increased risk of uterine cancer, and to ascertain what percentage of uterine cancers will be missed in cervical screening programs if these cells are not reported. METHODS: The study was a retrospective cohort design of 1585 women with shed endometrial cells, each matched with three women without shed cells. All were linked with cancer registry data to check for uterine cancer diagnosis. Cox proportional hazards regression was used to check for any increase in cancer risk with shed endometrial cells. Using the calculated relative risks for uterine cancer diagnosis, we estimated the number of uterine cancers in South Australia associated with benign endometrial cells. RESULTS: The presence of benign endometrial cells in a cervical cytology test increases the risk of uterine cancer sixfold. However, screening women with benign cells would involve a major increase in pathology work for only an 18% increase in uterine cancers detected. CONCLUSIONS: Until cytology systems have a higher sensitivity in detecting which benign endometrial cells are associated with uterine cancer, pathology laboratories are unlikely to be required to report these cells on tests. Inability to adjust for symptomatic status may have reduced the relevance of the results in this study.