An outbreak investigation of acute Diarrheal Disease, Nagpur District, Maharashtra, India.

BACKGROUND: Acute diarrheal disease (ADD) accounts for 12 million cases and 1216 deaths annually in India. On July 13, 2016, an ADD outbreak was reported from Sawargaon village from Nagpur district, Maharashtra. OBJECTIVE: The outbreak was investigated to describe the epidemiology and suggest control and preventive measures. METHODS: A case was defined as a person experiencing at least one loose stool in Sawargaon village between July 9, 2016, and July 31, 2016. We searched for cases by enhanced passive surveillance. We collected stool samples for bacterial culture and tested water from multiple water sources for fecal coliforms. We also reviewed sanitary practices and rainfall data. RESULTS: A total of 889 cases were identified, with 51% female, 280 hospitalizations (31%), and two deaths. The median age was 27 years (range 6 months to 90 years). Cases started on July 9, a week after heavy rains. District authorities started chlorination of water sources on July 13 and cases declined soon after. Two of nine stool samples tested positive for Vibrio cholera O1 serogroup. Of the 18 water samples collected, 16 (88%) samples from multiple sources, including wells, hand pumps, and taps, were positive for fecal coliforms. Of 1,885 households in the village, 450 (24%) households had no toilets and open defecation was commonly observed in the nearby river bed. CONCLUSIONS: This ADD outbreak was likely associated with drinking contaminated groundwater, which probably occurred after heavy rainfall in an area of open defecation. We recommended providing chlorinated drinking water, promoting safe sanitation practices, including building more public and private toilets, and enhancing diagnostic laboratory capacity.

Produce-associated foodborne disease outbreaks, USA, 1998-2013.

The US Food Safety Modernization Act (FSMA) gives food safety regulators increased authority to require implementation of safety measures to reduce the contamination of produce. To evaluate the future impact of FSMA on food safety, a better understanding is needed regarding outbreaks attributed to the consumption of raw produce. Data reported to the US Centers for Disease Control and Prevention's Foodborne Disease Outbreak Surveillance System during 1998-2013 were analysed. During 1998-2013, there were 972 raw produce outbreaks reported resulting in 34 674 outbreak-associated illnesses, 2315 hospitalisations, and 72 deaths. Overall, the total number of foodborne outbreaks reported decreased by 38% during the study period and the number of raw produce outbreaks decreased 19% during the same period; however, the percentage of outbreaks attributed to raw produce among outbreaks with a food reported increased from 8% during 1998-2001 to 16% during 2010-2013. Raw produce outbreaks were most commonly attributed to vegetable row crops (38% of outbreaks), fruits (35%) and seeded vegetables (11%). The most common aetiologic agents identified were norovirus (54% of outbreaks), Salmonella enterica (21%) and Shiga toxin-producing Escherichia coli (10%). Food-handling errors were reported in 39% of outbreaks. The proportion of all foodborne outbreaks attributable to raw produce has been increasing. Evaluation of safety measures to address the contamination on farms, during processing and food preparation, should take into account the trends occurring before FSMA implementation.

High-dose versus low-dose local anaesthetic for transversus abdominis plane block post-Caesarean delivery analgesia: a meta-analysis.

BACKGROUND: The optimal local-anaesthetic (LA) dose for transversus-abdominis-plane (TAP) block is unclear. In this meta-analysis, we aimed to determine whether TAP blocks for Caesarean delivery (CD) with low-dose (LD) LA demonstrated non-inferiority in terms of analgesic efficacy, compared with high-dose (HD) LA. METHODS: A literature search was performed for randomised controlled trials examining the analgesic efficacy of TAP blocks vs control after CD. The different dosing used in these studies was classified as HD or LD (bupivacaine equivalents >50 or ≤50 mg per block side, respectively). The pooled results of each dose group vs control were indirectly compared using the Q test. The primary outcome was 24 h opioid consumption. Secondary outcomes included 6 and 24 h postoperative pain scores, time to first analgesia, 6 h opioid consumption, opioid-related side-effects, and maternal satisfaction. RESULTS: Fourteen studies consisting of 770 women (389 TAP and 381 control) were included. Compared with controls, the 24 h opioid consumption (milligram morphine equivalents) was lower in HD [mean difference (MD) 95% confidence interval (CI) -22.41 (-38.56, -6.26); P=0.007; I2=93%] and LD [MD 95% CI -16.29 (-29.74, -2.84); P=0.02; I2=98%] TAP groups. However, no differences were demonstrated between the HD and LD groups (P=0.57). There were also no differences between the HD and LD groups for the 6 h opioid consumption, time to first analgesia, 6 and 24 h pain scores, postoperative nausea and vomiting, pruritus, and maternal satisfaction. CONCLUSIONS: Low-dose TAP blocks for Caesarean delivery provide analgesia and opioid-sparing effects comparable with the high-dose blocks. This suggests that lower doses can be used to reduce local anaesthetic toxicity risk without compromising the analgesic efficacy.

Comparison of boiling and chlorination on the quality of stored drinking water and childhood diarrhoea in Indonesian households.

We compared the impact of a commercial chlorination product (brand name Air RahMat) in stored drinking water to traditional boiling practices in Indonesia. We conducted a baseline survey of all households with children 1000 MPN/100 ml (RR 1·86, 95% CI 1·09-3·19) in stored water than in households without detectable E. coli. Although results suggested that Air RahMat water treatment was associated with lower E. coli contamination and diarrhoeal rates among children <5 years than water treatment by boiling, Air RahMat use remained low.

Strengthening routine immunization systems to improve global vaccination coverage.

BACKGROUND: Global coverage with the third dose of diphtheria-tetanus-pertussis vaccine among children under 1 year of age stagnated at ∼ 83-84% during 2008-13. SOURCES OF DATA: Annual World Health Organization and UNICEF-derived national vaccination coverage estimates. AREAS OF AGREEMENT: Incomplete vaccination is associated with poor socioeconomic status, lower education, non-use of maternal-child health services, living in conflict-affected areas, missed immunization opportunities and cancelled vaccination sessions. AREAS OF CONTROVERSY: Vaccination platforms must expand to include older ages including the second year of life. Immunization programmes, including eradication and elimination initiatives such as those for polio and measles, must integrate within the broader health system. GROWING POINTS: The Global Vaccine Action Plan (GVAP) 2011-20 is a framework for strengthening immunization systems, emphasizing country ownership, shared responsibility, equity, integration, sustainability and innovation. AREAS TIMELY FOR DEVELOPING RESEARCH: Immunization programmes should identify, monitor and evaluate gaps and interventions within the GVAP framework.

National patterns of Escherichia coli O157 infections, USA, 1996-2011.

US public health laboratories began reporting Escherichia coli O157 isolates to CDC in 1996. We describe temporal and geographical patterns of isolates reported from 1996 to 2011 and demographics of persons whose specimens yielded isolates. We calculated annual E. coli O157 isolation rates/100 000 persons by patient's state of residence, county of residence, age, and sex using census data. The average annual isolation rate was 0·84. The average isolation rate in northern states (1·52) was higher than in southern states (0·43). Counties with ⩾76% rural population had a lower isolation rate (0·67) than counties with ⩽25%, 26-50%, and 51-75% rural populations (0·81, 0·92, and 0·81, respectively). The highest isolation rate (3·19) was in children aged 1-4 years. Infections were seasonal with 49% of isolates collected during July to September. Research into reasons for higher incidence in northern states and for seasonality could guide strategies to prevent illnesses.

Nationwide outbreak of Salmonella Montevideo infections associated with contaminated imported black and red pepper: warehouse membership cards provide critical clues to identify the source.

In November 2009, we initiated a multistate investigation of Salmonella Montevideo infections with pulsed-field gel electrophoresis pattern JIXX01.0011. We identified 272 cases in 44 states with illness onset dates ranging from 1 July 2009 to 14 April 2010. To help generate hypotheses, warehouse store membership card information was collected to identify products consumed by cases. These records identified 19 ill persons who purchased company A salami products before onset of illness. A case-control study was conducted. Ready-to-eat salami consumption was significantly associated with illness (matched odds ratio 8·5, 95% confidence interval 2·1-75·9). The outbreak strain was isolated from company A salami products from an environmental sample from one manufacturing plant, and sealed containers of black and red pepper at the facility. This outbreak illustrates the importance of using membership card information to assist in identifying suspect vehicles, the potential for spices to contaminate ready-to-eat products, and preventing raw ingredient contamination of these products.

Leaving no one behind: Defining and implementing an integrated life course approach to vaccination across the next decade as part of the immunization Agenda 2030.

Strategic Priority 4 (SP4) of the Immunization Agenda 2030 aims to ensure that all people benefit from recommended immunizations throughout the life-course, integrated with essential health services. Therefore, it is necessary for immunization programs to have coordination and collaboration across all health programs. Although there has been progress, immunization platforms in the second year of life and beyond need continued strengthening, including booster doses and catch-up vaccination, for all ages, and recommended vaccines for older age groups. We note gaps in current vaccination programs policies and achieved coverage, in the second year of life and beyond. In 2021, the second dose of measles-containing vaccine (MCV2), given in the second year of life, achieved 71% global coverage vs 81% for MCV1. For adolescents, 60% of all countries have adopted human papillomavirus vaccines in their vaccination schedule with a global coverage rate of only 12 percent in 2021. Approximately 65% of the countries recommend influenza vaccines for older adults, high-risk adults and pregnant women, and only 25% recommended pneumococcal vaccines for older adults. To achieve an integrated life course approach to vaccination, we reviewed the evidence, gaps, and strategies in four focus areas: generating evidence for disease burden and potential vaccine impact in older age groups; building awareness and shifting policy beyond early childhood; building integrated delivery approaches throughout the life course; and identifying missed opportunities for vaccination, implementing catch-up strategies, and monitoring vaccination throughout the life course. We identified needs, such as tailoring strategies to the local context, conducting research and advocacy to mobilize resources and build political will. Mustering sufficient financial support and demand for an integrated life course approach to vaccination, particularly in times of COVID-19, is both a challenge and an opportunity.

Multistate outbreak of Escherichia coli O157:H7 infections associated with a national fast-food chain, 2006: a study incorporating epidemiological and food source traceback results.

A multistate outbreak of Escherichia coli O157:H7 infections occurred in the USA in November-December 2006 in patrons of restaurant chain A. We identified 77 cases with chain A exposure in four states - Delaware, New Jersey, New York, and Pennsylvania. Fifty-one (66%) patients were hospitalized, and seven (9%) developed haemolytic uraemic syndrome; none died. In a matched analysis controlling for age in 31 cases and 55 controls, illness was associated with consumption of shredded iceberg lettuce [matched odds ratio (mOR) 8·0, 95% confidence interval (CI) 1·1-348·1] and shredded cheddar cheese (mOR 6·2, CI 1·7-33·7). Lettuce, an uncooked ingredient, was more commonly consumed (97% of patients) than cheddar cheese (84%) and a single source supplied all affected restaurants. A single source of cheese could not explain the regional distribution of outbreak cases. The outbreak highlights challenges in conducting rapid multistate investigations and the importance of incorporating epidemiological study results with other investigative findings.

High-flow nasal oxygen for a high-risk patient undergoing sedation in the prone position.

We describe the use of high-flow nasal oxygen for an obese patient with obstructive sleep apnoea presenting for revision of a spinal cord stimulator. The use of high-flow nasal oxygen allowed the delivery of a high inspired oxygen concentration with humidification and improved patient comfort compared with our usual choice of device, the Hudson mask. It also provided continuous positive airways pressure which is likely to have reduced pharyngeal collapse and atelectasis. The use of high-flow nasal oxygen enabled the delivery and careful titration of deep sedation with propofol and remifentanil, to allow a successful revision procedure to take place without airway complications or significant oxygen desaturation in a high-risk patient in the prone position.

Arthroscopic electrothermal collagen shrinkage for symptomatic laxity of the scapholunate interosseous ligament.

The medical records, radiographs and operative reports of ten consecutive patients of average age 37 (range 19-67) years with wrist pain secondary to structural disruption of the scapholunate interosseous ligament (Geissler Type 2 injuries) who were treated with wrist arthroscopy and electrothermal collagen shrinkage of the scapholunate interosseous ligament were reviewed. Functional outcomes were assessed using the DASH scoring system at an average follow-up of 28 (range 12-44) months. At latest follow-up, nine patients (90%) were asymptomatic and had returned to their pre-injury functional level. The mean score on the DASH questionnaire was 20 (range 11-48). One patient developed wrist discomfort and mechanical symptoms 7 months postoperatively and required revision surgery. Our preliminary findings suggest that this may be a viable treatment option in the management of patients with symptomatic scapholunate interosseous ligament laxity without complete ligament disruption. Additional study is needed to better understand the role of this treatment modality.

Patient satisfaction after primary total and unicompartmental knee arthroplasty: an age-dependent analysis.

BACKGROUND: Patient-related outcomes have become the focus of increased attention when assessing knee arthroplasty. METHODS: We retrieved questionnaires from 485 (584 knees) patients at a minimum of 3years after undergoing primary knee arthroplasty. We excluded bilateral knee arthroplasty, leaving 141 UKA and 245 TKA who rated their satisfaction and expectation regarding pain, range of motion (ROM), daily living function (DLF), return to recreational activity (RRA) and ability to kneel (ATK) on a scale of 0 (worst) to 10 (best). We further collected data on pain level and the modified Cincinnati rating scale. Range of motion was documented pre- and postoperatively at a minimum of six months. The cohort was subdivided into three age groups and compared with each other (Group 1: <55, n=113; Group 2: 55-64, n=117; Group 3: 65+, n=155). RESULTS: Average satisfaction with pain, ROM and ATK for patients under 55 was higher for UKA than for TKA. Patients>65 with TKA were on average more satisfied than patients with UKA in these three items. However, patients under 55 with UKA were up to 2.9 times more likely to have their expectations met when compared to patients receiving TKA. Patients with UKA under 55 rated their joint as good/excellent in 96.0% versus patients in the same age group with TKA in 81.0%. CONCLUSIONS: We found that overall, younger patients who were treated with UKA demonstrated higher satisfaction scores in most subsets when compared with the patients of the same age group who received TKA.