Bengal Bay clone ST772-MRSA-V outbreak: conserved clone causes investigation challenges.

BACKGROUND: The Bengal Bay clone, ST772-MRSA-V, associated with multi-drug resistance, Panton-Valentine leukocidin (PVL) and skin and soft tissue infections, is emerging worldwide. In Norway, a country with low prevalence of meticillin-resistant Staphylococcus aureus (MRSA), increased occurrence of ST772-MRSA-V has also caused hospital outbreaks. The conserved nature of this clone challenged the outbreak investigations. AIM: To evaluate the usefulness of S. aureus protein A (spa) typing, multiple-locus variable number tandem repeat fingerprinting/analysis (MLVF/MLVA) and pulsed-field gel electrophoresis (PFGE) when investigating outbreaks with a conserved MRSA clone. METHODS: A panel of 25 MRSA isolates collected in 2004-2014, consisting of six hospital outbreak isolates and 19 sporadic isolates, were analysed using spa typing, polymerase chain reaction detection of genes encoding PVL, MLVF/MLVA and PFGE. FINDINGS: All isolates were ST772-MRSA-V-t657 and resistant to erythromycin, gentamicin and norfloxacin, and 88% were PVL positive. PFGE could not discriminate between the isolates (≥85% similarity). MLVF resolved five types [Simpson's index of diversity (SID)=0.56], MLVA resolved six types (SID=0.66), and both methods separated the hospital isolates into two defined outbreaks. CONCLUSION: MLVF/MLVA could not discriminate all epidemiologically unlinked cases and identical genotypes originated from a timespan of 10 years. MLVA was regarded as most suitable due to its higher discriminatory power and ability to provide unambiguous profiles. However, the Bengal Bay clone may require higher resolution methods for exact demarcation of outbreaks due to low diversity among isolates.

Measles virus genotyping an important tool in measles outbreak investigation in Norway, 2011.

This study describes 33 laboratory-confirmed cases of measles that occurred in Norway in 2011, mainly among unvaccinated children between seven months and 10 years of age. Laboratory testing included detection of anti-measles IgM- and IgG antibodies by enzyme-linked immunosorbent assay (ELISA) and molecular detection and characterisation of measles virus by polymerase chain reaction (PCR) and sequencing. Epidemiological data and genotyping revealed that the measles cases originated from eight separate importations, resulting in four outbreaks and four sporadic cases. Except for the first outbreak which affected 18 cases, limited secondary spread occurred in each of the three other outbreaks. The outbreaks were caused by measles virus genotypes B3, D4 and D9, whereas genotypes D8 and B3 were detected in the sporadic cases. This study highlights that genetic characterisation of measles virus is an essential tool in the laboratory surveillance of measles, especially in countries like Norway which are approaching the measles elimination goal. The investigation revealed that importation of measles resulted in subsequent transmission within Norway to non-vaccinated individuals, and twelve cases occurred in healthcare settings, involving both staff and children. The four cases detected among healthcare workers (HCWs) emphasised that the coverage of measles-mumps-rubella (MMR) vaccination among healthcare personnel needs to be improved and both primary and secondary vaccine failure was demonstrated in two fully immunised HCWs.

Ongoing outbreak of measles in Oslo, Norway, January-February 2011.

Between 19 January and 17 February 2011, 10 cases of measles (eight laboratory-confirmed and two probable) were reported in Oslo with the majority of cases in a mainly unvaccinated immigrant community. Of these, two cases were identified outside the immigrant community, in Norwegian children.

Costs and health consequences of chlamydia management strategies among pregnant women in sub-Saharan Africa.

OBJECTIVES: Chlamydia is the most common bacterial sexually transmitted infection worldwide and a major cause of morbidity-particularly among women and neonates. We compared costs and health consequences of using point-of-care (POC) tests with current syndromic management among antenatal care attendees in sub-Saharan Africa. We also compared erythromycin with azithromycin treatment and universal with age-based chlamydia management. METHODS: A decision analytical model was developed to compare diagnostic and treatment strategies, using Botswana as a case. Model input was based upon (1) a study of pregnant women in Botswana, (2) literature reviews and (3) expert opinion. We expressed the study outcome in terms of costs (US$), cases cured, magnitude of overtreatment and successful partner treatment. RESULTS: Azithromycin was less costly and more effective than erythromycin. Compared with syndromic management, testing all attendees on their first visit with a 75% sensitive POC test increased the number of cases cured from 1500 to 3500 in a population of 100,000 women, at a cost of US$38 per additional case cured. This cost was lower in high-prevalence populations or if testing was restricted to teenagers. The specific POC tests provided the advantage of substantial reductions in overtreatment with antibiotics and improved partner management. CONCLUSIONS: Using POC tests to diagnose chlamydia during antenatal care in sub-Saharan Africa entails greater health benefits than syndromic management does-and at acceptable costs-especially when restricted to younger women. Changes in diagnostic strategy and treatment regimens may improve people's health and even reduce healthcare budgets.

Cohort analysis of asylum seekers in Oslo, Norway, 1987-1995: effectiveness of screening at entry and TB incidence in subsequent years.

SETTING: Municipalities of Baerum and Oslo, Norway. OBJECTIVES: To examine the effectiveness of tuberculosis (TB) screening in asylum seekers 1987-1995, and to describe TB incidence rates after arrival. DESIGN: Register-based, retrospective cohort study of 19912 asylum seekers with a mean follow-up of 6.3 years. RESULTS: Seventy-six persons were diagnosed with TB, of whom 43 (57%) had pulmonary TB. Twenty-two cases (17 pulmonary) were found through screening at entry. Eleven persons had abnormal mass miniature X-rays (MMRs), but had inadequate follow-up and were diagnosed later through passive case finding. MMR itself had a sensitivity of 96% and a specificity of 98% for pulmonary TB, diagnosed within 1 year after arrival. TB prevalence at entry was 110/100000; for Somalis it was 577/100000. Incidence rates were stable in the total cohort after arrival, whereas rates for extra-pulmonary TB in Somalis increased. CONCLUSIONS: Screening on entry should continue, but follow-up of abnormal MMRs must be improved. There should be more emphasis on treatment of latent infection.

Occupational lung diseases among former goldminers in two labour sending areas.

OBJECTIVES: To compare and contrast the prevalence of pneumoconiosis in two groups of former migrant mineworkers in southern Africa, and to examine the effectiveness of the South African compensation system for occupational lung diseases. DESIGN: Comparison of two cross-sectional studies and follow-up data on compensation results. SETTING: The village of Thamaga, Botswana and the rural area of Libode, Eastern Cape, South Africa. SUBJECTS: Two hundred and thirty-four former underground mineworkers in Thamaga, and 238 in Libode. MAIN OUTCOME MEASURES: Prevalence and severity of pneumoconiosis, prevalence of radiological signs of tuberculosis (TB), Medical Bureau for Occupational Diseases (MBOD) certification committee decisions, and compensation results. RESULTS: Prevalence of pneumoconiosis > or = 2/1 was 15.4% in Libode and 13.6% in Thamaga. Significantly more Libode than Thamaga subjects (51.1% versus 29.0%) reported past TB treatment. Radiological signs of pulmonary TB were also more prevalent in Libode (33.3% v. 23.9%). Twenty-six per cent of Libode men and 16.1% of Thamaga men were certified with compensable disease. Libode payments were finalized within 30 months, whereas Thamaga cases only began receiving payments 52 months after medical examination, with 11 cases still pending 66 months after medical examination. CONCLUSION: There was a high prevalence of pneumoconiosis in both study groups. Many men were eligible for compensation but were previously uncompensated. The higher rate of compensable disease in the Libode group may relate to the higher prevalence of TB, as well as more active follow-up by the study group, including a large number of appeals. Socio-political changes in South Africa between 1994 and 1996 may also have influenced compensation results.

The epidemiology of adult lung disease in Botswana.

SETTING: Republic of Botswana. OBJECTIVES: To describe and analyse the epidemiology of adult lung disease in Botswana and provide information about risk factors. DESIGN: Register-based retrospective study. RESULTS: Poverty and human immunodeficiency virus (HIV) infection are major risk factors for lung disease. In 1997, TB caused 15.7%, pneumonia 8.3%, asthma/COPD 0.7% and lung cancer 0.4% of adult in-patient deaths, while 15.5% of deaths were classified as AIDS. Respiratory conditions accounted for 14.2% of hospital admissions and 18.1% of out-patient consultations. Pneumoconiosis was under-reported. Classification problems exist between AIDS, TB and pneumonia. The case fatality rate for in-patients with pneumonia was 5.6% in 1990 vs. 15.5% in 1997, and for TB patients it was 7.4% in 1990 vs. 11.2% in 1997. Morbidity rates also increased for pneumonia and TB through the 1990s. There was a steeper rise in pneumonia mortality and morbidity rates in females than males. The gender distribution in TB incidence remained unchanged, but the average age of female TB patients decreased by 7.7 years from 1983 to 1998, vs. a decrease of 5.3 years in males. CONCLUSIONS: Pulmonary TB and pneumonia are major causes of adult mortality and morbidity in Botswana. Incidences and case fatality rates are increasing, due to co-existent HIV infection. Non-communicable lung diseases are less common causes of death, and prevalences seem to be stable.

Former migrant mineworkers with respiratory disease: the South African compensation system, and implications for neighbouring countries.

In the region of Southern Africa, substantial numbers of people, primarily males, have been employed in the South African mining industry. Migrant workers from neighbouring countries have constituted a large part of the work force. Until recently, there has been little or no attention directed toward the state of health of these individuals, despite the fact that their work involves a high health risk, especially in regard to mine-related lung diseases. In addition, the South African workers' compensation programme has seldom been utilised by the migrant worker who is a victim of occupational disease. However, recent experiences from Botswana show that compensation claims can be successfully made from the neighbouring countries where the migrant workers originate. Efforts are being made to address the problem systematically, and the government of Botswana is actively involved. The major occupational lung disorders are described briefly, and differential diagnostic problems with pulmonary TB are discussed. Furthermore, a survey of the compensation system in South Africa is presented, and practical steps for medical examinations involving compensation claims are described.

Ngaka ya setswana, ngaka ya sekgoa or both? Health seeking behaviour in Batswana with pulmonary tuberculosis.

The health seeking behaviour of tuberculosis (TB) patients, and their beliefs and attitudes with regard to the disease, was studied in 212 Batswana with smear-positive pulmonary TB during 1993/94. There is an apparent resemblance between traditional ideas of disease being caused by pollution (breaking of taboos) and modern theories of spread via germs. TB may be regarded as a 'European disease' or as a 'Tswana disease' and this has implications for health behaviour. Patients who regard TB as a 'Tswana disease' may use modern medicine for symptom relief but traditional medicine to treat what they consider the cause of the disease. All patients were eventually diagnosed and initiated specific antituberculous treatment in a modern health facility. The median number of health facility visits was two, and the median delay period was 12 weeks. 95% of patients visited a modern health facility as their first step of action. Before start of specific treatment one or more alternative treatments was tried by 52% of patients during the delay period. After starting modern treatment, 47% of patients visited, or planned to visit, a traditional healer or a faith healer. Traditional explanations of disease seemed less prevalent in 1993/94 than in a study conducted among TB patients in Botswana ten years earlier, but few patients had a thorough understanding of TB from a biomedical point of view. More knowledge about patients' health seeking behaviour and perceptions would be useful for health workers. The findings of this study could offer suggestions for improvement in the area of health education.

Pulmonary tuberculosis in Kweneng District, Botswana: delays in diagnosis in 212 smear-positive patients.

SETTING: Health facilities in Kweneng District, Botswana. OBJECTIVES: To describe and analyse causes of delays in the diagnosis of smear-positive pulmonary tuberculosis. DESIGN: Cross-sectional descriptive study based on data from patient records and interviews of 212 cases. RESULTS: Median total delay was 12 weeks (mean 17.3), median patient's delay was three weeks (mean 5.1), median health services' delay was five weeks (mean 12.2). An inverse relationship was found between patient's delay and health services' delay. Treatment was started on the basis of positive acid-fast bacilli in 165 patients (78%), and chest X-ray findings in 47 (22%). Delayed sputum examination despite prolonged productive cough was common, and 31 patients (15%) had one or more negative initial investigations. Significant risk factors for delay were: first visit to a health post, and visiting a traditional or faith healer before start of treatment (total delay and health services' delay); treatment of a sexually transmitted disease in the last three years (total delay); staying in a village without a hospital, self-rated health being held as poor or very poor, and being married (health services' delay); and self-rated health being fair or good (patient's delay). CONCLUSIONS: Sputum must be examined in all patients with prolonged productive cough, and negative investigations should be repeated. Patients should be told to return if symptoms persist. Dialogue between modern health workers and traditional healers should be encouraged.

[Emergency services in Vest-Agder. A survey in 15 municipalities]. / Legevakt i Vest-Agder. En kartleggingsundersøkelse i 15 kommuner.

Data relating to out-of-hours services in the 15 local councils in Vest-Agder county were gathered through a postal survey. Organisation, the public's accessibility, use of services, communication systems, documentation, medical equipment, doctors' competence, doctors' safety and interaction with other primary care services and secondary health care providers are described. In order to ensure that the public have access to emergency medical care during normal opening hours, there is a need for change in health legislation. Improved daytime access would lessen the pressure on the out-of-hours services. Higher priority should be given by local councils to quality improvement of these services. Some centralization of services to facilities staffed by a doctor and auxiliary personnel is advocated. There should be greater restrictions on night-time house calls than is the case today. Doctors providing out-of-hours services should meet on a regular basis to exchange views and experiences. Greater responsibility should be assumed by local councils, for the continuing education of these doctors. The Norwegian health radio network should be more user-friendly.

Prevalence of occupational lung disease among Botswana men formerly employed in the South African mining industry.

OBJECTIVE: To determine whether previous health experiences affect the prevalence of occupational lung disease in a semirural Botswanan community where there is a long history of labour recruitment to South African mines. METHOD: A cross sectional prevalence study of 304 former miners examined according to a protocol including a questionnaire, chest radiograph, spirometry, and medical examination. RESULTS: Overall mean age was 56.7 (range 28-93) years, mean duration of service 15.5 (range 2-42) years. 26.6% had a history of tuberculosis. 23.3% had experienced a disabling occupational injury. Overall prevalence of pnemoconiosis (> 1/0 profusion, by the International Labour Organisation classification) was 26.6%-31.0%, and 6.8% had progressive massive fibrosis (PMF). Many were entitled to compensation under South African law. Both radiograph readers detected time response relations between pneumoconiosis and PMF among the 234 underground gold miners. PMF could result from < 5 years of exposure, but was not found < 15 years after first exposure. Both pulmonary tuberculosis (PTB) and pneumoconiosis were found to be associated with airflow limitation. CONCLUSIONS: Former miners in Botswana have a high prevalence of previously unrecognised pneumoconiosis, indicative of high previous exposures to fibrogenic respirable dust. Their pneumoconiosis went unrecognised because they had no access to surveillance after employment. Inadequate radiographic surveillance or failure to act on results when employed or when leaving employment at the mines could have contributed to under recognition. Community based studies of former miners are essential to fully evaluate the effects of mining exposures. Our findings indicate a failure of established measures to prevent or identify pneumoconiosis while these miners were in employment and show that few of the social costs of occupational lung diseases are borne by mining companies through the compensation system.

[Measures against driving under the influence of drugs--the county medical officer's role. A 2-year material from Vest-Agder]. / Tiltak mot propillekjøring--Fylkeslegens rolle. Et toårsmateriale fra Vest-Agder.

Driving under the influence of drugs is a serious road safety problem. Since 1995, the county medical officer of Vest-Agder has given measures to reduce this problem high priority. Maximum acceptable daily doses were introduced for psychoactive drugs, and the daily intake was calculated in the individual case, based on information about prescriptions for a minimum period of three months. A total of 46 cases led to reactions during the years 1995 and 1996; these consisted of a warning to the driver (38 cases), a recommendation to the police to suspend the license (23 cases) or advising the licensing authorities to change the conditions of the license (six cases). Combinations of psychoactive drugs were used in 39 cases. One of the benzodiazepines was judged to represent the highest risk in 32 cases, and an opioid analgesic in ten cases. Information was usually obtained from monitoring doctors' prescriptions, rarely directly from the doctors themselves. Greater alertness, combined with objective guidelines, might help reduce the problem. In our opinion, stricter regulations are not necessary.

[Tuberculosis and HIV infection in the Kweneng district, Botswana]. / Tuberkulose og HIV-infeksjon i Kweneng-distriktet, Botswana.

The prevalence of HIV infection in a group of Botswana tuberculosis patients was studied in a linked, anonymous survey that included 214 cases. The testing was done by ELISA serology. 45 of 214 patients (21%) were HIV positive. The HIV seropositivity reached 29% in the age group 15-49 years. 25% of the females (average age 34 years) and 18% of the males (average age 39 years) were HIV positive. 18 (40%) of the 45 HIV positive patients had AIDS. No significant differences were found between HIV positive and HIV negative patients with regard to clinical type of tuberculosis. The findings are discussed in relation to other studies from Africa.