An outbreak of hepatitis A virus infection in a secondary school in England with no undetected asymptomatic transmission among students.

In June 2019 the Health Protection Team in Yorkshire and Humber, England, was notified of cases of hepatitis A virus (HAV) infection in staff at a secondary school. Investigation revealed that an earlier case worked as a food handler in the school kitchen. Indirect transmission through food from the canteen was considered the most likely route of transmission. Cases were described according to setting of exposure. Oral fluid was obtained from students for serological testing. Environmental investigations were undertaken at settings where food handling was considered a potential transmission risk. Thirty-three confirmed cases were linked to the outbreak. All of those tested (n = 31) shared the same sequence with a HAV IB genotype. The first three cases were a household cluster and included the index case for the school. A further 19 cases (16 students, 3 staff) were associated with the school and consistent with indirect exposure to the food handler. One late onset case could not be ruled out as a secondary case within the school and resulted in vaccination of the school population. Five cases were linked to a bakery where a case from the initial household cluster worked as a food server. No concerns about hygiene standards were noted at either the school or the bakery. Oral fluid samples taken at the time of vaccination from asymptomatic students (n = 219, 11-16 years-old) showed no evidence of recent or current infection. This outbreak included household and foodborne transmission but limited (and possibly zero) person-to-person transmission among secondary school students. Where adequate hygiene exists, secondary transmission within older students may not occur.

[Current state of antibiotic resistance of pathogens causing community-acquired urinary tract infections in Russia, Belarus and Kazakhstan: results of the international multicenter study Darmis-2018].

OBJECTIVE: To study in vitro activity of antimicrobials against clinical isolates from patients with community-acquired urinary tract infections (UTIs) in different regions of Russia, Belarus and Kazakhstan in 2017-2018. MATERIALS AND METHODS: A total of 1260 isolates collectedin the Russian Federation, Belarus and Kazakhstanas a part of the international multicenter prospective epidemiological study of the dynamics of antimicrobial resistance of uropathogens causing community-acquired urinary tract infections in different subsets of patients ("DARMIS-2018") were included in the analysis. 1124 strains represented the Enterobacterales order. Uropathogenswere isolated from children and adults of both sexes of all age groups with acute (and recurrences of chronic) community-acquired UTIs including pregnant women with asymptomatic bacteriuriain 34 centers of 26 cities of Russia, Kazakhstan and Belarus in 2017-2018. RESULTS: Enterobacterales jointly comprised a total of 89,2% of all isolated bacterial pathogens (88,9% in the adult subset; 89,3% in the subset of pregnant women and 91,4% in the subset of children and adolescents under 18). The most prevalent species were Escherichia coli (69,4% in the adult subset; 73,6% in the subset of pregnant women and 77,1% in the subset of children and adolescents under 18) and Klebsiella pneumoniae (11,5% in the subset of adults; 10,4% in the subset of pregnant women and 7,1% in the subset of children and adolescents under 18 years of age). The maximum activity against E. coli among oral drugs demonstrated fosfomycin (97,9% in the adult subset; 95,9% in the subset of pregnant women and 99,1% in the subset of children and adolescents under 18) and nitrofurantoin (97,9% in adult subset; 100% in the subset of pregnant women and 96,3% in the subset of children and adolescents under 18). Out of the parenteral drugs meropenem (out of carbapenems) and amikacin showed the highest activity (99,5% and 97,7% in the adult subset; 99,5% and 99,1% in the subset of pregnant women; 100% and 97,2% in the subset of children and adolescents under 18 years of age, respectively). Ampicillin, amoxicillin/clavulanic acid and trimethoprim/sulfamethoxazole demonstrated the lowest in vitro activity against Escherichia coli (less than 80% for everypatient subset). The susceptibility of E. colito ciprofloxacin was 60,4% in the adult subset; 80,0% in the subset of pregnant women and 80,6% in the subset of children and adolescents under 18. The rate of production of extended spectrum beta-lactamases among E. coli isolates based on the results of phenotypic tests was 21,9%. CONCLUSIONS: Results of this study indicate the increase of resistance of community-acquired isolates of Enterobacterales and in particular E. coli to the most of antimicrobials in Russia, Belarus and Kazakhstan.

School-based vaccination programmes: An evaluation of school immunisation delivery models in England in 2015/16.

Schools are increasingly being used to deliver vaccines. In 2015/16 three school-based vaccination programmes were delivered to adolescents in England: human papillomavirus (HPV), meningococcal groups A, C, W and Y disease (MenACWY) and tetanus, diphtheria and polio (Td/IPV). We assessed how school delivery models impact vaccine coverage and how a delivery model for one programme may impact another. Routinely collected national data were analysed to ascertain the school grade achieving highest coverage within each one-dose programme and to compare two-dose delivery models (within year vs across years) for the HPV vaccine. We also assessed whether the HPV delivery model was associated with coverage in other programmes. MenACWY and Td/IPV coverage was highest in younger school grades. Overall similar HPV coverage was achieved with both models (86.7% two doses within one year, 85.8% two doses across two years, p = 0.20). High two-dose HPV coverage in 2015/16 was reported in areas that achieved high HPV coverage in 2013/14 when three doses were required. Areas with high three-dose coverage in 2013/14 achieved higher coverage with a within-one-year approach (92.0% vs 85.2%, p < 0.001), whilst areas reporting low coverage in 2013/14 achieved lower but similar coverage in 2015/16 with both models (79.2% vs 80.9% p = 0.29). MenACWY and Td/IPV coverage were higher in areas with high HPV coverage in 2013/14. Among high HPV coverage areas, MenACWY coverage was higher when HPV doses were delivered within year. School-based programmes should be offered as early as feasible and acceptable to optimise coverage. The choice of delivery model for HPV should take into account local performance and provider experience. Single providers may delivery multiple vaccines and the delivery for one programme may affect the performance of other programmes. Providers should consider local circumstances including past and current vaccine coverage and factors influencing coverage when deciding what delivery model to adopt.

Changes to country-specific hepatitis A travel vaccination recommendation for UK travellers in 2017-responding to a vaccine shortage in the national context.

OBJECTIVES: A routine review of hepatitis A travel vaccination recommendations was brought forward in June 2017 due to hepatitis A vaccine shortages and a concurrent outbreak in men who have sex with men (MSM). There were three objectives: first, to document the review process for changing the recommendations for the UK travellers in June 2017. Second, to study the impact of these changes on prescribing in general practice in 2017 compared with the previous 5 years. Third, to study any changes in hepatitis A notifications in June-October 2017 compared with the previous 5 years. STUDY DESIGN: This is an observational study. METHODS: Travel vaccination recommendations for countries with either low-risk (<20%) or high-risk (>90%) status according to child hepatitis A seroprevalence were not changed. A total of 67 intermediate-risk countries with existing recommendations for most travellers and with new data on rural sanitation levels were shortlisted for the analysis. Data on child hepatitis A seroprevalence, country income status, access to sanitation in rural areas and traveller volumes were obtained. Information about the vaccine supply was obtained from Public Health England. Changes to the existing classification were made through expert consensus, based on countries' hepatitis A seroprevalence, sanitation levels, level of income, volume of travel and hepatitis A traveller cases. Data on the number of combined and monovalent hepatitis A-containing vaccines prescribed in England, 2012-2017, were obtained from the National Health Service Business Service Authorities. The number of monthly prescriptions for January-September 2017 was compared with the mean number of prescriptions for the same month in the previous 5 years (t-test, α = 5%, df = 4). The number of hepatitis A cases notified in June-October 2017 not related to the MSM outbreak was compared with the number of notifications in the same months in previous years. RESULTS: A total of 36 countries were downgraded based on good access (80+% of population) to sanitation in rural areas and the intermediate-risk status in terms of child hepatitis A seroprevalence. For these countries, vaccination would only be recommended to travellers staying long term, visiting friends and relatives or staying in areas without good sanitation. There was a significant decline in hepatitis A vaccine prescriptions in June-September 2017, and there was no increase in the number of notifications. CONCLUSIONS: Hepatitis A vaccination recommendations for travel were revised in 2017 following a systematic approach to maintain continuity of supply after a hepatitis A vaccine shortage and increased hepatitis A vaccine demand related to a large outbreak. Improved access to good sanitation in rural areas and low seroprevalence estimates among children have led to 36 countries to no longer require vaccination for most travellers. These changes do not seem to have impacted on hepatitis A notifications in England, although further research will be needed to quantify the impact more precisely.

Results from the Survey of Antibiotic Resistance (SOAR) 2014-16 in Russia.

Objectives: To determine antibiotic susceptibility in isolates of Streptococcus pneumoniae and Haemophilus influenzae collected in 2014-16 from Russia. Methods: MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints. Results: A total of 279 S. pneumoniae and 279 H. influenzae were collected. Overall, 67.0% of S. pneumoniae were penicillin susceptible by CLSI oral/EUCAST and 93.2% by CLSI intravenous (iv) breakpoints. All were fluoroquinolone susceptible, with amoxicillin, amoxicillin/clavulanic acid and ceftriaxone susceptibility ≥92.8% by CLSI and PK/PD breakpoints. Isolates showed lower susceptibility to cefuroxime, cefaclor, macrolides and trimethoprim/sulfamethoxazole by CLSI criteria: 85.0%, 76.7%, 68.8% and 67.7%, respectively. Generally, susceptibility was slightly lower by EUCAST criteria, except for cefaclor, for which the difference in susceptibility was much greater. Penicillin-resistant isolates had low susceptibility (≤60%) to all agents except fluoroquinolones. All 279 H. influenzae were ceftriaxone susceptible, 15.4% were ß-lactamase positive and ≥97.5% were amoxicillin/clavulanic acid susceptible (CLSI, EUCAST and PK/PD breakpoints). Four isolates were fluoroquinolone non-susceptible by current EUCAST criteria. A major discrepancy was found with azithromycin susceptibility between CLSI (99.3%) and EUCAST and PK/PD (2.2%) breakpoints. Trimethoprim/sulfamethoxazole was poorly active (62.7% susceptible). Conclusions: Susceptibility to penicillin (oral), macrolides and trimethoprim/sulfamethoxazole was low in S. pneumoniae from Russia. However, isolates were fully susceptible to fluoroquinolones and ≥92.8% were susceptible to amoxicillin, amoxicillin/clavulanic acid and ceftriaxone. Isolates of H. influenzae only showed reduced susceptibility to ampicillin, cefaclor, clarithromycin and trimethoprim/sulfamethoxazole. Some differences were detected between CLSI, EUCAST and PK/PD breakpoints, especially with cefaclor, cefuroxime and macrolides. These data suggest further efforts are required to harmonize international breakpoints.

Predictors of coverage of the national maternal pertussis and infant rotavirus vaccination programmes in England.

This study assessed variation in coverage of maternal pertussis vaccination, introduced in England in October 2012 in response to a national outbreak, and a new infant rotavirus vaccination programme, implemented in July 2013. Vaccine eligible patients were included from national vaccine coverage datasets and covered April 2014 to March 2015 for pertussis and January 2014 to June 2016 for rotavirus. Vaccine coverage (%) was calculated overall and by NHS England Local Team (LT), ethnicity and Index of Multiple Deprivation (IMD) quintile, and compared using binomial regression. Compared with white-British infants, the largest differences in rotavirus coverage were in 'other', white-Irish and black-Caribbean infants (-13·9%, -12·1% and -10·7%, respectively), after adjusting for IMD and LT. The largest differences in maternal pertussis coverage were in black-other and black-Caribbean women (-16·3% and -15·4%, respectively). Coverage was lowest in London LT for both programmes. Coverage decreased with increasing deprivation and was 14·0% lower in the most deprived quintile compared with the least deprived for the pertussis programme and 4·4% lower for rotavirus. Patients' ethnicity and deprivation were therefore predictors of coverage which contributed to, but did not wholly account for, geographical variation in coverage in England.

REMOVED: Investigating misophonia: A review of the literature, clinical implications and research agenda reflecting current neuroscience and emotion research perspectives.

This article has been removed: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been removed at the request of the authors due to errors in the author list.

High added value of a population-based participatory surveillance system for community acute gastrointestinal, respiratory and influenza-like illnesses in Sweden, 2013-2014 using the web.

In 2013-2014, the Public Health Agency of Sweden developed a web-based participatory surveillance system, Hӓlsorapport, based on a random sample of individuals reporting symptoms weekly online, to estimate the community incidence of self-reported acute gastrointestinal (AGI), acute respiratory (ARI) and influenza-like (ILI) illnesses and their severity. We evaluated Hӓlsorapport's acceptability, completeness, representativeness and its data correlation with other surveillance data. We calculated response proportions and Spearman correlation coefficients (r) between (i) incidence of illnesses in Hӓlsorapport and (ii) proportions of specific search terms to medical-advice website and reasons for calling a medical advice hotline. Of 34 748 invitees, 3245 (9·3%) joined the cohort. Participants answered 81% (139 013) of the weekly questionnaires and 90% (16 351) of follow-up questionnaires. AGI incidence correlated with searches on winter-vomiting disease [r = 0·81, 95% confidence interval (CI) 0·69-0·89], and ARI incidence correlated with searches on cough (r = 0·77, 95% CI 0·62-0·86). ILI incidence correlated with the web query-based estimated incidence of ILI patients consulting physicians (r = 0·63, 95% CI 0·42-0·77). The high response to different questionnaires and the correlation with other syndromic surveillance systems suggest that Hӓlsorapport offers a reasonable representation of AGI, ARI and ILI patterns in the community and can complement traditional and syndromic surveillance systems to estimate their burden in the community.

Quantifying the incidence and cost of acute gastrointestinal illness in Sweden, 2013-2014.

In Sweden, acute gastrointestinal illness (AGI) incidence, severity, impact on productivity, related healthcare usage and associated costs are not ascertained. We measured these in 2013-2014 using a population-based cohort reporting weekly. We defined AGI as ⩾3 episodes of loose stools or vomiting/24 h; or loose stools or vomiting with ⩾2 other gastrointestinal symptoms. After each AGI episode, we collected information about perceived severity, healthcare use and absenteeism. We calculated incidence rates, AGI absenteeism and costs comprising direct healthcare costs and productivity loss due to work/school absenteeism. A total of 3241 participants reported 1696 AGI episodes [incidence 360/1000 person-years, 95% confidence interval (CI) 326-395; highest in the <5 years age group]. In the <5 years age group, 31% of episodes were perceived as mild, 61% as moderate and 8% as severe; 9·4% led to primary-care consultations, and 1·4% to hospital admissions. In the ⩾5 years age group, 18% of episodes were perceived as mild, 64% as moderate and 18% as severe; 6·4% led to primary-care consultations, and 1·9% to hospital admissions. AGI caused 8 891 000 days of absenteeism (95% CI 6 009 000-12 780 000). AGI cost €1 005 885 000 (95% CI 754 309 000-1 257 195 000) nationally for the year. In Sweden, a minority of cases perceive AGI as a mild illness. AGI is a burden on the healthcare system and causes productivity loss, with high costs. Countries may consider these estimates when prioritizing health interventions.

RESULTS OF MONITORING METALLO-BETA-LACTAMASE-PRODUCING STRAINS OF PSEUDOMONAS AERUGINOSA IN A MULTI-PROFILE HOSPITAL.

The authors present the results of long-term monitoring of metallo-beta-lactamase (MBL) producing strains of Pseudomonas aeruginosa in the Republican Hospital No 2 of Yakutsk, Russian Federation. Hospitals across Russia, as well as the rest of the world, face a rapid appearance and a virtually unchecked spread of multiresistant and panresistant nosocomial pathogens. Especially prevalent are multidrug-resistant isolates of P. aeruginosa, most often found among the patients of intensive care and intensive therapy units, as well as surgery departments. The aim of this study is to investigate the prevalence of metallo-beta-lactamase-producing strains of P. aeruginosa in a multi-profile hospital. 2,135 isolates of P. aeruginosa were studied, collected during a time span of seven years (2008-2014) from clinical specimens of hospitalised patients in acute surgery, purulent surgery, neurosurgery, otolaryngology, coloproctology departments, intensive care and intensive therapy, burn units, as well as intensive care unit for patients with acute cerebrovascular accidents and coronary care unit. Strains were identified and re-identified using established methods, NEFERMtest 24 (MICROLATEST) biochemical microtest and API (bioMerieux) test systems were used. For all carbapenem-resistant strains a phenotype screening for MBL was performed using the double-disks method with EDTA. In order to identify VIM-type and IMP-type MBL genes a real-time multiplex polymerase chain reaction was used. Among the investigated strains the largest number of P. aeruginosa - 35.6% (761 isolates) was found in patients at intensive care and intensive therapy units. Clonal expansion of extensively drug-resistant strain P. aeruginosa ST235 (VIM-2) was determined, the resistance mechanism of which is connected to MBL. Sensitivity determination of MBL-producing isolates of P. aeruginosa has shown that isolated strains have a high level of resistance (100%) to all tested antibacterial agents: piperacillin, piperacillin-tazobactam, ceftazidime, cefepime, cefoperazone-sulbactam, aztreonam, imipenem, meropenem, doripenem, gentamicin, netilmicin, amikacin, ciprofloxacin, levofloxacin, fosfomicin.

Can we achieve high uptakes of influenza vaccination of healthcare workers in hospitals? A cross-sectional survey of acute NHS trusts in England.

It is unknown which intervention strategies are used or effective to increase influenza vaccine uptake by healthcare workers (HCWs) in acute hospitals in England. We undertook a survey in acute hospitals, described strategies employed from 2008 to 2012 and used multivariable binomial regression to identify those effective. Eighty out of 166 trusts responded and reported 25 strategies. Every intervention showed increased use: peer vaccination from 3·8% to 38·8% (+921%); educational DVDs from 3·8% to 22·5% (+492%); Twitter from 2·5% to 12·5% (+400%) and Facebook from 1·3% to 6·3% (+384%). Peer vaccination increased uptake by 7·3% [95% confidence interval (CI) 1·1-13·6, P = 0·02] overall; educational DVDs by 9·7% overall (95% CI 1·8-17·6, P = 0·02), 11·9% in non-doctor, non-nurse HCWs (95% CI 0·9-22·8, P = 0·03). For doctors, using a champion doctor increased uptake by 17·8% (95% CI 7·6-28·0, P < 0·01). No intervention increased uptake by nurses. Increasing uptake requires multi-intervention strategies targeted at different HCW groups.

First detection of VIM-4 metallo-ß-lactamase-producing Escherichia coli in Russia.

An Escherichia coli isolate co-producing VIM-4 metallo-ß-lactamase and CTX-M-15 extended spectrum ß-lactamase was recovered from the urine of a patient with head trauma in Moscow, Russia. The bla(VIM-4) and bla(CTX-M-15) genes were carried, respectively, by transmissible plasmids of IncW and IncI1 groups. The nucleotide sequence of the VIM-4-encoding integron was nearly identical to that of In416, which represent a large group of structurally related integrons previously found in Enterobacteriaceae all around the Mediterranean basin. This is the first report of a metallo-ß-lactamase-producing E. coli in Russia.

Sodium and chloride exclusion and retention by non-grafted and grafted melon and Cucurbita plants.

The effects of grafting on Na and Cl(-) uptake and distribution in plant tissues were quantified in a greenhouse experiment using six combinations of melon (Cucumis melo L. cv. Arava) and pumpkin (Cucurbita maxima Duchesne×Cucurbita moschata Duchesne cv. TZ-148): non-grafted, self-grafted, melons grafted on pumpkins, and pumpkins grafted on melons. Total Na concentration in shoots of plants with pumpkin or melon rootstocks was <60 mmol kg(-1) and >400 mmol kg(-1), respectively, regardless of the scion. In contrast, shoot Cl(-) concentrations were quite similar among the different scion-rootstock combinations. Na concentrations in exudates from cut stems of plants with a pumpkin rootstock were very low (<0.18 mM), whereas those in the exudates of plants with melon rootstocks ranged from 4.7 mM to 6.2 mM, and were quite similar to the Na concentration in the irrigation water. Root Na concentrations averaged 11.7 times those in the shoots of plants with pumpkin rootstocks, while in plants with melon rootstocks, values were similar. Two mechanisms could explain the decrease in shoot Na concentrations in plants with pumpkin rootstocks: (i) Na exclusion by the pumpkin roots; and (ii) Na retention and accumulation within the pumpkin rootstock. Quantitative analysis indicated that the pumpkin roots excluded ∼74% of available Na, while there was nearly no Na exclusion by melon roots. Na retention by the pumpkin rootstocks decreased its amount in the shoot by an average 46.9% compared with uniform Na distribution throughout the plant. In contrast, no retention of Na could be found in plants grafted on melons.

Hepatitis A outbreak in an Orthodox Jewish community in London, July 2010.

A cluster of hepatitis A cases in the Orthodox Jewish community in London, United Kingdom in July 2010 has triggered extensive contact tracing and vaccination. Two primary cases imported from a common source in Israel and three secondary cases have resulted in immunisation of over 900 contacts to date. Rapid response by local public health, primary care services and a dedicated community health team, and active hepatitis A vaccination rather than immunoglobulin treatment were used to avert a larger outbreak.

Integrating background knowledge from internet databases into predictive toxicology models.

While data integration for data analysis has been investigated extensively in biological applications, it has not yet been so much the focus in computational chemistry and quantitative structure-activity relationship (QSAR) research. With the availability and growing number of chemical databases on the web, such data integration efforts become an intriguing possibility (and, in fact, a necessity). In this paper, we take a first step towards the following vision and scenario for predictive toxicology applications. Given a new structure to be predicted, the first step would be to gather (integrate) all relevant information from internet databases for the structure itself, and all structures with available information for the endpoint of interest. In a second step, the collected information is combined statistically into a prediction of the new structure. We simulate this scenario with three endpoints (data sets) from the DSSTox database and collect information from three public chemical databases: PubChem, ChemBank and Sigma-Aldrich. In the experiments, we investigate whether the addition of background knowledge from the three databases can improve predictive performance (over using chemical structure alone) in a statistically significant way. For this purpose, we define groups of features (belonging together from an application point of view) from the three databases, and perform a variant of forward selection to include these feature groups in a prediction model. Our experiments show that the integration of background knowledge from internet databases can significantly improve prediction performance, especially for regression tasks.

Acquired carbapenemases in Gram-negative bacterial pathogens: detection and surveillance issues.

Acquired carbapenemases are emerging resistance determinants in Gram-negative pathogens, including Enterobacteriaceae, Pseudomonas aeruginosa and other Gram-negative non-fermenters. A consistent number of acquired carbapenemases have been identified during the past few years, belonging to either molecular class B (metallo-beta-lactamases) or molecular classes A and D (serine carbapenemases), and genes encoding these enzymes are associated with mobile genetic elements that allow their rapid dissemination in the clinical setting. Therefore, detection and surveillance of carbapenemase-producing organisms have become matters of major importance for the selection of appropriate therapeutic schemes and the implementation of infection control measures. As carbapenemase production cannot be simply inferred from the resistance profile, criteria must be established for which isolates should be suspected and screened for carbapenemase production, and for which tests (phenotypic and/or genotypic) should be adopted for confirmation of the resistance mechanism. Moreover, strategies should be devised for surveillance of carbapenemase producers in order to enable the implementation of effective surveillance programmes. The above issues are addressed in this article, as a follow-up to an expert meeting on acquired carbapenemases that was recently organized by the ESCMID Study Group for Antibiotic Resistance Surveillance.

A MALDI TOF MS-based minisequencing method for rapid detection of TEM-type extended-spectrum beta-lactamases in clinical strains of Enterobacteriaceae.

A minisequencing method based on matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI TOF MS) was developed for rapid identification of single nucleotide polymorphisms at bla(TEM) gene codons 104, 164 and 238 associated with extended-spectrum activity on TEM-type beta-lactamases. The method was validated by testing the Escherichia coli and Klebsiella pneumoniae strains possessing the known bla(TEM) gene sequences.

Awareness of health effects of cooking smoke among women in the Gondar Region of Ethiopia: a pilot survey.

BACKGROUND: The burning of biomass fuels results in exposure to high levels of indoor air pollution, with consequent health effects. Possible interventions to reduce the exposure include changing cooking practices and introduction of smoke-free stoves supported by health education. Social, cultural and financial constraints are major challenges to implementation and success of interventions. The objective of this study is to determine awareness of women in Gondar, Ethiopia to the harmful health effects of cooking smoke and to assess their willingness to change cooking practices. METHODS: We used a single, administered questionnaire which included questions on household circumstances, general health, awareness of health impact of cooking smoke and willingness to change. We interviewed 15 women from each of rural, urban-traditional and middle class backgrounds. RESULTS: Eighty percent of rural women cooked indoors using biomass fuel with no ventilation. Rural women reported two to three times more respiratory disease in their children and in themselves compared to the other two groups. Although aware of the negative effect of smoke on their own health, only 20% of participants realised it caused problems in children, and 13% thought it was a cause for concern. Once aware of adverse effects, women were willing to change cooking practices but were unable to afford cleaner fuels or improved stoves. CONCLUSION: Increasing the awareness of the health-effects of indoor biomass cooking smoke may be the first step in implementing a programme to reduce exposure.