The largest prison outbreak of TB in Western Europe investigated using whole-genome sequencing.

BACKGROUND: In March 2011, the Department of Public Health East in Ireland were notified of two cases of TB in two prisoners sharing a cell. We define the resulting outbreak and highlight the role of public health and laboratory-based molecular epidemiology in mapping and control of a prison outbreak.METHODS: Cases were identified through clinical presentation, contact tracing, case-finding exercise or enhanced laboratory surveillance. Mycobacterium tuberculosis isolates were genotyped and underwent whole-genome sequencing (WGS).RESULTS: Of the 34 cases of TB linked to the outbreak, 27 were prisoners (79%), 4 prison officers (12%) and 3 community cases (9%). M. tuberculosis was isolated from 31 cases (culture positivity: 91%). A maximum of six single-nucleotide polymorphisms separated the isolates, with 22 being identical, suggestive of a highly infectious 'super-spreader´ within the prison. Isolates belonged to the Beijing sub-lineage, and were susceptible to first-line anti-TB agents. A case-finding exercise incidentally detected a prisoner with multidrug-resistant TB. Of the 143 prison officers screened, 52% had latent TB infection. Litigation costs exceeded five million euros.CONCLUSION: This constitutes the largest prison outbreak of TB in Western Europe investigated using WGS. A robust prison entry TB screening and education programme is required to effect better TB control, and prevent future outbreaks and attendant litigation.

Long-term follow-up of patients with spontaneous clearance of hepatitis C: does viral clearance mean cure?

Up to 40% of patients with hepatitis C virus (HCV) antibodies are negative for HCV RNA at initial evaluation. If there is a risk of viral re-activation, long term follow-up is required with attendant financial, psychological and medical implications. We investigated the risk of re-activation in the Irish anti-D cohort. Information was obtained from the national hepatitis C database which includes data on patients infected by anti-D immunoglobulin in two large outbreaks, 1977-9 and 1991-94. As part of a screening programme, starting in 1994, 64,907 females exposed to anti-D immunoglobulin were evaluated. Three hundred and forty-seven were found to be antibody positive but HCV RNA negative at initial assessment. 93% had subsequent RNA tests. There was no evidence of HCV recurrence in patients whose infection resolved spontaneously. It appears that two initial sequential negative results for HCV RNA are sufficient to confirm spontaneous viral clearance and probable cure of hepatitis C virus infection.

Progression of hepatitis C in the haemophiliac population in Ireland, after 30 years of infection in the pre-DAA treatment era.

INTRODUCTION: Prior to the introduction of viral inactivation of factor concentrates and screening of blood, 225 people with haemophilia became infected with hepatitis C (HCV) in Ireland. AIM: Our aim was to assess liver disease progression and mortality in this population after 30 years of infection. METHODS: Demographic and clinical data were collected from medical records in five hepatology units and one infectious disease unit retrospectively in 2005, and on four subsequent occasions. RESULTS: The participation rate was 73% (165/225). Eighty three percent of patients, who had been tested for RNA (n = 106/128), developed chronic HCV infection. Thirty four percent were co-infected with HIV. All-cause mortality, after approximately 30 years of infection with chronic HCV, was 44% in HIV positive patients and 29% in HIV negative patients. Liver-related mortality was 12.5% and did not vary significantly by HIV status. Thirty seven percent of patients had developed advanced liver disease, including 20% with cirrhosis and 9% with hepatocellular carcinoma. In the pre-interferon-free direct acting antivirals era, 57% (n = 60/106) of patients were treated for HCV, 65% of whom achieved a sustained virological response. Successfully treated patients had few adverse liver outcomes. CONCLUSION: After 30 years of infection, 40% of the patients who had evidence of chronic HCV had developed advanced liver disease, such as cirrhosis and HCC, or had died from liver-related causes. This proportion is high relative to similar international cohorts despite good anti-HCV treatment uptake and responses.

Reporting of Acute Flaccid Paralysis in Children under 15 years of age: Improving Surveillance, January 2009 - December 2014.

Acute Flaccid Paralysis (AFP) surveillance, including case investigation and specimen collection is a gold standard method for poliomyelitis surveillance. The expected annual non-polio AFP rate <15 years of age in Ireland is = 1/100 000 population. This study reviewed all cases of AFP reported to the Irish Paediatric Surveillance Unit and the Health Protection Surveillance Centre between January 2009 and December 2014 and compared reporting rates with the expected incidence rate annually. We assessed quality of surveillance data in terms of completeness of investigation for each case reported. Forty-three AFP cases in children <15 years were notified; 35 of which were confirmed. Guillain-Barre Syndrome (GBS) accounted for 48.6% (n=17) of AFP notifications. In 2014, the expected annual AFP target rate was reached. This study identified possible under-reporting of AFP paediatric cases in Ireland between 2009-2013. Completeness of investigations has improved over time, but requires further work.

A prolonged outbreak of invasive meningococcal disease in an extended Irish Traveller family across three Health Service Executive (HSE) areas in Ireland, 2010 to 2013.

Between March 2010 and November 2013 eight laboratory-confirmed cases of serogroup B, invasive meningococcal disease (IMD) were identified in an extended Irish Traveller family across three Health Service Executive (HSE) areas of Ireland. Cases were aged between 5 and 46 months, and were either a cousin or sibling of another case. All eight cases survived. Chemoprophylaxis was given to relevant nuclear family members and close contacts on each occasion, but failed to prevent further cases. Neisseria meningitidis isolates from six cases were highly related, belonging to the ST-41/44 clonal complex, and shared the porA designation 7­2,4. In November 2013, the outbreak control team recommended that directly observed ciprofloxacin chemoprophylaxis be administered simultaneously to the extended family, and that the four component meningococcal B (4CMenB) vaccine be administered to family members aged 2 months to 23 years inclusive and relevant close contacts of the eighth case. Subsequently these recommendations were implemented at three regional clinics. Additionally pharyngeal swabs (n=112) were collected to assess carriage rates of N. meningitidis in this extended family. Pharyngeal carriage of N. meningitidis was detected in 15 (13%) family members. From the epidemiological investigation and carriage study overcrowding was the most likely risk factor identified in this outbreak. To date, the combination of directly observed ciprofloxacin chemoprophylaxis and use of 4CMenB vaccine have controlled the outbreak with no further cases diagnosed.

Ultrio and Ultrio Plus non-discriminating reactives: false reactives or not?

BACKGROUND: The low, fluctuating levels of DNA characteristic of occult hepatitis B infection make its detection by nucleic acid testing (NAT) a challenge. METHODS: Four year's routine use of the Ultrio and Ultrio Plus assays in blood donations in New Zealand was analysed. RESULTS: 0·09% of donations tested with Ultrio and Ultrio Plus assays showed reactivity in the multiplex assay, but non-reactivity in all three discriminatory assays and relevant mandatory serological assays (anti-HIV, anti-HCV, HBsAg). These donations were more likely to be anti-HBc reactive (Ultrio, 13%; Ultrio Plus, 57%; random donors, 6·8%). Thirty-four per cent of these anti-HBc-reactive donations were also reactive in either an alternate NAT assay or on repeat multiplex testing. Thirteen per cent of the donors of the discriminatory-negative, anti-HBc-reactive donations who had given other Ultrio- or Ultrio Plus-tested donations had at least one other multiplex reactive donation. CONCLUSION: These findings suggest that their HBV DNA levels are around the assay's limit of detection, that false reactivity cannot be presumed when a donor fails to discriminate and that caution should be applied when deciding whether to continue accepting donations from such donors.

SU-E-T-554: PTV to Skin Proximity for Head and Neck IMRT Treatment Planning.

PURPOSE: The goal of this work was to evaluate measured vs. calculated surface dose as a function of PTV-to-skin proximity and calculation matrix oxel size, determine effects on plan quality, and provide parameters and levels of uncertainty for clinical use. METHODS: A right-sided CTV with the lateral border 5mm from the surface was delineated on the CT data of a head and neck phantom. A 5mm PTV was generated except laterally where distances of 0-5mm were used. A 7-field IMRT plan was generated using the Eclipse TPS. Optimization was performed where 95% of the PTV receives the prescription dose using a matrix size of 2mm3 . Dose calculations were repeated for grid sizes of 1, 3 and 5mm3 . For each plan nine point dose values were obtained just inside the phantom surface, corresponding to a 2cm2 grid near the central target region. Nine ultra-thin TLDs were placed on the phantom surface corresponding to the grid. Measured and calculated dose values were compared. Conformality, homogeneity and target coverage were compared. RESULTS: Surface dose is over-estimated by the TPS by 21 and 8% for 5 and 3mm3 voxels, respectively and accurately predicted for 2mm3 voxels. A voxel size of 1mm3 results in underestimation of 13%. Conformality improves with increasing PTV to skin distance and a CI of unity results for grid sizes of 1-3mm3 between 4 and 4.5mm. Hot spot decreases as the PTV moves away from the surface and falls below 110% at 4mm. Underdosage worsens as the PTV approaches the skin. CONCLUSIONS: For decreasing PTV-to-skin distance with this TPS, isodose conformality decreases, 'hot spot' increases, and target coverage degrades. Surface dose is accurately predicted for a 2mm3 voxel size, while choosing a finer or coarser grid results in underestimation or overestimation, respectively. All of the above appear to hold for VMAT.

Service implications of implementing guidance for oral bowel cleansing agents in colonoscopy.

INTRODUCTION: Bowel preparation has led to serious adverse events. Consequently, regulatory and advisory bodies have issued guidance,including a risk stratification of patients,aiming to minimise this risk. AIMS: To determine the impact of the new guidance on our current practice of Picolax used in colonoscopy with regard to patient stratification,compliance and service implementation. METHODS: Patients listed for day case colonoscopy during October 2009 were audited using data from the hospital and endoscopy databases. A follow-up, structured patient telephone interview evaluated side effects, the assessment process and patient experience. RESULTS: Of the participating 112 patients, 97.4% were clinically reviewed before colonoscopy,98.3% received written instructions and 70% verbal instructions. None had their preparation dispensed by a regulated professional. Although 62% of patients were retrospectively identified as 'at risk' (elderly, with congestive cardiac failure, cirrhosis or chronic kidney disease or on angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, diuretics or non-steroidal anti-inflammatory drugs), none were identified before their procedure. Significant events (postural hypotension, collapse, dizziness, palpitations, faint) were seen in 4.4%, all of whom could potentially be identified as 'at risk' using a stratification of low epidermal growth factor receptor with relevant co-morbidity (congestive cardiac failure or cirrhosis). CONCLUSIONS: Given the difficulties with compliance and the high prevalence of 'at risk' patients, the implementation will be challenging and require significant service redesign.

Surfers' awareness of the preventability of 'surfer's ear' and use of water precautions.

OBJECTIVE: To establish surfers' knowledge of the preventability of external auditory canal exostoses ('surfer's ear'), and their use of water precautions. METHOD: Survey of surfers conducted between December 2009 and March 2010 at beaches in Cornwall, UK. RESULTS: Ninety-two surfers were included (78 males and 14 females, mean age 27 years, standard deviation 7.9 years). Participants were grouped according to their awareness of the preventability of surfer's ear (55 aware, 37 unaware). These groups were comparable in age, surfing history and gender mix (p > 0.05). Surfers aware of the preventability of exostoses (66 per cent) were more likely to use water precautions than those who were not (38 per cent) (p < 0.01). Two surfers used water precautions regularly and 48 used them occasionally. Sixty-one of the 76 surfers who did not use water precautions (ear plugs) suggested they would consider doing so in the future. CONCLUSION: Awareness of the preventability of surfer's ear was associated with greater use of water precautions. Further research should explore reasons for the low uptake of such precautions. Most surfers not already using ear plugs would consider doing so in the future.

Inventory management.

A critical aspect of blood transfusion is the timely provision of high quality blood products. This task remains a significant challenge for many blood services and blood systems reflecting the difficulty of balancing the recruitment of sufficient donors, the optimal utilization of the donor's gift, the increasing safety related restrictions on blood donation, a growing menu of specialized blood products and an ever-growing imperative to increase the efficiency of blood product provision from a cost perspective. As our industry now faces questions about our standard practices including whether or not the age of blood has a negative impact on recipients, it is timely to take a look at our collective inventory management practices. This International Forum represents an effort to get a snap shot of inventory management practices around the world, and to understand the range of different products provided for patients. In addition to sharing current inventory management practices, this Forum is intended to foster an exchange of ideas around where we see our field moving with respect to various issues including specialty products, new technologies, and reducing recipient risk from blood transfusion products.

Monitoring and treatment of anti-D in pregnancy.

Prophylactic anti-D is a very safe and effective therapy for the suppression of anti-D immunization and thus prevention of haemolytic disease of the foetus and newborn. However, migration from countries with low health standards and substantial cuts in public health expenses have increased the incidence of anti-D immunization in many "developed" countries. Therefore, this forum focuses on prenatal monitoring standards and treatment strategies in pregnancies with anti-D alloimmunization. The following questions were addressed, and a response was obtained from 12 centres, mainly from Europe.