Who is dying from COVID-19 in the United Kingdom? A review of cremation authorisations from a single South Wales' crematorium.

Only studies in the UK on individuals dying from coronavirus disease 2019 (COVID-19) in hospital have been published, to date. Cremation law requires collection of clinical information that can improve understanding of deaths in both hospital and community settings. Age, sex, date and place of death, occupation, comorbidities and where infection acquired was recorded for all deaths from COVID-19, between 6 April and 30 May, for whom an application was made for cremation at a South Wales' crematorium. Of 752 cremations, 215 (28.6%) were COVID-19 (115 (53.5%) male and 100 (46.5%) female). Median age was 82 years (youngest patient 47 and the oldest 103 years). Over half the deaths (121/215: 56.3%) were over 80 years. Males' odds of dying in hospital, rather than the community were 1.96 times that of females (95% confidence intervals (CI) 1.03-3.74, P = 0.054) despite being of similar age and having a similar number of comorbidities. Only 21 (9.8%) of 215 patients had no comorbidities recorded. Patients dying in care homes were significantly older than those dying in hospital (median 88 years (interquartile (IQ) range 82-93 years) vs. 80 years (IQ range 71-87 years): P < 0.0001). Patients dying in hospital had significantly more comorbidities than those dying in care homes (median 2: IQ range 1-3 vs. 1: IQ range 1-2: P < 0.001). Sixty three (29.3%) of infections were hospital acquired and a further 55 (25.6%) acquired in care homes. In a series, of hospital and community deaths, persons over 80 with an average two comorbidities predominated. Men were more likely to die in hospital. Half the infections were acquired in hospitals or care homes with implications for management of the pandemic.

Subclinical infection and asymptomatic carriage of gastrointestinal zoonoses: occupational exposure, environmental pathways, and the anonymous spread of disease.

Asymptomatic carriage of gastrointestinal zoonoses is more common in people whose profession involves them working directly with domesticated animals. Subclinical infections (defined as an infection in which symptoms are either asymptomatic or sufficiently mild to escape diagnosis) are important within a community as unknowing (asymptomatic) carriers of pathogens do not change their behaviour to prevent the spread of disease; therefore the public health significance of asymptomatic human excretion of zoonoses should not be underestimated. However, optimal strategies for managing diseases where asymptomatic carriage instigates further infection remain unresolved, and the impact on disease management is unclear. In this review we consider the environmental pathways associated with prolonged antigenic exposure and critically assess the significance of asymptomatic carriage in disease outbreaks. Although screening high-risk groups for occupationally acquired diseases would be logistically problematical, there may be an economic case for identifying and treating asymptomatic carriage if the costs of screening and treatment are less than the costs of identifying and treating those individuals infected by asymptomatic hosts.

Extreme water-related weather events and waterborne disease.

Global climate change is expected to affect the frequency, intensity and duration of extreme water-related weather events such as excessive precipitation, floods, and drought. We conducted a systematic review to examine waterborne outbreaks following such events and explored their distribution between the different types of extreme water-related weather events. Four medical and meteorological databases (Medline, Embase, GeoRef, PubMed) and a global electronic reporting system (ProMED) were searched, from 1910 to 2010. Eighty-seven waterborne outbreaks involving extreme water-related weather events were identified and included, alongside 235 ProMED reports. Heavy rainfall and flooding were the most common events preceding outbreaks associated with extreme weather and were reported in 55·2% and 52·9% of accounts, respectively. The most common pathogens reported in these outbreaks were Vibrio spp. (21·6%) and Leptospira spp. (12·7%). Outbreaks following extreme water-related weather events were often the result of contamination of the drinking-water supply (53·7%). Differences in reporting of outbreaks were seen between the scientific literature and ProMED. Extreme water-related weather events represent a risk to public health in both developed and developing countries, but impact will be disproportionate and likely to compound existing health disparities.

Seroprevalence and risk factors associated with Escherichia coli O157 in a farming population.

Evidence suggests that frequent and direct exposure to domestic animals has made farmers less susceptible to symptomatic Escherichia coli O157 infection than other members of the community. We have quantified the seroprevalence of antibodies to E. coli O157 lipopolysaccharide (LPS) from a representative cohort of farm workers in three geographically distinct regions of the United Kingdom during two sampling rounds over a 2-year period. All participants completed a questionnaire to determine the range and extent of recent animal contact alongside other potential occupational and environmental exposure routes. A total of 31/946 (3.3%) serum samples contained antibodies to E. coli O157 LPS (from both rounds combined). On the second sampling round, a significant difference in seropositivity was apparent between the three regions, with enhanced seroprevalence linked to recent contact with beef cattle, having a private water supply and contact with a child under 5 years old. Only five seropositive people reported symptoms of a gastrointestinal tract infection, although these symptoms were mild. These results further support the premise of acquired immunity to E. coli O157 associated with prolonged antigenic exposures within the farming environment.

Two waves of pandemic influenza A(H1N1) 2009 in Wales--the possible impact of media coverage on consultation rates, April-December 2009.

In the United Kingdom, the influenza A(H1N1) 2009 pandemic had a distinct two-wave pattern of general practice consultations for influenza-like illness (ILI). We describe the epidemiology of the influenza pandemic in Wales between April and December 2009 using integrated data from a number of independent sources: GP surveillance, community virology surveillance, hospital admissions and deaths, and media enquiries monitoring. The first wave peaked in late July at 100 consultations per 100,000 general practice population and attracted intensive media coverage. The positivity rate for the A(H1N1)2009 influenza did not exceed 25% and only 44 hospitalisations and one death were recorded. By contrast, the second wave peaked in late October and although characterised by lower ILI consultation rates (65 consultations per 100,000 general practice population) and low profile media activity, was associated with much higher positivity rates for pandemic influenza A(H1N1)2009 (60%) and substantially more hospital admissions (n=379) and deaths (n=26). The large number of ILI-related consultations during the first wave in Wales probably reflected the intensive media activity rather than influenza virus circulating in the community. Data from community surveillance schemes may therefore have considerably overestimated the true incidence of influenza. This has implications for the future interpretation of ILI surveillance data and their use in policy making, and underlines the importance of using integrated epidemiological, virological and hospital surveillance data to monitor influenza activity.

Using the internet for rapid investigation of an outbreak of diarrhoeal illness in mountain bikers.

In summer 2008, we investigated an outbreak of diarrhoeal illness in participants of a mountain-bike event in Wales (UK) which had been affected by heavy rain. We conducted a retrospective cohort study to investigate the cause using an internet-based questionnaire. Fifty-three percent of those contacted responded, and 161 (46·5%) out of the 347 responders, reported gastrointestinal symptoms. Median day of onset was 3 days following the event. Ten riders reported receiving a laboratory-confirmed diagnosis of Campylobacter. Multivariate logistic regression analysis identified the inadvertent ingestion of mud (OR 2·5, 95% CI 1·5-4·2, P<0·001) and eating 'other' food during the event (OR 2·1, 95% CI 1·2-3·6, P=0·01) as significant risk factors for illness. We concluded that the outbreak was caused by Campylobacter, spread to the riders by the inadvertent ingestion of mud which had been contaminated with sheep faeces from the rural course. Mountain-bike race organizers should consider microbiological hazards when risk-assessing potential race courses. The internet is an efficient tool for the investigation of outbreaks in computer-literate populations.

A patient notification exercise following infection control failures in a dental surgery.

OBJECTIVES: To investigate the association between treatment by a dental healthcare worker (HCW) and patient infection with a blood-borne virus (BBV). DESIGN: Nested case control study. SETTING: A patient notification exercise (PNE) arising from a hepatitis C virus positive HCW that was undertaken because of deficiencies in infection control practice. METHODS: Cases were individuals with a BBV infection identified as a result of the PNE. Controls were randomly selected individuals with negative tests for BBVs. Detailed information on dental treatment was obtained from patient notes. Information on risk factors for BBV infection was obtained using a structured questionnaire administered by telephone interview. RESULTS: Thirty patients had evidence of infection with a BBV. The mean number of visits for treatment was 20.5 in cases and 18.6 in controls; the difference 1.8 (95% CI -5.4 to 9.1) was not statistically significant (p = 0.62). Transmission of hepatitis C in the dental setting was excluded by sequencing of the viral genome or establishing alternative risk factors. CONCLUSION: There was no evidence of transmission of hepatitis C virus from the HCW to patients, or transmission of a BBV from patient to patient. To ensure consistent practice within the UK the National Institute for Health and Clinical Excellence should produce guidance on PNEs for the NHS.

Group A streptococcal skin infection outbreak in an abattoir: lessons for prevention.

During a group A streptococcus (GAS) outbreak 21 abattoir workers developed skin infections. The unusual outbreak strain (emm 108.1) was cultured from five workers and four persons in the community with links to the abattoir. The attack rate was 26% in the lamb line. Communal nailbrushes were neither routinely disinfected nor changed, and had high bacterial counts. A cohort study found a higher risk from working in the gutting area and getting cuts on hands more than weekly. Despite high bacterial counts daily nailbrush use had a lower risk, as did always wearing disposable gloves. Working in the gutting area (OR 11.44) and nailbrush use at least once a day (OR 0.04) were significant in the multivariate model. Transmission of infection is likely to have occurred on carcasses. GAS infection among abattoir workers was once common. Simple hygiene measures, such as nailbrush use, may reduce the impact of future outbreaks.

A community outbreak of Campylobacter jejuni infection from a chlorinated public water supply.

An outbreak of Campylobacter jejuni infection occurred in a South Wales Valleys housing estate. Illness in estate residents was associated with tap water consumption [population attributable risk (PAR) 50%, relative risk (RR) 2.53, 95% confidence interval (CI) 1.9-3.37] and residence in the upper estate (PAR 49%, RR 2.44, 95% CI 1.83-3.24). Amongst upper estate residents, rates of diarrhoeal illness increased with rates of water consumption (OR 18, 95% CI 3.5-92.4 for heaviest consumers, chi2 trend P<0.0001). The upper estate received mains water via a covered holding reservoir. A crack in the wall of the holding reservoir was identified. Contamination with surface water from nearby pasture land was the likely cause of this outbreak. Service reservoirs are common in rural communities and need regular maintenance and inspection. The role of water in sporadic cases of campylobacter enteritis may be underestimated.

Risk factors for hospital-acquired methicillin-resistant Staphylococcus aureus bacteraemia: a case-control study.

A case-control study was undertaken in an acute district general hospital to identify risk factors for hospital-acquired bacteraemia caused by methicillin-resistant Staphylococcus aureus (MRSA). Cases of hospital-acquired MRSA bacteraemia were defined as consecutive patients from whom MRSA was isolated from a blood sample taken on the third or subsequent day after admission. Controls were randomly selected from patients admitted to the hospital over the same time period with a length of stay of more than 2 days who did not have bacteraemia. Data on 42 of the 46 cases of hospital-acquired bacteraemia and 90 of the 92 controls were available for analysis. There were no significant differences in the age or sex of cases and controls. After adjusting for confounding factors, insertion of a central line [adjusted odds ratio (aOR) 35.3, 95% confidence interval (CI) 3.8-325.5] or urinary catheter (aOR 37.1, 95% CI 7.1-193.2) during the admission, and surgical site infection (aOR 4.3, 95% CI 1.2-14.6) all remained independent risk factors for MRSA bacteraemia. The adjusted population attributable fraction, showed that 51% of hospital-acquired MRSA bacteraemia cases were attributable to a urinary catheter, 39% to a central line, and 16% to a surgical site infection. In the United Kingdom, measures to reduce the incidence of hospital-acquired MRSA bacteraemia in acute general hospitals should focus on improving infection control procedures for the insertion and, most importantly, care of central lines and urinary catheters.

Borna disease virus and the evidence for human pathogenicity: a systematic review.

BACKGROUND: Borna disease is a neurological viral disease of veterinary importance in central Europe, although Borna Disease virus (BDV) has been reported to be present in animals in most continents. The hypothesis that BDV is associated with human illness is controversial. However, should even a small fraction of mental illness be attributable to infection with BDV, this would be an important finding, not least because illness in that sub-population would, theoretically, be preventable. METHODS: We systematically reviewed the evidence: that BDV infects humans; for the role of BDV in human neuropsychiatric illness; to assess the suitability of currently available laboratory methods for human epidemiological studies. RESULTS: We identified 75 documents published before the end of January 2000, describing 50 human studies for BDV. There were five case studies and 44 (sero)prevalence studies, in a variety of patient groups. Nineteen prevalence studies (43%) investigated seroprevalence, 11 (25%) investigated viral prevalence and 14 (32%) investigated both. Seroprevalence ranged from 0% to 48%, and prevalence of virus or viral footprints from 0% to 82%. DISCUSSION: Although agreed gold standard tests and evidence for test specificity are lacking, there is evidence that humans are exposed to the virus. Further epidemiological studies are required to establish whether there are associations with disease.

Borna disease virus and mental health: a cross-sectional study.

BACKGROUND: Borna disease is an infectious neurological disease of horses, sheep and possibly other animals. A role for Borna disease virus (BDV) in human neurological and psychiatric illness has been proposed, but this hypothesis remains controversial. AIM: To investigate the epidemiology of BDV in UK farming communities. DESIGN: Retrospective cohort study. METHODS: We measured the seroprevalence of BDV in the PHLS Farm Cohort, a representative sample of those employed in agriculture in the UK, and investigated the clinical significance of our findings by comparing the prevalence of symptoms of neurotic psychopathology in those found seropositive and seronegative. RESULTS: Seroprevalence was 2.3% (95%CI 1.3- 4.0%) in 1994, 3.1% in 1996 (95%CI 1.9-5.0%) and 2.6% in 1999 (95%CI 1.5%-4.6%). Those living or working on livestock farms had higher seroprevalence (2.6%) than those on mixed (2.3%) or arable (1.6%) farms, but this was not statistically significant. Exposure to horses, sheep and cats did not increase risk of seropositivity. Seropositives were no more likely to report symptoms of psychiatric morbidity. DISCUSSION: UK farming populations appear to be exposed to Borna disease virus. However, we found no evidence that exposure to BDV was associated with morbidity in this healthy occupational cohort.

Declining incidence of chickenpox in the absence of universal childhood immunisation.

OBJECTIVE: To examine the epidemiology of chickenpox in Wales from 1986 to 2001. DESIGN: Descriptive analysis of chickenpox consultations reported by the Welsh general practice sentinel surveillance scheme for infectious diseases, compared with annual shingles consultation rates from the same scheme to exclude reporting fatigue and data from a general practice morbidity database to validate results. SETTING: A total of 226,884 patients registered with one of 30 volunteer general practices participating in the sentinel surveillance scheme. MAIN OUTCOME MEASURES: Age standardised and age specific incidence of chickenpox. RESULTS: Crude and age standardised consultation rates for chickenpox declined from 1986 to 2001, with loss of epidemic cycling. Rates remained stable in 0-4 year olds but declined in all older age groups, particularly those aged 5-14 years. Shingles consultation rates remained constant over the same period. Data from the morbidity database displayed similar trends. CONCLUSION: General practitioner consultation rates for chickenpox are declining in Wales except in pre-school children. These findings are unlikely to be a reporting artefact but may be explained either by an overall decline in transmission or increased social mixing in those under 5 years old, through formal child care and earlier school entry, and associated increasing rates of mild or subclinical infection in this age group. Further investigation, particularly by serological surveillance, is necessary before universal varicella immunisation can be considered in the UK.

Mental health of British farmers.

AIMS: To estimate the prevalence of neurotic symptoms in a sample of British farmers, to investigate whether farming characteristics are associated with psychiatric morbidity, and to test the hypothesis that British farmers have a higher prevalence of depression and thoughts of life not worth living than the British household population. METHODS: A total of 425 farmers from Hereford, Norwich, and Preston completed the Revised Clinical Interview Schedule (CIS-R) by computer between March and July 1999. The comparison cohort consisted of 9830 private householders aged 16-64 from the Office of Population Censuses and Surveys National Psychiatric Morbidity Surveys of Great Britain carried out in 1993 in which the CIS-R was administered. All analyses used the commands developed specifically for survey data available in Stata version 6.0. RESULTS: Taking a threshold of an overall score of 12 or more on the CIS-R, only 6% of farmers reported clinically relevant psychiatric morbidity. Psychiatric morbidity was not significantly associated with farm type or size in this study. Farmers reported a lower prevalence of psychiatric morbidity than the general population but were more likely to report thinking that life is not worth living, particularly after the low prevalence of psychiatric morbidity had been taken into account (odds ratio 2.56, 95% CI 1.39 to 4.69). When restricting the comparison to only rural or semirural householders, this increased risk was even more pronounced (odds ratio 3.26, 95% CI 1.51 to 7.02). CONCLUSIONS: The relation between depression and suicidal ideation seems to be quite different among farmers and the general population and warrants further investigation. We have shown it is possible to measure mental health systematically in a sample of British farmers. This study should be repeated in the aftermath of the foot and mouth crisis.

Possible underascertainment of variant Creutzfeldt-Jakob disease: a systematic study.

OBJECTIVES: To predict the size of the vCJD epidemic it is important to know whether the description of cases of vCJD in 1996 represent the first cases of a new disease entity or whether detection was due to increased surveillance of CJD in humans. Detection of earlier cases would suggest a shorter incubation period and might lead to predictions of epidemic size being revised. METHODS: All certified deaths (excluding external injury and poisoning) in residents of Wales aged 15-45, between 1985 and 1995, were reviewed to detect vCJD deaths that might have been overlooked. 12 091 deaths were reviewed. "Non-specific fatal disorders compatible with vCJD" were defined. Deaths recorded to diseases other than those defined were rejected from further analysis (8769). Remaining cases (3322) were subdivided. Group A comprised deaths recorded to suicide, transport accidents, and those that could not be ascertained (ICD9 rubrics E950-959, E800-848, and 7999), a total of 2698 cases. Group B comprised deaths due to neurological disease, psychiatric disease, or substance abuse (624). RESULTS: For group A, remaining brain material was identified (n=218, 8.1%) and examined by routine histology and immunocytochemistry for prion protein. No cases of vCJD were detected. For group B, review of remaining clinical information was undertaken. Of 624 cases, information was available on 447 (72%). Brain tissue was examined by routine histology and immunocytochemistry in 47 (7.5%) cases. Sufficient clinical and pathological information was available to exclude all these as potential cases of vCJD. CONCLUSION: Variant CJD is a new disease entity and not simply the result of better case ascertainment.

Public health management of an outbreak of group C meningococcal disease in university campus residents.

BACKGROUND: Increasing numbers of outbreaks of Group C meningococcal disease in teenagers and young adults led to a new policy in the UK in 1999 of vaccinating all new college students. The largest of these outbreaks involved seven students in one university, six of whom were from one hall of residence, and two of whom died. METHODS: Control of the outbreak involved close medical surveillance of resident students, mass chemoprophylaxis and vaccination, and wide dissemination of daily information bulletins. Investigation of the epidemiology of the outbreak involved searching for the network of close contacts between cases, a prevalence survey of carriage of meningogocci and a case control study of risk factors for carriage. RESULTS: Clinical cases could be linked by a discrete network of social contacts within the halls of residence, but the Group C epidemic strain (2a P1.5) was not detected in 454 students (upper 95% confidence interval 0.7%). Carriage of any meningococcal strain (19%) was associated with patronage of the campus bar (OR = 3.0, 0.99-9.1). CONCLUSION: Important factors in the control of the outbreak were rapid institution of mass chemopropylaxis and immunisation of residents, and involvement of student organizations in the dissemination of information about the disease and its control. The role of campus bars in dissemination of the carriage of meningogocci deserves further investigation.

Outbreak of Salmonella indiana associated with egg mayonnaise sandwiches at an acute NHS hospital.

An outbreak of Salmonella indiana infection in December 2000 affected 17 staff, relatives and patients at an acute NHS Hospital in Swansea. Epidemiological investigation identified egg mayonnaise sandwiches as the vehicle of infection. It was not possible to definitively determine the source of the infection or how the prepared sandwiches became contaminated. The most likely explanation was a pasteurisation failure of a batch of the egg roll used to make these sandwiches. Sandwiches are the most frequently identified vehicle of infection in foodborne outbreaks of salmonella infection in hospitals in England and Wales. The process of sandwich preparation has inherent risks because it involves considerable handling of food, which is consumed without further cooking. Care is required in all stages of preparation including the sourcing of materials used to produce the sandwiches. NHS Trusts should review their Hazard Analysis Critical Control Point plans for sandwich production.