Complex differences in infection rates between ethnic groups in Scotland: a retrospective, national census-linked cohort study of 1.65 million cases.

BACKGROUND: Ethnicity can influence susceptibility to infection, as COVID-19 has shown. Few countries have systematically investigated ethnic variations in infection. METHODS: We linked the Scotland 2001 Census, including ethnic group, to national databases of hospitalizations/deaths and serological diagnoses of bloodborne viruses for 2001-2013. We calculated age-adjusted rate ratios (RRs) in 12 ethnic groups for all infections combined, 15 infection categories, and human immunodeficiency virus (HIV), hepatitis B (HBV) and hepatitis C (HCV) viruses. RESULTS: We analysed over 1.65 million infection-related hospitalisations/deaths. Compared with White Scottish, RRs for all infections combined were 0.8 or lower for Other White British, Other White and Chinese males and females, and 1.2-1.4 for Pakistani and African males and females. Adjustment for socioeconomic status or birthplace had little effect. RRs for specific infection categories followed similar patterns with striking exceptions. For HIV, RRs were 136 in African females and 14 in males; for HBV, 125 in Chinese females and 59 in males, 55 in African females and 24 in males; and for HCV, 2.3-3.1 in Pakistanis and Africans. CONCLUSIONS: Ethnic differences were found in overall rates and many infection categories, suggesting multiple causative pathways. We recommend census linkage as a powerful method for studying the disproportionate impact of COVID-19.

Differences in all-cause hospitalisation by ethnic group: a data linkage cohort study of 4.62 million people in Scotland, 2001-2013.

OBJECTIVES: Immigration into Europe has raised contrasting concerns about increased pressure on health services and equitable provision of health care to immigrants or ethnic minorities. Our objective was to find out if there were important differences in hospital use between the main ethnic groups in Scotland. STUDY DESIGN: A census-based data linkage cohort study. METHODS: We anonymously linked Scotland's Census 2001 records for 4.62 million people, including their ethnic group, to National Health Service general hospitalisation records for 2001-2013. We used Poisson regression to calculate hospitalisation rate ratios (RRs) in 14 ethnic groups, presented as percentages of the White Scottish reference group (RR = 100), for males and females separately. We adjusted for age and socio-economic status and compared those born in the United Kingdom or the Republic of Ireland (UK/RoI) with elsewhere. We calculated mean lengths of hospital stay. RESULTS: 9.79 million hospital admissions were analysed. Compared with the White Scottish, unadjusted RRs for both males and females in most groups were about 50-90, e.g. Chinese males 49 (95% confidence interval [CI] = 45-53) and Indian females 76 (95% CI 71-81). The exceptions were White Irish, males 120 (95% CI 117-124) and females 115 (95% CI 112-119) and Caribbean females, 103 (95% CI 85-126). Adjusting for age increased the RRs for most groups towards or above the reference. Socio-economic status had little effect. In many groups, those born outside the UK/RoI had lower admission rates. Unadjusted mean lengths of stay were substantially lower in most ethnic minorities. CONCLUSIONS: Use of hospital beds in Scotland by most ethnic minorities was lower than by the White Scottish majority, largely explained by their younger average age. Other countries should use similar methods to assess their own experience.

Estimates of HIV infection among injecting drug users in Glasgow, 1985-1990.

OBJECTIVE: To use research and surveillance studies in Glasgow (Scotland, UK) to estimate the number of current injectors infected with HIV, the total number of injectors infected up to the end of 1990 and the recent incidence of infection. DESIGN: (A) Prevalence of injecting drug use was estimated using log-linear modelling. (B) Prevalence of HIV infection was determined from voluntary testing of a community-wide sample of injectors. (C) The number of infected current injectors was predicted by combining the distributions generated by (A) and (B). (D) Data on known HIV-positive injectors were used in conjunction with (C) to forecast the cumulative number of infected injectors. RESULTS: The number of current injectors was estimated to be 9400; the prevalence of HIV infection among 447 injectors recruited to the HIV prevalence study during 1990 was 1.1%. From these data, the number of HIV-positive current injectors in 1990 was estimated to be between 52 and 138. Between 1985 and 1990, 110 known HIV-positive injectors were registered or received treatment in Glasgow for HIV-related diseases; the total number of cases estimated to have occurred during this period was between 110 and 300. The incidence of infection in Glasgow during 1990 was likely to have been low in light of the finding that only one case in the prevalence study had not previously been diagnosed HIV-positive. CONCLUSIONS: Linkage of datasets from a variety of sources and studies has enabled the substantial refinement of estimates of the number of injectors and the proportion infected with HIV in Glasgow up to 1990.

Disinfection of hands and tubing of CAPD patients.

During a 3 month study the effectiveness of two methods of handwashing was assessed in a group of 31 patients undergoing continuous ambulatory peritoneal dialysis. A defined, double rinse with alcohol, prior to bag exchange, was found to be more convenient and significantly more effective than povidone-iodine alone or povidone-iodine followed by alcohol. Spraying the tubing around the bag connector with 70 per cent ethanol reduced the numbers of adherent skin organisms so reducing the likelihood of bacteria being drawn into the dialysate. Although there was no difference in the overall incidence of peritonitis in the two groups of patients studied, there was an unexpected drop in the incidence of peritonitis caused by coagulase-negative skin staphylococci. This was attributed to an overall awareness of the importance of handwashing and aseptic procedures during bag exchange. Monitoring the bacteriology of the catheter exit site may give some prior indication as to the likelihood of subsequent peritonitis especially with Staphylococcus aureus and Gram-negative bacilli.

Sexual behaviour and use of the condom by men attending gay bars and clubs in Glasgow and Edinburgh.

How widespread are the safer forms of sexual behaviour reportedly adopted by male homosexuals in recent years? A questionnaire was completed by 173 and 83 gay men attending gay bars and clubs in Edinburgh and Glasgow respectively. Comparisons were made between those who reported using the condom (n = 137, [54%]) and those who did not (n = 119, [46%]). Sixty percent of respondents reported more than 5 partners during the previous year. Condom use was much less common among men with less than 5 years' experience as a practising homosexual. Less than one-fifth of respondents reported always using a condom during anal intercourse. Orogenital contact without a condom was reported by 84% of all respondents, and unprotected anal intercourse by 40%, (over 30% for those who used condoms). About one-third of condom users but only 14% of non-users thought they were at risk of catching HIV because of their sexual behaviour, although 80% of users and 70% of non-users said their lifestyles had been affected by the HIV epidemic. While there were some encouraging signs of behaviour change, unprotected anal sex is still widely practised. Gay bars and clubs represent important venues for conveying the safer sex message.

PIP: Completed questionnaires were received from 173 and 83 gay men attending gay bars and clubs in Edinburgh and Glasgow, respectively, in a study of respondents' sexual behavior and condom use. The questionnaire response rate in Glasgow was half that achieved in Edinburgh. Respondents were of mean age 28 years who had had sex with men in the past year. 21% also reported having at least one female sex partner during that period. 60% reported having more than five sex partners during the previous year. 137 reported using condoms and 119 reported not using them. Condom use was relatively less common among men with less than five years experience as a practicing homosexual. Less than 20% of respondents reported always using a condom during anal intercourse. Orogenital contact without a condom was reported by 84% of all respondents and unprotected anal intercourse by 40%. 31% of condom users and 14% of non-users thought they were at risk of contracting HIV because of their sexual behavior, but 80% of users and 70% of non-users said their lifestyles had been affected by the HIV epidemic. The authors note on the basis of these findings that unprotected anal sexual intercourse remains widely practiced despite some encouraging signs of behavior change. As such, gay bars and clubs are important venues in which safer sex messages could be conveyed.

Distribution of HIV and acute hepatitis B infection among drug injectors in Glasgow.

This study compared the distributions of known human immunodeficiency virus (HIV) and acute hepatitis B virus (HBV) infection among drug injectors in Glasgow over a 3.5 year period. Data were obtained from all relevant laboratory request forms submitted to Glasgow's 3 virology laboratories during the period 1 January 1986 to 30 June 1989. The overall prevalence of HIV among those tested was 3.7% (66/1786). There were 125 cases of acute HBV infection. The male:female ratios for HIV and acute HBV were 1:1 and 2:1, respectively. Thirty-four per cent of persons with HIV were aged under 21 years compared with 53% with acute HBV. Three out of 10 areas of the city accounted for 92% of HIV infection but only 66% of acute HBV infection. HIV infection was not detected among drug injectors in 4 areas of the city but at least 2 cases of acute HBV infection were recorded in all 10 areas. The geographical and age distribution of acute HBV infection in Glasgow suggests that the potential for future spread of HIV among drug injectors remains considerable.

Knowledge of HIV and condom use among heterosexual patients at a Glasgow genito-urinary medicine clinic.

Knowledge of HIV and knowledge of, attitudes to and use of the condom were assessed by a survey of a sample of 778 heterosexual patients attending the genito-urinary medicine clinic at the Glasgow Royal Infirmary. The mean age was 27.4 years for men and 24.5 years for women. Over two-thirds of the men and about half of the women reported more than one sexual partner during the previous year. More than 70% reported having intercourse at least three times each week. Knowledge about HIV transmission and the condom was generally good. Over three quarters of the respondents approved of the use of the condom. However, only 27% male and 24% female respondents reported using the condom, with 11% and 8% respectively using it always. Condom use was associated with a positive attitude to the condom, having received information from the media about the condom, educational status, a belief that condoms prevented sexually transmitted diseases, and having had sex education in school. It was unrelated to age, marital status, the number of sexual partners or the frequency of sexual intercourse. The most common reported reason for not using the condom was use of another form of contraceptive.

PIP: Knowledge of HIV and knowledge of, attitudes towards, and use of the condom were assessed by a survey which sampled 778 heterosexual patients who attended the genitourinary medicine clinic at the Glasgow Royal Infirmary. The mean age was 27.4 years for men and 24.5 years for women. Over 2/3 of the men and about 1/2 of the women reported more than 1 sexual partner during the previous year. More than 70% reported having intercourse at least 3 times/week. Knowledge concerning HIV transmission and the condom was generally good. Over 3/4 of those responding approved of condom use. However, only 27% of the male and 24% of the female respondents reported actual condom use, with 11% and 8%, respectively, using it consistently. Condom use was associated with a positive attitude towards the condom, with having received information from the media about the condom, with educational status, with a belief that condoms prevented sexually transmitted diseases, and with having had sex education in school. It was not related to age, marital status, number of sexual partners, or frequency of sexual intercourse. The most commonly reported reason for not using the condom was the use of another form of contraceptive.

Sexual behaviour and use of the condom among Ugandan students.

HIV infection is widespread in Uganda. Have its university students, the country's leaders of tomorrow, taken appropriate action? A questionnaire was completed by 661 men and 270 women in a one-in-four sample of Makerere University undergraduates (93% response rate). More than 60% of the men and 36% of the women reported at least two sexual partners in the past year. Over 18% of respondents reported at least one episode of sexually transmitted disease in the past year. Most respondents correctly identified the main routes of HIV transmission but risk was also often incorrectly associated with non-penetrative sex. Only a minority saw the condom as an effective preventive method: most saw it as unsafe or an encouragement to promiscuity. Condoms had been used by 35% of men and 24% of women but were currently always used by only 9% of men and 11% of women. The condom was approved of by only one quarter of respondents. Condom use increased with the number of sexual partners but was less likely if the respondent had seen official publicity about the condom. Whilst there were some encouraging signs of behaviour change, opportunities for the spread of HIV continued to abound in this important group. More positive promotion of the condom is urgently required.

Antibiotic susceptibility of streptococcal strains associated with infective endocarditis.

Seventy-six strains of various species of streptococci isolated from patients with infective endocarditis were tested for their susceptibility to 13 antibiotics by an agar dilution method. The antibiotics tested were: benzyl-penicillin, ampicillin, cefotaxime, vancomycin, erythromycin, rifampicin, pristinamycin, gentamicin, netilmicin, tobramycin, amikacin, dibekacin and streptomycin. Excluding enterococci, 91% of strains were sensitive to benzylpenicillin. Resistance to benzylpenicillin was only found in some strains of S. sanguis I, S. sanguis II and S. mitis. Enterococci were more sensitive to ampicillin. Cefotaxime was highly active against all strains, except enterococci. Vancomycin was active against all strains. Resistance to erythromycin was found in 16% of isolates. Rifampicin and pristinamycin were highly active against all strains, except some enterococci. Gentamicin and netilmicin were the most active of the six aminoglycosides tested. High level resistance to streptomycin was seen in six strains. Overall, S. agalactiae was more resistant to the aminoglycosides than the other species. Among the non-groupable streptococci, strains of S. mitis, S. sanguis I and S. sanguis II were the least sensitive to many antibiotics. Benzylpenicillin remains the antibiotic of choice for the treatment of IE caused by streptococci. If the MIC exceeds 0.1 mg l-1, an aminoglycoside (netilmicin or gentamicin) should be added and the duration of treatment increased from 4 to 6 weeks.

Pneumococcal bacteraemia--a continuing challenge.

In a retrospective study of pneumococcal bacteraemia in a large district hospital over an eight-year period 103 cases were identified. Although all age groups were represented, an unexpectedly large number of cases occurred among elderly males. The overall case fatality rate was 34 per cent, ranging from 13 per cent in children to 42 per cent in the elderly. Most children had preexisting disease and did have pneumonia. Pre-existing diseases were of three main types: (i) disorders of the respiratory system; (ii) disorders of metabolism; (iii) disorders of the immune system. Six patients had no spleen. Almost all patients received appropriate antibiotics. Most deaths occurred during the first 48 h of treatment. The prospects for the prevention of fatal pneumococcal bacteraemia are reviewed in the light of these findings.

Species identification and antibiotic sensitivity of coagulase-negative staphylococci from CAPD peritonitis.

Forty-three strains of coagulase-negative staphylococci were obtained from dialysis effluent during 41 episodes of CAPD peritonitis. Eighty per cent of these were found to be Staphylococcus epidermidis but several other species also occurred. A recurrent infection lasting 15 weeks was caused by Staph. haemolyticus. Multiple antibiotic resistance was found to be common. Of 13 antibiotics tested, only vancomycin was active against all strains although most strains were also sensitive to rifampicin, netilmicin and cefamandole. Vancomycin was chosen for the initial treatment of CAPD peritonitis caused by coagulase-negative staphylococci and eradicated the organism in 29 of 30 episodes.

Evaluation of the API 20 STREP system for species identification of streptococci associated with infective endocarditis.

A rapid commercial system (API 20 STREP gallery, API System, France) for the identification of streptococci was compared with conventional biochemical or serological methods. 77 clinical isolates from patients with infective endocarditis and six reference strains were tested. Biochemical tests showing differences between conventional methods and the API gallery were the acidification of inulin and the Voges-Proskauer reaction, but these differences did not affect the final identification of any strain. 75 strains were identified by the API system and 70 by conventional methods. 69 strains (25 groupable and 44 of 51 non-groupable streptococci) were given the same identity by both methods. One S. morbillorum was only identified by the conventional method. Seven S. sanguis I strains were identified only by the API system and confirmed by additional biochemical tests. The API gallery is a useful method for identifying streptococci associated with infective endocarditis, agreeing with conventional methods in 90% of strains. Results are usually available in 24 h.

Vancomycin and tobramycin in the treatment of CAPD peritonitis.

Seventy-five episodes of continuous ambulatory peritoneal dialysis (CAPD) peritonitis were studied during a 1 year period at the Queen Elizabeth Hospital, Birmingham. When two simple culture methods were used in parallel, the causative organisms were identified in 97% of cases. Nearly two thirds of episodes of peritonitis were caused by coagulase-negative staphylococci (C-NS), many of which were multiply antibiotic-resistant. On the basis of detailed antibiotic sensitivities, intraperitoneal vancomycin and tobramycin were chosen for the initial treatment of CAPD peritonitis. With this regime, a cure was achieved in 32 of 38 episodes, compared with 15 of 27 episodes when cefuroxime was used. All but 1 of 24 episodes caused by C-NS were cured by vancomycin.

Septicemia caused by Agrobacterium sp.

Agrobacterium radiobacter biovar 2 was repeatedly grown from the blood of an elderly patient receiving artificial ventilation and broad-spectrum antibiotics. No source of the organism was found, but the septicemia ceased when cefotaxime was given. Sera from the patient showed a fourfold rise in antibody against the organism and higher titers than sera from all but 1 of 50 healthy blood donors. The organism did not contain the plasmid associated with plant oncogenicity. This case may be only the second in which Agrobacterium sp. has been clearly linked with human infection.

Indices of effectiveness of medical and surgical treatment in 40 cases of prosthetic valve endocarditis.

Forty patients with prosthetic valve endocarditis (PVE) presenting during a 12-year period at a single hospital were studied. Twenty-six were male and 14 female and ages ranged from 19 to 67 years. During the first six post-operative months, most episodes were caused by staphylococci (38%) and Gram negative bacilli (24%). Between 6 and 11 months no episodes were seen, but thereafter streptococci predominated (50%). The overall mortality was 58% (66% during first six months; 36% thereafter). Nine of 23 patients undergoing re-operation died, most deaths occurring in patients in cardiac failure prior to surgery. Eleven deaths occurred in the 17 patients treated with antibiotics alone. Six of these were pyrexial at death and all but one was infected by a virulent organism. The remaining five were apyrexial at death and all had staphylococcal PVE. Our findings suggest: (1) all cases occurring during the first six months should be initially treated as 'early' PVE; (2) in staphylococcal PVE, apyrexia may not mean cure; (3) the principal guides to prognosis in PVE are the patient's cardiac status and the nature of the infecting organism.

Prophylaxis of infective endocarditis for dental procedures. Report of a working party of the European Society of Cardiology.

Bacterial endocarditis still remains a serious disease with significant morbidity and mortality. In patients with known valve disease, most cases are caused by oral viridans streptococci. These organisms are present in vast numbers on the gum margins and in gum pockets. They cause transient bacteraemia during eating and tooth brushing. More substantial, but short-lived bacteraemia can occur during dental treatment such as extraction and scaling. Bacteria may then become attached to abnormal endocardium leading to the development of infective endocarditis. Prophylaxis of endocarditis during dental procedures in patients with known valve disease should thus be aimed at reducing the number of bacteria entering the blood stream and eliminating those that get there. This can be sought first by good oro-dental hygiene and secondly by the use of prophylactic antibiotics. In this paper, we set out simple guidelines for practitioners in those countries that do not already have recommendations of their own. They are based on guidelines already in use in the United Kingdom, France, Switzerland and the United States.