Emergence of a multidrug-resistant (ASSuTTm) strain of Salmonella enterica serovar Typhimurium DT120 in England in 2011 and the use of multiple-locus variable-number tandem-repeat analysis in supporting outbreak investigations.

In summer 2011, two outbreaks of a unique, multidrug-resistant strain of Salmonella enterica serovar Typhimurium phage type 120 (DT120) occurred mainly in the Midlands, England. The first outbreak occurred among guests attending a wedding in July 2011 ('Wedding outbreak'), followed by a more geographically dispersed outbreak in August and September 2011 ('Midlands outbreak'). Fifty-one cases were confirmed. Detailed epidemiological and environmental health investigations suggested that pork was the most likely source of both outbreaks. All human samples and one pork sample showed the specific multiple-locus variable-number tandem-repeat analysis (MLVA) profile 3-11-12-NA-0211, with at most two loci variations. Trace-back investigations suggested a link to a butcher's shop and a pig farm in the East Midlands. The investigations highlight the utility of molecular analysis (MLVA) in supporting epidemiological investigations of outbreaks caused by S. Typhimurium DT120. Safe handling and cooking of pork by food business operators and consumers are key interventions to prevent future outbreaks.

Development of a decision framework for establishing a health register following a major incident.

INTRODUCTION: Health registers have been established in the United Kingdom (UK) and elsewhere following mass exposure to novel agents or known agents, but there is no consensus on the criteria for establishing such registers. OBJECTIVE: This study aimed to develop a decision framework to assess the need for establishing a health register for major chemical, biological, radiological, and nuclear (CBRN) incidents. METHODS: The study comprised three stages. In the first stage, the study team prepared a list of potential criteria that may be used to assess the need for setting up a health register based on literature review and personal experiences in previous incidents. In the second stage, the potential criteria were evaluated in two Delphi rounds involving experts and key decision makers from the UK Health Protection Agency (HPA) and academic organizations. In the final stage, the criteria were converted into a decision framework, and its utility was tested using four fictional scenarios. RESULTS: A total of 11 statements were proposed by the study group. These criteria were revised following feedback from 16 experts in the first Delphi round. All 11 statements achieved consensus at the end of the second Delphi round. Pilot testing of the agreed criteria on four fictional scenarios confirmed validity and reliability for use in the decision process. CONCLUSIONS: A decision framework to assess the need for setting up a health register after a major incident was agreed upon and tested using fictional scenarios. Further areas of work for practical implementation of the criteria and related planning for systems and protocols have been identified.

The need for commissioning circumcision services for non-therapeutic indications in the NHS: lessons from an incident investigation in Oxford.

INTRODUCTION: Male circumcision for religious reasons is not available in the NHS. In this report, we present the results of an investigation conducted by the Thames Valley Health Protection Unit (TVHPU) at an unregulated circumcision 'camp' in Oxford in 2006. METHODS: A detailed investigation was initiated following notification by a general practitioner of two children with circumcision-related complications at a 'camp'. Telephone interviews were conducted with the 'camp' organizers, the operating surgeon, GPs and paediatric surgeons. A field visit was carried out by TVHPU staff to assess implementation of infection control practices. RESULTS: Thirty-two children were circumcised over a 3 day period in the library of an Islamic faith school by a single, medically qualified individual. Among the 29 children with follow-up information, 13 (44.8%) developed complications requiring medical intervention. Information obtained from interviews and the field visit confirmed the lack of implementation of standard infection control practices. CONCLUSION: This incident highlights the harm associated with circumcision in young children by unregulated operators due to lack of compliance with best surgical and infection control guidance. There is an urgent need for commissioning circumcision services for religious reasons in the NHS.

Drinking water incidents due to chemical contamination in England and Wales, 2006-2008.

Contamination of drinking water by microbiological and chemical agents can lead to adverse health effects. In England and Wales, the Chemicals Hazards and Poisons Division (CHaPD) of the Health Protection Agency provides expert advice on the consequences to public health of chemical contamination incidents affecting drinking water. In this study, we extracted data from the National Database on the type and nature of drinking water contamination events reported to the CHaPD between 2006 and 2008. Eighty-two incidents with confirmed chemical contamination were identified. Among the 70 incidents where data was available, 40% (28/70) of incidents related to contamination of drinking water provided by private suppliers, 31% (22/70) were due to contamination occurring close to the point of consumption (i.e. near consumer) and 29% (20/70) related to incidents where public water supplies were identified as the contaminated source. For the majority of incidents, little or no information was available on the critical exposure variables such as duration of contamination and actual or estimates of the population affected. Reassuringly, the levels of exposure in most incidents were considered unlikely to cause serious immediate or long term ill health effects. Recording of exposure data for reported contamination incidents needs to be improved.

Factors influencing adherence to anti-retroviral treatment in children with human immunodeficiency virus in South India--a qualitative study.

The aim of the study was to gain a deeper understanding of the factors that influence adherence to Anti-Retroviral Treatment (ART) in a paediatric population in South India. Semi-structured interviews, guided by a questionnaire based on literature review, were undertaken with 14 primary caregivers of children with Human Immunodeficiency Virus (HIV) on ART focussing on the factors influencing adherence and non-adherence. Adherence to ART was assessed by caregiver reported adherence for the last three days. The framework approach was used for analysis of the transcribed interviews. Adherence behaviour in children taking ART was influenced by medication, child, caregiver, family and healthcare service related factors. Medication related factors such as palatability, formulation, and difficult regime were among the common reasons for non-adherence. While a supportive family appeared to contribute to adherence, some caregivers were reluctant to inform their extended family members for fear of isolation. All participants were strongly appreciative of the study centre's model of care and this had a positive effect on adherence behaviour. From the public health point of view, the respondents' reluctance to access publicly funded HIV care services is a cause for concern. Almost all caregivers were sceptical of the quality of free ART medications provided by public services, indicating an urgent need for appropriate education to alleviate their concerns. The cost of ART was reported by caregivers as an important barrier, particularly by those with low income. Most caregivers recommended wider access to free ART, availability of child-friendly medications and adherence counselling as important interventions to improve adherence. All caregivers in this study reported some difficulty in sustaining adherence in their children. Further research on improving adherence in children by tailoring interventions to the specific needs of caregivers and their families is warranted.

UK vaccination schedule: persistence of immunity to hepatitis B in children vaccinated after perinatal exposure.

OBJECTIVE: To assess persistence of immunity to hepatitis B (HBV) in primary school children vaccinated following perinatal exposure. DESIGN: Serological survey. SETTING: Five UK sites (Berkshire East, Birmingham, Buckinghamshire, Milton Keynes and Oxfordshire). PARTICIPANTS: Children from 3 years 4 months to 10 years of age (mean age 6.2 years), vaccinated against HBV from birth following perinatal exposure. INTERVENTIONS: A single booster dose of the paediatric formulation of a recombinant HBV vaccine. MAIN OUTCOME MEASURES: Titres of antibody against hepatitis B Surface Antigen (anti-HBs) measured immediately before and 21-35 days after the HBV vaccine booster. RESULTS: Prebooster anti-HBs titres were >10 mIU/ml in 84.6% of children (n=26; 95% CI 65.1 to 95.6%). All children (n=25, 95% CI 86.3 to 100%) had titres >100 mIU/ml after the booster. CONCLUSIONS: This study of antibody persistence among UK children born to hepatitis B infected women, immunised with a 3-dose infant schedule with a toddler booster suggests sustained immunity through early childhood. These data should prompt further studies to address the need for a preschool booster. TRIAL REGISTRATION: Eudract Number 2008-004785-98.