Evaluation of current equine welfare issues in Ireland: causes, desirability, feasibility and means of raising standards.

REASONS FOR PERFORMING STUDY: Significant potential threats to the health and welfare of horses exist in Ireland when supply exceeds demand and the identification system for horses is not yet robust. OBJECTIVES: To secure engagement with stakeholder groups and determine their perception of equine welfare in Ireland and encourage the development of inclusive, rather than imposed, policy solutions. METHODS: A 3 round, web-based Policy Delphi incorporating novel vignette methodology was conducted from November 2007-March 2008 to canvass opinion (in both quantitative and qualitative forms) on the perceived most significant equine welfare issues. Vignettes (narratives depicting potential compromise to equine welfare) were employed. Quantitative data were collected in the form of scoring on a 9 point Likert scale with labelled end-points, qualitative information as text subsequently analysed for themes. RESULTS: All 44 respondents completed all rounds. Major equine welfare issues were identified as welfare of horses during the disposal process and at unregulated gatherings. Assessed quantitatively on a 9 point Likert scale (0 = minimal; 8 = maximal), respondents scored the desirability and feasibility of improving standards, median 8 and 6, respectively, for both issues identified. Basic themes identified in respondents' quotes as reasons to raise equine welfare standards were ideological, protection of animal welfare, safe-guarding the reputation of the equine industry and safety (of people, horses and environment). Themes for reasons for low standards were societal norms, fiscal pressures, indolence, indifference and ignorance. Themes underpinning potential means for achieving meaningful change (solutions) were legislation, enforcement, education/training, fiscal remedies, increasing awareness and a combination of these. CONCLUSIONS: Mechanisms aimed at raising standards must be based on an understanding of motivational drivers for currently low standards. POTENTIAL RELEVANCE: The challenge is to translate the findings and this heightened awareness into meaningful change to the benefit of horses and those who care for them.

Essential veterinary education in food safety, food hygiene and biosecurity: a global perspective.

A big challenge for veterinary educators is to stimulate interest in public health medicine and make the curriculum interesting, and relevant, to veterinary students. Veterinary public health encompasses many areas, including zoonosis control, food safety, animal health and biosecurity, animals as sentinels of environmental hazards and the contribution of animal waste to pollution of food and water, so there is no shortage of ammunition for the veterinary educator in the competition for students' attention. Veterinary educators, not the students, will have failed if graduates complete their studies without being convinced of the importance and relevance of veterinary public health.

Dissemination of Cronobacter spp. (Enterobacter sakazakii) in a powdered milk protein manufacturing facility.

The microbial contamination of air filters and possible links to contaminated product in a powdered milk protein-processing facility were investigated. Over a 10-month period, seven air filters, the environment, and powdered product were analyzed for the presence of Cronobacter spp. The effects of air filter installation, maintenance, and subsequent dissemination of Cronobacter were investigated. A total of 30 isolates were characterized by pulsed-field gel electrophoresis (PFGE). PFGE revealed the presence of three clonal populations distributed throughout the manufacturing site. This study highlights the need for proper installation of air filters to limit the dissemination of microorganisms into processing sites.

Molecular analysis of the Enterobacter sakazakii O-antigen gene locus.

Nucleotide polymorphism associated with the O-antigen-encoding locus, rfb, in Enterobacter sakazakii was determined by PCR-restriction fragment length polymorphism analysis. Based on the analysis of these DNA profiles, 12 unique banding patterns were detected among a collection of 62 strains from diverse origins. Two common profiles were identified and were designated serotypes O:1 and O:2. DNA sequencing of the 12,500-bp region flanked by galF and gnd identified 11 open reading frames, all with the same transcriptional direction. Analysis of the proximal region of both sequences demonstrated remarkable heterogeneity. A PCR assay targeting genes specific for the two prominent serotypes was developed and applied for the identification of these strains recovered from food, environmental, and clinical samples.

Development of multiple-locus variable-number tandem-repeat analysis for the molecular subtyping of Enterobacter sakazakii.

The genomic content of Enterobacter sakazakii strain ATCC BAA-894 was analyzed for variable-number tandem repeats (VNTRs). In this study we report the development of a multiple-locus VNTR analysis (MLVA) strategy for the subtyping of E. sakazakii. The method is based on a GeneScan analysis of four VNTR loci labeled with multiple fluorescent dyes. This approach was applied to a collection of 112 isolates representing all 16 of the currently defined E. sakazakii biogroups. MLVA successfully discriminated among these isolates and compared favorably with pulsed-field gel electrophoresis. The method was relatively fast and easy to perform. The potential value of MLVA as an epidemiological tool is discussed.

Application of pulsed-field gel electrophoresis to characterise and trace the prevalence of Enterobacter sakazakii in an infant formula processing facility.

Enterobacter sakazakii (E. sakazakii) contamination of powdered infant formula (PIF) and its processing environment was monitored between April 2005 and March 2006. The purpose of the monitoring programme was to locate points of contamination, investigate clonal persistence, and identify possible dissemination routes along the processing chain. A total of 80 E. sakazakii isolates were recovered from the manufacturing facility. The overall frequency of isolation of E. sakazakii in intermediate and final product was 2.5%, while specific locations in the processing environment were contaminated at frequencies up to 31%. All E. sakazakii isolates were characterised by pulsed-field gel electrophoresis (PFGE). XbaI macrorestriction digests yielded 19 unique pulse-types that could be grouped into 6 clusters of between 5 and 32 isolates. The formation of large clusters was consistent with the presence of a number of clones in the manufacturing environment. While the majority of isolates were of environmental origin (72.5%), no cluster was confined to one specific location and indistinguishable PFGE profiles were generated from isolates cultured from the manufacturing environment, sampling points along the processing chain and from intermediate and final product. These findings suggest that the manufacturing environment serves as a key route for sporadic contamination of PIF. These data will support the development of efficient intervention measures contributing to the reduction of E. sakazakii in the PIF processing chain.

Enterobacter sakazakii: an emerging pathogen in powdered infant formula.

Enterobacter sakazakii represents a significant risk to the health of neonates. This bacterium is an emerging opportunistic pathogen that is associated with rare but life-threatening cases of meningitis, necrotizing enterocolitis, and sepsis in premature and full-term infants. Infants aged <28 days are considered to be most at risk. Feeding with powdered infant formula (PIF) has been epidemiologically implicated in several clinical cases. Infants should be exclusively breast-fed for the first 6 months of life, and those who are not should be provided with a suitable breast-milk substitute. PIF is not a sterile product; to reduce the risk of infection, the reconstitution of powdered formula should be undertaken by caregivers using good hygienic measures and in accordance with the product manufacturer's food safety guidelines.

Changing incidence of Pneumocystis carinii pneumonia as initial AIDS defining disease in the United Kingdom.

OBJECTIVE: To determine whether the incidence of Pneumocystis carinii pneumonia (PCP) as the initial AIDS-defining disease in adult AIDS cases in the United Kingdom is changing over time and to examine factors likely to affect it. SUBJECTS AND METHODS: A total of 4419 adult AIDS cases diagnosed in the United Kingdom between January 1989 and December 1992 were analysed using logistic regression models. An initial diagnosis of PCP was used as the outcome variable and the possible effects of age, sex, exposure category, ethnic group, half year of diagnosis, geographical area of report, and whether or not the individuals had been aware of their HIV infection when AIDS was diagnosed was examined. RESULTS: A significant decline in PCP incidence was observed over time. Incidence of PCP declined among subjects who had been aware of their infection for 9 months or more before AIDS diagnosis. There was no evidence of a change in PCP incidence over time for subjects who had had HIV infection diagnosed 3 or less months before an AIDS diagnosis. Individuals who had been aware of their HIV infection, individuals reported from the Thames health regions, and non-white patients were much less likely to have had a diagnosis of PCP. CONCLUSIONS: The decline of PCP incidence in subjects aware of their serostatus, and therefore more likely to have received primary prophylaxis, suggests that they may have benefited from this treatment. Our findings provide evidence of the value of an early HIV diagnosis and confirmation of the beneficial effects of primary prophylaxis for PCP.

Clostridium difficile: an update on its epidemiology and role in hospital outbreaks in England and Wales.

Data from the surveillance system of general outbreaks of infectious intestinal disease and from laboratory reports collated by the Communicable Disease Surveillance Centre (CDSC) and requests for outbreak investigation by the PHLS Anaerobe Reference Unit were used to evaluate the current epidemiology of Clostridium difficile infection in England and Wales. Between January 1992 and December 1996, CDSC received 10,220 laboratory reports of C difficile isolation from patient's faeces and 26,873 of toxin in faeces. Over 75% of all reports were of people aged 64 years and over. The surveillance system captured a minimum data set on 694 hospital outbreaks of infectious intestinal disease. C. difficile was responsible for 109 (15%) outbreaks affecting 1625 people, of whom 1152 were found to have a C. difficile toxin producing strain. The median duration of outbreaks was 11 days. Fingerprinting by Pyrolysis Mass Spectrometry (PMS) was performed by the PHLS Anaerobe Reference Unit in 60 outbreaks, and typing by Polymerase Chain Reaction ribotyping (PCR) in 14.

Outbreaks of salmonellosis in hospitals in England and Wales: 1992-1994.

Data from the surveillance scheme of general outbreaks of infectious intestinal disease in England and Wales were used to describe the epidemiology of outbreaks of salmonellosis in hospitals from 1992-1994. Outbreaks of infectious intestinal disease in hospitals accounted for 15% (189/1275) of all outbreaks. A salmonella was the implicated pathogen in 12% (22/189). The mode of transmission was described as mainly person to person in 12 outbreaks, mainly foodborne in eight and equal or unknown proportions of foodborne and person to person in two. The most common strain involved was Salmonella enteritidis PT4 (11 outbreaks). The mean duration of outbreaks was 16 days. The mean attack rate in patients was 25% but varied from 2-67%. Illness was reported in 260 patients, of whom 130 had a laboratory confirmed infection. Eight hundred and twenty-six asymptomatic patients were tested, 31 of whom were positive. The salmonella infection was believed to have contributed to the deaths of five patients. Ill staff (115) were tested and 68 were positive; 1508 well staff were tested and 33 were positive. Outbreaks of salmonellosis in hospitals are preventable. Attack rates can be high and outbreaks are often prolonged, with high morbidity and associated disruption of hospital services. There is need for effective infection control policies, appropriate training of staff, simple surveillance systems and readily available expert advice to ensure outbreaks are rapidly controlled.

Application of molecular methods to a nosocomial outbreak of Salmonella enteritidis phage type 4.

A nosocomial outbreak of Salmonella enteritidis phage type 4 occurred in July 1995. Seven definite cases were identified over 13 days affecting four wards in a London hospital. The outbreak strain was characterized by plasmid profile typing and pulsed-field gel electrophoresis (PFGE), and was unusual in that it did not possess a 38 MDa plasmid common to most isolates of S. enteritidis PT 4 made from humans and food animals in England and Wales. Seven asymptomatic excreters were identified on screening. No additional cases occurred on wards after standard isolation procedures were implemented. No common or continuing food or dietary source was identified. Results of epidemiological, microbiological and environmental investigations suggested that the outbreak was due to person-to-person transmission within the hospital. The source of the outbreak was not established but was probably due to admission of a patient with an unrecognized infection of S. enteritidis PT 4. The study highlights the importance of close collaboration between hospital staff, epidemiologists and microbiologists, and demonstrates the value of molecular techniques for strain subdivision in outbreak investigations.

The organisms reported to cause infective myocarditis and pericarditis in England and Wales.

It is difficult to acquire an overall perspective of the range of organisms responsible for infective myocarditis or pericarditis, and their relative importance, as most studies have involved only case reports or case series of a single organism. This study analyses reports to the Communicable Disease Surveillance Centre, of the Public Health Laboratory Service. Reports where myocarditis or pericarditis was included as the main clinical features between 1990 and 1993 were studied. Between 1990 and 1993, 368 cases of myocarditis and/or pericarditis were reported to CDSC. Viruses were reported to cause 253 (69%) cases, bacteria were responsible for 49 (13%) cases, mycoplasma for 32 (9%) cases, chlamydia for 16 (4%) cases and Mycobacterium tuberculosis for nine (2%) cases. Infection with coxsackie B virus was most frequently associated with a mixed picture of myo/pericarditis, whereas influenzae virus was associated with pericarditis or myocarditis alone. This information will provide clinicians with details of the more likely pathogens responsible for these conditions.

Outbreaks of infectious intestinal disease in residential institutions in England and Wales 1992-1994.

Data from the surveillance scheme of all general outbreaks of infectious intestinal disease in England and Wales reported to or otherwise identified, by the Public Health Laboratory Service Communicable Disease Surveillance Centre (CDSC) in 1992 and 1994 were used to describe the epidemiology of outbreaks of infectious intestinal disease in residential institutions. Outbreaks in residential institutions accounted for 22% (282/1275) of all outbreaks with most, 95% (268/282), occurring in homes for the elderly. The commonest pathogens in these 282 outbreaks were small round structured viruses 48% (132), salmonellas 17% (49). Clostridium perfringens 8% (23), rotavirus 5% (15) and Shigella sonnei 2% (6). The mode of transmission was described as mainly person to person in 71% (200 outbreaks) and mainly foodborne in 21% (58 outbreaks). The mean duration of outbreaks was 9 days. Duration of outbreaks varied with both the mode of transmission and the pathogen involved. The mean attack rate was 37%. Illness was reported in 5872 people. One or more individuals were admitted to hospital in 22% of outbreaks. Twenty-six deaths were reported, of which 18 were attributed to salmonellosis. Outbreaks in residential institutions are common. Attack rates are high and outbreaks are often prolonged, with high morbidity and mortality. There is a need for effective infection control policies which include appropriate training of staff, simple surveillance systems and readily available expert advice to ensure outbreaks are rapidly controlled.

Undernotification of tuberculosis in patients with AIDS.

The purpose of this study was to establish the extent of undernotification of tuberculosis in AIDS patients resident in 2 inner London local authorities. For residents of the 2 authorities, statutory notifications of tuberculosis between 1986 and 1992 were compared, using soundex codes of surnames, sex and year of birth, with AIDS cases reported to the Public Health Laboratory Service (PHLS) AIDS Centre during the same period where TB had been recorded on the AIDS report form. In 36 of 613 AIDS cases reported as residents of the 2 authorities tuberculosis was recorded on the AIDS report form. Matching revealed that only 2 (6%) of these cases had been notified to the local authority. These results highlight the need to resolve the dilemma between concerns about patient confidentiality and the statutory requirement to notify tuberculosis so that clinical management of contacts can be undertaken and the true impact of HIV infection on the incidence of tuberculosis in the UK can be elucidated.

AIDS defining diseases in the UK: the impact of PCP prophylaxis and twelve years of change.

We examined all reports of adult AIDS cases made to the 2 national surveillance centres in the UK for changes in AIDS defining conditions between January 1982 and September 1994. Differences and changes among persons diagnosed since January 1988 who had and had not been aware of their HIV infection prior to their AIDS diagnosis were of particular interest. Pneumocystis carinii pneumonia (PCP) is the AIDS defining disease most often reported at the initial AIDS diagnosis. Its proportion of all AIDS cases has increased significantly between January 1982 and December 1987 and decreased markedly thereafter. Since January 1988 a significant decrease in the proportion of cases diagnosed with cryptosporidial infection was also observed while increases were observed in the proportion of cases diagnosed with: HIV wasting (chi(1)(2) = 5.56) PML (chi(1)(2) = 19.47), mycobacterium avium complex (chi(1)(2) = 35.76) and pulmonary tuberculosis (chi(1)(2) = 144.0). For cases diagnosed between January 1988 and September 1994, PCP was more likely to be diagnosed in patients previously unaware of their HIV infection (P < 0.01) as was extrapulmonary TB (P < 0.01). In contrast, the following diseases were more likely to be diagnosed in patients already aware of their HIV infection prior to the diagnosis of AIDS: oesophageal candidiasis (P < 0.001), HIV wasting (P = 0.07), mycobacterium avium complex (P = 0.0001), cytomegalovirus disease (P < 0.001), HIV encephalopathy (P = 0.0009) and cryptosporidial infection (P = 0.02). Prophylaxis and anti-retroviral therapy appear to have had a significant impact on the temporal changes of the most frequently diagnosed AIDS diseases. While PCP prophylaxis has substantially reduced the likelihood of a PCP diagnosis at AIDS, the corresponding increase in other opportunistic infections suggests that there may be a need for improved prophylaxis for these conditions.

Food safety and animal production systems: controlling zoonoses at farm level.

Controlling zoonotic agents in animal and poultry reservoirs has the effect of reducing the challenge to food safety management systems in processing and further along the food chain. Producing and maintaining healthy stock requires good husbandry practices, which include stock selection and veterinary attention. Feed is a key input, both as a source of pathogen-free nutrients and as a balanced dietto maintain healthy livestock. Safe water, appropriate vermin and wildlife control and an optimum environment to reduce stress are important if animals are to perform. Farms are not sterile environments and initiatives to reduce the zoonotic hazards have to be practical, economically feasible and flexible, depending on the scale of the enterprise, the species being farmed, and the epidemiology of the zoonotic agents in the particular geographical region. Education of farmers and stockmen is crucial to successful on-farm control of zoonoses, as an understanding of why control measures are necessary, and how they can be applied, will improve compliance with protocols and procedures. This understanding is a first step towards the implementation of a longitudinal integrated food safety assurance approach to zoonosis control in the pre-harvest phase of the food chain.

Trends in antimicrobial susceptibility among isolates of Campylobacter species in Ireland and the emergence of resistance to ciprofloxacin.

Measurements were made of the susceptibility to six commonly prescribed antibiotics, including erythromycin, tetracycline and ciprofloxacin, of 130 isolates of Campylobacterjejuni and 15 isolates of Campylobacter coli cultured from human and poultry sources during 2000. The results were compared with the results from a collection of strains isolated between 1996 and 1998. The levels of resistance to erythromycin remained low, 2 per cent and 4.4 per cent for the human and poultry isolates, respectively. Resistance to tetracycline had increased to 31 per cent and 24.4 per cent from 13.9 per cent and 18.8 per cent for the human and poultry isolates, respectively. However, the resistance to ciprofloxacin of the strains isolated during 2000 had increased to 30 per cent, whereas between 1996 and 1998 there had been no resistance to this agent among human isolates, and only 3.1 per cent resistance among poultry isolates. The molecular basis for this resistance has been shown to be the result of a single amino acid substitution, Thr-86-Ile, in the gyrA subunit of DNA gyrase in Cjejuni. A subset of 59 isolates was tested by molecular methods and all of the 25 phenotypically resistant isolates possessed this substitution. None of the human isolates had been treated with ciprofloxacin before their laboratory isolation.

Factors associated with lack of awareness of HIV infection before diagnosis of AIDS.

OBJECTIVE: To identify characteristics of people likely to be unaware of their HIV infection before diagnosis of AIDS defining disease. DESIGN: Survey of continuing surveillance of voluntarily reported AIDS cases. SUBJECTS: 4127 adults with AIDS diagnosed during 1989-92 and reported to the Public Health Laboratory Service AIDS Centre. SETTING: England and Wales. MAIN OUTCOME MEASURE: Lack of prolonged awareness of infection before diagnosis of AIDS, defined as an interval of nine months or less between first positive test result and diagnosis of AIDS. RESULTS: Of 3556 adults with known dates of first positive HIV test result and AIDS diagnosis, 1742 (49%) had been unaware of their infection for up to nine months before AIDS was diagnosed. Lack of awareness was independently and positively associated with infection through heterosexual contact (odds ratio 4.46, 95% confidence interval 3.15 to 6.33), AIDS reported outside the Thames regions (1.64, 1.38 to 1.96), and being non-white (1.99, 1.51 to 2.61). Women were less likely to be unaware than men (0.50, 0.33 to 0.76), and people diagnosed in 1992 were least likely to be unaware (0.48, 0.39 to 0.60). Those aged 25-49 years at diagnosis were less likely to be unaware than those aged 15-24 years and those aged 50 and over. CONCLUSIONS: People with certain characteristics are more likely than others to be unaware of their HIV infection before AIDS is diagnosed and are therefore less likely to receive prophylaxis. Methods for educating this heterogeneous group need to be investigated.

Study of infectious intestinal disease in England: rates in the community, presenting to general practice, and reported to national surveillance. The Infectious Intestinal Disease Study Executive.

OBJECTIVE: To establish the incidence and aetiology of infectious intestinal disease in the community and presenting to general practitioners. Comparison with incidence and aetiology of cases reaching national laboratory based surveillance. DESIGN: Population based community cohort incidence study, general practice based incidence studies, and case linkage to national laboratory surveillance. SETTING: 70 general practices throughout England. PARTICIPANTS: 459 975 patients served by the practices. Community surveillance of 9776 randomly selected patients. MAIN OUTCOME MEASURES: Incidence of infectious intestinal disease in community and reported to general practice. RESULTS: 781 cases were identified in the community cohort, giving an incidence of 19.4/100 person years (95% confidence interval 18.1 to 20.8). 8770 cases presented to general practice (3.3/100 person years (2.94 to 3.75)). One case was reported to national surveillance for every 1.4 laboratory identifications, 6.2 stools sent for laboratory investigation, 23 cases presenting to general practice, and 136 community cases. The ratio of cases in the community to cases reaching national surveillance was lower for bacterial pathogens (salmonella 3.2:1, campylobacter 7.6:1) than for viruses (rotavirus 35:1, small round structured viruses 1562:1). There were many cases for which no organism was identified. CONCLUSIONS: Infectious intestinal disease occurs in 1 in 5 people each year, of whom 1 in 6 presents to a general practitioner. The proportion of cases not recorded by national laboratory surveillance is large and varies widely by microorganism. Ways of supplementing the national laboratory surveillance system for infectious intestinal diseases should be considered.

International epidemiological and microbiological study of outbreak of Salmonella agona infection from a ready to eat savoury snack--I: England and Wales and the United States.

OBJECTIVES: To identify the source of an international outbreak of food poisoning due to Salmonella agona phage type 15 and to measure how long the underlying cause persisted. DESIGN: Case-control study of 16 primary household cases and 32 controls of similar age and dietary habit. Packets of the implicated foodstuff manufactured on a range of days were examined for salmonella. All isolates of the epidemic phage type were further characterised by pulsed field gel electrophoresis. RESULTS: 27 cases were identified, of which 26 were in children. The case-control study showed a strong association between infection with S agona phage type 15 and consumption of a peanut flavoured ready to eat kosher savoury snack imported from Israel. S agona phage type 15 was isolated from samples of this snack. The combined food sampling results from the United Kingdom, Canada, the United States, and Israel showed that contaminated snacks were manufactured on at least seven separate dates during a four month period between October 1994 and February 1995. Voluntary recalls of the product successfully interrupted transmission. CONCLUSIONS: Rapid international exchanges of information led to the identification of the source of a major outbreak of S agona in Israel and of associated cases in North America. The outbreak showed the value of the Salm-Net surveillance system and its links outside Europe, both for increasing case ascertainment and for improving the information on the duration of the fault at the manufacturing plant.