Clinical impact and public health challenges of a PVL-MRSA bacteraemia outbreak amongst people who inject drugs in South Yorkshire, UK.

Background: Panton-Valentine leukocidin (PVL) Staphylococcus aureus (SA) is an emergent public health concern. PVL toxin has been mostly associated with methicillin-sensitive S. aureus (MSSA)-related skin and soft tissue infections occurring in high-risk groups such as people who inject drugs (PWID). The emergence of PVL methicillin-resistant S. aureus (MRSA) infection is causing severe and life-threatening disease in PWID. Clinical cases: We present an outbreak of eight PVL-MRSA bacteraemia cases at a UK teaching hospital between 2018 and 2022. An additional four patients developed bacteraemia with PVL-negative MRSA of the same multilocus sequence type (MLST). All patients were PWID and aged 33-51 years old. Four patients developed MRSA bacterial endocarditis. Three patients died. These cases represent the initial cases detected at Doncaster and Bassetlaw Teaching Hospitals of what is an ongoing and developing outbreak. Management: An outbreak investigation has been undertaken in association with the UK Health Security Agency. Epidemiological factors have been explored, including via direct contact at a local sheltered accommodation and the possibility of a contaminated drug supply. Whole-genome sequencing confirmed that all isolates were closely related and of the same MLST (sequence type 5). A community substance misuse group disseminated health education on the prevention of PVL-MRSA. Preventing infection in PWID presents a major challenge due to the impact of addiction on engagement with services and the significant barriers faced by our patients in observing infection prevention measures. Conclusion: PVL-MRSA is of major public health concern and outbreak investigation and mapping out local epidemiological patterns plays a vital role in preventing further spread throughout the community. Additionally, this work enables targeted and early treatment in patients in high-risk categories for disease. These cases of PVL-MRSA infection in PWID highlights the transmissibility, pathogenic potential and severe clinical disease spectrum within this population. Further work is required to tackle transmission and infection from this pathogenic strain.

Insomnia and the late nineteenth-century insomniac: the case of Albert Kimball.

This article explores the emergence, in late nineteenth-century Britain and the USA, of the 'insomniac' as a distinct pathological and social archetype. Sleeplessness has of course been a human problem for millennia, but only since the late-Victorian period has there been a specific diagnostic name for the individual who suffers chronically from insufficient sleep. The introductory section of the article, which notes the current panic about sleep problems, offers a brief sketch of the history of sleeplessness, acknowledging the transhistorical nature of this condition but also pointing to the appearance, during the period of the Enlightenment, of the term 'insomnia' itself. The second section makes more specific historical claims about the rise of insomnia in the accelerating conditions of everyday life in urban society at the end of the nineteenth century. It traces the rise of the insomniac as such, especially in the context of medical debates about 'neurasthenia', as someone whose identity is constitutively defined by their inability to sleep. The third section, tightening the focus of the article, goes on to reconstruct the biography of one exemplary late nineteenth-century insomniac, the American dentist Albert Kimball, in order to illustrate the claim that insomnia was one of the pre-eminent symptoms of a certain crisis in industrial and metropolitan modernity as this social condition was lived by individuals at the fin de siècle.