Initiatives to improve childhood immunisation uptake: a randomised controlled trial.
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Child Health Services↗
Biomedical subjects
M R Evans
Publications and source records attributed to M R Evans.
Food safety and national food-safety agencies.
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Food Contamination↗
Refined tuberculosis contact tracing in a low incidence area.
Our aim was to evaluate the efficacy of a revised tuberculosis (TB) contact tracing procedure in South Glamorgan whereby routine annual radiological surveillance was abandoned and contacts were either discharged or referred to chest clinic following their initial screening. We reviewed and evaluated data from the TB contact tracing clinic, the Public Health Service Mycobacterium Reference Unit, Cardiff and the Consultant in Communicable Diseases Control, South Glamorgan Health Authority and compared these results with those of our previous study. One hundred and three index cases and 732 contacts were identified. Seven hundred and seven contacts, 526 close and 181 casual, were screened, of whom 102 casuals should not have been. One hundred and sixty-one contacts were given BCG vaccination. Fifty-four contacts were referred to the chest clinic. Seven cases of TB were detected, all in young, unvaccinated, close contacts of pulmonary disease. Twenty-one contacts were given chemoprophylaxis, 20 of whom were close contacts of pulmonary TB and one of extrapulmonary disease. Five contacts who were screened and initially discharged developed TB later: in two the protocol had not been followed and three presented with extrapulmonary TB. Compared with the results of the previous protocol fewer contacts were unnecessarily screened and referrals to the chest clinic increased, as did the number given chemoprophylaxis. The case finding rate is similar to that found prior to the revision of the protocol. The yield from tracing casual contacts continues to be nil. It is very low in contacts of extrapulmonary disease. When the protocol was followed no case of pulmonary TB was missed. The revised protocol seems to be as effective as the previous, more complex protocol. In our area, one of low incidence of TB, screening of casual contacts and of contacts of extrapulmonary TB is not cost-effective. We will concentrate even more on screening close contacts of pulmonary TB.
Adolescent↗
A campylobacter outbreak associated with stir-fried food.
An outbreak of gastrointestinal illness affecting 12 of 29 customers of a 'Hawaiian' theme restaurant specializing in stir-fried food occurred in Cardiff, Wales in February 1997. Campylobacter jejuni serotype HS50 phage type 49 (PT49) was isolated from 5 cases. A total of 47 isolates of C. jejuni HS50 PT49 were identified from Wales during 1997, of which 11 were isolated in late February or early March and from the Cardiff area. In the outbreak, illness was associated with eating stir-fried chicken pieces (relative risk 4.81, 95% confidence interval (CI) 0.76-30.44, P=0.03) and a dose-response relationship between risk of illness and amount of chicken consumed was observed (chi2-test for linear trend 3.96, P=0.047). Undercooking of chicken was probably due to a combination of inadequate cooking time and use of large chicken pieces. This is the first time that stir-fried food has been associated with a campylobacter outbreak. The incident also illustrates the value of routine campylobacter subtyping in supporting outbreak investigation.
Campylobacter Infections↗
Management of tuberculosis in Wales: 1986-92.
OBJECTIVES: To describe the epidemiology of childhood tuberculosis in Wales and to assess the standard of management of patients with tuberculosis. DESIGN: Retrospective study of data retrieved from case notes and review of radiographs of all identified patients. SUBJECTS: Forty eight cases of tuberculosis and 10 of tuberculosis chemoprophylaxis in children under 15 years of age, in Wales, between January 1986 and December 1992. MAIN OUTCOME MEASURES: Management of childhood tuberculosis in Wales compared with the published recommendations of the Joint Tuberculosis Committee of the British Thoracic Society. RESULTS: Documentation was poor in most of the 48 cases of tuberculosis and only 31 (65%) were formally notified. One third of patients were asymptomatic and were detected by contact tracing; only eight (17%) were culture positive. Only 20% of patients from ethnic minorities had previously been immunised with BCG. Management and chemotherapy varied widely. Few patients were managed jointly by paediatricians and chest doctors. Only 10% completed treatment with a recommended chemotherapy regimen. In 37% of patients treatment was inadequate, and in the remainder either the choice of drugs or the duration of treatment was inappropriate. No patient died, nor had any relapsed by June 1995. CONCLUSIONS: Very few cases of childhood tuberculosis were managed according to the recommendations of the British Thoracic Society.
Adolescent↗
A retrospective cohort study of risk factors for missing preschool booster immunisation.
AIM: To identify factors associated with non-uptake of preschool booster immunisation. DESIGN: Data from the computerised child health system was used to study all children born in 1990 and living in South Glamorgan, Wales, on their 5th birthday. Factors associated with preschool booster uptake were investigated using multiple logistic regression. RESULTS: Preschool booster coverage in the study cohort was 91.4%. After adjustment for other variables, uptake was associated most strongly with completed primary immunisation for diphtheria, tetanus, and polio vaccine or first dose measles, mumps, and rubella vaccine. Identifying children who miss either of these predicts 52.4% of those who miss the preschool booster. CONCLUSION: Effective targeting of children who have missed previous immunisations could improve preschool booster uptake and ensure maximum uptake of at least one dose of measles, mumps, and rubella vaccine. Achieving optimum measles vaccine coverage is vital to achieve the goal of measles elimination.
Child, Preschool↗
Use of sequential case-control studies to investigate a community Salmonella outbreak in Wales.
STUDY OBJECTIVE: To establish the source of a community outbreak of Salmonella typhimurium definitive type 124. DESIGN: Two stage case-control study. SETTING: Three districts in south east Wales. SUBJECTS: Cases of salmonella food poisoning and community controls. MAIN RESULTS: An initial case-control study identified an association between illness and eating ham (odds ratio 4.50, 95% confidence intervals 1.10, 21.8) and also found a possible association between illness and food bought from delicatessen stores (odds ratio 5.03, 95% confidence intervals 1.01, 32.3). However, only after a second stage case-control study was a single common ham producer identified as the source (odds ratio 25.0, 95% confidence intervals 2.33, 1155). CONCLUSION: Sequential case-control studies are an important and underused tool in the investigation of community outbreaks.
Adolescent↗
Travel brochures need to carry better health advice.
Most people travelling abroad on holiday from the United Kingdom consult a travel brochure and book with a travel agent. Travel brochures are therefore potentially an important source of travel health advice. We assessed the quantity and quality of health advice of 143 travel brochures for 1994/5 winter and 1995 summer seasons available from a high street travel agent. Only 11% carried health information in a prominent location, 64% put health information at the end (often in small print), and 25% contained no health information at all. Much advice was superficial, and only a minority mentioned safe drinking water (24%), safe food (22%), or safe sex (3%). Better health advice more prominently displayed is needed in travel brochures. Public health practitioners should collaborate with travel companies and travel agents to improve the quality and quantity of health information provided to travellers.
Communicable Disease Control↗
Uptake of measles containing vaccines in the measles, mumps, and rubella second dose catch-up programme in Wales.
A two dose schedule for measles, mumps, and rubella (MMR) vaccination was introduced in England and Wales on 1 October 1996 in order to prevent the accumulation of susceptible individuals and thus prevent future epidemics. A routine second dose of MMR vaccine is now offered with the diphtheria, tetanus and polio (DTPol) preschool booster. In addition a second dose of MMR is being offered to all children born since 1 January 1990 without documented histories of two doses of measles containing vaccine in a catch up programme due to end in March 1998. Progress in the catch up programme in Wales was assessed by examining uptake of all possible combinations of measles containing vaccines in four birth cohorts by 1 May 1997. Of 126,550 children born between January 1990 and March 1993 (aged 4 years, 1 month to 7 years, 3 months) and living in Wales on 1 May 1997, 63,855 (50.5%) had received two doses of measles containing vaccine and 120,668 (95.4%) had received at least one dose, but 5882 children (4.6%) had no record of having received any measles containing vaccine. Uptake of the preschool DTPol booster in the same cohort was 87.2%. Uptake of two measles containing vaccines varied between health authority (range: 35.4-58.3%) and between birth cohorts (range: 40.0-81.8%). Few (18.4%) previously unimmunised children had attended for the MMR catch-up dose. Successful elimination of measles may depend on targeting this group in order to improve coverage. Although this analysis was carried out during the catch-up programme, these data suggest that the programme may not reach the children who most need to be immunised.
Child↗
A large outbreak of Q fever in the West Midlands: windborne spread into a metropolitan area?
The largest outbreak of the zoonotic disease Q fever recorded in the United Kingdom (UK) occurred in Birmingham in 1989. One hundred and forty-seven cases were identified, 125 of whom were males, and 130 of whom were between 16 and 64 years of age. Fewer cases of Asian ethnic origin were observed than expected (p < 0.01), and more smokers (p < 0.005). A case control study (26 cases and 52 matched controls) produced no evidence that direct contact with animals or animal products had caused the outbreak. The epidemic curve suggested a point source exposure in the week beginning 10 April. The home addresses of cases were clustered in a rectangle 11 miles (18.3 km) north/south by 4 miles (6.7 km) east/ west, and attack rates became lower towards the north. Directly south of this area were farms engaged in outdoor lambing and calving, a potent source of coxiella spores. A retrospective computerised analysis showed that the geographical distribution of cases was associated with a source in this area (p < 0.00001). On 11 April, unusual southerly gales of up to 78 mph (130 km/h) were recorded. The probable cause of the outbreak was windborne spread of coxiella spores from farmland to the conurbation.
Adolescent↗
Adverse events associated with mefloquine. Patients may start to take cheaper over the counter regimens.
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Antimalarials↗
Monitoring influenza immunisation uptake in nursing homes.
People who live in nursing homes are at particular risk of influenza and its complications. Immunisation can reduce the incidence, duration, and severity of influenza and prevent outbreaks in institutions, but there is no established system to monitor vaccine uptake. In the late summer of 1995, all 31 nursing homes in South Glamorgan were sent an immunisation register and matrons were asked to record the immunisation histories of their residents. Thirty homes responded; vaccine uptake among their residents averaged 77%. Most residents were immunised by mid-November, in good time for the anticipated influenza season. The method we used to monitor immunisation uptake was simple and efficient, yielding almost complete enumeration of the study population, and could be adapted for use elsewhere to monitor vaccine coverage in this high risk group each year.
Aged↗
Ozone and childhood wheezy episodes. Needs testing as an a priori hypothesis.
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Child↗
Cryptosporidiosis outbreak associated with an educational farm holiday.
In April 1995 an outbreak of cryptosporidiosis occurred among 43 schoolchildren and four staff after a week's holiday at a rural farm. A retrospective cohort study found illness to be 3.8 times more likely in those who handled calves and 1.5 times more likely in those who habitually bit their nails or sucked their thumbs. Cryptosporidium oocysts were detected in faecal specimens from six of the 29 pupils and one of the four staff who were ill. Infection occurred in children despite supervised handwashing. The infection hazards of farm visits need more publicity, and further study on the risks of cryptosporidiosis transmission in the farm environment is required to guide preventive measures.
Adult↗
Alveolar macrophage activation in HIV infection.
Alveolar macrophage function is critical to the pulmonary immune response to infection. It is not known whether alveolar macrophages from HIV-infected individuals function normally in vivo. We have measured neopterin concentration, a marker of macrophage activation, in induced sputum, serum and saliva samples from control and HIV-infected subjects, with and without intercurrent lower respiratory tract infection (LRTI). Induced sputum (IS) neopterin concentration was increased in non-AIDS HIV positive (NAHIV) subjects (mean 3.5 nmol/l) compared to controls (mean 0.6 nmol/l) (P = 0.01) and it was further increased in patients with AIDS (mean = 27.7 nmol/l) (P = 0.002). When only those without LRTI were considered, the difference between the NAHIV and AIDS groups remained significant (P = 0.007). Those with LRTI had a significantly higher IS neopterin concentration (mean 53.2 nmol/l) than those without LRTI (mean 3.9 nmol/l) (P = 0.001). Contamination of the sample with saliva was not significant as there was no correlation between IS and saliva neopterin concentration (R = 0.1) and the concentration of neopterin was not related to the proportion of alveolar macrophages in IS samples (R = 0.2). Similarly there was no correlation between IS and serum neopterin concentration (R = 0.1). These results indicate that alveolar macrophages from NAHIV and AIDS subjects were in an activated state in vivo and that LRTI caused further stimulation (reflected in higher IS neopterin concentrations).
Adult↗
A hospital outbreak of salmonella food poisoning due to inadequate deep-fat frying.
In an outbreak of plasmid-free Salmonella enteritidis phage type 4 (PT4) food poisoning at a hospital for mentally handicapped people in July 1990, 101 residents and 8 staff were affected and a cohort study implicated beef rissoles cooked by deep-fat frying as the vehicle of infection (relative risk 2.92, 95% confidence interval 1.73-4.93, P << 0.001). Replication of the cooking process demonstrated that the rissoles achieved core temperatures of only 48-60 degrees C despite external temperatures of 91-95 degrees C and an oil temperature of 142-154 degrees C. No residual food was available for microbiological testing but plasmid-containing S. enteritidis PT 4 was isolated in shell eggs from the hospital kitchen.
Adult↗
Consecutive salmonella outbreaks traced to the same bakery.
Two consecutive community outbreaks of Salmonella enteritidis phage type 4 (PT4) traced to the same bakery occurred in Cardiff, Wales during August-September 1992. In the first outbreak, illness was associated with eating custard slices (odds ratio 23.8, 95% confidence interval 6.5-94.4, P < 0.0001), and in the second, with eating fresh cream cakes (odds ratio 15.8, 95% confidence interval 1.6-374, P = 0.004). Environmental investigations implicated cross-contamination during preparation of the cold-custard mix as the cause of the first outbreak, and inadequate cleaning and disinfection of nozzles used for piping cream in the second outbreak. S. enteritidis PT4 was isolated from fresh cream sponge cake retained by a case and from two fresh cream cakes and four environmental swabs obtained at the bakery. This incident illustrates the hazard of widespread environmental contamination with salmonella and the need for thorough environmental cleansing for any premises implicated in an outbreak of food poisoning.
Adolescent↗
A milk-borne campylobacter outbreak following an educational farm visit.
After a nursery school trip to a dairy farm, 20 (53%) of 38 children and 3 (23%) of 13 adult helpers developed gastrointestinal infection. Campylobacter jejuni was isolated from 15 primary cases and from 3 of 9 secondary household cases. A cohort study of the school party found illness to be associated with drinking raw milk (relative risk 5.4, 95% confidence interval 1.4-20.4, P = 0.001). There was a significant dose response relationship between amount of raw milk consumed and risk of illness (chi 2-test for linear trend 12.1, P = 0.0005) but not with incubation period, severity of symptoms or duration of illness. All 18 human campylobacter isolates were C. jejuni resistotype 02 and either biotype I (number 16) or biotype II (number 2). Campylobacter was also isolated from samples of dairy cattle and bird faeces obtained at the farm but these were of different resisto/biotypes. Educational farm visits have become increasingly popular in recent years and this outbreak illustrates the hazard of exposure to raw milk in this setting.
Adult↗