Blood borne virus testing of 2250 patients in an unusual, repeated dental patient notification exercise: challenges faced and lessons learnt.

OBJECTIVES: The objectives of this study were to ascertain the risk created for patients of two dental practices where infection control was found to be inadequate, and if the risk was deemed to be significant, initiate an investigation involving notification and blood borne virus (BBV) testing to establish if any patient-to-patient BBV transmissions had occurred as a result of these infection control breaches. STUDY DESIGN: A case study. METHODS: A public health investigation and patient notification. Investigations involved practice inspections, staff interviews and examination of invoices. The practices were not fully cooperative during the investigation and provided misleading information regarding the allegations. This led to two patient notification exercises, as more serious breaches were uncovered following the first notification exercise. Risk assessments of BBV transmission likelihood were undertaken and informed the nature of the advice given to patients. RESULTS: The health board wrote to 5100 patients informing them of the situation. BBV testing was offered in the second notification exercise and 2250 patients opted to be tested for HIV, hepatitis B and hepatitis C. There were no new cases of HIV or hepatitis B but less than five patients were found to be positive for hepatitis C. None of these cases were proven to have contracted their infection as a result of the dental infection control lapses. CONCLUSIONS: This incident was unusual in that the practice was found to be repeatedly and knowingly putting patients at risk, and attempts were made to cover up breaches during the investigation. In future, health boards would benefit from a risk assessment tool to aid decision making regarding notification exercises, and whether testing is indicated where risk to patients is low. This would help ensure that notification exercises do more good than harm.

Limited impact of awareness-raising campaigns on hepatitis C testing practices among general practitioners.

The global hepatitis strategy calls for increased effort to diagnose those infected, with a target of 90% diagnosed by 2030. Scotland's Action Plan on Hepatitis C included awareness-raising campaigns, undertaken during 2008-2011, to promote testing by general practitioners. We examined hepatitis C virus (HCV) testing practice among general practitioners before and following these campaigns. Scottish general practitioners were surveyed, using Dillman's method, in 2007 and 2013; response rates were 69% and 60%, respectively. Most respondents offer testing when presented with a risk history (86% in 2007, 88% in 2013) but only one-fifth actively sought out risk factors (19% in 2007, 21% in 2013). Testing was reportedly always/almost always/usually offered to people who inject drugs (84% in 2007, 87% in 2013). Significant improvements in the offer of testing were reported in patients with abnormal LFTs (41% in 2007, 65% in 2013, P<.001) and who had received medical/dental treatment in high prevalence countries (14% in 2007, 24% in 2013, P=.001). In 2013, 25% of respondents had undertaken HCV-related continued professional development. This group was significantly more likely to actively seek out risk factors (P=.009) but only significantly more likely to offer a test to patients who had received medical/dental treatment in high prevalence countries (P=.001). Our findings suggest that government-led awareness raising campaigns have limited impact on general practitioners' testing practices. If the majority of the HCV-infected population are to be diagnosed, practitioner-based or physician-centred interventions should be considered alongside educational initiatives targeted at professionals.

Managing the risk of viral haemorrhagic fever transmission in a non-high-level intensive care unit: experiences from a case of Crimean-Congo haemorrhagic fever in Scotland.

BACKGROUND: A case of Crimean-Congo haemorrhagic fever (CCHF) was imported into Scotland in 2012. AIM: To discuss the public health response to the case, and the control measures taken to prevent secondary transmission. METHODS: Following confirmation of the case, an incident management team (IMT) was convened to ensure that: (i) all individuals exposed to the case and/or their blood/body fluids were identified, assessed and followed-up appropriately; and (ii) the appropriate disinfection or disposal of equipment was used to manage the patient, laboratory specimens obtained from the case, and their environment. FINDINGS: Contact tracing identified 19 individuals who required follow-up and monitoring. No secondary cases occurred. Identification of laboratory specimens obtained prior to diagnosis proved challenging. The majority were traced, temporarily stored in sharps boxes and subsequently incinerated. A small number could not be recovered and consequently would have been disposed of through the routine hospital waste system. Biochemical and haematology analysers were decontaminated according to the manufacturers' instructions and liquid waste was discharged to drains. The patient's mattress, sphygmomanometer and pulse oximeter probe were incinerated. Decontamination of the clinical environment was undertaken following guidance from national experts. CONCLUSIONS: While national guidance for the management of cases of viral haemorrhagic fever (VHF) available at the time in the UK informed the approach taken to manage the risk of secondary transmission, a number of practical issues relating to infection control aspects of managing a patient with VHF in a non-high-level isolation unit environment were encountered. Close liaison between national experts and the IMT was key to the expedient response to the emerging issues.

Spinal Cord Ischemia Secondary to Hypovolemic Shock

A 44-year-old male presented with symptoms of spinal cord compression secondary to metastatic prostate cancer. An urgent decompression at the cervical-thoracic region was performed, and there were no complications intraoperatively. Three hours postoperatively, the patient developed acute bilateral lower-limb paralysis (motor grade 0). Clinically, he was in class 3 hypovolemic shock. An urgent magnetic resonance imaging (MRI) was performed, showing no epidural hematoma. He was managed aggressively with medical therapy to improve his spinal cord perfusion. The patient improved significantly, and after one week, he was able to regain most of his motor functions. Although not commonly reported, spinal cord ischemia post-surgery should be recognized early, especially in the presence of hypovolemic shock. MRI should be performed to exclude other potential causes of compression. Spinal cord ischemia needs to be managed aggressively with medical treatment to improve spinal cord perfusion. The prognosis depends on the severity of deficits, and is usually favorable.

Epidemiology and molecular investigation of hepatitis C infection following holiday haemodialysis.

BACKGROUND: Hepatitis C virus infection (HCV) is not infrequent among haemodialysis patients. Most published reports suggest that patient-to-patient spread, either directly or indirectly, is the most common mode of transmission in renal units. AIM: To investigate the source of an outbreak, and the route of transmission, of acute HCV infection in two Scottish patients occurring within eight weeks of receiving haemodialysis in the same unit while on holiday in Majorca. METHODS: This was an international epidemiological and molecular investigation of HCV infection among a cohort of haemodialysis patients from nine countries. FINDINGS: No further HCV-positive infections were observed among residents and holidaymakers receiving haemodialysis at the unit in Majorca. Molecular investigations confirmed that a Spanish healthcare worker (HCW) was the source of infection for the two Scottish patients. The investigators were unable to determine the route of transmission. CONCLUSIONS: This outbreak is the first reported case of HCW-to-patient transmission of HCV in a renal unit, and the third reported case of transmission involving a HCW who had not performed invasive procedures. The issue of whether renal units are an exceptional case with regards to the risk of transmission associated with non-invasive procedures should be considered, in conjunction with the need to improve surveillance of blood-borne virus transmissions in renal units in the UK and abroad.

Changes in the chemistry of acidified Adirondack streams from the early 1980s to 2008.

Lakes in the Adirondack region of New York have partially recovered in response to declining deposition, but information on stream recovery is limited. Here we report results of Adirondack stream monitoring from the early 1980s to 2008. Despite a 50% reduction in atmospheric deposition of sulfur, overall increases in pH of only 0.28 and ANC of 13 µeq L(-1) were observed in 12 streams over 23 years, although greater changes did occur in streams with lower initial ANC, as expected. In the North Tributary of Buck Creek with high dissolved organic carbon (DOC) concentrations, SO(4)(2-) concentrations decreased from 1999 to 2008 at a rate of 2.0 µmol L(-1) y(-1), whereas in the neighboring South Tributary with low DOC concentrations, the decrease was only 0.73 µmol L(-1) y(-1). Ca(2+) leaching decreased in the North Tributary due to the SO(4)(2-) decrease, but this was partially offset by an increase in Ca(2+) leaching from increased DOC concentrations.

Vaccination induced immunity to the hepatitis B virus among high-risk groups in Glasgow 1993-2001: evaluating the effectiveness of the United Kingdom's selective immunisation policy.

BACKGROUND AND AIMS: The United Kingdom has adopted a selective approach to the control of hepatitis B (HBV), vaccinating those at increased risk of infection through lifestyle, occupation or other factors such as close contact with a case or carrier. This paper sought to assess the effectiveness of the targeted HBV vaccination programme, by determining the level of immunity and exposure to HBV infection among three high risk groups (injecting drug users (IDUs), men who have sex with men (MSM) and heterosexuals attending genitourinary medicine clinics) at three time points between 1993-2001 in Glasgow, Scotland. METHODS: Residual sera from i) IDUs having a named HIV test and ii) MSM and heterosexual men and women attending GUM clinics and undergoing routine syphilis serology testing, were tested anonymously for HBV infection. RESULTS: The overall prevalence of HBV infection remained at a low level in all three risk groups. IDUs continue to be the group at greatest risk of infection. DISCUSSION: Despite the implementation of new initiatives targeting high-risk groups, vaccination levels remain low in the populations studied.

Hepatitis C virus infection among injecting drug users in Scotland: a review of prevalence and incidence data and the methods used to generate them.

It is estimated that of 50,000 persons in Scotland (1% of the county's population), infected with the hepatitis C virus (HCV), around 90% injected drugs. This paper reviews data on the prevalence and incidence of HCV, and the methods used to generate such information, among injecting drug users (IDUs), in Scotland. The prevalence estimate for HCV among IDUs in Scotland as a whole (44% in 2000), is comparable with those observed in many European countries. Incidence rates ranged from 11.9 to 28.4/100 person-years. The data have shaped policy to prevent infection among IDUs and have informed predictions of the number of HCV-infected IDUs who will likely progress to, and require treatment and care for, severe HCV-related liver disease. Although harm reduction interventions, in particular needle and syringe exchanges and methadone maintenance therapy, reduced the transmission of HCV among IDUs during the early to mid-1990s, incidence in many parts of the country remains high. The prevention of HCV among IDUs continues to be one of Scotland's major public health challenges.

Hepatitis C virus infection in Scotland: epidemiological review and public health challenges.

INTRODUCTION: In 2004, Scotland's Health Minister stated that the hepatitis C virus (HCV) "is one of the most serious and significant public health risks of our generation". METHODS: To appreciate the prevention and care challenges posed by HCV in Scotland, we reviewed all country-specific data on i) the prevalence of infection among different populations, ii) the numbers infected with HCV, and iii) the current and future HCV disease burden. RESULTS: An estimated 1% of Scotland's population has HCV; 85-90% of those infected were injecting drug users (IDUs). Reductions in HCV prevalence among young IDUs during the early 1990s suggest that the incidence of HCV had decreased; since then, the absence of further reductions highlight that existing prevention measures are insufficient. Two-thirds of the estimated 37,500 chronically HCV-infected individuals in Scotland remain undiagnosed and two-thirds of this group are former IDUs. An estimated 9,000 former IDUs were living with either moderate or severe HCV disease in 2004; if the current uptake of antiviral therapy continues, this number was estimated to double by 2016. Approximately 1,200 HCV-infected IDUs had developed liver failure by 2004; this figure was predicted to increase to 3,200 by 2020. CONCLUSIONS: Scotland faces three principal public health challenges: i) the prevention of HCV among current IDUs, ii) the diagnosis of HCV-infected persons, particularly those most in need of therapy to prevent severe HCV disease, and iii) the current and future provision of adequate resources to ensure that the movement of patients through the diagnostic and clinical care pathway is optimal.

Patient notification exercise following a dentist's admission of the periodic use of unsterilized equipment.

During 2001, Greater Glasgow National Health Service (NHS) Board undertook a patient notification exercise in a Glasgow dental practice following the admission, by the dentist, of the use of unsterilized dental equipment on patients. Four thousand and eighty-nine exposed patients were identified; of these, 1696 contacted the NHS helpline and 1005 were counselled and screened for hepatitis C virus (HCV), hepatitis B virus (HBV) and human immunodeficiency virus. One patient showed evidence of previous HBV infection and 13 had antibodies to HCV. Molecular investigation of the HCV isolates indicated no significant associations. The investigation found no evidence of patient-to-patient transmission of HCV among patients attending the practice of a dentist who admitted periodically using unsterilized equipment.

Hepatitis C virus among self declared non-injecting sexual partners of injecting drug users.

While much is known about hepatitis C virus (HCV) among injecting drug users (IDUs), there is scant information about the risk of HCV infection to non-injecting sexual partners of injecting drug users; it is possible that such individuals may have a greater risk of acquiring HCV than any other group barring injecting drug users. This study examines the prevalence of HCV among a population of non-injecting sexual partners of injecting drug users. Unlinked anonymous testing for anti-HCV of residual sera stored following the named HIV testing of specimens originally from persons who had indicated to their attending clinicians that they were non-injecting sexual partners of injecting drug users. The prevalence of anti-HCV among the sexual partners was 4.1% (25/611) overall, 6.4% (13/202) among heterosexual male and 3.0% (12/397) among the heterosexual female partners. None of the homosexual/bisexual partners were HCV antibody positive (0/12). Although we cannot be sure how non-injecting partners of injecting drug users acquire their HCV infection, having a relationship with someone who injects drugs may place an individual at appreciable risk of being infected; such individuals should consider being tested for HCV.

The feasibility and acceptability of collecting oral fluid from healthy children for anti-HCV testing.

This pilot study investigated the feasibility of surveying, anonymously, HCV infection among healthy children using an oral fluid specimen. Seventy seven per cent of children provided their assent, or where appropriate, consent to participate; 2.8% were anti-HCV positive. Oral fluid collection is acceptable to children and more extensive studies are indicated.

Establishment of a database of diagnosed HCV-infected persons in Scotland.

To provide a comprehensive understanding of the epidemiology of hepatitis C virus (HCV) infection in Scotland, a database of all persons known to have been infected with HCV in Scotland was established. Non-identifying data, held on the computers and requests forms in Scotland's principal and confirmatory HCV testing laboratories, were entered onto a National Database at the Scottish Centre for Infection and Environmental Health. As at December 2001, records from 13,519 persons in Scotland known to have been infected with HCV had been entered on to the database (one in 378 of Scotland's population). Of the 13,519, 69% were male and 90% of the 9,092 for whom risk factor information was available had injected drugs; 37% were from Greater Glasgow. Fifty-six per cent of the 13,519 were diagnosed between 1998 and 2001; 1,727 (23%) of the new diagnoses from 1998 to 2001 were aged under 25 years. The data provide an insight into the epidemiology of HCV infection in Scotland. They support other data, which indicate that the current major risk factor for HCV in the country is injecting drug use.

Cross infection control measures and the treatment of patients at risk of Creutzfeldt Jakob disease in UK general dental practice.

AIMS: To determine the suitability of key infection control measures currently employed in UK dental practice for delivery of dental care to patients at risk of prion diseases. SUBJECTS: Five hundred dental surgeons currently registered with the General Dental Council of the UK. DATA COLLECTION: Structured postal questionnaire. ANALYSIS: Frequencies, cross-tabulations and chi-squared analysis. RESULTS: The valid response rate to the questionnaire was 69%. 33% of practices had no policy on general disinfection and sterilisation procedures. Only 10 of the 327 responding practices (3%) possessed a vacuum autoclave. 49% of dentists reported using the BDA medical history form but less than 25% asked the specific questions recommended by the BDA to identify patients at risk of iatrogenic or familial CJD. However, 63% of practitioners would refer such patients, if identified, to a secondary care facility. Of the 107 practitioners who were prepared to provide dental treatment, 75 (70%) would do so using routine infection control procedures. CONCLUSIONS: Most of the dental practices surveyed were not actively seeking to identify patients at risk of prion diseases. In many cases, recommended procedures for providing safe dental care for such patients were not in place.

A method to detect the incidence of hepatitis C infection among injecting drug users in Glasgow 1993-98.

OBJECTIVES: To determine the incidence of HCV infection in a selected population of Glasgow injectors during the mid-1990s, using a retrospective cohort design. METHODS: Unlinked anonymous anti-HCV testing was undertaken on serum residues collected from injecting drug users (IDUs) having two or more voluntary named HIV tests between 1993 and 1998. RESULTS: Seventy-seven percent (164/212) of IDUs had detectable HCV antibody in their first specimen collected. Of the 44 IDUs who were initially HCV seronegative and had a subsequent specimen available for testing, 11 (25%) seroconverted, giving an estimated incidence of 28.4 per 100 person-years (95% CI 15.7-51.2); the incidence of infection was greatest amongst older males. CONCLUSION: This study provides evidence of continuing transmission of HCV among Glasgow IDUs during an era of interventions to prevent the spread of bloodborne infections in this population and demonstrates the application of the unlinked anonymous testing approach to gauge incidence rather than prevalence of infection.

Antibiotic prescribing by general dental practitioners in the Greater Glasgow Health Board, Scotland.

OBJECTIVE: To investigate antibiotic prescribing patterns by general dental practitioners (GDPs) in the Greater Glasgow Health Board Area, Scotland. STUDY DESIGN: A 10% sample of prescriptions were selected at random from 35,545 prescriptions written by GDPs over a 6-month period. MAIN OUTCOME MEASURES: Absolute and relative frequencies were used to describe the different classes of antibiotics used and the variations in prescribing practice. RESULTS: GDPs prescribed a wide range of antibiotics. Seventeen different antibiotics were prescribed with amoxycillin, metronidazole and penicillin V accounting for almost 90% of the prescriptions. In general the antibiotics were prescribed at the British National Formulary (BNF) recommended doses. There were, however, wide variations in the frequencies and durations of the prescriptions for all antibiotics. CONCLUSIONS: The present study provides evidence of sub-optimal prescribing of antibiotics by dentists in Scotland, with considerable variation from the recommended frequencies and doses.

Hepatitis C virus and oral lichen planus/lichenoid reactions: lack of evidence for an association.

Some studies have suggested an association between the mucocutaneous disorder lichen planus and chronic infection with hepatitis C virus. Most of these studies have been based purely on serological markers. The present study sought to detect hepatitis C virus RNA in both peripheral blood and in biopsy material collected from oral mucosal lesions. Twenty-seven patients were studied, six with classical lichen planus and 21 with oral lichenoid reactions. The diagnoses were confirmed by histopathological examination. Reverse transcription PCR was employed to detect hepatitis C virus RNA in the blood specimens. The same method was used to detect hepatitis C virus RNA in lesional tissue, following RNA extraction from sections of the biopsies. The virus was not detected in any of the paired blood and tissue specimens examined. It is concluded that hepatitis C virus is not commonly associated with oral lichen planus or lichenoid reactions in Scotland.

The effect of saliva specimen collection, handling and storage protocols on hepatitis C virus (HCV) RNA detection by PCR.

OBJECTIVES: Commercial assays can now be adapted to detect salivary anti-hepatitis C virus (HCV) antibodies, increasing the potential of saliva as a non-invasive diagnostic specimen suited to surveillance and epidemiological studies. However, current diagnostic algorithms involve confirmation of HCV infection by RT-PCR. Manipulation and storage conditions of serum can influence the stability of viral RNA. This study examined whether varying specimen collection, handling and storage protocols also affected subsequent HCV RNA detection by RT-PCR applied to saliva specimens. METHODS: Whole unstimulated saliva, together with saliva samples collected in two commercially available devices (Salivette and Omnisal) were obtained from 50 HCV seropositive intravenous drug users. The specimens were subjected to a number of handling and storage conditions, including heat treatment and prolonged storage, then examined for HCV RNA by RT-PCR using primers derived from the 5' non-coding region (5'NCR). RESULTS: HCV RNA was detected in saliva samples from 25 (50%) of the patients. No single collection device or handling procedure identified all the subjects with HCV RNA positive saliva though whole saliva yielded the greatest number of positive results. CONCLUSIONS: Collection and processing of saliva specimens for RT-PCR analysis is complex. At present, detection of salivary HCV RNA by PCR is not sufficiently sensitive for use as a diagnostic tool in epidemiological studies.

Barriers to the use of a diagnostic oral microbiology laboratory by general dental practitioners.

OBJECTIVE: To identify barriers on the use of diagnostic microbiology facilities in general dental practice. DESIGN: A cross-sectional survey using a postal questionnaire. SETTING: Primary/secondary care interface between the diagnostic oral microbiology laboratory, University of Glasgow Dental Hospital and School, Glasgow and dental practitioners within the surrounding health boards, 1998. SUBJECTS: All GDPs (797) within Argyll and Clyde, Ayrshire and Arran, Lanarkshire and Greater Glasgow Health Boards. MAIN OUTCOME MEASURES: The responses were expressed as both absolute and relative frequencies. RESULTS: Responses were received from 430 (55%). The most frequent reason for failure to use the service was lack of information, with more than half of the respondents claiming to be unaware of the facility. Lack of request forms and sampling equipment were also viewed as barriers to using the service. CONCLUSIONS: The laboratory is failing to successfully communicate its role in addressing the growing burden of antibiotic resistance in the community and must be more proactive in encouraging appropriate use and increasing accessibility of the service to GDPs.