Long term follow up after meningitis in infancy: behaviour of teenagers.

AIMS: To determine the effects of meningitis in infancy on subsequent teenage behaviour. METHODS: A national postal survey of parents and teachers using an established standard behavioural questionnaire. Subjects were 739 of the surviving children from the national incidence study of infantile meningitis in England and Wales carried out between 1985 and 1987, together with a group of 606 matched controls that had been recruited when the index cases were 5 years old. RESULTS: 46% of parents of children who had had meningitis with complications in infancy, compared with 21% of parents of control children rated their children as having behavioural problems. When the children were rated by their teachers, 37% and 23% respectively, were scored as having behavioural problems. There was no significant difference in behaviour between the 103 children who had had meningitis during the first month of life and the 634 who had had postneonatal meningitis. Eight of the index children had been excluded from school compared to none from the control group. CONCLUSIONS: The behaviour of teenage children who had meningitis in infancy is worse than that of control children who did not have infantile meningitis when rated by parents and teachers.

Meningitis in infancy in England and Wales: follow up at age 5 years.

OBJECTIVE: To describe important sequelae occurring among a cohort of children aged 5 years who had had meningitis during the first year of life and who had been identified by a prospective national study of meningitis in infancy in England and Wales between 1985 and 1987. DESIGN: Follow up questionnaires asking about the children's health and development were sent to general practitioners and parents of the children and to parents of matched controls. The organism that caused the infection and age at infection were also recorded. SETTING: England and Wales. PARTICIPANTS: General practitioners and parents of children who had had meningitis before the age of 1 year and of matched controls. MAIN OUTCOME MEASURES: The prevalence of health and developmental problems and overall disability among children who had had meningitis compared with controls. RESULTS: Altogether, 1584 of 1717 (92.2%) children who had had meningitis and 1391 of 1485 (93.6%) controls were successfully followed up. Among children who survived to age 5 years 247 of 1584 (15.6%) had a disability; there was a 10-fold increase in the risk of severe or moderate disability at 5 years of age among children who had had meningitis (relative risk 10.3, 95% confidence interval 6.7 to 16.0, P<0.001). There was considerable variation in the rates of severe or moderate disability in children infected with different organisms. CONCLUSION: The long term consequences of having meningitis during the first year of life are significant: 32 of 1717 (1.8%) children died within five years. Not only did almost a fifth of children with meningitis have a permanent, severe or moderately severe disability, but subtle deficits were also more prevalent.

Neonatal meningitis in England and Wales: 10 years on.

OBJECTIVES: To determine the incidence of neonatal meningitis in England and Wales. DESIGN: A national postal survey using the British Paediatric Surveillance Unit (BPSU) card scheme supplemented by information from other sources. SETTING: England and Wales 1996-1997. SUBJECTS: A total of 274 babies less than 28 days of age who were treated for meningitis. RESULTS: The incidence of neonatal meningitis in England and Wales has not changed since our previous study in 1985-1987. However, the acute phase mortality has fallen from 19.8% in 1985-1987 to 6.6% in this study. Group B streptococci (42%) and Escherichia coli (16%) remain the most common infecting microorganisms. Eight of 69 (12%) babies with group B streptococci and 4/26 (15%) with E coli died. Antibiotic regimens based on the third generation cephalosporins, notably cefotaxime, were most commonly used (84%). The BPSU scheme identified 72% of cases during the study period. Most cases of viral meningitis were not reported through the BPSU. Less than a third of samples from aseptic meningitis were examined for viruses; 56% of these were positive. CONCLUSIONS: Although the incidence of neonatal meningitis remains unchanged, mortality from this infection has fallen significantly. If this improvement is maintained as reflected in the level of sequelae at 5 years of age, then the fear surrounding meningitis during the neonatal period will have been dramatically reduced.

Guidelines for the microbiological quality of some ready-to-eat foods sampled at the point of sale. PHLS Advisory Committee for Food and Dairy Products.

These guidelines for the microbiological quality of ready-to-eat foods represent a revision and expansion of guidelines first published by the PHLS in September 1992 and revised in March 1996. The latest guidelines incorporate many of the constructive comments received from food examiners and other microbiologists within and outside the PHLS and from environmental health officers throughout the United Kingdom. This document reviews the changes and the reasons they were made and sets out the new guidelines. It also clarifies the role of food examiners in interpreting the microbiological results of formal samples.

A survey of the microbiological quality of private water supplies in England.

Results from statutory testing of private water supplies in nine Public Health Laboratories in England were compiled, and the effects of supply class, source, treatment and location on water quality were examined. A total of 6551 samples from 2911 supplies was examined, over a 2-year period, of which 1342 (21%) samples, and 949 (33%) supplies on at least one occasion, failed current regulations for Escherichia coli. Total coliforms, including E. coli, were detected in 1751 (27%) samples from 1215 (42%) supplies. The percentage of samples positive for E. coli was highest in summer and autumn, and lowest in winter. Samples taken from larger supplies and from boreholes were less frequently contaminated than those from other sources. Chlorination, filtration or UV light treatment improved the bacteriological quality of supplies, but still resulted in a low level of compliance with the regulations. The public health implications of the study are discussed.

Use of antibiotics in penetrating craniocerebral injuries. "Infection in Neurosurgery" Working Party of British Society for Antimicrobial Chemotherapy.

The Working Party was instituted to investigate the rationale of prophylactic and therapeutic antibiotic use in penetrating craniocerebral injuries (PCCI), and to make recommendations for current practice. A systematic review of papers on civilian and military PCCI over the past 25 and 50 years, respectively, was done via electronic databases and secondary sources, and data were evaluated. Guidelines on the removal of indriven bone or metal fragments only if further neural damage can be avoided were supported. However, no publications were identified where the data on infection or its treatment and prevention were complete or satisfactorily derived, and no controlled trials have been published. All studies were retrospective or anecdotal. Working Party recommendations are based on the data available and the professional experience and knowledge of the members. Broad-spectrum antibiotic prophylaxis is recommended for both military and civilian PCCI, Including those due to sports or recreational injuries.

The microbiological quality of ice used to cool drinks and ready-to-eat food from retail and catering premises in the United Kingdom.

A survey of 4,346 samples of ice from retail and catering premises examined 3,528 samples (81%) used to cool drinks and 144 samples (3%) from food displays. For 674 samples (15%), the origin was not recorded. Most samples of ice used to cool drinks or ready-to-eat food on displays did not contain coliforms, Escherichia coli, or enterococci. Of the ice used to cool drinks, 9% contained coliforms, 1% E. coli, and 1% enterococci in excess of 10(2) CFU/100 ml, and 11% had an aerobic plate count at 37 degrees C in excess of 10(3) CFU/ml. The microbiological quality of ice used to cool drinks was poorer when melt water was present in the ice buckets. Ice used in food displays was more contaminated than ice used to cool drinks, with 23% containing coliforms, 5% E. coli, and 8% enterococci at 10(2) CFU/100 ml or more. Twenty-nine percent of samples had an aerobic plate count greater than 10(3) CFU/ml. Ice that had been used to cool shellfish was of a lower microbiological quality than samples used to cool ready-to-eat fish, salads, or dairy produce. Samples of ice produced in commercial production facilities were of higher microbiological quality than samples of ice that were not. The microbiological quality of ice was dependent on the type of use, the type of premises, and the type and place of production. Although most ice samples were of acceptable microbiological quality, evidence from this study suggests that the microbiological quality of ice prepared and used at certain premises in the UK is a cause for concern.

The microbiological quality of cooked rice from restaurants and take-away premises in the United Kingdom.

The microbiological quality of 4,162 samples of cooked rice from restaurants and take-away premises in the United Kingdom was examined, including ready-to-eat rice purchased at point-of-sale and rice that was stored precooked for reheating on demand. The majority of point-of-sale cooked rice samples (1,855 of 1,972; 94%) were of acceptable microbiological quality, but 15 (1%) samples were of unacceptable quality (Bacillus spp. and B. cereus, > or = 10(5) CFU/g; Escherichia coli, > or = 10(4) CFU/g), indicating a potential risk to health. The prevalence of Bacillus spp., B. cereus, and E. coli was significantly greater in precooked stored rice than in point-of-sale cooked rice (P < 0.005 to 0.0005). Bacillus spp. (> or = 10(4) CFU/g), B. cereus (> or = 10(4) CFU/g), and E. coli (> or = 10(2) CFU/g) were present in 7%, 2%, and 9% of precooked stored samples, respectively, compared to 2%, 0.5%, and 1%, respectively in point-of-sale samples. Although final heating at the point of sale reduces the levels of microorganisms present in rice it will not inactivate the B. cereus emetic toxin if present. Rice from Indian premises was of poorer microbiological quality than that from Chinese and other premises. Although most point-of-sale cooked rice samples (94%) were of an acceptable microbiological quality, evidence from this study indicates that the microbiological quality of cooked rice sold from certain outlets in the UK is of concern.

Health risks associated with unpasteurized goats' and ewes' milk on retail sale in England and Wales. A PHLS Dairy Products Working Group Study.

A pilot study to determine the microbiological quality of unpasteurized milk from goats and ewes sampled from farm shops, health food shops, and other retail premises found that 47%, (47/100) of goats' and 50% (13/26) of ewes' milk samples failed the standards prescribed by the Dairy Products (Hygiene) Regulations 1995. In addition, Staphylococcus aureus, haemolytic streptococci or enterococci, were present in excess of 10(2) c.f.u./ml in 9 (7 %) 2 (2 %) and 19 (15%) samples, respectively. Salmonella, campylobacter, verocytotoxin-producing Escherichia coli O157:H7 and Listeria monocytogenes were not detected in the samples. At the time of purchase approximately half of the milk samples (58 %) were frozen, the rest were liquid. Farm outlets sold predominantly liquid milk, other retail premises sold a frozen product. The microbiological quality of goats' and ewes' milk, whether frozen or liquid, was not significantly different. Milk sold from farm shops was of lower quality than that from health food shops and other retail premises. In this pilot study most producers (92 %) supplied, and most retailers (76 %) sold unpasteurized goats' and ewes' milk that contained unacceptable levels of indicator organisms. The study was carried out during the winter when goats' milk production is reduced. The results indicate the need for a full representative study of unpasteurized goats' and ewes' milk on retail sale throughout the year.

Microbiological quality of retail imported unprepared whole lettuces: a PHLS Food Working Group Study. Public Health Laboratory Service.

A study of imported unprepared whole lettuces sampled from supermarkets, greengrocers, shops, and market stalls found that all were of acceptable microbiological quality. Twenty-seven out of 151 (18%) imported lettuce samples had Enterobacteriaceae levels of 10(4) CFU/g or more. However, these bacteria that constitute part of the natural microflora of unprepared vegetables may also be derived from the soil and/or by poor handling. The pathogens, Salmonella spp., Shigella spp., Campylobacter spp., Escherichia coli O157:H7, Vibrio cholerae, Listeria monocytogenes, and also Escherichia coli, an indicator of fecal contamination, were not detected in any imported lettuces, indicating that hygiene, harvesting, and production practices were good. Imported lettuces with Enterobacteriaceae levels of 10(4) CFU/g or more varied with type of retail premises and the temperature at which the lettuces were displayed. Samples from greengrocers, shops, and market stalls were more likely to contain Enterobacteriaceae at levels in excess of 10(4) CFU/g than those from supermarkets.

Microbiological investigation of halal butchery products and butchers' premises.

Halal butchers' premises were investigated as they had not been represented in a recent study of butchery products and butchers' premises conducted by the Local Authorities Coordinating Body on Food and Trading Standards and the PHLS. This study examined 183 raw prepared meats and 212 environmental samples from 105 halal butcher premises. Only raw meats were prepared on 97 of the premises visited; and the types of meat prepared on the remaining eight premises was not specified. Four halal butchers sold cooked meats prepared elsewhere. Salmonella spp. and Campylobacter spp. were detected in 12 (7%) and 52 (28%) of the 183 raw meat products, respectively. Five raw prepared meats (3%) contained both salmonella and campylobacter. Vero cytotoxin producing Escherichia coli O157 was isolated from a raw meat product that also contained campylobacter. No cooked meat products were available for collection. The physical separation of raw and unwrapped cooked meat products in premises that prepared raw and sold cooked meats was not recorded. Apron cloths were the most heavily contaminated environmental samples examined; hygiene indicator microorganisms indicated an increased risk of cross contamination. Managers in 85 premises had received no food hygiene training and 88 premises had no hazard analysis system in place. Improvements are needed to reduce the risk of cross contamination.

The contamination of pâté with Listeria monocytogenes--results from the 1994 European Community-Coordinated Food Control Program for England and Wales.

The Listeria monocytogenes contamination of 3,065 pâté products sampled at the point of retail sale in England and Wales was examined. Ninety-seven percent of samples were free of contamination with L. monocytogenes, 2.0% (60) had levels of less than 200 CFU/g, and 0.6% (18) had levels of 200 CFU/g or more. Fish and seafood pâté were significantly more commonly contaminated by L. monocytogenes than other pâté types (chi 2 test, P = 0.001). Pâté obtained from small retail shops was significantly more likely to be contaminated at levels of > or = 200 CFU/g (chi 2 tests, P < 0.0005) than that obtained from supermarkets. L. monocytogenes was isolated significantly more often (chi 2 tests, P < 0.00002) from packs of pâté that were open at the time of collection (3.8%) than those that were sold prepacked (1.2%). There were also significantly more samples (chi 2 test, P = 0.0009) where L. monocytogenes was recovered at higher levels (> or = 200 CFU/g) in opened, as compared to prepacked, samples. There was a significant difference in the rates and levels of contamination of opened samples between shops and supermarkets (chi 2 tests, P < 0.0025). Evidence from this study shows that most of the pâté sold in England and Wales is not contaminated with L. monocytogenes, and we suggest that the main areas of concern are cross-contamination and the length of display of pâté sold from opened packs.

The microbiological examination of butchery products and butchers' premises in the United Kingdom.

In a study of 1400 manufacturing butchers' premises, 2330 raw prepared meats, 2192 cooked meats and 4635 environmental samples were examined. Verocytotoxin-producing Escherichia coli O157:H7 (O157 VTEC) was isolated from five of 1400 (0.4%) premises. Three raw meat products contained O157 VTEC, and two raw meat preparation areas and two items of equipment used exclusively for cooked meats were contaminated with O157 VTEC. Salmonella spp. and Campylobacter spp. were detected in 84 of 2330 (4%) and 15 of 2330 (0.6%) raw meat products, respectively. Of the cooked meats examined, seven of 2192 (0.3%) samples were of unacceptable microbiological quality and a further 352 (16%) were of unsatisfactory quality. Of the unacceptable samples, two contained Salmonella spp. (Salm. typhimurium DT193, Salm. typhimurium PT104), three contained Staphylococcus aureus in excess of 10(4) cfu g-1, and two contained E. coli in excess of 10(4) cfu g-1. Neither Campylobacter spp. nor O157 VTEC were detected in cooked meats. In the majority of premises, raw and unwrapped cooked meat products were physically separated in displays (94%) and refrigerators (81%), and dedicated equipment/utensils (69-89%) were used for raw meat and unwrapped cooked meat products and other ready-to-eat foods. In approximately half (48%), there were separate serving counters and in 13%, separate staff for raw and cooked meats. Most managers (75%) had received some food hygiene training. However, in 29% of premises, one or more members of staff handled raw and then cooked or ready-to-eat foods without washing their hands, and in 11%, one or more staff members handled raw and cooked meats directly with bare hands. A documented hazard analysis and critical control point (HACCP) system was present in 17% of premises and in a further 31%, an undocumented HACCP system was in place. The low incidence of food-borne pathogens in cooked meat products and in the environmental areas examined, together with a high level of physical separation of raw and cooked meats, indicate that most manufacturing butchers' premises have appropriate physical control measures in place. However, HACCP and hygienic practice are areas that require improvement to reduce the risk of cross-contamination with food-borne pathogens from raw to cooked meats.

Surveillance of outbreaks of waterborne infectious disease: categorizing levels of evidence.

Public health surveillance requires the monitoring of waterborne disease, but sensitive and specific detection of relevant incidents is difficult. The Communicable Disease Surveillance Centre receives information from various sources about clusters of cases of illness in England and Wales. The reporter may suspect that water consumption or recreational water exposure is the route of infection, or subsequent investigation may raise the hypothesis that water is associated with illness. It is difficult to prove beyond reasonable doubt that such a hypothesis is correct. Water samples from the time of exposure are seldom available, some organisms are difficult to detect and almost everyone has some exposure to water. Therefore, we have developed a method of categorizing the degree of evidence used to implicate water. The categories take into account the epidemiology, microbiology and water quality information. Thus outbreaks are classified as being associated with water either 'strongly', 'probably' or 'possibly'. This system allows a broad database for monitoring possible effects of water and is not confined to the few outbreaks which have been intensively investigated or have positive environmental microbiology. Thus, for reported incidents, the sensitivity of classifying it as water associated should be high but this may be at the expense of specificity, especially with the 'possible' association.

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.

Food poisoning: notifications, laboratory reports, and outbreaks--where do the statistics come from and what do they mean?

Three main routine sources of data on food poisoning are used in England and Wales. The first is the statutory notification system, in which clinicians notify the 'proper officer' of their local authorities of cases or suspected cases of food poisoning, and the data are collated by the Office for National Statistics. Second and third are the reporting schemes for laboratory confirmed infections and general outbreaks of infectious intestinal disease, both of which are coordinated by the PHLS Communicable Disease Surveillance Centre. This review discusses the strengths and weaknesses of the three sources.