Mapping a nosocomial outbreak of measles, coinciding with a period of sustained transmission in South London in 2018.

A measles outbreak in London is described, involving 34 cases across two hospitals and a local community across two countries. After a single introduction to hospital, spread propagated via unvaccinated retail shop workers to healthcare staff, highlighting the importance of expanding occupational health policies to non-clinical hospital staff. Further spread into an under-vaccinated Traveller community is a reminder that measles can spread in the absence of herd immunity. Subsequently endemic measles transmission has been re-established in the UK.

A descriptive analysis of an outbreak of measles and a multilevel mixed-effects analysis of factors associated with case isolation in healthcare settings, London (February-June 2016).

OBJECTIVES: We described the epidemiology and healthcare exposures during a measles outbreak in London and identified factors associated with isolation on arrival to healthcare premises. STUDY DESIGN: We conducted a cohort study including all confirmed measles cases in London residents from February 1, 2016, to June 30, 2016, and semistructured interviews with two infection prevention and control teams (IPCTs). METHODS: We described the outbreak and conducted a multilevel mixed-effects analysis to assess the relationship between sociodemographic and clinical factors and isolation on arrival to healthcare premises. We summarised the interviews. RESULTS: There were 182 cases, mostly aged 17-35 years (46%; 84). Excluding cases younger than one year, 76% (92/120) were unvaccinated, including two healthcare workers. The majority presented with rash (97%; 174), and 42% (70/166) required hospitalisation. Of the recorded cases, 93% of cases (164/178) had visited a healthcare setting during their infectious period (median number of visits = 2). In 33% (59/178) of the visits, the case was isolated on arrival; when not isolated, four healthcare exposures resulted in further transmission. Presenting to the hospital as opposed to a general practitioner (GP) was associated with higher odds of isolation (odds ratio = 2.23, 95% confidence interval = 1.1-4.4) when adjusted for age, gender and presenting with a cough. The IPCT identified measles training using standardised risk assessments by triage nurses in accident and emergency and intelligence regarding measles activity in the community as positive measures to prevent healthcare exposures. CONCLUSIONS: We recommend opportunistic immunisation of unvaccinated young adults by GPs and that occupational health departments ensure their staff are protected against measles. Raising measles awareness in healthcare settings via training or regular sharing of current measles surveillance activity from public health to the IPCT and GP may improve triage and isolation of cases on arrival to healthcare premises.

Severe group A streptococcal infections in mothers and their newborns in London and the South East, 2010-2016: assessment of risk and audit of public health management.

OBJECTIVE: We describe cases of invasive group A Streptococcus (iGAS) in mothers or neonates and assess management according to national guidelines, which recommend administering antibiotics to both mother and neonate if either develops iGAS infection within 28 days of birth and investigation of clusters in maternity units. DESIGN: Cross-sectional retrospective study. SETTING AND POPULATION: Notified confirmed iGAS cases in either mothers or neonates with onset within 28 days of birth in London and the South East of England between 2010 and 2016 METHOD: Review of public health records of notified cases. MAIN OUTCOME MEASURES: Incidence and onset time of iGAS in postpartum mothers and babies, proportion given prophylaxis, maternity unit clusters within 6 months. RESULTS: We identified 134 maternal and 21 neonatal confirmed iGAS infections. The incidence (in 100 000 person years) of iGAS in women within 28 days postpartum was 109 (95% CI 90-127) compared with 1.3 in other females aged 15-44. For neonates the incidence was 1.5 (95% CI 9-23). The median onset time was 2 days postpartum [interquartile range (IQR) 0-5 days] for mothers and 12 days (IQR 7-15 days) for neonates. All eligible mothers and most (109, 89%) eligible neonates received chemoprophylaxis. Of 20 clusters (59 cases of GAS and iGAS) in maternity units, two clusters involved possible transmission. However, in 6 of 15 clusters, GAS isolates were not saved for comparison even after relevant guidance was issued. CONCLUSIONS: iGAS infection remains a potential postpartum risk. Prophylaxis among neonates and storage of isolates from maternity cases can be improved. TWEETABLE ABSTRACT: Are public health guidelines being followed in the management of mothers and their newborns to reduce the risk of iGAS infection?

Midwives' influenza vaccine uptake and their views on vaccination of pregnant women.

BACKGROUND: Pregnant women in England are now offered seasonal influenza vaccine. Midwives could be influential in promoting this, but specific information on their views on the policy and their role in its implementation is lacking. METHODS: London midwives were surveyed for their views on the new policy and their own vaccine uptake, using an anonymously self-completed semi-structured online survey via a convenience sampling approach. RESULTS: In total, 266 midwives responded. Sixty-nine percent agreed with the policy of vaccinating all pregnant women. Seventy-six percent agreed that midwives should routinely advise pregnant women on vaccination, but only 25% felt adequately prepared for this role. Just 28% wished to be vaccinators, due to concerns about increased workload and inadequate training. Forty-three percent received seasonal influenza vaccine themselves. Major reasons for non-uptake were doubts about vaccine necessity (34%), safety (25%) and effectiveness (10%); and poor arrangements for vaccination (11%). Suggested strategies for improving their own uptake included better access to evidence of effectiveness (67%) and improved work-based vaccination (45%). CONCLUSIONS: London midwives support influenza vaccination of pregnant women, but are more willing to give advice on, than to administer, the vaccine. Midwives' own influenza vaccine uptake could improve with more information and easier access to vaccination in their workplace.

Vaccinating health care workers during an influenza pandemic.

BACKGROUND: In response to the 2009 H1N1 influenza pandemic, health care workers (HCWs) were offered immunization with H1N1 vaccine in addition to seasonal flu vaccine. Previously, low rates of influenza vaccine uptake in HCWs have been attributed to concerns about vaccine clinical effectiveness, side effects and access difficulties. AIMS: To explore H1N1 influenza vaccination of HCWs in London during 2009-10 and examine reasons for vaccine refusal. METHODS: An online questionnaire survey of doctors and nurses working in two primary care trust (PCT) areas and one acute trust area was carried out in London. RESULTS: Only 59% of the 221 respondents had been immunized with H1N1 influenza vaccine and 43% with seasonal influenza vaccine. The commonest reasons for remaining unvaccinated were 'side effects', 'swine flu not severe' and 'concerns about clinical effectiveness of the vaccine'. Respondents who had been vaccinated that season gave positive feedback on their experience. CONCLUSIONS: While uptake among HCWs was greater for the pandemic vaccine than is usually seen with seasonal influenza vaccine, this survey suggests that in this area of London during the 2009 pandemic, HCWs refused H1N1 vaccination due to concerns about clinical effectiveness, side effects and perceptions that H1N1 infection was not generally severe. We found no evidence to suggest poor access was a barrier to H1N1 vaccination of HCWs. If good access is maintained, the key barrier to improving seasonal flu vaccine uptake lies with informing the personal risk assessment made by the HCW.

Lead: ongoing public and occupational health issues in vulnerable populations: a case study.

BACKGROUND: Lead has been recognized increasingly as a public health risk, although with the introduction of wide-ranging occupational and public health measures, levels of blood lead in the general population of the UK and other developed nations have been in decline in recent years. Nonetheless, cases of lead poisoning still occur. METHODS: We report on a large cluster of exposed lead workers and their families, including several children. The focus of the occupational and public health investigations was to identify the different groups at risk and the pathways by which potential exposures were taking place. RESULTS: Lead in the workplace was found to account for the raised blood lead levels amongst the workers with exposure occurring as a result of insufficient demarcation between 'clean' and 'dirty' areas, and from contamination of personal belongings with lead. Furthermore, there was evidence of para-occupational exposure of family members. CONCLUSIONS: The successful control of lead in this case required multidisciplinary working. Efforts included extensive workplace controls, along with the education and care of workers and their families, though complicated by lack of familiarity with the UK health service amongst the affected groups, language barriers, underlying low levels of literacy and high mobility.

Investigations and control measures following a non-travel-associated case of toxigenic Cornyebacterium diphtheriae, London, United Kingdom, December 2009-January 2010.

This article reports the investigation and control measures undertaken following the identification of a toxigenic strain of Cornyebacterium diphtheriae var gravis, designated ribotype Minsk , in a partially vaccinated teenager born in the United Kingdom with no recent history of travel or known contact with a case of diphtheria or a carrier. This case highlights the need for ongoing work to improve vaccine uptake rates to ensure children receive all scheduled vaccinations.

Evaluation of risk factors for the acquisition of bloodstream infections with extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella species in the intensive care unit; antibiotic management and clinical outcome.

Controlled studies that address risk factors for, and clinical outcomes after, infection with extended-spectrum beta-lactamase (ESBL)-producing organisms are scant, particularly in the intensive care unit (ICU). Our objectives were to elucidate risk factors for the acquisition of ESBL-producing organisms in ICU; and to compare mortality in patients with ESBL- and non-ESBL bloodstream infections (BSIs) after controlling for disease severity and timeliness of appropriate antibiotic therapy. A retrospective cohort study was undertaken in the ICU from March 2004 to May 2006. Cases included all adult ICU patients with a BSI due to an ESBL-producing E. coli or Klebsiella spp. (N=16); controls (N=39) comprised ICU patients with a BSI caused by a non-ESBL-producing E. coli or Klebsiella spp. Disease severity was measured using APACHE (Acute Physiological Assessment and Chronic Health Evaluation) and SOFA (Sequential Organ Failure Assessment) scores. Outcomes were recorded as discharge or death due to all causes. Although no statistically significant associations were demonstrated between individual risk factors and the acquisition of an ESBL-producing organism, appropriate therapy was delayed in cases (OR: 9.17; 95% CI: 2.00-42.20; P=0.0005) and survival estimates demonstrated a significantly increased early (<25 days after infection) mortality (OR for death 3.93; 95% CI: 1.05-14.63; P=0.03). Mortality in ICU, when adjusted for disease severity and appropriate antimicrobial therapy, though significant needs to be treated with caution due to the small number of cases (N=16 in 2 years). We believe that a high index of suspicion, early appropriate therapy and strict adherence to infection control are indicated in all patients at risk in ICU.

Regional brain metabolite abnormalities in inherited prion disease and asymptomatic gene carriers demonstrated in vivo by quantitative proton magnetic resonance spectroscopy.

INTRODUCTION: Inherited prion diseases are caused by mutations in the gene which codes for prion protein (PrP), leading to proliferation of abnormal PrP isomers in the brain and neurodegeneration; they include Gerstmann-Sträussler-Scheinker disease (GSS), fatal familial insomnia (FFI) and familial Creutzfeldt-Jakob disease (fCJD). METHODS: We studied two patients with symptomatic inherited prion disease (P102L) and two pre-symptomatic P102L gene carriers using quantitative magnetic resonance spectroscopy (MRS). Short echo time spectra were acquired from the thalamus, caudate region and frontal white matter, metabolite levels and ratios were measured and z-scores calculated for individual patients relative to age-matched normal controls. MRS data were compared with structural magnetic resonance imaging. RESULTS: One fCJD case had generalised atrophy and showed increased levels of myo-inositol (MI) in the thalamus (z=3.7). The other had decreased levels of N-acetylaspartate (z=4) and diffuse signal abnormality in the frontal white matter. Both asymptomatic gene carriers had normal imaging, but increased frontal white matter MI (z=4.3, 4.1), and one also had increased MI in the caudate (z=5.3). CONCLUSION: Isolated MI abnormalities in asymptomatic gene carriers are a novel finding and may reflect early glial proliferation, prior to significant neuronal damage. MRS provides potential non-invasive surrogate markers of early disease and progression in inherited prion disease.

Short TE quantitative proton magnetic resonance spectroscopy in variant Creutzfeldt-Jakob disease.

Variant Creutzfeldt-Jakob disease (vCJD) is a fatal neurodegenerative disorder. Clinical diagnosis is difficult in the early stages as the disease often presents with non-specific psychiatric and neurological symptoms. To investigate the diagnostic potential of quantitative short TE in vivo MRS, and the nature and anatomical distribution of biochemical abnormalities in vCJD, localised single-voxel spectra (TE/TR 30 ms/2,000 ms) were acquired from three brain regions: thalami, caudate nuclei and frontal white matter. Metabolite concentrations and ratios from three patients with definite or probable vCJD were compared with eight normal age-matched controls. Abnormal signal on T2-weighted MRI was apparent in the pulvinar region in all vCJD patients; this region also showed greatly increased myo-inositol [MI] (mean 2.5-fold, P=0.01) and decreased N-acetyl-aspartate (NAA; mean 2-fold, P=0.01). Two patients also showed increased [MI] (z=17, 11; one with decreased NAA, z=-12) in normal-appearing caudate nuclei. The magnitude of metabolite abnormalities in the thalami in moderately advanced vCJD suggests a potential role in earlier diagnosis. Short TE protocols allow the measurement of MI, which adds discriminant power to the MRS examination.

The neuropsychology of variant CJD: a comparative study with inherited and sporadic forms of prion disease.

OBJECTIVE: To assess cognitive function in variant Creutzfeldt-Jakob disease (vCJD). We describe the neuropsychological profiles of 10 cases and compare these data with cross sectional data obtained from patients with histologically confirmed sporadic CJD and cases with inherited prion disease with confirmed mutations in the prion protein gene. METHODS: Patients referred to the Specialist Cognitive Disorders Clinic at the National Hospital for Neurology and Neurosurgery and the National Prion Clinic at St Mary's Hospital, London for further investigation of suspected CJD were recruited into the study. The neuropsychological test battery evaluated general intelligence, visual and verbal memory, nominal skills, literacy skills, visual perception and visuospatial functions, and visuospatial and executive function. RESULTS: The results indicate that moderate to severe cognitive decline is a characteristic feature of vCJD. Specifically, verbal and visual memory impairments and executive dysfunction were pervasive in all disease groups. Nominal skills were impaired in variant and sporadic CJD, significantly so when compared with the inherited prion disease group. Perceptual impairment was less frequent in the vCJD group than in the sporadic and inherited groups. CONCLUSION: This study confirms the occurrence of generalised cognitive decline in patients with vCJD. Although decline in cognitive function ultimately affects all domains, there is a suggestion that some components of visual perception may be spared in vCJD. The results also suggest that nominal function may be preserved in some cases with inherited prion disease.

Early cognitive decline in Creutzfeldt-Jakob disease associated with human growth hormone treatment.

BACKGROUND: Most cases of Creutzfeldt-Jakob disease (CJD) in recipients of human cadaveric growth hormone present with a cerebellar syndrome. Dementia is thought to occur late and as a minor feature of the illness. However, neuropsychology data published on these cases are largely qualitative and anecdotal. The first published case does include a neuropsychological assessment seven months after the onset of a cerebellar syndrome, showing evidence of intellectual decline. Subsequent reports hint that cognitive problems may be present in the initial stages of the illness. OBJECTIVE: To assess early cognition in Creutzfeldt-Jakob disease in recipients of pituitary derived human growth hormone. METHODS: Detailed neuropsychology assessment is reported at referral (mean 4.5 months from the onset of symptoms; range 4 to 6 months) in five patients with histologically proven human growth hormone derived CJD. RESULTS: All cases presented with a cerebellar syndrome and only one had noticed mild memory problems. On formal testing, however, four had demonstrable mild intellectual decline, as measured on the WAIS-R. One case showed selective visual memory impairment and frontal executive dysfunction. CONCLUSIONS: These findings suggest that, although not the presenting feature, mild cognitive decline may be evident in the early stages of CJD associated with human cadaveric growth hormone treatment.

Dementia with Lewy bodies studied with positron emission tomography.

OBJECTIVE: To report a case initially fulfilling the clinical criteria for probable Alzheimer disease, although later clinical features suggested dementia with Lewy bodies. Oxygen 15-labeled positron emission tomograms revealed a pattern of hypometabolism characteristic of Alzheimer disease. At post mortem, there was no evidence of the pathological features of Alzheimer disease, but diffuse cortical Lewy bodies were seen in the pigmented brainstem nuclei and cerebral cortex. DESIGN: A case report. SETTING: Tertiary referral center. PATIENT: A 65-year-old white man presented with a 3-year history of memory loss and language difficulties. RESULTS: Oxygen 15-labeled positron emission tomograms revealed hypometabolism in the frontal, temporal, and parietal lobes, more severe on the left than right. Metabolism in the left caudate was just outside the 95% reference range. Occipital metabolism was normal. CONCLUSIONS: Positron emission tomographic studies have been reported to show occipital hypometabolism in dementia with Lewy bodies, in addition to the characteristic posterior bitemporal biparietal pattern of Alzheimer disease. We suggest that although this finding may favor a diagnosis of dementia with Lewy bodies, it is not necessary for diagnosis.

Sporadic fatal insomnia: a case study.

A 58-year-old man died after a 27-month illness characterized by insomnia, confirmed by polysomnography. He was homozygous for methionine at codon 129 of the prion gene but had no mutation in the prion gene. Neuropathology showed thalamic and olivary atrophy and no spongiform changes. Paraffin-embedded tissue blotting demonstrated abnormal prion protein in the brain. This is the first case of the sporadic form of fatal familial insomnia with demonstration of the disorder by polysomnography.

Bilateral thalamic pain secondary to bilateral thalamic infarcts relieved by a further unilateral ischaemic episode.

This study reports a patient with severe, debilitating bilateral thalamic pain caused by bilateral thalamic infarcts. The authors consider it to be a unique case as a further clinically unilateral lesion led to pain relief bilaterally.