An outbreak of serious illness and death among injecting drug users in England during 2000.

An outbreak of serious illness and death occurred in injecting drug users during 2000 in Scotland, Ireland and England. National and international collaboration was necessary for the investigation and management of this outbreak. In England and Wales active case-finding was initiated, coupled with standardised data collection and microbiological investigation of cases. Twenty-six definite or probable cases were identified in England between 1 April and 31 Aug. 2000; 17 of these occurred in the North. The overall case fatality was 50% (13/26). The principal apparent risk factor was a history of intramuscular or subcutaneous injection of heroin and the limited duration of the outbreak suggested that the problem might have been related to a particular supply of heroin. Clostridium novyi was isolated from two English cases. Taken in conjunction with contemporaneous microbiological and epidemiological results from Scottish and Irish cases, the probable aetiology for this outbreak was infection with C. novyi associated with both a particular supply of heroin and the method of preparation and injection used. A 'toolkit' was distributed in Sept. 2000 to all Consultants for Communicable Disease Control in England and Wales to assist them with the ongoing surveillance, investigation and management of this condition. Lessons learned have been used to produce guidance for the investigation and management of outbreaks of unexplained serious illness of possible infective aetiology.

Antibiotic resistant tuberculosis in the United Kingdom: 1993-1999.

BACKGROUND: The re-emergence of tuberculosis as a global health problem over the past two decades, accompanied by an increase in tuberculosis drug resistance, prompted the development of a comprehensive national surveillance system for tuberculosis drug resistance in 1993. METHODS: The UK Mycobacterial Resistance Network (Mycobnet), which includes all mycobacterial reference and regional laboratories in the UK, collects a minimum dataset on all individuals from whom an initial isolate of Mycobacterium tuberculosis complex has been isolated and submitted by source hospital laboratories. Data sought include susceptibility to first line antibiotics, demographic, geographical, and risk factor information. RESULTS: There were 25 217 reports of initial isolates of M tuberculosis complex in the UK between 1993 and 1999. All were tested for sensitivity to isoniazid, rifampicin, and ethambutol and 12 692 of the isolates were also tested for sensitivity to pyrazinamide and streptomycin. A total of 1523 (6.1%) isolates were resistant to one or more drugs, 1397 isolates (5.6%) were resistant to isoniazid with or without resistance to other drugs, and 299 (1.2%) were multidrug resistant. Although the numbers of drug resistant isolates increased over the period, the proportions remained little changed. Certain groups of people were at a higher risk of acquiring drug resistant tuberculosis including younger men, residents of London, foreign born subjects, patients with a previous history of tuberculosis and those infected with HIV. CONCLUSION: Although the proportion of drug resistant tuberculosis cases appears to be stable in the UK at present, more than one in 20 patients has drug resistant disease at diagnosis and more than one in 100 has multidrug resistant disease. Tuberculosis control measures should be strengthened to minimise the emergence of drug resistance through rapid diagnosis, rapid identification of drug resistance, supervised treatment, and maintenance of comprehensive surveillance.

Genitourinary medicine services in the United Kingdom are failing to meet current demand.

Recent increases in the incidence of sexually transmitted disease (STD) in the UK have given rise to concerns over the ability of genitourinary medicine (GUM) services to cope with increased demands. We conducted a postal survey to assess the capacity of GUM clinics to meet patient demand for both routine and emergency consultations. A questionnaire was sent to all lead GUM physicians in the UK. The response rate was 80%. In some clinics, patients had to wait for up to 28 days for routine appointments. Urgent appointment patients were seen within 24 h by only 54% of clinics and some had to wait for at least one week (5% of clinics). Prolonged waiting times were reported nationwide in addition to widely expressed concerns about the increasing workload. Additional resources should be made available to GUM services if the population's sexual health is to be improved.

Outbreak of Escherichia coli O157 infection associated with a music festival.

Seven persons who attended the Glastonbury Music Festival were infected with Vero cytotoxin-producing Escherichia coli O157 and an eighth person had serological evidence of infection. Cases were reported from different parts of England. Patients were interviewed by telephone about clinical symptoms, festival attendance, camping details, food history, water exposure, and contact with mud and animals. The interviews identified no common food source, differing use of water sources and widely dispersed camping sites. Escherichia coli O157 strains from seven persons and from a cow belonging to a herd that had previously grazed the site all belonged to phage type 2 and possessed genes for Vero cytotoxin 2. Drug resistance and DNA-based tests showed that six patients were infected with strains indistinguishable from each other and from the bovine isolate. The most likely vehicle of infection was mud contaminated with Escherichia coli O157 from infected cattle.

Clostridium difficile: an update on its epidemiology and role in hospital outbreaks in England and Wales.

Data from the surveillance system of general outbreaks of infectious intestinal disease and from laboratory reports collated by the Communicable Disease Surveillance Centre (CDSC) and requests for outbreak investigation by the PHLS Anaerobe Reference Unit were used to evaluate the current epidemiology of Clostridium difficile infection in England and Wales. Between January 1992 and December 1996, CDSC received 10,220 laboratory reports of C difficile isolation from patient's faeces and 26,873 of toxin in faeces. Over 75% of all reports were of people aged 64 years and over. The surveillance system captured a minimum data set on 694 hospital outbreaks of infectious intestinal disease. C. difficile was responsible for 109 (15%) outbreaks affecting 1625 people, of whom 1152 were found to have a C. difficile toxin producing strain. The median duration of outbreaks was 11 days. Fingerprinting by Pyrolysis Mass Spectrometry (PMS) was performed by the PHLS Anaerobe Reference Unit in 60 outbreaks, and typing by Polymerase Chain Reaction ribotyping (PCR) in 14.

An estimate of the proportion of diarrhoeal disease episodes seen by general practitioners attributable to rotavirus in children under 5 y of age in England and Wales.

Mean weekly incidence rates for a 4-week period of new episodes of infectious intestinal disease (IID) and laboratory reports of faecal isolations in children under 5 y of age presenting in general practice were used to estimate the incidence of IID due to rotavirus infection in England and Wales. Between January 1992 and December 1996, a total of 92452 new episodes of IID were seen at sentinel general practices and reported to the Royal College of General Practitioners (RCGP) Research Unit in Birmingham, UK. Of these 32% (29592) were in children under 5 y of age. During the same period the Communicable Disease Surveillance Centre (CDSC) in London, UK received 159532 reports of faecal identifications in children under 5 y of age; 69219 (43%) of these were due to rotavirus. By modelling RCGP data and laboratory reports, the proportion of episodes attributable to rotavirus infection was estimated to be 29% (95% CI: 24% to 34%). By extrapolation of RCGP data it was estimated that rotavirus accounted for 762000 of new episodes of IID nationally in children under 5 y of age between January 1992 and December 1996. Implementation of a rotavirus vaccination programme could substantially reduce the incidence of childhood diarrhoea.

Hospital admissions in children due to pneumococcal pneumonia in England.

Hospital records of 116 children under 5 years of age discharged from 11 hospitals in three regions in England with a diagnosis of lobar (pneumococcal) pneumonia were reviewed to estimate the proportion likely to be attributable to infection with Streptococcus pneumoniae. Of these, 100 (86%) had lobar/focal changes on chest X-ray consistent with pneumococcal infection, although only one (1%) had pneumococcus isolated from blood. However, a further 89 (89%) with a lobar/focal picture were considered to be likely or possibly due to pneumococcal infection on the basis of the white cell count, level of C-reactive protein, isolation of the S. pneumoniae from either sputum or nasopharingeal aspirate and failure to identify another responsible pathogen. Of 135 cases with a discharge diagnosis of bronchopneumonia or pneumonia (organism unspecified), two (1%) had S. pneumoniae isolated from blood and a further 95 (70%) had clinical or laboratory features consistent with pneumococcal infection or S. pneumoniae isolated from either sputum or nasopharyngeal aspirate. With the imminent availability of conjugate pneumococcal vaccines, there is a need for improved diagnostic methods for identifying the pathogens responsible for community-acquired pneumonia in young children.

General outbreaks of infectious intestinal disease in England and Wales: 1995 and 1996.

One thousand nine hundred and nineteen general outbreaks of infectious intestinal disease in England and Wales were reported to the PHLS Communicable Disease Surveillance Centre (CDSC) between 1 January 1995 and 31 December 1996, compared with 1073 in the previous two years. A minimum data set was received for 1568 (82%) of the 1919 outbreaks. Over 40,000 people were affected and about 2% of those who were ill were admitted to hospital. Seventy-one deaths were reported. The duration of outbreaks varied between less than one day and 202 days (median six days) according to the pathogen. Small round structured virus (SRSV) (43%) and salmonellas (15%) were the most commonly reported pathogens. In almost a quarter of the outbreaks (24%) the aetiology was unknown. Over half the outbreaks (64%) were reported to be transmitted from person to person, most of which were due to SRSV and occurred in residential homes and hospitals. Twenty-two per cent of outbreaks were described as mainly foodborne, 51% of which were due to salmonellas. The number of outbreaks reported in each region ranged from 52 in Wales to 512 in Northern and Yorkshire.

General outbreaks of infectious intestinal disease associated with milk and dairy products in England and Wales: 1992 to 1996.

Twenty general outbreaks of food poisoning in England and Wales associated with the consumption of milk and dairy products were reported to the PHLS Communicable Disease Surveillance Centre between 1992 and 1996. A total of 600 people were ill and at least 45 people were admitted to hospital but no deaths were reported. Salmonella species were responsible for 11 outbreaks, Campylobacter species for five, Vero cytotoxin producing Escherichia coli O157 (VTEC) for three, and Cryptosporidium parvum for one. Outbreaks were associated with hotels (2 outbreaks), a psychogeriatric hospital, schools (3), a Royal Air Force base, a farm visit, an outdoor festival (2), and community outbreaks associated with milk supplied direct from farms (8). Milk was implicated in 16 outbreaks; 10 of which were associated with unpasteurised milk. Two outbreaks were associated with eating contaminated ice cream, and two with eating contaminated cheese. All these outbreaks could have been prevented by pasteurisation and simple hygienic measures.

Infectious intestinal disease in elderly people.

This paper analyses routinely available data on infectious intestinal diseases occurring in people aged 65 years and over in England and Wales from 1990 to 1994. These data include annual reports of consultations with general practitioners in spotter practices collated by the Royal College of General Practitioners, notifications of food poisoning collated by the Office of Population Censuses and Surveys, hospital admissions extracted from Hospital Episode Statistics data, reports of general outbreaks and laboratory reports of faecal isolates both collated by the PHLS Communicable Disease Surveillance Centre, and death registrations held at the Office of Population Censuses and Surveys. From 1 January 1990 to 31 December 1994 a total of 8,910 episodes of infectious intestinal disease in people aged 65 years and over were seen in the 93 spotter practices that care for a population of all ages of about 700,000. This extrapolates to about 925,000 cases in elderly people in England and Wales, if consultation rates in spotter practices are representative. Twenty-seven thousand two hundred and thirty-three cases of food poisoning were notified and 46,216 faecal isolates were reported in people of the same age group. The commonest pathogens detected were campylobacter, Clostridium difficile and salmonellas. Thirteen thousand five hundred and eighty-five people aged 65 years and over were admitted to hospital with infectious intestinal disease between 1 April 1991 and 31 March 1994. The PHLS Communicable Disease Surveillance Centre learnt of 360 outbreaks in residential institutions and hospital wards for elderly people between 1 January 1992 and 31 December 1994, 52% of which were caused by small round structured viruses. Seven hundred and seventy-seven deaths attributable to infectious intestinal disease in elderly people were registered from 1990 to 1994. Infectious intestinal disease is a largely preventable group of conditions that cause substantial morbidity and mortality in elderly people. Appropriate food hygiene and infection control measures, particularly in institutions, will help to reduce the incidence of infectious intestinal disease in elderly people.

The cost of inpatient care for acute infectious intestinal disease in England from 1991 to 1994.

Routine data from Hospital Episode Statistics and the Compendium of Health Statistics were used to estimate costs incurred by hospitals for inpatient treatment of infectious intestinal disease in England from 1991 to 1994. The estimated cost for the three years was 83,139,685 pounds associated with 108,037 inpatient episodes. The annualised age specific incidence of patients admitted to hospital for infectious intestinal disease varied from 25 to 613 per 100,000 population and was highest in children under 4 years of age. The cost of inpatient treatment attributable to infectious intestinal disease is high, but it represents only a proportion of the total costs of diarrhoeal illness. More detailed studies are needed to describe the total economic impact of infectious intestinal disease.

General outbreaks of infectious intestinal disease in England and Wales 1992 to 1994.

Data from the surveillance scheme of general outbreaks of infectious intestinal disease in England and Wales, reported to the PHLS Communicable Disease Surveillance Centre (CDSC), were used to review 1280 of the 1594 outbreaks identified between 1 January 1992 and 31 December 1994 for which a minimum data set was captured. The number of outbreaks reported in each regional health authority ranged from 31 in Mersey to 221 in Yorkshire. The commonest pathogens reported were salmonellas in 32% (412) of outbreaks, small round structured virus (SRSV) in 27% (342), Clostridium perfringens in 7% (90), and Shigella sonnei in 4% (46). The main mode of transmission was described as foodborne in 50% (642), over half of which were caused by salmonellas, and person to person in 39% (496), over half of which were caused by SRSV. Most outbreaks transmitted from person to person occurred in hospitals and in residential institutions for elderly people. Outbreaks lasted from one to 217 days (median five days) and their duration varied with the pathogen. The median attack rate was 37%. Illness was reported in 34,158 people, 751 of whom (2%) were admitted to hospital. There were 55 deaths, 28 of which were associated with salmonella and 12 with SRSV. Most of the outbreaks reported and the associated morbidity and mortality could have been prevented by following standard food hygiene practices, implementing infection control policies, and ensuring that food entering kitchens was of the highest microbiological quality possible.