An international study of the quality of national-level guidelines on driving with medical illness.

BACKGROUND: Medical illnesses are associated with a modest increase in crash risk, although many individuals with acute or chronic conditions may remain safe to drive, or pose only temporary risks. Despite the extensive use of national guidelines about driving with medical illness, the quality of these guidelines has not been formally appraised. AIM: To systematically evaluate the quality of selected national guidelines about driving with medical illness. DESIGN: A literature search of bibliographic databases and Internet resources was conducted to identify the guidelines, each of which was formally appraised. METHODS: Eighteen physicians or researchers from Canada, Australia, Ireland, USA and UK appraised nine national guidelines, applying the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. RESULTS: Relative strengths were found in AGREE II scores for the domains of scope and purpose, stakeholder involvement and clarity of presentation. However, all guidelines were given low ratings on rigour of development, applicability and documentation of editorial independence. Overall quality ratings ranged from 2.25 to 5.00 out of 7.00, with modifications recommended for 7 of the guidelines. Intra-class coefficients demonstrated fair to excellent appraiser agreement (0.57-0.79). CONCLUSIONS: This study represents the first systematic evaluation of national-level guidelines for determining medical fitness to drive. There is substantive variability in the quality of these guidelines, and rigour of development was a relative weakness. There is a need for rigorous, empirically derived guidance for physicians and licensing authorities when assessing driving in the medically ill.

Existing medications among non-pregnancy-related listeriosis patients in England, 2007-2009.

To identify which medications were most commonly taken by non-pregnancy-related listeriosis patients prior to illness, we compared the medications reported by 512 cases identified via national surveillance in England between 2007 and 2009 with national prescription data, using British National Formulary (BNF) coding. Relative risks and corresponding confidence intervals were calculated, as appropriate, for BNF chapters and sections. Among listeriosis cases, the rates for cytotoxic drugs, drugs affecting the immune response and corticosteroids were significantly higher than for other medications. However, interactions between medications and how medications might confound or be confounded by concurrent medical conditions need to be investigated further. Nevertheless our findings suggest that targeting food-safety advice to prevent this foodborne disease in certain treatment groups is warranted.

Molecular epidemiology of human Campylobacter jejuni shows association between seasonal and international patterns of disease.

We sought to explain seasonality and other aspects of Campylobacter jejuni epidemiology by integrating population genetic and epidemiological analysis in a large 3-year longitudinal, two-centre, population-based study. Epidemiological information was collected for 1505 isolates, which were multilocus sequence-typed. Analyses compared pathogen population structure between areas, over time, and between clinical presentations. Pooled analysis was performed with published international datasets. Subtype association with virulence was not observed. UK sites had nearly identical C. jejuni populations. A clade formed by ST45 and ST283 clonal complexes showed a summer peak. This clade was common in a Finnish dataset but not in New Zealand and Australian collections, countries with less marked seasonality. The UK, New Zealand and Australian collections were otherwise similar. These findings map to known in-vitro differences of this clade. This identifies a target for studies to elucidate the drivers of the summer peak in human C. jejuni infection.

Large outbreak of verocytotoxin-producing Escherichia coli O157 infection in visitors to a petting farm in South East England, 2009.

In the summer of 2009, an outbreak of verocytotoxigenic Escherichia coli O157 (VTEC O157) was identified in visitors to a large petting farm in South East England. The peak attack rate was 6/1000 visitors, and highest in those aged <2 years (16/1000). We conducted a case-control study with associated microbiological investigations, on human, animal and environmental samples. We identified 93 cases; 65 primary, 13 secondary and 15 asymptomatic. Cases were more likely to have visited a specific barn, stayed for prolonged periods and be infrequent farm visitors. The causative organism was identified as VTEC O157 PT21/28 with the same VNTR profile as that isolated in faecal specimens from farm animals and the physical environment, mostly in the same barn. Contact with farm livestock, especially ruminants, should be urgently reviewed at the earliest suspicion of a farm-related VTEC O157 outbreak and appropriate risk management procedures implemented without delay.

Risk factors for mortality in non-pregnancy-related listeriosis.

We examined non-pregnancy-related listeriosis cases in England and Wales reported to the Health Protection Agency between 1990 and 2009 (n=1864) using unconditional multivariate logistic regression analysis to identify factors independently associated with mortality. A subset analysis of cases between 2005 and 2009 (n=694) investigated the additional effect of antibiotic therapy on survival. In these cases particular malignancies, alcoholism, cardiovascular disease, increasing age, and treatment to reduce gastric acid secretion were positively associated with mortality. The absence of a concurrent condition and presence of autoimmune disease had a protective effect. The subset analysis identified illness in winter or spring as a risk factor and antibiotic therapy as a protective factor for mortality. The impact of antibiotic therapy, seasonality and reduced gastric acid status on survival should be further investigated. Policy-makers and clinicians need to more broadly advise those at risk of contracting this disease and dying as a consequence.

A Salmonella Typhimurium phage type (PT) U320 outbreak in England, 2008: continuation of a trend involving ready-to-eat products.

In March 2008, the Health Protection Agency in England conducted a retrospective case-control study to investigate the cause of 179 cases of the newly recognized, fully antimicrobial-sensitive Salmonella Typhimurium PT U320. Forty-three symptomatic laboratory-confirmed case-patients and 84 asymptomatic location-matched controls were interviewed by telephone about exposures in the 3 days prior to illness or interview. Multivariate logistic analysis indicated consumption of pre-packaged egg sandwiches (odds ratio 3·29, 95% confidence interval 1·19-9·09) was independently associated with illness. Eight of the 15 case-patients who consumed egg sandwiches did so from retail chain A (53·3%) whereas none of the eight controls consumed similar sandwiches (χ2=7·20, P≤0·01). A review of the pre-packaged egg sandwich ingredients suggested this outbreak was probably caused by exposure to an ingredient common to pre-packaged sandwiches and prepared salads but we established a definitive epidemiological link with only the former. Short shelf-life, product diversity and investigation lag hinder epidemiological investigations of such popular products, providing continued challenges for food safety enforcement of freshly prepared produce.

A 17-year review of foodborne outbreaks: describing the continuing decline in England and Wales (1992-2008).

Systematic national surveillance of foodborne disease outbreaks effectively serves the development of public health policy on food safety. The Health Protection Agency has maintained a collaborative surveillance system for foodborne outbreaks in England and Wales since 1992. Up to 2008, 2429 foodborne outbreaks were identified, described and analysed for changes over time. Salmonella spp. accounted for half of the outbreaks, although the proportion of these decreased over the surveillance period. Similarly, the proportion of outbreaks caused by Clostridium perfringens decreased, while those attributed to Campylobacter spp. and Vero cytotoxin-producing Escherichia coli O157 increased. Although poultry meat was the most frequently implicated food vehicle in outbreaks followed by miscellaneous foods and red meats, the proportion of outbreaks attributed to meats in fact decreased over time but those linked to miscellaneous foods did not. Over the surveillance period, the proportion of outbreaks linked to eggs and S. Enteritidis non-phage-type 4, particularly in food service establishments, increased, highlighting the importance of this organism/setting/vehicle association. Contributory factors in most outbreaks were cross-contamination, inadequate heat treatment, and inappropriate food storage. This study describes the overall decline in foodborne outbreaks, providing evidence that the introduction and adherence to effective control measures provide the best means of minimizing the risk of foodborne infection.

Emergence of pregnancy-related listeriosis amongst ethnic minorities in England and Wales.

Listeriosis is a rare but severe food-borne disease that predominantly affects pregnant women, the unborn, newborns, the elderly and immunocompromised people. Following a large outbreak in the 1980s, specific food safety advice was provided to pregnant women and the immunocompromised in the United Kingdom. Following two coincident yet unconnected cases of pregnancy-related listeriosis in eastern European women in 2008, a review of the role of ethnicity in pregnancy-related listeriosis in England and Wales was undertaken in 2009. Cases reported to the national listeriosis surveillance scheme were classified as 'ethnic', belonging to an ethnic minority, or 'non-ethnic' based on their name, and trends were examined. Between 2001 and 2008, 1,510 cases of listeriosis were reported in England and Wales and, of these, 12% were pregnancy-related cases. The proportion of pregnancy-related cases classified as ethnic increased significantly from 16.7% to 57.9% (chi-square test for trend p=0.002). The reported incidence among the ethnic population was higher than that among the non-ethnic population in 2006, 2007 and 2008 (Relative Risk: 2.38, 95% confidence interval: 1.07 to 5.29; 3.82, 1.82 to 8.03; 4.33, 1.74 to 10.77, respectively). This effect was also shown when analysing data from January to September 2009, using extrapolated live births as denominator. Increased immigration and/or economic migration in recent years appear to have altered the population at risk of pregnancy-related listeriosis in England and Wales. These changes need to be taken into account in order to target risk communication strategies appropriately.

Human listeriosis in England, 2001-2007: association with neighbourhood deprivation.

Listeriosis is a rare but severe food-borne disease that predominantly affects pregnant women, the unborn, newborns, the elderly and immunocompromised people. Despite the high mortality rate of the disease, its socio-economic determinants have not been studied in detail, meaning that health inequalities that might exist in relation to this disease are not apparent. Laboratory surveillance data on listeriosis cases reported in England between 2001 and 2007 were linked to indices of deprivation and denominator data using patients' postcodes. Incidence relative to increasing quintiles of deprivation was calculated by fitting generalised linear models while controlling for population size. Patient food purchasing and consumption data were scrutinised and compared with commercial food purchasing denominator data to further quantify the observed differences in disease incidence. For all patient groups, listeriosis incidence was highest in the most deprived areas of England when compared with the most affluent, and cases were more likely to purchase foods from convenience stores or from local services (bakers, butchers, fishmongers and greengrocers) than the general population were. Patients' risk profile also changed with increasing neighbourhood deprivation. With increased life expectancy and rising food prices, food poverty could become an increasingly important driver for foodborne disease in the future. While United Kingdom Government policy should continue to focus on small food businesses to ensure sufficient levels of food hygiene expertise, tailored and targeted food safety advice on the avoidance of listeriosis is required for all vulnerable groups. Failure to do so may enhance health inequality across socio-economic groups.

Prevalence and level of Listeria monocytogenes and other Listeria species in selected retail ready-to-eat foods in the United Kingdom.

Although listeriosis is a rare cause of human disease in the United Kingdom, an increase in the number of cases has been observed since 2001, almost exclusively in persons older than 60 years. This increase prompted this study on the microbiological safety of ready-to-eat (RTE) foods, which included those types potentially linked to cases of listeriosis. Between May 2006 and April 2007, 6,984 RTE foods were sampled (2,168 sliced meats, 1,242 hard cheese, 1,088 sandwiches, 878 butter, 725 spreadable cheese, 515 confectionery products containing cream, and 368 probiotic drinks). The food types with the highest prevalence of Listeria monocytogenes were sandwiches (7.0%) and sliced meats (3.7% within shelf life, 4.2% end of shelf life). L. monocytogenes at > 100 CFU/g (exceeding the European Commission's food safety criteria limit) only occurred in sandwiches (0.4%) and sliced meats (0.7% within shelf life, 1.0% end of shelf life). Contamination with L. monocytogenes at >100 CFU/g was more frequent in meats that were prepacked and/or of pack size > or = 300 g and in sandwiches that were supplied prepacked that contained salad vegetables as an ingredient. Satisfactory microbiological quality was associated with premises on which the management was trained in food hygiene and those that complied with hazard analysis and critical control point principles. This study provides important information about the microbiological safety of RTE foods and demonstrates that the control of L. monocytogenes in such foods, and in particular sandwiches and sliced meats, is essential in order to minimize the risk of this bacterium being present at levels hazardous to health at the point of consumption.

A re-evaluation of the impact of temperature and climate change on foodborne illness.

The effects of temperature on reported cases of a number of foodborne illnesses in England and Wales were investigated. We also explored whether the impact of temperature had changed over time. Food poisoning, campylobacteriosis, salmonellosis, Salmonella Typhimurium infections and Salmonella Enteritidis infections were positively associated (P<0.01) with temperature in the current and previous week. Only food poisoning, salmonellosis and S. Typhimurium infections were associated with temperature 2-5 weeks previously (P<0.01). There were significant reductions also in the impact of temperature on foodborne illnesses over time. This applies to temperature in the current and previous week for all illness types (P<0.01) except S. Enteritidis infection (P=0.079). Temperature 2-5 weeks previously diminished in importance for food poisoning and S. Typhimurium infection (P<0.001). The results are consistent with reduced pathogen concentrations in food and improved food hygiene over time. These adaptations to temperature imply that current estimates of how climate change may alter foodborne illness burden are overly pessimistic.

Investigation of an outbreak of Salmonella enterica serovar Newport infection.

A large outbreak of Salmonella enterica serotype Newport infection occurred in Northern Ireland during September and October 2004. Typing of isolates from patients confirmed that this strain was indistinguishable from that in concurrent outbreaks in regions of England, in Scotland and in the Isle of Man. A total of 130 cases were distributed unequally across local government district areas in Northern Ireland. The epidemic curve suggested a continued exposure over about 4 weeks. A matched case-control study of 23 cases and 39 controls found a statistically significant association with a history of having eaten lettuce in a meal outside the home and being a case (odds ratio 23.7, 95% confidence interval 1.4-404.3). This exposure was reported by 57% of cases. Although over 300 food samples were tested, none yielded any Salmonella spp. Complexity and limited traceability in salad vegetable distribution hindered further investigation of the ultimate source of the outbreak.

Impact of reduced numbers of isolates phage-typed on the detection of Salmonella outbreaks.

The aim of this study was to assess the effects of reductions in the number of isolates tested by phage-typing on the recognition of outbreaks of salmonellosis. Five outbreaks (categorized as 'small', 'medium' or 'large') which occurred in England in 2005 were used as examples. The outbreaks were caused by serotypes which were subdivided by phage-typing. Results indicated that reducing the number of isolates phage-typed would have an impact on the surveillance system, with one outbreak likely to have been missed altogether. However, this does not have a great effect on the 'time-to-detection' for the other outbreaks. Assuming no testing for phage-typing was undertaken it is likely that two out of five outbreaks would not have been detected. Assessing the value of phage-type information is important not only in deciding on the efficiency of the current surveillance system but also in providing a basis upon which to assess more detailed typing methodologies such as an antibiogram of molecular profile.

Demographic determinants for Campylobacter infection in England and Wales: implications for future epidemiological studies.

Despite a significant public health burden the epidemiology of human Campylobacter infection remains blurred. The identification of demographic determinants for Campylobacter infection is therefore essential for identifying potential areas for intervention. Demographic data from an active, population-based sentinel surveillance system for Campylobacter infection (from 2000 until 2003, n=15 907) were compared with appropriate denominator data from the 2001 United Kingdom Census. Incidence was higher in males from birth until the late teens and in females from 20 to 36 years. Age- and gender-specific differences in Campylobacter incidence were observed in different ethnic and socioeconomic groups and hence are all major drivers for Campylobacter infection. Epidemiological studies on Campylobacter infection need to take these factors into consideration during design and analysis. The collation of detailed epidemiological data and its comparison with appropriate denominator data provides a valuable epidemiological tool for studying infection.

Prepared salads and public health.

In recent years the importance of prepared salads as potential vehicles of gastrointestinal infection has been highlighted by several large outbreaks both nationally and across international boundaries. Between 1992 and 2006, 2274 foodborne general outbreaks of infectious intestinal disease were reported in England and Wales, of which 4% were associated with the consumption of prepared salads. In total, 3434 people were affected, with 66 hospitalizations and one death reported. The attribution of prepared salad types and pathogens among prepared salad associated outbreaks are presented and discussed. Findings from UK studies on salad vegetables, fruit and mixed salads from 1995 to 2007 (21 247 samples) indicate that most bacteria of concern with regard to human health are relatively rare in these products (98.6% of satisfactory quality); however, outbreaks of salmonellosis were uncovered associated with bagged salad leaves and fresh herbs during two such studies. Although it is known that fresh salad vegetables, herbs or fruit may become contaminated from environmental sources, only in recent years has the association of foods of nonanimal origin, such as salad vegetables, with foodborne illness become evident and recurrent, demonstrating that major health problems can arise from consumption of contaminated prepared salads if hygiene practices breakdown.

Prevalence and level of Listeria monocytogenes and other Listeria species in retail pre-packaged mixed vegetable salads in the UK.

As part of the European Commission (EC) co-ordinated programme for 2005, a study of pre-packaged ready-to-eat (RTE) mixed salads containing meat or seafood ingredients from retail premises was undertaken in the UK to determine the frequency and level of Listeria monocytogenes in these products. Almost all (99.8%; 2682/2686) samples were of satisfactory/acceptable microbiological quality. Two (0.1%) samples exceeded EC legal food safety criteria due to the presence of L. monocytogenes in excess of 100 cfu g(-1) (1.7 x 10(2), 9.9 x 10(2)cfu g(-1)) while another two (0.1%) were unsatisfactory due to L. welshimeri levels over 100 cfu g(-1) (1.2 x 10(3), 6.0 x 10(3) cfu g(-1)). Overall contamination of Listeria spp. and L. monocytogenes found in samples of mixed salads in the UK was 10.8% and 4.8%, respectively. Almost twice as many salad samples with meat ingredients were contaminated with Listeria spp. and L. monocytogenes (14.7% and 6.0%, respectively) compared to samples with seafood ingredients (7.4% and 3.8%, respectively). Pre-packaged mixed salads were contaminated with Listeria spp. and L. monocytogenes more frequently when: collected from sandwich shops; not packaged on the premises; stored or displayed above 8 degrees C. This study demonstrates that the control of L. monocytogenes in food manufacturing and at retail sale is essential in order to minimize the potential for this bacterium to be present in mixed salads at the point of consumption at levels hazardous to health.

Public health investigations of Salmonella Enteritidis in catering raw shell eggs, 2002-2004.

AIMS: In response to a dramatic change in the epidemiology of Salmonella Enteritidis in England and Wales thought to be associated with raw shell eggs, the Health Protection Agency initiated public health investigations to establish the incidence of Salmonella contamination and origin of eggs used by catering premises implicated in outbreaks of Salm. Enteritidis. METHODS AND RESULTS: Between October 2002 and November 2004, 16 971 eggs were sampled and Salmonella were recovered from 3.4%. Salmonella was isolated from 5.5% and 6.3% of Spanish and eggs of unknown origin, respectively, used in catering premises linked to outbreaks, a level significantly higher than that (1.1%) found in nonLion Quality UK eggs sampled. The small sample of UK Lion Quality eggs tested (reflecting their lack of use in premises visited) did not contain Salmonella. Several phage types of Salm. Enteritidis other than phage type 4 (PT 4) were identified with nonUK eggs. CONCLUSIONS: Eggs from Spain were implicated as a major source of infection. Eggs were contaminated more frequently with Salmonella when shells were dirty and/or cracked, and stored at above 8 degrees C. SIGNIFICANCE AND IMPACT OF THE STUDY: The use of Spanish eggs by the catering sector has been identified as a consistent significant factor in many of the outbreaks caused by Salm. Enteritidis nonPT4 in England and Wales during 2002-2004. Advice to caterers and hospitals that raw shell eggs should not be used in food that will either not be cooked or only lightly cooked should be reinforced.

Publication bias in foodborne outbreaks of infectious intestinal disease and its implications for evidence-based food policy. England and Wales 1992-2003.

Systematic national surveillance of outbreaks of infectious intestinal disease (IID) was introduced in England and Wales in 1992 to provide comprehensive information on causative organisms, sources or vehicles of infection and modes of transmission. We compared information from this system with that published in the peer-reviewed literature between 1 January 1992 and 31 January 2003 to assess the potential effect of publication bias on food-safety policy. During the study period 1763 foodborne outbreaks of IID were reported to national surveillance. Fifty-five were published in the peer-reviewed literature. The peer-reviewed literature overestimated the impacts of milk/milk products, miscellaneous foods (e.g. sandwiches) and desserts and underestimated those of poultry, fish and shellfish, red meat/meat products and eggs/egg products. Without systematic surveillance, knowledge of causative organisms, sources or vehicles of infection and modes of transmission, as gleaned from the peer-reviewed literature, would potentially distort food-safety policy.

Foodborne general outbreaks of Salmonella Enteritidis phage type 4 infection, England and Wales, 1992-2002: where are the risks?

Foodborne outbreaks of Salmonella enterica serovar Enteritidis phage type 4 (PT4) infection (n=497), reported to the Health Protection Agency Communicable Disease Surveillance Centre between 1992 and 2002, were compared with other pathogens (n=1148) to determine factors (season, setting, food vehicles, food safety faults) associated with this pathogen. Logistic regression was applied to control for potential confounding. Foodborne general outbreaks of S. Enteritidis PT4 infection were more likely to occur in the spring and summer, and were more often linked to schools, private residences and residential institutions. Eggs, egg products and the use of raw shell egg were strongly associated with this pathogen. Most outbreaks were linked to cross-contamination and inadequate heat treatment. This paper describes the decline in the S. Enteritidis PT4 epidemic, providing evidence that control measures introduced, e.g. improved biosecurity and vaccination, have worked. Continued surveillance of human and veterinary salmonellosis is essential to detect future problems.