Role of Food Handlers in Norovirus Outbreaks in London and South East England, 2013 to 2015.

Outbreaks caused by norovirus infection are common and occur throughout the year. Outbreaks can be related to food outlets either through a contaminated food source or an infected food handler. Both asymptomatic and symptomatic food handlers are potentially implicated in outbreaks, but evidence of transmission is limited. To understand potential food handler transmission in outbreak scenarios, epidemiological and microbiological data on possible and confirmed norovirus outbreaks reported in London and South East England in a 2-year period were reviewed. One hundred eighty-six outbreaks were associated with a food outlet or registered caterer in this period. These occurred throughout the year with peaks in quarter 1 of study years. A case series of 17 outbreaks investigated by the local field epidemiological service were evaluated further, representing more than 606 cases. In five outbreaks, symptomatic food handlers were tested and found positive for norovirus. In four outbreaks, symptomatic food handlers were not tested. Asymptomatic food handlers were tested in three outbreaks but positive for norovirus in one only. Environmental sampling did not identify the causative agent conclusively in any of the outbreaks included in this analysis. Food sampling identified norovirus in one outbreak. Recommendations from this study include for outbreak investigations to encourage testing of symptomatic food handlers and for food and environmental samples to be taken as soon as possible. In addition, sampling of asymptomatic food handlers should be considered when possible. However, in light of the complexity in conclusively identifying a source of infection, general measures to improve hand hygiene are recommended, with specific education among food handlers about the potential for foodborne pathogen transmission during asymptomatic infection, as well as reinforcing the importance of self-exclusion from food handling activities when symptomatic.

The value of uncertainty in critical illness? An ethnographic study of patterns and conflicts in care and decision-making trajectories.

BACKGROUND: With increasingly intensive treatments and population ageing, more people face complex treatment and care decisions. We explored patterns of the decision-making processes during critical care, and sources of conflict and resolution. METHODS: Ethnographic study in two Intensive Care Units (ICUs) in an inner city hospital comprising: non-participant observation of general care and decisions, followed by case studies where treatment limitation decisions, comfort care and/or end of life discussions were occurring. These involved: semi-structured interviews with consenting families, where possible, patients; direct observations of care; and review of medical records. RESULTS: Initial non-participant observation included daytime, evenings, nights and weekends. The cases were 16 patients with varied diagnoses, aged 19-87 years; 19 family members were interviewed, aged 30-73 years. Cases were observed for <1 to 156 days (median 22), depending on length of ICU admission. Decisions were made serially over the whole trajectory, usually several days or weeks. We identified four trajectories with distinct patterns: curative care from admission; oscillating curative and comfort care; shift to comfort care; comfort care from admission. Some families considered decision-making a negative concept and preferred uncertainty. Conflict occurred most commonly in the trajectories with oscillating curative and comfort care. Conflict also occurred inside clinical teams. Families were most often involved in decision-making regarding care outcomes and seemed to find it easier when patients switched definitively from curative to comfort care. We found eight categories of decision-making; three related to the care outcomes (aim, place, response to needs) and five to the care processes (resuscitation, decision support, medications/fluids, monitoring/interventions, other specialty involvement). CONCLUSIONS: Decision-making in critical illness involves a web of discussions regarding the potential outcomes and processes of care, across the whole disease trajectory. When measures oscillate between curative and comfort there is greatest conflict. This suggests a need to support early communication, especially around values and preferred care outcomes, from which other decisions follow, including DNAR. Offering further support, possibly with expert palliative care, communication, and discussion of 'trial of treatment' may be beneficial at this time, rather than waiting until the 'end of life'.

Widening inequalities in the risk factors for cardiovascular disease amongst men in England between 1998 and 2006.

OBJECTIVES: Cardiovascular disease is a major cause of morbidity and mortality for which there are many modifiable risk factors. This study investigated changes in social inequalities of cardiovascular disease risk factors amongst men aged 20-64 years in England between 1998 and 2006. STUDY DESIGN: Repeated cross-sectional study. METHODS: Health Survey for England data from 1998, 2003 and 2006 were used. The following physiological risk factors were considered: body mass index, waist-to-hip ratio, blood pressure and total serum cholesterol level. The behavioural risk factors considered were limited physical exercise, smoking status and level of social support. The National Statistics Socio-economic Classification was used to measure socio-economic position. An index of inequality for each risk factor was calculated, and change in inequality over time was assessed by t-tests. RESULTS: Significant cross-sectional inequality was found for waist-to-hip ratio, systolic blood pressure, smoking, limited physical exercise and social support at one or more time points. Between 1998 and 2006, there was a significant increase in inequality for smoking status [relative index of inequality (RII) 4.06-6.65 (t-test: 2.88, P = 0.003)] and limited physical exercise [RII 1.06-1.74 (t-test: 2.92, P = 0.003)]; these increases in inequality over time were due to improvements for those in higher socio-economic classes. CONCLUSIONS: Policies have not had the desired impact of reducing inequalities. Although the long-term effects of these policies might not yet be apparent, available evidence needs to be used to monitor impact and direct policy change to address the possibility of widening inequalities.