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Summary Background The management of patients with highly infectious diseases (HIDs) is a challenge for healthcare provision requiring a high level of care without compromising the safety of other patients and healthcare workers. Aim To study the infection control practice in isolation facilities participating in the European Network for Highly Infectious Diseases (EuroNHID) project. Methods A survey was conducted during 2009 of 48 isolation facilities caring for patients with HIDs in 16 European countries. Checklists and standard evaluation forms were used to collect and interpret data on hand hygiene, routine hygiene and disinfection, and waste management. Findings Forty percent of HIDs had no non-hand-operated sinks or alcohol-based antiseptic distributors, while 27% did not have procedures for routine hygiene, final disinfection, or safe discarding of non-disposable objects or equipment. There was considerable variation in the management of waste and in the training of housekeeping personnel. EuroNHID has developed recommendations for hand hygiene, disinfection, routine hygiene, and waste management. Conclusions Most aspects of hand hygiene, routine hygiene and disinfection, and waste management were considered at least partially adequate in the majority of European isolation facilities dedicated for the care of patients with HIDs. But considerable variability was observed, with management of waste and training of housekeeping personnel being generally less satisfactory.

Summary Isolation of patients with highly infectious diseases (HIDs) in hospital rooms with adequate technical facilities is essential to reduce the risk of spreading disease. The European Network for Infectious Diseases (EUNID), a project co-funded by European Commission and involving 16 European Union member states, performed an inventory of high level isolation rooms (HIRs, hospital rooms with negative pressure and anteroom). In participating countries, HIRs are available in at least 211 hospitals, with at least 1789 hospital beds. The adequacy of this number is not known and will depend on prevailing circumstances. Sporadic HID cases can be managed in the available HIRs. HIRs could also have a role in the initial phases of an influenza pandemic. However, large outbreaks due to natural or to bioterrorist events will need management strategies involving healthcare facilities other than HIRs.

Summary The European Network for Infectious Diseases (EUNID) is a network of clinicians, public health epidemiologists, microbiologists, infection control, and critical-care doctors from the European member states, who are experienced in the management of patients with highly infectious diseases. We aim to develop a consensus recommendation for infection control during clinical management and invasive procedures in such patients. After an extensive literature review, draft recommendations were amended jointly by 27 partners from 15 European countries. Recommendations include repetitive training of staff to ascertain infection control, systematic use of cough and respiratory etiquette at admission to the emergency department, fluid sampling in the isolation room, and analyses in biosafety level 3/4 laboratories, and preference for point-of-care bedside laboratory tests. Children should be cared for by paediatricians and intensive-care patients should be cared for by critical-care doctors in high-level isolation units (HLIU). Invasive procedures should be avoided if unnecessary or done in the HLIU, as should chest radiography, ultrasonography, and renal dialysis. Procedures that require transport of patients out of the HLIU should be done during designated sessions or hours in secure transport. Picture archiving and communication systems should be used. Post-mortem examination should be avoided; biopsy or blood collection is preferred.

Travellers to many tropical areas remain at risk of contracting malaria. Resistance of malaria parasites to a number of drugs continues to increase in degree and distribution, so that some older, trusted prophylactic drugs, such as chloroquine, are no longer useful in some parts of the world. Despite the introduction of new drugs and the reduction of malaria risk in some areas, such as parts of India, the number of people travelling continues to increase and malaria reports in the UK are not decreasing. New updated prevention guidelines from the Health Protection Agency Advisory Committee on Malaria Prevention (ACMP) in UK travellers (Chiodini P, Hill D, Lalloo D, Lea G, Walker E, Whitty C, et al. Guidelines for malaria prevention in travellers from the United Kingdom. London: Health Protection Agency; January 2007. Available from: http://www.hpa.org.uk/infections/topics_az/malaria/default.htm) aim to raise awareness of the risks of malaria and help UK travel health advisors in giving malaria prevention advice to all those who need it. Together with the ACMP malaria treatment guidelines it is hoped that the risk of illness and death from malaria in UK travellers can be reduced. This article summarises the new ACMP malaria prevention guidelines.

SUMMARYData were extracted from the case records of UK patients admitted with laboratory-confirmed influenza A(H1N1)pdm09. White and non-White patients were characterized by age, sex, socioeconomic status, pandemic wave and indicators of pre-morbid health status. Logistic regression examined differences by ethnicity in patient characteristics, care pathway and clinical outcomes; multivariable models controlled for potential confounders. Whites (n = 630) and non-Whites (n = 510) differed by age, socioeconomic status, pandemic wave of admission, pregnancy, recorded obesity, previous and current smoking, and presence of chronic obstructive pulmonary disease. After adjustment fora prioriconfounders non-Whites were less likely to have received pre-admission antibiotics [adjusted odds ratio (aOR) 0·43, 95% confidence interval (CI) 0·28–0·68,P P = 0·018). However, there were no significant differences by ethnicity in delayed admission, severity at presentation for admission, or likelihood of severe outcome.

Purpose The handling of human remains may pose a risk for transmission of highly infectious agents. The use of appropriate biosafety measures is very important in case of management of patients deceased from highly infectious diseases (HIDs), such as Ebola virus disease. This paper presents the capabilities and resources in this field in 16 European countries, and suggests indications for the safe post-mortem management of HID patients. Methods The European Network for Highly Infectious Diseases conducted in 2009 a survey in 48 isolation facilities in 16 European countries. A set of standardized checklists, filled during on-site visits, have been used for data collection. Results Thirty-nine facilities (81.2 %) reported to have written procedures for the management of human remains, and 27 (56.2 %) for the performance of autopsies in HID patients. A Biosafety Level 3 autopsy room was available in eight (16.6 %) facilities, other technical devices for safe autopsies were available in nine (18.7 %). Overall, four facilities (8.3 %) reported to have all features explored for the safe management of human remains. Conversely, in five (10.4 %) none of these features were available. Conclusions The level of preparedness of surveyed isolation facilities in the field of post-mortem management in case of HIDs was not satisfactory, and improvements are needed.

BACKGROUND: Highly Infectious Diseases (HIDs) are (i) easily transmissible form person to person; (ii) cause a life-threatening illness with no or few treatment options; and (iii) pose a threat for both personnel and the public. Hence, even suspected HID cases should be managed in specialised facilities minimizing infection risks but allowing state-of-the-art critical care. Consensus statements on the operational management of isolation facilities have been published recently. The study presented was set up to compare the operational management, resources, and technical equipment among European isolation facilities. Due to differences in geography, population density, and national response plans it was hypothesized that adherence to recommendations will vary. METHODS AND FINDINGS: Until mid of 2010 the European Network for Highly Infectious Diseases conducted a cross-sectional analysis of isolation facilities in Europe, recruiting 48 isolation facilities in 16 countries. Three checklists were disseminated, assessing 44 items and 148 specific questions. The median feedback rate for specific questions was 97.9% (n = 47/48) (range: n = 7/48 (14.6%) to n = 48/48 (100%). Although all facilities enrolled were nominated specialised facilities' serving countries or regions, their design, equipment and personnel management varied. Eighteen facilities fulfilled the definition of a High Level Isolation Unit'. In contrast, 24 facilities could not operate independently from their co-located hospital, and five could not ensure access to equipment essential for infection control. Data presented are not representative for the EU in general, as only 16/27 (59.3%) of all Member States agreed to participate. Another limitation of this study is the time elapsed between data collection and publication; e.g. in Germany one additional facility opened in the meantime. CONCLUSION: There are disparities both within and between European countries regarding the design and equipment of isolation facilities. With regard to the International Health Regulations, terminology, capacities and equipment should be standardised.

An outbreak of trichinellosis that occurred in the United Kingdom is described. Members of four households consumed pork salami from northern Serbia, the Federal Republic of Yugoslavia. Eight cases of trichinellosis occurred. Clinical and laboratory features of the cases were typical with myalgia (7 cases), fever (6), headache (5), periorbital oedema (4), non-specific ST/T wave changes on electrocardiogram (3), Trichinella antibodies (6), eosinophilia (7) and raised serum creatine kinase (3). All recovered. Trichinella larvae were detected in the salami. During pre-travel counselling, travellers should be advised about possible risk from cured pork products which have been produced locally in Trichinella endemic areas.

Objective.To collect data about personal protective equipment (PPE) management and to provide indications for improving PPE policies in Europe.Design.Descriptive, cross-sectional survey.Setting and Participants.Data were collected in 48 isolation facilities in 16 European countries nominated by National Health Authorities for the management of highly infectious diseases (HIDs).Methods.Data were collected through standardized checklists at on-site visits during February-November 2009. Indications for adequate PPE policies were developed on the basis of a literature review, partners' expert opinions, and the collected data.Results.All facilities have procedures for the selection of PPE in case of HID, and 44 have procedures for the removal of PPE. In 40 facilities, different levels of PPE are used according to a risk assessment process, and in 8 facilities, high-level PPE (eg, positive-pressure complete suits or Trexler units) is always used. A fit test is performed at 25 of the 40 facilities at which it is applicable, a seal check is recommended at 25, and both procedures are used at 17. Strategies for promoting and monitoring the correct use of PPE are available at 42 facilities. In case of a sudden increase in demand, 44 facilities have procedures for rapid supply of PPE, whereas 14 facilities have procedures for decontamination and reuse of some PPE.Conclusions.Most isolation facilities devote an acceptable level of attention to PPE selection and removal, strategies for the promotion of the correct use of PPE, and ensuring adequate supplies of PPE. Fit test and seal check procedures are still not widely practiced. Moreover, policies vary widely between and within European countries, and the development of common practice procedures is advisable.Infect Control Hosp Epidemiol2012;33(10):1008-1016

Introduction: The Influenza Clinical Information Network (FLU-CIN) was established to gather detailed clinical and epidemiological information about patients with laboratory confirmed A(H1N1)pdm09 infection in UK hospitals. This report focuses on the clinical course and outcomes of infection in pregnancy.Methods: A standardised data extraction form was used to obtain detailed clinical information from hospital case notes and electronic records, for patients with PCR-confirmed A(H1N1)pdm09 infection admitted to 13 sentinel hospitals in five clinical 'hubs' and a further 62 non-sentinel hospitals, between 11th May 2009 and 31st January 2010.Outcomes were compared for pregnant and non-pregnant women aged 15-44 years, using univariate and multivariable techniques.Results: Of the 395 women aged 15-44 years, 82 (21%) were pregnant; 73 (89%) in the second or third trimester. Pregnant women were significantly less likely to exhibit severe respiratory distress at initial assessment (OR?=?0.49 (95% CI: 0.30-0.82)), require supplemental oxygen on admission (OR?=?0.40 (95% CI: 0.20-0.80)), or have underlying co-morbidities (p-trend Conclusions: Since the expected prevalence of pregnancy in the source population was 6%, our data suggest that pregnancy greatly increased the likelihood of hospital admission with A(H1N1)pdm09. Pregnant women were less likely than non-pregnant women to have respiratory distress on admission, but severe outcomes were equally likely in both groups.

Triage tools have an important role in pandemics to identify those most likely to benefit from higher levels of care. We compared Community Assessment Tools (CATs), the CURB-65 score, and the Pandemic Medical Early Warning Score (PMEWS); to predict higher levels of care (high dependency--Level 2 or intensive care--Level 3) and/or death in patients at or shortly after admission to hospital with A/H1N1 2009 pandemic influenza. This was a case-control analysis using retrospectively collected data from the FLU-CIN cohort (1040 adults, 480 children) with PCR-confirmed A/H1N1 2009 influenza. Area under receiver operator curves (AUROC), sensitivity, specificity, positive predictive values and negative predictive values were calculated. CATs best predicted Level 2/3 admissions in both adults [AUROC (95% CI): CATs 0.77 (0.73, 0.80); CURB-65 0.68 (0.64, 0.72); PMEWS 0.68 (0.64, 0.73), p

SummaryOne hundred and eighty–one stool specimens from patients with various types of diarrhoea (135 patients) or from non-diarrhoeal controls (23 acute medical patients, 23 inflammatory bowel disease in remission) were investigated using a colony–blot DNA hybridization assay for the presence of Verocytotoxin–producing (VTEC), enteroaggregative (EAggEC) and diffusely adherent (DAEC)Escherichia coli. Twelve patients had probe–positive EAggEC in the stool and 8 of these had diarrhoea, 6 following recent travel. Eight patients had DAEC, 7 of whom had travellers diarrhoea. Six of 10 (60%) travellers with gastroenteritis, but without a recognized enteric pathogen, were positive for EAggEC (4) or DAEC (2). Five of 10 (50%) travellers with gastroenteritis related to a recognized enteric pathogen also had DAEC identified in their stool. Of the 23 acute medical control patients 11 had been abroad, 4 of these were immigrants and had EAggEC. VTEC were not found and, with one exception, immunoassays for antibodies toE. coliO 157 and O 2 lipopolysaccharides were negative.

BackgroundStatins are drugs that are used to lower plasma cholesterol levels. Recently, contradictory claims have been made about possible additional effects of statins on progression of a variety of inflammatory disorders, including infections. We therefore examined the clinical course of patients admitted to hospital with 2009 pandemic influenza A(H1N1), who were or weren't taking statins at time of admission.MethodsA retrospective case-control study was performed using the United Kingdom Influenza Clinical Information Network (FLU-CIN) database, containing detailed information on 1,520 patients admitted to participating hospitals with confirmed 2009 pandemic influenza A(H1N1) infection between April 2009 and January 2010. We confined our analysis to those aged over 34 years. Univariate analysis was used to calculate unadjusted odds ratios (OR) and 95 percent confidence intervals (95%CI) for factors affecting progression to severe outcome (high dependency or intensive care unit level support) or death (cases); two multivariable logistic regression models were then established for age and sex, and for age, sex, obesity and "indication for statin" (e.g., heart disease or hypercholesterolaemia).ResultsWe found no statistically significant association between pre-admission statin use and severity of outcome after adjustment for age and sex [adjusted OR: 0.81 (95% CI: 0.46-1.38); n = 571]. After adjustment for age, sex, obesity and indication for statin, the association between pre-admission statin use and severe outcome was not statistically significant; point estimates are compatible with a small but clinically significant protective effect of statin use [adjusted OR: 0.72 (95% CI: 0.38-1.33)].ConclusionsIn this group of patients hospitalized with pandemic influenza, a significant beneficial effect of pre-admission statin use on the in-hospital course of illness was not identified. Although the database from which these observations are derived represents the largest available suitable UK hospital cohort, a larger study would be needed to confirm whether there is any benefit in this setting.

To determine clinical characteristics of patients hospitalized in the United Kingdom with pandemic (H1N1) 2009, we studied 1,520 patients in 75 National Health Service hospitals. We characterized patients who acquired influenza nosocomially during the pandemic (H1N1) 2009 outbreak. Of 30 patients, 12 (80%) of 15 adults and 14 (93%) of 15 children had serious underlying illnesses. Only 12 (57%) of 21 patients who received antiviral therapy did so within 48 hours after symptom onset, but 53% needed escalated care or mechanical ventilation; 8 (27%) of 30 died. Despite national guidelines and standardized infection control procedures, nosocomial transmission remains a problem when influenza is prevalent. Health care workers should be routinely offered influenza vaccine, and vaccination should be prioritized for all patients at high risk. Staff should remain alert to the possibility of influenza in patients with complex clinical problems and be ready to institute antiviral therapy while awaiting diagnosis during influenza outbreaks.

Malaria is the tropical disease most commonly imported into the UK, with 1500-2000 cases reported each year, and 10-20 deaths. Approximately three-quarters of reported malaria cases in the UK are caused by Plasmodium falciparum, which is capable of invading a high proportion of red blood cells and rapidly leading to severe or life-threatening multi-organ disease. Most non-falciparum malaria cases are caused by Plasmodium vivax; a few cases are caused by the other two species of Plasmodium: Plasmodium ovale or Plasmodium malariae. Mixed infections with more than 1 species of parasite can occur; they commonly involve P. falciparum with the attendant risks of severe malaria. Management of malaria depends on awareness of the diagnosis and on performing the correct diagnostic tests: the diagnosis cannot be excluded until 3 blood specimens have been examined by an experienced microscopist. There are no typical clinical features of malaria, even fever is not invariably present. The optimum diagnostic procedure is examination of thick and thin blood films by an expert to detect and speciate the malarial parasites; P. falciparum malaria can be diagnosed almost as accurately using rapid diagnostic tests (RDTs) which detect plasmodial antigens or enzymes, although RDTs for other Plasmodium species are not as reliable. The treatment of choice for non-falciparum malaria is a 3-day course of oral chloroquine, to which only a limited proportion of P. vivax strains have gained resistance. Dormant parasites (hypnozoites) persist in the liver after treatment of P. vivax or P. ovale infection: the only currently effective drug for eradication of hypnozoites is primaquine. This must be avoided or given with caution under expert supervision in patients with glucose-6-phosphate dehydrogenase deficiency (G6PD), in whom it may cause severe haemolysis. Uncomplicated P. falciparum malaria can be treated orally with quinine, atovaquone plus proguanil (Malarone) or co-artemether (Riamet); quinine is highly effective but poorly tolerated in prolonged dosage and is always supplemented by additional treatment, usually with oral doxycycline. ALL patients treated for P. falciparum malaria should be admitted to hospital for at least 24 h, since patients can deteriorate suddenly, especially early in the course of treatment. Severe falciparum malaria, or infections complicated by a relatively high parasite count (more than 2% of red blood cells parasitized), should be treated with intravenous therapy until the patient is well enough to continue with oral treatment. In the UK, the treatment of choice for severe or complicated malaria is currently an infusion of intravenous quinine. This may exacerbate hypoglycaemia that can occur in malaria; patients treated with intravenous quinine therefore require careful monitoring. Intravenous artesunate reduces high parasite loads more rapidly than quinine and is more effective in treating severe malaria in selected situations. It can also be used in patients with contra-indications to quinine. Intravenous artesunate is unlicensed in the EU. Assistance in obtaining artesunate may be sought from specialist tropical medicine centres, on consultation, for named patients. Patients with severe or complicated malaria should be managed in a high dependency or intensive care environment. They may require haemodynamic support and management of acute respiratory distress syndrome, disseminated intravascular coagulation, renal impairment/failure, seizures, and severe intercurrent infections including gram-negative bacteraemia/septicaemia. Falciparum malaria in pregnancy is more likely to be severe and complicated: the placenta contains high levels of parasites. Stillbirth or early delivery may occur and diagnosis can be difficult if parasites are concentrated in the placenta and scanty in the blood. The treatment of choice for falciparum malaria in pregnancy is quinine; doxycycline is contraindicated in pregnancy but clindamycin can be substituted for it, and is equally effective. Primaquine (for eradication of P. vivax or P. ovale hypnozoites) is contraindicated in pregnancy; after treatment for these infections a pregnant woman should take weekly chloroquine prophylaxis until after delivery when hypnozoite eradication can be considered. Children are over-represented in the incidence of malaria in the UK, probably because completely susceptible UK-born children accompany their overseas-born parents on visits to family and friends in endemic areas. Malaria in children (and sometimes in adults) may present with misleading symptoms such as gastrointestinal features, sore throat or lower respiratory complaints; the diagnosis must always be sought in a feverish or very sick child who has visited malaria-endemic areas. Children can be treated with most of the antimalarial regimens which are effective in adults, with appropriate dosage adjustment. Doxycycline plus quinine should not be given to children under 12 years as doxycycline is contraindicated in this age group, but clindamycin can be substituted for doxycycline, and pyrimethamine-sulfadoxine (Fansidar) may also be an effective substitute. An acute attack of malaria does not confer protection from future attacks: individuals who have had malaria should take effective anti-mosquito precautions and chemoprophylaxis during future visits to endemic areas.

Travellers to malaria-endemic destinations are at risk of significant disease and, sometimes, death. Current malaria protection strategies, including chemoprophylaxis, can never be completely effective. In some cases, protective measures are discontinued or misapplied while the risk of infection still exists. In others, suboptimal measures are used, or even no measures at all, because of poor information or inappropriate risk-benefit assessment. In very rare cases, inexplicable failure of prophylaxis occurs. If malaria is contracted whilst abroad the danger to the individual is often further compounded by a lack of high-quality medical facilities and an uncertain supply of effective drugs for treatment. The advent of newer, well tolerated, drugs for treating malaria provides an opportunity to review the role of standby emergency self-medication in travellers visiting or staying (for work or other reasons) in areas where there is a risk of contracting malaria. This article was prepared following a meeting convened in London on Africa Malaria Day in 2002, in which the current opinions of experts in travel medicine and specifically malaria were discussed. It reviews opinion on the current effectiveness and acceptance of prevention strategies, as well as the role of standby emergency medication for falciparum malaria. © 2004 Elsevier Ltd. All rights reserved.

Objectives. Evaluation of the Department of Health 1996 guidance, the Memorandum on the Management and Control of Viral Haemorrhagic Fevers. Methods. Description of the public health management in 2000 of the fifth UK patient confirmed to have Lassa fever. Results. Delayed risk categorisation of the patient occurred for a variety of reasons. DH Guidance was followed once infection control advice was sought. Active surveillance of 125 contacts was extremely resource intense, involving over 3000 communications. Self-monitoring by healthcare workers should be considered in future. Advice on use of ribavirin prophylaxis is not included in the Memorandum, nor advice or templates for information sheets for contacts. Information sheets are now available from the Health Protection Agency in the event of future cases. International aspects not adequately addressed include the need for reliable risk assessment to be carried out before patients are medically evacuated from the country of origin, and the steps required to repatriate UK nationals. Effective and efficient communication is required between national and international organisations involved in such incidents. Conclusions. If guidelines are unclear or impracticable they will not be followed. It is important that lessons are learned and documented and that national guidance be regularly reviewed.

Because tuberculosis (TB) is primarily a pulmonary disease, we examined the cytokine responses of CD4(+) T lymphocytes in bronchoalveolar lavage (BAL) fluid after incubation with purified protein derivative (PPD) in human immunodeficiency virus-negative patients with TB and control subjects with nontuberculous respiratory disease. Parallel blood and BAL fluid samples from each subject were incubated with or without PPD, and the proportions of CD4(+) T lymphocytes producing interferon (IFN)-gamma or tumor necrosis factor (TNF)-alpha were measured by flow cytometry. The proportions of PPD-activated IFN-gamma- and TNF-alpha-producing CD4(+) cells were low among control subjects (median, 0.33% and 0.78%, respectively). By contrast, among patients with TB, strong IFN-gamma and TNF-alpha responses were demonstrated (median, 24.0% and 32.4%, respectively), regardless of whether the TB was pulmonary or nonpulmonary. Measurement of type 1 cytokine production by CD4(+) T lymphocytes in response to PPD in BAL fluid is a promising new diagnostic test for active TB in immunocompetent individuals.

We report the cases of two patients, brother and sister, both with pulmonary tuberculosis. Both patients complied poorly with treatment. One developed multi-drug resistant disease, whilst the other did not. We aimed to show that the two infecting strains were the same, and then to compare the fitness of the resistant strain to that of the sensitive strain.The isolates were typed by RFLP. The fitness of the multi-drug resistant tuberculosis strain was determined by calculating the ratio of generation produced by the drug-resistant and a drug-susceptible strain in a mixed culture. The number of bacteria present in this broth culture was estimated using the Miles and Misra technique. The number of drug-resistant bacteria present was determined by inoculating aliquots of broth onto Middlebrook 7H10 agar with 5mg/l rifampicin.The infecting strain of Mycobacterium tuberculosis was shown to be the same on RFLP typing in both cases. It was found that the multi-drug resistant organism had decreased fitness compared to the sensitive organism.The decreased relative fitness of the resistant strain implies a physiologic cal cost for the development of drug resistance.

Background In Emergency and Medical Admission Departments (EDs and MADs), prompt recognition and appropriate infection control management of patients with Highly Infectious Diseases (HIDs, e.g. Viral Hemorrhagic Fevers and SARS) are fundamental for avoiding nosocomial outbreaks. Methods The EuroNHID (European Network for Highly Infectious Diseases) project collected data from 41 EDs and MADs in 14 European countries, located in the same facility as a national/regional referral centre for HIDs, using specifically developed checklists, during on-site visits from February to November 2009. Results Isolation rooms were available in 34 facilities (82,9%): these rooms had anteroom in 19, dedicated entrance in 15, negative pressure in 17, and HEPA filtration of exhausting air in 12. Only 6 centres (14,6%) had isolation rooms with all characteristics. Personnel trained for the recognition of HIDs was available in 24 facilities; management protocols for HIDs were available in 35. Conclusions Preparedness level for the safe and appropriate management of HIDs is partially adequate in the surveyed EDs and MADs.

a Clinical Research Group, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK b Department of Infectious Diseases, Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK c Imperial College London, Department of Infection & Tropical Medicine, Imperial College, Lister Unit, Northwick Park, Harrow, Middlesex HA1 3UJ, UK d Hospital for Tropical Diseases, Mortimer Market Centre, Capper Street off Tottenham Court Road, London WC1E 6AU, UK e Gates Malaria Partnership, London School of Hygiene and Tropical Medicine, 50 Bedford Square, London WC1B 3DP, UK f Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK g Royal Free Hospital, Infection Services, Pond Street, Hampstead, London NW3 2QG, UK

Twenty-nine healthy persons were Schick tested as part of their occupational health examination. All but three of them had been previously immunised against diphtheria. One unimmunised person had a history of diphtheria. Blood samples were taken before and at varied intervals after the Schick tests in order to determine whether the Schick test antigen was immunogenic. Of the 29 persons tested, 21 were Schick-negative, three were Schick-positive. Four pseudoreactors were Schick-negative, one pseudoreactor was Schick-positive. Only four of the 29 had any significant rise in antitoxin titre after Schick testing. Three of these were Schick-negative, while one was a pseudoreactor who was negative at a later reading. We conclude that Schick testing is not reliably immunogenic and that, contrary to expectation, it cannot be assumed to elicit a useful booster response in previously immunised persons.

A 36-year-old woman became ill with meningitis caused by Listeria monocytogenes. She had eaten soft cheese from which a similar organism was isolated.

Summary The data available from reports received by the PHLS Communicable Disease Surveillance Centre show that toxoplasmosis is associated with two main types of disease; a glandular or acute form with high antibody levels, and an ocular or late form with lower antibody levels. Reports show a seasonal variation, with a slight dip in incidence during the summer. Young adults are the group most commonly reported; of particular interest however is the very low incidence of toxoplasmosis in children, which throws some doubt on the importance of cat faeces in the transmission of this disease. A surprisingly low number of congenital cases was reported, perhaps because some cases have few or none of the recognised stigmata, and are therefore not investigated.

Highly infectious diseases involve clinical syndromes ranging from single to multiorgan infections and pose a constant threat to the public. In the absence of a definite treatment for most causative agents, patients benefit from maximum supportive care as clinical conditions may deteriorate in the short term. Hence, following initial case identification and isolation, rapid transportation to a specialized treatment unit must be considered in order to minimize the risk of secondary infections, but this is limited by available infrastructure, accessible care en route and the patient's clinical condition. Despite the development of consensus curricula for the clinical management of highly infectious patients, medical transportation lacks a common European approach. This article describes, as examples, three current European concepts for the domestic relocation of highly infectious patients by ground vehicles and aircraft with respect to national legislation and geography.

Between January 1983 and April 1984 60 patients completed their admission to an infectious diseases unit for management of methicillin-resistant Staphylococcus aureus. All had been shown to be colonized with a particular epidemic strain (EMRSA), and most isolates were from the nose or from broken skin sites. Eight patients were thought to have systemic EMRSA infection, of whom three had bacteraemia. Ten of the 60 patients died of severe underlying disease, eight were discharged home well but still colonized with EMRSA, four never had positive isolates after admission, and the remaining 38 cleared their EMRSA colonization in an average of 2 months. Five patients had further isolates of EMRSA after three negative, weekly screening tests and one after four negative screenings. No patients had further isolates after five or more negative screening tests.