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101. Safety and Immunogenicity of Coadministering a Combined Meningococcal Serogroup C and Haemophilus influenzaeType b Conjugate Vaccine with 7-Valent Pneumococcal Conjugate Vaccine and Measles, Mumps, and Rubella Vaccine at 12 Months of Age

Author

Miller, Elizabeth, Andrews, Nick, Waight, Pauline, Findlow, Helen, Ashton, Lindsey, England, Anna, Stanford, Elaine, Matheson, Mary, Southern, Joanna, Sheasby, Elizabeth, Goldblatt, David, and Borrow, Ray

Abstract

ABSTRACTThe coadministration of the combined meningococcal serogroup C conjugate (MCC)/Haemophilus influenzaetype b (Hib) vaccine with pneumococcal conjugate vaccine (PCV7) and measles, mumps, and rubella (MMR) vaccine at 12 months of age was investigated to assess the safety and immunogenicity of this regimen compared with separate administration of the conjugate vaccines. Children were randomized to receive MCC/Hib vaccine alone followed 1 month later by PCV7 with MMR vaccine or to receive all three vaccines concomitantly. Immunogenicity endpoints were MCC serum bactericidal antibody (SBA) titers of =8, Hib-polyribosylribitol phosphate (PRP) IgG antibody concentrations of =0.15 µg/ml, PCV serotype-specific IgG concentrations of =0.35 µg/ml, measles and mumps IgG concentrations of >120 arbitrary units (AU)/ml, and rubella IgG concentrations of =11 AU/ml. For safety assessment, the proportions of children with erythema, swelling, or tenderness at site of injection or fever or other systemic symptoms for 7 days after immunization were compared between regimens. No adverse consequences for either safety or immunogenicity were demonstrated when MCC/Hib vaccine was given concomitantly with PCV and MMR vaccine at 12 months of age or separately at 12 and 13 months of age. Any small differences in immunogenicity were largely in the direction of a higher response when all three vaccines were given concomitantly. For systemic symptoms, there was no evidence of an additive effect; rather, any differences between schedules showed benefit from the concomitant administration of all three vaccines, such as lower overall proportions with postvaccination fevers. The United Kingdom infant immunization schedule now recommends that these three vaccines may be offered at one visit at between 12 and 13 months of age.

Published
2011
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102. CORRESPONDENCE.

Author

Miller, Elizabeth, Waight, Pauline, Rousseau, Stephen A., Hambling, Milton H., Rushton, Peter, Ellis, David, Jones, Gill, McGlashan, J.A., Talukder, M.Q.-K., Duggan, Maureen B., Wharton, Brian, Oakeshott, Pippa, Nicholl, Jon, Lewis, L.S., Rose, Geoffrey, Skrabanek, Petr, Senn, S.J., and Ginsburg, Jean

Subjects
*LETTERS, *MEDICAL care, *RUBELLA
Abstract

Reports several correspondence on medical health care. Susceptibility to rubella among pregnant women in Asia; Association of Β hemolytic streptococcus with necrosing fascilitis; Comments on feeding technique for babies and children in the Third World countries.

Published
1990

103. Kinetics of Antibody Persistence following Administration of a Combination Meningococcal Serogroup C and Haemophilus influenzaeType b Conjugate Vaccine in Healthy Infants in the United Kingdom Primed with a Monovalent Meningococcal Serogroup C Vaccine

Author

Borrow, Ray, Andrews, Nick, Findlow, Helen, Waight, Pauline, Southern, Joanna, Crowley-Luke, Annette, Stapley, Lorraine, England, Anna, Findlow, Jamie, and Miller, Elizabeth

Abstract

ABSTRACTThe kinetics of antibody persistence following the administration of a combination meningococcal serogroup C and Haemophilus influenzaetype b (Hib) conjugate vaccine (Menitorix) in the second year of life in children primed with two doses of one of three monovalent meningococcal serogroup C (MCC) vaccines was investigated. The study subjects were administered either Menitorix at 12 to 15 months of age, followed by the seven-valent pneumococcal conjugate vaccine (PCV7) and the measles, mumps, and rubella vaccine 4 to 6 weeks later, or all three vaccines concomitantly at 12 to 15 months of age. Blood samples were collected before and 1, 2, 12, and 24 months after the boosting. Sera were analyzed for meningococcal serogroup C serum bactericidal antibody (SBA) and IgG as well as Hib-polyribosylribitol phosphate (PRP)-specific IgG. The antibody persistence data from this study were compared to those of a prior study of Southern et al. (Clin. Vaccine Immunol. 14:1328-1333, 2007) in which children were given three primary doses of a vaccine containing both the MCC and the Hib vaccines but were boosted only with a Hib conjugate vaccine. The magnitude of the meningococcal SBA geometric mean titer was higher for those subjects primed with the MCC vaccine conjugated to tetanus toxoid (NeisVac-C) than for those primed with one of two MCC vaccines conjugated to CRM197(Menjugate or Meningitec) up to 1 year following boosting. Two years after boosting, the percentages of subjects with putatively protective SBA titers of =8 for children primed with NeisVac-C, Menjugate, and Meningitec were 43%, 22%, and 23%, respectively. Additional booster doses of the MCC vaccine may be required in the future to maintain good antibody levels; however, there is no immediate need for a booster during adolescence, as mathematical modeling has shown that persisting herd immunity is likely to control disease for a number of years.

Published
2010
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104. A relational database for management of flow cytometry and ELISpot clinical trial data

Author

Cavenaugh, James S., Snell, Paul, Jeffries, David, Waight, Pauline A., and McConkey, Samuel J.

Abstract

Although relational databases are widely used in bioinformatics with deposited and finalized data, they have not received widespread usage among immunologists for managing raw laboratory data such as that generated by ELISpot or flow cytometry assays. Almost no published guidance exists for immunologists to design appropriate and useful data management systems.We describe the design and implementation of a Microsoft Access relational database used in a clinical trial in which the primary immunogenicity measures were ELISpot and intracellular cytokine staining.Our data management system enabled us to perform sophisticated queries and to interpret our data as quantitatively as possible. It could easily be used without modification by other researchers using automated plate reading of ELISpot plates or four color flow cytometry.We illustrate in detail the use of a flexible data management system for two of the most widely used immunological techniques. Minor modifications for more colors or other outputs can easily be implemented. Based on this example, other modifications could be easily envisaged for any other quantitative output. © 2006 International Society for Analytical Cytology

Published
2007
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105. Impact of outpatient neuraminidase inhibitor treatment in patients infected with influenza A(H1N1)pdm09 at high risk of hospitalization: an Individual Participant Data (IPD) meta-analysis

Author

Venkatesan, Sudhir, Myles, Puja R., Leonardi-Bee, Jo, Muthuri, Stella G., Al Masri, Malak, Andrews, Nick, Bantar, Carlos, Dubnov-Raz, Gal, Gérardin, Patrick, Koay, Evelyn S.C., Loh, Tze Ping, Memish, Ziad A., Miller, Elizabeth, Oliva, Maria E., Rath, Barbara A., Schweiger, Brunhilde, Tang, Julian W., Tran, Dat, Vidmar, Tjasa, Waight, Pauline A., Nguyen-Van-Tam, Jonathan S., Venkatesan, Sudhir, Myles, Puja R., Leonardi-Bee, Jo, Muthuri, Stella G., Al Masri, Malak, Andrews, Nick, Bantar, Carlos, Dubnov-Raz, Gal, Gérardin, Patrick, Koay, Evelyn S.C., Loh, Tze Ping, Memish, Ziad A., Miller, Elizabeth, Oliva, Maria E., Rath, Barbara A., Schweiger, Brunhilde, Tang, Julian W., Tran, Dat, Vidmar, Tjasa, Waight, Pauline A., and Nguyen-Van-Tam, Jonathan S.

Abstract

Background: While evidence exists to support the effectiveness of neuraminidase inhibitors (NAIs) in reducing mortality when given to hospitalized patients with A(H1N1)pdm09 virus infection, the impact of outpatient treatment on hospitalization has not been clearly established. We investigated the impact of outpatient NAI treatment on subsequent hospitalization in patients with A(H1N1)pdm09 virus infection. Methods: We assembled general community and outpatient data from 9 clinical centers in different countries collected between January 2009 and December 2010. We standardized data from each study center to create a pooled dataset and then used mixed-effects logistic regression modeling to determine the effect of NAI treatment on hospitalization. We adjusted for NAI treatment propensity and preadmission antibiotic use, including “study center” as a random intercept to account for differences in baseline hospitalization rate between centers. Results: We included 3376 patients with influenza A(H1N1)pdm09, of whom 3085 (91.4%) had laboratory-confirmed infection. Eight hundred seventy-three patients (25.8%) received outpatient or community-based NAI treatment, 928 of 2395 (38.8%) with available data had dyspnea or respiratory distress, and hospitalizations occurred in 1705 (50.5%). After adjustment for preadmission antibiotics and NAI treatment propensity, preadmission NAI treatment was associated with decreased odds of hospital admission compared to no NAI treatment (adjusted odds ratio, 0.24; 95% confidence interval, 0.20–0.30). Conclusions: In a population with confirmed or suspected A(H1N1)pdm09 and at high risk of hospitalization, outpatient or community-based NAI treatment significantly reduced the likelihood of requiring hospital admission. These data suggest that community patients with severe influenza should receive NAI treatment.

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106. Impact of outpatient neuraminidase inhibitor treatment in patients infected with influenza A(H1N1)pdm09 at high risk of hospitalization: an Individual Participant Data (IPD) meta-analysis

Author

Venkatesan, Sudhir, Myles, Puja R., Leonardi-Bee, Jo, Muthuri, Stella G., Al Masri, Malak, Andrews, Nick, Bantar, Carlos, Dubnov-Raz, Gal, Gérardin, Patrick, Koay, Evelyn S.C., Loh, Tze Ping, Memish, Ziad A., Miller, Elizabeth, Oliva, Maria E., Rath, Barbara A., Schweiger, Brunhilde, Tang, Julian W., Tran, Dat, Vidmar, Tjasa, Waight, Pauline A., Nguyen-Van-Tam, Jonathan S., Venkatesan, Sudhir, Myles, Puja R., Leonardi-Bee, Jo, Muthuri, Stella G., Al Masri, Malak, Andrews, Nick, Bantar, Carlos, Dubnov-Raz, Gal, Gérardin, Patrick, Koay, Evelyn S.C., Loh, Tze Ping, Memish, Ziad A., Miller, Elizabeth, Oliva, Maria E., Rath, Barbara A., Schweiger, Brunhilde, Tang, Julian W., Tran, Dat, Vidmar, Tjasa, Waight, Pauline A., and Nguyen-Van-Tam, Jonathan S.

Abstract

Background: While evidence exists to support the effectiveness of neuraminidase inhibitors (NAIs) in reducing mortality when given to hospitalized patients with A(H1N1)pdm09 virus infection, the impact of outpatient treatment on hospitalization has not been clearly established. We investigated the impact of outpatient NAI treatment on subsequent hospitalization in patients with A(H1N1)pdm09 virus infection. Methods: We assembled general community and outpatient data from 9 clinical centers in different countries collected between January 2009 and December 2010. We standardized data from each study center to create a pooled dataset and then used mixed-effects logistic regression modeling to determine the effect of NAI treatment on hospitalization. We adjusted for NAI treatment propensity and preadmission antibiotic use, including “study center” as a random intercept to account for differences in baseline hospitalization rate between centers. Results: We included 3376 patients with influenza A(H1N1)pdm09, of whom 3085 (91.4%) had laboratory-confirmed infection. Eight hundred seventy-three patients (25.8%) received outpatient or community-based NAI treatment, 928 of 2395 (38.8%) with available data had dyspnea or respiratory distress, and hospitalizations occurred in 1705 (50.5%). After adjustment for preadmission antibiotics and NAI treatment propensity, preadmission NAI treatment was associated with decreased odds of hospital admission compared to no NAI treatment (adjusted odds ratio, 0.24; 95% confidence interval, 0.20–0.30). Conclusions: In a population with confirmed or suspected A(H1N1)pdm09 and at high risk of hospitalization, outpatient or community-based NAI treatment significantly reduced the likelihood of requiring hospital admission. These data suggest that community patients with severe influenza should receive NAI treatment.

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107. Impact of outpatient neuraminidase inhibitor treatment in patients infected with influenza A(H1N1)pdm09 at high risk of hospitalization: an Individual Participant Data (IPD) meta-analysis

Author

Venkatesan, Sudhir, Myles, Puja R., Leonardi-Bee, Jo, Muthuri, Stella G., Al Masri, Malak, Andrews, Nick, Bantar, Carlos, Dubnov-Raz, Gal, Gérardin, Patrick, Koay, Evelyn S.C., Loh, Tze Ping, Memish, Ziad A., Miller, Elizabeth, Oliva, Maria E., Rath, Barbara A., Schweiger, Brunhilde, Tang, Julian W., Tran, Dat, Vidmar, Tjasa, Waight, Pauline A., Nguyen-Van-Tam, Jonathan S., Venkatesan, Sudhir, Myles, Puja R., Leonardi-Bee, Jo, Muthuri, Stella G., Al Masri, Malak, Andrews, Nick, Bantar, Carlos, Dubnov-Raz, Gal, Gérardin, Patrick, Koay, Evelyn S.C., Loh, Tze Ping, Memish, Ziad A., Miller, Elizabeth, Oliva, Maria E., Rath, Barbara A., Schweiger, Brunhilde, Tang, Julian W., Tran, Dat, Vidmar, Tjasa, Waight, Pauline A., and Nguyen-Van-Tam, Jonathan S.

Abstract

Background: While evidence exists to support the effectiveness of neuraminidase inhibitors (NAIs) in reducing mortality when given to hospitalized patients with A(H1N1)pdm09 virus infection, the impact of outpatient treatment on hospitalization has not been clearly established. We investigated the impact of outpatient NAI treatment on subsequent hospitalization in patients with A(H1N1)pdm09 virus infection. Methods: We assembled general community and outpatient data from 9 clinical centers in different countries collected between January 2009 and December 2010. We standardized data from each study center to create a pooled dataset and then used mixed-effects logistic regression modeling to determine the effect of NAI treatment on hospitalization. We adjusted for NAI treatment propensity and preadmission antibiotic use, including “study center” as a random intercept to account for differences in baseline hospitalization rate between centers. Results: We included 3376 patients with influenza A(H1N1)pdm09, of whom 3085 (91.4%) had laboratory-confirmed infection. Eight hundred seventy-three patients (25.8%) received outpatient or community-based NAI treatment, 928 of 2395 (38.8%) with available data had dyspnea or respiratory distress, and hospitalizations occurred in 1705 (50.5%). After adjustment for preadmission antibiotics and NAI treatment propensity, preadmission NAI treatment was associated with decreased odds of hospital admission compared to no NAI treatment (adjusted odds ratio, 0.24; 95% confidence interval, 0.20–0.30). Conclusions: In a population with confirmed or suspected A(H1N1)pdm09 and at high risk of hospitalization, outpatient or community-based NAI treatment significantly reduced the likelihood of requiring hospital admission. These data suggest that community patients with severe influenza should receive NAI treatment.

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108. Impact of outpatient neuraminidase inhibitor treatment in patients infected with influenza A(H1N1)pdm09 at high risk of hospitalization: an Individual Participant Data (IPD) meta-analysis

Author

Venkatesan, Sudhir, Myles, Puja R., Leonardi-Bee, Jo, Muthuri, Stella G., Al Masri, Malak, Andrews, Nick, Bantar, Carlos, Dubnov-Raz, Gal, Gérardin, Patrick, Koay, Evelyn S.C., Loh, Tze Ping, Memish, Ziad A., Miller, Elizabeth, Oliva, Maria E., Rath, Barbara A., Schweiger, Brunhilde, Tang, Julian W., Tran, Dat, Vidmar, Tjasa, Waight, Pauline A., Nguyen-Van-Tam, Jonathan S., Venkatesan, Sudhir, Myles, Puja R., Leonardi-Bee, Jo, Muthuri, Stella G., Al Masri, Malak, Andrews, Nick, Bantar, Carlos, Dubnov-Raz, Gal, Gérardin, Patrick, Koay, Evelyn S.C., Loh, Tze Ping, Memish, Ziad A., Miller, Elizabeth, Oliva, Maria E., Rath, Barbara A., Schweiger, Brunhilde, Tang, Julian W., Tran, Dat, Vidmar, Tjasa, Waight, Pauline A., and Nguyen-Van-Tam, Jonathan S.

Abstract

Background: While evidence exists to support the effectiveness of neuraminidase inhibitors (NAIs) in reducing mortality when given to hospitalized patients with A(H1N1)pdm09 virus infection, the impact of outpatient treatment on hospitalization has not been clearly established. We investigated the impact of outpatient NAI treatment on subsequent hospitalization in patients with A(H1N1)pdm09 virus infection. Methods: We assembled general community and outpatient data from 9 clinical centers in different countries collected between January 2009 and December 2010. We standardized data from each study center to create a pooled dataset and then used mixed-effects logistic regression modeling to determine the effect of NAI treatment on hospitalization. We adjusted for NAI treatment propensity and preadmission antibiotic use, including “study center” as a random intercept to account for differences in baseline hospitalization rate between centers. Results: We included 3376 patients with influenza A(H1N1)pdm09, of whom 3085 (91.4%) had laboratory-confirmed infection. Eight hundred seventy-three patients (25.8%) received outpatient or community-based NAI treatment, 928 of 2395 (38.8%) with available data had dyspnea or respiratory distress, and hospitalizations occurred in 1705 (50.5%). After adjustment for preadmission antibiotics and NAI treatment propensity, preadmission NAI treatment was associated with decreased odds of hospital admission compared to no NAI treatment (adjusted odds ratio, 0.24; 95% confidence interval, 0.20–0.30). Conclusions: In a population with confirmed or suspected A(H1N1)pdm09 and at high risk of hospitalization, outpatient or community-based NAI treatment significantly reduced the likelihood of requiring hospital admission. These data suggest that community patients with severe influenza should receive NAI treatment.

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109. Impact of outpatient neuraminidase inhibitor treatment in patients infected with influenza A(H1N1)pdm09 at high risk of hospitalization: an Individual Participant Data (IPD) meta-analysis

Author

Venkatesan, Sudhir, Myles, Puja R., Leonardi-Bee, Jo, Muthuri, Stella G., Al Masri, Malak, Andrews, Nick, Bantar, Carlos, Dubnov-Raz, Gal, Gérardin, Patrick, Koay, Evelyn S.C., Loh, Tze Ping, Memish, Ziad A., Miller, Elizabeth, Oliva, Maria E., Rath, Barbara A., Schweiger, Brunhilde, Tang, Julian W., Tran, Dat, Vidmar, Tjasa, Waight, Pauline A., Nguyen-Van-Tam, Jonathan S., Venkatesan, Sudhir, Myles, Puja R., Leonardi-Bee, Jo, Muthuri, Stella G., Al Masri, Malak, Andrews, Nick, Bantar, Carlos, Dubnov-Raz, Gal, Gérardin, Patrick, Koay, Evelyn S.C., Loh, Tze Ping, Memish, Ziad A., Miller, Elizabeth, Oliva, Maria E., Rath, Barbara A., Schweiger, Brunhilde, Tang, Julian W., Tran, Dat, Vidmar, Tjasa, Waight, Pauline A., and Nguyen-Van-Tam, Jonathan S.

Abstract

Background: While evidence exists to support the effectiveness of neuraminidase inhibitors (NAIs) in reducing mortality when given to hospitalized patients with A(H1N1)pdm09 virus infection, the impact of outpatient treatment on hospitalization has not been clearly established. We investigated the impact of outpatient NAI treatment on subsequent hospitalization in patients with A(H1N1)pdm09 virus infection. Methods: We assembled general community and outpatient data from 9 clinical centers in different countries collected between January 2009 and December 2010. We standardized data from each study center to create a pooled dataset and then used mixed-effects logistic regression modeling to determine the effect of NAI treatment on hospitalization. We adjusted for NAI treatment propensity and preadmission antibiotic use, including “study center” as a random intercept to account for differences in baseline hospitalization rate between centers. Results: We included 3376 patients with influenza A(H1N1)pdm09, of whom 3085 (91.4%) had laboratory-confirmed infection. Eight hundred seventy-three patients (25.8%) received outpatient or community-based NAI treatment, 928 of 2395 (38.8%) with available data had dyspnea or respiratory distress, and hospitalizations occurred in 1705 (50.5%). After adjustment for preadmission antibiotics and NAI treatment propensity, preadmission NAI treatment was associated with decreased odds of hospital admission compared to no NAI treatment (adjusted odds ratio, 0.24; 95% confidence interval, 0.20–0.30). Conclusions: In a population with confirmed or suspected A(H1N1)pdm09 and at high risk of hospitalization, outpatient or community-based NAI treatment significantly reduced the likelihood of requiring hospital admission. These data suggest that community patients with severe influenza should receive NAI treatment.

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112. Epidemiology: Rubella susceptibility and the continuing risk of infection in pregnancy.

Author

Miller, Christine L., Miller, Elizabeth, and Waight, Pauline A.

Subjects
RUBELLA vaccines, RUBELLA, DISEASE susceptibility
Abstract

Reports on the rubella susceptibility and the continuing risk of infection in pregnancy. Campaign of Department of Health and Social Security uptake of rubella vaccination in schoolgirls and women; Study on the monitor of rubella susceptibility and infection in pregnancy; Data on vaccination of non-immune women; Survey on rubella infections in pregnancy in 1985 and 1986.

Published
1987
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113. Monitoring the emergence of community transmission of influenza A/H1N12009 in England: a cross sectional opportunistic survey of self sampled telephone callers to NHS Direct.

Author

Elliot, Alex J., Powers, Cassandra, Thornton, Alicia, Obi, Chinelo, Hill, Caterina, Simms, Ian, Waight, Pauline, Foord, david, Povey, Enid, Wreghitt, Tim, Goddard, Nichola, Ellis, Joanna, Bermingham, Alison, Sebastianpillai, Praveen, Lackenby, Angie, Zambon, Maria, Brown, David, Smith, Gillian E., Gill, O Noel, and Maguire, Helen

Subjects
H1N1 influenza, INFECTIOUS disease transmission, INFLUENZA
Abstract

The article discusses a study which investigated the emergence of community transmission of influenza A/H1N1 in England based on results from self sampling of NHS Direct callers with influenza-like illness. People in six Strategic Health Authorities with cold of flu symptoms or both were involved in the study, who called the NHS Direct multi-channel health advice and information service. It was found that a reliable indication of local community transmission was provided by Testing in Health Protection Agency regional laboratories.

Published
2009
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114. Monitoring the emergence of community transmission of influenza A/H1N1 2009 in England: a cross sectional opportunistic survey of self sampled telephone callers to NHS Direct.

Author

Elliot AJ, Powers C, Thornton A, Obi C, Hill C, Simms I, Waight P, Maguire H, Foord D, Povey E, Wreghitt T, Goddard N, Ellis J, Bermingham A, Sebastianpillai P, Lackenby A, Zambon M, Brown D, Smith GE, and Gill ON

Subjects
Adolescent, Adult, Aged, Community-Acquired Infections epidemiology, Community-Acquired Infections transmission, Cross-Sectional Studies, England epidemiology, Humans, Influenza, Human epidemiology, Middle Aged, Telephone, Young Adult, Influenza A Virus, H1N1 Subtype, Influenza, Human transmission
Abstract

Objective: To evaluate ascertainment of the onset of community transmission of influenza A/H1N1 2009 (swine flu) in England during the earliest phase of the epidemic through comparing data from two surveillance systems., Design: Cross sectional opportunistic survey., Study Samples: Results from self samples by consenting patients who had called the NHS Direct telephone health line with cold or flu symptoms, or both, and results from Health Protection Agency (HPA) regional microbiology laboratories on patients tested according to the clinical algorithm for the management of suspected cases of swine flu., Setting: Six regions of England between 24 May and 30 June 2009., Main Outcome Measure: Proportion of specimens with laboratory evidence of influenza A/H1N1 2009., Results: Influenza A/H1N1 2009 infections were detected in 91 (7%) of the 1385 self sampled specimens tested. In addition, eight instances of influenza A/H3 infection and two cases of influenza B infection were detected. The weekly rate of change in the proportions of infected individuals according to self obtained samples closely matched the rate of increase in the proportions of infected people reported by HPA regional laboratories. Comparing the data from both systems showed that local community transmission was occurring in London and the West Midlands once HPA regional laboratories began detecting 100 or more influenza A/H1N1 2009 infections, or a proportion positive of over 20% of those tested, each week., Conclusions: Trends in the proportion of patients with influenza A/H1N1 2009 across regions detected through clinical management were mirrored by the proportion of NHS Direct callers with laboratory confirmed infection. The initial concern that information from HPA regional laboratory reports would be too limited because it was based on testing patients with either travel associated risk or who were contacts of other influenza cases was unfounded. Reports from HPA regional laboratories could be used to recognise the extent to which local community transmission was occurring.

Published
2009
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