Search

This paper describes the development and implementation of the xsel program in Western NSW. The program supports identified high school students from regional, rural and remote communities to access the study of English, maths and science at an academically selective level. A program review was undertaken during 2012 using a structured questionaire to develop deeper understandings of the operational challenges, initial successes and potential improvements available to the program after three years of operation. The program review involved interviews with Principals, classroom teachers, students and parents of the program. The summative information from this process and initial planning documentation informs the content of this paper. The xsel program is unique in that it applies a combination of on-line learning, distance education and traditional bricks and mortar schooling to meet the learning needs of a particular equity group; talented and gifted secondary students. The program has taken on one aspect of the geographic challenge of equitable access to educational opportunity and builds the capacity of rural educators to cooperate, collaborate and co-create and overcome the “tyranny of distance”(Blainey, 1966).

Biosecurity measures are traditionally applied to laboratories, but they may also be usefully applied in highly specialized clinical settings, such as the isolation facilities for the management of patients with highly infectious diseases (eg, viral hemorrhagic fevers, SARS, smallpox, potentially severe pandemic flu, and MDR- and XDR-tuberculosis). In 2009 the European Network for Highly Infectious Diseases conducted a survey in 48 isolation facilities in 16 European countries to determine biosecurity measures for access control to the facility. Security personnel are present in 39 facilities (81%). In 35 facilities (73%), entrance to the isolation area is restricted; control methods include electronic keys, a PIN system, closed-circuit TV, and guards at the doors. In 25 facilities (52%), identification and registration of all staff entering and exiting the isolation area are required. Access control is used in most surveyed centers, but specific lacks exist in some facilities. Further data are needed to assess other biosecurity aspects, such as the security measures during the transportation of potentially contaminated materials and measures to address the risk of an "insider attack."

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.

Background Although generally mild, the 2009–2010 influenza A/H1N1 pandemic caused two major surges in hospital admissions in the UK. The characteristics of patients admitted during successive waves are described. Methods Data were systematically obtained on 1520 patients admitted to 75 UK hospitals between May 2009 and January 2010. Multivariable analyses identified factors predictive of severe outcome. Results Patients aged 5–54 years were over-represented compared with winter seasonal admissions for acute respiratory infection, as were non-white ethnic groups (first wave only). In the second wave patients were less likely to be school age than in the first wave, but their condition was more likely to be severe on presentation to hospital and they were more likely to have delayed admission. Overall, 45% had comorbid conditions, 16.5% required high dependency (level 2) or critical (level 3) care and 5.3% died. As in 1918–1919, the likelihood of severe outcome by age followed a W-shaped distribution. Pre-admission antiviral drug use decreased from 13.3% to 10% between the first and second waves (p=0.048), while antibiotic prescribing increased from 13.6% to 21.6% (p

Background Early identification of patients with H1N1 influenza-related pneumonia is desirable for the early instigation of antiviral agents. A study was undertaken to investigate whether adults admitted to hospital with H1N1 influenza-related pneumonia could be distinguished clinically from patients with non-H1N1 community-acquired pneumonia (CAP). Methods Between May 2009 and January 2010, clinical and epidemiological data of patients with confirmed H1N1 influenza infection admitted to 75 hospitals in the UK were collected by the Influenza Clinical Information Network (FLU-CIN). Adults with H1N1 influenza-related pneumonia were identified and compared with a prospective study cohort of adults with CAP hospitalised between September 2008 and June 2010, excluding those admitted during the period of the pandemic. Results Of 1046 adults with confirmed H1N1 influenza infection in the FLU-CIN cohort, 254 (25%) had H1N1 influenza-related pneumonia on admission to hospital. In-hospital mortality of these patients was 11.4% compared with 14.0% in patients with inter-pandemic CAP (n=648). A multivariate logistic regression model was generated by assigning one point for each of five clinical criteria: age ≤65 years, mental orientation, temperature ≥38°C, leucocyte count ≤12×10 9 /l and bilateral radiographic consolidation. A score of 4 or 5 predicted H1N1 influenza-related pneumonia with a positive likelihood ratio of 9.0. A score of 0 or 1 had a positive likelihood ratio of 75.7 for excluding it. Conclusion There are substantial clinical differences between H1N1 influenza-related pneumonia and inter-pandemic CAP. A model based on five simple clinical criteria enables the early identification of adults admitted with H1N1 influenza-related pneumonia.

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.

Claire Swales and Barbara Bannister highlight revised guidelines on malaria prevention published in January.

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: It has been suggested that deterioration of tuberculosis (TB) during appropriate treatment, termed a paradoxical reaction (PR), is more common and severe in HIV positive individuals on highly active antiretroviral therapy (HAART). Method: A study was undertaken to determine the frequency of PR and its associated features in a population of HIV+TB+ patients and a similar sized group of HIV−TB+ individuals. Results: PR occurred in 28% of 50 HIV+TB+ patients and 10% of 50 HIV−TB+ patients. Disseminated TB was present in eight of 13 HIV+TB+ patients and four of five HIV−TB+ patients with PR. In 28 HIV+TB+ patients starting HAART, PR was significantly associated with commencing HAART within 6 weeks of starting antituberculosis treatment (p = 0.03) and was more common in those with disseminated TB (p = 0.09). No association was found between development of PR and baseline CD4 count or CD4 response to HAART. Conclusions: PR is common in HIV infected and uninfected individuals with TB. Early introduction of HAART and the presence of disseminated TB appear to be important in co-infected patients.

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.

Viral haemorrhagic fevers are viral infections that can cause shock, haemorrhage and multi-organ dysfunction. Their geographical distribution is limited by the ecology of their vectors, and many of them exist in tropical zones. The most common viral haemorrhagic fevers are not transmissible from person to person, and no viral haemorrhagic fevers are a threat to casual contacts. However, four viruses for which prevention and treatment are unreliable or not available (Crimean-Congo, Ebola, Lassa and Marburg) can be transmitted to health-care or laboratory workers. Household and health-care-related transmission is mainly limited to carers of severely ill patients, particularly patients who are highly dependent or suffering severe haemorrhage. Specialist laboratories and clinical referral centres advise on the risk assessment of suspected cases and support management of proven cases. Patients with fever after visiting viral haemorrhagic fever-endemic areas are often infected with falciparum malaria, which can cause life-threatening disease if it is not recognized and treated. Malaria should always be excluded before considering a diagnosis of viral haemorrhagic fever. If malaria or another treatable disease is not evident, or there is a definite history of direct viral haemorrhagic fever exposure, advice should be sought from an expert unit, to arrange early and safe case-management.

Viral respiratory infections are the major cause of asthma exacerbations [1], while subjects with asthma are more likely to suffer significant morbidity when infected [2]. The severity and duration of respiratory insult depend on complex viral-host interactions. Abnormalities of the innate and adaptive immune response have been demonstrated in humans and in animal models of asthma [3]. These phenomena may explain the increased vulnerability of asthmatics to viral respiratory infections. Although less common than rhinovirus, which is responsible for 33–55% of asthma exacerbations in children and adults, seasonal influenza infection is a well-recognised cause of asthma exacerbations (3–23%) [1]. Dawood et al. [4] reported on a systematic surveillance programme for influenza-related hospitalisations of children in the USA. The proportion of children with asthma during seasonal influenza was 32% from 2003 to 2009, while 44% of children hospitalised with H1N1 in 2009 had asthma. O’Riordan et al. [5], in a paediatric hospital-based series, also found asthma to be more frequent during the H1N1 influenza pandemic of 2009 than in previous years of seasonal influenza (22% versus 6%). The remarkable increase in the risk of hospital admission in asthmatics with pandemic H1N1, compared with both seasonal influenza A and rhinovirus, may be explained by a lack of adaptive immunity to the H1N1 virus in many young asthmatic patients. Children with asthma were also more likely to require intensive care unit admission during the pandemic than with seasonal influenza A (22% versus 16%) [4]. In a prospective study during the autumn of 2009, Kloepfer et al. [6] collected nasal swabs for viral identification on a weekly basis. They found that children with asthma were more likely to become infected with H1N1 than children without …

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

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.

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.

Viral haemorrhagic fevers (VHFs) are severe infections capable of causing haemorrhagic disease and fatal multi-organ failure. Crimean-Congo, Marburg, Ebola and Lassa viruses cause both sporadic cases and large epidemics over wide endemic areas.Original articles and reviews identified by PubMed search and personal reading; European and United States national guidance and legislation. World Health Organization information, documents and reports. VHFs cause significant morbidity and mortality in their endemic areas; they can cause healthcare-related infections, and their broad diversity and range are increasingly recognized.There is uncertainty about the risks presented by VHFs in non-endemic countries, particularly in healthcare environments. Consensus on the best modes of care and infection control are only slowly emerging.With increasing commerce in rural and low-income areas, VHF outbreaks increasingly expand, causing social and economic damage.New ecologies, viral strains and clinical syndromes are being discovered. There is a great need for rapid diagnostic tests and effective antiviral treatments. Vaccine development programmes are challenged by multiple viral strains and the need for trials in rural communities.

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.

EDITOR —Ness et al suggest that service personnel in the Gulf should be randomised to receive either active anthrax vaccination or placebo, but they fail to appreciate the issues behind the decision to give the vaccine.1 The independent Advisory Group on Medical Countermeasures assessed that there was a real …

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.