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Hepatitis C (HCV) is an emerging health concern across the world, with 170 million people chronically infected and at risk of liver cancer, cirrhosis or liver failure. There is no vaccination and so it is important to learn as much as possible about how to prevent future infection. Modes of transmission include intravenous drug use (IDU), blood products, tattooing and, to a lesser extent, sexual intercourse. Homelessness is a risk factor of HCV because of the environments and behaviours associated with homeless communities such as poor hygiene, poor nutrition and high levels of IDU. The aim of this project was to determine the prevalence of HCV and its risk factors amongst the homeless community of Oxford, which is the second largest in the country. Ninety-eight individuals of the Oxford homeless community were interviewed and tested for HCV. The results gave an estimated HCV prevalence of 26.5 percent. The major risk factors in this population were IDU (past and present), age (over 20 years old) and sharing the paraphernalia used by i.v. drug users (e.g. spoons, foil and filters). With the exception of age, these risk factors could all be targeted in an attempt to reduce this prevalence and combat the major public health concern that HCV poses to the homeless community of Oxford. [ABSTRACT FROM AUTHOR]

Objective: To compare maternal morbidity in HIV-infected and uninfected pregnant women., Methods: Major maternal morbidity (severe febrile illness, illnesses requiring hospital admissions, surgical revisions, or illnesses resulting in death) was measured prospectively in a cohort of HIV-infected and uninfected women followed from 36 weeks of pregnancy to 6 weeks after delivery. Odds ratios of major morbidity and associated factors were examined using logistic regression., Results: Major morbidity was observed in 46/129 (36%) and 104/390 (27%) of the HIV-infected and HIV-uninfected women, respectively, who remained in followup. In the multivariable analysis, major morbidity was independently associated with HIV infection, adjusted odds ratio (AOR) 1.7 (1.1 to 2.7), nulliparity (AOR 2.0 (1.3 to 3.0)), and lack of, or minimal, formal education (AOR 2.1 (1.1 to 3.8))., Conclusions: HIV was associated with a 70% increase in the odds of major maternal morbidity in these Ugandan mothers.

Topical corticosteroids may be indicated in pregnant women with skin conditions, but their safety in pregnancy is unclear. We used the UK General Practice Research Database to conduct a population-based cohort study to investigate whether maternal exposure to topical corticosteroids results in adverse pregnancy outcomes. We identified 35,503 pregnant women prescribed topical corticosteroids during the period from 85 days before last menstrual period (LMP) to delivery or fetal death and 48,630 unexposed women. We found no associations of maternal exposure to topical corticosteroids with orofacial cleft (and its two subtypes, i.e., cleft lip ± palate (CLP) and cleft palate alone (CP)), preterm delivery, and fetal death (including miscarriage and stillbirth). The findings were similar when excluding exposure before LMP. In contrast, maternal exposure to potent/very potent topical corticosteroids shortly before and during pregnancy was significantly associated with fetal growth restriction (adjusted relative risk 2.08; 95% confidence interval 1.40-3.10; number needed to harm, 168), which was confirmed by a significant dose-response relationship (P=0.025) and the sensitivity analysis excluding exposure before LMP. The increased risk for fetal growth restriction should be considered when prescribing potent/very potent topical corticosteroids to pregnant women, and appropriate obstetric care should be provided.

Background: Symptoms are part of the initial evaluation of children with acute illness, and are often used to help identify those who may have serious infections. Meningococcal disease is a rapidly progressive infection that needs to be recognised early among children presenting to primary care., Aim: To determine the diagnostic value of presenting symptoms in primary care for meningococcal disease., Design of Study: Data on a series of presenting symptoms were collected using a parental symptoms checklist at point of care for children presenting to a GP with acute infection. Symptom frequencies were compared with existing data on the pre-hospital features of 345 children with meningococcal disease., Setting: UK primary care., Method: The study recruited a total of 1212 children aged under 16 years presenting to their GP with an acute illness, of whom 924 had an acute self-limiting infection, including 407 who were reported by parents to be febrile. Symptom frequencies were compared with those reported by parents of 345 children with meningococcal disease. Main outcome measures were diagnostic characteristics of individual symptoms for meningococcal disease., Results: Five symptoms have clinically useful positive likelihood ratios (LR+) for meningococcal disease: confusion (LR+ = 24.2, 95% confidence interval [CI] = 11.5 to 51.3), leg pain (LR+ = 7.6, 95% CI = 4.9 to 11.9), photophobia (LR+ = 6.5, 95% CI = 3.8 to 11.0), rash (LR+ = 5.5, 95% CI = 4.3 to 7.1), and neck pain/stiffness (LR+ = 5.3, 95% CI = 3.5 to 8.3). Cold hands and feet had limited diagnostic value (LR+ = 2.3, 95% CI = 1.9 to 3.0), while headache (LR+ = 1.0, 95% CI = 0.8 to 1.3), and pale colour (LR+ = 0.3, 95% CI = 0.2 to 0.5) did not discriminate meningococcal disease in children., Conclusion: This study confirms the diagnostic value of classic 'red flag' symptoms of neck stiffness, rash, and photophobia, but also suggests that the presence of confusion or leg pain in a child with an unexplained acute febrile illness should also usually prompt a face-to-face assessment to exclude meningococcal disease. Telephone triage systems and primary care clinicians should consider these as 'red flags' for serious infection.

Background: To report the experience of health workers who had played key roles in the early stages of implementing the prevention of mother-to-child HIV transmission services (PMTCT) in Uganda., Methods: Interviews were conducted with 15 key informants including counsellors, obstetricians and PMTCT coordinators at the five PMTCT test sites in Uganda to investigate the benefits, challenges and sustainability of the PMTCT programme. Audio-taped interviews were held with each informant between January and June 2003. These were transcribed verbatim and manually analysed using the framework approach., Results: The perceived benefits reported by informants were improvement of general obstetric care, provision of antiretroviral prophylaxis for HIV-positive mothers, staff training and community awareness. The main challenges lay in the reluctance of women to be tested for HIV, incomplete follow-up of participants, non-disclosure of HIV status and difficulties with infant feeding for HIV-positive mothers. Key informants thought that the programme's sustainability depended on maintaining staff morale and numbers, on improving services and providing more resources, particularly antiretroviral therapy for the HIV-positive women and their families., Conclusion: Uganda's experience in piloting the PMTCT programme reflected the many challenges faced by health workers. Potentially resource-sparing strategies such as the 'opt-out' approach to HIV testing required further evaluation.

To study the effect of HIV infection on quality of life (QOL) during pregnancy and puerperium, QOL was measured in a cohort study at St. Francis Hospital Nsambya, Kampala, Uganda. Dartmouth COOP charts were administered to 132 HIV-positive and 399 HIV-negative women at 36 weeks of pregnancy and six weeks post-partum. Responses were coded from 0 = best health-status to 4 = worst health-status and scores of 3-4 defined as poor. Odds ratios (OR) (95% confidence intervals(CI)) for poor scores were calculated and independent predictors of poor QOL examined using logistic regression. In pregnancy, HIV-positive women were more likely to have poor scores in feelings: OR = 3.2(1.9-5.3), daily activities: OR = 2.8(1.4-5.5), pain: OR = 2.1(1.3-3.5), overall health: OR = 1.7(1.1-2.7) and QOL: OR = 7.2(3.6-14.7), all p= 0.2). HIV infection was independently associated with poor QOL: OR = 8.5(3.8-19). Findings in puerperium were similar to those in pregnancy except more HIV-positive women had poor scores in social activities: OR = 2.5(1.4-4.7) and change in health: OR = 5.4(2-14.5) and infant death also predicted poor QOL: OR = 6.7(2.4-18.5). The findings reflect HIV's adverse impact on maternal QOL and the need for interventions to alleviate this infection's social and emotional effects.

Objectives: The antibiotic policies of hospitals and primary care trusts (PCTs) in South East England were audited in the summer of 2004, to see how they had improved since 2000., Methods: Antibiotic policies were obtained from pharmacists in NHS hospitals and PCTs, and examined for dates, formats, evidence base for policies, the type of guidance given on dosage, length of treatment, choice of antibiotics, coverage of common infections and reasons for prophylaxis., Results: Twenty-three hospital and 25 primary care policies were examined. The average age of policies was 12 months, but 13 were more than 2 years old. The commonest format was an A4-sized document available in an electronic version. Primary care policies were more uniform than hospital policies. More primary care than hospitals' policies gave evidence to support their guidance. Ten policies used plain English for dosages, and 38 (79%) policies made few or no cautionary points about the drugs recommended. Respiratory and urinary infections were covered in most policies, but guidance on gastroenteritis and antibiotic prophylaxis was less frequent. There was little advice in the policies on the management of methicillin-resistant Staphylococcus aureus., Conclusions: Primary care policies have improved since 2000, using a national model for evidence and a consistent style. Hospitals could benefit from similar national guidance, especially in the evidence to support the contents of antibiotic policies.

Background: Community prescribing of antibiotics has decreased substantially in the UK in recent years. We examine the association between pneumonia mortality and recent changes in community-based antibiotic prescribing for lower respiratory tract infections (LRTI)., Methods: Retrospective analysis of aggregated data for pneumonia mortality, influenza incidence, and antibiotic prescribing for LRTI in England and Wales during 12-week winter periods between 1993/94 and 1999/2000., Results: Winter antibiotic prescribing for LRTI showed a 30.0% decline since 1995/96. Over the same period, there was a 50.6% increase in winter excess pneumonia mortality adjusted for influenza incidence. Negative binomial regression analysis showed that the incidence of influenza alone had a significant association with winter pneumonia mortality (P<0.001). The analysis also showed the reduction in antibiotic prescribing had a small but significant association with mortality (P<0.001), when simultaneously modelling for influenza incidence., Conclusions: Our findings suggest an association between recent reductions in antibiotic prescribing for LRTI in general practice and an increase in pneumonia mortality in England and Wales. This retrospective study of aggregate data represents the first attempt to assess the effect of limiting antibiotic prescribing on patient outcomes, and highlights the need to identify which patients benefit from antibiotic treatment for LRTI.

Knowledge of the epidemiology of invasive pneumococcal disease (IPD) will aid in planning the use of pneumococcal vaccines. A United Kingdom (UK)-based surveillance in England and Wales (1995-1997) of 11,528 individuals with IPD and a local enhanced surveillance in the Oxford (UK) area (1995-1999) have been analyzed. IPD has a high attack rate in children, with 37.1-48.1 cases per 100,000 infants <1 year old per year, and in older persons, with 21.2-36.2 cases per 100,000 persons >65 years old per year, for England, Wales, and Oxford. The 7-valent conjugate vaccine includes serotypes causing < or =79% of IPD in children <5 years old, but only 66% in adults >65 years old. The data also indicate that IPD varies by serotype, age, and country, emphasizing that the epidemiology of IPD is heterogeneous and requires continued surveillance.

Background: Good prescribing practice has an important part to play in the fight against antimicrobial resistance. Whilst it was perceived that most hospitals and Health Authorities possessed an antibiotic policy, a review of antibiotic policies was conducted to gain an understanding of the extent, quality and usefulness of these policies., Methods: Letters were sent to pharmacists in hospitals and health authorities in across the South East region of the National Health Service Executive (NHSE) requesting antibiotic policies. data were extracted from the policies to assess four areas; antibiotic specific, condition specific, patient specific issues and underpinning evidence., Results: Of a possible 41 hospital trusts and 14 health authorities, 33 trusts and 9 health authorities (HAs) provided policies. Both trust and HA policies had a median publication date of 1998 (trust range 1993-99, HA 1994-99). Eleven policies were undated. The majority of policies had no supporting references for the statements made. All policies provided some details on specific antibiotics. Gentamicin and ciprofloxacin were the preferred aminoglycoside and quinolone respectively with cephalosporins being represented by cefuroxime or cefotaxime in trusts and cephradine or cephalexin in HAs. 26 trusts provided advice on surgical prophylaxis, 17 had meningococcal prophylaxis policies and 11 covered methicillin resistant Staphylococcus aureus (MRSA). There was little information for certain groups such as neonates or children, the pregnant or the elderly., Conclusion: There was considerable variation in content and quality across policies, a clear lack of an evidence base and a need to revise policies in line with current recommendations.

Individuals without a spleen have an increased risk of overwhelming post-splenectomy infection (OPSI). Improved awareness in recent years has stimulated increased efforts to prevent OPSI. Published guidelines have described policies for immunization, chemoprophylaxis and other measures considered beneficial to asplenic patients, yet OPSI episodes continue to occur. In an attempt to investigate why serious infections are still being seen, we have conducted a nationally based survey of recent OPSI episodes, using mainly a network of medical microbiologists. Data including clinical background to both splenectomy and OPSI episode, immunization and chemoprophylaxis history have been collated. Forty-two cases of overwhelming infection were reported by June 1996. Patients of all ages were affected with OPSI occurring up to 59 years after splenectomy. A mortality rate of 45% was seen. Pneumococcal infection caused at least 37 of 42 episodes, but only 12 patients had received pneumococcal vaccine. Four cases were possible vaccine failures. Only 22% of individuals had taken any chemoprophylaxis since splenectomy, and only one carried a medical alert card. Much more needs to be done to ensure that asplenic patients are warned of the risks of infection, and given at least pneumococcal vaccine. The role of antibiotics for either continual prophylaxis or as a reserve supply for self-prescription at appropriate times also needs greater discussion. Further work on improving pneumococcal vaccine response together with suitable programmes for revaccination are required. Surveillance should continue until the incidence of OPSI reaches an irreducible minimum.

Background: Standard laboratory techniques, such as viral culture and serology, provide only circumstantial or retrospective evidence of viral infections of the central nervous system (CNS). We assessed the diagnostic accuracy of PCR of cerebrospinal fluid (CSF) in the diagnosis of viral infections of the CNS., Methods: We examined all the CSF samples that were received at our diagnostic virology laboratory between May, 1994, and May, 1996, by nested PCR for viruses associated with CNS infections in the UK. We collected clinical and laboratory data for 410 patients from Oxford city hospitals (the Oxford cohort) whose CSF was examined between May, 1994, and May, 1995. These patients were classified according to the likelihood of a viral infection of the CNS. We used stratified logistic regression analysis to identify the clinical factors independently associated with a positive PCR result. We calculated likelihood ratios to estimate the clinical usefulness of PCR amplification of CSF., Findings: We tested 2233 consecutive CSF samples from 2162 patients. A positive PCR result was obtained in 143 patients, including 22 from the Oxford cohort. Logistic regression analysis of the Oxford cohort showed that fever, a virus-specific rash, and a CSF white-cell count of 5/microL or more were independent predictors of a positive PCR result. The likelihood ratio for a definite diagnosis of viral infection of the CNS in a patient with a positive PCR result, relative to a negative PCR result, was 88.2 (95% CI 20.6-378). The likelihood ratio for a possible diagnosis of viral infection of the CNS in a patient with a negative PCR result, relative to a positive PCR result, was 0.10 (0.03-0.39)., Interpretation: A patient with a positive PCR result was 88 times as likely to have a definite diagnosis of viral infection of the CNS as a patient with a negative PCR result. A negative PCR result can be used with moderate confidence to rule out a diagnosis of viral infection of the CNS. We believe that PCR will become the first-line diagnostic test for viral meningitis and encephalitis.

New meningococcal vaccines are needed in the United Kingdom with some urgency. Almost all Neisseria meningitidis disease in this country is caused by serogroups B and C. Infants have the highest attack rates, but also make the poorest immunological responses to potential vaccines. The development of vaccines that protect infants is a significant challenge. A capsule-based serogroup B vaccine is unlikely to be successful in infants because the capsule is poorly immunogenic and the polysaccharide molecule mimics a human epitope. Without completely discounting capsule as an immunogen, alternate antigens are being considered for immunisation: outer membrane proteins (OMP), iron regulating proteins, and lipopolysaccharide. Vaccines based on OMP have been used in several phase 3 trials in South Africa, Cuba, Brazil, Norway, and Chile, in which two doses of vaccine were given. The Cuban and Norwegian vaccines have been compared in phase 2 trials in Iceland and Chile. Potential limitations are epitope heterogeneity and the theoretical ability of N. meningitidis to adapt even to hosts who have received polyvalent vaccines. A phase 2 trial of a hexavalent class 1 OMP vaccine is under way in Gloucester, with 100 babies receiving injections at 2, 3, and 4 months. Serogroup C vaccines have been developed from capsular polysaccharide but, unconjugated, these vaccines do not protect those under 2 years of age. Conjugate vaccines with C and AC polysaccharides are immunogenic in infants, but antibody titres may wane quickly.(ABSTRACT TRUNCATED AT 250 WORDS)

Conjugate vaccines against Haemophilus influenzae type b (Hib) may modify Hib pharyngeal colonization. Hib colonization was compared in 371 infants and their families. In Oxfordshire, infants received PRP-T (polyribosylribitol phosphate conjugated to tetanus toxoid) and in Buckinghamshire they did not (controls). Infants were followed at 6, 9, and 12 months of age. Also, 6 unvaccinated Hib carriers were vaccinated and followed for 6 weeks. Hib acquisition was lower in vaccinees than controls (P < .01). During surveillance, 1.5% of vaccinees and 6.3% of controls carried Hib (P = .04). Among those with family Hib exposure, the carriage rates were 8.7% and 38.5% (P = .07), respectively. Hiv carriage rates were lower among vaccinees' unvaccinated siblings. Giving conjugate vaccine to a child carrying Hib did not rapidly terminate carriage. Thus, a primary means by which herd immunity to Hib is induced in a vaccinated population may be through reduction or delay in the initial acquisition of Hib.

Efficacy of the Haemophilus influenzae type b (Hib) conjugate vaccine PRP-T (Pasteur-Merieux) was evaluated in a controlled community intervention study in the Oxford region, UK. PRP-T was offered to infants from May 1, 1991 in three of the region's eight districts and from July 1, 1991, in a fourth district. It was given by separate injection in addition to the standard diphtheria, tetanus, and pertussis vaccine according to an accelerated 2, 3, and 4 month schedule without a booster dose in the second year of life. By October 1, 1992, more than 90% of infants in vaccine districts had received at least one dose of PRP-T. None of the infants given three doses had developed Hib infection, whereas 11 infections occurred in the control population (vaccine efficacy 100%, 95% CI 80-100%). Intention-to-treat analysis also showed a high estimate of efficacy for the vaccine (90%, 50-99%). Follow-up of study children until November 1, 1993, has shown only 1 vaccine failure in an infant, and no invasive infections in those older than 1 year (average age 22 months). PRP-T vaccine had high protective efficacy with an accelerated immunisation schedule. Furthermore, the vaccine appears to remain protective through the second year of life without a booster dose. These findings provide encouragement for use of PRP-T in the Expanded Programme of Immunisation.

In order to describe hospital bed usage by people with HIV disease in a provincial setting, a retrospective analysis of admissions to hospital wards in Oxford was undertaken for people admitted to hospital with all HIV-related illnesses or complications of HIV-related treatment. A total of 83 people were identified as having been admitted to hospital between January 1986 and the end of August 1990. Average length of hospital stay, the number of admissions per observed person-year and the in-patient days per observed person-year decreased. Of the 2,446 days spent in hospital, 913 were by people with an AIDS diagnosis; 1,533 days were spent by people who did not fulfil the World Health Organisation/Centers for Disease Control (WHO/CDC) classification for AIDS but who were admitted because of their HIV disease. AIDS is an end-point of infection with HIV. Pre-AIDS morbidity, a spectrum of illness of increasing severity from minor illness up to the point of WHO/CDC level AIDS, is a major determinant of hospital care and has previously been underestimated. In order to calculate the best estimates of hospital care needed, HIV disease should be regarded as a single entity and the artificial barrier dividing HIV illnesses from AIDS should be discarded.

For a seven year period (1985-91) clinical and epidemiological data were prospectively collected on children aged < 10 years with microbiologically confirmed invasive Haemophilus influenzae type b infection in the Oxford region to study the epidemiology of the disease and determine the potential impact of early primary immunisation in infants. Computer records of primary immunisations given to these cases were retrospectively analysed and, where necessary, hospital and general practitioner records were searched to determine the immunisation history. Over the seven year period, 416 cases of invasive H influenzae type b disease were reported. Widescale immunisation against H influenzae type b began in 1991 as part of a regional trial. The estimated annual incidence for invasive disease between 1985 and 1990 was 35.5 cases per 100,000 children aged less than 5 years; for H influenzae type b meningitis it was 25.1 per 100,000 children aged less than 5 years. The cumulative risks for invasive disease and meningitis by the fifth birthday were one in 560 and one in 800 respectively. The majority of disease (71%) occurred in children less than 2 years of age with the peak monthly incidences at 6 and 7 months of age. The overall mortality was 4.3% and 50% of these deaths occurred suddenly. Most (91%) of the children had received at least one primary immunisation against diphtheria, tetanus, and pertussis before H influenzae type b infection and there was only one case of parental refusal of immunisation. None had received H influenzae type b immunisation. Given a vaccine uptake of 90% by 5 months of age it is estimated that at least 82% of the H influenzae type b infections could have been prevented. Extrapolated nationally, 1150 cases of infection and 50 deaths could be prevented each year by routine primary immunisation.

Recent changes in the NHS have left many defects in the systems for the control of communicable diseases and infection and their surveillance and the management of outbreaks. Clear, explicit legislation is needed, placing the responsibilities on health authorities. New teams led by consultants need to be set up to investigate and manage outbreaks of communicable diseases of all types.

Enriched Columbia medium was tested against Levinthal medium for the isolation of Haemophilus influenzae type b. In both media, Haemophilus influenzae type b recovery and antigen-antibody precipitation halos were equivalent. Haemophilus influenzae type b colony size and iridescence were superior on enriched Columbia medium. Enriched Columbia medium is inexpensive, simply prepared and easily standardised.

The immunogenicity and safety of a new Haemophilus influenzae type b conjugate vaccine, PRP-T, was studied in 107 infants from the Oxford district. The vaccine was given concurrently with diphtheria, pertussis, tetanus, and polio vaccines at 2, 3, and 4 months of age. Symptoms after immunisation were recorded by a parent. Sera were obtained before the first immunisation and at 5 months of age and the antibodies were measured by both radioimmunoassay and enzyme linked immunosorbent assay (ELISA). No serious adverse reactions were observed and there was no increase in the incidence of expected minor side effects. By radioimmunoassay, the geometric mean titre of serum anticapsular antibody increased from 0.09 micrograms/ml before immunisation to 5.01 micrograms/ml after three immunisations. Ninety eight per cent of children had antibody concentrations consistent with protection (greater than or equal to 0.15 micrograms/ml). IgG antibody concentrations measured by ELISA correlated well with total antibody concentrations measured by radioimmunoassay (r = 0.864). These results provide encouragement that routine immunisation against H influenzae type b at 2, 3, and 4 months of age, could prevent most cases of disease in children in the UK.

In the UK an accelerated schedule for immunisation against diphtheria, tetanus, and pertussis (injections at 2, 3, and 4 months of age) was introduced in 1990 to replace the more widely spaced schedule of 3, 5, and 9 months. There is concern, however, that the new schedule may be less immunogenic and therefore less protective than the old schedule. We have measured serum concentrations of antibodies against diphtheria, pertussis, and tetanus in infants immunised according to the two regimens. Both schedules resulted in protective concentrations of antibody against tetanus and diphtheria and in satisfactory antibody responses to three pertussis antigens (filamentous haemagglutinin, pertussis toxin, fimbriae). However, immunisation by the old schedule led to significantly higher antibody concentrations against both diphtheria and tetanus than did immunisation by the new schedule (p less than 0.01). In infants immunised with the new schedule, postimmunisation antibody concentrations against tetanus toxoid and against two pertussis antigens (pertussis toxin and fimbriae) were significantly lower in infants in whom preimmunisation (maternally derived) antibody concentrations were high (p less than 0.02). The findings suggest that with an accelerated immunisation schedule maternal antibodies can have an inhibitory effect on the responses to immunisation against tetanus and pertussis.

An outbreak of cryptosporidiosis resulted in 516 cases in Wiltshire and Oxfordshire. The outbreak caused widespread interest and led to an official inquiry. The majority of cases were in children; 8% of cases were admitted to hospital and the median duration of illness was 3 weeks. The geographical distribution of cases matched the distribution of water supplies from three treatment works and cryptosporidium oocysts were found at these works and in the treated water. Attack rates in electoral wards supplied by the three treatment works were significantly higher than in other wards. The cause of the outbreak appeared to be the failure of normal treatment to remove oocysts. Measures at the treatment works reduced the number of oocysts detected in treated water, after which the outbreak came to an end. The conclusion of the investigations was that cryptosporidiosis is a risk of conventionally treated public water supplies.

We examined the effect of the decision in 1981 in Oxfordshire to cease routine vaccination of schoolchildren for tuberculosis. All notifications, laboratory and death certificate reports of tuberculosis between 1973 and 1989 were reviewed. Results showed that the incidence of tuberculosis in Oxfordshire continued to decline with an annual 5 per cent decrease. The incidence increased with age from a mean annual rate of 6.18 per 100,000 at age 0-10 to 19.90 per 100,000 at age 71-80. There was a higher incidence in the Asian population, with a mean annual rate of 79.6 per 100,000 compared with 7.35 per 100,000 in non-Asians. Four cases had occurred since 1981 in children who had not been immunized routinely at school. All four children had other risk factors in addition to not receiving BCG vaccine. We did not find a need to resume the routine vaccination programme. However, the findings demonstrated the need to be effective in contract-tracing and in vaccinating those most at risk.

This study attempted to find the incidence of scarlet fever in the Oxford region, including the proportion of patients from whom Streptococcus pyogenes could be isolated. General practitioners collected throat swabs from patients with suspected scarlet fever. The swabs were examined for viral and bacterial pathogens. Children admitted to hospital were used as controls. Twenty-five of 105 patients with suspected scarlet fever grew Str. pyogenes; M type 4 was the commonest type. The clinical diagnosis of scarlet fever was not always confirmed by throat culture. The annual incidence of scarlet fever was estimated to be 0.3 cases per 1000 per year.

The effectiveness of two rubella vaccines (RA 27/3 and Cendehill) in women vaccinated post partum was compared. Significantly more women who received RA 27/3 gave satisfactory seroconversion responses than women who received Cendehill (97.6% vs 82.2%). This difference was reflected in the geometric mean titres (43.6 vs 17.0). More women who received RA 27/3 had minor side-effects, but the difference was not significant. The serological response to both vaccines was not affected by the concurrent administration of anti-D immunoglobulin. In view of these findings, the replacement of Cendehill vaccine with RA 27/3 vaccine for women vaccinated post partum should be considered.

The prevalence of hospital-acquired infection was measured in 47 hospitals in 14 countries in four continents. The aim was to establish the evidence that hospital infection is a common and serious problem throughout the world. Using a standard protocol, 28,861 patients were observed by local teams of doctors and nurses in their own hospitals. The prevalence rates in individual hospitals varied from 3% to 21% (median 8.4%). The highest rates were seen on intensive care (13.3%), surgical (13.1%) and orthopaedic wards (11.2%). Children under the age of 1 year (infection prevalence 13.5%) and adults over 64 years (prevalence 12.0%) suffered more infection than others. In children the commonest infections were of the lower respiratory tract, of the skin and gastroenteritis. In the elderly, urinary-tract infections predominated. The prevalence of postoperative wound infection in individual hospitals ranged from 5.2% to 34.4%, with even greater variation when the wounds were analysed as clean, clean-contaminated and contaminated. The micro-organisms isolated from infected patients were similar to previous surveys: Escherichia coli and Staphylococcus aureus each caused a sixth of the infections with positive microbiological results. When examined, 30% of patients were on antimicrobial drugs. Penicillin, ampicillin/amoxycillin and gentamicin were the commonest antibiotics used.

Twenty general practices in four areas in Britain were surveyed to establish their needs for and practices of sterilising and disinfecting equipment. Of the 327 items of equipment and instruments examined in the survey, 190 were satisfactorily decontaminated, 100 were treated in a way judged to result in doubtful decontamination, and in 37 cases treatment was considered unsatisfactory. Decontamination apparatuses (autoclaves, hot air ovens, and hot water disinfectors) were generally in good working order, but the use of chemical disinfectants was often inappropriate. Recommendations were made on appropriate methods of decontamination for various items in common use in general practice. By virtue of the large numbers of patients treated by general practitioners there is a substantial possibility of transmitting infection; having appropriate methods for decontaminating instruments and equipment is therefore imperative.

Women attending for family planning advice at area health authority and general practitioner clinics were offered a test of rubella antibody status. The acceptance rate was approximately 50 per cent. Of the 100 women tested, 15 were not immune and 8 of these were subsequently vaccinated. In this study, the cost of the service was estimated to be 1-50 pounds per woman, or approximately 5000 pounds to prevent one case of congenital rubella. On this basis the assessment of rubella immunity in women using reliable contraception is considered to be feasible and could prove even more worthwhile on a cost-benefit basis if applied to an entirely nulliparous group.

The results of typing all group A streptococci isolated in one laboratory in 5 years were reviewed to see if the collected information showed epidemiological patterns. The great majority of the 5858 streptococci typed came from patients seen in general practice: 72% from throat swabs and 11% from skin lesions. Eight types, M types 1, 2, 3, 4, 6, 12, 22 and type 28 R accounted for 65% of strains. These eight types had different patterns: types 2 and 6 caused small circumscribed outbreaks and were uncommon between epidemics; types 3, 4 and 12 caused larger, wider epidemics, whereas types 1, 22 and 28 R had a more stable pattern. Type 4 was more commonly resistant to tetracycline than most other types, a finding which affected the apparent incidence of tetracycline resistance in group A streptococci. Streptococci from superficial sites were more likely to have serum opacity factor and to lack a detectable M-antigen than strains isolated from the throat. Routine typing of streptococci helped to detect outbreaks of infection in special groups. It is concluded that regular streptococcal typing should be continued in some places.

The response of 310 patients with typhoid or paratyphoid fevers to current antibiotic therapy was studied retrospectively. Most patients were of Asian or European origin, thus reflecting the areas in which they were infected. Of the 244 patients with well-recorded therapy 63% were treated with chloramphenicol, 22% with co-trimoxazole and the remainder with various penicillins. There was little difference in response in terms of resolution of fever. Symptoms persisted in only two of 153 (1.3%) patients given chloramphenicol but side-effects led to a change of treatment in nine of these patients. Co-trimoxazole was not significantly inferior and amoxycillin performed well, but the small number of cases treated with ampicillin or mecillinam did not respond as well as those treated with the other drugs.

A prospective survey of children in the Oxford region identified 200 cases of systemic Haemophilus influenzae type b disease in the first three and a half years of the study. The annual incidence in children less than 5 years of age was 33.4/100,000. This represents a cumulative incidence of one systemic infection in 600 children before their 5th birthday. The mortality was 5.0%. The risk of H influenzae type b meningitis was one in 850 with a mortality of 5.6%, and substantial morbidity among survivors. From the total live birth rate, about 1300 cases of systemic H influenzae type b disease, over 900 cases of H influenzae type b meningitis, and 65 deaths would be predicted annually in children in the United Kingdom.

A primary school teacher was found to have pulmonary tuberculosis. Subsequent investigations showed that nine of her 32 pupils had been infected. The problem is discussed in the light of current recommendations designed to protect schoolchildren.