Babatunde Olowokure

Social deprivation and hospital admission for respiratory infection:an ecological study

STUDY OBJECTIVE To examine the relationship between social deprivation and risk of hospital admission for respiratory infection. METHODS AND SUBJECTS Ecological study using hospital episode statistics and population census data. Cases were residents of the West Midlands Health Region admitted to hospital with a diagnosis of respiratory infection, acute respiratory infection, pneumonia or influenza over a 5-year period. Postcodes of cases were used to assign Townsend deprivation scores; these were then ranked and divided into five deprivation categories. Poisson regression analysis was used to estimate the magnitude of effect for associations between deprivation category and hospital admission by age and admitting diagnosis. MAIN RESULTS There were 136755 admissions for respiratory infection, equivalent to an annual admission rate of 27.1 per 1000 population (95% CI = 26.9-27.2). Deprivation was associated with increased admission rates for all respiratory infection (P < 0.0001) and affected all age-groups. The greatest effect was in the 0-4 years age-group with admission rates 91% higher in the most deprived children compared to the least deprived. Hospital admissions for acute respiratory infection and pneumonia were both significantly associated with deprivation (P < 0.0001). CONCLUSIONS Respiratory infection is associated with social inequalities in all age-groups, particularly in children. Prevention of respiratory infection could make an important contribution to reducing health inequalities.

Effect of social factors on winter hospital admission for respiratory disease: a case–control study of older people in the UK

BACKGROUND Every winter, hospitals in the UK and other developed countries experience a surge in respiratory admissions. Ecological studies suggest that social circumstances may be an important determinant. AIM To establish the most important factors associated with winter hospital admissions among older people presenting with acute respiratory disease, especially the relative effect of social factors. DESIGN OF STUDY case-control study. SETTING Seventy-nine general practices in central England. METHOD Of a cohort of patients consulting medical services with lower respiratory tract infection or exacerbation of chronic respiratory disease, 157 hospitalised cases were compared to 639 controls. Social, medical, and other factors were examined by interview and GP records. RESULTS Measures of material deprivation were not significant risk factors for admission at either individual or area level, although social isolation (odds ratio [OR] 4.5; 95% confidence interval [CI] = 1.3 to 15.8) resulted in an increased risk of admission. The most important independent risk factor was the presence of chronic obstructive pulmonary disease (COPD; OR 4.0; 95% CI = 1.4 to 11.4), other chronic disease (OR 2.9; 95% CI = 1.2 to 7.0), or both (OR 6.7; 95% CI = 2.4 to 18.4). Being housebound was also an independent risk factor (OR 2.2; 95% CI = 1.0 to 4.8). CONCLUSION Socioeconomic factors had little relative effect compared with medical and functional factors. The most important was the presence of long-term medical conditions (especially COPD), being housebound, and having received two or more courses of oral steroid treatment in the previous year. This combination of factors could be used by primary medical services to identify older patients most vulnerable to winter admissions. Clinicians should ensure that patients with COPD are better supported to manage their condition.

Multiple outbreaks of Salmonella braenderup associated with consumption of iceberg lettuce

The aim of this study was to describe the findings from an outbreak investigation following several apparently unrelated community outbreaks of gastroenteritis. Epidemiological, environmental, laboratory and traceback investigations were used to identify the source of the outbreak. We enrolled 23 (of 29) laboratory confirmed cases and 24 neighbourhood case-nominated controls in a case-control study which revealed that illness was associated with consumption of iceberg lettuce (matched odds ratio 8.0 (95% CI 1.1–355) contaminated with Salmonella braenderup. Several eating establishments were affected and the lettuce was traced back to a single producer in Spain. This is the first UK report implicating S. braenderup in an outbreak due to lettuce. The results highlight the need to increase attention to the various stages in the farm-to-fork process to reduce produce-associated outbreaks related to the global food trade.

Rumor surveillance and avian influenza H5N1

We describe the enhanced rumor surveillance during the avian influenza H5N1 outbreak in 2004. The World Health Organization’s Western Pacific Regional Office identified 40 rumors; 9 were verified to be true. Rumor surveillance informed immediate public health action and prevented unnecessary and costly responses.

Absenteeism in schools during the 2009 influenza A(H1N1) pandemic: a useful tool for early detection of influenza activity in the community?

Certain influenza outbreaks, including the 2009 influenza A(H1N1) pandemic, can predominantly affect school-age children. Therefore the use of school absenteeism data has been considered as a potential tool for providing early warning of increasing influenza activity in the community. This study retrospectively evaluates the usefulness of these data by comparing them with existing syndromic surveillance systems and laboratory data. Weekly mean percentages of absenteeism in 373 state schools (children aged 4-18 years) in Birmingham, UK, from September 2006 to September 2009, were compared with established syndromic surveillance systems including a telephone health helpline, a general practitioner sentinel network and laboratory data for influenza. Correlation coefficients were used to examine the relationship between each syndromic system. In June 2009, school absenteeism generally peaked concomitantly with the existing influenza surveillance systems in England. Weekly school absenteeism surveillance would not have detected pandemic influenza A(H1N1) earlier but daily absenteeism data and the development of baselines could improve the timeliness of the system.

Clinical and economic assessment of different general population strategies of pertussis vaccine booster regarding number of doses and age of application for reducing whooping cough disease burden: a systematic review.

Pertussis continues to be an important cause of morbidity and mortality in children too young to be fully protected despite high vaccination coverage. This has been attributed to waning immunity in older people, leading to the development of strategies to increase levels of immunity. A systematic review was conducted to assess the clinical and cost effectiveness of four population-based strategies for pertussis booster vaccination: single booster at 12-24 months old, single pre-school booster, single adolescent booster and multiple boosters in adulthood every 10 years. Electronic databases and Internet resources were searched to June 2006. Nine observational studies, four mathematical models and eight economic evaluations were included, evaluating four different strategies. Strong evidence to recommend any of these strategies was not found.

Understanding the evolution and spread of chikungunya virus in the Americas using complete genome sequences

Abstract Local transmission of chikungunya virus (CHIKV) was first detected in the Americas in December 2013, after which it spread rapidly throughout the Caribbean islands and American mainland, causing a major chikungunya fever epidemic. Previous phylogenetic analysis of CHIKV from a limited number of countries in the Americas suggests that an Asian genotype strain was responsible, except in Brazil where both Asian and East/Central/South African (ECSA) lineage strains were detected. In this study, we sequenced thirty-three complete CHIKV genomes from viruses isolated in 2014 from fourteen Caribbean islands, the Bahamas and two mainland countries in the Americas. Phylogenetic analyses confirmed that they all belonged to the Asian genotype and clustered together with other Caribbean and mainland sequences isolated during the American outbreak, forming an ‘Asian/American’ lineage defined by two amino acid substitutions, E2 V368A and 6K L20M, and divided into two well-supported clades. This lineage is estimated to be evolving at a mean rate of 5 × 10−4 substitutions per site per year (95% higher probability density, 2.9–7.9 × 10−4) and to have arisen from an ancestor introduced to the Caribbean (most likely from Oceania) in about March 2013, 9 months prior to the first report of CHIKV in the Americas. Estimation of evolutionary rates for individual gene regions and selection analyses indicate that (in contrast to the Indian Ocean Lineage that emerged from the ECSA genotype followed by adaptive evolution and with a significantly higher substitution rate) the evolutionary dynamics of the Asian/American lineage are very similar to the rest of the Asian genotype and natural selection does not appear to have played a major role in its emergence. However, several codon sites with evidence of positive selection were identified within the non-structural regions of Asian genotype sequences outside of the Asian/American lineage.

International flight-related transmission of pandemic influenza A(H1N1)pdm09: an historical cohort study of the first identified cases in the United Kingdom.

Transporting over two billion passengers per year, global airline travel has the potential to spread emerging infectious diseases, both via transportation of infectious cases and through in‐flight transmission. Current World Health Organization (WHO) guidance recommends contact tracing of passengers seated within two rows of a case of influenza during air travel.

The disposal of used sharps by diabetic patients living at home.

The disposal of sharps generated in the community has been identified as an area of public health and environmental health concern. While there is a large amount of literature on sharps disposal practices in healthcare settings, the sharps disposal practices of diabetic patients living at home has been poorly documented. This study describes the sharps disposal practices of diabetic patients in South Staffordshire, an English health district. A randomly selected sample of 1,348 adult (aged ⩾̸ 16 years) diabetic patients were obtained from the district population-based diabetes register. A self-administered questionnaire was posted to the sample. Non-responders received up to two reminders. A response rate of 91% was achieved. Household containers were used by: 34.1% of respondents for syringes; 35.1% for lancets; and 27.6% for needles. Sharps boxes were the least used method of sharps disposal. Many respondents indicated that they had received only verbal information on how to dispose of their sharps. Those who recalled receiving information were more likely to dispose of their sharps safely. The results of this study suggest that sharps are disposed of in the most convenient manner, into the household waste. This contributes to environmental pollution and places people at risk of physical and psychological trauma.

Chikungunya virus outbreak, Dominica, 2014.

To the Editor: Chikungunya is a dengue-like mosquitoborne viral disease that has caused outbreaks in Africa, Asia, and the Pacific Islands (1). St. Martin reported the first documented occurrence of autochthonous transmission of chikungunya in the Caribbean islands in December 2013 (2). Dominica reported its first case on January 17, 2014 (3). This report describes the outbreak of chikungunya in Dominica through July 12, 2014. Cases were characterized by using guidelines issued by the Centers for Disease Control and Prevention (CDC) and the Pan American Health Organization (4). Surveillance of chikungunya cases began on January 16, 2014, and data were collected on patients’ age, sex, residence, date of illness onset, clinical features, and travel history. The virus was detected at the Caribbean Public Health Agency (CARPHA) laboratory in Trinidad by using a real-time PCR (rPCR) developed by CDC; some testing was also done at CDC’s Arboviral Diseases Branch in Fort Collins, Colorado, USA, by using an IgM ELISA and a plaque-reduction neutralization test, as appropriate. All suspected infections were laboratory confirmed through April 30, 2014, when community transmission was established. Thereafter, testing was done only for patients hospitalized >48 hours, women in their third trimester of pregnancy, patients who died, or patients thought to be infected and coming from geographic areas where chikungunya transmission was not yet established.. During December 15, 2013–July 12, 2014, a total of 3,559 chikungunya cases were reported in Dominica, of which 141 were confirmed by laboratory testing (134 [95%] by rPCR, 7 [5%] by serologic methods). The remaining 3,418 patients were considered infected (Figure), indicating an overall attack rate of 5% (on the basis of Dominica’s census population for 2011, 71,293). Retrospective investigation showed that the 2 index patients experienced onset of illness during the week beginning December 15, 2013, and 1 of the patients had recently traveled from St. Martin. The 2 patients were unrelated and resided far apart. Figure Confirmed and suspected chikungunya cases, by week of illness onset, Dominica, December 15, 2013–October 26, 2014. Of the 141 confirmed patients, 78 (55%) were female and 60 (43%) were male; data on sex was unavailable for 3 patients. Mean age of the patients was 34 years (range 13 days–87 years; median 30 years). Thirty (21%) of the patients were children <9 years of age; 76 (55%) were 19–49 years of age. Most patients experienced fever (95%) and arthralgia (72%), and 21% of patients experienced rash. No deaths associated with chikungunya infection in Dominica were reported during the study period. Across all age groups, more patients were female than male, as reported in previous outbreaks (5,6). This trend may suggest that, compared with men and boys, women and girls have greater health-seeking behaviors, greater levels of skin exposure, and potentially greater exposure due to peridomestic activities (7). In this study, a disproportionate number of patients were <9 years of age, unlike findings for chikungunya outbreaks in Indonesia and Reunion Island, where children <9 years of age were least affected (7). Of all confirmed patients, 55% were 19–49 years of age, suggesting that the outbreak had economic effects because workplace productivity may substantially decrease if disease sequelae (e.g., arthralgia and arthritis) cause those affected to take time off from work. Genotypic sequencing identified the Asian genotype of chikungunya as the strain currently circulating in the Caribbean (8,9). The East/Central/South African genotype was responsible for the Reunion Island outbreak, and an overall attack rate of 35% was reported after retrospective and active case detection (6). Differences in transmission and pathogenicity between genotypes require further investigation. In response to the Dominica outbreak, a risk communication plan was developed and implemented on January 17, 2014, and consisted of 2 phases: an onset emergency phase and a control phase. Both phases targeted audiences through audio, print, and social media. To control and reduce the mosquito population in and around the homes of chikungunya patients, vector control activities (i.e., source reduction, application of larvicides, and fogging) were intensified with assistance from CARPHA and Yale University, New Haven, CT, USA. In addition, CARPHA and the Pan American Health Organization arranged for delivery of insecticide-treated bed nets for use in hospitals and other health care settings. Although the introduction of chikungunya into the Caribbean islands may have been anticipated because of the broad distribution of the Aedes aegypti mosquito vector and suitable climatic conditions, our findings show that this outbreak could not be prevented. The continuing geographic spread of the disease emphasizes the ongoing challenge posed by mosquitoborne viral infections resulting from globalization and indicates a need for innovative prevention and control strategies.