Martin Wiselka

Influenza vaccination of the elderly: perceptions and policies of general practitioners and outcome of the 1985–86 immunization programme in Trent, UK

The policies, organization and outcome of the influenza vaccination programmes for the elderly were studied in randomly selected general practices in Trent during the winter of 1985-86. Data from 127 practices, covering approximately one-fifth of the 668 800 people in Trent 65 years of age and older, were studied in detail. Altogether 87% of practices offered vaccine to selected elderly patients and 93.5% gave it upon request. However, less than one-fifth of the elderly population covered by the survey were vaccinated against influenza and the number of doses prescribed by individual practitioners and practice immunization rates varied considerably. The higher immunization rates were correlated with certain practice immunization policies and procedures Reasons for non-acceptance of vaccine were also identified. The observations suggest that provision of educational materials about the risks and benefits of influenza vaccine and a re-appraisal of practice strategies relating to the influenza immunization programme may increase the number of elderly people who are immunized.

The cost of treatment failure: resource use and costs incurred by hepatitis C virus genotype 1–infected patients who do or do not achieve sustained virological response to therapy

Chronic hepatitis C virus (HCV) infection places a considerable economic burden on health services. Cost‐effectiveness analyses of antiviral treatment for patients with chronic HCV infection are dependent on assumptions about cost reductions following sustained virological response (SVR) to therapy. This study quantified the medium‐term difference in health resource usage and costs depending on treatment outcome. Retrospective chart review of patients with HCV genotype 1 infection who had received at least 2 months pegylated interferon and ribavirin therapy, with known treatment outcome was conducted. Disease status was categorized as chronic hepatitis, cirrhosis or decompensated liver disease. Health resource use was documented for each patient in each disease state. Unit costs were from the NHS ‘Payment by Results’ database and the British National Formulary. One hundred and ninety three patients (108 SVR, 85 non‐SVR) with mean follow‐up of 3.5 (SVR) and 4.9 (non‐SVR) years were enrolled. No SVR patient progressed to a more severe liver disease state. Annual transition rates for non‐SVR patients were 7.4% (chronic hepatitis to cirrhosis) and 4.9% (cirrhosis to decompensated liver disease). By extrapolation of modelled data over a 5‐year post‐treatment period, failure of patients with chronic hepatitis to achieve SVR was associated with a 13‐fold increase (roughly £2300) in costs, whilst for patients who were retreated, the increase was 56‐fold, equating to more than £10 000. Achievement of an SVR has significant effects on health service usage and costs. This work provides real‐life data for future cost‐effectiveness analyses related to the treatment for chronic HCV infection.

Vitamin D deficiency and TB disease phenotype

Background Extrapulmonary TB is increasingly common, yet the determinants of the wide clinical spectrum of TB are poorly understood. Methods We examined surveillance data (Birmingham, UK: 1980–2009 and USA Centers for Disease Control: 1993–2008) to identify demographic factors associated with extrapulmonary TB. We then directly tested association of these factors and serum 25-hydroxycholecalciferol (25(OH)D) concentration with extrapulmonary TB by multivariable analysis in a separate UK cohort. Results Data were available for 10u2005152 and 277u2005013 TB cases for Birmingham and US, respectively. Local-born individuals of white ethnicity had a lower proportion of extrapulmonary disease when compared with local-born non-whites (p<0.0001); both groups had a lower proportion of extrapulmonary disease when compared with foreign-born non-whites (p<0.0001). In a separate UK cohort (n=462), individuals with extrapulmonary TB had lower mean serum 25(OH)D concentration than those with pulmonary TB (11.4 vs 15.2u2005nmol/L, respectively, p=0.0001). On multivariable analysis, vitamin D deficiency was strongly associated with extrapulmonary TB independently of ethnicity, gender and other factors. Doubling in serum 25(OH)D concentration conferred substantially reduced risk of extrapulmonary disease (OR 0.55, 95% CI 0.41 to 0.73). Conclusions We identify vitamin D deficiency as a probable risk factor for extrapulmonary dissemination in TB, which may account for the associations of dark-skinned ethnicity and female gender with extrapulmonary disease. Our findings implicate vitamin D status in Mycobacterium tuberculosis containment in vivo and, given the high prevalence of deficiency, may inform development of novel TB prevention strategies.

Response to DAA therapy in the NHS England Early Access Programme for rare HCV subtypes from low and middle income countries

Please cite this article as: da Silva Filipe, A., Sreenu, V., Hughes, J., Aranday-Cortes, E., Irving, W.L., Foster, G.R., Agarwal, K., Rosenberg, W., Macdonald, D., Richardson, P., Aldersley, M.A., Wiselka, M., Ustianowski, A., McLauchlan, J., Thomson, E.C., Response to DAA Therapy in the NHS England Early Access Programme for Rare HCV Subtypes from Low and Middle Income Countries, Journal of Hepatology (2017), doi: http://dx.doi.org/ 10.1016/j.jhep.2017.06.035

Latent tuberculosis infection screening and treatment in HIV: insights from evaluation of UK practice

Latent TB infection (LTBI) screening and treatment in HIV-positive individuals in the UK is advocated by the British HIV Association (BHIVA) and National Institute for Health and Care Excellence (NICE), although each recommends differing strategies. We undertook an evaluation of UK practice, relating the responses to the local HIV/TB disease burden. 162 of 188 (86%) UK geographical areas responded; only 93/162 (57.4%) offer LTBI testing with considerable heterogeneity in practice, and no difference in HIV/TB burden between areas offering testing and those who do not. Only 33/93 (35.5%) and 6/93 (6.5%) reported full compliance with BHIVA and NICE guidance respectively. A uniform national guideline is required.

High levels of neurological involvement but low mortality in miliary tuberculosis: a 6-year case-series from the UK

Tuberculosis (TB) remains one of the biggest global health challenges. Whilst the greatest burden of active disease is seen in Asia and Africa [1], TB remains a significant issue in the UK. Miliary TB is one of the severest manifestations of TB disease [2–4]. Up-to-date clinicopathological data on miliary TB from the developed world are lacking. We undertook a comprehensive 6-year review (2007–2012) of cases presenting to a single UK centre with an ethnically diverse population with high levels of population exchange with the Indian Subcontinent and Africa. Miliary TB was defined as the presence of miliary nodules on thoracic imaging in patients who presented with symptoms compatible with the diagnosis and either culture of Mycobacterium tuberculosis complex or culture-negative patients with clinical and/or histological features compatible with TB who were commenced on a course of antituberculous therapy (ATT). Miliary TB: high level of CNS involvement best investigated by head MRI which suggests re-evaluation of NICE guidance http://ow.ly/X3CDK

Rat bite fever: an unusual cause of a maculopapular rash

Rat bite fever (RBF) is a rare zoonosis caused worldwide by Streptobacillus monoliformis with Spirillum minus cases restricted to Asia.1 Transmission arises mainly by scratches or bites from colonised rats.1 At-risk groups include veterinarians, sewerage and laboratory workers or rat owners.1 Patients typically present within 7u2005days of exposure with an acute febrile illness characterised by headache, myalgia, migratory polyarthralgia and a rash.2 In the UK, one–two cases are diagnosed per year3 predominantly caused by S monoliformis. 2 It is likely underdiagnosed due to a wide differential diagnosis and low culture sensitivity.2 If not suspected and treated with an appropriate antibiotic such as penicillin, mortality may reach 13%.1nnA …

A Multi-Faceted Approach of One Teaching Hospital NHS Trust during the Clostridium difficile Epidemic—Antibiotic Management and Beyond

The incidence of Clostridium difficile infection (CDI) in the UK rose dramatically during the early years of this century, in part associated with the emergence of the hyper-virulent ribotype 027 strain. The University Hospitals of Leicester (UHL), a 2000-bed acute UK NHS Trust, implemented a number of interventions, which led to an 80% reduction in new cases over a twelve month period. Changes were introduced as a result of collaboration between the Infection Prevention team, the departments of Microbiology and Infectious Diseases, and with the support of the Trust Executive. These strategies are described in detail and included; implementation of antimicrobial stewardship, specific hygiene and cleaning measures, the introduction of a care pathway form for all infected patients, the opening of an isolation ward for patients with CDI, strengthened organisation and clinical management, and rigorous attention to education within the Trust. The implementations described are of continued relevance in the face of new infection challenges, such as the increasing incidence of multi-drug resistant organisms.

A nested case–control study of predictors for tuberculosis recurrence in a large UK Centre

BackgroundTuberculosis (TB) recurrence represents a challenge to control programs. In low incidence countries, the prevailing risk factors leading to recurrence are poorly characterised.MethodsWe conducted a nested case–control study using the Leicester TB service TBIT database. Cases were identified from database notifications between 1994 and 2014. Controls had one episode and were matched to cases on a ratio of two to one by the date of notification. Multiple imputation was used to account for missing data. Multivariate conditional logistic regression analysis was employed to identify clinical, sociodemographic and TB specific risk factors for recurrence.ResultsFrom a cohort of 4628 patients, 82xa0TB recurrences occurred (1.8%). Nineteen of 82 patients had paired isolates with MIRU-VNTR strain type profiles available, of which 84% were relapses and 16% reinfections. On multivariate analysis, smoking (OR 3.8; pu2009=u20090.04), grade 3/4 adverse drug reactions (OR 5.6; pu2009=u20090.02), ethnicity ‘Indian subcontinent’ (OR 8.5; pu2009=u2009<0.01), ethnicity ‘other’ (OR 31.2; pu2009=u20090.01) and receipt of immunosuppressants (OR 6.8; pu2009=u2009<0.01) were independent predictors of TB recurrence.ConclusionsWithin this UK setting, the rate of TB recurrence was low, predominantly due to relapse. The identification of an elevated recurrence risk amongst the ethnic group contributing most cases to the national TB burden presents an opportunity to improve individual and population health.

Reply to: “Reply to: ‘Response to DAA therapy in the NHS England Early Access Programme for rare HCV subtypes from low and middle income countries’”

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