Paul Cosford

An Outbreak of Cryptosporidium parvum across England & Scotland Associated with Consumption of Fresh Pre-Cut Salad Leaves, May 2012

Background We report a widespread foodborne outbreak of Cryptosporidium parvum in England and Scotland in May 2012. Cases were more common in female adults, and had no history of foreign travel. Over 300 excess cases were identified during the period of the outbreak. Speciation and microbiological typing revealed the outbreak strain to be C. parvum gp60 subtype IIaA15G2R1. Methods Hypothesis generation questionnaires were administered and an unmatched case control study was undertaken to test the hypotheses raised. Cases and controls were interviewed by telephone. Controls were selected using sequential digit dialling. Information was gathered on demographics, foods consumed and retailers where foods were purchased. Results Seventy-four laboratory confirmed cases and 74 controls were included in analyses. Infection was found to be strongly associated with the consumption of pre-cut mixed salad leaves sold by a single retailer. This is the largest documented outbreak of cryptosporidiosis attributed to a food vehicle.

Safer out of hours primary care

The death of a patient given an overdose of diamorphine by an out of hours doctor has raised questions about out of hours services. Paul Cosford and Justyn Thomas argue that wide ranging changes are required

A collaborative strategy to tackle tuberculosis in England

312 www.thelancet.com Vol 385 January 24, 2015 The UK has the second highest rate of tuberculosis among western European countries. Tuberculosis clinics in London manage more cases a year than those in all other western European capital cities put together. Rates of tuberculosis are now nearly fi ve times higher in the UK than in the USA. Lack of progress with tuberculosis control in the UK does not just represent a risk to domestic public health, but also an international embarrassment with examples of cases acquired in the UK leading to infections in other low-incidence countries. In recognition of this unacceptable trend, Public Health England has led a coalition of stakeholders to develop a forum, the national Tuberculosis Oversight Group, where innovation and good practice are shared between local, regional, and national health leaders. These discussions have led to local changes, with several areas establishing tuberculosis control boards and systematic cohort review, and the identifi cation of tuberculosis as a major priority for Public Health England. However, the implementation of improved tuberculosis control measures has not been universal, and there is still unacceptable variation in the quality of clinical and public health measures across England. A collaborative strategy to tackle tuberculosis in England There are some limitations to the study. First, the subtle eff ects of the HMGCR variants meant that the investigators had to use large numbers of cases and controls, and the associations between the variants and type 2 diabetes are not statistically beyond reproach—more cases and controls would help confi rm the fi ndings. Second, we cannot be certain that the variants operate directly and solely through the HMGCR gene, although there is some evidence that these variants alter splicing of HMGCR transcripts. Finally, genetic studies are not completely exempt from the confounders and biases of epidemiological studies—survival and index event biases can aff ect genetic studies, and further work with larger numbers of incident cases would provide more reassurance that the genetic associations with type 2 diabetes are real. However, the associations with body-mass index seem to be statistically robust and provide a mechanism downstream of the HMGCoA-reductase eff ect (increased body-mass index leading to increased insulin resistance, and to increased diabetes). In summary, Swerdlow and colleagues have used naturally occurring human genetic variation to provide another piece of evidence about the side-eff ects of statins, but have not cast any doubt on the evidence that the benefi ts of statins vastly outweigh their risks.

Advantages of airport screening for Ebola

The Ebola virus outbreak in west Africa has been described by WHO as the “most severe acute health emergency in modern times.” In the UK, Public Health England (PHE) has instituted enhanced entry screening for Ebola in passengers coming from Sierra Leone, Guinea, and Liberia. Screening is already in place at Heathrow and will shortly roll out to Gatwick and St Pancras (Eurostar). …

Public Health England’s reply to editorial on its draft report on shale gas extraction

Law and colleagues comment on Public Health England’s (PHE’s) draft report on potential public health impacts of exposures to chemical and radioactive pollutants as a result of shale gas extraction.1 2 Three of the authors also reviewed health risks associated with shale gas exploitation, and their conclusions regarding risks identified and the need for further monitoring of emissions …

Tackling the public health needs of refugees

In their editorial, Arnold and colleagues outline their view on what is needed to respond to the health needs of refugees resettling in the UK.1 They highlight the potentially complex health needs of this group and argue that clinicians in the UK need to be appropriately prepared. We fully agree and describe below the work that Public Health England (PHE) is engaged …

Place sustainability at the heart of the quality agenda

If the guiding ethos of health systems throughout the world were ‘live for the day,’ two pillars of quality would suffice. Effective use of finite resources, measured by evidence-based outcomes relating to patient health, safety and experience is, without question, the predominant pillar.1–5 Next to effectiveness is its close ally, efficiency.3 Efficient use of resources minimises waste, thus maximising the quantity of high-quality healthcare and, in combination, with effectiveness provides the critical measure of productivity. Living for the day, however, is a high-risk mindset, and if a health system is also to prosper ‘tomorrow,’ a sensible precaution must be to embrace a further pillar of quality: sustainability. Put simply, this concerns the use of resources in a way to build, rather than undermine, operative resilience for the future delivery of high-quality healthcare.6 Risk to quality, due to misuse of resources, arises both externally and internally. External risk results from using resources in a way that destabilises the foundations of the interconnected economic, societal or environmental world in which the health system operates. Internal risk results from using resources in a way …

Local action on outdoor air pollution to improve public health

ObjectivesThe National Institute for Health and Care Excellence, jointly with Public Health England, have developed a guideline on outdoor air pollution and its links to health. The guideline makes recommendations on local interventions that can help improve air quality and prevent a range of adverse health outcomes associated with road-traffic-related air pollution.MethodsThe guideline was based on a rigorous assessment of the scientific evidence by an independent advisory committee, with input from public health professionals and other professional groups. The process included systematics reviews of the literature, expert testimonies and stakeholder consultation.ResultsThe guideline includes recommendations for local planning, clean air zones, measures to reduce emissions from public sector transport services, smooth driving and speed reduction, active travel, and awareness raising.ConclusionsThe guideline recommends taking a number of actions in combination, because multiple interventions, each producing a small benefit, are likely to act cumulatively to produce significant change. These actions are likely to bring multiple public health benefits, in addition to air quality improvements.

Sustaining tuberculosis decline in the UK

The re-emergence of tuberculosis in England began in the late 1980s increasing to a peak in 2011; since then incidence has fallen throughout the UK, in both the UK and non-UK born population, including in children.1 After 4 consecutive years of declining incidence of tuberculosis, sustained progress is finally being made with a 30% decline between 2011 and 2015.1 However, tuberculosis incidence in the UK remains higher than in most other high-income European countries and more than four times higher than in the USA.

Lack of Secondary Transmission of Ebola Virus from Healthcare Worker to 238 Contacts, United Kingdom, December 2014

In December 2014, Ebola virus disease (EVD) was diagnosed in a healthcare worker in the United Kingdom after the worker returned from an Ebola treatment center in Sierra Leone. The worker flew on 2 flights during the early stages of disease. Follow-up of 238 contacts showed no evidence of secondary transmission of Ebola virus.