Richard Puleston

Maternal Obesity and Infant Mortality: A Meta-Analysis

BACKGROUND AND OBJECTIVES: Despite numerous studies reporting an elevated risk of infant mortality among women who are obese, the magnitude of the association is unclear. A systematic review and meta-analysis was undertaken to assess the association between maternal overweight or obesity and infant mortality. METHODS: Four health care databases and gray literature sources were searched and screened against the protocol eligibility criteria. Observational studies reporting on the relationship between maternal overweight and obesity and infant mortality were included. Data extraction and risk of bias assessments were performed. RESULTS: Twenty-four records were included from 783 screened. Obese mothers (BMI ≥30) had greater odds of having an infant death (odds ratio 1.42; 95% confidence interval, 1.24–1.63; P < .001; 11 studies); these odds were greatest for the most obese (BMI >35) (odds ratio 2.03; 95% confidence interval, 1.61–2.56; P < .001; 3 studies). CONCLUSIONS: Our results suggest that the odds of having an infant death are greater for obese mothers and that this risk may increase with greater maternal BMI or weight; however, residual confounding may explain these findings. Given the rising prevalence of maternal obesity, additional high-quality epidemiologic studies to elucidate the actual influence of elevated maternal mass or weight on infant mortality are needed. If a causal link is determined and the biological basis explained, public health strategies to address the issue of maternal obesity will be needed.

Influenza vaccination for immunocompromised patients: systematic review and meta-analysis from a public health policy perspective.

Background Immunocompromised patients are vulnerable to severe or complicated influenza infection. Vaccination is widely recommended for this group. This systematic review and meta-analysis assesses influenza vaccination for immunocompromised patients in terms of preventing influenza-like illness and laboratory confirmed influenza, serological response and adverse events. Methodology/Principal Findings Electronic databases and grey literature were searched and records were screened against eligibility criteria. Data extraction and risk of bias assessments were performed in duplicate. Results were synthesised narratively and meta-analyses were conducted where feasible. Heterogeneity was assessed using I2 and publication bias was assessed using Beggs funnel plot and Eggers regression test. Many of the 209 eligible studies included an unclear or high risk of bias. Meta-analyses showed a significant effect of preventing influenza-like illness (odds ratio [OR] = 0.23; 95% confidence interval [CI] = 0.16–0.34; p<0.001) and laboratory confirmed influenza infection (OR = 0.15; 95% CI = 0.03–0.63; p = 0.01) through vaccinating immunocompromised patie nts compared to placebo or unvaccinated controls. We found no difference in the odds of influenza-like illness compared to vaccinated immunocompetent controls. The pooled odds of seroconversion were lower in vaccinated patients compared to immunocompetent controls for seasonal influenza A(H1N1), A(H3N2) and B. A similar trend was identified for seroprotection. Meta-analyses of seroconversion showed higher odds in vaccinated patients compared to placebo or unvaccinated controls, although this reached significance for influenza B only. Publication bias was not detected and narrative synthesis supported our findings. No consistent evidence of safety concerns was identified. Conclusions/Significance Infection prevention and control strategies should recommend vaccinating immunocompromised patients. Potential for bias and confounding and the presence of heterogeneity mean the evidence reviewed is generally weak, although the directions of effects are consistent. Areas for further research are identified.

The first recorded outbreak of cryptosporidiosis due to Cryptosporidium cuniculus (formerly rabbit genotype), following a water quality incident

We report the first identified outbreak of cryptosporidiosis with Cryptosporidium cuniculus following a water quality incident in Northamptonshire, UK. A standardised, enhanced Cryptosporidium exposure questionnaire was administered to all cases of cryptosporidiosis after the incident. Stool samples, water testing, microscopy slides and rabbit gut contents positive for Cryptosporidium were typed at the Cryptosporidium Reference Unit, Singleton Hospital, Swansea. Twenty-three people were microbiologically linked to the incident although other evidence suggests an excess of 422 cases of cryptosporidiosis above baseline. Most were adult females; unusually for cryptosporidiosis there were no affected children identified under the age of 5 years. Water consumption was possibly higher than in national drinking water consumption patterns. Diarrhoea duration was negatively correlated to distance from the water treatment works where the contamination occurred. Oocyst counts were highest in water storage facilities. This outbreak is the first caused by C. cuniculus infection to have been noted and it has conclusively demonstrated that this species can be a human pathogen. Although symptomatically similar to cryptosporidiosis from C. parvum or C. hominis, this outbreak has revealed some differences, in particular no children under 5 were identified and females were over-represented. These dissimilarities are unexplained although we postulate possible explanations.

Influenza vaccination for immunocompromised patients: summary of a systematic review and meta-analysis

Vaccination of immunocompromised patients is recommended in many national guidelines to protect against severe or complicated influenza infection. However, due to uncertainties over the evidence base, implementation is frequently patchy and dependent on individual clinical discretion. We conducted a systematic review and meta‐analysis to assess the evidence for influenza vaccination in this patient group. Healthcare databases and grey literature were searched and screened for eligibility. Data extraction and assessments of risk of bias were undertaken in duplicate, and results were synthesised narratively and using meta‐analysis where possible. Our data show that whilst the serological response following vaccination of immunocompromised patients is less vigorous than in healthy controls, clinical protection is still meaningful, with only mild variation in adverse events between aetiological groups. Although we encountered significant clinical and statistical heterogeneity in many of our meta‐analyses, we advocate that immunocompromised patients should be targeted for influenza vaccination.

Parameters for the mathematical modelling of Clostridium difficile acquisition and transmission: a systematic review.

Introduction Mathematical modelling of Clostridium difficile infection dynamics could contribute to the optimisation of strategies for its prevention and control. The objective of this systematic review was to summarise the available literature specifically identifying the quantitative parameters required for a compartmental mathematical model of Clostridium difficile transmission. Methods Six electronic healthcare databases were searched and all screening, data extraction and study quality assessments were undertaken in duplicate. Results were synthesised using a narrative approach. Results Fifty-four studies met the inclusion criteria. Reproduction numbers for hospital based epidemics were described in two studies with a range from 0.55 to 7. Two studies provided consistent data on incubation periods. For 62% of cases, symptoms occurred in less than 4 weeks (3-28 days) after infection. Evidence on contact patterns was identified in four studies but with limited data reported for populating a mathematical model. Two studies, including one without clinically apparent donor-recipient pairs, provided information on serial intervals for household or ward contacts, showing transmission intervals of <1 week in ward based contacts compared to up to 2 months for household contacts. Eight studies reported recovery rates of between 75% - 100% for patients who had been treated with either metronidazole or vancomycin. Forty-nine studies gave recurrence rates of between 3% and 49% but were limited by varying definitions of recurrence. No study was found which specifically reported force of infection or net reproduction numbers. Conclusions There is currently scant literature overtly citing estimates of the parameters required to inform the quantitative modelling of Clostridium difficile transmission. Further high quality studies to investigate transmission parameters are required, including through review of published epidemiological studies where these quantitative estimates may not have been explicitly estimated, but that nonetheless contain the relevant data to allow their calculation. [Systematic review reference: CRD42012003081]

Multi-Centre Observational Study of Transplacental Transmission of Influenza Antibodies following Vaccination with AS03A-Adjuvanted H1N1 2009 Vaccine

Introduction Illness and death from influenza increase during pregnancy. In the United Kingdom pregnant women were targeted in a national programme for vaccination during the H1N1 2009–10 pandemic. Methods In this study, pregnant women were recruited in labour from November 9, 2009 to March 10, 2010. Pandemic vaccination status was determined. Venous cord blood collected at delivery was evaluated for transplacental transfer of antibodies by measurement of haemagglutination inhibition and microneutralization titres. Results Samples were collected from 77 vaccinated and 27 unvaccinated women. Seroprotection (HI titre ≥1∶40) was detected in 58 (75.3%, 95% CI 64.2–84.4) cord blood samples from vaccinated women and 5 (18.5%, 95% CI 6.3–38.1) from unvaccinated women (P<0.0001). There was evidence of transplacental seroprotection 8 days after maternal immunization (77.9%, 95 CI 66.2–87.1), maintained in most cases for at least 16 weeks. Discussion Immunization of pregnant women with AS03A-adjuvanted vaccine is followed by transplacental transfer of passive immunity at titres consistent with clinical protection in three-quarters of new-born infants. The findings support national and international pandemic H1N1 2009 recommendations for immunization during pregnancy.

Two Linked Enteroinvasive Escherichia coli Outbreaks, Nottingham, UK, June 2014.

These outbreaks highlight the necessity to consider this bacterium as a potential pathogen in foodborne outbreaks.

Neuraminidase inhibitors for influenza: a review and public health perspective in the aftermath of the 2009 pandemic

Please cite this paper as: Beck et al. on behalf of the UK Antiviral Effectiveness Review Group. (2012) Neuraminidase inhibitors for influenza: a review and public health perspective in the aftermath of the 2009 pandemic. Influenza and Other Respiratory Viruses 7(Suppl. 1), 14–24.

An audit of neonatal and infant hepatitis B immunisation and serological testing in two counties of England, 2007–12

We audited adherence to national hepatitis B virus (HBV) immunisation policy for neonates and infants born to HBV positive mothers in two counties of England during 2007/08 to 2011/12 (n=112 in County X, n=190 in County Y). Over the five year period, 29.9% of at risk neonates in County X and 23.5% in County Y required hepatitis B immunoglobulin (HBIG) at birth. The annual median age of HBIG administration was 0.0–0.5 days. The annual median coverage and timeliness of the first (coverage range 92.3–100.0%; age of administration range 0.0–0.0 days), second (83.8–100.0%; 32.0–42.0 days), third (81.1–100.0%; 62.0–81.0 days) and fourth dose HBV immunisations (44.4–91.9%; 378.0–443.0 days) and serological testing (8.6–81.0%; 450.0–707.0 days) were calculated. Statistically significant variation was found in the coverage of third and fourth dose immunisations in County Y, age of fourth dose immunisation in County X, and the coverage and timeliness of serological testing in both counties (p < 0.05). HBIG and the first three HBV immunisations were commonly administered according to the national schedule. Fourth dose immunisations and serological tests showed poor adherence. We advocate public health interventions to improve immunisation programme outcomes and hepatitis B surface antigen testing.

A paradigm shift in approach to antimicrobials is needed

The focus on antimicrobial resistance highlights the challenges of providing healthcare when antibiotic effectiveness has changed.1 Improved antibiotic stewardship is important, but new agents are also needed, especially to treat inherently resistant organisms ( Acinetobacter baumannii ) and those acquiring new resistance mechanisms ( Escherichia coli and Klebsiella spp), yet the pipeline of new antimicrobials is running dry. Economics explains why few antimicrobials are in …