Robert M Douglas

Effect of Infection Control Measures on the Frequency of Upper Respiratory Infection in Child Care: A Randomized, Controlled Trial

Background. Acute upper respiratory infections are common in children who attend child care, and preventing transmission of disease in this setting depends on actions by child care staff. We set out to discover whether transmission of respiratory infections in child care could be reduced by improved infection control procedures. Methods. We performed a cluster, randomized, controlled trial of an infection control intervention conducted in child care centers in 1 city in Australia. The intervention was training of child care staff about transmission of infection, handwashing, and aseptic nosewiping technique. Implementation of the intervention was recorded by an observer. Illness was measured by parent report in telephone interviews every 2 weeks. Results. There were 311 child-years of surveillance for respiratory symptoms. By multivariable analysis, there was no significant reduction in colds in intervention center children across the full age range. However, a significant reduction in respiratory illness was present in children 24 months of age and younger. When compliance with infection control practices was high, colds in these children were reduced by 17%. Conclusions. This trial supports the role of direct transmission of colds in young children in child care. The ability of infection control techniques to reduce episodes of colds in children in child care was limited to children 24 months of age and under.

Health effects of exposure to cyanobacteria (blue–green algae) during recreational water–related activities

Abstract: The aim of this study was to investigate effects on health of exposure to cyanobacteria as a result of recreational water activities. Participants, who were aged six years and over, were interviewed at water recreation sites in South Australia, New South Wales and Victoria on selected Sundays during January and February 1995. Telephone follow–up was conducted two and seven days later to record any subsequent diarrhoea, vomiting, flu–like symptoms, skin rashes, mouth ulcers, fevers and eye or ear irritations. On the Sundays of interview, water samples from the sites were collected for cyanobac–terial cell counts and toxin analysis. There were 852 participants, of whom 75 did not have water contact on the day of interview and were considered unexposed. The 777 who had water contact were considered exposed. No significant differences in overall symptoms were found between the unexposed and exposed after two days. At seven days, there was a significant trend to increasing symptom occurrence with duration of exposure (P = 0.03). There was a significant trend to increasing symptom occurrence with increase in cell count (P = 0.04). Participants exposed to more than 5000 cells per mL for more than one hour had a significantly higher symptom occurrence rate than the unexposed. Symptoms were not correlated with the presence of hepatotoxins. These results suggest symptom occurrence was associated with duration of contact with water containing cyanobacteria, and with cyanobacterial cell density. The findings suggest that the current safety threshold for exposure of 20 000 cells per mL may be too high. (Aust N Z J Public Health 1997; 21: 562–6)

Effect of beta lactam antibiotic use in children on pneumococcal resistance to penicillin: prospective cohort study.

Abstract Objective: To examine the relation between use of antibiotics in a cohort of preschool children and nasal carriage of resistant strains of pneumococcus. Design and participants: Prospective cohort study over two years of 461 children aged under 4 years living in Canberra, Australia. Main outcome measures: Use of drugs, respiratory symptoms, and visits to doctors were documented in a daily diary by parents of the children during 25 months of observation. Isolates of pneumococci, which were cultured from nasal swabs collected approximately six monthly, were tested for antibiotic resistance. Results: From the four swab collections 631 positive pneumococcal isolates from 461 children were found, of which 13.6% were resistant to penicillin. Presence of penicillin resistant pneumococci was significantly associated with childrens use of a β lactam antibiotic in the two months before each swab collection (odds ratio 2.03 (95% confidence interval 1.15 to 3.56, P=0.01)). The odds ratio of the association remained >1 (though did not reach significance at the 0.05 level) for use in the six months before swab collection. The association was seen in children who received only penicillin or only cephalosporin antibiotics in that period. The odds ratio was 4.67 (1.29 to 17.09, P=0.02) in children who had received both types of β lactam in the two months before their nasal swab. The modelled odds of carrying penicillin resistant pneumococcus was 4% higher for each additional day of use of β lactam antibiotics in the six months before swab collection. Conclusions: Reduction in β lactam use could quickly reduce the carriage rates of penicillin resistant pneumococci in early childhood. In view of the propensity of these organisms to be spread among children in the community, the prevalence of penicillin resistant organisms may fall as a consequence. What is already known on this topic Resistance to pneumococcal antibiotics is increasing worldwide One possible cause of resistance is the excessive use of antibiotics in children with respiratory symptoms Few cross sectional studies have looked at the association between antibiotic use and subsequent carriage of organisms resistant to penicillin What this study adds Carriage of pneumococcus is high in preschool Australian children throughout the year and highest in winter The likelihood of carrying penicillin resistant pneumococcus is doubled in children who have used any β lactam antibiotic in the two months before testing The likelihood of a child carrying a penicillin resistant pneumococcus is increased by 4% for each additional day of β lactam use in the six months before testing

Effect of Infection Control Measures on the Frequency of Diarrheal Episodes in Child Care: A Randomized, Controlled Trial

Background. Diarrheal infections are common in children who attend child care, and preventing transmission of disease in this setting depends on actions by child care staff. We set out to discover whether transmission of gastrointestinal infections in child care could be reduced by improved infection control procedures. Methods. We performed a cluster randomized, controlled trial of an infection control intervention conducted in child care centers for 1 city in Australia. The intervention was training of child care staff about transmission of infection and handwashing and focused on both staff and child behavior. Implementation of the intervention was recorded by an observer. Illness was measured by parent report in telephone interviews every 2 weeks. Results. There were 311 child-years of surveillance for diarrheal episodes. The rate of episodes of diarrhea was 1.9 per child-year in intervention centers and 2.7 per child-year in control centers. Multivariable analysis showed that diarrheal episodes were significantly reduced in intervention center children by 50%. However, the impact of the intervention was confined to children over 24 months of age. For those centers in which childrens compliance with handwashing was high, diarrheal episodes were reduced by 66%. Conclusions. This trial supports education about infection control, for staff and children in child care, as a means of reducing transmission of diarrhea. Reduction in episodes of diarrhea in children in child care was limited to children over 24 months of age.

Can methods applied in medicine be used to summarize and disseminate conservation research

SUMMARY To ensure that the best scientific evidence is available to guide conservation action, effective mechanisms for communicatingtheresultsofresearcharenecessary.In medicine, an evidence-based approach assists doctors in applying scientific evidence when treating patients. The approach has required the development of new methodsforsystematicallyreviewingresearch,andhas led to the establishment of independent organizations to disseminate the conclusions of reviews. (1) Such methods could help bridge gaps between researchers and practitioners of environmental conservation. In medicine, systematic reviews place strong emphasis on reviewing experimental clinical trials that meet strict standards. Although experimental studies are much less common in conservation, many of the components of systematic reviews that reduce the biases when identifying, selecting and appraising relevantstudiescouldstillbeappliedeffectively.Other methods already applied in medicine for the review of non-experimental studies will therefore be required in conservation. (2) Using systematic reviews and an evidence-based approach will only be one tool of many to reduce uncertainty when making conservationrelated decisions. Nevertheless an evidence-based approach does complement other approaches (for example adaptive management), and could facilitate the use of the best available research in environmental management.(3)Inmedicine,theCochraneCollaboration was established as an independent organization to guide the production and dissemination of systematic reviews. It has provided many benefits that could applytoconservation,includingaforumforproducing and disseminating reviews with emphasis on the requirements of practitioners, and a forum for feedback between researchers and practitioners and improved access to the primary research. Without the Cochrane Collaboration, many of the improvements in research communication that have occurred in

The public health impact of minor injury

The mortality and hospital morbidity data usually used to quantify the burden of injury are generally considered to represent only the tip of the iceberg. This article documents the population-based morbidity arising from non-hospitalised injuries and demonstrates the public health importance of this group of injuries. A prospective cohort study was conducted in an Australian population using a sample of injured adults to identify the health outcomes arising from the range of injuries. The total health loss caused by injury experienced by these subjects over the period of injury recovery was calculated and then weighted to provide population estimates. This study has shown that minor injuries are responsible for the greater part of the injury-related health burden in the adult community. Injuries that can be coded as 1 on the Abbreviated Injury Scale account for 80% of the morbidity arising over the first six months after injury and about 75% of the estimated lifetime morbidity. The lifetime estimates of morbidity resulting from injuries not considered serious enough to admit to hospital were of an order of magnitude higher than those that resulted in either death or hospitalisation. Sprains contributed as much to the total morbidity as all other injuries types combined and limb injuries contributed more to the total morbidity than injuries to the more central structures. The results of this study provide a strong argument for the recognition of the public health importance of minor injury. Strategies for the prevention and management of minor injury must be included in national programmes for injury control.

Antibiotic resistance in Streptococcus pneumoniae isolated from children.

Objective: To determine the level of antibiotic resistance in pneumoniae (S. pneumoniae) isolated from nasal swabs of healthy children.

Respiratory Tract Infections as a Public Health Challenge

Acute respiratory infections have everywhere become the province of clinicians and the pharmaceutical industry. A public health approach is needed with systematic efforts to minimize transmission, maximize prevention, and harness the research and surveillance effort to decrease their incidence and severity. These infections have a huge incidence, morbidity burden, and economic impact in all societies. Several factors now demand renewed attention to prevention. They include the growing costs and potentially limited benefits of an expanded pharmacotherapeutic approach; the serious change in antibiotic susceptibility of the common respiratory pathogens; the advances made in vaccinology in recent years; and the need to promote equity and share limited health resources across the worlds population. Care should not be restricted to those in affluent countries who can afford increasingly expensive treatment.

Chlorinated drinking water and micronuclei in urinary bladder epithelial cells.

Background: Evidence for a causal relationship between disinfection byproducts in chlorinated water and cancer is not conclusive. This study investigates the association between disinfection byproducts in chlorinated water, as measured by trihalomethane concentration, and the frequency of micronuclei in urinary bladder epithelial cells, thereby assessing the carcinogenic potential of disinfection byproducts. Methods: A cohort study was undertaken in 1997 in 3 Australian communities with varying levels of disinfection byproducts in the water supply. Exposure was assessed using both available dose (total trihalomethane concentration in the water supply) and intake dose (calculated by adjusting for individual variations in ingestion, inhalation, and dermal absorption). Micronuclei in urinary bladder epithelial cells were used as a preclinical biomarker of genotoxicity. Results: Cells were scored for micronuclei for 228 participants, of whom 63% were exposed to disinfection by products and 37% were unexposed. Available dose of total trihalomethane for the exposed group ranged from 38 to 157 &mgr;g/L, whereas intake dose ranged from 3 to 469 &mgr;g/kg per day. Relative risk for DNA damage to bladder cells, per 10 &mgr;g/L of available dose total trihalomethane, was 1.01 (95% confidence interval [CI] = 0.97–1.06) for smokers and 0.996 (CI = 0.961–1.032) for nonsmokers. Relative risk, per 10 &mgr;g/kg per day of intake dose of total trihalomethane, was 0.99 (CI = 0.96–1.03) for smokers and 1.003 (CI = 0.984-1.023) for nonsmokers. Conclusion: This study provides no evidence that trihalomethane concentrations, at the levels we investigated, are associated with DNA damage to bladder cells.

Chinese Herbal Medicine in the Treatment of Acute Respiratory Tract Infections: Review of Randomized and Controlled Clinical Trials

We carried out a modified search of the Chineseand Englishin a more rigorous fashion the assumptions which are built into Chinese clinical practice. language literature and identified 27 clinical trials on the role of Chinese herbal medicine (CHM) in the treatment of acute respiratory infections [1–27]. Twenty-six of the identified studies were References published in Chinese-language journals and only one appeared in 1. Kong XT, Fang HT, Jiang GQ, Zhai-SZ, O’Connell DL, Brewster DR. an English-language journal. A range of methods was used to Treatment of acute bronchiolitis with Chinese herbs. Arch Dis Child describe the clinical outcomes of the treatment, including an ‘‘ef1993;68:468–71. 2. Hu J. A clinical study on curative effect of 529 cases of pneumonia in fect rate’’ and comparison of a group of clinical symptoms. The children [in Chinese]. Chinese Journal of Integrated Traditional and herbal medicine groups were reported to have a significantly higher Western Medicine 1984;4:672. ‘‘effect rate’’ in 15 of 22 studies, and generally the studies in 3. Yu RH. Investigation on preliminary therapeutic effect of combined Chiwhich herbal medicines were compared with Western medicines nese and Western medicine for treatment of acute tonsillitis [in Chinese]. (often antibiotics), claimed greater improvement in patient’s cliniChinese Journal of Integrated Traditional and Western Medicine 1984; cal symptoms and physical signs (table 1). 4:750. 4. Zhang HC, Li FX, Zhu XD. Therapeutic effects of febrifugal and detoxiTable 1. Reported treatment outcomes of clinical trials on the role cant drugs in treating pneumonia in adults—an analysis of 108 cases of Chinese herbal medicine in the treatment of acute respiratory [in Chinese]. Chinese Journal of Integrated Traditional and Western infections. Medicine 1985;5:515, 537–9. 5. Xue D, Cheng SH, Wu XF. Treatment of severe infantile pneumonia with CHM vs. control traditional Chinese medicine and herbs [in Chinese]. Chinese Journal of Integrated Traditional and Western Medicine 1988;8:234. No. studies No. studies with 6. Yan CR, Shen W, Zhang DS, Zheng JX. A report of 38 cases of infantile No. studies with significant no significant pneumonia treated with Chinese herbal aerosol [in Chinese]. Chinese Variable with variable improvement difference Journal of Integrated Traditional and Western Medicine 1988;8:748. 7. Sun XD. A report of 94 cases of paediatric bronchopneumonia treated ‘‘Cured’’ (‘‘effect rate’’) 22 15 7 with combined Chinese and Western medicines [in Chinese]. Chinese Fever 18 14 4 Journal of Integrated Traditional and Western Medicine 1988;8:749. Cough 11 9 2 8. Zhang DY, Yang WW, Gao XC. Comparison of Chinese medicine with Chest crackles 12 8 4 Western medicine for treatment of paediatric bronchitis. Chinese Journal Hospitalization 9 6 3 of Integrated Traditional and Western Medicine 1989;9:30. Laboratory findings 9. Pang JC. Clinical investigation on 50 cases of severe paediatric pneumonia (X-ray or WBC count) 6 4 2 treated with Danshi (Salviae miltiorrhirae) injection [in Chinese]. Chinese Journal of Integrated Traditional and Western Medicine 1990; NOTE. CHM Å Chinese herbal medicine. 10:566. 10. Zhu CY. A report of 56 cases of paediatric pneumonia with heart failure treated by combined Chinese and Western medicine [in Chinese]. ChiDespite these apparently favorable results, definitive conclusions nese Journal of Integrated Traditional and Western Medicine 1991; about efficacy are difficult to draw. There was insufficient informa11:56. tion on randomization and baseline comparisons; outcome mea11. Hu RS, Li YQ, Yuan W, et al. Clinical and experimental study of Xiao sures were either complicated or of doubtful validity, and in most Er Ke Chaun Ling oral liquid in treating infantile bronchopneumonia instances the terms were poorly defined or explained. Data analysis [in Chinese]. Chinese Journal of Integrated Traditional and Western and presentation were generally too limited to enable us to assess Medicine 1992;12:719–37. the adequacy of the statistical analysis. At a time when there is 12. Luo H, Zou DW, Qie JR, et al. Treatment of upper respiratory tract growing dissatisfaction with the application of antibiotics and infection with a mixt. 716 compound [in Chinese]. Chinese Journal of when herbal medicine is increasing in popularity as an alternative Integrated Traditional and Western Medicine 1993;13:709, 730–2. approach in some Western countries, there is some urgency to test 13. Wu KH, Hu TC, Liu XF. Clinical investigation on 119 cases of paediatric pneumonia treated with Jieduling (defebrile and detoxication) injection [in Chinese]. Chinese Journal of Integrated Traditional and Western Medicine 1994;14:106–7. This article is a part of a series of papers presented at a symposium entitled 14. Li MZ, Lu S, Tong QM, et al. Investigation on therapeutic effect of ‘‘International Conference on Acute Respiratory Infections’’ that was held 7– Shuanghuanglian injection for treatment of paediatric pneumonia [in 10 July 1997 in Canberra, Australia. This symposium was organized by the Chinese]. Chinese Journal of Integrated Traditional and Western MediCochrane Collaboration Review Group on Acute Respiratory Infections and cine 1994;14:232–3. the National Centre for Epidemiology and Population Health at The Australian 15. Chang GZ, Li QC, Li M, Shen HQ, Yao QX. Investigation on therapeutic National University. effect of Yanholer powder in treatment of 220 cases of acute tonsillitis Reprints or correspondence: Prof. Robert M. Douglas, National Centre for [in Chinese]. Chinese Journal of Integrated Traditional and Western Epidemiology and Population Health, Australian National University, CanMedicine 1994;14:309–10. berra, ACT 0200, Australia (Bob.Douglas@anu.edu.au). 16. Li YX, Zhang YH. Investigation on therapeutic effect of Chinese medicine Clinical Infectious Diseases 1999;28:235–6 in treating paediatric pneumonia [in Chinese]. Chinese Journal of Inteq 1999 by the Infectious Diseases Society of America. All rights reserved. 1058–4838/99/2802–0013