- Email: [email protected]
Flu in the middle of summer: lessons from an influenza outbreak in a primary school
e98 1
Division of Emergency Medicine, All India Institute of Medical Sciences, New Delhi 2 Health Department, Municipal Corporation of Delhi
Aims and objectives: Cholera is endemic and a highly seasonal disease. It constitutes a major burden of disease in Emergency Department (ED). We studied the endemicity characteristics of cholera in South Delhi and the preventive measures taken by health authorities in order to reduce the impact of the disease. Methods and material: Design: Retrospective cross sectional study Source: the registry of health department (infectious disease) Municipal Corporation of Delhi. Duration covered: 4 years (2001-2004). The suspected cases were defined by the sudden appearance of watery diarrhea, with or without dehydration, in endemic areas. Rectal swabs from all suspected cases were bacteriologically examined to confirm the disease. Statistical analysis: SPSS version 10 Results: 401 confirmed cases with mean age of 16.7 14 years, (range 3 months to 85 years), 64% males, and 44 % children (<12 years) were reported. Mean declaration time was 3.2 1 days. There was decrease in the number of cases in 2003 (66) as compared to annual average 100. 81% cases were detected between months of April and August which represent summer and monsoon season. The risk factors included living in village (51%) or resettlement colonies (22%), poor personal hygiene (60%), contaminated drinking water (22%), poor sanitation (95%) Government piped water supply- (in 3/4 th of contaminated water cases). First case isolation was done in March while the last in December each year. 21% (83/401) cases were untraced after initial detection. Preventive measures included distribution of - ORS (32 packets/case), Chlorine tablets (mean 4130 /case), posters, pamphlets, hand bills in the affected area. Conclusions: Taking into account the frequency of cholera in Delhi, interventions should be designed that make it possible to prevent and control the reappearance of the disease and its spread to neglected areas. Seasonal variations should also be considered. The hygienic practices were more important than contaminated water sources for transmission of cholera significant untraced cases warrant strengthening the surveillance. Cholera is a medical emergency that can have a favorable prognosis with properly organized management.
P 120 STRATEGIES USED TO INCREASE CHLAMYDIA SCREENING IN GENERAL PRACTICE: A QUALITATIVE STUDY Freeman E 1, McNulty CAM 2, Oliver I 3, FordYoung W 4, Randall S 5
Abstracts 2
Health Protection Agency Primary Care Unit, Microbiology Dept, Gloucestershire Royal Hospital, Great Western Road, Gloucester GL1 3 NN 3 Health Protection Agency (South West), The Wheelhouse, Bond’s Mill, Stonehouse GL10 3RF 4 Broken Cross Surgery, Fallibroome Road, Macclesfield SK10 3LA 5 St Mary’s Hospital, Portsmouth PO3 6AD Background and objectives: The National Chlamydia Screening Programme is being implemented across England to control chlamydia through the early detection and treatment of asymptomatic infection, to prevent the development of sequelae and to reduce onward transmission. The Programme offers opportunistic chlamydia screening in both healthcare and non healthcare settings, to all under 25 year olds who have ever been sexually active. The objective is to explore strategies used by chlamydia screening coordinators and practice staff to implement genital chlamydia screening within general practices. Methods: Study design Qualitative phenomenological study using individual semi-structured interviews. Selection methods We purposively selected screening coordinators, in phase 1 and 2 of the English National Chlamydia Screening Programme. Interview methods Open questions were asked about: the factors that determined high chlamydia screening rates, maintaining motivation for screening, and strategies to increase screening in general practices. Results: Coordinators reported that successful screening practices had a champion who drove the screening process forward. These practices had normalised screening, so all at-risk patients were offered opportunistic screening whenever they attended. This was facilitated by a variety of time saving methods including computer prompts, test kits in the reception area, youth clinics and receptionist involvement. The coordinators sustained chlamydia screening through frequent reminders, newsletters containing chlamydia screening rates, and advertising to the ‘at risk’ population. Coordinators’ interpersonal skills were as important as sexual health experience. Coordinators reported that to facilitate chlamydia screening across all practices, screening could be included in the General Medical Services (GMS) contract, and a higher national profile was needed amongst health professionals and the public. Conclusions: All practice staff need to be encouraged to become champions of the Chlamydia Screening Programme through education, especially aimed at older clinicians and receptionists. The NHS should consider including chlamydia screening in the GMS contract. Increased public awareness will allow screening to be undertaken more quickly and by non-medical staff.
P 121
1
Gloucestershire Research & Development Support Unit, Gloucestershire Royal Hospital, Great Western Road, Gloucester GL1 3 NN
FLU IN THE MIDDLE OF SUMMER: LESSONS FROM AN INFLUENZA OUTBREAK IN A PRIMARY SCHOOL
Abstracts
e99
Nsutebu EF 1, Hatton P 2, Brady A 3, Schweiger M 3, Ellis J 4 1
Leeds Health Protection Unit, BD6 3XH Health Protection Agency - Yorkshire and Humber 3 Health Protection Agency - Leeds, LS15 7TR 4 Health Protection Agency - London, NW9 5HT E-mail address: [email protected] 2
The Leeds Health Protection Unit (HPU) was notified of an outbreak of an influenza-like illness at a Primary School in June 2004. Specimens from 2 out of 5 children who had viral swabs were confirmed influenza A (H1N1). The outbreak resulted in a total of 112 children (attack rate 45.3% of those who completed the questionnaire), 2 staff and 84 family members being ill. Fifty percent of those who were ill visited their GPs and one child was admitted to hospital with influenza like symptoms. The control measures implemented consisted of promoting personal hygiene and exclusion of children who were ill from school. The open plan nature of the school and a World Day celebrated at the school the day before the outbreak was notified, may have contributed to spread of the infection. During the World Day celebrations, all the children were kept together in a hall for long periods during the day. Prompt collection of viral swabs and initiation of control measures appear to have been important in identifying the cause and helping to control this influenza outbreak. Date of onset of illness 14 12
Frequency
10 8 6 4 2 0
09
.0
04 7. .0 4 01 6.0 .0 4 29 6.0 .0 4 28 6.0 .0 4 26 6.0 .0 4 25 6.0 .0 4 24 6.0 .0 4 23 6.0 .0 4 22 6.0 .0 4 21 6.0 .0 4 20 6.0 .0 4 19 6.0 .0 4 18 6.0 .0 4 17 6.0 .0 4 16 6.0 .0 4 15 6.0 .0 4 14 6.0 .0 4 13 6.0 .0 4 12 6.0 .0 4 11 6.0 .0 4 10 6.0 .0
03
6.
04
Cryptococcus neoformans, the third commonest cause of invasive fungal infection in solid organ transplant recipients, often poses significant diagnostic and therapeutic challenges. Described here is the case of a 28-year old male, who four years previously had received a liver transplant for seronegative hepatitis. He presented initially to his general practitioner with two raised pruritic papules on his scalp, which did not respond to empirical antibiotics and evolved into two crusting ulcers on his scalp (see picture 1). A skin biopsy revealed fungal elements and C. neoformans was grown in culture. Initially only a local superficial skin infection was assumed and fluconazole was commenced at the referring hospital. Two weeks into the treatment, he required hospital admission due to general malaise, nausea, diarrhoea and progression of scalp lesions; he was found to have renal impairment and a markedly elevated tacrolimus level. Extensive evaluation, including detailed imaging and laboratory investigations revealed disseminated cryptococcosis with elevated serum cryptococcal antigen titre and multiple pulmonary nodules (picture 2), which on histopathological examination were confirmed as cryptococcal infection. There was no clinical evidence of central nervous system involvement. The complex and prolonged treatment involved liposomal amphotericin B (combined with flucytosine initially) and required negotiation of drug interactions and toxicities. The patient improved, with healing of skin lesions and a decrease in cryptococcal antigenaemia. He continues with long-term fluconazole maintenance therapy. This case illustrates several principles in the management of infections in immunocompromised patients: A high index of suspicion for cryptococcal infection should be maintained. Full identification of fungal isolates should be undertaken as per British Society for Medical Mycology proposed standards of care for patients with invasive fungal infections. These patients should preferably be managed by a specialist centre. An infection at any site with C. neoformans in such a patient is best assumed to be disseminated until proven otherwise. Treatment is complex and particular attention should be paid to drug interactions and toxicities.
Date of onset of illness
Figure 1
Epidemic curve for illness in the school.
P 123 DOUBLE JEOPARDY
Clinical lessons
Hughes HC, Browning L, Turner GDH, Jeffery KJM
P 122
John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU
INFECTION IN THE IMMUNOCOMPROMISED HOST: ‘‘NOT-JUST-SKIN-DEEP’’ David MD, Das I Dept of Microbiology and Infection Control, University Hospital Birmingham NHS Foundation Trust
The diagnosis and clinical management of invasive fungal infection (IFI) in the immunocompromised host is a challenging but evolving field. Over recent years, the epidemiology of these infections has changed, both with increasing overall incidence and with a shift in causative pathogens. Despite the development of molecular
Division of Emergency Medicine, All India Institute of Medical Sciences, New Delhi 2 Health Department, Municipal Corporation of Delhi
Aims and objectives: Cholera is endemic and a highly seasonal disease. It constitutes a major burden of disease in Emergency Department (ED). We studied the endemicity characteristics of cholera in South Delhi and the preventive measures taken by health authorities in order to reduce the impact of the disease. Methods and material: Design: Retrospective cross sectional study Source: the registry of health department (infectious disease) Municipal Corporation of Delhi. Duration covered: 4 years (2001-2004). The suspected cases were defined by the sudden appearance of watery diarrhea, with or without dehydration, in endemic areas. Rectal swabs from all suspected cases were bacteriologically examined to confirm the disease. Statistical analysis: SPSS version 10 Results: 401 confirmed cases with mean age of 16.7 14 years, (range 3 months to 85 years), 64% males, and 44 % children (<12 years) were reported. Mean declaration time was 3.2 1 days. There was decrease in the number of cases in 2003 (66) as compared to annual average 100. 81% cases were detected between months of April and August which represent summer and monsoon season. The risk factors included living in village (51%) or resettlement colonies (22%), poor personal hygiene (60%), contaminated drinking water (22%), poor sanitation (95%) Government piped water supply- (in 3/4 th of contaminated water cases). First case isolation was done in March while the last in December each year. 21% (83/401) cases were untraced after initial detection. Preventive measures included distribution of - ORS (32 packets/case), Chlorine tablets (mean 4130 /case), posters, pamphlets, hand bills in the affected area. Conclusions: Taking into account the frequency of cholera in Delhi, interventions should be designed that make it possible to prevent and control the reappearance of the disease and its spread to neglected areas. Seasonal variations should also be considered. The hygienic practices were more important than contaminated water sources for transmission of cholera significant untraced cases warrant strengthening the surveillance. Cholera is a medical emergency that can have a favorable prognosis with properly organized management.
P 120 STRATEGIES USED TO INCREASE CHLAMYDIA SCREENING IN GENERAL PRACTICE: A QUALITATIVE STUDY Freeman E 1, McNulty CAM 2, Oliver I 3, FordYoung W 4, Randall S 5
Abstracts 2
Health Protection Agency Primary Care Unit, Microbiology Dept, Gloucestershire Royal Hospital, Great Western Road, Gloucester GL1 3 NN 3 Health Protection Agency (South West), The Wheelhouse, Bond’s Mill, Stonehouse GL10 3RF 4 Broken Cross Surgery, Fallibroome Road, Macclesfield SK10 3LA 5 St Mary’s Hospital, Portsmouth PO3 6AD Background and objectives: The National Chlamydia Screening Programme is being implemented across England to control chlamydia through the early detection and treatment of asymptomatic infection, to prevent the development of sequelae and to reduce onward transmission. The Programme offers opportunistic chlamydia screening in both healthcare and non healthcare settings, to all under 25 year olds who have ever been sexually active. The objective is to explore strategies used by chlamydia screening coordinators and practice staff to implement genital chlamydia screening within general practices. Methods: Study design Qualitative phenomenological study using individual semi-structured interviews. Selection methods We purposively selected screening coordinators, in phase 1 and 2 of the English National Chlamydia Screening Programme. Interview methods Open questions were asked about: the factors that determined high chlamydia screening rates, maintaining motivation for screening, and strategies to increase screening in general practices. Results: Coordinators reported that successful screening practices had a champion who drove the screening process forward. These practices had normalised screening, so all at-risk patients were offered opportunistic screening whenever they attended. This was facilitated by a variety of time saving methods including computer prompts, test kits in the reception area, youth clinics and receptionist involvement. The coordinators sustained chlamydia screening through frequent reminders, newsletters containing chlamydia screening rates, and advertising to the ‘at risk’ population. Coordinators’ interpersonal skills were as important as sexual health experience. Coordinators reported that to facilitate chlamydia screening across all practices, screening could be included in the General Medical Services (GMS) contract, and a higher national profile was needed amongst health professionals and the public. Conclusions: All practice staff need to be encouraged to become champions of the Chlamydia Screening Programme through education, especially aimed at older clinicians and receptionists. The NHS should consider including chlamydia screening in the GMS contract. Increased public awareness will allow screening to be undertaken more quickly and by non-medical staff.
P 121
1
Gloucestershire Research & Development Support Unit, Gloucestershire Royal Hospital, Great Western Road, Gloucester GL1 3 NN
FLU IN THE MIDDLE OF SUMMER: LESSONS FROM AN INFLUENZA OUTBREAK IN A PRIMARY SCHOOL
Abstracts
e99
Nsutebu EF 1, Hatton P 2, Brady A 3, Schweiger M 3, Ellis J 4 1
Leeds Health Protection Unit, BD6 3XH Health Protection Agency - Yorkshire and Humber 3 Health Protection Agency - Leeds, LS15 7TR 4 Health Protection Agency - London, NW9 5HT E-mail address: [email protected] 2
The Leeds Health Protection Unit (HPU) was notified of an outbreak of an influenza-like illness at a Primary School in June 2004. Specimens from 2 out of 5 children who had viral swabs were confirmed influenza A (H1N1). The outbreak resulted in a total of 112 children (attack rate 45.3% of those who completed the questionnaire), 2 staff and 84 family members being ill. Fifty percent of those who were ill visited their GPs and one child was admitted to hospital with influenza like symptoms. The control measures implemented consisted of promoting personal hygiene and exclusion of children who were ill from school. The open plan nature of the school and a World Day celebrated at the school the day before the outbreak was notified, may have contributed to spread of the infection. During the World Day celebrations, all the children were kept together in a hall for long periods during the day. Prompt collection of viral swabs and initiation of control measures appear to have been important in identifying the cause and helping to control this influenza outbreak. Date of onset of illness 14 12
Frequency
10 8 6 4 2 0
09
.0
04 7. .0 4 01 6.0 .0 4 29 6.0 .0 4 28 6.0 .0 4 26 6.0 .0 4 25 6.0 .0 4 24 6.0 .0 4 23 6.0 .0 4 22 6.0 .0 4 21 6.0 .0 4 20 6.0 .0 4 19 6.0 .0 4 18 6.0 .0 4 17 6.0 .0 4 16 6.0 .0 4 15 6.0 .0 4 14 6.0 .0 4 13 6.0 .0 4 12 6.0 .0 4 11 6.0 .0 4 10 6.0 .0
03
6.
04
Cryptococcus neoformans, the third commonest cause of invasive fungal infection in solid organ transplant recipients, often poses significant diagnostic and therapeutic challenges. Described here is the case of a 28-year old male, who four years previously had received a liver transplant for seronegative hepatitis. He presented initially to his general practitioner with two raised pruritic papules on his scalp, which did not respond to empirical antibiotics and evolved into two crusting ulcers on his scalp (see picture 1). A skin biopsy revealed fungal elements and C. neoformans was grown in culture. Initially only a local superficial skin infection was assumed and fluconazole was commenced at the referring hospital. Two weeks into the treatment, he required hospital admission due to general malaise, nausea, diarrhoea and progression of scalp lesions; he was found to have renal impairment and a markedly elevated tacrolimus level. Extensive evaluation, including detailed imaging and laboratory investigations revealed disseminated cryptococcosis with elevated serum cryptococcal antigen titre and multiple pulmonary nodules (picture 2), which on histopathological examination were confirmed as cryptococcal infection. There was no clinical evidence of central nervous system involvement. The complex and prolonged treatment involved liposomal amphotericin B (combined with flucytosine initially) and required negotiation of drug interactions and toxicities. The patient improved, with healing of skin lesions and a decrease in cryptococcal antigenaemia. He continues with long-term fluconazole maintenance therapy. This case illustrates several principles in the management of infections in immunocompromised patients: A high index of suspicion for cryptococcal infection should be maintained. Full identification of fungal isolates should be undertaken as per British Society for Medical Mycology proposed standards of care for patients with invasive fungal infections. These patients should preferably be managed by a specialist centre. An infection at any site with C. neoformans in such a patient is best assumed to be disseminated until proven otherwise. Treatment is complex and particular attention should be paid to drug interactions and toxicities.
Date of onset of illness
Figure 1
Epidemic curve for illness in the school.
P 123 DOUBLE JEOPARDY
Clinical lessons
Hughes HC, Browning L, Turner GDH, Jeffery KJM
P 122
John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU
INFECTION IN THE IMMUNOCOMPROMISED HOST: ‘‘NOT-JUST-SKIN-DEEP’’ David MD, Das I Dept of Microbiology and Infection Control, University Hospital Birmingham NHS Foundation Trust
The diagnosis and clinical management of invasive fungal infection (IFI) in the immunocompromised host is a challenging but evolving field. Over recent years, the epidemiology of these infections has changed, both with increasing overall incidence and with a shift in causative pathogens. Despite the development of molecular