Health Protection Unit Research Articles

Tracking elimination of HIV transmission in men who have sex with men in England: a modelling study

SummaryBackgroundTo manage the HIV epidemic among men who have sex with men (MSM) in England, treatment as prevention strategies based on test and treat were strengthened between 2011 and 2015, and supplemented from 2015 by scale-up of pre-exposure prophylaxis (PrEP). We examined the effect of these interventions on HIV incidence and investigated whether internationally agreed targets for HIV control and elimination of HIV transmission by 2030 might be within reach among MSM in England.MethodsWe used a novel, age-stratified, CD4-staged Bayesian back-calculation model to estimate HIV incidence and undiagnosed infections among adult MSM (age ≥15 years) during the 10-year period between 2009 and 2018. The model used data on HIV and AIDS diagnoses routinely collected via the national HIV and AIDS Reporting System in England, and knowledge on the progression of HIV through CD4-defined disease stages. Estimated incidence trends were extrapolated, assuming a constant MSM population from 2018 onwards, to quantify the likelihood of achieving elimination of HIV transmission, defined as less than one newly aquired infection per 10 000 MSM per year, by 2030.FindingsThe peak in HIV incidence in MSM in England was estimated with 80% certainty to have occurred in 2012 or 2013, at least 1 year before the observed peak in new diagnoses in 2014. Results indicated a steep decrease in the annual number of new infections among MSM, from 2770 (95% credible interval 2490–3040) in 2013 to 1740 (1500–2010) in 2015, followed by a steadier decrease from 2016, down to 854 (441–1540) infections in 2018. A decline in new infections was consistently estimated in all age groups, and was particularly marked in MSM aged 25–34 years, and slowest in those aged 45 years or older. Similar trends were estimated in the number of undiagnosed infections, with the greatest decrease after 2013 in the 25–34 years age group. Under extrapolation assumptions, we calculated a 40% probability of achieving the defined target elimination threshold by 2030.InterpretationThe sharp decrease in HIV incidence, estimated to have begun before the scale up of PrEP, indicates the success of strengthening treatment as prevention measures among MSM in England. To achieve the 2030 elimination threshold, targeted policies might be required to reach those aged 45 years or older, in whom incidence is decreasing at the slowest rate.FundingUK Medical Research Council, UK National Institute of Health Research Health Protection Unit in Behavioural Science and Evaluation, and Public Health England.

Emergence of Dominant Toxigenic M1T1 Streptococcus Pyogenes Clone During Increased Scarlet Fever Activity in England: A Population-Based Molecular Epidemiological Study

Background: England is experiencing scarlet fever activity unprecedented in modern times. In 2016, England's scarlet fever seasonal rise coincided with an unexpected elevation in invasive Streptococcus pyogenes infections. We describe the molecular-epidemiological investigation of these events and emergence of a new emm1 lineage. Methods: We analysed changes in S. pyogenes emm-genotypes, and notifications of scarlet fever and invasive disease 2014-2016 using regional and national data. We analysed genomes of 135 non-invasive and 552 invasive emm1 isolates from 2009-2016, and compared 2800 global emm1 sequences. Expression of Streptococcal pyrogenic exotoxin (Spe)A by sequenced non-invasive emm1 isolates was quantified. Findings: Coincident with national increases in scarlet fever and invasive disease, emm1 S. pyogenes infections increased significantly, accounting for 32·6% (47/144) of pharyngeal isolates in North West London and 41·9% (267/637) of invasive isolates nationally in March-May 2016. Sequences of emm1 isolates from 2009-2016 demonstrated emergence of a new emm1 lineage (M1UK), with overlap of pharyngitis, scarlet fever, and invasive M1UK strains, that could be genotypically distinguished from pandemic emm1 isolates (M1global). Compared with M1global , median expression of SpeA increased 9-fold in M1UK isolates. M1UK expanded nationally to represent 84% (252/299) of all emm1, genomes in 2016; analysis identified two M1UK isolates outside the UK. Interpretation: A dominant new emm1 S. pyogenes lineage characterized by increased SpeA production has emerged during increased S. pyogenes activity in England. The expanded reservoir of M1UK and recognised invasive potential of emm1 S. pyogenes provide plausible explanation for increased invasive disease, and rationale for global surveillance. Funding Statement: Supported by grants from Medical Research Council (MR/P022669/1); NIHR Health Protection Unit in AMR and HCAI (HPRU-2012-10047); NIHR BRC SpyVAC; Conor Kerin Foundation. NNL is a Sir Henry Wellcome Postdoctoral Research Fellow funded by the Wellcome Trust (103197/Z/13/Z); EJ is a Rosetrees/Stoneygate 2017 Imperial College Research Fellow (M683). Declaration of Interests: JP is a consultant to Next Gen Diagnostics LLC; other authors declare no interests. Ethics Approval Statement: Clinical data were linked to isolates and anonymized in accordance with Research Ethics approval 06/Q0406/20.

Can outbreak research be achieved in a population with impaired capacity? Findings from a study of a scabies outbreak in residential care

BackgroundDisease outbreaks in residential care where dementia is prevalent are an important public health concern and challenging to study. To explore the feasibility of outbreak research in a population lacking mental capacity we studied scabies outbreaks in residential care homes for elderly people. MethodsBetween Jan 23, 2014, and April 23, 2015, participants were recruited from ten residential care homes in South East England reporting scabies outbreaks to their local health protection unit. Preliminary visits were organised in advance of clinical visits to assess mental capacity and, when appropriate, seek consent from residents to be recruited and clinically examined. When residents did not have the capacity to consent, advice was sought from a personal consultee (usually next of kin) via telephone and followed up with written confirmation. When a personal consultee could not be contacted or did not exist, advice was sought from a nominated consultee (institution staff). Researchers were trained to assess mental capacity and did so at each visit because capacity often fluctuates in this population. During two clinical visits, residents were fully examined and skin conditions recorded and photographed. When scabies was diagnosed, skin scrapes and blood samples were taken for analysis and stored for future research. The study was approved by Camberwell St Giles NRES Committee (12/LO/0001). FindingsOf 295 residents approached, 144 (49%) were assessed as having capacity to consent and 122 (41%) gave written consent; consultee advice was sought for 151 (51%). All 24 nominated consultees and 117 (92%) of 127 personal consultees advised that they thought the person without capacity would wish to take part. Consent or positive advice was obtained from 264 (89%) of 295 residents for clinical examinations and skin scrapes and from 187 (71%) of 264 residents for photography of skin conditions. Separate consent for storage of tissue and blood samples was introduced partway through and consent or positive advice was obtained for 100 (66%) of 151 residents. 231 (88%) of 264 residents were examined: 155 (67%) had dementia, of whom 54 (35%) were able to give written consent, and differences in the perceived and assessed capacity between care home staff and researchers were noted. 191 (83%) of the 231 participants were examined at both clinical visits. Reasons why 40 residents were not examined at the 6 week follow-up visit included: deceased (13, 33%), respite or re-enablement (10, 25%), unwell or distressed (7, 18%), admission to hospital (5, 13%), unable to schedule appointment (3, 8%), and refused (2, 5%). 12 (6%) of 191 participants experienced fluctuating mental capacity. Clinical visits took place within a median 5 days (IQR 3–8) of notification of the outbreak to the study team. InterpretationPublic health research during outbreaks in residential care is complex but achievable. It requires substantial resource and training to deliver rapid and repeated assessment of mental capacity and obtain timely consultee advice in line with the Mental Capacity Act 2005. FundingPublic Health England and the British Skin Foundation.

Investigation of an outbreak of vomiting in nurseries in South East England, May 2012.

On 30 May 2012, Surrey and Sussex Health Protection Unit was called by five nurseries reporting children and staff with sudden onset vomiting approximately an hour after finishing their lunch that day. Over the following 24 h 50 further nurseries supplied by the same company reported cases of vomiting (182 children, 18 staff affected). Epidemiological investigations were undertaken in order to identify the cause of the outbreak and prevent further cases. Investigations demonstrated a nursery-level attack rate of 55 out of 87 nurseries (63·2%, 95% confidence interval 52·2-73·3). Microbiological tests confirmed the presence of Bacillus cereus in food and environmental samples from the catering company and one nursery. This was considered microbiologically and epidemiologically consistent with toxin from this bacterium causing the outbreak. Laboratory investigations showed that the conditions used by the caterer for soaking of pearl haricot beans (known as navy bean in the USA) used in one of the foods supplied to the nurseries prior to cooking, was likely to have provided sufficient growth and toxin production of B. cereus to cause illness. This large outbreak demonstrates the need for careful temperature control in food preparation.

Evaluation of the Health Protection Event-Based Surveillance for the London 2012 Olympic and Paralympic Games.

The Health Protection Agency (HPA) (currently Public Health England) implemented the Health Protection Event-Based Surveillance (EBS) to provide additional national epidemic intelligence for the 2012 London Olympic and Paralympic Games (the Games). We describe EBS and evaluate the system attributes. EBS aimed at identifying, assessing and reporting to the HPA Olympic Coordination Centre (OCC) possible national infectious disease threats that may significantly impact the Games. EBS reported events in England from 2 July to 12 September 2012. EBS sourced events from reports from local health protection units and from screening an electronic application 'HPZone Dashboard' (DB). During this period, 147 new events were reported to EBS, mostly food-borne and vaccine-preventable diseases: 79 from regional units, 144 from DB (76 from both). EBS reported 61 events to the OCC: 21 of these were reported onwards. EBS sensitivity was 95.2%; positive predictive value was 32.8%; reports were timely (median one day; 10th percentile: 0 days - same day; 90th percentile: 3.6 days); completeness was 99.7%; stability was 100%; EBS simplicity was assessed as good; the daily time per regional or national unit dedicated to EBS was approximately 4 hours (weekdays) and 3 hours (weekends). OCC directors judged EBS as efficient, fast and responsive. EBS provided reliable, reassuring, timely, simple and stable national epidemic intelligence for the Games.

Do genitourinary physicians report notifiable diseases? A survey in South East England

Genitourinary medicine work requires public health actions. Notifiable infections may be seen in genitourinary medicine, but concerns over confidentiality could delay public health actions and outbreak management. To assess genitourinary medicine clinicians' awareness of notification of infectious disease, reporting practices and liaison with Health Protection Units, we sent postal surveys to 140 genitourinary medicine clinicians (SE HPA region) that explored prior public health training, Health Protection Unit liaison and management of possible clinical scenarios. Fifty-seven respondents reported median genitourinary medicine experience of 12 years; 29% had prior public health training, nine on the British Association for Sexual Health and HIV course. A total of 90% had heard of Health Protection Units and understood their role. Approximately one-third would not report key diseases at all, most reporting only on laboratory confirmation. In all, 83% would only notify acute hepatitis on lab confirmation; 50% would report suspected measles immediately (44% awaiting lab confirmation) and 40% would not pass on any patient details without consent. Clinicians have good knowledge of notification of infectious disease conditions but responses suggest it is not always used in clinical context. Reporting delays occur waiting for lab confirmation and liaison with local Health Protection Units may be hindered by confidentiality concerns, potentially delaying public health action. Doctors with prior public health training are more likely to report appropriately.

Timeliness of Electronic Reporting and Acceptability of Public Health Follow-Up of Routine Nonparatyphoidal and Nontyphoidal Salmonella Infections, London and South East England, 2010 to 2011

Nonparatyphoidal and nontyphoidal Salmonella (NTS) infections are major causes of food poisoning in England. Diagnostic laboratories and clinicians have a statutory responsibility to report NTS infection cases to the Health Protection Agency via various means, with electronic reporting encouraged as the universal method. The Health Protection Agency (Public Health England since 1 April 2013) refers cases to environmental health departments for follow-up. Timeliness of reporting and adequacy of NTS infection case follow-up are key factors in the implementation of public health actions. Laboratories, health protection units, and environmental health departments in London and South East (SE) regions of England completed three surveys between December 2010 and April 2011, collecting data about the NTS infection case reporting methods and the time elapsed between symptom onset and public health actions. The median period between symptom onset and public health investigation was 25 days in London and 23 days in SE when electronic reporting was used and 12 days in London and 11 days in SE when other means of reporting were used. The most common follow-up method was a telephone questionnaire in London (53%) and a postal questionnaire in SE (52%). The telephone questionnaire had the highest response rate (98% in London; 96% in SE). Timeliness and efficiency of electronic NTS infection case reports can be improved by decreasing the electronic laboratory report period and using telephone-administered questionnaires to maximize the public health benefit when following up single cases of NTS infection.

From Facebook to Tracebook: A Justified Means to Prevent Infection Risks?

After arrival in a hospital, a man with suspected meningococcal septicaemia slips into a coma. One of his friends posts a message on the patient’s Facebook ‘wall’ informing three named contacts that the patient has meningitis and tells them to speak to a doctor. At the request of the Health Protection Unit (HPU), this message is later modified, to reduce unnecessary anxiety and to provide better guidance (Mandeville et al., 2013). Based on the harm principle and considerations of reasonableness, it will be argued that in this case the HPU is justified to contact the close contacts of the patient individually (via Facebook or otherwise), and to require the enterprising ‘friend’ of the patient to post a modified message on the patient’s Facebook wall advising close contacts to contact the HPU, without naming close contacts. Generally, the internal logic of social networking sites like Facebook (sharing personal information with a broad range of ‘friends’) is contrary to the logic of health care systems (keeping breaches of confidentiality to a minimum). Social networking sites (SNS) could justifiably be used for contract tracing, provided that such use complies with the well-established norms of health care systems.

Tips for GP trainees working in public health

Public health is a specialty in which few of us have practical experience. It’s generally poorly covered at medical school but believe me, there’s more to this stuff than statistics and John Snow’s pump handle. Until 2013, the typical GP placement would involve working in the primary care trust (PCT), primarily in the Department of Public Health, and working within the local Health Protection Unit (HPU) covering disease outbreak response work and their on-call service. Under the reforms of the Health and Social Care Act of 2012 both agencies will no longer exist. From April 2013 public health placements are with Public Health England (PHE), encompassing the work formerly conducted with the Health Protection Agency and some of the work of the former PCT. This could be in the national PHE office or with the regional PHE units. Your involvement with the assessment and planning of population health will be within the Local Government Association (LGA), that is local authority. Here you will have a chance to work with the commissioning support service (CSS) and the health and wellbeing board (HWB) on health needs assessments and strategic planning of local health care. A summary of the new public health system and its organisations is available on the PHE (https://www.gov.uk/government/organisations/public-health-england) and local.gov (www.local.gov.uk/health) websites.

P6.005 Multidisciplinary Approach to Managing a Syphilis Outbreak in Southend-On-Sea, Essex UK

BackgroundIn 2012 the Essex Health Protection Unit of the Health Protection Agency(HPA) was alerted to a significant rise in syphilis in Southend. 27 cases were diagnosed in 2011 and 15...

Outbreak of measles in Central and Eastern Cheshire, UK, October 2008–February 2009

We describe the largest outbreak of measles in Central and Eastern Cheshire (North West England) since the MMR vaccine was introduced in 1988, the majority of cases were not vaccinated and more than 20% of the cases belonged to the travelling community. Over 4 months,147 clinical cases of measles were notified locally to the Cheshire & Merseyside Health Protection Unit (CMHPU). Of these, 67 (45.6%) were laboratory confirmed, 42 (28.6%) were negative, and one was equivocal, leaving 23 probable and 14 possible cases. The primary case was probably an 8-year-old unvaccinated travelling child, symptomatic on 1 October 2008. Measles spread locally and within school-aged children until early February 2009. Most of Central and Eastern Cheshire, including 23 educational institutions (playgroups, nurseries, primary schools, secondary schools, colleges), were affected, showing that there were enough susceptible/unvaccinated children to sustain an outbreak. Nearly a quarter of the confirmed cases (15/67, 22.4%) were aged <13 months and too young to be vaccinated under the UK immunization schedule. This outbreak is a reminder of the importance of achieving herd immunity to prevent spread and protect those at risk of severe illness or complications. There were no fatalities in this outbreak and no significant complications were reported.

The role of public health in climate change and sustainability: is the UK public health community’s response adequate?

Climate change is the greatest public health disaster facing us today. Sucharita Yarlagadda, Premila Webster and Elizabeth Haworth from the University of Oxford suggest that only with firm and decisive action now can we hope to avert or mitigate an impending public health catastrophe1 While there is a scientific consensus that the global climate is changing, with increasing climate variability and extremes, rising temperatures and sea levels and increased frequency of natural disasters which impact on human health,2,3,4 against a backdrop of persistent world economic pressures, the role of the specialty of public health in responding to environmental and climate change is not clear and needs to be defined. Many governments, including those of the UK have committed to tackling climate change through adaptation and mitigation and carbon abatement measures. The Climate Change Act 2008 sets a legally binding target for reducing UK greenhouse gas emissions by at least 34% by 2020 and by 80% by 2050, using the 1990 baseline.5 The NHS has shown leadership in this area through the Good Corporate Citizenship model,6 the NHS carbon reduction strategy7 and the NHS Sustainable Development Unit's route map for sustainable health.8 These aim to, at least, meet government targets and demonstrate early success with a 10% reduction of the 2007 NHS carbon footprint by 2015. Since April 2010, a new mandatory emissions trading scheme has come into force, requiring increased efforts by NHS organizations to meet government carbon targets.9 Alongside this is growing evidence of substantial financial and health benefits of low carbon business models in response to climate change and sustainability.6,10 As recommended by the Lancet and University College London a new Public Health movement is needed.4 The time to act is now. However, there still seems to be a huge gap between knowledge/ evidence and coordinated public health action. To clarify the public health role, a UK-wide internet based survey of public health departments (service public health, academic public health and the health protection units) was conducted in April 2010. It sought to allow an assessment of climate change as a public health problem, identify actions and innovations already taken, and to promote a coordinated public health response. The preliminary results were presented at the 2010 Faculty of Public Health Conference. The response rate of 32% overall was disappointing, despite a reminder. Over 90% of this considerable UK public health workforce who responded agreed that climate change is an important health problem requiring public health action. Many respondents highlighted the need for a stronger NHS mandate and prioritisation, such as through the NHS operational framework. Most believed that further training and development is essential for effective action, but the urgency is sidelined by current restriction of financial resources to deal with this problem. Although the public health workforce believes that action is needed and there is a public health strategy11 and encouraging response by primary care trusts12 neither an overarching plan nor effective coordination exists. What is good for the planet is also good for health and policies and structural drivers to mitigate and adapt to climate change would have a large positive effect on population health, for example the health co-benefits of walking or cycling to work that both reduce emissions and improve health and wellbeing.13 Emergency plans must be improved, kept up to date and include an effective service response to unpredictable weather patterns because of climate associated disasters and problems. These include floods and related water contamination incidents, droughts, heat waves, food shortages, as well as the problem of emerging diseases such as arthropod-borne infections and other environmentally linked diseases such as skin cancers and cataracts due to reduction/loss of the ozone layer. …

P35 A collaborative approach to controlling an HIV outbreak among intravenous drug users

BackgroundIn 2008 an intravenous drug user (IVDU) admitted to the infectious diseases unit was diagnosed with late-stage HIV. He named five injecting partners, of whom three tested negative for HIV,...

P11 HIV test uptake in the GU clinic: juniors hot on the heels of the consultants

BackgroundData from the Health Protection Agency shows that 25% of people living with HIV in the UK are unaware of their diagnosis. This has serious health implications for them and...

Working together to promote hygiene

Working together to promote hygiene QHow do you ensure that you meet essential standard 8? AWe follow the guidance provided by the Health Protection Agency in the first instance and work closely with our local infection control link nurse who provides advice guidance and support to ensure we are meeting the necessary requirements. The manager is responsible for developing, monitoring and reviewing our infection control strategy for the home. This includes the safe handling and disposal of clinical waste, spillages, provision of protective clothing and handwashing. She annually reviews the infection control strategy to ensure its continuing suitability and effectiveness so that any issues arising from the review are addressed for the following year. This also highlights any new infection trends nationally, or existing common infectious disease patterns locally, so preventative action can be taken. If at anytime a resident has been diagnosed with an infectious disease, the manager ensures that the NHS North Lincolnshire community infection prevention and control team are contacted immediately and their guidelines are followed. Extensive policies and procedures in the home ensure effective management and control of infection. An up-to-date list of infectious diseases is maintained and the Health Protection Agency are notified if a resident is diagnosed. We have good links with the health protection unit for support and advice. A registered provider of infection control training is used to ensure that staff receive appropriate guidance. At the entrance of our home we display information, e.g. posters, to highlight the importance of following infection control procedures. For example, we have a prompt in the signing in book to use the alcohol hand wash, which is provided when entering the home. Suitable and effective guidance on handwashing is in place to minimize risks associated with cross infection. We communicate with our visitors through social media, monthly newsletters and the noticeboard in the entrance. These forums are used to share necessary information and request feedback. Every comment from the people who use our service, including professionals and residents, is taken on board and actioned if it helps improve our practices. Regular reviews are held with residents, family members and professionals to discuss and share information. All of the aforementioned communication methods are used to promote effective infection control methods in order to maintain a high standard of care.

Complying with CQC standard 6

Complying with CQC standard 6 How do you ensure that you meet essential standard 6? Contact with all parties involved in the care of a resident begins at the referral stage. A thorough preadmission process takes place. An allocated member of the home’s staff speaks to the prospective residents and their next of kin. A corporate preadmission assessment document is used. At least a ‘show round’ visit is advocated, but trial visits are also encouraged. We request that the resident or representative sign a ‘consent to sharing of information’ document, thus abiding by the Data Protection Act. Existing assessments or support plans are obtained from the allocated social worker or care manager. Once a resident is admitted, appropriate records, such as care plans, are developed, then reviewed and evaluated at least monthly. Staff are advised to ensure resident and relative involvement and other professionals, such as GPs, district nurses, continence and tissue viability specialists and the care home support team, are consulted or invited to attend. A visit sheet is contained within the care plan and visiting professionals are encouraged to write their feedback on this form. There is also a detailed transfer form for movement around services. The home uses external records, such as local surgery or social service documentation, continence screening charts or ‘poor discharge’ feedback forms. Local Do Not Resuscitate and East Midlands Ambulance Service forms are used for end-of-life care, so all parties, such as out of hours GPs, are aware of a resident’s condition. The home has an up-to-date business continuity plan in place, with appropriate agencies listed and contact details of the health protection unit or the environmental health officer in the event of an outbreak.

Harmonised Regulation and Labelling of Product Emissions – A New Initiative by the European Commission

Paul Harrison Derrick Crump Stylianos Kephalopoulos Chuck Yu Christine Daumling Christophe Rousselle Institute of Environment and Health, Cranfield University, Bedfordshire MK43 0AL, UK PTCH Consultancy Ltd, Market Harborough, Leicestershire LE16 9BX, UK European Commission Joint Research Centre, Institute for Health & Consumer Protection, Chemical Assessment and Testing Unit, Policy interface and harmonisation processes, T.P. 281, 21027-Ispra (VA), Italy ISBE, Caldecotte, Milton Keynes MK7 8HQ, UK Indoor Hygiene – AgBB, Federal Environment Agency, UBA-DG Dahlem, Corrensplatz 1, 14195 Berlin, Germany ANSES, French Agency for Food, Environmental and Occupational Health & Safety – Risk Assessment Department, Maisons-Alfort, France

Predictive power of Koplik’s spots for the diagnosis of measles

Measles is a major cause of mortality globally. In many countries, management of measles is based on clinical suspicion, but the predictive value of clinical diagnosis depends on knowledge and population prevalence of measles. In the pre-vaccine era with high measles incidence, Koplik's spots (KS) were said to be "pathognomonic". This study prospectively evaluated test properties and diagnostic odds ratios (OR) of KS. Data including KS status were prospectively collected for a six-month period on all suspected measles cases reported to the North-West London Health Protection Unit. Saliva test kits were sent to all cases and KS test properties were analysed against measles confirmation by PCR or IgM testing (gold standard). The positive predictive value (PPV) of clinically suspecting measles was 50%. Using KS as diagnostic tool improved the PPV to 80% and the presence of KS was associated with confirmed measles in the multi-variable analysis (OR 7.2, 95% Confidence Interval 2.1-24.9, p=0.001). We found that Koplik's spots were highly predictive of confirmed measles and could be a good clinical tool to enable prompt measles management and control measures, as action often needs to be taken in the absence of laboratory confirmation. We suggest that current clinical case definitions might benefit from the inclusion of KS.

Control measures for invasive group A streptococci (iGAS) outbreaks in care homes

The incidence of invasive group A streptococcal infections (iGAS) is increasing in Europe, with a particularly high morbidity and mortality in the elderly. Control of outbreaks in care homes is therefore important; but is unclear how best to manage these incidents. We attempted to identify which control measures are most likely to be effective. We undertook literature searches using PubMed and Google Scholar and contacted colleagues in Health Protection Units in England for unpublished outbreaks. We identified 31 outbreaks; of which 20 had sufficient detail for further analysis. Overall carriage rates of GAS in care home residents identified in outbreak investigations were 4.7%, and in staff 3.2%. In 8 outbreaks mass antibiotic prophylaxis was offered, in 9 selective prophylaxis only and in 3 none at all. Surveillance swabbing had limited influence on decisions regarding prophylaxis. A few papers mentioned the role of environmental contamination and the risk from an affected roommate. Pooling of results from these outbreaks failed to suggest any clear advantage to either a selective or mass antibiotic prophylaxis strategy in controlling spread. Systematic investigation and data collection from future outbreaks could be of benefit in informing future policy.

Panton-Valentine Leukocidin associated Staphylococcus aureus infections in London, England: Clinical and socio-demographic characterisation, management, burden of disease and associated costs

Routine notification of Staphylococcus aureus producing the Panton-Valentine Leucocidin toxin (PVL-SA) to the North East & Central London Health Protection Unit, a communicable disease control unit covering a population of 2.8 million, identified 115 cases in 2009-2010, including 99 skin and soft tissue infections (SSTIs), 15 severe infections and one asymptomatic colonisation. Most cases occurred in children and young adults, unequally distributed geographically and socio-economically. The majority of infections were community acquired and 60% were caused by methicillin resistant strains. Overall, 27% of cases had previous SSTIs, and 32% had contacts with SSTIs suggestive of PVL-SA albeit these were not confirmed microbiologically. This suggests that characteristics of PVL-SA infection in cases and their families are not recognised as such leading to delay in diagnosis and low case ascertainment. A lack of governance around effective case management may also be contributing to the burden of disease. Further studies are recommended to evaluate key aspects of PVL-SA management including the effectiveness of decolonisation in the elimination of carriage and prevention of local spread.