Infectious Intestinal Disease In England Research Articles

Neighbourhood unemployment and other socio-demographic predictors of emergency hospitalisation for infectious intestinal disease in England: A longitudinal ecological study

Previous studies have observed that infectious intestinal disease (IID) related hospital admissions are higher in more deprived neighbourhoods. These studies have mainly focused on paediatric populations and are cross-sectional in nature. This study examines recent trends in emergency IID admission rates, and uses longitudinal methods to investigate the effects of unemployment (as a time varying measure of neighbourhood deprivation) and other socio-demographic characteristics on IID admissions for adults and children in England. A longitudinal ecological analysis was performed using Hospital Episode Statistics on emergency hospitalisations for IID, collected over the time period 2012-17 across England. Analysis was conducted at the neighbourhood (Lower-layer Super Output Area) level for three age groups (0-14; 15-64; 65+ years). Mixed-effect Poisson regression models were used to assess the relationship between trends in neighbourhood unemployment and emergency IID admission rates, whilst controlling for measures of primary and secondary care access, underlying morbidity and the ethnic composition of each neighbourhood. From 2012-17, declining trends in emergency IID admission rates were observed for children and older adults overall, while rates increased for some sub-groups in the population. Each 1 percentage point increase in unemployment was associated with a 6.3, 2.4 and 4% increase in the rate of IID admissions per year for children [IRR=1.06, 95%CI 1.06-1.07], adults [IRR=1.02, 95%CI 1.02-1.03] and older adults [IRR=1.04, 95%CI 1.036-1.043], respectively. Increases in poor primary care access, the percentage of people from a Pakistani ethnic background, and the prevalence of long-term health problems, in a neighbourhood, were also associated with increases in IID admission rates. Increasing trends in neighbourhood deprivation, as measured by unemployment, were associated with increases in emergency IID admission rates for children and adults in England, despite controlling for measures of healthcare access, underlying morbidity and ethnicity. Research is needed to improve understanding of the mechanisms that explain these inequalities, so that effective policies can be developed to reduce the higher emergency IID admission rates experienced by more disadvantaged communities.

Asymptomatic Rotavirus Infections in England: Prevalence, Characteristics, and Risk Factors

Rotavirus is a major cause of infectious intestinal disease in young children; a substantial prevalence of asymptomatic infection has been reported across all age groups. In this study, the authors determined characteristics of asymptomatic rotavirus infection and potential risk factors for infection. Healthy persons were recruited at random from the general population of England during the Study of Infectious Intestinal Disease in England (1993-1996). Rotavirus infection was identified using reverse-transcription polymerase chain reaction. Multivariable logistic regression was used to compare exposures reported by participants with rotavirus infection with those of participants who tested negative. Multiple imputation was used to account for missing responses in the data set. The age-adjusted prevalence of asymptomatic rotavirus infection was 11%; prevalence was highest in children under age 18 years. Attendance at day care was a risk factor for asymptomatic rotavirus infection in children under age 5 years; living in a household with a baby that was still in diapers was a risk factor in older adults. The results suggest that asymptomatic rotavirus infection is transmitted through the same route as rotavirus infectious intestinal disease: person-to-person contact. More work is needed to understand the role of asymptomatic infections in transmission leading to rotavirus disease.

Community Incidence of Norovirus-associated Infectious Intestinal Disease in England: Improved Estimates Using Viral Load for Norovirus Diagnosis

Existing estimates of the incidence of infectious intestinal disease (IID) caused by norovirus are based on electron microscopy or reverse transcription-polymerase chain reaction (RT-PCR). Neither method accurately represents norovirus disease burden: Electron microscopy has poor diagnostic sensitivity, and RT-PCR has poor diagnostic specificity. In this study, viral load measurements were used to identify cases of norovirus-associated IID and to produce new incidence estimates for England. IID cases were ascertained in the Study of Infectious Intestinal Disease in England (1993-1996), and stool specimens were tested by semiquantitative real-time RT-PCR for norovirus. The age-adjusted community incidence of norovirus-associated IID was 4.5/100 person-years (95% credibility interval: 3.8, 5.2), equating to 2 million episodes/year. Among children aged less than 5 years, the community incidence was 21.4/100 person-years (95% credibility interval: 15.9, 27.7), and the incidence of consultations to general practitioners for norovirus-associated IID was 3.2/100 person-years (95% credibility interval: 2.6, 3.8), with 100,000 children visiting their general practitioner for norovirus-associated IID each year. Norovirus is the most common cause of IID in the community in England and is responsible for a similar number of pediatric primary care consultations as rotavirus.

Detection by PCR of eight groups of enteric pathogens in 4,627 faecal samples: re-examination of the English case-control Infectious Intestinal Disease Study (1993–1996)

The English case-control Infectious Intestinal Disease Study (1993-1996) failed to detect an enteric pathogen or toxin in 49% of cases of gastroenteritis. In the present study, polymerase chain reaction (PCR) assays were applied to DNA and cDNA generated from 4,627 faecal samples from cases and controls archived during the original study for the detection of norovirus, rotavirus, sapovirus, Campylobacter spp., Salmonella spp., enteroaggregative Escherichia coli, Cryptosporidium spp., and Giardia spp. The percentage of archived samples from cases and from controls in which at least one agent (or toxin) was detected increased from 53% in the original study to 75% and from 19 to 42%, respectively, after the application of PCR assays. Among cases, the following percentages of enteric pathogens were detected: norovirus 36%, rotavirus A 31%, sapovirus 4%, Salmonella spp. 6%, Campylobacter jejuni 13%, Campylobacter coli 2%, other Campylobacter spp. 8%, enteroaggregative E. coli 6%, Giardia spp. 2%, and Cryptosporidium spp. 2%. The present study provides additional insight into the aetiology of infectious intestinal disease in England and highlights the occurrence of viral infections in cases as well as in asymptomatic individuals. Other notable findings include the frequent presence of Campylobacter spp. other than C. jejuni or C. coli, the high frequency of multiple agents in 41% of cases and in 13% of controls, and the variation in the aetiology and rate of infection found for different age groups. The results demonstrate the greater sensitivity of PCR-based methods compared to current conventional methods.

Outbreaks of waterborne infectious intestinal disease in England and Wales, 1992–2003

We reviewed the epidemiological and microbiological characteristics of 89 reported outbreaks of waterborne infectious intestinal disease affecting 4321 people in England and Wales over the period 1992-2003. Public water supplies were implicated in 24 outbreaks (27%), private water supplies in 25 (28%), swimming pools in 35 (39%) and other sources in five outbreaks (6%). Cryptosporidium was implicated in 69% of outbreaks, Campylobacter sp. in 14%, Giardia in 2%, E. coli O157 in 3% and Astrovirus in 1%. From 2000, there was a consistent decline in the number of outbreaks of waterborne disease associated with public water supplies. The incidence rate of outbreaks in recipients of private water supplies may be as high as 35 times the rate in those receiving public water supplies (1830 vs. 53 per million population). Private water suppliers need to be aware of the importance of adequate treatment and the prevention of faecal contamination of storage water. Swimming-pool operators need to ensure chlorination and in particular adequate filtration measures are in place.

Foodborne transmission of infectious intestinal disease in England and Wales, 1992–2003

This paper reports information on foodborne outbreaks of infectious intestinal disease (IID) in England and Wales during the period 1992–2003 collected as part of a major investigation into Breakdowns in Food Safety. Between 1992 and 2003, 7620 general outbreaks of IID were reported to the Communicable Disease Surveillance Centre and in 1729 (23%) the mode of transmission was described as foodborne. In total, 39,625 people were affected and 68 deaths reported. Salmonella spp. were implicated in over half of all foodborne outbreaks. During the surveillance period, the proportion of outbreaks attributed to Salmonella spp., Clostridium perfringens and Vero cytotoxin-producing Escherichia coli O157 decreased, whereas the proportion of outbreaks attributed to Campylobacters increased.

The study of infectious intestinal disease in England: socio-economic impact.

To assess the socio-economic impact of infectious intestinal disease (IID) on the health care sector, cases and their families, cases of IID ascertained from a population cohort component and those presenting to general practices were sent a socio-economic questionnaire 3 weeks after the acute episode. The impact of the illness was measured and the resources used were identified and costed. The duration, severity and costs of illness linked to viruses were less than those linked to bacteria. The average cost per case of IID presenting to the GP was Pound Sterling253 and the costs of those not seeing a GP were Pound Sterling34. The average cost per case was Pound Sterling606 for a case with salmonella, Pound Sterling315 for campylobacter, Pound Sterling164 for rotavirus and Pound Sterling176 for SRSV. The estimated cost of IID in England was Pound Sterling743m expressed in 1994/5 prices. The costs of IID are considerable and the duration of the illness was found to be longer than previous reports have suggested.

The study of infectious intestinal disease in England: what risk factors for presentation to general practice tell us about potential for selection bias in case-control studies of reported cases of diarrhoea.

Cases reported to national surveillance systems commonly form the sampling frame for population-based case-control studies of infectious intestinal diseases (IID). However, reported cases represent a minority of all cases in the population, differ systematically from unreported cases, and their use in case-control studies could introduce biases. Case reporting is a selective process involving multiple stages, the first of which requires presentation by a symptomatic person to the health services. Factors affecting a person's likelihood of presentation will thus affect the characteristics of reported cases. Data from a large study of IID in England were used to investigate factors influencing presentation to a general practitioner (GP) following an episode of IID. Multivariable logistic regression was performed, comparing GP presenters with non-presenters. Explanatory variables used were illness severity, recent foreign travel and socioeconomic indicators. Severe illness (OR = 12.54, 95% CI: 7.58-20.74), recent foreign travel (OR = 2.4, 95% CI: 1.39-4.14), leaving full-time education at an earlier age (OR = 2.06, 95% CI: 1.22-3.50) and housing categories representing lower socioeconomic status (SES) were all independently associated with GP presentation. Case reporting to national surveillance is shaped by complex biological and social factors, of which illness severity appears to be the most important. Results from case-control studies comparing cases of IID identified by surveillance with population controls are likely to generalize mainly to cases severe enough to be reported. Controlling for educational and SES (mostly housing) is required.

Vero cytotoxin-producing Escherichia coli in a study of infectious intestinal disease in England

An investigation of infectious intestinal disease in England included examination of feces for Vero cytotoxin-producing Escherichia coli (VTEC). Using DNA probe hybridization 27 VTEC strains were identified, 12 were from cases, and of these three belonged to serogroup O157. The remaining 15 strains were isolated from controls. The strains were confirmed biochemically as E. coli, they were serotyped and characterized according to their toxin production, the presence of sequences encoding intimin (eae) and enterohemolysin was determined and resistance to antimicrobial agents was determined. Six of the nine cases with non-O157 VTEC were less than 16 years old, only two of the 15 controls were under 16. Infection with more than one micro-organism was also considered.

Surveillance of foodborne outbreaks of infectious intestinal disease in England and Wales 1992–1999 contributing to evidence-based food policy?

Between 1992 and 1999, a total of 1426 general outbreaks of infectious intestinal disease reported to the Public Health Laboratory Service (PHLS) Communicable Disease Surveillance Centre (CDSC) were described as foodborne. Where the evidence base to support the conclusions drawn was provided (66.3% of outbreaks) a combination of microbiological and analytical evidence was reported in 4% of outbreaks (60/1426); microbiological evidence alone in 10% of outbreaks (149/1426); analytical evidence alone in 23% of outbreaks (322/1426); microbiological evidence in combination with descriptive epidemiology in 3% of outbreaks (46/1426) and descriptive epidemiology alone in 26% of outbreaks (365/1426). Information supplied to CDSC by local investigators appears to be of varying quality and depth and may be influenced by the individual characteristics of outbreaks such as size and duration, outbreak setting, causative organism, vehicles of infection and time of year. These findings have implications for the use of these surveillance data in developing evidence-based food policy. Public health (2002) 116 , 75–80

Surveillance of foodborne outbreaks of infectious intestinal disease in England and Wales 1992–1999: contributing to evidence-based food policy?

Between 1992 and 1999, a total of 1426 general outbreaks of infectious intestinal disease reported to the Public Health Laboratory Service (PHLS) Communicable Disease Surveillance Centre (CDSC) were described as foodborne. Where the evidence base to support the conclusions drawn was provided (66.3% of outbreaks) a combination of microbiological and analytical evidence was reported in 4% of outbreaks (60/1426); microbiological evidence alone in 10% of outbreaks (149/1426); analytical evidence alone in 23% of outbreaks (322/1426); microbiological evidence in combination with descriptive epidemiology in 3% of outbreaks (46/1426) and descriptive epidemiology alone in 26% of outbreaks (365/1426). Information supplied to CDSC by local investigators appears to be of varying quality and depth and may be influenced by the individual characteristics of outbreaks such as size and duration, outbreak setting, causative organism, vehicles of infection and time of year. These findings have implications for the use of these surveillance data in developing evidence-based food policy. Public health(2002) 116, 75–80

General outbreaks of infectious intestinal diseases linked with private residences in England and Wales, 1992-9: questionnaire study

The inception of the Food Standards Agency in April 2000 has given food safety issues a high public and political profile. Recently, concerns about food hygiene have focused on the...

The study of infectious intestinal disease in England: risk factors for cases of infectious intestinal disease with Campylobacter jejuni infection.

This is a case-control study aimed at identifying risk factors for intestinal infection with Campylobacter jejuni. Cases were defined as subjects with diarrhoea occurring in community cohorts or presenting to General Practitioners (GPs) with Campylobacter jejuni in stools. Controls were selected from GP lists or cohorts, matched by age, sex, and GP practice. Travel abroad and consumption of chicken in a restaurant were statistically significantly associated with being a case. There was no statistically significant risk associated with consumption of chicken other than in restaurants nor with reported domestic kitchen hygiene practices. Consumption of some foods was associated with a lower risk of being a case. Most cases remained unexplained. We suggest that infection with low numbers of micro-organisms, and individual susceptibility may play a greater role in the causation of campylobacter infection than previously thought. It is possible that in mild, sporadic cases infection may result from cross contamination from kitchen hygiene practices usually regarded as acceptable. Chicken may be a less important vehicle of infection for sporadic cases than for outbreaks, although its role as a source of infection in both settings requires further clarification in particular in relation to the effect of domestic hygiene practices. The potential effect of diet in reducing the risk of campylobacteriosis requires exploration.

A study of infectious intestinal disease in England: risk factors associated with group A rotavirus in children.

To identify risk factors for infectious intestinal disease (IID) due to rotavirus group A in children aged under 16 years. Case-control study of cases of IID with rotavirus infection presenting to general practitioners (GPs) or occurring in community cohorts, and matched controls. There were 139 matched pairs. In children under 16 years the following risk factors were significantly associated with rotavirus IID: living in rented council housing (adjusted OR = 3.78, P = 0.022), accommodation with more than five rooms (OR = 0.72, P = 0.002), contact with someone ill with IID (OR = 3.45, P < 0.001). Some foods were associated with decreased risk. In infants, bottle feeding with or without breast feeding was associated with increased risk (OR = 9.06, P < 0.05). Contact with persons with IID, living in rented council housing and accommodation with fewer rooms, were significant risk factors for sporadic rotavirus IID in children whereas breast feeding is protective in infants.

Characterisation of strains of enteroaggregative Escherichia coli isolated during the infectious intestinal disease study in England.

Strains of Escherichia coli, hybridising with a DNA probe for enteroaggregative E. coli (EAggEC), were isolated from patients with infectious intestinal disease (IID) or gastro-enteritis, and healthy controls during the study of IID in England. Of 3506 cases presenting with an IID, 160 (4.6%) had faecal EAggEC as compared with 46 (1.7%) of 2772 healthy controls, 53% of EAggEC isolated from each of the 'case' and the 'control' groups adhered in a 'stacked-brick' formation. Strains from cases and controls belonged to over 39 and 14 different serogroups respectively, and approximately half of the strains isolated did not react with antisera in the current somatic antigen serotyping scheme. Forty-nine cases with EAggEC (31%) had a known history of foreign travel. Over 50% of strains isolated from cases and controls were resistant to one or more of eight antimicrobials, and antimicrobial resistance was not statistically significantly more common among cases with a known history of foreign travel (p = 0.57). These data form part of the largest investigation carried out on these organisms in the UK to date and provide the most comprehensive analysis of strains of EAggEC isolated from the general population of England.

Study of infectious intestinal disease in England: rates in the community, presenting to general practice, and reported to national surveillance

Objective: To establish the incidence and aetiology of infectious intestinal disease in the community and presenting to general practitioners. Comparison with incidence and aetiology of cases reaching national laboratory based...

Outbreaks of infectious intestinal disease in residential institutions in England and Wales 1992–1994

Data from the surveillance scheme of all general outbreaks of infectious intestinal disease in England and Wales reported to or otherwise identified, by the Public Health Laboratory Service Communicable Disease Surveillance Centre (CDSC) in 1992 and 1994 were used to describe the epidemiology of outbreaks of infectious intestinal disease in residential institutions. Outbreaks in residential institutions accounted for 22% (282/1275) of all outbreaks with most, 95% (268/282), occurring in homes for the elderly. The commonest pathogens in these 282 outbreaks were small round structured viruses 48% (132), salmonellas 17% (49). Clostridium perfringens 8% (23), rotavirus 5% (15) and Shigella sonnei 2% (6). The mode of transmission was described as mainly person to person in 71% (200 outbreaks) and mainly foodborne in 21% (58 outbreaks). The mean duration of outbreaks was 9 days. Duration of outbreaks varied with both the mode of transmission and the pathogen involved. The mean attack rate was 37%. Illness was reported in 5872 people. One or more individuals were admitted to hospital in 22% of outbreaks. Twenty-six deaths were reported, of which 18 were attributed to salmonellosis. Outbreaks in residential institutions are common. Attack rates are high and outbreaks are often prolonged, with high morbidity and mortality. There is a need for effective infection control policies which include appropriate training of staff, simple surveillance systems and readily available expert advice to ensure outbreaks are rapidly controlled.

Outbreaks of salmonellosis in hospitals in England and Wales: 1992–1994

Data from the surveillance scheme of general outbreaks of infectious intestinal disease in England and Wales were used to describe the epidemiology of outbreaks of salmonellosis in hospitals from 1992–1994. Outbreaks of infectious intestinal disease in hospitals accounted for 15% ( 189 1275 ) of all outbreaks. A salmonella was the implicated pathogen in 12% ( 22 189 ). The mode of transmission was described as mainly person to person in 12 outbreaks, mainly foodborne in eight and equal or unknown proportions of foodborne and person to person in two. The most common strain involved was Salmonella enteritidis PT4 (11 outbreaks). The mean duration of outbreaks was 16 days. The mean attack rate in patients was 25% but varied from 2–67%. Illness was reported in 260 patients, of whom 130 had a laboratory confirmed infection. Eight hundred and twenty-six asymptomatic patients were tested, 31 of whom were positive. The salmonella infection was believed to have contributed to the deaths of five patients. Ill staff (115) were tested and 68 were positive; 1508 well staff were tested and 33 were positive. Outbreaks of salmonellosis in hospitals are preventable. Attack rates can be high and outbreaks are often prolonged, with high morbidity and associated disruption of hospital services. There is need for effective infection control policies, appropriate training of staff, simple surveillance systems and readily available expert advice to ensure outbreaks are rapidly controlled.

A pilot study of infectious intestinal disease in England

Pilot studies to test methods to determine the incidence, agents, risk factors and socioeconomic costs of infectious intestinal disease (IID) in England were carried out as recommended by the Committee on the Microbiological Safety of Food (the Richmond Committee) by eight general practices. There were case control and enumeration studies of patients presenting to general practice with IID, a population-based prospective cohort study, and a survey of socioeconomic costs of cases of IID. Information on risk factors was obtained by questionnaire (self-administered compared with interview) and a stool sample was requested on all cases and controls. Response rates in the GP case control study were 75% for case questionnaires and 74% for stools; for controls the figures were 70% and 68% respectively. The acceptance rate into the cohort study was 49%; this was significantly higher where phone contact was made. The rate was similar if recruitment was by individual or household. Follow-up of the cohort by negative reporting was complete for up to 6 months. Direct postage by subject was required to obtain fresh stool specimens. Estimates were obtained of presentation rates of IID and the distribution of risk factors which were used to plan the main study. The pilot study demonstrated that it is possible to undertake a national study based in general practice to determine the incidence of IID in the population and presenting to GPs and its agents, risk factors and costs.