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Merrick R, McKerr C, Song J, Donnelly K, Gerrard R, Morgan M, Williams C, Craine N. Transferring inpatients between wards drives large nosocomial COVID-19 outbreaks, Wales, 2020-22: a matched case-control study using routine and enhanced surveillance data. J Hosp Infect 2024; 145:1-10. [PMID: 38081454 DOI: 10.1016/j.jhin.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND The role of the hospital environment in the spread of COVID-19 is unclear. AIM To measure associations between ward characteristics and outbreak size to inform mitigations. METHODS Wards with large (case wards) and small (control wards) outbreaks in three acute hospitals were compared. Cases were healthcare-associated COVID-19 inpatients (positive polymerase chain reaction test ≥8 days post admission). Case wards were adult medical/surgical wards with ≥10 cases within rolling 14-day periods, between April 1st, 2020 and April 30th, 2022. Control wards were equivalents with 2-9 cases. Demographic and laboratory data were extracted from routine surveillance systems. Continuous data were aggregated fortnightly and analysed as binary variables according to median values. Each case ward was compared with two control wards matched on outbreak start date (±14 days) to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs) using univariable and conditional multivariable logistic regression. FINDINGS From 170 outbreaks (median: 5 cases; interquartile range: 2-9), 35 case wards were identified. Community admissions were lower in case wards vs control wards (5 vs 10 median admissions; P<0.01, respectively), whereas transfers between wards within the same hospital were higher (58 vs 29 median transfers; P<0.01, respectively). Wards with more transfers in the preceding fortnight were significantly more likely to experience a large outbreak (≥35 vs <35 transfers; adjusted OR: 9.08; 95% CI: 2.5-33). CONCLUSION We recommend safely minimizing patient movements, such as by asking clinicians to record the rationale for transfer, to reduce the likelihood of disease transmission.
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Affiliation(s)
- R Merrick
- UK Field Epidemiology Training Programme (UKFETP), UK Health Security Agency, UK; Public Health Wales, UK
| | | | | | | | | | - M Morgan
- UK Field Epidemiology Training Programme (UKFETP), UK Health Security Agency, UK; Public Health Wales, UK
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McKerr C, Chalmers RM, Elwin K, Ayres H, Vivancos R, O’Brien SJ, Christley RM. Cross-sectional household transmission study of Cryptosporidium shows that C. hominis infections are a key risk factor for spread. BMC Infect Dis 2022; 22:114. [PMID: 35105330 PMCID: PMC8807379 DOI: 10.1186/s12879-022-07086-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 01/07/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Infection with the Cryptosporidium parasite causes over 4000 cases of diagnosed illness (cryptosporidiosis) in England and Wales each year. The incidence of sporadic disease has not been sufficiently established, and how frequently this arises from contact with other infected people is not well documented. This project aimed to explore potential transmission in the home and attempt to identify asymptomatic infections, which might play a role in transmission. Risk factors and characteristics associated with spread of infection in the home were described including any differences between Cryptosporidium species. METHODS The study identified cryptosporidiosis cases from North West England and Wales over a year and invited them and their household to take part. Each household was sent a study pack containing study information and a questionnaire, and stool sample kits to provide samples from consenting household members. Cryptosporidium-positive stool samples, identified by immunofluorescence microscopy, were characterised using molecular methods to help describe any patterns of transmission. Characteristics of households with and without additional cases were described, and compared using odds ratios (OR) and a multivariable logistic regression identified independent risk factors for household transmission. Data collection ran for one year, beginning in September 2018 with an initial pilot phase. RESULTS We enrolled 128 index cases and their households. Additional illness occurred in over a quarter of homes, each reporting an average of two additional cases. The majority of these were undiagnosed and unreported to surveillance. This burden was even greater in households where the index case was infected with C. hominis versus C. parvum, or the index case was under five years old, with mums and siblings most at risk of secondary infection. Only having an index case of C. hominis was independently associated with transmission in the multivariable model (OR 4.46; p = 0.01). CONCLUSIONS Cryptosporidium was a considerable burden in the home. At-risk homes were those where the index was less than five years old and/or infected with C. hominis. Of particular risk were female caregivers and siblings. Hygiene advice should be specifically directed here. This work provides evidence for humans as sources of C. hominis infection and that person-person is a key pathway. We recommend that all stools submitted for the investigation of gastrointestinal pathogens are tested for Cryptosporidium to better capture cases, inclusion of speciation data in routine surveillance, and the consideration of specific clinical advice on prevention for high-risk homes.
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Affiliation(s)
- Caoimhe McKerr
- NIHR Health Protection Research Unit in Gastrointestinal Infections, The University of Liverpool, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, The University of Liverpool, Liverpool, UK
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
- Swansea Medical School, Swansea University, Swansea, UK
- Present Address: Public Health Wales, Cardiff, UK
| | - Rachel M. Chalmers
- Cryptosporidium Reference Unit, Public Health Wales, Swansea, UK
- Swansea Medical School, Swansea University, Swansea, UK
- Present Address: Public Health Wales, Cardiff, UK
| | - Kristin Elwin
- Cryptosporidium Reference Unit, Public Health Wales, Swansea, UK
- Present Address: Public Health Wales, Cardiff, UK
| | - Heather Ayres
- Cryptosporidium Reference Unit, Public Health Wales, Swansea, UK
- Present Address: Public Health Wales, Cardiff, UK
| | - Roberto Vivancos
- NIHR Health Protection Research Unit in Gastrointestinal Infections, The University of Liverpool, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, The University of Liverpool, Liverpool, UK
- Field Epidemiology Services, Public Health England, Liverpool, UK
| | - Sarah J. O’Brien
- NIHR Health Protection Research Unit in Gastrointestinal Infections, The University of Liverpool, Liverpool, UK
| | - Robert M. Christley
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, The University of Liverpool, Liverpool, UK
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
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McKerr C, Chalmers RM, Vivancos R, O'Brien SJ, Mugarza J, Christley RM. Cross-sectional investigation of household transmission of Cryptosporidium in England and Wales: the epiCrypt study protocol. BMJ Open 2019; 9:e026116. [PMID: 31230003 PMCID: PMC6596955 DOI: 10.1136/bmjopen-2018-026116] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 04/08/2019] [Accepted: 05/23/2019] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Infection with the Cryptosporidium parasite causes over 4000 cases of diagnosed illness (cryptosporidiosis) in England and Wales each year. Risk factors are often estimated from outbreak investigations, and in the UK include ingestion of contaminated water and food, farm/animal contact and person-to-person spread in institutions. However, reported outbreaks only represent about 10% of cases and the transmission routes for sporadic disease may not be the same. Contact with other people has been highlighted as a factor in the transmission of Cryptosporidium, but the incidence of sporadic disease has not been sufficiently established, and how frequently this arises from contact with other infected people is not well documented. This project will estimate the amount of secondary spread that occurs in the home and potentially identify asymptomatic infections which might have a role in transmission. Risk factors and characteristics associated with secondary spread will be described including any differences in transmission between Cryptosporidium species. METHODS AND ANALYSIS The study will prospectively identify cryptosporidiosis cases from North West England and Wales over 1 year and invite them and their household to take part. Each household will complete a questionnaire and each household member will be asked to provide a stool sample. Clinical, demographic and home variables will be described, and further analyses undertaken to investigate associations with secondary spread in the home. Cryptosporidium-positive stool samples, identified by immunofluorescence microscopy, will be characterised using molecular methods to describe patterns of transmission. Data collection is expected to take 1 year, beginning in September 2018. ETHICS AND DISSEMINATION The study has been approved by the North West-Liverpool East NHS Research Ethics Committee (Reference: 18/NW/0300) and the Confidentiality and Advisory Group (Reference 18/CAG/0084). Outputs will include scientific conferences and peer-reviewed publications. In addition, a short, lay report of findings will be produced for participants, who can opt to receive this when they take part. TRIAL REGISTRATION NUMBER CPMS ID: 39458.
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Affiliation(s)
- Caoimhe McKerr
- NIHR Health Protection Research Unit in Gastrointestinal Infections, University of Liverpool, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Neston, UK
| | - Rachel M Chalmers
- Cryptosporidium Reference Unit, Public Health Wales, Swansea, UK
- Swansea University Medical School, Swansea, UK
| | - Roberto Vivancos
- Field Epidemiology Services, Health Protection, Public Health England, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, The University of Liverpool, Liverpool, UK
| | - Sarah J O'Brien
- NIHR Health Protection Research Unit in Gastrointestinal Infections, University of Liverpool, Liverpool, UK
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Julie Mugarza
- NIHR Clinical Research Network North West Coast, Liverpool, UK
| | - Robert M Christley
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Neston, UK
- Department of Epidemiology and Population Health, Institute of Infection and Global Health, University of Liverpool, Neston, UK
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McKerr C, O’Brien SJ, Chalmers RM, Vivancos R, Christley RM. Exposures associated with infection with Cryptosporidium in industrialised countries: a systematic review protocol. Syst Rev 2018; 7:70. [PMID: 29720280 PMCID: PMC5932784 DOI: 10.1186/s13643-018-0731-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 04/13/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cryptosporidium is a protozoan parasite of humans and other animals worldwide and is one of the greatest contributors to human diarrhoeal illness. Transmission can occur indirectly via contaminated food or water, or directly via contact with animals or other infected people. Risk exposures are often identified from outbreak investigations, but a subset of cases remains unexplained, and sources for sporadic disease and pathways to infection are still unclear. Given the few systematic syntheses of reported evidence in industrialised populations, the aim of this review is to consolidate the literature to describe exposures associated with human cryptosporidiosis in industrialised countries, specifically including the UK, and describe any differences between outbreak-associated and sporadic disease. METHODS/DESIGN Where relevant, methods will follow the recommendations made in the Cochrane Handbook for Systematic Reviews of Interventions. Three steps will be used to identify the literature including electronic database searching using PubMed, Scopus, Embase and Web of Science; reference list trawling; and an exploration of the grey literature. Screening of results will be undertaken by two reviewers using pre-defined criteria. Studies conducted in industrialised countries and reporting on human subjects will be included. All observational studies will be included where they report exposures and relevant quantitative results. Data will be extracted using a standardised form. Study quality will be assessed using the ROBINS-I tool. Data will be summarised presenting the papers' main findings including population under study, outcomes, and exposures, and whether these were considered outbreak or sporadic cases. A narrative summary will also be included. Where populations are appropriate, available data will be pooled in a meta-analysis combining the significant exposures across studies. DISCUSSION This review aims to consolidate the evidence for transmission routes and exposures for Cryptosporidium in industrialised countries, with particular reference to how these may apply to the UK. In addition, the review will seek to describe differences between outbreak and sporadic cases. This will help to identify those most vulnerable, highlighting pathways where interventions and public health response may be appropriate. SYSTEMATIC REVIEW REGISTRATION PROSPERO number CRD42017056589 .
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Affiliation(s)
- Caoimhe McKerr
- NIHR Health Protection Research Unit in Gastrointestinal Infections, The University of Liverpool, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, The University of Liverpool, Liverpool, UK
- Institute of Infection and Global Health, University of Liverpool, Waterhouse Building (2nd Floor, Block F), 1-5 Brownlow Street, Liverpool, L69 3GL UK
| | - Sarah J. O’Brien
- NIHR Health Protection Research Unit in Gastrointestinal Infections, The University of Liverpool, Liverpool, UK
| | | | - Roberto Vivancos
- NIHR Health Protection Research Unit in Gastrointestinal Infections, The University of Liverpool, Liverpool, UK
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, The University of Liverpool, Liverpool, UK
- Field Epidemiology Services, Public Health England, Liverpool, UK
| | - Robert M. Christley
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, The University of Liverpool, Liverpool, UK
- Institute of Infection and Global Health, University of Liverpool, Waterhouse Building (2nd Floor, Block F), 1-5 Brownlow Street, Liverpool, L69 3GL UK
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McKerr C, Coetzee N, Edeghere O, Suleman S, Verlander N, Banavathi K. Association between post-craniotomy Propionibacterium acnes infection and dural implants: a case–control study. J Hosp Infect 2017; 97:389-396. [DOI: 10.1016/j.jhin.2017.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 07/04/2017] [Indexed: 10/19/2022]
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McKerr C, Adak GK, Nichols G, Gorton R, Chalmers RM, Kafatos G, Cosford P, Charlett A, Reacher M, Pollock KG, Alexander CL, Morton S. An Outbreak of Cryptosporidium parvum across England & Scotland Associated with Consumption of Fresh Pre-Cut Salad Leaves, May 2012. PLoS One 2015; 10:e0125955. [PMID: 26017538 PMCID: PMC4446264 DOI: 10.1371/journal.pone.0125955] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 03/28/2015] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND We report a widespread foodborne outbreak of Cryptosporidium parvum in England and Scotland in May 2012. Cases were more common in female adults, and had no history of foreign travel. Over 300 excess cases were identified during the period of the outbreak. Speciation and microbiological typing revealed the outbreak strain to be C. parvum gp60 subtype IIaA15G2R1. METHODS Hypothesis generation questionnaires were administered and an unmatched case control study was undertaken to test the hypotheses raised. Cases and controls were interviewed by telephone. Controls were selected using sequential digit dialling. Information was gathered on demographics, foods consumed and retailers where foods were purchased. RESULTS Seventy-four laboratory confirmed cases and 74 controls were included in analyses. Infection was found to be strongly associated with the consumption of pre-cut mixed salad leaves sold by a single retailer. This is the largest documented outbreak of cryptosporidiosis attributed to a food vehicle.
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Affiliation(s)
- Caoimhe McKerr
- Public Health England, Field Epidemiology Services, London, England, United Kingdom
- Field Epidemiology Training Programme, Public Health England, London, England, United Kingdom
| | - Goutam K. Adak
- Department of Gastrointestinal, Emerging & Zoonotic Infections, Public Health England, London, England, United Kingdom
| | - Gordon Nichols
- Department of Gastrointestinal, Emerging & Zoonotic Infections, Public Health England, London, England, United Kingdom
- Norwich Medical School, University of East Anglia, Norwich, England, United Kingdom
- Faculty of Medicine, University of Thessaly, Larissa, Greece
- European Centre for Environment and Human Health, University of Exeter, Exeter, England, United Kingdom
| | - Russell Gorton
- Public Health England, Field Epidemiology Services, London, England, United Kingdom
| | - Rachel M. Chalmers
- Cryptosporidium Reference Unit, Public Health Wales, Swansea, Wales, United Kingdom
| | - George Kafatos
- Statistics, Modelling and Economics Department, Public Health England, London, England, United Kingdom
| | - Paul Cosford
- Public Health England, London, England, United Kingdom
| | - Andre Charlett
- Statistics, Modelling and Economics Department, Public Health England, London, England, United Kingdom
| | - Mark Reacher
- Public Health England, Field Epidemiology Services, London, England, United Kingdom
| | | | | | - Stephen Morton
- Public Health England Centre, Yorkshire & Humber, England, United Kingdom
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McKerr C, Lo YC, Edeghere O, Bracebridge S. Evaluation of the national Notifiable Diseases Surveillance System for dengue fever in Taiwan, 2010-2012. PLoS Negl Trop Dis 2015; 9:e0003639. [PMID: 25794177 PMCID: PMC4368052 DOI: 10.1371/journal.pntd.0003639] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 02/24/2015] [Indexed: 11/27/2022] Open
Abstract
Background In Taiwan, around 1,500 cases of dengue fever are reported annually and incidence has been increasing over time. A national web-based Notifiable Diseases Surveillance System (NDSS) has been in operation since 1997 to monitor incidence and trends and support case and outbreak management. We present the findings of an evaluation of the NDSS to ascertain the extent to which dengue fever surveillance objectives are being achieved. Methodology We extracted the NDSS data on all laboratory-confirmed dengue fever cases reported during 1 January 2010 to 31 December 2012 to assess and describe key system attributes based on the Centers for Disease Control and Prevention surveillance evaluation guidelines. The system’s structure and processes were delineated and operational staff interviewed using a semi-structured questionnaire. Crude and age-adjusted incidence rates were calculated and key demographic variables were summarised to describe reporting activity. Data completeness and validity were described across several variables. Principal Findings Of 5,072 laboratory-confirmed dengue fever cases reported during 2010–2012, 4,740 (93%) were reported during July to December. The system was judged to be simple due to its minimal reporting steps. Data collected on key variables were correctly formatted and usable in > 90% of cases, demonstrating good data completeness and validity. The information collected was considered relevant by users with high acceptability. Adherence to guidelines for 24-hour reporting was 99%. Of 720 cases (14%) recorded as travel-related, 111 (15%) had an onset >14 days after return, highlighting the potential for misclassification. Information on hospitalization was missing for 22% of cases. The calculated PVP was 43%. Conclusions/Significance The NDSS for dengue fever surveillance is a robust, well maintained and acceptable system that supports the collection of complete and valid data needed to achieve the surveillance objectives. The simplicity of the system engenders compliance leading to timely and accurate reporting. Completeness of hospitalization information could be further improved to allow assessment of severity of illness. To minimize misclassification, an algorithm to accurately classify travel cases should be established. In Taiwan, around 1,500 cases of dengue fever are reported annually. Surveillance and outbreak preparedness are important activities aimed at reducing the burden of dengue fever worldwide. A national web-based Notifiable Diseases Surveillance System (NDSS) for dengue fever has been established since 1997 in Taiwan to monitor trends, and support case and outbreak management. We evaluated this surveillance system based on the Centers for Disease Control and Prevention guidelines and operational staff interviews to ascertain the extent to which stated objectives are being achieved. The results indicate that the NDSS for dengue fever surveillance works well, is easy to use, and can be used to accurately identify cases. The findings have informed recommendations to improve surveillance and its use in outbreak response, including efforts to improve data completeness. Comprehensive surveillance exemplified by the NDSS for dengue fever in Taiwan is necessary for establishing a clear picture of the local burden and distribution of dengue fever to effectively support public health response.
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Affiliation(s)
- Caoimhe McKerr
- Field Epidemiology Training Programme, Public Health England, London, United Kingdom
- Field Epidemiology Service, Public Health England, United Kingdom
| | - Yi-Chun Lo
- Office of Preventive Medicine, Centers for Disease Control, Taipei, Taiwan
- * E-mail:
| | - Obaghe Edeghere
- Field Epidemiology Service, Public Health England, United Kingdom
| | - Sam Bracebridge
- Field Epidemiology Training Programme, Public Health England, London, United Kingdom
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Waldram A, McKerr C, Gobin M, Adak G, Stuart JM, Cleary P. Control selection methods in recent case-control studies conducted as part of infectious disease outbreaks. Eur J Epidemiol 2015; 30:465-71. [PMID: 25762171 DOI: 10.1007/s10654-015-0005-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 02/20/2015] [Indexed: 02/01/2023]
Abstract
Successful investigation of national outbreaks of communicable disease relies on rapid identification of the source. Case-control methodologies are commonly used to achieve this. We assessed control selection methods used in recently published case-control studies for methodological and resource issues to determine if a standard approach could be identified. Neighbourhood controls were the most frequently used method in 53 studies of a range of different sizes, infections and settings. The most commonly used method of data collection was face to face interview. Control selection issues were identified in four areas: method of identification of controls, appropriateness of controls, ease of recruitment of controls, and resource requirements. Potential biases arising from the method of control selection were identified in half of the studies assessed. There is a need to develop new ways of selecting controls in a rapid, random and representative manner to improve the accuracy and timeliness of epidemiological investigations and maximise the effectiveness of public health interventions. Innovative methods such as prior recruitment of controls could improve timeliness and representativeness of control selection.
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Affiliation(s)
- Alison Waldram
- Field Epidemiology Service Liverpool, Public Health England, Liverpool, UK,
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Mavrodaris A, Sibal B, McKerr C, Hawker JI. Outbreak of acute respiratory infection in a care home for the vulnerable elderly: investigation, management and challenges. Public Health 2014; 128:944-7. [PMID: 25301701 DOI: 10.1016/j.puhe.2014.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 05/22/2014] [Accepted: 07/21/2014] [Indexed: 11/15/2022]
Affiliation(s)
- A Mavrodaris
- Health Sciences Research Division, B-162, Warwick Medical School, University of Warwick, CV4 7AL, UK.
| | - B Sibal
- Public Health England, Birmingham, UK
| | - C McKerr
- Public Health England, Birmingham, UK
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