Use of an oxygen planar optode to assess the effect of high velocity microsprays on oxygen penetration in a human dental biofilms in-vitro

BACKGROUND

Dental plaque biofilms are the causative agents of caries, gingivitis and periodontitis. Both mechanical and chemical strategies are used in routine oral hygiene strategies to reduce plaque build-up. If allowed to mature biofilms can create anoxic microenvironments leading to communities which harbor pathogenic Gram-negative anaerobes. When subjected to high velocity fluid jets and sprays biofilms can be fluidized which disrupts the biofilm structure and allows the more efficient delivery of antimicrobial agents.

METHODS

To investigate how such jets may disrupt anoxic niches in the biofilm, we used planar optodes to measure the dissolved oxygen (DO) concentration at the base of in-vitro biofilms grown from human saliva and dental plaque. These biofilms were subject to "shooting" treatments with a commercial high velocity microspray (HVM) device.

RESULTS

HVM treatment resulted in removal of much of the biofilm and a concurrent rapid shift from anoxic to oxic conditions at the base of the surrounding biofilm. We also assessed the impact of HVM treatment on the microbial community by tracking 7 target species by qPCR. There was a general reduction in copy numbers of the universal 16S RNA by approximately 95%, and changes of individual species in the target region ranged from approximately 1 to 4 log reductions.

CONCLUSION

We concluded that high velocity microsprays removed a sufficient amount of biofilm to disrupt the anoxic region at the biofilm-surface interface.

Membrane proteomic analysis reveals overlapping and independent functions of Streptococcus mutans Ffh, YidC1, and YidC2

A comparative proteomic analysis was utilized to evaluate similarities and differences in membrane samples derived from the cariogenic bacterium Streptococcus mutans, including the wild-type strain and four mutants devoid of protein translocation machinery components, specifically ∆ffh, ∆yidC1, ∆yidC2, or ∆ffh/yidC1. The purpose of this work was to determine the extent to which the encoded proteins operate individually or in concert with one another and to identify the potential substrates of the respective pathways. Ffh is the principal protein component of the signal recognition particle (SRP), while yidC1 and yidC2 are dual paralogs encoding members of the YidC/Oxa/Alb family of membrane-localized chaperone insertases. Our results suggest that the co-translational SRP pathway works in concert with either YidC1 or YidC2 specifically, or with no preference for paralog, in the insertion of most membrane-localized substrates. A few instances were identified in which the SRP pathway alone, or one of the YidCs alone, appeared to be most relevant. These data shed light on underlying reasons for differing phenotypic consequences of ffh, yidC1 or yidC2 deletion. Our data further suggest that many membrane proteins present in a ∆yidC2 background may be non-functional, that ∆yidC1 is better able to adapt physiologically to the loss of this paralog, that shared phenotypic properties of ∆ffh and ∆yidC2 mutants can stem from impacts on different proteins, and that independent binding to ribosomal proteins is not a primary functional activity of YidC2. Lastly, genomic mutations accumulate in a ∆yidC2 background coincident with phenotypic reversion, including an apparent W138R suppressor mutation within yidC1.

The Biology of Streptococcus mutans

As a major etiological agent of human dental caries, Streptococcus mutans resides primarily in biofilms that form on the tooth surfaces, also known as dental plaque. In addition to caries, S. mutans is responsible for cases of infective endocarditis with a subset of strains being indirectly implicated with the onset of additional extraoral pathologies. During the past 4 decades, functional studies of S. mutans have focused on understanding the molecular mechanisms the organism employs to form robust biofilms on tooth surfaces, to rapidly metabolize a wide variety of carbohydrates obtained from the host diet, and to survive numerous (and frequent) environmental challenges encountered in oral biofilms. In these areas of research, S. mutans has served as a model organism for ground-breaking new discoveries that have, at times, challenged long-standing dogmas based on bacterial paradigms such as Escherichia coli and Bacillus subtilis. In addition to sections dedicated to carbohydrate metabolism, biofilm formation, and stress responses, this article discusses newer developments in S. mutans biology research, namely, how S. mutans interspecies and cross-kingdom interactions dictate the development and pathogenic potential of oral biofilms and how next-generation sequencing technologies have led to a much better understanding of the physiology and diversity of S. mutans as a species.

Biology of Oral Streptococci

Bacteria belonging to the genus Streptococcus are the first inhabitants of the oral cavity, which can be acquired right after birth and thus play an important role in the assembly of the oral microbiota. In this article, we discuss the different oral environments inhabited by streptococci and the species that occupy each niche. Special attention is given to the taxonomy of Streptococcus, because this genus is now divided into eight distinct groups, and oral species are found in six of them. Oral streptococci produce an arsenal of adhesive molecules that allow them to efficiently colonize different tissues in the mouth. Also, they have a remarkable ability to metabolize carbohydrates via fermentation, thereby generating acids as byproducts. Excessive acidification of the oral environment by aciduric species such as Streptococcus mutans is directly associated with the development of dental caries. However, less acid-tolerant species such as Streptococcus salivarius and Streptococcus gordonii produce large amounts of alkali, displaying an important role in the acid-base physiology of the oral cavity. Another important characteristic of certain oral streptococci is their ability to generate hydrogen peroxide that can inhibit the growth of S. mutans. Thus, oral streptococci can also be beneficial to the host by producing molecules that are inhibitory to pathogenic species. Lastly, commensal and pathogenic streptococci residing in the oral cavity can eventually gain access to the bloodstream and cause systemic infections such as infective endocarditis.

Differential oxidative stress tolerance of Streptococcus mutans isolates affects competition in an ecological mixed-species biofilm model

Streptococcus mutans strongly influences the development of pathogenic biofilms associated with dental caries. Our understanding of S. mutans behaviour in biofilms is based on a few well-characterized laboratory strains; however, individual isolates vary widely in genome content and virulence-associated phenotypes, such as biofilm formation and environmental stress sensitivity. Using an ecological biofilm model, we assessed the impact of co-cultivation of several S. mutans isolates with Streptococcus oralis and Actinomyces naeslundii on biofilm composition following exposure to sucrose. The laboratory reference strain S. mutans UA159 and clinical isolates Smu44 (most aciduric), Smu56 (altered biofilm formation) and Smu81 (more sensitive to oxidative stress) were used. Our data revealed S. mutans isolates varied in their ability to compete and become dominant in the biofilm after the addition of sucrose, and this difference correlated with sensitivity to H₂ O₂ produced by S. oralis. Smu81 was particularly sensitive to H₂ O₂ and could not compete with S. oralis in mixed-species biofilm, despite forming robust biofilms on its own. Thus, diminished oxidative stress tolerance in S. mutans isolates can impair their ability to compete in complex biofilms, even in the presence of sucrose, which could influence the progression of a healthy biofilm community to one capable of causing disease.

Post-transcriptional regulation by distal Shine-Dalgarno sequences in the grpE-dnaK intergenic region of Streptococcus mutans

A unique 373 bp region (igr66) between grpE and dnaK of Streptococcus mutans lacks a promoter but is required for optimal production of DnaK. Northern blotting using probes specific to hrcA, igr66 or dnaK revealed multiple transcripts produced from the dnaK operon and 5'-RACE mapped 5' termini of multiple dnaK transcripts within igr66. One product mapped to a predicted 5'-SL (stem-loop) and two others mapped just 5' to Shine-Dalgarno (SD)-like sequences located immediately upstream to dnaK and to a predicted SL 120 bp upstream of the dnaK start codon (3'-SL). A collection of cat reporter-gene strains containing mutant derivatives of igr66 were engineered. Chloramphenicol acetyltransferase (CAT) activity varied greatly between strains, but there were no correlative changes in cat mRNA levels. Interestingly, mutations introduced into the SD-like sequences 5' to the 3'-SL resulted in an 83-98% decrease in CAT activity. Markerless point mutations introduced upstream of dnaK in the SD-like sequences impaired growth at elevated temperatures and resulted in up to a 40% decrease in DnaK protein after heat shock. Collectively, these results indicate processing within igr66 enhances translation in a temperature dependent manner via non-canonical ribosome binding sites positioned >120 bp upstream of dnaK.

A unique open reading frame within the comX gene of Streptococcus mutans regulates genetic competence and oxidative stress tolerance

Streptococcus mutans displays complex regulation of genetic competence, with ComX controlling late competence gene transcription. The rcrRPQ operon has been shown to link oxidative stress tolerance, (p)ppGpp metabolism and competence in S. mutans. Importantly, an rcrR polar (ΔrcrR-P) mutant is hyper-transformable, but an rcrR non-polar (ΔrcrR-NP) mutant cannot be transformed. Transcriptome comparisons of the rcrR mutants using RNA-Seq and quantitative real-time polymerase chain reaction revealed little expression in the 5' region of comX in ΔrcrR-NP, but high level expression in the 3' region. Northern blotting with comX probes revealed two distinct transcripts in the ΔrcrR-P and ΔrcrR-NP strains, and 5' Rapid Amplification of cDNA Ends mapped the 5' terminus of the shorter transcript to nt +140 of the comX structural gene, where a unique 69-aa open reading frame, termed XrpA, was encoded in a different reading frame than ComX. Two single-nucleotide substitution mutants (comX::T162C; comX::T210A) were introduced to disrupt XrpA without affecting the sequence of ComX. When the mutations were in the ΔrcrR-NP genetic background, ComX production and transformation were restored. Overexpression of xrpA led to impaired growth in aerobic conditions and decreased transformability. These results reveal an unprecedented mechanism for competence regulation and stress tolerance by a gene product encoded within the comX gene that appears unique to S. mutans.

Phylogenomics and the dynamic genome evolution of the genus Streptococcus

The genus Streptococcus comprises important pathogens that have a severe impact on human health and are responsible for substantial economic losses to agriculture. Here, we utilize 46 Streptococcus genome sequences (44 species), including eight species sequenced here, to provide the first genomic level insight into the evolutionary history and genetic basis underlying the functional diversity of all major groups of this genus. Gene gain/loss analysis revealed a dynamic pattern of genome evolution characterized by an initial period of gene gain followed by a period of loss, as the major groups within the genus diversified. This was followed by a period of genome expansion associated with the origins of the present extant species. The pattern is concordant with an emerging view that genomes evolve through a dynamic process of expansion and streamlining. A large proportion of the pan-genome has experienced lateral gene transfer (LGT) with causative factors, such as relatedness and shared environment, operating over different evolutionary scales. Multiple gene ontology terms were significantly enriched for each group, and mapping terms onto the phylogeny showed that those corresponding to genes born on branches leading to the major groups represented approximately one-fifth of those enriched. Furthermore, despite the extensive LGT, several biochemical characteristics have been retained since group formation, suggesting genomic cohesiveness through time, and that these characteristics may be fundamental to each group. For example, proteolysis: mitis group; urea metabolism: salivarius group; carbohydrate metabolism: pyogenic group; and transcription regulation: bovis group.

Phenotypic heterogeneity of genomically-diverse isolates of Streptococcus mutans

High coverage, whole genome shotgun (WGS) sequencing of 57 geographically- and genetically-diverse isolates of Streptococcus mutans from individuals of known dental caries status was recently completed. Of the 57 sequenced strains, fifteen isolates, were selected based primarily on differences in gene content and phenotypic characteristics known to affect virulence and compared with the reference strain UA159. A high degree of variability in these properties was observed between strains, with a broad spectrum of sensitivities to low pH, oxidative stress (air and paraquat) and exposure to competence stimulating peptide (CSP). Significant differences in autolytic behavior and in biofilm development in glucose or sucrose were also observed. Natural genetic competence varied among isolates, and this was correlated to the presence or absence of competence genes, comCDE and comX, and to bacteriocins. In general strains that lacked the ability to become competent possessed fewer genes for bacteriocins and immunity proteins or contained polymorphic variants of these genes. WGS sequence analysis of the pan-genome revealed, for the first time, components of a Type VII secretion system in several S. mutans strains, as well as two putative ORFs that encode possible collagen binding proteins located upstream of the cnm gene, which is associated with host cell invasiveness. The virulence of these particular strains was assessed in a wax-worm model. This is the first study to combine a comprehensive analysis of key virulence-related phenotypes with extensive genomic analysis of a pathogen that evolved closely with humans. Our analysis highlights the phenotypic diversity of S. mutans isolates and indicates that the species has evolved a variety of adaptive strategies to persist in the human oral cavity and, when conditions are favorable, to initiate disease.

Progress dissecting the oral microbiome in caries and health

Recent rapid advances in "-omics" technologies have yielded new insights into the interaction of the oral microbiome with its host. Associations of species that are usually considered to be acid-tolerant with caries have been confirmed, while some recognized as health-associated are often present in greater proportions in the absence of caries. In addition, some newly identified bacteria have been suggested as potential contributors to the caries process. In spite of this progress, two major challenges remain. The first is that there is a great deal of heterogeneity in the phenotypic capabilities of individual species of oral bacteria. The second is that the most abundant taxa in oral biofilms display remarkable phenotypic plasticity, i.e., the bacteria associated most strongly with health or with caries can morph rapidly in response to alterations in environmental pH, carbohydrate availability and source, and oxygen tension and redox environment. However, new technologic advances coupled with "old-fashioned microbiology" are starting to erode the barriers to a more complete understanding of oral biofilm physiology and ecology, and in doing so are beginning to provide insights for the creation of novel cost-effective caries control therapies.

YidC1 and YidC2 are functionally distinct proteins involved in protein secretion, biofilm formation and cariogenicity of Streptococcus mutans

The cariogenic bacterium Streptococcus mutans has two paralogues of the YidC/Oxa1/Alb3 family of membrane protein insertases/chaperones. Disruption of yidC2 results in loss of genetic competence, decreased membrane-associated ATPase activity and stress sensitivity (acid, osmotic and oxidative). Elimination of yidC1 has less severe effects, with little observable effect on growth or stress sensitivity. To examine the respective roles of YidC1 and YidC2, a conditional expression system was developed allowing simultaneous elimination of both endogenous YidCs. The function of the YidC C-terminal tails was also investigated and a chimeric YidC1 protein appended with the C terminus of YidC2 enabled YidC1 to complement a ΔyidC2 mutant for stress tolerance, ATP hydrolysis activity and extracellular glyceraldehyde-3-phosphate dehydrogenase (GAPDH) activity. Elimination of yidC1 or yidC2 affected levels of extracellular proteins, including GtfB, GtfC and adhesin P1 (AgI/II, PAc), which were increased without YidC1 but decreased in the absence of YidC2. Both yidC1 and yidC2 were shown to contribute to S. mutans biofilm formation and to cariogenicity in a rat model. Collectively, these results provide evidence that YidC1 and YidC2 contribute to cell surface biogenesis and protein secretion in S. mutans and that differences in stress sensitivity between the ΔyidC1 and ΔyidC2 mutants stem from a functional difference in the C-termini of these two proteins.

A whole water catchment approach to investigating the origin and distribution of Cryptosporidium species

AIMS

Investigating the distribution and origin of Cryptosporidium species in a water catchment affected by destocking and restocking of livestock as a result of a foot and mouth disease epidemic.

METHODS AND RESULTS

Surface water, livestock and wildlife samples were screened for Cryptosporidium and oocysts characterised by sequencing SSU rRNA and COWP loci, and fragment analysis of ML1, ML2 and GP60 microsatellite loci. Oocyst concentrations in water samples (0-20.29 per 10 l) were related to rainfall events, amount of rainfall and topography. There was no detectable impact from catchment restocking. Cryptosporidium spp. found in water were indicative of livestock (Cryptosporidium andersoni and Cryptosporidium parvum) and wildlife (novel genotypes) sources. However, C. andersoni was not found in any animals sampled. Calf infections were age related; C. parvum was significantly more common in younger animals (<4 weeks old). Older calves shared Cryptosporidium bovis, Cryptosporidium ryanae and C. parvum. Wildlife shed C. parvum, Cryptosporidium ubiquitum, muskrat genotype II and deer genotype.

CONCLUSIONS

Several factors affect the occurrence of Cryptosporidium within a catchment. In addition to farmed and wild animal hosts, topography and rainfall patterns are particularly important.

SIGNIFICANCE AND IMPACT OF THE STUDY

These factors must be considered when undertaking risk-based water safety plans.

Effects of emissions from different type of residential heating upon cyclic guanosine monophosphate (cGMP) in blood platelets of residents

We hypothesized that different types of residential heating would be associated with different levels of indoor carbon monoxide (CO) and further that this might result in a differential in the concentration of cyclic 3':5' guanosine monophosphate (cGMP) in blood platelets in exposed residents. Individuals, who were recruited from homes using different fuel for heating, donated a venous blood sample in the winter and in the summer. In the winter the median blood platelet cGMP value for the group using liquid propane gas (LPG) was 65% higher than for the group using piped natural gas for heating (p <0.001). Also in the group using LPG, the median concentration of cGMP in the winter was 39% higher than the summer median (p < 0.003). The mean indoor concentrations of CO were measured over a period of 1 week during the winter and were <1 ppm. We conclude that observed differences were associated with emissions from different types of heating but that CO exposure alone is too low to explain these.

Alerting and Surveillance Using Poisons Information Systems (ASPIS): Outcomes from an international working group

BACKGROUND

In recent years, awareness of the risks of chemical and poison exposure has increased, and a number of highly publicized terrorist events have heightened community fears. In particular, there is concern surrounding the potential risk of a covert release, which underpins the need to develop robust methods of population surveillance.

AIMS AND METHODS

This article outlines the proceedings of a working group and focuses on the need for greater international cooperation and understanding of existing toxicological surveillance systems in a variety of countries. Poison control centers have well-established local networks and experienced staff, which make them well-placed to detect chemical and poison release. This needs further development to ensure timely detection of signals, which might be better achieved by robust international networks and consistent use of data collection tools. We illustrate some of the strengths and weaknesses of existing surveillance methods, and present a position statement on the minimum dataset required by future surveillance systems.

CONCLUSIONS

Poison control centers provide a useful platform for developing surveillance activity. Having proposed a number of common aims and objectives, it is hoped that these consensus statements will inform decision makers and stimulate discussion of how international toxicological surveillance programs might best be developed.

The influence of local politicians on pedestrian safety

AIM

To determine whether local politicians influence the distribution of traffic calming measures.

METHODS

Longitudinal ecological study in two UK cities. Local political constituencies were categorized by representation by members of the cabinet structure as a marker of influence. The density of traffic calming features per political area, adjusted for the historical pattern of road injuries, was compared between cabinet represented and non-represented areas.

RESULTS

Traffic calming density was significantly associated with cabinet representation status, adjusted for historical collision risk (risk ratio 2.77, 95% confidence interval 1.37 to 5.61).

CONCLUSION

These results support the hypothesis that senior local politicians are effective advocates for enhancing safety in their areas.

Effects on patients with asthma of eradicating visible indoor mould: a randomised controlled trial

BACKGROUND

It is not clear whether associations between respiratory symptoms and indoor mould are causal. A randomised controlled trial was conducted to see whether asthma improves when indoor mould is removed.

METHODS

Houses of patients with asthma were randomly allocated into two groups. In one group, indoor mould was removed, fungicide was applied and a fan was installed in the loft. In the control group, intervention was delayed for 12 months. Questionnaires were administered and peak expiratory flow rate was measured at baseline, 6 months and 12 months.

RESULTS

Eighty-one houses were allocated to the intervention group and 83 to the control group; 95 participants in 68 intervention houses and 87 in 63 control houses supplied follow-up information. Peak expiratory flow rate variability declined in both groups, with no significant differences between them. At 6 months, significantly more of the intervention group showed a net improvement in wheeze affecting activities (difference between groups 25%, 95% CI 3% to 47%; p = 0.028), perceived improvement of breathing (52%, 95% CI 30% to 74%; p<0.0001) and perceived reduction in medication (59%, 95% CI 35% to 81%; p<0.0001). By 12 months the intervention group showed significantly greater reductions than the controls in preventer and reliever use, and more improvement in rhinitis (24%, 95% CI 9% to 39%; p = 0.001) and rhinoconjunctivitis (20%, 95% CI 5% to 36%; p = 0.009).

CONCLUSIONS

Although there was no objective evidence of benefit, symptoms of asthma and rhinitis improved and medication use declined following removal of indoor mould. It is unlikely that this was entirely a placebo effect.

Exposure to school children as a risk factor in a community outbreak of hepatitis A in young adults: a case control study

To investigate risk factors during a community outbreak of hepatitis A we carried out a case- control study of 35 cases and 49 matched controls using an interviewer-administered questionnaire on clinical history, travel, household details including domestic toilet facilities, infectious contacts, and food history. Of 99 cases notified in the city during the outbreak year, 50 (51%) were young adults age 15-34 years. Hepatitis A infection was independently associated with household contact with a case (P=0.0005), and sharing a household with children in primary school (OR 3.4, 95% CI 1.2-9.5, P=0.008) with risk increasing with number of primary-school pupils in the household (chi(2) for linear trend 6.47, P=0.01). We concluded that in a population with a low prevalence of hepatitis A, adults who live in the same household as primary-school-age children are at increased risk of acquiring the infection during community outbreaks.

A case-control study of domestic kitchen microbiology and sporadic Salmonella infection

The microbiology of domestic kitchens in the homes of subjects who had suffered sporadic Salmonella infection (cases) was compared with control domestic kitchens. Case and control dishcloths and refrigerator swabs were examined for the presence of Salmonella spp., total Enterobacteriaceae counts and total aerobic colony counts. Salmonella spp. were isolated from both case and control dishcloths and refrigerators but there were no significant differences between the two groups. Colony counts were similar in case and control dishcloths and refrigerator swabs. There was no relationship between the total counts and presence of Salmonella . There was no evidence that cases of Salmonella infection were more likely to have kitchens which were contaminated with these bacteria or have higher bacterial counts than controls. Total bacterial counts were poor indicators of Salmonella contamination of the domestic kitchen environment. Further factors which could not be identified by a study of this design may increase risk of Salmonella food poisoning. These factors may include individual susceptibility of the patient. Alternatively, sporadic cases of Salmonella food poisoning may arise from food prepared outside the home.

Traffic calming policy can reduce inequalities in child pedestrian injuries: database study

OBJECTIVES

To determine whether area wide traffic calming distribution reflects known inequalities in child pedestrian injury rates. To determine whether traffic calming is associated with changes in childhood pedestrian injury rates.

DESIGN

Small area ecological study, longitudinal analysis of injury rates with cross sectional analysis of traffic calming and method of travel to school.

SETTINGS

Two cities in the United Kingdom.

PARTICIPANTS

4-16 year old children between 1992 and 2000.

MAIN OUTCOME MEASURES

Area wide traffic calming distribution by area deprivation status and changes in injury rate/1000.

RESULTS

The most deprived fourth of city A had 4.8 times (95% CI 3.71 to 6.22) the number of traffic calming features per 1000 population compared with the most affluent fourth. Injury rates among the most deprived dropped from 9.42 to 5.07 from 1992-94 to 1998-2000 (95% CI for change 2.82 to 5.91). In city B, the traffic calming ratio of the most to least deprived fourth was 1.88 (95% CI 1.46 to 2.42); injury rates in the deprived areas dropped from 8.92 to 7.46 (95% CI for change -0.84 to 3.77). Similar proportions of 9-12 year olds walked to school in both cities.

CONCLUSIONS

Area wide traffic calming is associated with absolute reductions in child pedestrian injury rates and reductions in relative inequalities in child pedestrian injury rates.

Effectiveness of rugby headgear in preventing soft tissue injuries to the head: a case-control and video cohort study

OBJECTIVE

To determine if headgear use by rugby players was associated with a reduced risk of head or facial laceration, abrasion, or fracture.

METHODS

An emergency department based case-control study in South Wales, UK, with cases being rugby players treated for superficial head and facial injuries and controls being their matched opponents during the game. A review of videos of the 41 games in the 1999 Rugby World Cup was also carried out to compare with the case-control study. Odds ratios (OR) and 95% confidence intervals (95% CI) were used to measure association between exposure (headgear wearing) and outcome (head and facial injuries).

RESULTS

In the case-control study, 164 pairs were analysed, with headgear worn by 12.8% of cases and 21.3% of controls. Headgear use was associated with substantial but non-significant reductions in superficial head (OR = 0.43, 95% CI 0.13 to 1.19) and facial (OR = 0.57, 95% CI 0.21 to 1.46) injuries. The video study followed 547 players over 41 games, during which there were 47 bleeding injuries to the head. Headgear use significantly reduced the risk of bleeding head injury in forwards (OR = 0.14, 95% CI 0.01 to 0.99, p = 0.02), but not in backs. There was also a higher risk of facial injury among forwards, but this was not significant.

CONCLUSIONS

The combined results suggest that headgear can prevent certain types of superficial head injuries in players at all levels of the game, but the evidence is strongest for superficial head injury in elite forwards. A randomised controlled trial would be the best way to study this further.

Laboratory testing policies and their effects on routine surveillance of community antimicrobial resistance

OBJECTIVE

To investigate the effects of laboratory testing policies, particularly selective testing, rule-based reporting and isolate identification, on estimates of community antimicrobial resistance.

MATERIALS AND METHODS

Antibiotic resistance estimates were analysed from an all-Wales dataset for approximately 300 000 community isolates of common pathogens.

RESULTS

Selective testing policies were often associated with markedly increased resistance, particularly for second-line testing. Site-specific testing tended to yield variant resistance estimates for eye and ear isolates. Estimates from rule-based reporting deviated markedly from test-result-based reporting. Urinary isolates reported as Escherichia coli showed greater susceptibility than those reported as undifferentiated urinary 'coliforms'. The proportion of isolates tested for an antibiotic by a laboratory was a useful indicator of selective testing in this dataset. Selective testing policies had invariably been applied where the proportion of isolates of a species tested against an antibiotic was <90%. As this proportion fell with increasingly selective policies, divergence from pooled-all-Wales non-selective estimates tended to increase, with a bias to increased resistance.

CONCLUSIONS

Selective testing, rule-based reporting and urinary coliform identification policies all had significant effects upon resistance estimates. Triage based upon the proportion of isolates tested seemed a useful tool in assigning analysis resources. Where <20% of isolates were tested, selective policies with inherent bias to increased resistance were common, the low number of isolates gave high potential sampling errors, and little confidence could be placed in the resistance estimate. Where 20-90% of isolates were tested, detailed analysis sometimes revealed resistance estimates that might be usefully retrieved. Where >/=90% of isolates were tested, there was no evidence of selective testing, and inter-laboratory variation in estimates appeared to be safely ascribable to other effects, e.g. methodology or real variation in resistance levels.

The frequency of inherited disorders database: prevalence of Huntington disease

A database of the frequency of human inherited disorders is being established for use in a clinical context, in medical research, for epidemiological studies, and in the planning of genetic services. Each entry includes the disease name categorized by organ system, an Online Mendelian Inheritance in Man (OMIM) number, the mode of inheritance, the population origin, a prevalence and/or incidence rate and a literature reference. The Frequency of Inherited Disorders Database (FIDD) currently contains 1,580 entries relating to 280 different Mendelian disorders. FIDD will be prospectively maintained and can be accessed at http://www.uwcm.ac.uk/uwcm/mg/fidd/. A more refined and systematic literature search that will serve to expand the size, scope and scale of the database is currently in progress. The coverage of neurological and neuromuscular disorders is however considered to be nearly complete. In this first description of FIDD, Huntington disease was used to illustrate the structure and scope of the database as well as its potential scientific utility. A total of 100 published articles on the prevalence of Huntington disease were appraised. Prevalence and incidence rates varied between different ethnic groups and between different countries. Possible reasons for this variation are discussed.

Risk factors for salmonella food poisoning in the domestic kitchen--a case control study

Domestic kitchen food handling risk factors for sporadic salmonella food poisoning are largely unknown. We compared food consumption and food handling practices, opportunities for cross contamination and refrigerator temperature control, in 99 households in South East Wales in 1997/8 with a case of salmonella food poisoning, and control households matched for electoral ward. On univariate analyses, cases were significantly more likely than control respondents to have purchased free-range eggs in the preceding week, and more likely than control households to have handled frozen whole chicken in the previous week, and to handle raw chicken portions at least weekly. In multivariate analysis, only consumption of raw eggs and handling free-range eggs were significant risk factors, independent of the age structure of the family and of the season.

The seasonal distribution of campylobacter infection in nine European countries and New Zealand

In all temperate countries campylobacter infection in humans follows a striking seasonal pattern, but little attention has been given to exploring the epidemiological explanations. In order to better characterize the seasonal patterns, data from nine European countries and New Zealand have been examined. Several European countries with weekly data available showed remarkably consistent seasonal patterns from year to year, with peaks in week 22 in Wales, week 26 in Scotland, week 32 in Denmark, week 30 in Finland and week 33 in Sweden. In Europe, the seasonal peak was most prominent in Finland and least prominent in Scotland and Austria. In New Zealand the seasonality was less consistent since the peak was more prolonged. Possible explanations for the seasonal peaks are discussed. Research into the causes of campylobacter seasonality should help considerably in elucidating the sources of human infection.

Development and use of a population based injury surveillance system: the all Wales Injury Surveillance System (AWISS)

This report details the development and use of a population based emergency room surveillance system in the UK. Despite some difficulties in accessing high quality data the system has stimulated a considerable number of research and intervention projects. While surveillance systems with high quality data collection and coding parameters remain the gold standard, imperfect systems, particularly if population based, can play a substantial part in stimulating injury prevention initiatives.

The public health significance of VTEC O157

Surveillance of human VTEC O157 has been reported in several countries, based on laboratory evidence. The incidence is generally less than 10 per 100000 (the highest incidence is in children), with regional variations and a marked seasonality. Laboratory selection criteria and reporting have contributed to, but cannot entirely explain, variations within and between countries. Surveillance data and outbreaks in definable cohorts indicate that the spectrum of illness ranges from diarrhoea through acute bloody diarrhoea, with about 5% of cases developing haemolytic uraemic syndrome; less than 50% of patients report frank blood in their stools. Studies of sporadic cases have associated illness with beef products (particularly if undercooked and eaten outside the home), cooked sliced meat meals and contact with a household member with diarrhoea. Outbreaks have been attributed to contaminated foods (including beefburgers) and water, animal contact and person-to-person spread. Secondary transmission by the primary case in a household is of particular concern, and household transmission has been estimated at 4%, with patients excreting for around 10 days following onset. Recommendations for control have highlighted measures on farms, in slaughterhouses, retail and catering food premises, and in the home.

Public health management of an outbreak of group C meningococcal disease in university campus residents

BACKGROUND

Increasing numbers of outbreaks of Group C meningococcal disease in teenagers and young adults led to a new policy in the UK in 1999 of vaccinating all new college students. The largest of these outbreaks involved seven students in one university, six of whom were from one hall of residence, and two of whom died.

METHODS

Control of the outbreak involved close medical surveillance of resident students, mass chemoprophylaxis and vaccination, and wide dissemination of daily information bulletins. Investigation of the epidemiology of the outbreak involved searching for the network of close contacts between cases, a prevalence survey of carriage of meningogocci and a case control study of risk factors for carriage.

RESULTS

Clinical cases could be linked by a discrete network of social contacts within the halls of residence, but the Group C epidemic strain (2a P1.5) was not detected in 454 students (upper 95% confidence interval 0.7%). Carriage of any meningococcal strain (19%) was associated with patronage of the campus bar (OR = 3.0, 0.99-9.1).

CONCLUSION

Important factors in the control of the outbreak were rapid institution of mass chemopropylaxis and immunisation of residents, and involvement of student organizations in the dissemination of information about the disease and its control. The role of campus bars in dissemination of the carriage of meningogocci deserves further investigation.

Changes in sports injuries to children between 1983 and 1998: comparison of case series

BACKGROUND

Sports injuries sustained by children are worrying because they prevent and deter participation in physical activity. Before we can address such injuries we need to understand the size of the problem and whether there have been changes in occurrence. A study of sports injuries to children, carried out in a Cardiff Accident and Emergency department in 1983, provided the data against which to compare data gathered in 1998.

METHODS

Data on all sports injuries to children aged 16 and under treated between September and December 1998 were compared with those reported for the same hospital, age group, injury and period in 1983.

RESULTS

A total of 953 injuries were treated in 1998, representing an increase of 54 per cent [95 per cent confidence interval (CI) 44-64 per cent]. The male:female distribution remained constant and the majority of injuries were due to rugby and soccer. The number of females injured playing rugby and soccer increased and a wider range of sports led to injuries for both males and females. Amongst 10-15-year-olds injury risk increased from 1 in 78 for boys in 1983 to 1 in 22 in 1998 (p < 0.0001). For girls, the increase was from 1 in 117 to 1 in 55 (p < 0.0001). The number of soccer- and rugby-related fractures increased by 52 per cent (95 per cent CI 22-87 per cent).

CONCLUSIONS

Sports injury rates have increased considerably over 15 years. With minimal population change, little variation in minor injuries and only small improvements in data capture, the main reason for change appears to be increased participation.

Addressing environmental health concerns near Trecatti landfill site, United Kingdom

Residents near the Trecatti landfill site located in South Wales, United Kingdom, expressed concern about odors and health effects they attributed to site emissions. The authors compared routinely collected, population-based, health data from potentially exposed electoral wards (i.e., United Kingdom electoral tracts) with data from both wards nearby, matched for socioeconomic deprivation scores, and with wards where residents were likely to attend the same hospital. Mortality rates were higher for all causes and neoplastic diseases (but not respiratory disease) in the exposed wards, but there was no change in rates after the site opened. Hospital data revealed a transient increase in admissions for asthma during the 3 yr that preceded the peak in odor complaints. The birth prevalence of congenital malformations was raised in the exposed wards, but the authors could not exclude a possible artifact resulting from differences in reporting practices between hospitals. The absence of environmental monitoring in the community during the period of public concern was a significant weakness of this study.

Short report: Is regional paediatric surveillance useful? Experience in Wales

The Welsh Paediatric Surveillance Unit was established in 1994 to monitor the incidence and prevalence of a number of uncommon disorders of childhood in Wales. Its work complements that of the British Paediatric Surveillance Unit. Information from consultant paediatricians is obtained by means of a monthly card return system; return rate is over 90%.

Community exposures to chemical incidents: development and evaluation of the first environmental public health surveillance system in europe

OBJECTIVE

To describe the frequency, nature and location of acute chemical incidents in Wales, and the morbidity in employees, emergency responders and the general public who were exposed.

DESIGN

Active multi-agency community-based surveillance system.

SETTING

Wales, 1993-5.

MAIN OUTCOME MEASURES

Frequency, nature and location of incidents, populations potentially exposed and with symptoms.

RESULTS

Most of the 402 incidents identified were not associated with sites governed by the Control of Industrial Major Accident Hazard Regulations but with smaller industrial sites and commercial premises. About two in every thousand of the estimated 236 000 members of the public considered to be at risk from exposure reported symptoms, which were mainly nausea, headaches, and irritation of the eye, skin and respiratory tract. The most commonly reported chemicals that members of the public were exposed to were smoke toxins, miscellaneous organics, toxic gases and flammable gases. A health authority was reported to be involved in only 34 (8%) of the incidents and in only 3 of the 29 incidents where more than 100 members of the public were exposed.

CONCLUSION

A geographically defined, multi-agency surveillance system can identify high risk locations and types of incidents, together with the chemicals most likely to be involved. Such ongoing surveillance information is essential for appropriate policy making, emergency planning, operational management and training.

Major chemical incidents: bridging the occupational--public health gap

Increasing awareness and concern about possible long-term health effects of exposure to chemicals after major chemical incidents has opened up a new area of public health activity. However, progress is hampered by a lack of low level exposures in potentially highly susceptible subgroups of the populations, and by a lack of expertise in public health. The challenge is to extend the toxicological and epidemiological experience developed in the occupational setting to the community level. To better define the problem population surveillance of acute chemical hazards, first set up in Wales, has been extended throughout the UK, and is also being piloted internationally. Further work is needed to address specific problems of the epidemiological follow-up of populations exposed, the assessment of the psychological consequences at the community level, and risk perception and communication. Organisational arrangements for the public health management of incidents and their sequelae must move beyond short-term funding and market competition and must incorporate the expertise of the occupational disciplines.

Assessment of impact on health of residents living near the Nant-y-Gwyddon landfill site: retrospective analysis

OBJECTIVES

To compare indices of health in a population living near a landfill site with a population matched for socioeconomic status and to review environmental monitoring data.

DESIGN

Ecological study with small area statistics and environmental reports.

SETTING

Electoral wards in valleys of South Wales.

SUBJECTS

Populations in the five wards near the landfill site who had formally complained of odours (exposed population), and comparison populations in 22 wards in the same unitary authority within the same fifth of Townsend score.

OUTCOME MEASURES

Mortality, rates of hospital admission, measures of reproductive health (proportion of all births and stillbirths of infants weighing <2500 g; rates of admissions for spontaneous abortion; rates of all reported congenital malformations). Environmental data on site emissions.

RESULTS

There were no consistent differences in mortality, rates of hospital admissions, or proportion of low birthweight infants between the two populations. There was an increased maternal risk of having a baby with a congenital abnormality in residents near the site, both before its opening (relative risk 1.9; 95% confidence interval 1.3 to 2.85; P<0.001) and after (1.9; 1.23 to 2.95; P=0.003). Environmental monitoring showed that hydrogen sulphide from the site was probably responsible for odours.

CONCLUSIONS

The area surrounding the landfill site has an increased rate of reported congenital malformations, which predated the opening of the landfill, although the cluster of cases of gastroschisis post-dated its opening. Several chemicals emitted from the site, including hydrogen sulphide and benzene, were found in air samples in the nearby community. Further studies of the reproductive risk in such communities are needed to examine the safety of waste disposal sites.

Risk factors for carriage of Neisseria meningitidis during an outbreak in Wales

In a school outbreak of meningococcal disease in Wales, we compared risk factors for the carriage of Neisseria meningitidis B15 P1.16 with carriage of any meningococci. Students had throat swabs and completed a questionnaire. Sixty (7.9%) carried meningococci; risk for carriage was higher in those >14 years of age.

An international outbreak of Salmonella enteritidis associated with lasagne; lessons on the need for cross-national co-operation in investigating food-borne outbreaks

We investigated an outbreak of Salmonella enteritidis involving at least 19 British tourists returning from one hotel in another European country. A retrospective cohort study of 47 hotel guests identified lasagne as the most likely vehicle of transmission (RR 11.5; 95% CI 3.0-44.1; P < 0.0001). However, difficulties in information exchange and lack of formal mechanisms to agree on the aims of the cross-national investigation hampered efficient management of the outbreak. The factors leading to contamination of the food vehicle were not identified and therefore specific action to prevent reoccurrence could not be taken. There is need to develop protocols for cross-national investigations of outbreaks in Europe which should include specifying objectives, roles and responsibilities of investigators and control agencies, with formal reporting of the outcome of the investigation.

Acute health effects of the Sea Empress oil spill

STUDY OBJECTIVE

To investigate whether residents in the vicinity of the Sea Empress tanker spill suffered an increase in self reported physical and psychological symptoms, which might be attributable to exposure to crude oil.

DESIGN

Retrospective cohort study; postal questionnaire including demographic details, a symptom checklist, beliefs about health effects of oil and the Hospital Anxiety and Depression and SF-36 mental health scales.

SETTING

Populations living in four coastal towns on the exposed south Pembrokeshire coast and two control towns on the unexposed north coast.

PATIENTS

539 exposed and 550 unexposed people sampled at random from the family health services authority age-sex register who completed questionnaires.

MAIN RESULTS

Adjusted odds ratios for self reported physical symptoms; scores on the Hospital Anxiety and Depression and SF-36 mental health scales, in 1089 people who responded out of a possible 1585 (69%).

CONCLUSIONS

Living in areas exposed to the crude oil spillage was significantly associated with higher anxiety and depression scores, worse mental health; and self reported headache (odds ratio = 2.35, 95% CI 1.56, 3.55), sore eyes (odds ratio = 1.96, 95% CI 1.06, 3.62), and sore throat (odds ratio = 1.70, 95% CI 1.12, 2.60) after adjusting for age, sex, smoking status, anxiety, and the belief that oil had affected health. People living in exposed areas reported higher rates of physical and psychological symptoms than control areas. Symptoms significantly associated with exposure after adjustment for anxiety and health beliefs were those expected from the known toxicological effect of oil, suggesting a direct health effect on the exposed population.

Undercooked hens eggs remain a risk factor for sporadic Salmonella enteritidis infection

The prevalence of salmonella contamination in hens' eggs remains high. A case control study of sporadic cases of Salmonella enteritidis infection in Wales in 1997 confirmed the association of infection with consumption of raw or lightly cooked eggs.

Surveillance of influenza in Wales: interpreting sentinel general practice rates using contemporaneous laboratory data. Opportunities and limitations

OBJECTIVES

To evaluate the opportunities and limitations of using laboratory data to enhance sentinel general practice surveillance of influenza.

DESIGN

Descriptive study of active sentinel surveillance of clinically diagnosed influenza in general practice and passive total population surveillance of laboratory reports of influenza A, influenza B, Mycoplasma pneumoniae, and respiratory syncitial virus infections.

SETTING

Wales.

SUBJECTS

Total sentinel practices population (currently 228,130); population of Wales (2,913,000, 1994 mid-year estimate).

MAIN OUTCOME MEASURES

Simplicity, flexibility, acceptability, sensitivity, predictive value positive, representativeness, and timeliness of a surveillance system. Rate of influenza and other respiratory infections.

RESULTS

Sentinel general practice surveillance of influenza in Wales is simple, flexible, acceptable, timely, representative, and relatively sensitive. Current laboratory surveillance is complex and less timely than sentinel practice surveillance but is complete and has a relatively high positive predictive value. For the period January 1993 to September 1996, peaks in rates of influenza reported by sentinel practices during winters 1993/94 and 1995/96 were temporally associated with increased rates of laboratory confirmed influenza A and respiratory syncitial virus, whereas the peak in 1994/95 was associated with increased rates of laboratory confirmed influenza B, M pneumoniae, and respiratory syncitial virus.

CONCLUSIONS

Timely laboratory data can add value to influenza data already obtained from sentinel general practice surveillance. However continuous audit is essential to resolve the possible limitations of either surveillance system.

Use of sequential case-control studies to investigate a community Salmonella outbreak in Wales

STUDY OBJECTIVE

To establish the source of a community outbreak of Salmonella typhimurium definitive type 124.

DESIGN

Two stage case-control study.

SETTING

Three districts in south east Wales.

SUBJECTS

Cases of salmonella food poisoning and community controls.

MAIN RESULTS

An initial case-control study identified an association between illness and eating ham (odds ratio 4.50, 95% confidence intervals 1.10, 21.8) and also found a possible association between illness and food bought from delicatessen stores (odds ratio 5.03, 95% confidence intervals 1.01, 32.3). However, only after a second stage case-control study was a single common ham producer identified as the source (odds ratio 25.0, 95% confidence intervals 2.33, 1155).

CONCLUSION

Sequential case-control studies are an important and underused tool in the investigation of community outbreaks.

Control of hydatid disease in Wales

OBJECTIVES

To evaluate the success of the south Powys hydatid control programme by analysis of trends in cystic disease in humans and sheep and dog infestation.

DESIGN

A review of hospital admissions for human hydatid disease in 1984-90, abattoir prevalence surveys of hydatid cysts in adult sheep, arecoline acetarsol and coproantigen surveys of prevalence of Echinococcus infestation in dogs.

SETTING

All hospitals in England and Wales, three abattoirs, and dog populations in mid ands south east Wales.

SUBJECTS

Residents of England and Wales admitted to hospital between 1984 and 1990 with a new diagnosis of human hydatid disease (International Classification of Diseases (ICD), ninth revision, code 122) acquired in the United Kingdom.

RESULTS

The average annual incidence of human hydatid disease in Powys, mid-Wales, fell from 3.9x10(-5) in 1974-83 to 2.3x10(-5) in 1984-90. Age specific incidence rates in Wales declined over this period only in children, and no cases occurred in children (<15 years) in Powys. Two Welsh children who lived in Gwent and mid-Glamorgan were infected. Prevalence of hydatid cysts in old sheep from south Wales declined during the control period, but in 1993 prevalence of cysts was 13%. Prevalence of E granulosus infestation was zero in the control area in 1993, but it was 2.4% in Powys dogs outside the control area in 1989 and 9.2% in dogs in Gwent in 1991.

CONCLUSIONS

Human hydatid disease has been successfully controlled in south Powys but cystic echinococcosis is still endemic in sheep in mid-Wales, and there is a focus of infection in humans, sheep, and dogs in the bordering areas of Gwent and mid-Glamorgan. There is considerable potential for an upsurge in human cases if control measures are relaxed.

Chaos under canvas: a Salmonella enteritidis PT 6B outbreak

An outbreak of Salmonella enteritidis PT 6B food poisoning, the first reported of this recently described phage type, resulted in illness among 46 of 49 members of a camping group in North Wales, 33 of whom were hospitalized. Epidemiological evidence (P < 0.0001) indicated that a lemon meringue pie was the vehicle of infection. Fresh shell eggs, stored after purchase at ambient temperature, appear to be the most likely source of infection, with multiplication during preparation and subsequent storage of the pie a significant contributory factor. Campers may be at greater risk than others and should consider the use of cold boxes for the transport and storage of eggs, and avoid the preparation of lightly cooked egg products under these basic conditions.

Outbreak investigation: the need for 'quick and clean' epidemiology

Epidemiology investigations of outbreaks of infectious disease have to be carried out rapidly but must be methodologically sound. In 14 of 25 consecutive Salmonella outbreaks in Wales from 1986 to 1990 case-control or cohort studies were undertaken. Food vehicles of infection were identified by statistically significant associations with cases in 13 of the 14, including three outbreaks where there were less than 10 cases. The particular problems of epidemiological field investigations are discussed.

The role of the pre-symptomatic food handler in a common source outbreak of food-borne SRSV gastroenteritis in a group of hospitals

A common source outbreak of small round structure virus (SRSV) gastroenteritis affected 81 patients and 114 staff in four hospitals served by one central hospital kitchen. Eating salad items was found to be significantly associated with illness. In a cohort study of a staff buffet function eating turkey salad sandwiches was associated with illness (relative risk = 2.4; 95% CI = 1.4-4.1; P = 0.003), and a case control study of patients in one hospital showed an odds ratio of 6.6 (95% CI = 1.0-71.6; P = 0.04) for eating tuna salad and becoming ill. One of two food handlers who prepared the salads became ill the day following food preparation; she also had a young child at home who had been ill with a gastrointestinal illness during the previous two days. Contamination of food by mechanical transmission of the virus from the child via clothes and hands of the mother, or pre-symptomatic faecal excretion in the mother are possible explanations of contamination of food.

Human hydatid disease: evaluation of an ELISA for diagnosis, population screening and monitoring of control programmes

The routine use of ELISA and complement fixation tests in the diagnosis of suspected clinical cases of hydatid disease was evaluated. In the ELISA test, dialysed and filtered sheep cyst fluid was used as antigen and two positive cut-off points--+3SD and +2SD of the mean absorbance values of the control sera--were evaluated. The predictive values of ELISA tests were 82% and 90% for positive tests, and 86% and 82% for negative tests, respectively with the two cut-off points. In a population survey of blood donors and veterinary workers in Powys, 4% and 8%, respectively, had ELISA values above the lower cut-off point. However, it would not be appropriate to use the same test for diagnostic population screening in Wales since the predictive value of the test is likely to be very low in this setting. Serological surveys with the ELISA may be of use in monitoring the progress of the South Powys Hydatid Control Programme. The use of cumulative percentages was found to be a useful method of comparing whole distributions of results in different populations.