Shiga toxin-producing Escherichia coli (STEC) O157 outbreak associated with likely transmission in an inflatable home paddling pool in England, June 2017

In June 2017, an outbreak of Shiga toxin-producing Escherichia coli (STEC) O157 infection with phage type 21/28 and identical genotypic profiles involving three children from Staffordshire was reported. Two cases developed haemolytic uraemic syndrome (HUS). Person-to-person transmission via a shared inflatable home paddling pool was the most likely route of infection, following contamination by the first case. The source of infection in the first case was not identified. We recommend that individuals experiencing gastroenteritis should not bathe in paddling pools and that water should be changed at frequent intervals throughout the day to minimise the spread of infection.

An outbreak of Legionnaires’ disease associated with a display spa pool in retail premises, Stoke-on-Trent, United Kingdom, July 2012

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An outbreak of Legionnaires' disease associated with a display spa pool in retail premises, Stoke-on-Trent, United Kingdom, July 2012

Twenty-one confirmed cases of Legionnaires’ disease (Legionella pneumophila serogroup 1) were identified in the Stoke-on-Trent area of England with onsets since 2 July 2012. Sequence-based typing results are available for nine cases; all are a unique type (ST1268). Initial interviews highlighted a number of possible environmental sources. Inspection of premises of interest revealed an operating spa pool on display, from which the outbreak strain was identified. All cases had visited the retail premise with this spa pool.

A cluster of Listeria monocytogenes infections in hospitalised adults, Midlands, England, February 2011

Hospital-acquired listeriosis cases are not commonly reported but remain a significant public health problem. We report on three cases in patients with underlying conditions occurring during one week in February 2011. The cases had common exposure to pre-packed sandwiches and salads manufactured in compliance with regulations. Breaches in cold chain and shelf life controls at hospital level were identified as key contributing factors. Rigorous hospital food management systems remain important for patient safety.

A cluster of Listeria monocytogenes infections in hospitalised adults, Midlands, England, February 2011

Hospital-acquired listeriosis cases are not commonly reported but remain a significant public health problem. We report on three cases in patients with underlying conditions occurring during one week in February 2011. The cases had common exposure to pre-packed sandwiches and salads manufactured in compliance with regulations. Breaches in cold chain and shelf life controls at hospital level were identified as key contributing factors. Rigorous hospital food management systems remain important for patient safety.

Legionnaires’ disease cluster linked to a metal product aqueous pre-treatment process, Staffordshire, England, May 2008

In May 2008, a report of two workers from the same construction equipment manufacturing plant who were admitted to hospital with Legionnaires’ disease confirmed by urine antigen prompted an outbreak investigation. Both cases were middle aged men, smokers, and with no travel, leisure or other common community exposure to Legionella sources. There were no wet cooling towers at the plant or in the surrounding area. No increase in respiratory disease or worker absenteeism occurred at the plant during the preceding month. Wider case ascertainment including alerts to hospitals and medical practitioners yielded no further cases. The environmental investigation (and sampling of water systems for Legionella) identified a Legionella pneumophila serogroup1 (Mab 2b) count of >3.0x104cfu/l in water samples from an aqueous metal pre-treatment tunnel, which generates profuse water aerosol. Drainage, cleaning and biocide treatment using thiazalone eliminated Legionella from the system.

Legionnaires' disease cluster linked to a metal product aqueous pre-treatment process, Staffordshire, England, May 2008

In May 2008, a report of two workers from the same construction equipment manufacturing plant who were admitted to hospital with Legionnaires disease confirmed by urine antigen prompted an outbreak investigation. Both cases were middle aged men, smokers, and with no travel, leisure or other common community exposure to Legionella sources. There were no wet cooling towers at the plant or in the surrounding area. No increase in respiratory disease or worker absenteeism occurred at the plant during the preceding month. Wider case ascertainment including alerts to hospitals and medical practitioners yielded no further cases. The environmental investigation (and sampling of water systems for Legionella) identified a Legionella pneumophila serogroup1 (Mab 2b) count of >3.0x10(4)cfu/l in water samples from an aqueous metal pre-treatment tunnel, which generates profuse water aerosol. Drainage, cleaning and biocide treatment using thiazalone eliminated Legionella from the system.

A swimming pool-associated outbreak of cryptosporidiosis in Staffordshire, England, October to December 2007

In October 2007 an increase in laboratory-confirmed cryptosporidiosis cases in Staffordshire, England prompted an outbreak investigation. Case ascertainment included interviewing suspected cases and contacts and obtaining faecal specimens from those with diarrhoea for laboratory identification. Over a three-month period we identified 57 cases of cryptosporidiosis (39 confirmed) distributed across 36 households. The majority of cases (69%) were younger than 20 years. The most plausible exposure was multiple swimming episodes (56% of cases) in 13 local public swimming pools. One large swimming pool was most frequently visited by swimmers and considered a significant contributor to transmission because of substandard filtration and maintenance systems. Control measures focused on inspecting and improving operating standards at swimming pools, hygiene information to swimmers, and early detection and exclusion of cases. The rapid case investigation described in this paper provided adequate information for the early detection and control of a typical seasonal swimming pool related cryptosporidiosis outbreak. Ensuring adequate filtration standards at public swimming pools particularly before the high use periods of late summer and autumn remains a priority.

A swimming pool-associated outbreak of cryptosporidiosis in Staffordshire, England, October to December 2007

In October 2007 an increase in laboratory-confirmed cryptosporidiosis cases in Staffordshire, England prompted an outbreak investigation. Case ascertainment included interviewing suspected cases and contacts and obtaining faecal specimens from those with diarrhoea for laboratory identification. Over a three-month period we identified 57 cases of cryptosporidiosis (39 confirmed) distributed across 36 households. The majority of cases (69%) were younger than 20 years. The most plausible exposure was multiple swimming episodes (56% of cases) in 13 local public swimming pools. One large swimming pool was most frequently visited by swimmers and considered a significant contributor to transmission because of substandard filtration and maintenance systems. Control measures focused on inspecting and improving operating standards at swimming pools, hygiene information to swimmers, and early detection and exclusion of cases. The rapid case investigation described in this paper provided adequate information for the early detection and control of a typical seasonal swimming pool related cryptosporidiosis outbreak. Ensuring adequate filtration standards at public swimming pools particularly before the high use periods of late summer and autumn remains a priority.

Pontiac fever outbreak associated with a spa-pool, United Kingdom, April 2008

On 16 April 2008, public health authorities in North West England were notified of six suspected cases of non-pulmonary legionellosis, five of whom were admitted to three different hospitals and one seen by a general practitioner. These cases presented with influenza-like symptoms: fever, headache, and muscle pain, with or without nausea. They were part of a group of seven women who had spent the weekend of 11-13 April at a residential leisure resort where they were using a spa pool (otherwise known as Jacuzzi or whirlpool).

Integrating prevention of mother-to-child HIV transmission into antenatal care: learning from the experiences of women in South Africa

In 1999, for the first time in South Africa, a Mother-to-Child HIV Transmission (MTCT) prevention programme was implemented at the routine primary care level and not as part of a research protocol. A total of 264 women attending prenatal care in these clinics were interviewed in Xhosa using a standardized questionnaire. All had been offered HIV testing, and 95% had accepted. Women who had not been tested were four times more likely to believe that in the community families reject HIV-positive women (p<0.005). Of women who tested, 19% were HIV positive and 83% had told their partner that they had taken the test. HIV-positive women who had not disclosed testing to their partners were three times more likely to believe that, in the community, partners are violent towards HIV-positive women (p<0.005); 86% stated that they would have taken AZT if found to be HIV positive. Only 11% considered that the use of formula feeding indicated that a woman was HIV positive. In conclusion, routine prenatal HIV testing and interventions to reduce perinatal HIV transmission are acceptable to the majority of women in a South African urban township, despite an awareness of discrimination in the community towards HIV-positive women.

A pilot study of a rapid assessment method to identify places for AIDS prevention in Cape Town, South Africa

A multidisciplinary approach appears promising for focusing interventions. The PLACE method (priorities for local AIDS control efforts) identifies where prevention programmes can access sexual networks containing individuals with high rates of new partner acquisition and provides information about whether sexually transmitted disease (STD) or AIDS prevention programmes are in place at those sites. The method provides useful information at relatively low cost, regardless of the phase of the HIV or STD epidemic. For example, in the growth phase of an epidemic, information on where people with high rates of new partner acquisition meet new sexual partners could be used to inform targeted surveillance or screening programmes to catch early cases.

Evaluation of a video based health education strategy to improve sexually transmitted disease partner notification in South Africa

OBJECTIVES

To evaluate the feasibility and impact of a health education intervention promoting partner notification for sexually transmitted diseases (STDs).

METHODS

The research setting was a busy public health clinic in a rural district in KwaZulu Natal, South Africa. A before/after quantitative study design was used to measure the effect of an audiovisual presentation of a compelling love drama, posters, and pamphlets. Measures collected from all consenting STD index patients during a 6 week pre-intervention (control) phase were compared with those collected during a 6 week intervention phase. A qualitative evaluation assessed whether the intervention accurately portrayed the intended educational messages.

RESULTS

150 index patients (55% female) were interviewed in the control phase and 185 index patients (64% female) in the intervention phase. The intervention phase showed improvements on several measures of self efficacy about notifying casual partners, such as a belief among index patients that a greater proportion of their casual partners would see the importance of seeking treatment as a result of their notification interaction. The rate of contact cards returned per index patient was 0.27 in the intervention phase, compared with 0.20 in the control phase (95% CI for the rate difference: -0.05, 0.17). The qualitative research found that the intervention was thoroughly enjoyed by patients and clinicians, but a fundamental problem with it was that patients received confused messages about the relation between HIV/AIDS and other STDs. This has potentially negative consequences for partner notification.

CONCLUSION

The intervention needs further development, and then could provide a highly acceptable, cost effective model for health education in clinics in developing countries.

Acceptability and feasibility of Micralax applicators and of methyl cellulose gel placebo for large-scale clinical trials of vaginal microbicides

OBJECTIVE(S)

To evaluate the feasibility and acceptability of the Micralax applicator and of methyl cellulose placebo gel for use in vaginal microbicide clinical trials.

DESIGN

A two-centre prospective study following women for 2 months.

SETTING

Two primary health care clinics in South Africa.

PATIENTS, PARTICIPANTS

Female volunteers (n = 28) 18 years or older who were HIV negative and had no clinically detectable genital tract abnormalities or reproductive tract infections.

INTERVENTIONS

Participants used pre-filled Micralax applicators to apply methyl cellulose gel every other day, as well as up to 1 h before to every episode of vaginal sex.

MAIN OUTCOME MEASURE(S)

Consistency in the weight of gel dispensed per application; side-effects attributed to applicator or gel use; and acceptability of the applicator and of the gel.

RESULTS

Over a 2 month follow-up period the 22 women completing the study reported no adverse events related to gel or applicator use. The Micralax applicator proved acceptable. The gel was not too messy and did not reduce sexual frequency or pleasure. On average, the applicator dispensed 4.7 ml per use (close to the 4 ml planned).

CONCLUSIONS

The Micralax applicator performs well as a delivery system for potential vaginal microbicides; and methyl cellulose is an appropriate placebo for future microbicide trials.

Public health lessons from a pilot programme to reduce mother-to-child transmission of HIV-1 in Khayelitsha

OBJECTIVE

Short-course antiretroviral therapy (ART) has been shown to be effective in reducing mother-to-child transmission (MTCT) of HIV-1. This article details the public health lessons learnt from a district-based pilot programme where a short-course zidovudine (ZDV) regimen has been used in a typical South African peri-urban setting.

METHODS

The pilot programme was initiated at two midwife obstetric units in January 1999. Lay counsellors conducted pre- and post-test counselling and nurses took blood for HIV enzyme-linked immunosorbent assay (ELISA) testing. Short-course ZDV was administered antenatally (from 36 weeks' gestation) and during labour. Mother-infant pairs were followed up at eight child health clinics where free formula feed was dispensed weekly. Infants received co-trimoxazole prophylaxis and were ELISA tested for HIV at 9 and 18 months. After 17 months protocol changes aimed at eliminating weaknesses included initiation of ZDV at 34 weeks, self-administration of the first dose of ZDV with the onset of labour, and rapid HIV testing for both mothers and infants.

RESULTS

Voluntary counselling and testing was shown to be highly acceptable, with individual counselling more effective than group counselling. Based on less than optimal availability of records, ZDV utilisation was encouraging with up to 59% of subjects initiating treatment, 3 weeks' median duration of ZDV use, and up to 88% receiving at least one intrapartum ZDV dose. Self-administration of the intrapartum dose reached 41%.

CONCLUSIONS

Short-course antenatal and intrapartum ART to prevent MTCT of HIV1 was shown to be feasible.

Strategies for partner notification for sexually transmitted diseases

BACKGROUND

Partner notification has been practiced for decades, with substantial resources directed towards it, and with little evidence on whether it has made a public health impact on disease transmission. Most of the evaluations were not randomized controlled trials, and were conducted in the United States, prior to the HIV/AIDS epidemic. There are reasons to question whether partner notification for gonorrhoea and chlamydia is applicable to HIV. It is also questionable whether interventions for the developed world are applicable to the developing world.

OBJECTIVES

This review aims to compare the effects of various sexually transmitted disease (STD) partner notification strategies, including to compare provider referral with contract and patient referral, and to compare different patient referral strategies to each other. In addition to updating previous reviews, it addresses partner notification in developing countries as well as in developed countries, with particular consideration for HIV/AIDS. It attempts to address some of the methodological limitations of earlier reviews.

SEARCH STRATEGY

The search strategy included MEDLINE, EMBASE, Psychological Abstracts, Sociological Abstracts, the Cochrane Controlled Trials register, the proceedings of the International AIDS Conferences and the International Society for STD Research meetings.

SELECTION CRITERIA

The review includes published or unpublished randomised controlled trials (RCTs) comparing two or more partner notification strategies for people diagnosed with STDs.

DATA COLLECTION AND ANALYSIS

For each comparison within each study, the difference in the rate of partners elicited, notified, medically evaluated, harmed, etc, the 95% confidence interval, and if significant, the numbers needed to treat (NNT) were calculated.

MAIN RESULTS

We found 11 RCTs, including 8014 participants. Only two trials were conducted in developing countries, and only two trials were conducted among HIV positive patients. There was some risk of bias in all the included trials. The review found moderately strong evidence that: 1. provider referral alone, or the choice between patient and provider referral, when compared with patient referral among patients with HIV or any STD, increases the rate of partners presenting for medical evaluation; 2. contract referral, when compared with patient referral among patients with gonorrhoea, results in more partners presenting for medical evaluation; 3. verbal, nurse-given health education together with patient-centred counselling by lay workers, when compared with standard care among patients with any STD, results in small increases in the rate of partners treated.

REVIEWER'S CONCLUSIONS

There is a need for evaluations of interventions combining provider training and patient education, and for evaluations conducted in developing countries. All partner notification evaluations, but especially those among HIV positive patients, need to measure potential harmful effects, such as domestic violence, to ensure that partner notification does more good than harm.

Evaluation of a new type of direct digital radiography machine

OBJECTIVE

To evaluate a recently developed low-dose, large-field, direct digital X-ray scanning system for medical use.

METHOD

Radiation dose, image quality, diagnostic capability and clinical utility of the unit were compared with those of conventional radiography.

RESULTS

Radiation doses ranged from 3% to 5% of conventional radiographic values, and a mean of 1 line-pair per millimetre could be detected. Ease of use, anatomical coverage and tolerance to patient motion were advantages. However, image quality was inferior to that of conventional radiographs, with limited fine detail visibility and penetration. Only 67 of 156 (42.9%) pathological features seen on conventional radiographs were detected, including 13 of 41 fractures (31.7%) and 11 of 18 pneumothoraces (61.1%).

CONCLUSION

Although image quality and diagnostic performance were not ideal, potential roles in triage, foreign body detection and possibly screening were promising. Radiographic factors may have affected sensitivity. This machine demonstrated useful attributes that may, with improvement, be beneficial in the imaging of trauma and other patients.

Risk factors for meningococcal disease in Cape Town

OBJECTIVE

To determine the risk factors associated with meningococcal disease among children living in Cape Town.

DESIGN

A case-control study was conducted from October 1993 to January 1995.

SETTING

The study population consisted of all children under the age of 14 years who were resident in the Cape Town metropolitan region. Cases and controls were selected from Red Cross War Memorial Children's Hospital.

RESULTS

A total of 70 cases and 210 controls were interviewed. Significant risk factors for meningococcal disease included being breast-fed for less than 3 months (adjusted odds ratio (OR) 2.4); overcrowding (adjusted OR 2.3); and age less than 4 years (adjusted OR 2.3). Exposure to two or more household members who smoked was also a risk factor, but only in the presence of a recent upper respiratory tract infection (adjusted OR 5.0).

CONCLUSION

This is the first case-control study in South Africa examining risk factors for meningococcal disease. It provides further evidence for reduction of smoking, reduction of overcrowding and promotion of breast-feeding as important public health measures.

Using age to predict cervical infection in women presenting with lower genital tract syndrome in Cape Town

In developing countries without access to laboratory testing, the syndromic management of cervicitis in women with lower genital tract symptoms results in overtreatment. We evaluated the validity of using different age cut-offs to predict the risk of cervical infection in women attending a clinic for sexually transmitted diseases in Cape Town. Specimens from 161 women with lower genital tract symptoms were examined microbiologically for evidence of cervicitis (gonorrhoea and/or chlamydial infection). Women with cervicitis (median 21 years) were significantly younger than those not infected (median 23 years). Retrospective simulation using the age cut-offs (< 45 years (current approach), < 30 years, and < 25 years) to predict cervicitis showed that specificity could be increased (overtreatment reduced) from 17% to 50% if presumptive diagnoses of cervicitis were restricted to women aged under 25 years. Lowering the age cut-off would severely limit sensitivity, however, and as many as 9% and 20%, respectively, of infected women would go untreated if the age cut-offs < 30 and < 25 years were used. The use of a lower age cut-off would therefore serve neither individual nor public health in the presumptive diagnosis and treatment of cervicitis in a high risk population, and would result in a substantially lower detection rate.

An assessment of care provided by a public sector STD clinic in Cape Town

A study was undertaken in a Cape Town public sector STD clinic to evaluate the content and quality of care provided since it has been recognized that appropriate improvements in the management of conventional sexually transmitted diseases (STDs), including provision of correct therapy, health education, condom promotion and partner notification, could result in a reduced incidence of HIV infection. Our objectives were to assess patients' needs for health education and to assess the quality of STD management in terms of health education, condom promotion, partner notification, the validity of the clinical diagnoses and the adequacy of the treatments prescribed. The study subjects were sampled systematically, according to their gender. Patients included in the study were given a standardized interview and their clinical records reviewed. Specimens were collected for laboratory investigations. For each STD detected, the treatment was defined as adequate if drugs currently known to be active against that infection were prescribed. One hundred and seventy men and 161 women were included in the study (median age: females 22 years, males 26 years). While almost all patients believed their STD may have been caused by unprotected sexual intercourse, many also believed it may have been caused by other factors, such as bewitchment with traditional medicine. Only 21% of male and 37% of female patients received any education about STD transmission during the clinic visit, and only 25% of male and 36% of female patients received education about condom use. As a result of the low sensitivity of the clinicians' diagnoses, 16% of men and 61% of women left the clinic with at least one infection inadequately treated. The majority of patients were not receiving education for the prevention of STDs including HIV. Many were not receiving adequate treatment for their infections. The introduction of a syndromic management protocol in this setting would substantially reduce the proportion of inadequately-treated patients. However, syndromic protocols, and the means by which they are implemented, need to take into account problems with the clinical detection of genital ulcerative disease and candidiasis in women.

The sensitivity of a syndromic management approach in detecting sexually transmitted diseases in patients at a public health clinic in Cape Town

OBJECTIVES

To evaluate the sensitivity of a syndromic diagnostic procedure in detecting and treating sexually transmitted diseases (STDs) and genital tract infections (GTIs).

METHODS

All new patients presenting at an STD clinic were sampled systematically by gender over a 6-week period. After the patient's clinical consultation, the clinical records were reviewed. Thereafter all patients were given a thorough genital examination by the research physician, and specimens were collected for laboratory investigations. In a retrospective simulation clinicians' syndromic diagnoses were validated against the laboratory findings, or for genital ulcer syndrome against the findings of the research physician.

RESULTS

170 men and 161 women were included in the sample. Ninety-five per cent of patients were black and the median age was 22 years for women and 26 years for men. In this setting, the Western Cape syndromic diagnostic procedure achieved reasonable levels of sensitivity in detecting Neisseria gonorrhoeae and Chlamydia trachomatis in men and women, and in detecting Trichomonas vaginalis and bacterial vaginosis in women. However, it was estimated to be only 36.4% sensitive in detecting genital ulcers in women, and between 0% and 12.3% sensitive in detecting Candida albicans. With syndromic management 8.2% of men and 32.9% of women would leave the clinic with at least one infection inadequately treated.

CONCLUSIONS

Despite the introduction of syndromic protocols, it is likely that a proportion of STDs and GTIs are not being detected and treated owing to the high prevalence of multiple syndromes and mixed infections, both symptomatic and asymptomatic.

The 1992 measles epidemic in Cape Town--a changing epidemiological pattern

Over the last 6 years there has been a decline in the incidence of measles in Cape Town. However, during August 1992 an outbreak occurred, with cases reported at many schools in children presumably immunised. The objectives of this study were to characterise the epidemic in Cape Town and to determine possible reasons for the outbreak. The investigation consisted of two components--a description of the epidemic and an investigation of an outbreak at one primary school. Results indicate that during the last 4 months of the year, 757 cases were notified in Cape Town, compared with 144 in the first 8 months. The epidemic affected mainly white and coloured children over 5 years of age (P < 0.001). In contrast, during the period before the epidemic most cases occurred in black children and in those aged less than 1 year (P < 0.001). There was no significant increase in hospitalised cases. Investigation of the outbreak at one school revealed that the attack rate was 7.6% (25/329 children). Immunisation coverage (at least one dose of any measles vaccine) was 91% and vaccine efficacy was estimated to be 79% (95% CI 55-90); it was highest for monovalent measles (100%) and lowest for measles-mumps-rubella (74%). The epidemiology of measles in Cape Town has thus changed as evinced in this epidemic, with an increase in the number of cases occurring in older, previously vaccinated children. The possible reasons for this include both primary and secondary vaccine failure.(ABSTRACT TRUNCATED AT 250 WORDS)

Measles control in the urbanising environment

The relationship between urbanisation and measles control is examined. In urban settings in developing regions measles is a disease of particular importance, since it tends to affect children at a younger age and with greater severity than in rural settings. A further finding in urban areas, especially peri-urban slums, is the lower measles vaccination coverage rates compared with rural regions. Factors identified as determinants of measles vaccination coverage among children under 2 years of age in urban areas include: home delivery; being born outside the urban setting; and length of stay in the city. These factors are probably related to the low socioeconomic status and lack of social integration experienced by new urban immigrants. A number of additional obstacles, such as distance, economic and cultural barriers, and inconvenient clinic hours all prevent parents from gaining easy access to vaccination services. In order to address the problems of measles control in expanding urban settings, a regional approach--with full integration of curative and preventive services--is called for. A more effective use of existing services will probably go a long way towards improving urban vaccination coverage with resultant measles control.

Measles vaccination coverage and its determinants in a rapidly growing peri-urban area

A study was undertaken to ascertain the vaccination coverage of children aged 12-23 months living in Khayelitsha, a peri-urban township outside Cape Town, and to identify factors associated with measles vaccination coverage. A stratified proportional cluster sampling technique was used to select 46 clusters of 10 children each. Three strata were defined according to area of residence. The vaccination status of each child was determined from the preschool card. Usable information was obtained for 432 children; in 75.4% of cases the respondent was the child's mother, and 69.4% of children possessed a preschool card. Measles vaccination coverage was 63.5% (95% confidence interval 58-67%). Three factors had a significant association with incomplete measles vaccination: less than 6 months' residence in the area (odds ratio (OR) 3.1), having been born outside Cape Town (OR 2.5), and home delivery (OR 2.0). The mothers' level of education and children's age were not associated with measles vaccination status. Children in the New Shanty area were identified as a high-risk group. Carers of children in the New Shanty area were the least likely to know of the need for measles vaccination and to be visited by a community health worker. Greater efforts are required to identify high-risk children and areas.

Crowding and alcohol abuse as risk factors for tuberculosis in the Mamre population. Results of a case-control study

As part of a community health programme, a population-based case-control study was undertaken to determine whether crowding and alcohol are risk factors for tuberculosis in Mamre. Forty notified cases of tuberculosis were compared with 84 randomly selected controls. Cases and controls were group-matched for age and sex. Seventy-six per cent of dwellings had a housing density ratio greater than 100%. There was no association between crowding and tuberculosis, but cases lived in houses that were significantly older than those of controls (odds ratio, 4,8, 95% confidence interval 1,5-15,6). There was an association between alcohol problems in the household and tuberculosis (odds ratio adjusted for employment status 2,2, 95% confidence interval 1,3-3,8). Further studies using refined methods are needed to evaluate the role of crowding in tuberculosis. The need for alcohol intervention campaigns in conjunction with tuberculosis control programmes directed at high-risk groups should be considered.