We identified low but escalating risk of severe M. chimaera infection associated with heater-coolers with cases in a quarter of cardiothoracic centers. Our investigations strengthen etiological evidence for the role of heater-coolers in transmission and raise the possibility of an ongoing, international point-source outbreak. Active management of heater-coolers and heightened clinical awareness are imperative given the consequences of infection.

ObjectiveTo assess the effectiveness of internal and international travel restrictions in the rapid containment of influenza.MethodsWe conducted a systematic review according to the requirements of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Health-care databases and grey literature were searched and screened for records published before May 2014. Data extraction and assessments of risk of bias were undertaken by two researchers independently. Results were synthesized in a narrative form.FindingsThe overall risk of bias in the 23 included studies was low to moderate. Internal travel restrictions and international border restrictions delayed the spread of influenza epidemics by one week and two months, respectively. International travel restrictions delayed the spread and peak of epidemics by periods varying between a few days and four months. Travel restrictions reduced the incidence of new cases by less than 3%. Impact was reduced when restrictions were implemented more than six weeks after the notification of epidemics or when the level of transmissibility was high. Travel restrictions would have minimal impact in urban centres with dense populations and travel networks. We found no evidence that travel restrictions would contain influenza within a defined geographical area.ConclusionExtensive travel restrictions may delay the dissemination of influenza but cannot prevent it. The evidence does not support travel restrictions as an isolated intervention for the rapid containment of influenza. Travel restrictions would make an extremely limited contribution to any policy for rapid containment of influenza at source during the first emergence of a pandemic virus.

Maternal pertussis vaccination has been introduced in several countries to protect infants from birth until routine infant vaccination takes place. This review assesses existing evidence on the effectiveness and safety of immunization in pregnancy. The search was finalized in April 2017 and was based on searches using several databases. The selection criteria included any experimental or observational study reporting on the immunogenicity, effectiveness or safety of vaccination with a pertussis-containing vaccine in pregnant women and their infants. Following de-duplication and exclusions, we identified 8395 studies, which were reduced to 46 for inclusion. The overall risk of bias was low, with the exception of some early studies and pharmacovigilance safety data. The evidence demonstrates efficient transplacental transfer of maternal antibodies in infants whose mothers were vaccinated with Tdap or Tdap/IPV in pregnancy, with good evidence that this protects against disease in young infants. Safety studies covering more than 150 000 women vaccinated mostly in the late second or third trimesters are generally consistent and provide reassurance of no significant increased risk of recognized maternal conditions or of adverse events (including congenital anomalies) in infants born to vaccinated women. The clinical significance of reduced seroconversion to pertussis following routine immunization is not yet clear, but no increased risk of pertussis in infants whose mothers were vaccinated in pregnancy was found following primary immunizations in North American and English studies. Most post-booster studies suggest that any blunting effect is short-lived and that longer-term protection in infants from active immunization is not compromised.

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Fifteen cases of Shiga toxin-producing Escherichia coli (STEC) O157 infection were associated with the consumption of contaminated food from two related butchers’ premises in the north-east of England. Ten cases were admitted to hospital and seven cases developed haemolytic uraemic syndrome. A case control study found a statistically significant association with the purchase of raw and/or ready-to-eat (RTE) food supplied by the implicated butchers’ shops. Isolates of STEC O157 were detected in two raw lamb burgers taken from one of the butchers’ premises. Subsequent environmental sampling identified STEC O157 in bovine faecal samples on the farm supplying cattle to the implicated butchers for slaughter. Whole genome sequencing (WGS) was performed on the Illumina HiSeq 2500 platform on all cultures isolated from humans, food and cattle during the investigation. Quality trimmed Illumina reads were mapped to the STEC O157 reference genome Sakai using bwa-mem, and single nucleotide polymorphisms (SNPs) were identified using gatk2. Analysis of the core genome SNP positions (>90 % consensus, minimum depth 10×, mapping quality (MQ)≥30) revealed that all isolates from humans, food and cattle differed by two SNPs. WGS analysis provided forensic-level microbiological evidence to support the epidemiological links between the farm, the butchers’ premises and the clinical cases. Cross-contamination from raw meat to RTE foods at the butchers’ premises was the most plausible transmission route. The evidence presented here highlights the importance of taking measures to mitigate the risks of cross-contamination in this setting.

Healthcare workers (HCWs) are at increased risk of exposure to respiratory pathogens and may transmit infection to vulnerable patients. This study summarises a recent systematic review, which aimed to assess evidence that influenza or pneumococcal vaccination of HCWs provides indirect protection for those patients most at risk of severe or complicated acute respiratory infection. A number of healthcare databases and sources of grey literature were searched using a predefined strategy, and citations screened for eligibility in accordance with specified inclusion criteria. Risk of bias was assessed using validated tools and results summarised qualitatively. Twenty papers were included in the final review, all of which considered influenza vaccination of HCW. As such, planned subanalysis of pneumococcal vaccination was discarded. The majority of primary research studies included (11/14) were conducted in long‐term care facilities, but there was marked heterogeneity in terms of the population, intervention/exposure and outcomes considered. Consistency in the direction of effect was observed across several different outcome measures, suggesting that influenza vaccination of HCWs is likely to offer some protection. Further evidence is, however, required from acute care settings.

SummaryWe aimed to examine the effect of age upon the control of anticoagulation with warfarin in ordinary clinical practice, using a retrospective examination of routine anticoagulation clinic records from the University Hospital, Nottingham.Considerable over-anticoagulation (international normalisation ratio (INR) >6.0) during induction occurred in 54 (11%) of 495 patients and was more likely in older patients (p<0.05). Lesser degrees of over-anticoagulation during induction (INR>4.0) were also more common in older patients, occurring in 58% of those aged 75 or above. Loading doses of warfarin were not reduced in older patients. INR in the maintenance phase rose with age (p<0.001) despite lower maintenance doses of warfarin (p<0.001). An INR>6.0 in the maintenance phase was noted in 24 (3%) of 739 patients and again was more likely in older patients (p<0.05). Patients using ambulance transport to the clinic were older than those who did not (p< 0.01) and those aged over 75 had shorter intervals between clinic visits (p<0.01).We conclude that doctors using warfarin therapy do not take sufficient account of the increased sensitivity of older people to warfarin. Hospital anticoagulant policies need implementation and evaluation.