In early 2005, the EU started preparing for the next influenza pandemic. Recently, ECDC has prepared a report on the state of pandemic preparedness in the EU and EEA countries, available on the ECDC website (http://ecdc.europa.eu). The report concludes that although much has been done, more still needs to be done. Health sectors in all countries have developed preparedness plans and, at national level, these plans are becoming operational. Through close liaison, ECDC has prepared extensive guidance, taking care not to duplicate what WHO has already provided in devising guidance that applies for seasonal influenza. ECDC estimates, however, that even if a developed European country works hard and commits considerable additional resources, it will take Europe another 2–3 years of hard work and investment.

WHO is confident that there has been no reduction in the threat of a pandemic and that although unpredictable, it can be considered as inevitable. Whereas citizens might expect to be protected by now, and policy makers might feel that enough time, effort and resources have been committed, it is apparent that Europe has never been more vulnerable to a pandemic. Equally, however, compared with previous flu pandemics, the armoury of countermeasures has never been greater and includes antivirals, human H5N1 vaccines, evidence-based public health measures and modern business continuity planning. Each countermeasure needs careful planning and organisation to reduce suffering and death. Essentially, 2008 will be another busy year on pandemic preparedness. WHO is revisiting its makers to increase collaboration and exchange of plans and common exercises between countries. It seems likely that the French presidency of the EU will make pandemic preparedness one of its priorities, although working on pandemic preparedness has been and will need to be a feature under every EU presidency until at least 2010.

ECDC recognises that although, in the event of a flu pandemic, there are various measures that could be used to reduce peak levels of flu transmission and delay transmission towards the decline that occurs naturally in summer months, and/or until pandemic vaccines start becoming available, it is unlikely that “one size will fit all countries and communities” except for the few measures that are at the “relatively easy” (handwashing and personal respiratory hygiene) or “very difficult – don’t do it” (border closure) extremes. Although it is not in their mandate to prescribe policy to support Member States, ECDC has published an interim “Guide to Public Health Measures to Reduce the Impact of Influenza Pandemics During Phase 6” (available from the ECDC website) presenting all the measures that Member States and institutions individually or collectively could consider to reduce the impact of an influenza pandemic.

In recognition that “Global Preparedness” means that respiratory hygiene needs to become a daily routine before the event, ECDC has recently produced an “Influenza Communication Toolkit”. The aim is to assist health communicators in devising communication campaigns to tackle seasonal influenza. It offers advice on how to develop campaigns and includes prototype materials with information and key messages.
The toolkit can be found at: http://ecdc.europa.eu/Health_
topics/ Seasonal %20 Influenza/toolkit/pdf/ECDC
%20Influenza%20Toolkit%20%20Guideline%20for%20Use.pdf.

In November 2007, the UK Department of Health launched a 2007 winter campaign to encourage the public to practise correct respiratory and hand hygiene when coughing and sneezing. The key campaign messages are:
Catch it: germs spread easily. Always carry tissues to catch your cough or sneeze.
Bin it: germs can live for several hours on tissues. Dispose of your tissues as soon as possible.
Kill it: hands can transfer germs to any surface you touch. Clean your hands as soon as you can.
The campaign will run until spring 2008 and includes advertising on buses, trains and the London Underground, posters in shopping centres, screen savers, and ads in the London free press. A PR programme will engage with stakeholders and gain media coverage of campaign messages, and posters will be distributed to GP surgeries, hospital and community pharmacists, HPUs, A&E departments, NHS walk-in centres, libraries and police stations. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_080839.

Despite the extensive amount of clinical data that exists, the debate continues about how influenza is transmitted, in particular, the relative extent to which airborne (including droplet as well as true airborne transmission) and contact transmission could be involved. This information is vital as the basis to inform infection control planning efforts. In a recent review (Lancet Infect Dis 2007;7:257–65) Brankston et al describe a systematic literature review. They concluded that in reality data regarding the identification of specific transmission modes are limited; however, transmission occurs at close range rather than over long distances, suggesting that airborne transmission, as traditionally defined, is unlikely to be of significance. Further research is required to define better how the virus can transmit via the airborne route. The important role of hygiene measures is stressed in a recent literature review published in the British Medical Journal (Jefferson et al, BMJ, 27 Nov 2007) which finds that physical barriers, such as regular handwashing and wearing masks, gloves and gowns, could be more effective than drugs to prevent the spread of viruses such as influenza and SARS. The 51 studies compared any intervention to prevent animal-to-human or human-to-human transmission of respiratory viruses, such as isolation, quarantine, social distancing, barriers, personal protection and hygiene, to doing nothing or to other types of intervention. They found that handwashing and wearing masks, gloves and gowns were effective individually in preventing the spread of respiratory viruses, and were even more effective when combined.

The report recognises that, worldwide, bacterial food-borne zoonotic infections are the most common cause of human intestinal disease, with Salmonella and Campylobacter accounting for over 90% of all reported cases of bacteria-related food poisoning. It is estimated that one-third of the population in developed countries are affected by food-borne diseases every year. It is also predicted that about 1% of the European population will be infected with Campylobacter every year.

Campylobacteriosis and Salmonellosis were the most commonly reported zoonotic diseases with 175,561 and 160,649 cases, respectively; a reduction in confirmed cases from 2005. Campylobacter were most commonly detected in fresh poultry meat where on average 35% samples were positive. Salmonella was most commonly found in fresh poultry and pork meat, where 5.6% and 1.0% of samples were found positive. These agents make up the overwhelming majority of all zoonotic infections, but are only a fraction of the true number of cases in the EU; 4,916 confirmed cases of VTEC were reported, compared to 3,217 in 2005, the difference being mainly due to reports from the Czech Republic, which accounted for 92% of the increase. VTEC was detected mainly in cattle and related products. The number of listeriosis cases increased to 1,583. The incidence rates of this infection in Europe have shown a significant increase over the past 5 years. Listeriosis is an important food-borne zoonosis due to disease severity and high mortality (average mortality 14.2%). Listeria were most commonly reported from ready-to-eat fish products, cheeses and other ready-to-eat products.

In 2006, 5,710 food-borne outbreaks were reported. As in 2005, Salmonella was the most common cause of those outbreaks. For the first time, however, food-borne viruses were the second most frequent cause. The number of viral outbreaks is assumed to have been severely under-reported in previous years. The majority of the reported food-borne Salmonella outbreaks were associated with eggs, while meat was the second most common source. The report concludes that although control programmes aimed at lowering the risk of zoonotic infections have been successful, there is room for improvement.
See: www.efsa.europa.eu/EFSA/ efsa_locale-178620753812_1178671313012.htm.

Effective surveillance of emerging infectious diseases requires a system able to transmit locally detected outbreak reports at an early stage, for example, when an epidemiologic investigation is still under way. In 2001, the Robert Koch Institute (RKI) implemented a new electronic surveillance system (SurvNet) for infectious disease outbreaks in Germany. The SurvNet system ensures continuous updating of outbreak reports as more cases are identified or linked to the outbreak, long before an outbreak investigation has been finalised. This system also facilitates the rapid electronic linkage of apparently independent outbreaks, for example, in different states, enabling subsequent analysis of the entire meta-outbreak. It is interesting to note that EFSA is currently building a reporting system for food-borne outbreaks in the EU using the methods developed in SurvNet.

In a recent report (Emerging Infectious Diseases, Oct 2007) Krause et al from the RKI evaluated data from 30,578 outbreak reports captured in Germany in 2001–2005. Of note is the fact that the most common settings among the 10,008 entries for 9,946 outbreaks in 2004 and 2005 were households (5,262; 53%), followed by nursing homes (1,218; 12%), and hospitals (1,248; 12%).
 
Of these outbreaks, 90% were caused by pathogens of the intestinal tract (eg, Salmonella, norovirus, rotavirus, hepatitis A virus, enteropathogenic E. coli, and Campylobacter) and 10% were caused by the influenza virus, Mycobacterium tuberculosis, measles virus, and others. Whereas households were reported as the most frequent settings for outbreaks associated with Salmonella, rotavirus and Campylobacter (accounting for 38, 25 and 14% of total outbreaks for each of these pathogens, respectively) this was not the case for norovirus where hospitals and nursing homes were cited as the setting for 66% of reported outbreaks compared with only 13% for the household setting. It is possible that this reflects the
under-reporting of norovirus infections in the home. In 999 outbreaks caused by S. enteritidis spp., 14% (141) were associated with food; this association was found for 8% (28/359) Campylobacter outbreaks, 1% (16/1,239) norovirus outbreaks, and 0.2% (2/940) rotavirus outbreaks.

The incidence of Listeria in the UK has been increasing steadily since 2001, from an average 109 cases per year between 1990 and 2000 as compared with 185 per year between 2001 and 2006. The increase has predominantly occurred in patients aged 60 years and over presenting with bacteraemia in the absence of central nervous system (CNS) involvement. In the first 20 weeks of 2007, a provisional 70 cases of listeriosis from England and Wales were reported to the Health Protection Agency Centre for Infections. A 67% increase in incidence from the same period in 2006 and the highest reported incidence for this period since active surveillance of listeriosis began in 1990. Forty-seven (66%) of the 70 cases were aged ≥60 years and 50 cases (70%) presented with bacteraemia in the absence of CNS involvement. There is little or no data to indicate how or why these increases are occurring, but typing data do not indicate a single strain common-source outbreak or cluster. See: http://www.hpa.org.uk/hpr/archives/2007/news2007/news2107.htm#listeria.

The EC Commission has asked one of the EU standing scientific advisory committees (Scientific Committee on Emerging and Newly Identified Health Risks – SCENIHR) to consider the possible risk that exposure to biocides or active substances in biocidal products could favour the emergence or selection of cross-resistance mechanisms (in bacterial species) that could reduce the efficacy of antibiotic molecules during therapy.

In 1999, the Scientific Steering Committee recommended in its opinion on antimicrobial resistance (http://ec.europa.eu/food/fs/sc/ssc/out50_en.pdf) “prudent use of antimicrobials”, “reduction of the overall use of antimicrobials in a balanced way in all areas” and the identification of major contributors to resistance. Further, it recommended in its opinion on triclosan (http://ec.europa.eu/food/fs/sc/ssc/out269_en.pdf) “that the potential for biocides, in general, to induce antimicrobial resistance of importance to clinical medicine, or management of the environment be kept under continuous review and if new evidence were to indicate significant risk of biocides causing anti-microbial resistance to antibiotics used in human medicines, then appropriate action to manage these risks might be needed”.

A report on the implementation of the Biocidal Products Directive is foreseen in the near future, which could lead to the review of certain provisions. In light of recent scientific evidence, clarification is sought as to whether cross-resistance to antibiotics should be an additional criterion to consider in the common principles for biocidal product dossiers. Therefore, clarification of the following questions is sought: (1) Does current scientific evidence indicate that the use of certain active substances in biocidal products contributes to the occurrence of antibiotic resistant bacteria, both in humans and in the environment? If so, how does this effect compare to resistance due to the application of medicinal products or veterinary medicinal products and other applications? (2) If yes, which types of active substances, modes of action or application areas create the highest risks for increasing antibiotic resistance? (3) If yes, what are the extent of the resulting antibiotic resistance and the relative contribution of the different applications to the risk of increasing antibiotic resistance? (4) How can the development of antibiotic resistance due to the use of active substances in biocidal products be examined and measured? Could the committee advise on the methodologies? (5) Please identify relevant gaps in scientific knowledge and suggest major research needs. The deadline for delivery of opinions is June 2008.
For further details see: http://ec.europa.eu/health/ph_risk/committees/04_scenihr/04_scenihr_en.htm.

Anti-microbial resistance remains one of the key problems within community and hospital settings in Europe. It is recognised that this must be tackled by prudent antibiotic use, but also through improved public and professional education.

The objective of the DG Sanco funded e-Bug project is to disseminate an antibiotic and hygiene teaching resource for 9–16 year olds across Europe. The aim is that all children will leave school with the knowledge of prudent antibiotic use and how to reduce the spread of infections. The resource will encourage better understanding of infections and antibiotic resistance and how infections are spread. It will reinforce awareness of the benefits of antibiotics, but will also teach how inappropriate use can have an adverse effect on an individual’s “good bugs” and antibiotic resistance in the community. The areas of hand and food and respiratory hygiene and spread of infections in the community will be covered. Decreased spread of respiratory, gastrointestinal and skin infections will, in turn, contribute to the reduction in antibiotic use, and reduce the spread of antibiotic resistance.

To achieve this, a series of pupil activities will be created for junior (for 9–11 year olds) and senior schools (for 12–15 year olds) linking in with each country’s National Curriculum, taking account of specific cultural needs and problems. Activity worksheets will be developed for use in conjunction with a website, which will be developed and hosted by the National electronic Library of Infection (NeLI) in the UK. The website will have downloadable resources and will host interactive games, quizzes and links to other resources and websites.

The pack will be developed and trialled in England. The consortium consists of 10 associated countries (300 million) covering 55% of the European population including Belgium, Czech Republic, Denmark, France, Great Britain, Greece, Italy, Poland, Portugal and Spain. Collaborating countries (Croatia, Finland, Hungary, Ireland, Latvia, Lithuania, Slovakia and Slovenia) (34 million) covering 7% of the European population will be involved in the consultation and launch to help them to coordinate their activities for further implementation of the project results in their countries. It is estimated that this initiative will reach 76% of the European population. The project is led by Cliodna McNulty, who heads the Health Protection Agency Primary Care Unit in Gloucester, UK.
For further details contact Cliodna.McNulty@hpa.org.uk.

On 23 August 2007, WHO published its latest World Health Report – ‘A Safer Future: Global Public Health Security in the 21st Century’, analysing threats to public health from previous centuries and examining how new threats can be managed. Since the 1970s, 39 new diseases have emerged in the world – a rate of one a year – according to the report, which also says that it would be “extremely naïve and complacent to assume that there will not be another disease like AIDS, another Ebola, or another SARS, sooner or later”.

The report examines lessons learned from these and other diseases, as well as pandemic preparedness to avian flu and potential new threats. The document concludes with six recommendations regarded as vital to head off future threats to global public health:

• full implementation of the revised International Health Regulations (2005) by all countries;

• global cooperation in surveillance and outbreak alert and response;

• open sharing of knowledge, technologies and materials, including viruses and other laboratory samples, necessary to optimise secure global public health;

• global responsibility for capacity building within the public health infrastructure of all countries;

• cross-sectoral collaboration within governments;

• increased global and national resources for training, surveillance, laboratory capacity, response networks, and prevention campaigns.

The report is available at: http://www.who.int/whr/2007/whr07_en.pdf.

On 21 November 2007, the UN launched the International Year of Sanitation (IYS) to accelerate progress for 2.6 billion people worldwide who are without proper sanitation facilities. UN Secretary-General Ban Ki-moon said “Access to sanitation is deeply connected to virtually all the Millennium Development Goals, in particular those involving the environment, education, gender equality and the reduction of child mortality and poverty”.

An annual investment of about US$ 10 billion (EUR 6.85 billion) is needed to reach the Millennium Development Goal (MDG) target of halving the number of people without basic sanitation by 2015. If sustained, the same investment could achieve basic sanitation for the entire world within 10–20 years. However, if current trends continue, there will still be 2.4 billion people without basic sanitation in 2015.

Motivated by the IYS 2008, a coalition of more than 50 prominent multi and bilateral organisations, NGOs, businesses, governmental and research institutions active in the field of sustainable sanitation formed the “Sustainable Sanitation Alliance” or SuSanA and have collaborated to produce a joint road map for IYS 2008; it will include major regional conferences on sanitation as part of capacity building initiatives, including one that will focus on school sanitation, and encourage public and private partnerships to help tap into the comparative strengths of each sector to accelerate progress, advocate and raise awareness on sanitation, leverage additional funding, and develop country-level road maps.

Although the focus is on sanitation, there is also recognition that unwashed hands transmit the bacteria, viruses and parasites found in human faeces directly to foods and mouths, and to be effective in reducing diarrhoeal diseases, sanitation programmes must include efforts to promote hygiene. The section of the IYS website devoted to hygiene promotion states “Simply washing hands with soap and water can be a major factor in saving lives and improving health and nutrition. However social stigma prevents people from speaking openly about hygiene and the lives of millions of people are affected as a result. The International Year of Sanitation aims to address these challenges by raising awareness of the benefits of good hygiene and by helping to break the taboos about speaking out for changes in behaviour”.
For more details of the International Year of Sanitation go to: http://esa.un.org/iys/index.shtml.

Ministers and leaders from 15 East Asian countries gathered in Beppu City in Japan for two days of talks about sanitation and hygiene in the region. Organized by WHO WPRO and other partners, the East Asia Ministerial Conference on Sanitation and Hygiene is the highest-level gathering of its kind ever to be held in this region. Approximately 180 representatives from participating countries, including ministers of health and water and senior government officials joined the discussion and debate on key issues concerning promotion of hygiene and sanitation in the developing countries in general and in the region in particular. The principal topic for discussion was the critical problem of almost 1 billion people in the region without access to household sanitation and hygiene and the challenges of meeting the Millennium Development Goal (MDG) on sanitation. The EASAN Declaration can be viewed at http://esa.un.org/iys/docs/EASanDeclaration.pdf.

Prof. K.J. Nath, IFH South East Asia Regional Co-ordinator and Member, Scientific Advisory Board, represented the IFH at the Conference along with an information booth and poster exhibition. He presided over a technical session on “Hygiene & Sanitation” and the IFH concept of knowledge based advocacy for hygiene behaviour change in the developing countries for promotion of health and prevention of infectious diseases was highlighted. 

As in previous years, the Secretariat for the global public private partnership on handwashing (PPPHW) hosted the 2-day University of Handwashing in Washington DC,
13–14 September 2007. The workshop brought together over 40 participants representing global PPPHW member organisations, country coordinators, and sector specialists to share and discuss successes, challenges, and next steps. The workshop featured updates from partner organisations, PPPHW country updates, and presentations on some of the most recent developments in handwashing research and programming. The proceedings and presentations from the event are now available from http://www.globalhandwashing.org/index.html.

As part of their contribution to the launch of the “Global Year of Sanitation” the Stockholm Water Institute (SIWI) has produced a special issue of Water Front. As part of this issue, SIWI invited IFH and the Water Supply and Sanitation Collaborative Council (WSSCC) to contribute a feature on hygiene. For decades, access to water and sanitation has been seen as essential in reducing the preventable disease burden in developing countries. There is now a belief that a key mistake has been to undertake water and sanitation programmes in isolation, and that reducing the disease burden is best achieved by programmes that also integrate hygiene promotion. Indications are that hygiene can prevent the spread of infectious diseases at a fraction of the cost of other health interventions; a recent analysis carried out as part of the “Disease Control Priorities Project” showed that, for the “high burden” diseases (such as HIV/AIDS, malaria, diarrhoeal disease and TB), hygiene promotion is the most cost effective intervention in terms DALYs averted (up to $3.35 per DALY averted due to diarrhoea disease compared with, for example, up to approx $1,000 per DALY averted by anti-retroviral treatment of HIV/AIDS.

IFH believes that, fundamental to hygiene promotion, is the need to recognise the home and the community as an environment where all human activities occur. Whereas most people recognise that hygiene means “handwashing”, in reality, a whole range of issues need to be addressed, if hygiene promotion is to achieve maximum health benefits which include hand hygiene and personal hygiene, food hygiene (cooking, storing, preventing cross contamination), ensuring safe water at the point of use, safe disposal of faeces (both human and animal), general hygiene (laundry, surfaces, toilets, baths, sinks), disposal of solid waste, control of wastewater and rainwater. It also includes situations where there is more risk – care of those who are infected and those who are more vulnerable to infection. IFH believes that a key need is to ensure that we look at hygiene holistically from the point of view of the family and the range of actions that they need to undertake to protect themselves from infectious diseases. We need to recognise the family as the cornerstone; this makes sense since all of these actions are interrelated, and some activities like handwashing are central to all of them.

Developing a strategy for building hygiene practice into the daily life of communities in developing countries is a significant challenge. Although there is growing awareness about the importance of hygiene, this does not necessarily translate into commitment to action by national and international government and non-government agencies. Promotion of a holistic approach requires a lead agency, and a proper infrastructure at national, district and local levels for actioning a coordinated hygiene promotion programme. Equally important, there must be sufficient numbers of trained field workers who are responsible for, and committed to, hygiene education and motivation at community and family level. Community workers and/or teachers are best placed to understand the community and best placed to develop appropriate programmes. It is only by combining their knowledge of local conditions, local needs and constraints, with an understanding of the means to prevent infection through hygiene practice, that hygiene behaviour can be improved. Key to hygiene promotion is communicating to the target audience in a way that will motivate behavioural change. A number of approaches are currently being pioneered which include the “Health in Your Hands” campaign being developed by the Global Public Private Partnership on Handwashing (http://www.globalhandwashing.org). This is based on marketing a small number of simple messages on when and how to wash hands through various communication channels including the mass media and direct communication. Programmes which use participatory approaches involving community health clubs and schools (WASH in schools, http://www.schools.watsan.net/page/248) are also being developed.

The full article can be found at: www.siwi.org .

In a new article published in the Journal of Hospital Infection (2007;67:9–21), Pittet et al describe the scientific rationale which was used in the development of the WHO Global Patient Safety Challenge Campaign – “Clean Care is Safer Care” – to promote hand hygiene in healthcare facilities. The central concept – ‘My five moments for hand hygiene’ – bears strong similarities to the IFH approach to home hygiene in that it emphasises the need for a “user-centred” and “risk-assessment” approach. It also recognises that optimising the health benefits of hand hygiene depend not just on getting people to wash their hands, but getting them to apply hand hygiene properly, at the right time and in conjunction with other infection control measures. This is very much in line with the “Framework for Hand Hygiene” developed in our recent IFH report on hand hygiene in the home and community, which recognised that, although a single factor such as the hands may be a “sufficient cause” of infection transmission, spread of infection frequently involves a number of “component causes” which, together or independently, work to determine the overall risk. The WHO group used an evidence-based hand transmission model based on “geographical” visualisation. Focusing on a single patient, the healthcare setting was divided into two virtual geographical areas, the “patient zone” and the “healthcare zone”. The geographical representation of the two zones and the critical sites within these zones was then used to identify the five moments for hand hygiene – before patient contact, before an aseptic task, after body fluid exposure risk, after patient contact and after contact with patient surroundings.

They chose to describe their approach in the following way “‘My five moments for hand hygiene’ can be compared to wearing a safety belt while driving. Although the risk through neglecting a single preventive gesture may be very low, cumulative negligence results in a high total number of fatal outcomes due to the sheer frequency of the risk situation. A high standard of cleaning of the healthcare environment and all objects brought in close contact with patients is required if the proposed hand hygiene concept is to make sense”.

Targeted cleaning to tackle MRSA hotspots is the key to reducing hospital infections

In November 2007, Lancet Infectious Diseases published a detailed review by
Dr Stephanie Dancer of the evidence related to MRSA transmission in hospitals. In this article, she argues the need for a risk-based or targeted approach to hospital hygiene, in line with the approach advocated by the IFH for home hygiene.
Dr Dancer argues “cleaning should focus on objects which people frequently touch rather than on ‘catch-all blitzes’”. MRSA rates in UK hospitals have been falling in recent years, with latest figures showing just over 6,000 new cases in the last 12 months. The decline has not been fast enough to meet the government’s target to halve MRSA rates by next year. Dr Dancer argues that hospital cleaning tends to concentrate on areas of visible dirt such as floors, but would be much more effective if they targeted hotspots that hands came in contact with. She believes that without such strategies, campaigns to get people to wash their hands are ineffective.

Dr Dancer argues that hospital hygiene is usually assessed visually, but this does not necessarily correlate with microbiological risk. In her article, she considers the evidence for all stages of the MRSA transmission cycle between humans and their environment as the basis for developing a risk-based approach to hospital cleaning. The greatest risk for patients is contaminated near-patient hand-touch sites in clinical areas. From her own studies, she found that bed linen, patient gowns and overbed tables were the most common sources with over 40% of these sites contaminated. Door handles, bed-rails, furniture and taps were also common sources. The case is further supported by studies that have seeded viral or other molecular fragments onto a door handle or a telephone, and then charted their movements. Such studies show the importance of sites that human hands touch more frequently. She points out that, “buffing the floors in outpatient departments might improve the appearance of the waiting areas, but patients do not generally acquire MRSA from floors”.

She also considers the question, “Why do we not simply advocate more attention towards hand hygiene, to interrupt the final common pathway in the acquisition of MRSA?”. She says, “There can be no doubt that prioritising hand hygiene is the single most beneficial intervention. However, the problem with the cleaning of hands is that it is impossible to get everyone to do it at the most appropriate time. And even if everyone does wash their hands properly, the effects of exemplary hand hygiene are eroded if the environment is heavily contaminated with MRSA”.

She concludes, “In the UK, we continue to debate the importance of hospital cleaning in relation to increasing numbers of patients acquiring MRSA. However, there is little direct evidence for the effectiveness of cleaning because it has never been afforded scientific status. We do not yet know exactly what impact cleaning could have on control, but this ignorance should not be used as an excuse for doing nothing”.

A new study has been carried out in the US to estimate the incidence of invasive MRSA infections. These data represent the first nationwide estimate of the burden of MRSA using data from the Active Bacterial Core Surveillance/Emerging Infections Program Network. The data, which covers July 2004 to December 2005 and was taken from nine mostly urban regions, was published in the Journal of the American Medical Association (JAMA  2007;298(15):1763–71). Reports of MRSA were classified as either healthcare-associated (either hospital-onset or community-onset) or community-associated (patients without established healthcare risk factors for MRSA). The study identified 8,987 cases of invasive MRSA. Most of these (58.4%) were found in community healthcare settings, 26.6% were in hospitals, 13.7% were infections not associated with healthcare facilities, and 1.3% could not be classified.

The study estimated that the rate of invasive MRSA in 2005 was 31.8 per 100,000 persons, but that rate was higher for certain populations including those 65 and older, blacks and males rather than females. The lowest rate was for children
5–17 years of age. Based on these data, the researchers estimated that there were 94,360 cases of invasive MRSA in the US as a whole in 2005, and 18,650 deaths caused by these infections although the researchers do not know if MRSA was the cause in all cases. If these deaths all were related to staph infections, the total would exceed other better-known causes of death including AIDS, which killed an estimated 17,011 Americans in 2005.

The study covers only invasive MRSA infections. Community-associated MRSA, which is transmitted from person-to-person, has become the most frequent cause of skin and soft tissue infections presenting to emergency departments in the US. Although community outbreaks that can affect diverse populations ranging from sports teams to prison inmates to childcare attendees, usually involve the skin, MRSA also can cause a severe, sometimes fatal invasive disease. Studies of community-associated MRSA have determined that isolates causing these infections are distinct and are susceptible to most non-lactam antimicrobial agents, carry staphylococcal cassette chromosome type IV, and frequently encode the necrotic cytotoxin known as Panton-Valentine leukocidin.

In developing countries, urban agriculture is promoted as a way to reduce urban poverty, improve food security and enhance the urban environment. Cultivation of produce close to urban markets reduces transport, handling and production costs, making food products readily available to the urban poor. Due to rapid urbanisation and the absence of wastewater treatment facilities, urban farmers often use wastewater either directly from sewage drains or indirectly through
wastewater-polluted irrigation water. Although it is recognised that wastewater use in agriculture is increasing due to the rising water scarcity worldwide, there is concern that the use of wastewater for agricultural purposes can pose a significant public health risk. Little information is available on the quality of agricultural produce from
wastewater-irrigated fields and⁄or its quality at local markets.

In the recent issue of Tropical Medicine and International Health, Ensink et al describe a 12-month study carried out in Faisalabad, Pakistan, where it is estimated that 25% of vegetable production is irrigated with wastewater. In this study, wastewater-irrigated produce was sampled every 14 days and analysed for the presence of E. coli and helminth eggs. Samples were collected from wastewater irrigated fields at the time of harvest, after which the same batch of vegetables was followed to the market from where it was collected 12 hours later and reanalysed. The study found that E. coli concentrations on vegetables collected in the field were low with on average 1.9 E. coli g^-1 of vegetable, but the same vegetables collected from the market were found to harbour higher E. coli concentrations with a mean concentration of 14.3 E. coli g^-1.
 
This indicates that use of faecally polluted irrigation water contributes less to faecal pollution levels of produce purchased at markets compared with faecal pollution taking place post-harvest due to poor hygiene at the local market. The authors conclude that improved hygiene at the local market, through for example, availability of extra clean water stand posts is a more cost effective measure to improve produce quality then wastewater treatment.
The full report can be found in Trop Med Int Health 2007;12(suppl 2):2–7.

A reminder to take care with the cleaning of bottles used for infant feeding formula was given at the International Association for Food Protection (IAFP) meeting in Florida, July 2007. Worldwide there has been increased interest in Enterobacter sakazakii, an infrequent but often severe cause of illness in small babies. The organism can be found in the formula itself but has good survival abilities and has been isolated from a range of surfaces in the home. Cross contamination of formula via unclean bottles is a potential route of infection. Work undertaken at the University of Wales Institute Cardiff (UWIC) indicated that so called “sterilised bottles” (this term often used by healthcare professionals and manufacturers can be misleading) were often inadequately decontaminated. A random selection of “ready-to-use” bottles were often unclean (as measured by ATP), with 81% having at least one inadequately cleaned site. The inside of the screw cap was the site most likely to fail. Aerobic colony counts, especially the screw cap, were sometimes high and although no enterobacteria were isolated Staphylococcus aureus was (4% of sites tested). Units “sterilised” by steam were most likely to fail.

Whilst breast feeding is normally recommended by healthcare professionals, an estimated 500,000 babies in the UK are bottle fed at some stage and households are likely to have at least five bottles for every child. This highlights the need for education of consumers in how bottles should be stored, cleaned and disinfected. For further details contact Professor Chris Griffith (cgriffith@uwic.ac.uk).

A recent study presented by Blaser and Chen of the New York University School of Medicine, at the Annual Meeting of the Infectious Diseases Society of America (IDSA) suggests that although H. pylori can cause ulcers and stomach cancer it can also protect children from asthma. The authors suggest that although there is a biological cost to having H. pylori in terms of increased risk for ulcers and stomach cancer, these typically occur later in life. Meanwhile, asthma is serious especially in young children, and can be fatal. The study was based on the results of National Health and Nutrition Examination Survey (NHANES) 1999–2000. Researchers compared participants aged 3–19 and found that overall, those with H. pylori in their stomachs were 35% less likely to have ever had asthma and 44% less likely to have early-onset asthma, before age 5.

H. pylori could protect against asthma by priming the immune system, said Dr Blaser. H. pylori bacteria are transmitted from person-to-person, so once it has become diminished in the population, it is also less likely to be passed on. Although unproven, the relatively quick disappearance of H. pylori from our systems is consistent with the idea that widespread antibiotic use is changing human microbiology. Fifty years ago, more than half of American children had H. pylori in their stomachs, but today it is fewer than one in 10 children ages 13 and younger. Other factors in the decline of H. pylori include improvements in childhood living conditions and smaller family size.
For more details see: http://http.hivma.org/PrintFriendly.aspx?id=7056.

A new study, by Clayton, Thompson and Meade which appeared in the November 2007 online edition of the European Heart Journal  has found strong evidence that recent respiratory infections increase the risk of heart attacks and strokes. It has been recognised for some years that there is an excess of deaths from heart disease and stroke during winter months, over and above those directly attributable to deaths from respiratory disease. The team, from the London School of
Hygiene & Tropical Medicine’s Medical Statistics Unit, carried out a case-control study in a general practice database of 2 million patients registered with 500 GPs. They found a doubling of risk of heart attack and stroke in the week following respiratory infection, which reduced over time so that there was little excess risk beyond 1 month. There was also evidence of an association between recent urinary tract infection and subsequent heart attack or stroke. The researchers say that the benefit of reducing respiratory infection, either through ensuring high immunisation rates or by treating and preventing infection, may be substantial.
The full article can be found at: http://eurheartj.oxfordjournals.org/cgi/content/full/29/1/96

1. Infection Patterns in the World

Proposed definitions of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). Millar B.C., Loughrey A., Elborn J.S., Moore J.E. Journal of Hospital Infection 2007;67:109-13.
A new type of methicillin-resistant Staphylococcus aureus (MRSA) is emerging as a significant pathogen in otherwise healthy individuals in the community. This MRSA is distinct from healthcare-associated (HA)-MRSA, in terms of epidemiology, microbiology and clinical manifestations. At present there is a lack of consensus as to the terminology used to describe community-associated (CA)-MRSA. This confusion is further compounded with the recent emergence of nosocomial transmission of CA-MRSA within hospitals. The aim of this article is to highlight the differences between HA-MRSA and CA-MRSA and to propose standard definitions of the various subgroups of CA-MRSA.

Norovirus activity – United States 2006-2007. Morbidity Mortality Weekly Report 2007;56(33):842-6.
In late 2006, CDC began receiving requests for information about a perceived increase in the number of outbreaks of acute gastroenteritis (AGE), especially those involving person-to-person transmission in long-term care facilities. No national surveillance system exists for AGE outbreaks, including those caused by norovirus, unless food-borne transmission is suspected. CDC solicited information from the health departments of 24 states who reported a total of 1,316 AGE outbreaks, onset during October-December 2006; a median of 50% occurred in long-term care facilities, and a median of 26% had laboratory confirmation of norovirus by RT-PCR. Of these 24 states, 22 (92%) reported an increase in the number of outbreaks compared with the same period in 2005.

Transmission of influenza A in human beings. Brankston G., Gitterman L., Hirji Z., Lemieux C., Gardam M. The Lancet Infectious Diseases 2007;7:257-65.
Infection control precautions to prevent airborne, droplet, and contact transmission are quite different and will need to be decided on and planned before a pandemic occurs. Despite vast clinical experience, there continues to be much debate about how influenza is transmitted. This paper describes a systematic review of the literature to better inform infection control planning efforts. The review suggests that existing data are limited to identify specific modes of transmission. However, it was concluded that transmission occurs at close range rather than over long distances, suggesting that airborne transmission, as traditionally defined, is unlikely to be of significance. Further research is required to better define how the virus may transmit via the airborne route.

SurvNet electronic surveillance system for infectious disease outbreaks, Germany. Krause G., Altmann D., Faensen D., et al. Emerging Infectious Diseases 2007 Oct.
In 2001, the Robert Koch Institute (RKI) implemented a new electronic surveillance system(SurvNet) for infectious disease outbreaks in Germany. SurvNet has captured 30,578 outbreak reports in 2001-2005. The most common settings among the 10,008 entries for 9,946 outbreaks in 2004 and 2005 were households (5,262; 53%), nursing homes (1,218; 12%), and hospitals (1,248; 12%).

Invasive methicillin-resistant Staphylococcus aureus infections in the United States. Klevens R.M., Morriso M:A:, Nadle J., et al. JAMA2007;298(15):1763-71.
Data was taken from population-based surveillance for invasive MRSA in 9 sites across the US during 2004 and 2005. Reports of MRSA were classified as either healthcare-associated (either hospital-onset or community-onset) or community-associated (patients without established health care risk factors for MRSA). There were 8987 observed cases of invasive MRSA reported. Most infections were healthcare-associated: 5250 (58.4%) were community-onset infections, 2389 (26.6%) were hospital-onset infections; 1234 (13.7%) were community-associated infections, and 114 (1.3%) could not be classified. In 2005, the standardized incidence rate of invasive MRSA was 31.8 per 100 000 (interval estimate, 24.4-35.2). Incidence rates were highest among persons 65 years and older, blacks and males. There were 1598 in-hospital deaths among patients with MRSA infection.

The true burden and risk of cholera: implications for prevention and control.
Zuckerman J.N., Rombo L., Fisch A. The Lancet Infectious Diseases 2007;7:521-30.
Cholera is a substantial health burden on the developing world. The exact scale of the problem is uncertain because of limitations in existing surveillance systems, differences in reporting procedures, and failure to report cholera to WHO; official figures are likely to greatly underestimate the true prevalence of the disease. We have identified, through extensive literature searches, additional outbreaks of cholera to those reported to WHO, many of which originated from the Indian subcontinent and southeast Asia.

Skin and soft tissue infections caused by methicillin-resistant Staphylococcus aureus USA300 clone. Johnson J.K., Khoie T., Shurland S., Kreisel K., Stine O.C., Roghmann M.C. Emerging Infectious Diseases 2007;13:1195-200.
MRSA infections and skin and soft tissue infections (SSTIs) were studies in outpatients receiving care at the Baltimore Veterans Care Service during 2001-2005. MRSA infections increased from 0.2 to 5.9 per 1,000 visits (>80% of MRSA infections were caused by USA300). SSTI visits increased from 20 to 61 per 1,000 visits (p<0.01). These increases in community-associated MRSA infections and SSTIs suggest that USA300 is becoming more virulent and has a greater propensity to cause SSTIs.

Methicillin-resistant Staphylococcus aureus in meat products, the Netherlands. van Loo I.H.M., Diederen B.M.W., Savelkoul P.H.M., et al. Emerging Infectious Diseases 2007;13
The authors investigated the extent of S. aureus presence in meat and found
36 S. aureus strains in 79 samples. Two meat samples (2.5%) contained MRSA. Furthermore, S. aureus is found regularly in low amounts in meat sold to consumers. This study demonstrates that MRSA has entered the food chain. As the amounts were very low, the pathogen is not likely to cause disease, especially if meat is properly prepared before consumption. However, contamination of food products may be a potential threat for the acquisition of MRSA by those who handle the food.

Irrigated urban vegetable production in Ghana: microbiological contamination in farms and markets and associated consumer risk groups. Amoah P., Drechsel P., Henseler M., Abaidoo R.C. Journal of Water and Health 2007;5:455-66.
Over 12 months, April 2004-June 2005, lettuce samples from the same production sites in 2 cities were followed and analyzed along the “farm to fork” pathway for total and faecal coliform (FC) and helminth egg numbers. Questionnaire surveys were conducted among producers, sellers and consumers. The study identified the farm as the main point of lettuce contamination. Besides the irrigation water, contamination was also attributed to manure application and already contaminated soil. Despite poor sanitary conditions in markets, post-harvest handling and marketing did not further increase the farm-gate contamination levels.

Occurrence of Escherichia coli O157 on hides of slaughtered cattle. Nastasijevic I., MitrovicR., Buncic S. Letters in Applied Microbiology 2007;46:126-31.
A total of 355 swabs were taken on the slaughterline from 5 areas of hide of each of 71 cattle in an abattoir in Serbia. E. coli O157 was isolated from the hides of 20 animals (28.2%). The occurrence of the pathogen was: hooves (11.3%), brisket (8.4%), rump (7.0%), neck (4.2) and flank (2.8%). Factors that had effects on the occurrence included visible dirtiness of the hide, cattle’s age category, geographical origin of the animals and season. This study confirmed the hide as an important potential source of related contamination of beef carcasses.

Pasteurella multocida meningitis: case report and review of the literature.
O’Neill E., Moloney A., Hickey M. Journal of Infection 2005;50:344-5.
Pasteurella multocida forms part of the normal flora in the nasopharynx of many domestic and wild animals. Most human P. multocida infections are soft tissue infections due to animal bites. P. multocida meningitis is a rare condition. The paper reports a case of P. multocida meningitis with a complicated outcome and review the literature of this condition.

Survey of Salmonella contamination of raw shell eggs used in catering premises in the UK. Health Protection Report 2007.
The Food Standards Agency (FSA) has published a survey of salmonella contamination in raw shell eggs used in catering premises in the UK November 2005 to December 2006, and was one of two surveys launched following an unusual number of SalmonellaEnteritidis outbreaks associated with the use of eggs in catering premises during 2002 to 2004. 9,528 eggs were collected from 1,567 catering premises. Salmonella was isolated from six pooled samples (0.38%) of eggs. Of these, five were SalmonellaEnteritidis (0.31%). The eggs were produced in eight European countries (France, Germany, Poland, Portugal, Republic of Ireland, Spain, The Netherlands, and the UK), with most (89%) originating from the UK.

Importance of the environment for patient acquisition of methicillin-resistant Staphylococcus aureus in the intensive care unit: A baseline study. Wilson A.P., Hayman S., Whitehouse T., et al. Critical Care Medicine 2007;35(10):2275-9.
This study assessed environmental contamination with MRSA in critical care and the likelihood of new patient acquisition if carriers were (or not) moved to single rooms; 2,436 samples were taken from environments around 114 patients, plus 349 samples from doctors’ hands and telephones. Of 47 bed areas where MRSA strains were identified that were not found initially on patients, only 1 patient subsequently acquired the same strain. Five other patients became colonized with new strains, but these were not found in their environment beforehand. Of 52 colonized patients, 34 had a similar strain found subsequently in their environment. It was concluded that whereas MRSA-colonized patients frequently contaminates their environment, transmission from the environment to the patient was not commonly identified.

Dampness and mold in the home and depression: an examination of mold-related illness and perceived control of one’s home as possible depression pathways. Shenassa E.D., Daskalakis C., Liebhaber A., Braubach M., Brown M.J. American Journal of Public Health 2007;97:1893-9.
Using survey data from 8 European cities the authors evaluated the association between residence in a damp and moldy dwelling and the risk of depression and investigated whether depression was mediated by perception of control over one’s home or mold-related physical illness. Dampness and mold were associated with depression, independent of individual and housing characteristics. This association was independently mediated by perception of control over one’s home and by physical health.

Nasal carriage of methicillin-resistant Staphylococcus aureus in medical students. Baliga S., Bansil R., Suchitra U., Bharati B., Vidyalakshmi K., Shenoy S. Journal of Hospital Infection 2007; 5 Dec.
A study was conducted to ascertain the nasal carriage of MRSA among 50 medical students in Kasturba Medical College, Mangalore posted in surgical wards, medical wards, ICU, postoperative wards and the microbiology laboratory. All 26 postgraduates (100%) and 18 undergraduates (75%) were colonised with S. aureus. Of these, only one undergraduate (4.16%) and 11 postgraduates (42.3%) were colonised with MRSA.

Methicillin-resistant Staphylococcus aureus carriage among district nurse patients and medical admissions in a UK district.
Thomas S., Karas J.A., Emery M., Clark G. Journal of Hospital Infection 2007;66:369-73.
The study was carried out in the medical assessment unit of the local hospital and district nurse patient (DNP) population in Huntingdonshire. In all, 162 participants were recruited. Factors found to be significantly associated with MRSA colonization were age (76.6 years), presence of wound/ulcer, hospital admission in the past year, past history of MRSA, and antibiotic use in the preceding 6 months. The only independent predictor for MRSA colonization was found to be past history of MRSA. The DNP population are a significant reservoir for MRSA in the community and policies on screening high-risk patients need to reflect this.

Community-associated methicillin-resistant Staphylococcus aureus prevalence: how common is it? A methodological comparison of prevalence ascertainment. Furaya E.Y., Cook H.A., Lee M,.H., et al. American Journal of Infection Control 2007;35:359-66.
Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infections are becoming increasingly prevalent. There is geographic variation in their reported prevalence across the United States; however, studies reporting on CA-MRSA prevalence also demonstrate great variability in their case-finding methodology. A comparison of three different methods to ascertain CA-MRSA prevalence revealed that variability in case-finding methodologies can lead to different prevalence estimates. Key factors to consider when comparing CA-MRSA rates include the definition of CA-MRSA, choice of denominator, and method and setting of sample collection.

Wastewater-irrigated vegetables: market handling versus irrigation water quality. Jeroen H., Ensink J., Mahmood T. Dalsgaard A. Tropical Medicine and International Health 2007;12(suppl 2):2-7.
Vegetables irrigated with untreated domestic wastewater were, at the time of harvest, analysed for the presence of the faecal indicator, Escherichia coli, and helminth eggs in Faisalabad, Pakistan. Vegetables from the same harvested batch were collected approximately 12 hours later from the local market. The results of the survey suggest that unhygienic post harvest handling was the major source of produce contamination. Interventions at the market, such as the provision of clean water to wash produce in, are better ways to protect public health and more cost effective than wastewater treatment.

Prevalence of Salmonella enterica serovars and genovars from chicken carcasses in slaughterhouses in Spain. Capita R., Alonso-Calleja C., Prieto M. Journal of Applied Microbiology 2007;103(5):1366-75.
A total of 336 chicken carcasses were collected from 6 slaughterhouses in Northwestern Spain. Salmonella were detected in 60 (17·9%) carcasses. Isolates belonged to 9 different serotypes, with Salmonella Enteritidis being the most common. Three strains (5%) were resistant to one antibiotic and 24 (40%) were multi-resistant. Salmonella serotypes and phage types detected are among those most frequently associated with human diseases in Spain. This study emphasizes the importance of controlling this pathogen in poultry products.

A new microbiological problem in intensive care units: environmental contamination by MRSA with reduced susceptibility to glycopeptides. Perdelli F., Dallera M., Cristina M.L., et al. International Journal of Hygiene and Environmental Health 2007; 23 Jul.
The study evaluated the percentage of MRSA strains with reduced susceptibility to glycopeptides in four intensive care units by environmental sampling of air and surfaces. Antibiograms revealed that 85.7% of all air samples were positive for MRSA, and that 64.3% of all the samples were heterogeneously resistant to glycopeptides. Methicillin resistance was recorded in 41.0% of surface samples, and 32.5% of all samples proved positive for hGISA.

The effect of humidity on the survival of MRSA on hard surfaces. Makison J., Swan J. Health & Safety Laboratory
The study measured the effect that different humidities potentially achievable on a hospital ward have on survival of MRSA on hard surfaces. The investigation revealed that surface type had a greater effect on the rate of reduction of MRSA than that of humidity and that different types of disinfectant/detergent appear to have different efficacies on different surface/material types. This report and the work it describes were undertaken by the UK Health and Safety laboratory of the Department of health.

Human noroviruses in swine and cattle. Mattison K., Shukla A., Cook A., et al. Emerging Infectious Diseases 2007;13(8):1184-8.
GIII (bovine), GII.18 (swine), and GII.4 (human) norovirus sequences, were isolated from animal faecal samples demonstrating that GII.4-like strains can be present in livestock. In addition, GII.4-like noroviral RNA was detected from a retail meat sample. This finding highlights a possible route for indirect zoonotic transmission of noroviruses through the food chain.

Physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review. Jefferson T., Foxlee R., Del Mar C., et al. British Medical Journal 2007; 27 Nov.
This paper describes a systematic review of evidence for the effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses. Of 2300 titles scanned 138 full papers were retrieved, including 49 papers of 51 studies. It was concluded that routine long term implementation of some physical measures to interrupt or reduce the spread of respiratory viruses might be difficult but many simple and low cost interventions could be useful in reducing the spread.

Environmental contamination with rhinovirus and transfer to fingers of healthy individuals by daily life activity. Winther B., McCue K., Ashe K., Rubino J.R., Hendley J.O. Journal of Medical Virology 2007;79:1606-10.
Fifteen adults with rhinovirus colds stayed overnight in a hotel. Ten touched sites in each room were tested for rhinovirus RNA. Transfer to fingertips of 5 subjects was examined by drying virus containing mucus from each subject onto light switches, telephone dial buttons and telephone handsets. After an interval of 1 or 18 hours the subject flipped the light switch, pressed the button, held the handset; 35% of the 150 sites in the rooms were contaminated. Common virus-positive sites were door handles, pens, light switches, TV remote controls, faucets, and telephones. Rhinovirus was transferred from surfaces to fingertips in 18/30 (60%) trials 1 hour after contamination and in 10/30 (33%) of trials 18 hours (overnight) after contamination.

“My five moments for hand hygiene”: a user-centred design approach to understand, train, monitor and report hand hygiene. Sax H., Allegranzi B., Larson E., Boyce J., Pittet D. Journal of Hospital Infection 2007;67:9-21.
The WHO Global Patient Safety Challenge “Clean Care is Safer Care” has developed educational and promotional tools using a user-centred design approach and incorporating strategies of human factors engineering, cognitive behaviour science and elements of social marketing. This has resulted in a concept called “My five moments for hand hygiene” which describes the moments when hand hygiene is required to effectively interrupt microbial transmission during the care sequence. “My five moments for hand hygiene” bridges the gap between scientific evidence and daily health practice and provides a basis to understand, teach, monitor and report hand hygiene practices.

A clarion call for greater investment in global sanitation. Durrhein D. Lancet 2007;370:1592-3.
Diarrhoeal disease continues to be a leading cause of death in developing countries, particularly affecting children in the first 5 years of life. The hindrance on global development resulting from inadequate sanitation is recognised in the MDGs, and a target to halve the proportion of people without access to basic sanitation by 2015 has been established. Although global sanitation coverage increased from 49% to 59% between 1990 and 2004, on the basis of current performance the shortfall will be almost 600 million people by the target date in 2015. The vigour with which other MDGs have been approached has not yet been mirrored in tackling the sanitation shortfall. Indeed, in sub-Saharan Africa the number of people with unsafe sanitation is increasing.

Severe case of invasive community-acquired methicillin-resistant Staphylococcus aureus infection in Norway. Heggelund L., Samdal H.H., Eggum R., Jacobsen T., Bruun T., Elstrøm P. Eurosurveillance 2007; vol 12, issue 11, 8 Nov.
In Norway the rate of MRSA colonisation and infection is low, but rapidly increasing. The proportion of severe invasive MRSA infections has remained low, and up to now all infections diagnosed outside hospitals have been non-severe skin and soft tissue infections. MRSA harbouring ST80, SCCmec IV and PVL are characteristic for community-acquired strains. This report describes, for the first time, a CA-MRSA strain with such properties causing a very severe invasive thoracic wall infection in Norway.

Public health measures in an influenza pandemic – the importance of surveillance. Nicoll A. Eurosurveillance 2007: vol 12, issue 11, 1 Nov.
One of the most controversial aspects of planning for a pandemic concerns public health measures that could reduce its impact. There are many measures it is proposed could be taken with the aim of pushing back the bulk of transmission towards the natural decline that occurs in the warmer summer months, and when specific pandemic vaccines become available. In Europe, it is unlikely that “one size will fit all” except for the few measures that are at the “relatively easy” (handwashing and personal respiratory hygiene) or “very difficult – don’t do it” (border closure) extremes. Even if simple solutions were possible, it is not in the mandate of the ECDC to prescribe policy. To inform discussions and decisions by member states and EU bodies, ECDC have published an interim Guide to Public Health Measures to Reduce the Impact of Influenza Pandemics during Phase 6 - “The ECDC Menu”. The primary intended audience is those who develop policy and decision makers, although secondary audiences are all those concerned with influenza, the public and the media.

Microbiologic evaluation of microfiber mops for surface disinfection. Rutala W.A., Gergen M.F., Webber D.J. American Journal of Infection Control 2007;35(9): 569-73.
The effectiveness of microfiber mops to reduce microbial levels on floors was investigated. We compared the efficacy of microfiber mops with that of conventional, cotton string mops in 3 test conditions (cotton mop and standard wringer bucket, microfiber mop and standard wringer bucket, microfiber system). The microfiber system demonstrated superior microbial removal compared with cotton string mops when used with a detergent cleaner. The use of a disinfectant did not improve the microbial elimination demonstrated by the microfiber system.

Effect of chlorhexidine and benzalkonium chloride on bacterial biofilm formation. Houari A., Di MartinoP. Letters in Applied Microbiology 2007;45:652-6.
The study showed that chlorhexidine and benzalkonium chloride inhibited biofilm formation of different bacterial species but were able to induce biofilm development for Staph. epidermidis at sub-MICs. The study suggests that sublethal exposure to cationic antiseptics may contribute to the persistence of staphylococci through biofilm induction.

Consumer antibacterial soaps: effective or just risky? Aiello A.E., Larson E.L., Levy S.B. Clinical Infectious Diseases 2007:45(suppl 2):S137-47.
This systematic literature review assessed studies that examined the efficacy of products containing triclosan, compared with that of plain soap, in the community setting, and evaluated findings of studies carried out to evaluate the emergence of antibiotic resistant bacteria associated with their use. The PubMed database was searched, using relevant keyword combinations, for articles published between 1980 and 2006; 27 studies were identified as being relevant to the review. Soaps containing triclosan within the range of concentrations commonly used in the community setting (0.1%-0.45% wt/vol) were no more effective than plain soap at preventing infectious illness symptoms and reducing bacterial levels on the hands. The authors concluded that several laboratory studies demonstrated evidence of triclosan-adapted cross resistance to antibiotics.

Effect of city-wide sanitation programme on reduction in rate of childhood diarrhoea in northeast Brazil: assessment by two cohort studies. Barreto M.L., Genser B., Strina A., et al. Lancet 2007;370:1622-8.
A city-wide sanitation intervention was started in Salvador, Brazil, in 1997 to improve sewerage coverage from 26% of households to 80%. The aim was to investigate the epidemiological effect of this city-wide sanitation programme on diarrhoea morbidity in children less than 3 years of age. Diarrhoea prevalence fell by 21% (95% CI 18-25%) - from 9.2 (9.0-9.5) days per child-year before the intervention to 7.3 (7.0-7.5) days per child-year afterwards. After adjustment for baseline sewerage coverage and potential confounding variables, overall prevalence reduction was estimated as 22% (19-26%).

The effectiveness of existing and modified cleaning regimens in a Welsh hospital.
Griffith C.J., Obee P., Cooper R.A., Burton N.F., Lewis M. Journal of Hospital Infection 2007;66:352-9.
The effectiveness of an existing ward-cleaning regimen was assessed at selected sites over 14 days and shown to be highly variable. The cleaning regimen was subsequently modified in two stages, both changes involving a rinse stage and substituting cloths with disposable paper towels. One modification continued using the existing detergent; the other replaced detergent with a quaternary ammonium sanitiser. Both modifications yielded significantly lower and more consistent bacterial counts. Assessment of residual organic soil using ATP detection demonstrated that failure rates (measurements exceeding benchmark clean value of 500 relative light units fell from 86-100% after existing cleaning methods, to 0-14% after modified cleaning. Incorporating quaternary ammonium sanitiser into the cleaning regimen produced a further slight, but not significant, improvement in cleaning efficacy.

Importance of the environment in methicillin-resistant Staphylococcus aureus acquisition: the case for hospital cleaning. Dancer S.J. Lancet 2007; 369:442-3.
In the UK, we continue to debate the importance of hospital cleaning in relation to increasing numbers of patients acquiring methicillin-resistant MRSA. However, there is little direct evidence for the effectiveness of cleaning because it has never been afforded scientific status. This detailed review of the evidence which shows why removal of dirt might have more impact on the control of MRSA than previously thought.

Environmental decontamination with hydrogen peroxide vapor (HPV) in the control of an MRSA outbreak. Otter J. Abstracts of the International Conference on Antimicrobial Agents and Chemotherapy, K-464.
Following a UK hospital outbreak of MRSA, where it was not possible to empty the ward, the ward was decontaminated using HPV in sequential clinical areas and assessed the level of environmental contamination before and after. Weekly swabbing was then carried out to examine the rate of recontamination and monitored patient infection by admission and discharge screening over four weeks. There was a sustained environmental impact and no patients acquired MRSA for the 4 weeks after HPV. The authors found a fairly high staff carriage rate and conducted patient and staff decolonization in addition to the HPV decontamination and other infection control measures so were not able to conclude which was the most important intervention.

After the flood: an evaluation of in-home drinking water treatment with combined flocculent-disinfectant following Tropical Storm Jeanne – Gonaives, Haiti, 2004. Colindres R.E., Jain S., Bowen A., Mintz E., Domond P. Journal of Water and Health 5(3):367-74.
During a tropical Storm in Haiti in September 2004 local leaders distributed PūR^®, a flocculent-disinfectant product for household water treatment, to affected populations. Knowledge, attitudes, practices, and drinking water quality was evaluated. After distribution, PūR^® was the most common in-home treatment method (58%) followed by chlorination (30%), plant-based flocculation (6%), boiling (5%), and filtration (1%). Although water sources tested appeared clear, fecal coliform bacteria were detected in all sources (range 1 - >200 cfu/100 ml). Chlorine was present in 10 (45%) of 22 stored drinking water samples in households using PūR^®.

New water disinfection system using UVA light-emitting diodes.
Hamamoto A., Mori M., Takahashi A., et al. Journal of Applied Microbiology 2007;2291-8.
This study evaluated a new disinfection device equipped with high-energy UVA-LED. Vibrio parahaemolyticus, enteropathogenic Escherichia coli, Staphylococcus aureus and Escherichia coli DH5α were reduced by greater than 5-log₁₀ stages within 75 min at 315 J cm² of UVA. Salmonellaenteritidis was reduced greater than 4-log₁₀ stages within 160 min at 672 J cm² of UVA.

Inactivation of Bacillus anthracis spores by liquid biocides in the presence of food residue. Hilgren J., Swanson K.M., Diez-Gonzalez F., Cords B. Applied Environmental Microbiology 2007;73:6370-7.
Biocide inactivation of Bacillus anthracis spores in the presence of food residues after a 10 minute treatment time was investigated. Inoculated carriers were exposed to various concentrations of peroxyacetic acid, sodium hypochlorite (NaOCl) or hydrogen peroxide (H2O2) for 10 minutes. This research provides new information regarding the usefulness of peroxygen biocides for B. anthracis spore inactivation when food residue is present. This work also provides guidance for adjusting decontamination procedures for food-soiled and cold surfaces.

Outbreak management and implications of a nosocomial norovirus outbreak.
Johnston CP, Qiu H, Ticehurst JR, et al. Clinical Infectious Diseases 2007;45(5):534-40.
The study identified 355 cases that affected 90 patients and 265 healthcare workers and that were clustered in the coronary care unit and psychiatry units. Attack rates were 5.3% (7 of 133) for patients and 29.9% (29 of 97) for healthcare workers in the coronary care unit and 16.7% (39 of 233) for patients and 38.0% (76 of 200) for healthcare workers in the psychiatry units. Aggressive infection-control measures, including closure of units and thorough disinfection using sodium hypochlorite, were required to terminate the outbreak. Costs associated with this outbreak were estimated to be $657,644. The authors conclude that the significant disruption of patient care and cost of the outbreak support aggressive efforts to prevent transmission of noroviruses in health care settings.

Hand washing: changes in the skin flora. Gerais M. American Journal of Infection Control 2007;35:417-20.
Frequent hand washing may result in skin damage and increase the number of microorganisms that colonize the skin. The purpose of this study was to evaluate changes in total flora of healthy and damaged hands that were caused by the use of gloves, soap, and antiseptics. Damaged or healthy hands did not present statistically significant differences (p>.05) in terms of qualitative analysis of epidemiologically important microorganisms; however, washing with water and soap was effective only for healthy hands.

Early communication: does a national campaign to improve hand hygiene in the NHS work? Initial English and Welsh experience from the NOSEC study (National Observational Study to Evaluate the CleanYourHandsCampaign). Gould D.J., Hewitt-Taylor J., Drey N.S., Gammon J., Chudleigh J., Weinberg J.R. Journal of Hospital Infection 2007;66:293-6.
The NPSA “CleanYour HandsCampaign” seeks to improve healthcare workers’ hand-hygiene behaviour and was rolled out to 187 hospitals between December 2004 and June 2005.It consists of provision of “near-patient alcohol hand rub at the bedside”, “talking walls” (posters on each ward changed every month) and “patient empowerment” (materials telling patients to ask HCWs to clean their hands). The aims of the NOSEC study are to determine whether the campaign is implemented successfully and sustained, whether it results in increased hand hygiene, and to document changes in healthcare-associated infection rates. This communication reports on changes in soap and AHR use and HCAI rates in the baseline and roll out phases, and on implementation of main CYHC components at 6 and 12 months post roll out.

Is an increase of MRSA in Oslo, Norway, associated with changed infection control policy? Andersen B.M., Rasch M.,Syversen G. Journal of Infection 2007;55(6):531-8.
During 1993-2006, 358 MRSA cases were registered in Oslo; 43.9% detected in Ullevål University Hospital, 21.2% in nursing homes, and 18.7% in primary healthcare. One out of three (30.4%) were import-associated, and one out of 10 (11.2%) were healthcare personnel. From 2004 on, a new National MRSA Control Guideline was introduced in primary healthcare, served by the community infection control. From 2004 on, there was a 4-6-fold increase of MRSA in primary healthcare and nursing homes. Increase of MRSA cases at Ullevål was import-associated or from outbreaks in primary healthcare. Th