Chills and vomiting have traditionally been associated with severe bacterial infections and bacteremia. However, few modern studies have in a prospective way evaluated the association of these signs with bacteremia, which is the aim of this prospective, multicenter study. Patients presenting to the emergency department with at least one affected vital sign (increased respiratory rate, increased heart rate, altered mental status, decreased blood pressure or decreased oxygen saturation) were included. A total of 479 patients were prospectively enrolled. Blood cultures were obtained from 197 patients. Of the 32 patients with a positive blood culture 11 patients (34%) had experienced shaking chills compared with 23 (14%) of the 165 patients with a negative blood culture, P = 0.009. A logistic regression was fitted to show the estimated odds ratio (OR) for a positive blood culture according to shaking chills. In a univariate model shaking chills had an OR of 3.23 (95% CI 1.35–7.52) and in a multivariate model the OR was 5.9 (95% CI 2.05–17.17) for those without prior antibiotics adjusted for age, sex, and prior antibiotics. The presence of vomiting was also addressed, but neither a univariate nor a multivariate logistic regression showed any association between vomiting and bacteremia. In conclusion, among patients at the emergency department with at least one affected vital sign, shaking chills but not vomiting were associated with bacteremia.

Topical medicaments used in the treatment and prevention of pressure sores in patients in three hospitals were examined for Pseudomonas aeruginosa and Staphylococcus aureus contamination. Contamination rates were found to vary between hospitals and were affected by differences in the packaging of the product and in the method of application used by the nursing staff.

1. Experience of 4½ years of intravenously administered scarlatinal antitoxin, in 1204 cases, confirms the tentative conclusions reached in 1928, viz. that the acute stage of the disease can generally be arrested in 12–24 hours, complications almost wholly prevented, and the period of morbidity reduced to a little over a fortnight.

2. These effects were obtained in hospital wards where over 50 per cent, of the cases, generally about 75 per cent, and including all the worst, were so treated, and it is possible that the reduction of mass infection obtained in the wards by this means is an essential condition for obtaining such results. Under such conditions relapses and cross-infections were very rare.

3. Some evidence was obtained that intravenous antitoxin administered in the acute stage of scarlet fever largely prevents the onset of septic complications, including the late septic type itself, scarlatina anginosa; and that it may be of striking benefit in the treatment of the septic type, even at a late stage.

4. The importance of proved clinical potency and freedom from dangerous reactions of each individual batch of serum to be employed, is stressed.

5. Indications and contra-indications are stated.

6. Certain precautions and details of technique are recommended.

(1) The antiseptic and bactericidal properties of Flavines and Brilliant Green. Extended investigations have confirmed the original values. It has been shown that the inferior potencies recorded by certain other workers depend on the use of methods unsuited for the observation of antiseptic properties, i.e. they fail to detect inhibition of bacterial activity i.e. bacteriostatic action, which is exhibited to a marked degree by flavine and brilliant green.

(2) For the therapy of a local bacterial infection, as in a wound, such bacteriostatic action is of great value. It is not essential that the chemical agent should by itself actually kill the organisms. Highly successful results can be obtained by a co-operation of the antiseptic and the tissues, so that the pathogenic action of the organisms is restrained. The flavines in virtue of their low toxicity to mammalian tissues and their high bacteriostatic power are therefore specially suited to act as local therapeutic agents. In addition, the fact that they are not neutralised by admixture with serum enables them to be applied clinically by a relatively simple method which does not necessitate frequent renewal.

(3) The “fundamental error” to which the method of testing chlorine antiseptics originally practised by Dakin, is liable, and which Dakin and Dunham have drawn attention to, has been shown not to affect our previous results with Chloramine-T. The difference between our values and the others is due to the fact that we employed 80 per cent. serum in the test.medium, which is much more active in neutralising this antiseptic than is 33 to 50 per cent. serum employed by Dakin and his co-workers.

The distribution of phage types was studied among 577 strains of Salmonella typhi from Indonesia. Chemotype, colicinogeny, and tetrathionate reductase activity were also studied for most of these strains. The current phage type formula for Java was determined to be: A, D2, D6, E1a, E2, M1, and 46, but two other large groups of strains were also found, I +IV and degraded Vi + strains. Significant differences in S. typhi strain distributions were noted between two localities on Java with respect to phage type and tetrathionate reductase activity. Comparisons were made with past phage typing studies in Jakarta as well as with more recent studies in other parts of south-east Asia. Phage types A, Dl, D2, and El persisted at a rather steady level in Jakarta for 28 years. Evidence was found for epidemiological links to European and Asian areas. Antibiotic resistance among these Indonesian S. typhi strains was rare.

Genetic polymorphisms of the LMP/TAP gene coded by the HLA-II region may be associated with outcomes of HBV infection. We conducted a case-control study to test the hypothesis, including a persistent group of 155 patients with chronic hepatitis B and 36 healthy carriers, a recovered group of 165 individuals spontaneously recovered from HBV infection, and an uninfected group of 278 healthy normal controls. Genotypes of eight polymorphisms of the LMP/TAP gene were analysed by PCR–RFLP. A logistic regression model was used to analyse statistical differences in polymorphisms or haplotypes in different groups. Of the eight polymorphisms, two (TAP1 codon 637 and LMP7 codon 145) were observed to have statistically significant association with outcomes of HBV infection (P<0·05). The two-locus haplotype constructed with two such polymorphisms was analysed. The frequencies of haplotypes B (Asp-Lys), C (Gly-Gln), and D (Gly-Lys) were found to be increased significantly in the persistent group, compared to healthy controls (OR 2·26, 95% CI 1·62–3·15, P<0·001; OR 2·37, 95% CI 1·69–3·32, P<0·001; OR 4·38, 95% CI 1·78–10·77, P=0·001, respectively). The prevalence of haplotypes B (Asp-Lys), C (Gly-Gln), and D (Gly-Lys) were also significantly higher in the persistent infectious group than in the recovered group (OR 2·68, 95% CI 1·81–3·98, P<0·001; OR 2·40, 95% CI 1·62–3·55, P<0·001; OR 3·03, 95% CI 1·22–7·55, P=0·017, respectively). These findings indicated that genetic polymorphisms of the LMP/TAP gene might be an important factor in determining the outcome of HBV infection.

Outbreaks of infectious intestinal disease are common in schools. Case control studies are useful in the investigation of infectious disease outbreaks but the time interval between illness and investigation can lead to recall bias, particularly in young children. We describe an outbreak of Salmonella enteritidis phage type 34a infection involving 54 clinical cases in two adjacent schools, and a novel approach to overcome recall bias. The likely dates of infection were identified from the epidemic curve. We created a visual display of the menu from those days and asked 9 cases and 18 matched controls to identify their food preferences from this display. Preference for chocolate mouse was significantly associated with illness (P = 0.006). The results of the case control study agreed with the findings of the environmental investigation. We believe our approach could be used in other circumstances, where subjects are young children or recall bias is a concern.

1. Of 318 Polish refugees now living in this country 30% gave a history of typhus fever; nearly half of these had complement-fixing antibodies to a titre of 1–5 or more to epidemic typhus. A further 12% without such a history similarly had these antibodies making a total of 22% of 318 refugees. None of the 174 British born controls had antibodies up to this titre.

2. Brill-Zinsser disease may occur from time to time among immigrants or visitors from typhus endemic areas to this country, but it is unlikely to be a serious problem.

3. The clinical diagnosis of Brill-Zinsser disease may not be easy because the characteristic rash is not always to be seen. Any patient of Eastern European origin or who has a history of typhus complaining of fever and severe headache should be examined serologically by the rickettsial agglutination or the complement-fixation test for specific epidemic typhus antibodies. The Weil-Felix reaction may be positive, but a negative result will not exclude a diagnosis of Brill-Zinsser disease.

We acknowledge with gratitude the help, interest and advice of Dr E. S. Murray, of the School of Public Health, Harvard University and Dr Janet Niven and also the technical assistance of Mr J. P. Brooks, FIMLT. We have to thank Messrs Lederle for their kindness in supplying the rickettsial antigens and in addition those who helped us to obtain the specimens and the volunteers who supplied them.

Several epidemiological studies suggest a possible involvement of viral infection in the development of epilepsy. While recent research from in vitro studies increasingly supports the role of herpes simplex virus type 1 (HSV-1) in the pathogenesis of epilepsy, little is known about the role of other viral infections such as influenza. Using data from the Clinical Practice Research Datalink (CPRD), we conducted a matched case-control analysis to assess the association between GP-diagnosed influenza infections and the risk of developing an incident diagnosis of epilepsy. During the study period 11 244 incident epilepsy cases and 44 976 matched control patients were identified. Prior exposure to influenza was reported in 7·5% of epilepsy cases and 6·7% of controls [adjusted odds ratio (aOR) 1·12, 95% confidence interval (CI) 1·03–1·22]. Prior history of ‘complicated influenza’, i.e. influenza associated with a possible super-infection, was associated with a slightly increased epilepsy risk (aOR 1·64, 95% CI 1·10–2·46), particularly if recorded within the 2 months preceding the epilepsy diagnosis (aOR 6·03, 95% CI 1·10–33·2). Our findings suggest that prior influenza exposure does not appear to materially alter the risk of developing epilepsy. By contrast, influenza episodes accompanied by complications were associated with a slightly increased epilepsy risk.

The purpose of these papers was:

(i) To ascertain the standardized death-rates for tuberculosis among the urban Chinese of Hong Kong.

(ii) To review the more important articles dealing with tuberculosis among the chinese.

(iii) To compare the data obtained in (ii) with those found in this survey of urban Chinese in Hong Kong.

Transmission of hepatitis C (HCV) in Pakistan is a continuing public health problem; 15 years ago it was linked to the practice of reusing therapeutic instruments in healthcare settings. We sought to examine current risk factors for HCV transmission in a hospital population in Karachi, Pakistan. We enrolled 300 laboratory-confirmed HCV-positive participants and 300 laboratory-confirmed HCV-negative participants from clinics at Indus Hospital. Independent and significant risk factors for both men and women were: receiving ⩾12 injections in the past year, blood transfusions, having had dental work performed, and delivery in hospital or transfusion for women. Interestingly, being of Mohajir origin or born in Sindh province were protective. Encouragingly, a strong protective effect was observed for those that reported bringing their own needle for injections (59%). The widespread reuse of therapeutic needles in healthcare settings in Karachi remains a major driver of the HCV epidemic.

Prevention of secondary household transmission of Shiga toxin-producing Escherichia coli (STEC) is important in outbreak settings. We examined factors contributing to secondary household transmission during STEC outbreaks in daycare centres in Japan. Suspected STEC outbreaks in daycare centres were identified by the National Epidemiological Surveillance of Infectious Diseases. Questionnaires were sent to local health centres that responded to outbreaks. Secondary household transmission rates were calculated, and factors affecting secondary household transmission rate were analysed by multilevel analysis. The secondary household transmission rates in 16 outbreaks ranged from 0% to 34·4% (median 4·4%). The highest rate (23·0%) was observed in siblings aged 6–9 years, and the infection rate was significantly higher for mothers than for fathers and grandparents (P < 0·05). Using multilevel analysis, the following variables were selected in the best model: information provided face-to-face (vs. letter or telephone) to families of children in daycare centres (at initial response), STEC type and lag time (days) between onset and providing information. Early response and hygiene education by visiting local health centre staff may be effective measures to prevent secondary household transmission in STEC outbreaks. Hygiene education should be emphasized for children aged 6–9 years, as well as for younger children.

In this outbreak of diphtheria certain individuals suffered from diphtheria, and others from sore throat probably diphtheritic. These individuals obtained their milk supply from two cows. Members of one household who did not drink milk, or who used it only after sterilisation, escaped infection. The cows yielding the milk were found to be suffering from an eruptive disease of the udder, and both from the lesions and from the milk cultures of virulent diphtheria bacilli were isolated. The pathological condition in the cows preceded, by a short interval, the onset of the disease in the patients. Having regard to Power's epidemiological investigations, and to Klein's experimental work, this observation was of the greatest interest and naturally suggested the hypothesis that the lesions were due, primarily, to a specific diphtheritic infection of the cow. Further investigations weakened this view, for it must be noted:—

(1) That in a cow intentionally submitted to infection from the diseased cows and in which there occurred the eruptive condition of the udder, neither in the vesicular nor in the ulcerative stage of the disease could diphtheria bacilli be demonstrated.

(2) That in calves infected with the eruptive disease no diphtheria bacilli could be demonstrated.

(3) That in a calf, in spite of the fact that it had received 10, 000 units of diphtheria antitoxin, the vesicular eruption was experimentally produced. The last is probably the strongest point in support of the dual nature of the condition in the cows.

It is conceivable that pathological lesions in the cow such as those described, if infected with the diphtheria bacillus, might form a suitable nidus for its growth and permit of the infection of large quantities of milk over a considerable period. Though we have as yet no evidence on the subject it is possible that a profound change in the virulence of the diphtheria bacillus for the human subject might be effected by such passage through the cow1.

The disgusting habit the milkers in this part of England have, of spitting on their hands before milking, would easily account for the infection of the lesions, even in the absence of obvious diphtheria in the cowman; knowing, as we now do, that apparently healthy individuals are not uncommonly the hosts of the diphtheria bacillus.

The experiments made with the view of ascertaining whether the eruptive condition was genuine cowpox, are opposed to that view; for two calves, and one cow successfully infected with the eruptive condition and subsequently vaccinated with vaccine lymph, developed a typical vaccinia.

The somewhat limited time and material available have prevented us from investigating the matter so fully as we should have wished, or on a scale proportionate to its interest and practical importance. We hope at some future time to go further into the matter.

Our best thanks are due to Mr Sidney Villar, F.R.C.V.S., for bringing the outbreak to our notice, and for his help in the veterinary side of the question; and to Dr Carson Smyth for his kindness in allowing us facilities for taking cultures from the throats of his patients.

A cold-adapted influenza A virus, CR-37 (H1N1), derived from genetic reassortment between A/Ann Arbor/6/60 (H2N2) cold-adapted variant virus and A/California/10/78 (H1N1) wild-type virus, was tested in Japanese adult volunteers. The CR-37 live virus preparation induced only low-grade clinical reactionsin volunteers for the first 3–4 days after inoculation. Two vaccinees who did not show any antibody changes became febrile (over 38–0 °C). Skin tests using the vaccine preparation and uninfected allantoic fluid were performed, and indicated that one of these two vaccinees was positive for the CR-37 vaccine preparation. A high proportion of the vaccinees whose sera had a haemagglutination-inhibition (HI) antibody titre against thevaccine strain of ≤ 64 before inoculation, seroconverted in both HI and neuraminidase-inhibition (NA1) antibody titrations, and only a few seroconverted in the titration of antibody against type-specific internal antigens. The serological examinations against heterotypic H1N1 variants indicated that the cold-adapted live influenza virus vaccine could induce a broad spectrum of HI antibody reactivity and immunity of long duration.

A retrospective cohort study was conducted from 1 January 2006 to 31 December 2009 in Michigan to estimate the prevalence of HIV and hepatitis co-infection and identify associated factors. The prevalence of co-infection was 4·1% [95% confidence interval (CI) 3·8–4·5]. Multivariable logistic regression analysis revealed a significant association between co-infection and being male and: of Black race [odds ratio (OR) 2·0, 95% CI 1·2–3·6] and of Other race (OR 3·5, 95% CI 1·7–7·0) compared to Hispanic race. A significant association was found between co-infection and risk categories of blood products (OR 11·1, 95% CI 6·2–20·2), injecting drug user (IDU) (OR 3·6, 95% CI 2·7–4·8) and men who have sex with men/IDU (OR 3·4, 95% CI 2·4–4·9) in addition to two interactions; one between sex and current HIV status and the other between current HIV status and age at HIV diagnosis. Our results document the changing epidemiology of HIV–hepatitis co-infection which can guide preventive measures and interventions to reduce the prevalence of hepatitis co-infection.

In a recent publication1 I described a gas analysis apparatus suitable for rapid and accurate laboratory work. This apparatus is, however, somewhat cumbrous, and cannot easily be conveyed from place to place, as is very often required in investigations relating to questions of hygiene. It also occupies a good deal of working space in a laboratory, as it cannot be moved from its place without a good deal of trouble. On the other hand the already existing forms of portable gas analysis apparatus for technical work are too inaccurate for many of the requirements of work in hygiene and physiology. I have therefore designed an apparatus with a view to meeting these defects as far as possible2.

Staphylococci from 22 cases of toxic shock syndrome with onsets between 1981 and March 1983 have been studied. Another four cases were detected by abstract surveillance. Three of these patients died. The case histories show that the syndrome occurs in women during menstruation as well as in males and in children, and is associated with Staphylococcus aureus infections.

The production of enterotoxins (A, B, C) and toxic shock toxin by S. aureus isolates from toxic shock syndrome was investigated. Twenty-two of the 23 isolates were found to be toxigenie: 7 produced enterotoxin A, 8 produced enterotoxin B, 3 produced enterotoxin C and 13 produced toxic shock toxin. The latter was found with enterotoxin A in five cases, and with enterotoxins A and B in only one case.

Sixty-three percent of 40 S. aureus strains isolated from the vagina of patients with diseases other than toxic shock syndrome produced toxin; eight of these strains produced toxic shock toxin.

Varicella is a common and highly contagious childhood disease which impacts the public worldwide. Hong Kong children can only be vaccinated against the disease in private practice. The varicella vaccination rate of local children in preschool is uncertain. Therefore a cross-sectional kindergarten-based parent-administered questionnaire survey was conducted in Hong Kong during 2012. Twelve kindergartens were randomly selected from a complete school list from the Education Bureau of Hong Kong. In total, 1285/1538 (83·6%) parents consented to join the study and completed the questionnaires. The overall varicella infection rate was 19·5% and the uptake of varicella vaccination rate was 57·6%. Barriers against varicella vaccination were mostly due to parental uncertainties about the effectiveness of vaccine, lack of recommendations from doctors or government, and adverse side-effects of the vaccine. The government and healthcare professional bodies are strongly recommended to further enhance health education among healthcare professionals, encouraging their active promotion of varicella vaccination for their patients. Furthermore, health education through various stakeholders is crucial to enhance parental awareness of varicella, as well as the effectiveness and safety of varicella vaccine.

In all countries which make statistical returns, attention has been directed to the large proportion of children failing to complete one year of life. Even the most highly civilised races lose in this way more than ten per cent, of their potential citizens as will appear from the data contained in the following table (Deutsche Sterbetafeln, 1910).

Co-receptor tropism has been identified to correlate with HIV-1 transmission and the disease progression in patients. A molecular epidemiology investigation of co-receptor tropism is important for clinical practice and effective control of HIV-1. In this study, we investigated the co-receptor tropism on HIV-1 variants of 85 antiretroviral-naive patients with Geno2pheno algorithm at a false-positive rate of 10%. Our data showed that a majority of the subjects harboured the CCR5-tropic virus (81.2%, 69/85). No significant differences in gender, age, baseline CD4+ T-cell counts and transmission routes were observed between subjects infected with CXCR4-tropic or CCR5-tropic virus. The co-receptor tropism appeared to be associated with the virus genotype; a significantly more CXCR4-use was predicted in CRF01_AE infections whereas all CRF07_BC and CRF08_BC were predicted to use CCR5 co-receptor. Sequences analysis of V3 revealed a higher median net charge in the CXCR4 viruses over CCR5 viruses (4.0 vs. 3.0, P < 0.05). The predicted N-linked glycosylation site between amino acids 6 and 8 in the V3 region was conserved in CCR5 viruses, but not in CXCR4 viruses. Besides, variable crown motifs were observed in both CCR5 and CXCR4 viruses, of which the most prevalent motif GPGQ existed in both viral tropism and almost all genotypes identified in this study except subtype B. These findings may offer important implications for clinical practice and enhance our understanding of HIV-1 biology.