It is more than 25 years since the first case of AIDS was reported in the United Kingdom. In December 1981 a gay man was referred to a London hospital with opportunistic infections indicative of immunosuppression. National surveillance began the following year, in September 1982, with the notification of deaths and clinical reports of AIDS and Kaposi's sarcoma plus laboratory reports of opportunistic infections. Since then epidemiological surveillance systems have evolved, adapting to, and taking advantage of advances in treatments and laboratory techniques. The introduction of the HIV antibody test in 1984 led to the reporting of HIV-positive tests by laboratories and the establishment of an unlinked anonymous survey in 1990 measuring undiagnosed HIV infection among gay men attending sexual health clinics. The widespread use of highly active antiretroviral therapies (HAART) since 1996 has averted many deaths among HIV-positive gay men and has also resulted in a large reduction in AIDS cases. This led to a need for an enumeration of gay men with HIV accessing NHS treatment and care services (1995 onwards), more clinical information on HIV diagnoses for epidemiological surveillance (2000 onwards) and the routine monitoring of drug resistance (2001 onwards). Twenty-five years after the first case of AIDS was reported, gay and bisexual men remain the group at greatest risk of acquiring HIV in the United Kingdom. Latest estimates suggest that in 2004, 26 500 gay and bisexual men were living with HIV in the United Kingdom, a quarter of whom were undiagnosed. In this review, we examine how national surveillance systems have evolved over the past 25 years in response to the changing epidemiology of HIV/AIDS among gay and bisexual men in the United Kingdom as well as advances in laboratory techniques and medical treatments. We also reflect on how they will need to continue evolving to effectively inform health policy in the future.

The efforts of the Metropolitan Asylums Board in Victorian London to isolate cases of smallpox in hospitals, and so limit its spread, set off a controversy about ‘hospital influence’, i.e. alleged escapes of the disease into the neighbourhood. When, in 1870, the Board began to gather cases of smallpox into its new intra-urban isolation hospitals, nearby householders resisted, and in 1881 their fear of aerial transmission was endorsed by a government medical inspector, W. H. Power. Not all agreed with Power, but as a result from 1885 the Board removed almost all known cases of smallpox in London to hospital ships moored in the Thames Estuary. The ships failed to provide adequate and secure accommodation, however, and so Board smallpox hospitals were erected on the adjacent Dartford marshes. After 1903, there being no more smallpox epidemics in Britain, these isolation hospitals and many similar ones outside other towns and cities were little used for their main intended purpose. Their retention for many years thereafter can be seen as an application of the precautionary principle; it bears on current contingency plans in Britain and elsewhere for dealing with serious epidemics.

Enterotoxigenic Escherichia coli (ETEC) is a common cause of profuse watery diarrhoea in the developing world, often leading to severe dehydration or death. We found only 15 population-based studies in low and medium human development index (HDI) countries from 1984 to 2005 that evaluate disease incidence. Reported incidence ranged from 39 to 4460 infections/1000 persons per year. The peak incidence of ETEC appeared to occur between ages 6 and 18 months. A median of 14% (range 2–36%) of diarrhoeal specimens were positive for ETEC in 19 facility- and population-based studies conducted in all age groups and 13% (range 3–39%) in 51 studies conducted in children only. Heat-labile toxin (LT)-ETEC is thought to be less likely to cause disease than heat-stable toxin (ST)-ETEC or LT/ST-ETEC. Because population-based studies involve enhanced clinical management of patients and facility-based studies include only the most severe illnesses, reliable data on complications and mortality from ETEC infections was unavailable. To reduce gaps in the current understanding of ETEC incidence, complications and mortality, large population-based studies combined with facility-based studies covering a majority of the corresponding population are needed, especially in low-HDI countries. Moreover, a standard molecular definition of ETEC infection is needed to be able to compare results across study sites.

On 9 June 2006 the Pan American Health Organization (PAHO) presented the Minister of Health of Brazil with the International Elimination of Transmission of Chagas' Disease Certificate. This act was the culmination of an intensive process that began in 1991 with the Southern Cone Initiative, a joint agreement between the governments of Argentina, Bolivia, Brazil, Chile, Paraguay, Uruguay and Peru, to control Chagas' disease by the elimination of the main vector, Triatoma infestans. This initiative has been highly successful and the prevalence area of the vector diminished rapidly in the last years. As a consequence, the current seroprevalence in children aged between 0 and 5 years is of the order of 10−5, a clear indication that transmission, if it is occurring, is only accidental. In this review I calculate the basic reproduction number, R0, for Chagas' disease and demonstrate that its relatively low value (1·25) explains why vectorial transmission was interrupted relatively easily. In addition, I used a mathematical model to forecast how long the remaining cases of the disease, as well as the additional vertically transmitted cases will last.

Mathematical modelling of infectious diseases has gradually become part of public health decision-making in recent years. However, the developing status of modelling in epidemiology and its relationship with other relevant scientific approaches have never been assessed quantitatively. Herein, using antibiotic resistance as a case study, 60 published models were analysed. Their interactions with other scientific fields are reported and their citation impact evaluated, as well as temporal trends. The yearly number of antibiotic resistance modelling publications increased significantly between 1990 and 2006. This rise cannot be explained by the surge of interest in resistance phenomena alone. Moreover, modelling articles are, on average, among the most frequently cited third of articles from the journal in which they were published. The results of this analysis, which might be applicable to other emerging public health problems, demonstrate the growing interest in mathematical modelling approaches to evaluate antibiotic resistance.

It is generally accepted that Professor Ignaz Semmelweis was the first to identify the mode of transmission of puerperal sepsis. However no appropriate statistical analysis of Semmelweis's data supporting his theory has been reported. Mean annual percent maternal mortality rates for the Allgemeines Krankenhaus and Dublin Maternity Hospitals (1784–1858) were analysed. The introduction of pathological anatomy at the Allgemeines Krankenhaus in 1823 was associated with increased mortality. After 1840 maternal mortality was higher in Clinic 1 which was staffed by male obstetricians and medical students who, unlike the midwives in Clinic 2, attended autopsies. The introduction of chlorine washing of the male clinicians’ hands in Clinic 1 by Semmelweis in 1847 reduced mortality, whereas the cessation of handwashing after Semmelweis left Vienna in 1850 was associated with increased mortality. This statistical analysis supports Semmelweis's hypothesis that ‘the cadaveric particles adhering to the hand had … caused the preponderant mortality in the first Clinic’.

There has been increasing concern regarding the rise of Acinetobacter infections in critically ill patients. We extracted information regarding the relative frequency of Acinetobacter pneumonia and bacteraemia in intensive-care-unit (ICU) patients and the antimicrobial resistance of Acinetobacter isolates from studies identified in electronic databases. Acinetobacter infections most frequently involve the respiratory tract of intubated patients and Acinetobacter pneumonia has been more common in critically ill patients in Asian (range 4–44%) and European (0–35%) hospitals than in United States hospitals (6–11%). There is also a gradient in Europe regarding the proportion of ICU-acquired pneumonias caused by Acinetobacter with low numbers in Scandinavia, and gradually rising in Central and Southern Europe. A higher proportion of Acinetobacter isolates were resistant to aminoglycosides and piperacillin/tazobactam in Asian and European countries than in the United States. The data suggest that Acinetobacter infections are a growing threat affecting a considerable proportion of critically ill patients, especially in Asia and Europe.

The global incidence of Shigella infection has been estimated at 80–165 million episodes annually, with 99% of episodes occurring in the developing world. To identify contemporary gaps in the understanding of the global epidemiology of shigellosis, we conducted a review of the English-language scientific literature from 1984 to 2005, restricting the search to low and medium human development countries. Our review yielded 11 population-based studies of Shigella burden from seven countries. No population-based studies have been conducted in sub-Saharan Africa or in low human development countries. In studies done in all age groups, Shigella incidence varied from 0·6 to 107 episodes/1000 person-years. S. flexneri was the most commonly detected subgroup in the majority of studies. Case-fatality rates ranged from 0% to 2·6% in population-based studies and from 0% to 21% in facility-based studies. This review highlights the large gaps in data on the burden of Shigella infections for low human development index countries and, more specifically, for sub-Saharan Africa.

Extensively drug-resistant tuberculosis (XDR TB) has emerged as a threat to TB control efforts in several high-burden areas, generating international concern. XDR TB is now found in every region of the world, but appears most worrisome in the context of HIV and in resource-limited settings with congregate hospital wards. Here, we examine the emergence and transmission dynamics of the disease, incorporating the mathematical modelling literature related to airborne infection and epidemiological studies related to the operations of TB control programmes in resource-limited settings. We find that while XDR TB may present many challenges in the setting of resource constraints, the central problems highlighted by the emergence of XDR TB are those that have plagued TB programmes for years. These include a slow rate of case detection that permits prolonged infectiousness, the threat of airborne infection in enclosed spaces, the problem of inadequate treatment delivery and treatment completion, and the need to develop health systems that can address the combination of TB and poverty. Mathematical models of TB transmission shed light on the idea that community-based therapy and rapid detection systems may be beneficial in resource-limited settings, while congregate hospital wards are sites for major structural reform.

We performed a systematic review to estimate the effectiveness of vaccination, in addition to chemoprophylaxis, in preventing meningococcal disease among household contacts. Medline, EMBASE, EMGM, and EUIBIS were used for data collection. Studies reporting on at least 100 primary cases and on subsequent cases in household settings with follow-up of more than 2 weeks after onset of disease in the primary case were reviewed. A meta-analysis was used to calculate the average attack rate in household contacts given chemoprophylaxis 14–365 days after onset of disease in the primary case. In total, 652 studies were identified, five studies and one unpublished report met the inclusion criteria. The weighted average attack rate was 1·1/1000 household contacts (95% CI 0·7–1·7). This review supports vaccination of household contacts in addition to chemoprophylaxis to reduce the risk of meningococcal disease among household contacts of a case caused by a vaccine-preventable serogroup.

We considered a Bayesian analysis for the prevalence of tuberculosis cases in New York City from 1970 to 2000. This counting dataset presented two change-points during this period. We modelled this counting dataset considering non-homogeneous Poisson processes in the presence of the two-change points. A Bayesian analysis for the data is considered using Markov chain Monte Carlo methods. Simulated Gibbs samples for the parameters of interest were obtained using WinBugs software.

A compartmental, age-structured mathematical model was developed and recent US pertussis epidemiology data were used to evaluate the impact on pertussis infection rates of routine and targeted adult immunization strategies. Model simulations predict that the implementation of adolescent immunization only could reverse the current rise in pertussis infection rates but may lead to a resurgence of pertussis in subsequent decades. In contrast, inclusion of a routine adult strategy is likely to lead to sustained control of pertussis. Routine adult vaccination could control the disease even with relatively low coverage rates of 40% for routine vaccination of all adults every 10 years, or 65% for a targeted vaccination of close contacts of newborns completed by one booster dose for all adults. The model also predicts that the optimal age for this booster dose is 40 years. These results support the 2006 American Academy of Immunization Practices' recommendations for adolescent and adult vaccination against pertussis.

Few studies have examined the relationship between viral activity and bacterial invasive disease, considering both influenza virus and respiratory syncytial virus (RSV). This study aimed to assess the potential relationship between invasive pneumococcal disease (IPD), meningococcal disease (MD), and influenza virus and RSV activity in The Netherlands. Correlations were determined between population-based data on IPD and MD during 1997–2003 and influenza virus and RSV surveillance data. Incidence rate ratios of disease during periods of high influenza virus and RSV activity over the peri-seasonal and summer baseline periods were calculated. The analyses comprised 7266 and 3072 cases of IPD and MD. When data from all seasons were included, the occurrence of pneumococcal bacteraemia and MD correlated significantly with influenza virus and RSV activity both in children and adults. Periods of increased influenza virus and RSV activity showed higher rates of pneumococcal bacteraemia in older children and adults than the peri-season period. Rates of MD in children were also higher during periods of increased influenza virus activity; the same appeared true for MD in older children during periods of increased RSV activity. Although no causal relationship may be inferred from these data, they support a role for influenza virus and RSV in the pathogenesis of IPD and MD.

The influenza virus continues to pose a significant threat to public health throughout the world. Current avian influenza outbreaks in humans have heightened the need for improved surveillance and planning. Despite recent advances in the development of vaccines and antiviral drugs, seasonal epidemics of influenza continue to contribute significantly to general practitioner workloads, emergency hospital admissions, and deaths. In this paper we review data produced by the Royal College of General Practitioners Weekly Returns Service, a sentinel general practice surveillance network that has been in operation for over 40 years in England and Wales. We show a gradually decreasing trend in the incidence of respiratory illness associated with influenza virus infection (influenza-like illness; ILI) over the 40 years and speculate that there are limits to how far an existing virus can drift and yet produce substantial new epidemics. The burden of disease caused by influenza presented to general practitioners varies considerably by age in each winter. In the pandemic winter of 1969/70 persons of working age were most severely affected; in the serious influenza epidemic of 1989/90 children were particularly affected; in the millennium winter (in which the NHS was severely stretched) ILI was almost confined to adults, especially the elderly. Serious confounders from infections due to respiratory syncytial virus are discussed, especially in relation to assessing influenza vaccine effectiveness. Increasing pressure on hospitals during epidemic periods are shown and are attributed to changing patterns of health-care delivery.

An abattoir survey was undertaken to determine the prevalence of foodborne zoonotic organisms colonizing cattle, sheep and pigs at slaughter in Great Britain. The study ran for 12 months from January 2003, involved 93 abattoirs and collected 7703 intestinal samples. The design was similar to two previous abattoir surveys undertaken in 1999–2000 allowing comparisons. Samples were examined for VTEC O157, Salmonella, thermophilic Campylobacter and Yersinia enterocolitica. The prevalence of VTEC O157 faecal carriage was 4·7% in cattle, 0·7% in sheep and 0·3% in pigs. A significant decrease in sheep was detected from the previous survey (1·7%). Salmonella carriage was 1·4% in cattle, a significant increase from the previous survey of 0·2%. In sheep, faecal carriage was 1·1% a significant increase from the previous survey (0·1%). In pigs, carriage was 23·4%, consistent with the previous study. Thermophilic Campylobacter spp. were isolated from 54·6% of cattle, 43·8% of sheep and 69·3% of pigs. Y. enterocolitica was isolated from 4·5% of cattle, 8·0% of sheep and 10·2% of pigs.

Salmonella Newport causes more than an estimated 100 000 infections annually in the United States. In 2002, tomatoes grown and packed on the eastern shore of Virginia contaminated with a pan-susceptible S. Newport strain caused illness in 510 patients in 26 states. In July–November 2005, the same strain caused illness in at least 72 patients in 16 states. We conducted a case-control study during the 2005 outbreak, enrolling 29 cases and 140 matched neighbourhood controls. Infection was associated with eating tomatoes (matched odds ratio 9·7, 95% confidence interval 3·3–34·9). Tomatoes were traced back to the eastern shore of Virginia, where the outbreak strain was isolated from pond water used to irrigate tomato fields. Two multistate outbreaks caused by one rare strain, and identification of that strain in irrigation ponds 2 years apart, suggest persistent contamination of tomato fields. Further efforts are needed to prevent produce contamination on farms and throughout the food supply chain.

This paper provides one of the first assessments of the burden of both the public health investigation and the economic costs associated with an apparent outbreak of Legionnaires' disease (LD) in South East London. In addition to epidemiological, microbiological and environmental investigations, we collected data on the staff time and resources committed by the 11 main organizations responsible for managing the outbreak. Of the overall estimated costs of £455 856, only 14% (£64 264) was spent on investigation and control of the outbreak compared with 86% (£391 592) spent on the hospital treatment of the patients. The time and money spent on public health services in this investigation appear to represent good value for money considering the potential costs of a major outbreak, including the high case-fatality rate in LD generally and the high health-care costs. Further research is needed to determine optimum strategies for the cost-effective use of health system resources in investigations of LD. Whether the threshold for investigation of cases should be based on observed incidence rates or the cost-effectiveness of investigations, or both, should be debated further.

The efficacy of vaccine when time since exposure is prolonged (more than 1 week from onset of illness in the index case) is unknown, but is likely to be significantly lower than human normal immunoglobulin (HNIG). We estimated the number of additional secondary cases that may occur through giving vaccine instead of HNIG to contacts of cases of hepatitis A who are identified more than 1 week after onset in the index case. This was calculated for different levels of vaccine efficacy, assuming HNIG efficacy to be 80–90%. The number of households that need to be treated to prevent one secondary case was calculated using estimates of secondary attack ratios (AR). If more than 1 week has elapsed from onset of illness in the index case, for an average household size of 2·3 people, a vaccine efficacy of 50% and an AR of 10–25%, 8–26 households would need to be treated with vaccine before one additional secondary case would be observed. As UK public health professionals manage around one hepatitis A case per month, it would take from 8 months to over 2 years for them to observe one additional case amongst contacts using vaccine rather than HNIG. It is unlikely that an average practitioner would notice if vaccine were 30% less effective than HNIG. Public health practice and advice to patients and contacts should be based on evidence as well as experience.