Persistence of fluoroquinolone-resistant, multidrug-resistant Streptococcus pneumoniae in a long-term-care facility: efforts to reduce intrafacility transmission.

OBJECTIVE: We describe an effort to reduce transmission of a multidrug-resistant Streptococcus pneumoniae (MDRSP) in a long-term-care facility (LTCF). DESIGN: Longitudinal cross-sectional study. SETTING: An LTCF in New York City with ongoing disease due to an MDRSP strain among residents with AIDS since a 1995 outbreak. The MDRSP outbreak strain was susceptible to vancomycin but not to other antimicrobials tested, including fluoroquinolones. PARTICIPANTS: Residents and staff members of the LTCF during 1999 through 2001. INTERVENTION: Implementing standard infection control measures, and developing and implementing "enhanced standard" infection control measures, modified respiratory droplet prevention measures to reduce inter-resident transmission. RESULTS: Before the intervention, nasopharyngeal carriage of the MDRSP outbreak strain was detected in residents with AIDS and residents with tracheostomies who were not dependent on mechanical ventilation. The prevalence of nasopharyngeal carriage of the MDRSP outbreak strain was 7.8% among residents who had AIDS and 14.6% among residents with tracheostomies. After training sessions on standard and enhanced standard infection control measures, the staff appeared to have good knowledge and practice of the infection control measures. After the intervention, new transmission among residents with tracheostomies was prevented; however, these residents were prone to persistent tracheal carriage and needed ongoing enhanced standard infection control measures. Ongoing transmission among residents with AIDS, a socially active group, was documented, although fewer cases of disease due to the outbreak strain occurred. CONCLUSIONS: Infection control contributed to less transmission of MDRSP in the LTCE Additional strategies are needed to reduce transmission and carriage among certain resident populations.     

Invasive group A streptococcal infection in older adults in long-term care facilities and the community, United States, 1998-2003

Limited information exists on the incidence and characteristics of invasive group A streptococcal (GAS) infections among residents of long-term care facilities (LTCFs). We reviewed cases of invasive GAS infections occurring among persons > or =65 years of age identified through active, population-based surveillance from 1998 through 2003. We identified 1,762 invasive GAS cases among persons > or =65 years, including 1,662 with known residence type (LTCF or community). Incidence of invasive GAS infection among LTCF residents compared to community-based elderly was 41.0 versus 6.9 cases per 100,000 population. LTCF case-patients were 1.5 times as likely to die from the infection as community-based case-patients (33% vs. 21%, p<0.01) but were less often hospitalized (90% vs. 95%, p<0.01). In multivariate logistic regression modeling, LTCF residence remained an independent predictor of death. Additional prevention strategies against GAS infection in this high-risk population are urgently needed.     

Nursing home outbreak of invasive group a streptococcal infections caused by 2 distinct strains.

OBJECTIVE: To identify factors contributing to a cluster of deaths from invasive group A streptococcus (GAS) infection in a nursing home facility and to prevent additional cases. DESIGN: Outbreak investigation. SETTING: A 146-bed nursing home facility in northern Nevada. METHODS: We defined a case as the isolation of GAS from a normally sterile site in a resident of nursing home A. To identify case patients, we reviewed resident records from nursing home A, the local hospital, and the hospital laboratory. We obtained oropharyngeal and skin lesion swabs from staff and residents to assess GAS colonization and performed emm typing on available isolates. To identify potential risk factors for transmission, we performed a cohort study and investigated concurrent illness among residents and surveyed staff regarding infection control practices. RESULTS: Six residents met the case patient definition; 3 (50%) of them died. Among invasive GAS isolates available for analysis, 2 distinct strains were identified: emm11 (3 isolates) and emm89 (2 isolates). The rate of GAS carriage was 6% among residents and 4% among staff; carriage isolates were emm89 (8 isolates), emm11 (2 isolates), and emm1 (1 isolate). Concurrently, 35 (24%) of the residents developed a respiratory illness of unknown etiology; 41% of these persons died. Twenty-one (30%) of the surveyed employees did not always wash their hands before patient contacts, and 27 (38%) did not always wash their hands between patient contacts. CONCLUSIONS: Concurrent respiratory illness likely contributed to an outbreak of invasive GAS infection from 2 strains in a highly susceptible population. This outbreak highlights the importance of appropriate infection control measures, including respiratory hygiene practices, in nursing home facilities.     

A preventable outbreak of pneumococcal pneumonia among unvaccinated nursing home residents in New Jersey during 2001.

OBJECTIVE: To characterize risk factors for invasive pneumococcal infection in a nursing home outbreak. DESIGN: Outbreak investigation, case-control study. SETTING: A 114-bed nursing home in New Jersey. PARTICIPANTS: Case-patients were nursing home residents hospitalized with febrile respiratory illness and radiographic findings consistent with pneumonia, and either sputum specimens positive for diplococci or blood cultures positive for Streptococcus pneumoniae, with illness onset during April 3-24, 2001. Control-patients were selected randomly from remaining residents without respiratory symptoms. METHODS: Chart reviews were performed for case-patients and control-patients. Serotyping and susceptibility testing were performed on S. pneumoniae isolates. Long-term-care facilities (LTCFs) were surveyed to assess compliance with a state regulation mandating pneumococcal vaccination of residents 65 years and older. RESULTS: Nine case-patients were identified, with a median age of 86 years (range, 78 to 100 years). The median age of control-patients was 86 years (range, 58 to 95 years). No case-patients versus 9 (50%) control-patients received pneumococcal vaccine before the outbreak (OR, 0; CI95, 0-0.7). Recent antibiotic use, pneumonia history, and physical functioning were not associated with illness. Illness attack rate was 16% among all unvaccinated residents versus 0 among vaccinated residents. S. pneumoniae serotype 14, included in pneumococcal vaccine, was isolated from blood cultures of 7 case-patients. Of 361 LTCFs (42%) that replied to the survey, 28 (8%) were not complying with state immunization regulations. CONCLUSIONS: This outbreak occurred in an LTCF with low vaccine coverage. Implementing standing order programs, enforcing regulations, documenting vaccinations, and providing education might increase coverage among nursing home residents.     

Failure to control an outbreak of multidrug-resistant Streptococcus pneumoniae in a long-term-care facility: emergence and ongoing transmission of a fluoroquinolone-resistant strain.

OBJECTIVES: To characterize risk factors associated with pneumococcal disease and asymptomatic colonization during an outbreak of multidrug-resistant Streptococcus pneumoniae (MDRSP) among AIDS patients in a long-term-care facility (LTCF), evaluate the efficacy of antimicrobial prophylaxis in eliminating MDRSP colonization, and describe the emergence of fluoroquinolone resistance in the MDRSP outbreak strain. DESIGN: Epidemiologic investigation based on chart review and characterization of SP strains by antimicrobial susceptibility testing and PFGE and prospective MDRSP surveillance. SETTING: An 80-bed AIDS-care unit in an LTCF PARTICIPANTS: Staff and residents on the unit. RESULTS: From April 1995 through January 1996, 7 cases of MDRSP occurred. A nasopharyngeal (NP) swab survey of all residents (n=65) and staff (n=70) detected asymptomatic colonization among 6 residents (9%), but no staff. Isolates were sensitive only to rifampin, ofloxacin, and vancomycin. A 7-day course of rifampin and ofloxacin was given to eliminate colonization among residents: NP swab surveys at 1, 4, and 10 weeks after prophylaxis identified 1 or more colonized residents at each follow-up with isolates showing resistance to one or both treatment drugs. Between 1996 and 1999, an additional 6 patients were diagnosed with fluoroquinolone-resistant (FQ-R) MDRSP infection, with PFGE results demonstrating that the outbreak strain had persisted 3 years after the initial outbreak was recognized. CONCLUSIONS: Chemoprophylaxis likely contributed to the development of a FQ-R outbreak strain that continued to be transmitted in the facility through 1999. Long-term control of future MDRSP outbreaks should rely primarily on vaccination and strict infection control measures.     

Managing the challenge of an acute gastroenteritis outbreak caused by a Norwalk-like virus in a 239 bed long-term care facility

Outbreak management in long-term care facilities (LTCFs) highlights the differences between the ’ideal’ and ’real’ practicalities of implementing appropriate control measures. Infection control practitioners must develop workable strategies in an environment where it may not be possible to adopt traditional outbreak management procedures.This paper documents events during a large, prolonged outbreak of Norwalk-like virus, genotype II, affecting residents and staff of a 239 bed LTCF in Queensland. Diagnosis was confirmed from one faecal specimen. The case rate was 37 per cent with a total of 76 residents and 25 staff and volunteers meeting the criteria set in the case definition. Three peaks of infection were noted. Implementing standard mechanisms to isolate and cohort affected residents was not possible due to psychosocial and environmental factors in the setting. In addition, staffing shortages already in existence were compounded due to illness.The lack of facility-specific outbreak policies and procedures contributed to the slow resolution of the outbreak. An education programme focused on developing a collaborative, problem solving relationship among all disciplines. The result was the development of specific gastroenteritis outbreak management guidelines that reflect the realities of managing an outbreak event in a LTCF. This article outlines the management issues, solutions and outcomes associated with this outbreak.     

Prevalence and predictors of influenza vaccination among residents of long-term care facilities

Influenza is a respiratory illness which results in significant morbidity and mortality, especially in the older population. Older people living in Long-Term Care Facilities (LTCFs) have a significantly higher risk of infection and complications from influenza. Influenza vaccine is considered the best strategy to prevent infection in high-risk populations. In Australia, the Communicable Diseases Network Australia (CNDA) suggests a vaccination coverage rate of 95% in both staff and residents¹. This study aims to measure the vaccination coverage rates for residents in LTCFs and identify predictors of vaccination uptake for these individuals.This study was conducted in nine LTCFs in four sites from March to September 2018. This was done via medical record reviews for residents over 65 years old in these LTCFs, collecting information such as vaccination status, age, gender, ethnicity and occupation. Simple and multivariable logistic regression was used to calculate the Odds Ratio (OR) to determine significant predictors of influenza vaccination uptake.The overall vaccination rate among LTCF residents was 83.6%. Significant predictors of vaccination were LTCF location, ethnicity and previous year vaccination status. Residents in LTCF Site D were less likely to be vaccinated compared to Site A (OR 0.11, 95% CI 0.02–0.61), non-Caucasians were less likely to get vaccinated (OR 0.09, 95% CI 0.01–0.67), and residents who refused the 2017 vaccine were less likely to be vaccinated (OR 0.04, 95% CI 0.01–0.15).Compared with previous Australian studies on LTCF vaccination rates, the overall vaccination rate was high in these LTCFs (83.6% versus 66–84%), but it varied across different sites. Reasons for varying vaccination rates should be explored further – for example, lower rates in non-Caucasians with diverse cultural backgrounds. Better understanding the causes of under-vaccination can help improve vaccination programs in LTCFs.     

Management of a large healthcare-associated outbreak of Panton-Valentine leucocidin-positive meticillin-resistant Staphylococcus aureus in Germany

We report the largest documented healthcare-associated outbreak of Panton-Valentine leucocidin-positive meticillin-resistant Staphylococcus aureus (PVL(+) MRSA) in Europe. Six index patients from three long-term care facilities (LTCFs) were screened positive for PVL(+) MRSA in 2004 on admission to a community hospital in Germany. The purpose of this prospective study was to describe the prevalence of PVL(+) MRSA in the LTCFs before and after infection control interventions. Screening for MRSA with or without PVL was performed in all three LTCFs in 2004 [453 residents, 240 healthcare workers (HCWs)] and 2005 (440 residents, 192 HCWs). Swabs from anterior nares and wounds, if applicable, were collected. Colonised residents and staff were treated with mupirocin nasal ointment and topical antiseptics, and staff were provided with hygiene education. Total MRSA carrier rate of residents and HCWs in 2004 was 11.3% (PVL(+) MRSA 9.1%, PVL(-) MRSA 2.2%). There were comparable carrier rates between residents and HCWs in each LTCF. All PVL(+) MRSA isolates were of clonal origin (MLST 22) representing a novel spa sequence type t310. A decrease in total MRSA prevalence (from 11.3 to 5.5%) and PVL(+) MRSA (from 9.1 to 3.3%) was observed in 2005. The rate of PVL(-) MRSA remained unaffected. No symptomatic skin infections were noted among residents or HCWs. In this outbreak incomplete control of PVL(+) MRSA presumably resulted from difficult and delayed detection and decolonisation of carriers, incomplete compliance with control measures and lack of enforcement by public health authorities.     

Prevention of influenza in long-term-care facilities. Long-Term-Care Committee of the Society for Healthcare Epidemiology of America.

Influenza is a frequent cause of epidemic and endemic respiratory illness in long-term-care facilities (LTCFs), resulting in considerable morbidity and mortality. Detection of influenza outbreaks in this setting can be difficult, because the clinical presentation in older adults is atypical and other pathogens also cause influenza-like illness (ILI) during the influenza season. Use of the standard case definition for influenza has not been effective in detecting episodes in residents of LTCFs. Alternative case-definitions that reflect the atypical presentation of influenza in this population have been recommended but not validated. The use of rapid tests for the detection of influenza in conjunction with more sensitive case definitions of ILI may lead to the earlier detection of influenza outbreaks in LTCFs, earlier initiation of infection control measures, and reduction in transmission. The definition of outbreak, eg, the number of episodes of ILI or episodes of confirmed influenza A that would result in the initiation of antiviral chemoprophylaxis, remains controversial in this setting. The use of newer antivirals could limit the side effects seen in older adults in LTCFs. However, annual vaccination of residents and staff remains the most effective way to prevent the introduction of influenza A or influenza B into LTCFs. In addition, vaccination of LTCF residents reduces rates of illness and pneumonia due to influenza, as well as cardiopulmonary exacerbation, hospitalization, and death.     

Preventing antimicrobial-resistant bacterial infections among older adults in long-term care facilities

For older adults in long-term care facilities (LTCFs), the rate of infections caused by antimicrobial resistant strains of bacteria has increased and is prompting renewed interest in investing health care resources for prevention and control of these pathogens. This document offers a simple framework to combat infections due to antimicrobial resistant bacteria in LTCF residents by providing a multi-step approach consisting of four major strategies: prevent infection, diagnose and treat infection effectively, use antimicrobials wisely, and prevent transmission. Recommendations from this multi-step approach are directed at LTCF medical directors and practicing clinicians involved with the medical care of older adult LTCF residents.     

Foodborne and waterborne infections in elderly community and long-term care facility residents,Victoria, Australia

We calculated rates of foodborne and waterborne infections reported to the health department in Victoria, Australia, during 2000-2009 for elderly residents of long-term care facilities (LTCFs) and the community. We used negative binomial regression to estimate incidence rate ratios, adjusting for age, sex, and reporting period. We analyzed 8,277 infections in elderly persons. Rates of campylobacteriosis, legionellosis, listeriosis, toxigenic Escherichia coli infections, and shigellosis were higher in community residents, and rates of Salmonella infection were higher in LTCF residents. Each year, 61.7 Campylobacter infections were reported per 100,000 LTCF residents, compared with 97.6 per 100,000 community residents. LTCF residents were at higher risk for S. enterica serotype Typhimurium associated with outbreaks. Rates of foodborne infections (except salmonellosis) were similar to or lower for LTCF residents than for community residents. These findings may indicate that food preparation practices in LTCFs are safer than those used by elderly persons in the community.     

Risk factors for colonization with methicillin-resistant Staphylococcus aureus in a long-term-care facility in Slovenia.

OBJECTIVE: To evaluate risk factors associated with methicillin-resistant Staphylococcus aureus (MRSA) colonization in a long-term-care facility (LTCF) for the elderly in Slovenia. SETTING: A 351-bed community LTCF for the elderly. DESIGN AND PARTICIPANTS: This was a case-control study. MRSA carriage was identified in 102 of 127 residents of the facility's nursing unit. Two swabs were taken: one from the anterior nares and one from the largest skin lesion. If no skin lesions were present, the axillae and the groin area were swabbed. Data were collected regarding gender, age, length of stay in the facility, underlying conditions, functional status, presence of wounds or pressure sores, presence of catheters, antibiotic treatments, and hospital admissions. RESULTS: We detected MRSA in 12 participants. Risk factors independently and significantly associated with MRSA colonization on the multivariate analysis were antibiotic treatments within 1 month before the investigation (odds ratio, 5.087; 95% confidence interval, 1.02 to 25.48; P = .048) and multiple hospital admissions in the 3 months before the investigation (odds ratio, 6.277; 95% confidence interval, 1.31 to 30.05; P = .022). CONCLUSIONS: This is the first assessment of risk factors for colonization with MRSA in an LTCF in Slovenia. MRSA poses a problem in this LTCE Our observations may be valuable in implementing active surveillance cultures in infection control programs in Slovenian LTCFs.     

Importance of bacterial burden among methicillin-resistant Staphylococcus aureus carriers in a long-term care facility.

OBJECTIVE: To evaluate the prevalence and transmission of methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization, as well as risk factors associated with MRSA carriage, among residents of a long-term care facility (LTCF). DESIGN: Prospective, longitudinal cohort study. SETTING: A 100-bed Veterans Administration LTCF. PARTICIPANTS: All current and newly admitted residents of the LTCF during an 8-week study period. METHODS: Nasal swab samples were obtained weekly and cultured on MRSA-selective media, and the cultures were graded for growth on a semiquantitative scale from 0 (no growth) to 6 (heavy growth). Epidemiologic data for the periods before and during the study were collected to assess risk factors for MRSA carriage. RESULTS: Of 83 LTCF residents, 49 (59%) had 1 or more nasal swab cultures that were positive for MRSA; 34 (41%) were consistently culture-negative (designated "noncarriers"). Of the 49 culture-positive residents, 30 (36% of the total of 83 residents) had all cultures positive for MRSA (designated "persistent carriers"), and 19 (23% of the 83 residents) had at least 1 culture, but not all cultures, positive for MRSA (designated "intermittent carriers"). Multivariate analysis showed that participants with at least 1 nasal swab culture positive for MRSA were likely to have had previous hospitalization (odds ratio, 3.9) or wounds (odds ratio, 8.2). Persistent carriers and intermittent carriers did not differ in epidemiologic characteristics but did differ in mean MRSA growth score (3.7 vs 0.7; P<.001). CONCLUSIONS: Epidemiologic characteristics differed between noncarriers and subjects with at least 1 nasal swab culture positive for MRSA. However, in this LTCF population, only the degree of bacterial colonization (as reflected by mean MRSA growth score) distinguished persistent carriers from intermittent carriers. Understanding the burden of colonization may be important when determining future surveillance and control strategies.     

Survey of long-term-care facilities in Iowa for policies and practices regarding residents with methicillin-resistant Staphylococcus aureus or vancomycin-resistant enterococci.

OBJECTIVES: To identify infection control policies and practices used by long-term-care facilities (LTCFs) in Iowa for residents with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE), and to estimate the prevalence of residents known to have these organisms. DESIGN: Survey. SETTING: LTCFs in Iowa from December 2002 through March 2003. RESULTS: Of the 429 LTCFs in Iowa, 331 (77%) responded to the survey. The estimated prevalence of residents known to have MRSA was 13.4 per 1,000 and that of residents known to have VRE was 2.3 per 1,000. Facilities owned by the government or those with an average of more than 86 occupied beds were more likely to have residents known to have MRSA and VRE (P = .002 and .007, respectively). Of the responding facilities, 7.3% acknowledged that they refused to accept individuals known to have MRSA and 16.9% acknowledged that they refused to accept those known to have VRE. Facilities in large communities (population, > 100,000) were least likely to deny admission to an individual known to have either MRSA or VRE (P = .05). Most facilities reported adhering to the national guidelines, but fewer than half (44.7%) of the respondents had heard of the Iowa Antibiotic Resistance Task Force's guidelines regarding residents with MRSA or VRE. CONCLUSIONS: Many LTCFs in Iowa care for residents known to have MRSA or VRE, but some refuse to admit these individuals. Infection control personnel and public health officials should work together to educate LTCF staff so that residents receive proper care and resistant organisms do not spread within this setting.     

Carbapenem-resistant Klebsiella pneumoniae associated with a long-term--care facility --- West Virginia, 2009-2011

On January 27, 2011, a West Virginia county health department was notified of a cluster of carbapenem-resistant Klebsiella pneumoniae (CRKP) cases detected by a local hospital (hospital A). CRKP infections frequently are resistant to a majority of antimicrobial agents and have an increased risk for morbidity and mortality. The West Virginia Bureau for Public Health (WVBPH) conducted field investigations to identify all cases, characterize risk factors for infection, and abstract data for a matched case-control study. Nineteen case-patients and 38 control patients were identified. Infection with CRKP was associated with admission from or prior stay at a local long-term--care facility (LTCF A). Pulsed-field gel electrophoresis (PFGE) analysis indicated that all five hospital A clinical specimens and all 11 point prevalence survey isolates from LTCF A were closely related. This is the first outbreak of CRKP identified in West Virginia. Recommendations to LTCF A included the following: 1) initiate surveillance for multidrug resistant organisms; 2) revise and improve infection prevention and control activities within the facility; 3) educate residents and their families, physicians, and staff members about CRKP; and 4) identify qualified personnel to coordinate infection control functions within the facility. Although LTCF A has made significant improvements, the outbreak investigation is ongoing. Additional site visits have been conducted, and additional colonized residents have been identified; the last clinical case was detected in July. These findings demonstrate the interconnectedness of the health-care system and factors potentially contributing to transmission of infection. Interventions targeting all levels of care are needed to prevent further CRKP transmission.     

Carriage of methicillin-resistant Staphylococcus aureus among hospital employees: prevalence, duration, and transmission to households.

OBJECTIVE: To assess the prevalence and duration of methicillin-resistant Staphylococcus aureus (MRSA) carriage among hospital employees and transmission to their households. DESIGN: A point-prevalence survey of MRSA carriage (nasal swabbing) of staff and patients throughout the hospital; a prevalence survey of MRSA carriage in 2 medical wards, with carriers observed to estimate carriage duration; and evaluation of transmission to MRSA-positive workers' families. All MRSA isolates were analyzed by pulsed-field gel electrophoresis. During the study, no MRSA outbreak was detected among hospitalized patients. SETTING: A 600-bed, public tertiary-care teaching hospital near Paris. RESULTS: Sixty MRSA carriers were identified among 965 healthcare providers (prevalence, 6.2%; CI95, 4.7%-7.7%). Prevalence was higher in staff from clinical wards than from elsewhere (9.0% vs 2.1%; P < .0001). Identity of isolates from employees and patients varied from 25% in medical wards to 100% in the long-term-care facility. MRSA carriage was identified in 14 employees from 2 medical wards (prevalence, 19.4%; CI95, 10.3%-28.5%). Prevalence depended on the length of service in these wards. Transmission to households was investigated in 10 MRSA-positive workers' families and was found in 4. All isolates from each family were identical. CONCLUSIONS: Few data are available concerning the prevalence of MRSA carriers among hospital employees in the absence of an outbreak among patients. MRSA transmission between patients and employees likely depends on the frequency and duration of exposure to MRSA-positive patients and infection control measures employed. Frequent transmission of MRSA from colonized healthcare workers to their households was documented.     

Methods of pain assessment in residents of long-term care facilities: a pilot study

OBJECTIVES: Structured programs for routine pain assessment and treatment are necessary to optimize care for residents of long-term care facilities (LTCFs). A pilot study was designed to develop, implement, and evaluate a system for pain assessment and monitoring in a LTCF. Additional goals were to determine whether a verbal and/or non-verbal tool adequately assess pain in residents of LTCFs and whether the pharmacologic therapy for pain changes with the implementation of a pain assessment and monitoring system. DESIGN: Quantitative, nonexperimental design using two pain assessment tools. SETTING: The study was conducted at a LTCF in a rural midwestern setting. PARTICIPANTS: The study population for phase I included residents on any pain medication (regularly scheduled or as needed) on the secure dementia unit. The target population for phase II consisted of residents on any pain medication on an open unit. INTERVENTION: Training was provided to the nursing staff on how to use two pain assessment tools, one verbal (colored visual analog scale) and one nonverbal (observed pain target behaviors), and documentation. In addition, a continuing education program on pain assessment and management in elderly residents and barriers to pain management in LTCFs was offered to medical providers. MEASUREMENTS: Evaluation with the colored visual analog scale (CVAS) occurred twice daily. Pain target behaviors were monitored throughout the day and recorded by nursing staff at the end of each shift. All residents in the study population were monitored daily for six months. RESULTS: Most of the residents on both units were unable to use the verbal tool; however, the nonverbal tool was used successfully for all residents studied. On the dementia unit, the use of pain medications increased, and pain target behaviors decreased during the study period; on the open unit, the use of pain medications remained stable, and pain target behaviors decreased. CONCLUSION: These data suggest that an increase in awareness of pain may facilitate an improvement in the assessment and management of pain in residents of LTCFs. The feasibility of the nonverbal pain monitoring method shown in this study has positive implications on quality of care issues if generalizable to a larger population.     

Possible community immunity to small round structured virus gastroenteritis in a rural aboriginal community

In April 1998 an outbreak of gastroenteritis affected visitors, but none of the Aboriginal residents, at a Territory Health Services luncheon in a rural Aboriginal community in Central Australia. The epidemiological features and identification of Small Round Structured Virus (SRSV) from two participants suggest that this was an outbreak caused by a SRSV. The attack rate in the visitors who ate or drank food at the luncheon was 73% (11 of 15). Seventeen Aboriginal residents were interviewed, none had gastroenteritis. The community potable water supply was contaminated with faecal bacteria around the time of the outbreak. No particular food could be implicated and laboratory examination of foods was not possible. It is proposed that past exposure to SRSVs may have resulted in the Aboriginal residents developing clinical immunity to infection. The process and consequences of the investigation in this community are also discussed.     

The Stonehouse survey: nasopharyngeal carriage of meningococci and Neisseria lactamica.

A total of 6234 nasopharyngeal swabs was collected during a survey of the population of Stonehouse, Gloucestershire in November 1986 as part of an investigation into an outbreak of meningococcal disease. The overall meningococcal carriage rate was 10.9%. The carriage rate rose with age from 2.1% in the 0- to 4-year-olds to a peak of 24.5% in the 15- to 19-year-olds, and thereafter declined steadily with age. Male carriers outnumbered female carriers of meningococci by 3:2. Group B (or non-groupable) type 15 sulphonamide-resistant strains which had caused the outbreak were isolated from 1.4% of subjects. The age distribution of carriers of these strains was similar to that of other meningococci apart from an additional peak in the 5-9-year age group and a more rapid decline in carriage with increasing age. Variations in the carriage rates of the outbreak strain were seen in children attending different schools and in the residents of different areas of the town. The low carriage rate of these strains in a community during a prolonged outbreak supports the hypothesis that these organisms are less transmissible but more virulent than other strains of pathogenic meningococci. Carriage of Neisseria lactamica, which is thought to be important in the development of meningococcal immunity, was most frequent in children under the age of 5 years and was six times commoner in this age group than carriage of Neisseria meningitidis. In older children and adults female carriers of N. lactamica increasingly outnumbered males in contrast to the male preponderance observed with meningococcal carriage.