infection societies

13th – 15th November 2018 | Sage Gateshead – Newcastle

infection societies

13th – 15th November 2018 | Sage Gateshead – Newcastle

infection societies

13th – 15th November 2018 | Sage Gateshead – Newcastle


TRAVEL & TROPICAL MEDICINE – Poster Nos. 094-111

Case report: A returning traveller with meningism after a long haul flight – an unusual presentation of multiple acyl-CoA dehydrogenase deficiency (MADD)

Abstract - 094

Poster 094

Case report: A returning traveller with meningism after a long haul flight – an unusual presentation of multiple acyl-CoA dehydrogenase deficiency (MADD)

Paul Hine1,2, Anna Stewart2, Joseph Taylor2, Andreas Trimidas2, Sylviane Defres3,2
1Liverpool School of Tropical Medicine. 2Royal Liverpool and Broadgreen University Hospitals Trust. 3Institute of Global Health, Liverpool

Introduction: We describe the case of an adult male, in whom long haul air travel unmasked an inborn error of metabolism, multiple acyl-CoA dehydrogenation deficiency (MADD). To our knowledge, this is the first case report of an inborn error of metabolism being unmasked by air travel.

Methods: A 28-year-old male presented with headache, vomiting, and photophobia two days after a flight from Goa, India. He had presented in a similar way previously after air travel, and his treating clinicians had diagnosed dehydration. On initial assessment he was treated as sepsis and possible meningitis. His lumbar puncture was normal, however, he developed a metabolic acidosis, hypoglycaemia, and hyperammonaemia. Acylcarnitine testing showed increased medium and long chain acylcarnitines consistent with multiple acyl-CoA dehydrogenation deficiency (MADD).

Discussion: Clinicians caring for returning travellers should be aware of non-infective diagnoses. It is likely that current surveillance systems under-estimate non-infective diagnoses for severe illness in returning travellers. There is limited data to indicate the prevalence of acute illness precipitated by air travel. Acute decompensations of multiple acyl-CoA dehydrogenation deficiency (MADD) and other inborn errors of metabolism may be precipitated by air travel. Clinicians must consider the potential for the mode of transport to precipitate decompensation of other illnesses when diagnosing illness in the returning traveller.

Once, twice, is three times always necessary? A UK single-centre retrospective analysis of malaria diagnostics

Abstract - 095

Poster 095

Once, twice, is three times always necessary? A UK single-centre retrospective analysis of malaria diagnostics

Blair Merrick1, John Lambert2, Caolan Duffy3, Tom Hepburn3, Matthias Schmid4
1Hospital for Tropical Diseases, London. 2Blood Sciences, Royal Victoria Infirmary, Newcastle upon Tyne. 3Newcastle Medical School. 4Infection and Tropical Medicine, Royal Victoria Infirmary, Newcastle upon Tyne

Introduction: Malaria is a treatable, but potentially fatal, protozoan infection. Each year 1300-1800 cases are imported into the UK leading to 2-8 deaths. Malaria must be considered in any febrile individual with a travel history to an endemic area in the past year. There are no reliable clinical signs or symptoms of disease. Guidelines therefore advise patients to have 3 blood films over a 48-hour period to exclude the diagnosis, should initial tests prove negative. This study looks at malaria diagnostics in a tropical medicine tertiary referral centre across a 7-year period. It reviews guideline adherence across primary and secondary care, and questions whether serial blood films are truly necessary. Because how often do we actually miss malaria on the first or second blood film?

Methods: All samples sent to the Newcastle upon Tyne NHS Hospitals Foundation Trust to be examined for malarial parasites between 2011-2017 were included. Each sample had thick and thin films prepared; these were reviewed independently by at least two trained microscopists in the laboratory (NEQAS assessed). The initial sample sent additionally had a rapid diagnostic test (CareStart™) performed to detect presence of malarial antigens (pLDH/ HRP-2).

Data collected included sample draw time, presence/ absence and subspecies of malarial parasites, and RDT result. Patient samples were separated into ‘episodes’ consisting either of one blood sample, two samples, or three or more samples. If samples (from same patient) were taken >30 days apart, or following new exposure risk, they were defined as a new episode.

Electronic patient records were accessed to identify travel history (available for 52% episodes), location sample was taken in (primary/ secondary care), and information that may influence results e.g. recent treatment for malaria.

Results: 3381 samples were separated into 2082 episodes. 1345 episodes consisted of one sample, 343 two samples, and 394 three or more samples. 612 (29.4%) episodes were from patients who had all samples sent from primary care, 1419 episodes (68.2%) all from secondary care. The remainder were patients referred from primary to secondary care to complete their work-up.

140 cases of malaria were diagnosed across the 7-year period (prevalence=6.7%). Falciparum subspecies made up majority of cases (69.3%), and most patients with malaria had a travel history to Central/West Africa (62.9% cases). No patient in the studied population who had an initial blood sample negative for malarial parasites subsequently went on to have a positive film i.e. the diagnosis was always made on the first sample. The negative predictive value of a negative test (no malaria parasites seen) was 100%. Two patients had a positive RDT but no malarial parasites on microscopy, both had been treated for malaria (elsewhere) in the preceding 30 days.

Discussion: Despite its limitations (retrospective review in single-centre), this study raises important questions that mandate consideration.  With such poor adherence to guidelines (especially primary care, where only 5.7% patients had a total of three blood films examined) do we need to consider targeted education strategies regarding current recommended practice? As a preventable cause of death, missing a diagnosis of malaria should be regarded as a never event.

That being said, over the study period no case of malaria was missed on the first sample sent for analysis. Therefore, could we in fact be less rigorous in our testing practices when looking to exclude malaria? Other countries are already moving away from recommending three blood films e.g. maximum of two films (Austria), one film followed by PCR testing (Spain).

Further work is necessary to see if results can be generalised across the UK. This will help determine which is the more appropriate tact going forward.

Double trouble from Columbia

Abstract - 096

Poster 096

Double trouble from Columbia

Stephen Woolley1,2, Jayne Jones1, Nicholas Beeching2
1Liverpool School of Tropical Medicine. 2TIDU, Royal Liverpool Hospital

Introduction: We present a case of a 61yo male (patient A) who presented with right upper quadrant pain, fever and jaundice and a 42yo female (patient B) who had diarrhoea, both of whom had their symptoms upon returning from a holiday in Columbia. 

Methods: In February 2018 a 61yo male presented to the local Emergency Department with right upper quadrant pain, fever and jaundice. He was referred to the infectious diseases team as ascending cholangitis and was commenced on intravenous pipercillin/tazobactam. A more detailed history revealed the patient had returned 2 weeks ago from a 2-week holiday in Cartagena, Colombia. On further questioning he did not undertake any high-risk activities and always ate in the local hotels that he resided in. 

Discussion: The patient’s blood parameters continued to rise despite the broad-spectrum antibiotics. His white cell count was 23.9 x 109 cells/L, C-reactive protein was 299 mg/L, and bilirubin was 154 mg/dL. On USS Liver revealed a large 15cm by 13cm hypoechoic spherical region consistent with a liver abscess. In view of the on going fevers and size of the abscess it was decided to drain the abscess via interventional radiology. The drain pus was sent for standard bacterial culture. Serology was also sent for Entamoeba histolytica to the Liverpool School of Tropical Medicine (LSTM) laboratory although it was felt that the abscess was bacterial in aetiology. The patient improved over the next 3 days before he started to spike temperatures. Whilst visiting patient A, patient B stated that she had diarrhoea and had been to the local Emergency Department on returning to the UK and was given a diagnosis of viral gastroenteritis and discharged. She was seen in the infectious diseases outpatient department, 4 weeks post returning to the UK, following a referral from her GP. She had a 5-week history of watery diarrhoea and weight loss of 12kg.  

Soldier soldier

Abstract - 097

Poster 097

Soldier soldier

Stephen Woolley1,2,3, Keri McLean1, Timothy Elmer4, Dennis Freshwater5, Lucy Lamb6,7
1TIDU, Royal Liverpool Hospital. 2Liverpool School of Tropical Medicine. 3Institute of Naval Medicine, Portsmouth. 4Defence Public Health Unit, Lichfield. 5Royal Centre of Defence Medicine, Birmingham. 6Department of Infection, Royal Free Hospital, London. 7Academic Department of Military Medicine, Royal Centre of Defence Medicine, Birmingham

Introduction: A twenty-four year old male infantry soldier with no medical history but recent occupational travel presented with acute jaundice and flu-like symptoms.  

Methods: Approximately six weeks after returning from jungle warfare training in Thailand (December 2017), he developed central abdominal pain associated with a seven-day history of diarrhoea. He underwent a laparoscopic appendectomy that histologically demonstrated severe acute diffuse suppurative appendicitis and peri-appendicitis with no perforation.  During this admission his liver function tests were deranged, 6 February 18, Alanine Transaminase (ALT) 933 IU/L, Alkaline Phosphatase (ALP) 96 IU/L, Bilirubin 51 umol/L. Synthetic liver function was normal; Prothrombin time (PT) 14.5 sec, Activated Partial Thromboplastin Time (APTT) 26.1 secs and Albumin 52g/L.   

Twenty-four hours after discharge he developed epigastric pain, associated with nausea and flu-like symptoms. Within a further seventy-two hours he became acutely jaundice and presented to a different hospital. He remained apyrexic with no focal symptoms. He denied a paracetamol overdose, excessive alcohol intake, smoking, recreational drug use, recent tattoos, piercings or injecting drugs. He had a single heterosexual partner for the past two years and denied sexual activity with men or sex workers. He had travelled to Thailand in November 2017 for occupational reasons (jungle warfare training with no freshwater exposure) and returned in December 2017. During the trip he had diarrhoea and vomiting for approximately 24 hours (4 December 17); otherwise he was well.  The patient received 3 separate doses of Hepatitis B vaccine in June 2015, July 2015 and April 2016 by the Army. 

Discussion: His liver function test were markedly deranged on admission; ALT 8640 U/L, ALP 241 U/L, Bilirubin 130 umol/L and albumin 44 g/L. Positive findings on examination were jaundice and two small lymph nodes in the left inguinal canal. A thickened gallbladder but no signs of stones or biliary dilatation were seen on liver ultrasound. The ultrasound did not demonstrate any evidence of portal vein occlusion. Paracetamol and salicylate levels were within normal parameters. Serology tests were sent for HIV, Hepatitis A/B/C and E, syphilis and leptospirosis. The patient also had 3 sets of blood cultures and stool culture taken. 

One year of advice calls to a tropical and infectious diseases referral centre: a retrospective, descriptive analysis from Liverpool, England

Abstract - 098

Poster 098

One year of advice calls to a tropical and infectious diseases referral centre: a retrospective, descriptive analysis from Liverpool, England

Tom Wingfield1,2,3,4, Mike Beadsworth1,2, Nick Beeching2,1, Emmanuel Nsutebu1
1Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool. 2Liverpool School of Tropical Medicine. 3Karolinska Institutet, Stockholm, Sweden. 4University of Liverpool

Introduction: The regional Tropical and Infectious Disease Unit (TIDU), in conjunction with the Liverpool School of Tropical Medicine (LSTM), provides specialist advice locally, regionally and nationally in England. The initial point of contact for consultation is predominantly a TIDU Specialist Registrar via the on-call telephone. Few data exist regarding the call volume, clinical advice given, communicable disease recognition, patient outcomes, costs, and remuneration of such services. To better understand and improve our service, we created and evaluated a system for recording advice calls to TIDU.

Methods: In May 2017, an electronic advice-call template was created, which recorded: date, receiving clinician details, caller details, patient details, clinical scenario, advice given, and outcome. This Word-based template was used by TIDU specialist trainees to record complex, external calls and is distinct from the dedicated weekday Tropical service provided by LSTM. A standard operating procedure (SOP) and criteria for recording calls was developed, agreed, and TIDU specialist trainees were trained in its use. The template was implemented in June 2017. In November 2017, six months post-implementation, the system’s data were analysed and presented to TIDU specialist trainees and consultants at a local audit and quality improvement project meeting. Reminder emails about the template and SOP and a satisfaction survey were sent out to TIDU specialist trainees and consultants in August 2017 and May 2018. Here, we present the analysis of advice calls recorded in the system database over the first 14 months (June 2017 to August 2018) of its use.

Results: 589 calls concerning 362 patients were documented (1.6 calls/patient, 10 calls/week). Each call, including note taking and generated tasks, was estimated to have an average duration of 10 minutes. 69% (248/360) of calls were from secondary healthcare, of which 50% (122/247) were from emergency/acute medicine departments. Median patient age was 43 (interquartile range 29-56, overall range 8-88) and 56% (203/362) were male. The most common clinical scenarios for which advice was sought were: systemic infection (48%); fever in the returned traveler (26%); rash (10%); pyrexia of unknown origin (7%); post-exposure prophylaxis following a needlestick injury or other non-sexual exposure (4%); and a new diagnosis of HIV (3%). The remaining calls consisted of advice on rabies post-exposure prophylaxis (1.5%), neurological syndromes without current evidence of infection (1%), and post-exposure prophylaxis following sexual exposure (0.5%). 43% (157/361) of referrals concerned returning travelers, of whom 59% (92/157) had undifferentiated fever. Advice about investigations and treatment was given to the caller in 92% (331/360) and 70% (251/360) of cases, respectively. TIDU specialist trainees involved TIDU consultants in 51% (184/360) of cases. 32% (116/361) of all the cases discussed were subsequently reviewed at our unit by admission/hospital-to-hospital transfer (15%), in a TIDU clinic (11%), or in a TIDU multi-disciplinary team meeting (6%). Of the TIDU specialist trainees who responded to the satisfaction survey, 100% (6/6) rated the new system as an improvement to the previous situation, predominantly due to enhanced continuity and accountability.

Discussion: The implementation of an advice call recording system was feasible and well received. In keeping with the role of a national tropical referral centre, returned travellers constituted the majority of advice calls. The previously unquantified burden of calls was higher than anecdotally expected, indicating a substantial proportion of specialist advice for patients external to TIDU. Moreover, one third of calls leading to a direct TIDU review either on an inpatient or outpatient basis. These novel data add to the limited existing literature on advice call burden, allow an improved understanding of current resource allocation and service development needs in our unit, and can contribute to improved patient care in the future.

An aetiological study of acute encephalitis syndrome in children in Karnataka State, South India

Abstract - 099

Poster 099

An aetiological study of acute encephalitis syndrome in children in Karnataka State, South India

Lance Turtle1,2, Gemma Buxton3, Mohammed Hussain4, Raquel Medialdea-Carrera1, Heather Isenman5, Jason Lee6, Tehmina Bharucha7, Bhagteshwar Singh2, Vishali Satishkumar4, Srinivasa Krishna4, M Veera-Shankar4, Vasanthapuram Ravi8, Vijaya Satchidanadam9, Mike Griffiths2,1, Tom Solomon2,1
1NIHR Health Protection Research Unit for Emerging and Zoonotic Infections, University of Liverpool. 2NIHR Global Health Research Group in CNS Infections, University of Liverpool. 3Royal Hospital for Sick Children, Edinburgh. 4Vijayanagar Institute of Medical Science (VIMS) Medical College, Bellary, India. 5Infectious Diseases, Christchurch Hospital, New Zealand. 6University of Liverpool. 7Infectious Diseases, Royal Free Hospital, London. 8Neurovirology, National Institute of Mental Health and Neurosciences, Bangalore, India. 9Microbiology and Cell Biology, Indian Institute of Science, Bangalore, India

Introduction: Acute encephalitis syndrome (AES) is an important problem in children throughout Asia. AES is often viral, with Japanese encephalitis (JE) the most frequent diagnosis in Asia. We undertook a study of the role of immunity in JE pathogenesis in South India. However, incidence of JE has reduced, yet many cases of AES still occur. Therefore, we conducted a cohort study to determine the clinical features and causes of AES in South Indian children.

Methods: The study was conducted on the paediatric wards of Vijayanagar Institute of Medical Sciences (VIMS) Medical College Hospital. AES was suspected if there was fever or history of fever, with seizures or clouding of consciousness or focal neurological signs. Clinical and epidemiological data, blood and (where available) cerebrospinal fluid (CSF) were collected, and specimens were stored. Subsequent serological testing was performed for JE, Zika, chikungunya, dengue and hepatitis E viruses, and scrub typhus. Molecular testing was by Fast-track Diagnostics® multiplex PCR for Herpes simplex virus 1 and 2, Varicella zoster virus, Enterovirus, mumps virus, human parechovirus, Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae.

Results: Three hundred and sixty children were recruited, of whom 328 fitted the case definition and had data available. Of these, a clinical diagnosis was made in 88 cases (27%). Only 171 patients (52%) had lumbar puncture (LP) performed. Twelve children had JE, 32 dengue AES and 47 had tuberculous meningitis. Twenty-five patients died in hospital. Seizures occurred in 286 patients, but in 94 the seizures were never witnessed by hospital staff, and there was no other neurological abnormality. None of these patients lost consciousness or died. Patients in whom seizures were witnessed by hospital staff or had other neurological signs were more likely to have a diagnosis made (p < 0.0001) and to die in hospital (p = 0.003).

Samples were available from 279 patients for further analysis. This identified an additional 8 cases of chikungunya virus infection, 4 cases of scrub typhus, 5 cases of H influenzameningitis, 1 case each of meningococcal disease, 1 enterovirus AES, 1 varicella zoster AES, and 22 cases with multiple pathogens. JE testing was inconclusive due to a technical issue; repeat testing is underway.

Discussion: AES diagnostics remain challenging in this setting, with many patients undiagnosed. Ninety-four children had unwitnessed seizures and no other neurological abnormality, these children had a better prognosis and were less likely to have a CNS infection diagnosed. We conclude that these children either had febrile seizures, or no seizures at all, leaving 234 patients with “true” AES, of whom 133 (56.7%) had some evidence of a pathogen detected. Future work should focus on identifying barriers to diagnostics, and on identifying novel causes of AES.


The United Kingdom’s experience of Zika virus infection (2016 – 2017)

Abstract - 100

Poster 100

The United Kingdom’s experience of Zika virus infection (2016 – 2017)

Christina Petridou, Zaneeta Dhesi, Emma Aarons
Rare and Imported Pathogens Laboratory, PHE Porton Down, Salisbury, United Kingdom

Introduction: Zika virus (ZIKV) is a flavivirus, initially isolated from a sentinel rhesus macaque in the Zika forest in Uganda in 1947, with the first human case reported in 1962.  Subsequently sporadic cases occurred in Africa and Asia but little was known about ZIKV until an outbreak in 2007 that affected three quarters of the population of Yap Island. Previously unreported in the Americas, it rapidly spreading throughout the Americas in 2016 resulting in an explosive outbreak, grabbing the worlds attention.  Once believed to be a benign, self-limiting infection, interest in the virus has grown as its link to severe congenital abnormalities in infants born to infected mothers and neurological conditions in adults was established. In addition ZIKV is the first mosquito-borne flavivirus which has been found to be sexually transmitted, which is a major cause of concern for pregnant women and couples considering pregnancy.

In the UK, testing for ZIKV is performed at the Rare and Imported Pathogens Laboratory (RIPL), at Public Health England (PHE) Porton Down using real-time reverse transcription PCR (rRT-PCR) in the acute phase of illness and serology. 

Here we present the UK’s experience of ZIKV during 2016, the height of the epidemic, and 2017. We look at the number of patients that were tested at RIPL and the proportion that were positive and where sexual transmission was throught to have occured and how they were diagnosed. Their demographics including their pregnancy status, clinical presentation and travel history are all reviewed. For those that tested negative, we review whether an alternative diagnosis was reached and we explore the reasons behind why some requests for testing were rejected. 

Methods: A retrospective review was performed searching by ZIKV requests between 1st of January 2016 and 31st of December 2017. Each individual RIPL request form and result was reviewed to establish the patients age, sex, pregnancy status, clinical presentation and travel destination.  For those patients who tested negative for ZIKV virus, an effort was made to establish whether an alternative diagnosis had been established. 

Results: In total there were 7761 requests for ZIKV testing at RIPL. Of these, 1322 were rejected and 6373 patients were tested.

Reasons for rejection included insufficient clinical details, reported symptoms that were not in keeping with ZIKV infection or samples sent from asymptomatic patients or from patients who had travelled to a destination with no reported ZIKV transmission.  

Of the 6373 patients who were tested, 546 had positive RT-PCR or serology results (8.5%) and 5845 were negative (91.5%). A significant proportion of patients tested were pregnant or trying to conceive, and this was mainly in those who tested negative.163 were PCR positive and the majority presented with a rash and were aged 30-34 and had travelled to Barbados. 2 were pregnant. There was a proportion of patients with positive serology where the diagnosis of ZIKV was in doubt due to cross reactions and nonspecific reactions. 

Discussion: The epidemic has largely subsided in 2018 however a large number of patients were tested for ZIKV in 2016 and 2017, allowing us to undertand the UK experience of ZIKV. The significant proportion of patients who tested negative and were pregnant or trying to conceive highlights the publics concern. The proportion of patients that had positive results was relatively high at 8.5% however the diagnosis was only confirmed by PCR in a third of these, and these patients tended to present with the classical symptoms of rash and fever. A significant proportion of patients with positive serological results likely had cross reactivity with other falviviruses and the phenomenon of original antigenic sin was also observed highlighting the difficulties of serological diagnosis. 

Fever, rash and hepatitis; what’s the differential?

Abstract - 101

Poster 101

Fever, rash and hepatitis; what’s the differential?

Francesca Knapper, Megan Jenkins, Mahableshwar Albur, Izak Heys

Southmead Hospital, Bristol

Introduction: A 55 year old male presented to the emergency department with a 7 day history of fever, myalgia and headache.  On the day of presentation he had developed diarrhoea and vomiting, and had had an episode transient confusion. He was previously fit and well with no significant past medical history. The patient lived with his wife and had returned from a family holiday to a resort in Cyprus 3 weeks prior to presentation.  On further questioning he worked as an electrical contractor and had been recently working in a local zoo, where he had been changing light bulbs in a warthog enclosure. 

Methods: On examination he had a fine maculopapular rash over his abdomen and back.  Chest was clear, heart sounds were normal and abdomen was soft.  Small reactive cervical, axillary, and inguinal lymph nodes were palpable. Observations on presentation showed a temperature of 38.7oC and a heart rate of 110, he was normotensive.

Results: Blood tests revealed a normal full blood count, CRP of 84, sodium of 119, normal renal function and an acute hepatitis.  ALT was 640, bilirubin 26 and ALP was 320. 

A CT head was normal and a lumber puncture had a normal WCC, protein and glucose. CSF viral PCR was negative.

Liver USS showed increased echogenicity in the liver consistent with hepatitis but no focal lesions.

Discussion: Initially he was started on Ceftriaxone to cover CNS infection pending the lumber puncture results. While an inpatient his liver function deteriorated before improving. A full infective screen was sent including specialist tests to the Rare and Imported Pathogens Lab (RIPL).

A case of non-falciparum malaria diagnosed on screening of donated blood 10 years after possible exposure

Abstract - 102

Poster 102

A case of non-falciparum malaria diagnosed on screening of donated blood 10 years after possible exposure

Megan Jenkins, Francesca Knapper
Southmead Hospital, Bristol

Introduction: A 27 year old student was referred to the Infectious diseases team following a positive malaria screening test for malaria antibodies on his blood donation in March 2018. Additional testing by PCR resulted in a positive test for malaria DNA, reflecting current infection with either plasmodium vivax,ovale or malariae. The sample was sent for further testing at the malaria reference laboratory to determine the species which is still awaited

Methods: There have been many documentated cases of malaria being transmitted via a blood transfusion and therefore screening blood donations for malarial antibodies in donors who are considered high risk has been ongoing in the English transfusion service for around 15 years. Screening outcomes are either negative or reactive, the reactive samples are then further investigated with a scorable immunofluorescence (IFAT) titre. If the reactivity is confirmed they are further investigated via PCR to determine if there is plasmodium DNA present. Over the 15 year period around 2% of samples are positive on screening via the antibody test and only 20 donations have had malarial DNA detected on PCR testing.

Discussion: Our patient was a Nigerian born male student who donated blood for the first time in March 2018. He last visited Nigeria 10 years previously and his only other travel in this period was to Belgium and South West USA. He had malaria as a child on a number of occasions which was treated with intravenous Quinine but doesn’t think he had any further episodes since around the age of 12. Over the past 10 years he has had no symptoms of relapsing malaria and remained well in himself. The diagnosis of non-falciparum malaria was extremely surprising to him as he was completely assymptomatic. His full blood count was within normal range for all parameters and he had no abnormalities on examination. He was treated with Chloroquine followed by Primaquine and further bloods have been sent to the reference laboratory with the results awaited.

The time period between exposure and diagnosis of malaria in this case was 10 years. If the patient had not attempted to donate blood he may never have been diagnosed as the sensitivity of malaria antigen assays is much lower than PCR. Low level parisitaemias in patients endemic to high risk countries but no longer constantly exposed have been shown to be assymptomatic for many years and this case demonstrates that a patient can be assymptomatic for 10 years and still have evidence of infection with non-falciparum malaria.



Where do medical students travel to on elective? An analysis of Newcastle University Medical School student elective travel 2006-2017

Abstract - 103

Poster 103

Where do medical students travel to on elective? An analysis of Newcastle University Medical School student elective travel 2006-2017

Victoria Parris1, Karen Smith2, Matthias Schmid3
1Royal Victoria Infirmary, Newacstle. 2School of Medical Education, Newcastle University. 3Royal Victoria Infirmary, Newcastle

Introduction: Medical students at Newcastle University Medical School undertake an elective at the end of their fourth year.  The elective period is divided into two blocks of four weeks duration, blocks can be in the same or a different country.  There is no published literature describing where UK medical students travel to on elective, or factors that influence their choice of destination.

Methods: A retrospective analysis of medical student elective destination data between 2006 to 2017 was undertaken.  If a student stayed in the same destination for both elective blocks this counted as one elective episode, if different countries were visited for the elective blocks this counted as two elective episodes.  Elective episodes spent in the UK were excluded from analysis.  Destination countries were categorised into regions and sub-regions according to the UN geoscheme, into income status according to World Bank classification, and into language using the country’s official language.  For countries with multiple official languages, if English, French or Spanish was an official language they were classified according to this language.

Results: Over the last 12 years, students reported travelling overseas on elective to 140 countries (4608 elective episodes).  33.7% of electives were to the top five destinations: Australia (9.5%), India (7.1%), Malaysia (6.4%), New Zealand (5.4%) and Canada (5.3%).

Europe accounted for only 3.1% of elective episodes, with 22 European countries visited during 148 electives.  Sub-regional destination patterns are observed;  62.3% of electives to Africa were to East Africa, within Asia 40.8% of electives were to South East Asia, 72.6% of electives to Oceania were to Australia and New Zealand, and 39.3% of travel to the Americas region was to the Caribbean.  The least popular sub-regions for electives were Central Asia (0 visits), Middle Africa (1 visit), Micronesia (6 visits), Eastern Europe (9 visits) and North Africa (9 visits).

Trends in elective destination have changed over the twelve year time period, most noticeably to Australia which accounted for 14.6% of overseas electives in 2006 and just 2.7% in 2017, the first year it ranked outside the top five destinations.  The Caribbean sub-region grew in popularity, from 8.1% of elective episodes in 2006 to 14.2% in 2017.  At a regional level, travel to Asia increased, due to emerging elective destinations including Mongolia, the Philippines and Sri Lanka.  Some temporal trends can be correlated with specific events, such as the last elective in Syria taking place the year before the start of the civil war, and a sharp drop in elective episodes to Malaysia following the deaths of two elective students.  The 2010 South Africa World cup and 2014 West Africa Ebola outbreak did not appear to impact African regional or sub-regional trends.

Of the 140 elective destination countries, 58 (41.4%) have English as an official language; 68.7% of electives were to these countries (range over time period 56.1-78%).  Electives to Arabic speaking countries were uncommon (0.9% of electives to 10 Arabic speaking counties).  Spanish speaking destinations accounted for 4.8% of elective episodes, Mandarin 1.6% and French 1.4%.  60.7% of electives were to a high or upper-middle income country, 39.3% were to a low or lower-middle income country, with no temporal pattern observed.

Discussion: The elective destinations of Newcastle medical students over a twelve year period are described.  The majority of electives are to destinations which are English speaking and of high or upper-middle income.  There has been a steady decline in the number of students undertaking electives in Australia.  Choice of elective destination by students may be influenced by multiple factors; understanding these could inform the delivery of elective programmes by medical schools.

Uptake and reasons for refusal of travel vaccine recommendations in 1329 new attendances at the Sheffield Travel Health Clinic

Abstract - 104

Poster 104

Uptake and reasons for refusal of travel vaccine recommendations in 1329 new attendances at the Sheffield Travel Health Clinic

Naomi Meardon1, Jacqueline Clark1, Amy Worthington1, Vicky Goodall1, Cariad Evans1, Tom Darton1,2
1Sheffield Teaching Hospitals NHS Foundation Trust. 2University of Sheffield

Introduction: Recommending vaccines to protect travellers against infectious diseases forms a key component of the pre-travel health consultation. When vaccines are taken up, this generally offers a highly effective, safe way of providing long-lasting protection for the individual and can reduce healthcare-associated costs relating to the management of unwell or concerned returning travellers. In this project we performed a retrospective analysis of the demographics, travel patterns, vaccine recommendations and barriers to vaccine uptake in travellers attending the Sheffield Travel Health Clinic (STHC, www.sth.nhs.uk/travel-clinic).

Methods: Travellers self-refer to the STHC, which is a private clinic operated within the NHS and based in the Department of Infectious Diseases at the Royal Hallamshire Hospital in Sheffield. Consultations are performed by specialist nurses or doctors tailored to the planned itinerary and activity, and details of each attendance are recorded in a Microsoft Excel database. All new attendances between April 2015 to August 2018 were included in this analysis.

Results: 1329 new clinic attendances were recorded over the 41 months studied (mean, 7.6/week). The majority of these were single visits 1145), however 81 individuals attended multiple times (range 2-5), for reasons including further travel, change of mind regarding vaccine uptake or receipt of booster vaccination (>4 weeks after initial visit). The median age of travellers was 36 years (IQR 25, 57) although there was a clear bimodal distribution with two peaks at ~25 and ~62 years. Most clinic attendees were members of the public (84%) rather than NHS Trust employees (15%) or their relatives (1%). Reasons for travel included holiday (69%), visiting friends and relatives (12%), aid work (9%), and business-related (9%) and the most common activities included backpacking (25%), trekking and camping (24)% and package holidays (20%). Single region itineraries were the most common destinations for travel: 38, 20, and 14% of attendances were for individuals travelling to Asia, Africa and South or Central America, respectively. 

During the 41-month period, recommendations were made for 3468 vaccines of which 2151 were taken up (62%). The most commonly accepted vaccinations were for yellow fever (94%), combined hepatitis A/typhoid (79%), cholera (77%) and quadrivalent meningococcal vaccine (73%). In contrast the least accepted vaccines included tick-borne encephalitis (47%), Japanese encephalitis (53%) and combined diphtheria/tetanus/polio vaccine (53%). Reasons for refusing recommended vaccines were recorded for 555/1393 (40%) attendances. The most common reasons cited included intention to ask GP for administration (specifically for DTP, hepatitis A and typhoid vaccines), high cost, insufficient time remaining prior to departure, and perceived risks associated with vaccination. In 285 cases, an additional reason for non-vaccination included national vaccine shortages.

Discussion: Vaccine recommendation is a cornerstone of the travel health consultation and is what most travellers seek in attending such a clinic. Relatively little data is available however, regarding the proportion of vaccine uptake in such specialist settings, where facilities are available to optimise this interaction and study reasons for vaccine hesitancy.

In this study we identified a reassuringly high rate of vaccine uptake compared to previous international studies. Refused vaccines broadly fell into two groups: those that are available without cost within the NHS and those which are relatively more expensive and less of a concern to travellers (specifically, Tick-Borne Encephalitis and Japanese Encephalitis). Further work is required to investigate the proportion of attendees who subsequently receive vaccination at their GP; this is important given the insufficient time allowed by most travellers prior to departure. In addition, more work is needed to optimise consultations involving more esoteric and unquantified infections such as TBE or JE in order to enable accurate discussions about risk/benefit of vaccine uptake.


Is it time to review the need for serial blood films in the diagnosis of malaria?

Abstract - 105

Poster 105

Is it time to review the need for serial blood films in the diagnosis of malaria?

Daniella Ross, Rebecca Sutherland
Regional Infectious Diseases Unit, Western General Hospital, Edinburgh

Introduction: Malaria is one of our most common imported infections in the UK with an estimated incidence of 1700 cases per year. Microscopy of thick and thin blood films is the gold standard in malaria diagnosis and UK guidelines recommend the need for three serial films. The rationale for three films is longstanding; cyclical parasitaemia could be missed with low levels of infection and the preparation and examination of blood films is highly user dependent with significant inter-user variation. The preparation and review of three separate films is, however, time consuming and comes with cost implications.

Our hypothesis, from departmental experience, was that patients presenting with symptoms suggestive of possible malaria are rarely diagnosed with malaria outwith their first blood film and rapid diagnostic test (RDT). We aimed to review the use of possible clinical predictors such as fever, thrombocytopenia, malaria prophylaxis and whether a patient was from an endemic country, in order to guide the need for three serial films.

Methods: A retrospective review of our blood result database was undertaken on all adult patients with a positive malaria diagnosis presenting to our teaching hospital within NHS Lothian from January 1, 2014 to August 1, 2018. We reviewed whether the diagnosis of malaria was made on first or subsequent blood films.


Case inclusion: We identified a total of 69 malaria positive patients. Of these; 7 had had a positive RDT but negative serial blood films having recently been fully treated in other countries. 1 patient had a false positive RDT confirmed with our reference laboratory. A total of 61 patients were therefore included for analysis. 

Case characteristics: 48 patients (79%) had P. falciparum malaria, 7 (11%) P. vivax, 1 (2%) P. ovale, 4 (7%) P. malariae and 1 (2%) had mixed infection with P. falciparum and P. ovale.

29 patients were from the UK, 17 from malaria endemic countries but living in the UK, and 13 were visiting tourists. 87% of patients had fever on presentation, 73% were thrombocytopenic on presentation and 20% had taken malarial prophylaxis, although 83% had been non-compliant with it.

Malaria diagnosis: In 59 out of 61 cases (97%), malaria diagnosis was made on first blood film. All cases of P. falciparum were diagnosed on first film.  In two cases (3%), malaria was diagnosed after initial negative film and initial negative RDT; both were Plasmodium vivax infections.

  • The first case was from an endemic country, was febrile, had a normal platelet count and was diagnosed with P. vivax on third film with an estimated parasitaemia of <1%.
  • The second case was a UK born traveller, was apyrexial, had taken anti-malarial prophylaxis, was thrombocytopenic and was diagnosed with P. vivax on their fourth film (taken due to ongoing symptoms without a confirmed diagnosis).

Discussion: In our setting, nearly all patients were diagnosed with malaria on their initial set of tests. Reassuringly all cases of P. falciparum were diagnosed on first film, although we understand that P. vivax is now well recognised as a cause of severe and potentially fatal disease. Two P. vivax diagnoses from our data set would have been missed should we only have examined one blood film.

We acknowledge the limitations of our study, particularly with regards to sample size. Using our data set, we propose that patients with our negative clinical predictors (those who are not from an endemic country, are apyrexial, have a normal platelet count and have not taken malarial prophylaxis), who have one negative blood film and RDT, could avoid the need for three serial blood films. This would therefore reduce unnecessary investigation provided appropriate safety netting and patient review was instigated.

Pancytopenia and fever post-chemotherapy for gestational trophoblastic disease

Abstract - 106

Poster 106

Pancytopenia and fever post-chemotherapy for gestational trophoblastic disease

Elena Ferran1, Christopher Chiu2, Ho Kwong Li1, Paul Middleton1, Frances Sanderson1, Aula Abbara1
1Imperial College Healthcare NHS Trust, London. 2Imperial College London

Introduction: A 47-year-old German female was admitted 24th January 2018 with a 2 month history of fevers which she first noted when she was working in Brazil; after fourteen days away, she returned to the UK and her fevers subsided. The fevers returned 1 week later during a subsequent holiday in Barbados. The fevers and rigors occurred twice each day and were associated with a reduced appetite, fatigue and 5kg weight loss. She noted her abdomen was distended but her bowel habit was normal. She had travelled extensively for work and leisure in the past year to South Africa, Cape Verde, Mauritius and Spain with her husband, who remained well throughout. She had no animal exposures and received all required vaccinations.

Her recent past medical history included having recently completed six months of chemotherapy for persistent gestational trophoblastic disease (GTD) after IVF treatment which was treated with chemotherapy; this included methotrexate then actinomycin D. She had her last dose of chemotherapy two weeks before her travel to Brazil and the onset of fevers.

Methods: On examination, positive findings were a fever to 38°C, massive splenomegaly, a 1cm cervical lymph node and bilateral inguinal lymph nodes. Initial laboratory results include: Hb 74 g/L (115-165 g/L), WCC 1.6 109/L (4-11 109/L), neutrophils 0.9 109/L (2-7.5 109/L), platelets 129 109/L (150-450 109/L). Renal and liver function were normal. CRP peaked at 79 mg/L (<5mg/L). The blood film confirmed the pancytopenia and showed atypical lymphocytes, neutropenia with toxic granulation and vacuolation. Malaria film and HIV tests were negative. CT chest, abdomen and pelvis with contrast confirmed the marked splenomegaly but a normal liver and no lymphadenopathy. She received empirical antibiotics (vancomycin, ciprofloxacin and gentamicin due to a penicillin allergy) whilst awaiting a bone marrow biopsy.

Discussion: Leishmania infantum is found in the Mediterranean region, the Old World and Latin American including Brazil and she had travelled to a number of countries in these areas in the last year. In view of the extensive travel history it is not clear if this is primary or reactivation of Visceral Leishmaniasis in the context of chemotherapy for GTD. It is, however, very likely that her overt disease was due to the immunosuppression from the recent chemotherapy.

HIV co-infection and immunosuppression post-transplant are recognised causes of Visceral Leishmaniasis reactivation but has not been as frequently documented in cases of immunosuppression post-chemotherapy although increasingly recognised.

The association between high risk countries for Strongyloides stercoralis infection and gram-negative bacteraemia in patients with renal transplants

Abstract - 107

Poster 107

The association between high risk countries for Strongyloides stercoralis infection and gram-negative bacteraemia in patients with renal transplants

Daniel Pan, Paul Arkell, Stephan Brincat, Catherine A. Cosgrove
St George’s Hospital, London

Introduction: Strongyloidiasis is a disease that is endemic in Africa, Asia and Latin America. Infection with strongloides stercoralis, the causative parasite can persist for decades. Complications include life-threatening gram-negative bacteraemia and hyperinfection syndrome, which are more likely to occur in the immunosuppressed. Curative treatment with ivermectin and/or albendazole is simple and cheap, with no severe side effects. We therefore aimed to examine whether screening for Strongyloides stercoralis was implemented in renal transplant patients from countries of high endemicity, in the setting of a country with low strongyloides stercocalis prevalence (the United Kingdom). We also aimed to see whether there was a relation between being from a high risk country and development of gram negative bacteraemia post renal transplant.

Methods: Retrospective observational study of a single renal transplantation centre in London, United Kingdom. Consecutive patients receiving renal transplants from 1st January 2009 to 1st January 2016 were included in the study. All patients were on varying doses of tacrolimus, mycophenolate mofetil and prednisolone as immunosuppresive therapy. Country of origin was determined by Onlytics, a validated software which determines ethnicity from patient name. Countries were then divided into those from Africa, Asian and Latin America (ie high risk for strongyloidiasis) and those who were not. Possible indicators for strongyloidiasis (strongyloides stercoralis serology, stool microscopy, eosinophil counts and blood cultures) as well as all-cause mortality were recorded. 

Student’s t-test or Mann-Whitney U were used to determine the relation between continuous variables depending on the normality of distribution. Chi-squared or Fisher’s exact test were used to determine the relation between categorical variables. Cox regression analysis was used to determine the relation to mortality.

Results: 264 patients were recruited. The median number of days of follow-up post transplantation was 1651 (IQR 823-2273). Over this period, 16 (6%) patients died. 154 (58%) were male. Median age was 52 (interquartile range 42-62). A third (30%) were from a high-risk country. 75 (29%) of patients had eosinophilia(>0.4 x109/L) at some point post transplantation. Serology was only performed in two patients (both of which was negative). Faecal ova cysts and parasites were performed in 15 (6%) patients, all of which were negative. Gram-negative bacteraemia post-transplant was present in 21 (8%) patients. 

There was no relation between being from a high-risk country and eosinophilia, either before or after renal transplantation. Patients from a higher risk country were more likely to have an episode of gram negative bacteraemia post renal transplantation (13 patients versus 8 patients, p=0.001).  However, being from a high-risk country was not related to death.

Discussion: Survival in the first seven years post renal transplantation was generally good and not related to any risk factors for strongyloidiasis infection.

Although the absolute number of patients with gram negative bacteraemia was low, patients from endemic countries were more likely to have an episode than those who were not. It is unknown however whether this is because of strongyloidiasis, since few, if any patients were screened adequately for the parasite.

Future work should look at whether mass screening and treatment would be cost effective in renal transplant patients from high risk countries living in the United Kingdom.

Strongly suspect this diagnosis in the renal transplant patient with acute shortness of breath

Abstract - 108

Poster 108

Strongly suspect this diagnosis in the renal transplant patient with acute shortness of breath

Daniel Pan, Paul Arkell, Neil Stone, Catherine A. Cosgrove
St George’s Hospital, London

Introduction: A 50-year old man of Angolian origin, but no significant travel history presented with a 4-week history of cough and worsening exercise tolerance. His past medical history included cytomegalovirus (CMV) viraemia in 2016 and prior renal transplantation in 2012 and 2016. He was on tacrolimus 8mg twice daily, mycophenolate modefetil (MMF) 500mg twice a day and prednisolone 5mg once a day for his renal allograft.  

Methods: The patient was admitted to the Infectious Diseases ward. Although he appeared breathless, there were no respiratory findings on physical examination. An initial arterial blood gas showed type one respiratory failure, with a paO2 of 13.4 on 8 litres of oxygen.  Chest radiography revealed reticulonodular shadowing throughout both lungs. Laboratory tests showed a normal white cell count (4.5 x 109/L), with differentials within normal limits, but a raised C-reactive protein of 257mg/L. He was started empirically on intravenous co-trimoxazole 120mg/kg/day and a 5 day course of high dose oral prednisolone 40mg twice daily to cover presumed severe pnemocystis jirovecii pneumonia (PJP). He also commenced on intravenous co-amoxiclav 1.2g three times a day and oral doxycycline 100mg once a day for atypical bacterial infection as well as intravenous gangciclovir 5mg/kg twice a day for CMV pneumonitis.

Discussion: Sputum microscopy grew Candida albicans and PCR came back positive for PJP only. Aspergillus antigen in the sputum and Beta-D glucan in the serum were both negative. CMV levels in the bood was low (441 IU/ml). Stool microscopy, culture and sensitivity and screening for ova, cysts and parasites were negative. Strongyloides serology was negative. Gangciclovir was stopped. The patient did not improve with initial empirical therapy. On day 5, co-amoxiclav and doxycycline was escalated to intravenous meropenem 2g three times a day and caspofungin 70mg once a day was added. Co-trimoxazole for PJP was switched to second line treatment with intravenous clindamycin 600mg four times a day and primaquine 30mg once daily.

The patient continued to deteriorate despite change in therapy. By day 6 of admission, the patient was in type 2 respiratory failure and was transferred to the intensive care unit for intubation and ventilation. On day 19, bronchoalveolar lavage was performed. By day 38, the patient went into multi-organ failure and passed away.

Intestinal parasitic infections in primary school children in Umuahia South, LGA Abia State, Nigeria

Abstract - 109

Poster 109

Intestinal parasitic infections in primary school children in Umuahia South, LGA Abia State, Nigeria

Onyinye Ukpai, Eze ThankGod
Zoology and Environmental Biology, Michael Okpara University of Agriculture, Umudike, Umuahia, Nigeria

Introduction: Intestinal parasitic infections are among the most common infections in humans worldwide. They are a big cause of morbidity and mortality, contributing greatly to the psychological retardation of humans especially children. Majority of infected persons live in poverty-stricken areas with poor sanitation. Poverty is more than lack of income or resources.  People live in poverty if they lack basic services such as health-care, security and education. Children usually make up more than half of those living in extreme poverty. Bearing in mind the SDGoals one, three and six, this study aimed to determine the prevalence of intestinal parasitic infections in primary-school children in some rural communities and the risk factors that could have influenced parasite transmission.

Methods: A cross sectional study was done in Umuahia South LGA, Abia State, Nigeria (50 26I N and 70 33I E) involving 340 primary-school children aged 5-16 years. Their faecal samples were subjected to standard diagnostic methods and examined under the microscope for the presence of intestinal parasites. Questionnaires were administered to collect socio–demographic data and ascertain the risk factors associated with parasite transmission.

Results: The overall prevalence of intestinal parasites was 40.88%. Six parasites were observed namely Ascaris lumbricoides, hookworm, Trichuris trichiura, Entamoeba histolytica, Entamoeba coli and Taenia solium. Mixed parasitism (12.06%) was also encountered with the combination of Ascaris lumbricoides and hookworm recording the highest occurrence. Highest prevalence by school was in Ogbodinibe/Umuodo Community School (48.76%). The highest prevalence by class was in primary three pupils (58.49%). The age group 5-7 years had the highest rate of infection (56.94%). Pupils whose parents were involved in business had the highest infection rate (64.2%). With respect to parents’ level of education, highest prevalence of infection was in pupils with parent with First School Leaving Certificate (50.30%). Highest infection rate was recorded in pupils who used harvested rain water as source of drinking water (82.35%). Infection based on toilet facilities used at home was highest among those that used pit latrine (44.15%). The prevalence of infection based on refuse disposal type used showed that highest infected group was among the pupils that used open baskets to put refuse (94.87%). Hygiene related infection showed that those who didn’t wash their hands after toileting had the highest prevalence of 54.54%.

Discussion: This study confirms the endemicity of intestinal parasites in the children. Infected children can be an infection focus for the community. This calls for intervention through provision of basic facilities such as potable water, health care (mass deworming programmes) and health education emphasizing control measures to drastically reduce the onslaught of intestinal parasitic infections.

Keywords: Intestinal parasitic infections, primary-school children, Abia State, Nigeria.



Investigating the utilisation of Rare and Imported Pathogens Laboratory testing through a hub-and-spoke model of laboratory practice

Abstract - 110

Poster 110

Investigating the utilisation of Rare and Imported Pathogens Laboratory testing through a hub-and-spoke model of laboratory practice

Aroon Bhardwaj Shah1, Umar Ebrahimsa2, Scott Pallett2, Nabeela Mughal2,3, Luke SP Moore2,3,4
1Imperial College School of Medicine, Imperial College London. 2Microbiology & Infectious Diseases, Chelsea and Westminster Hospital, London. 3North West London Pathology, Imperial College Healthcare NHS Trust, London. 4National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London

Introduction: Fever in the returned traveller has a wide differential diagnosis and traditional methods for testing individual pathogens increases costs and slows diagnoses. In order to improve efficacy and reduce cost the centralised Imported Fever Service is offered by the Rare and Imported Pathogens Laboratory (RIPL), Porton Down. Trusts referring samples through this service should have robust mechanisms ensuring time sensitive processing and integration of diagnostic RIPL results into patient care. The development of hub-and-spoke models for laboratory service provision in individual Trusts can complicate this process.

We conducted a multi-centre retrospective, observational study of patients for whom RIPL testing was undertaken by North West London Pathology a centralised laboratory situated at Charing Cross Hospital (CXH), serving the spoke sites Chelsea and Westminster trust (CW), Queen Charlottes (QC) Hammersmith (HH), St. Mary’s (SMH) & Hillingdon Hospitals (HiH).

Methods: RIPL sample reports were extracted from a laboratory information management database for six months between 01/04/2018 and 30/09/2018. Institutional databases were used to collect clinical and laboratory data including indication for testing, timed movements of samples, and the reported results.

Results: After de-duplication 52 requests were identified from 49 patients during the study period. Completed and documented RIPL results were available for 39 samples.  The remaining 13 samples were not processed; 9 not received, 2 insufficient details, 1 improper packaging, 1 leaked. Of the 39 completed RIPL samples 6 were from CW, 12 CX, 6 HH, 12 SMH, 1 QCCH, and 2 HiH. 59% (23) were female. The mean patient age was 35 years (range 1-78 years).

Sample logistics: The mean time between requesting a RIPL sample and receiving a result was 18days 14hours (range 3days 20hours – 84days 14hours) with 1 result still pending. Samples waited in the centralised CX laboratory prior to being sent to RIPL for a mean of 2days 14hours (range 0hours – 35days). The majority of the remaining turnaround time was at RIPL; mean 13days 10hours (range 2days 3hours – 79days). Overall it took notably longer for a RIPL sample to be resulted from a spoke site (19days 22hours) compared to requests from the central site, CX (15days 2hours).

Patient epidemiology & clinical presentation: The most common clinical presentation documented was fever (26/39), clinical features such as myalgia, arthralgia, vomiting and rashes were also recorded. 22 different countries were visited by patients from whom RIPL samples were taken.

RIPL results: 6 samples provided evidence supporting acute infections (4 Leptospirosis, 1 chikungunya and 1 dengue). 7 samples demonstrated only IgG evidence of tropical diseases (2 dengue, 2 yellow fever, 2 spotted fever and 1 anaplasmosis). 24 samples were negative. 1 sample was reported as stored and 1 result was still pending at the time of writing this audit. Overall 15.3% of returned RIPL results came back positive for an acute infection. This rose to 30% if only samples from those who had travelled to South-East Asia were considered. Half of RIPL results indicating acute infection (3/6) were from patients who had recently returned from South East Asia. 

Discussion: There was marked variation in turnaround time for RIPL samples, with a notable period spent waiting at the centralised laboratory prior to being sent to RIPL. This suggests that where hub-and-spoke models of pathology services are in place, there may be a need for a clear protocol regarding how RIPL samples should be handled to ensure an efficient system and effective patient care. 

The proportion of RIPL samples yielding evidence of current rare or imported infections appears to be relatively low. Clear guidelines need to be operationalised regarding when to send RIPL samples. 



Investigation and initial management of suspected MERS in patients admitted to Chelsea and Westminster Hospital between August 2017 and September 2018

Abstract - 111

Poster 111

Investigation and initial management of suspected MERS in patients admitted to Chelsea and Westminster Hospital between August 2017 and September 2018

Katherine Lewis1, Umar Ebrahimsa2, Scott Pallett2, Nabeela Mughal2,3, Luke Moore2,3,4
1Imperial College School of Medicine, Imperial College London. 2Microbiology & Infectious Diseases, Chelsea and Westminster Hospital, London. 3North West London Pathology, Imperial College Healthcare NHS Trust, London. 4National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London

Introduction: Middle Eastern respiratory syndrome (MERS) has the potential to cause severe respiratory compromise with an estimated 35% mortality rate.

Although rare in the UK, with five cases being identified since 2012, multiple healthcare associated outbreaks in other countries demonstrate the importance of early identification of risk factors such as travel history, camel, and relevant healthcare exposure. Effective management of suspected cases requires clear infection prevention and control guidance. In England, samples are tested at Public Health England (PHE) Laboratories in Birmingham or Manchester, and there exists a governance risk relating to the communication and documentation of these results at the referring hospital.

Analysis of patient pathways for the management of suspected MERS cases at a London teaching hospital will be examined in order to identify areas for improvement.

Methods: A retrospective single-centre audit was completed at an acute NHS Trust by reviewing all patients with suspected MERS presenting between August 2017 and September 2018. Clinical and laboratory data was collected using electronic health records. This included identification of risk factors such as travel history, presenting symptoms, investigation requests, documentation, bed status/movements, timing and documentation of key decisions, and final diagnosis. Collected data was then analysed for adherence to current PHE and Trust guidelines.

Results: A total of 10 patients were identified as potential cases of MERS, all 10 were tested. All tests returned a negative result. The most common presenting complaint was fever (4), followed by shortness of breath (3), cough (2) and chest pain (1). The majority (50%) visited Saudi Arabia, 2 visited Qatar, 2 visited Bahrain, and 1 visited United Arab Emirates.

7/10 had evidence of MERS as a differential diagnosis in the notes, with identification occurring in less than 90 minutes (mean time 61 minutes). Of the remaining 3 cases, no mention was made in one patient’s notes until the discharge summary, and no evidence whatsoever was available in the last 2.

8 patients had documented movement into a side room (6) or negative pressure room (2). Of these patients, 2 were admitted to a side room on arrival and a further 4 were isolated within 2 hours; all were moved within 21 hours 15 minutes. 1 patient was sent home post-sampling due to mildness of symptoms and 1 patient had no clear documentation of isolation in the A&E notes, although was admitted to a side room on arrival to the medical ward.

5 patients had documented the time of sample taking (mean time of 2 hours 1 minute after admission to A&E). Documentation of a MERS test result was noted in only 2/10 patients’ clinical records, and no reference laboratory reports were returned. The most common final diagnosis was influenza (40%) of which all were Influenza A.

Discussion: Identification and isolation of possible MERS cases has significant variation. There remains a considerable number of patients who are not isolated within 2 hours of identification (30%). The investigation and results of possible MERS cases is poorly documented.

There was little or no recording of when samples were received by PHL Birmingham and equally little documentation of when results were received.  An improvement in the feedback mechanism for results and documentation of management decisions will reduce the risk of error and has the potential to improve patient care.

Major Sponsors