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INTRODUCTION: Violence is increasingly recognised as a major public health issue yet health data are underutilised for describing the problem or developing responses. We use English emergency hospital admissions for assault over four years to examine assault demography and contribution to health inequalities. METHODS: Geodemographic cross-sectional analyses utilising records of all individuals in England (n = 120 643) admitted between 1 April 2002 and 31 March 2006. RESULTS: Over 4 years, rates of admission increased by 29.56% across England. Admissions peaked on Saturdays (22.34%) and Sundays (20.38%). Higher rates were associated with deprivation across all ages, including those <15 years, with a sixfold increase in admission rates between the poorest and wealthiest quintiles of residence. Logistic regression analyses indicate males are 5.59 times more likely to be admitted to hospital for assault and such admissions peak in those aged 15-29 years. Modelling based on national assault admissions and limited Accident and Emergency (A&E) data suggest that while more serious assaults requiring hospital admission have increased, assault attendances at A&Es have fallen. DISCUSSION: Hospital admission and A&E data identify a direct contribution made by violence to health inequalities. Levels of violence inhibit other interventions to improve people's health through, for instance, outdoor exercise or delivery of health-related services in affected areas. With disproportionate exposure to violence in poorer areas even in those under 15, early life primary prevention initiatives are required in disadvantaged communities to reduce childhood harm and the development of adult perpetrators and victims of violence.

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OBJECTIVE: To determine whether previous diagnosis with tuberculosis (TB) increases the risk of mortality. DESIGN: A retrospective survey of 439 TB patients in the city of Liverpool, population 439500, over an 8-year period. OUTCOMES: Mortality compared with the general population; cause of death as identified from death certificates. RESULTS: A total of 104 (23.7%) TB cases had died within the follow-up period. For 45-54 year olds, the standardised mortality ratio (SMR) was 1101, an 11-fold higher mortality than expected from the Liverpool population. The SMR then declined with age, but remained higher in males than in females. Death certificates showed that 34 (30.8%) died from TB and 26 (21%) from bronchopneumonia. Malignancy was the cause of death in 24 cases (28%), including 16 with lung tumours, all in patients aged under 75 years. This gave a 30-fold greater mortality from lung cancer compared with the general population aged under 75. CONCLUSIONS: TB increases the risk of mortality compared with the general population, with unexpectedly high mortality from lung cancer in cases aged under 75. Older patients die from TB itself or other chest diseases. Common risk factors for the Liverpool population probably contribute to elevated mortality from all chest-related diseases, including TB.

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SETTING: Despite declining tuberculosis mortality per head of population, there was little change in tuberculosis case fatality in England and Wales from 1974 to 1987. OBJECTIVE: To determine the trend in tuberculosis case fatality for England and Wales from 1988 to 2001. DESIGN: Annual deaths to notifications ratios (DNRs) for tuberculosis were calculated using published notification and mortality data, and analysed by age group and three disease sites (central nervous system [CNS], respiratory and other). DNRs for seven disease sites (miliary, bone and joint, CNS, respiratory, genitourinary, gastrointestinal and other) were calculated for 1998 and 1999 combined, using additional data from the enhanced tuberculosis surveillance programme. RESULTS: DNR for all ages and disease sites combined fell from 9.26% in 1988 to 5.59% in 2001 (r = -0.90; 95%CI -0.97 - -0.70). DNRs for 1998-1999 combined were 41% for miliary disease, 17% for bone and joint disease, 8% for CNS disease, 7% for respiratory disease, 2% for genitourinary and gastrointestinal disease and 0.6% for other disease. CONCLUSIONS: Some of the decrease in DNRs may be due to improving notification rates. True declines in overall case fatality reflect increases in the proportion of tuberculosis patients in younger age groups and with low mortality extra-pulmonary disease.

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We used routine surveillance data to investigate whether deprivation relates to hospital admission in a HIV-positive population. HIV-positive individuals living in the poorest areas were more likely to have spent one or more nights in hospital for HIV-related care (adjusted odds ratio = 1.6, p = 0.009, after controlling for infection route, disease stage and demographic variables). This implies that healthcare networks in poorer areas may incur disproportionately greater costs.

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In recent years enhanced surveillance of tuberculosis has been undertaken for England and Wales to monitor national epidemiological trends. The Chief Medical Officer's strategy for communicable diseases has identified the development of a national strategy for the control of tuberculosis as a priority. Regional and sub-regional variations in the occurrence of tuberculosis require further exploration to inform local implementation of the national strategy. Secular epidemiological trends in tuberculosis for the period 1918-2001 are described for a deprived urban area in the north west of England, and implications for local enhanced surveillance and control measures are discussed. A substantial decline in mortality and morbidity from tuberculosis is shown due to interruption of transmission following improvements to the housing stock and the introduction of chemotherapy and BCG vaccination. The proportion of incident cases of tuberculosis in non-white groups has markedly increased over the period observed. The local tuberculosis control programme now specifically targets recent non-white immigrants. Other urban areas may need to adopt similar measures to improve local control of tuberculosis.

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OBJECTIVES: To identify sources and routes of infection for sporadic cases of campylobacter infection in the North West of England. METHODS: Standard, structured questionnaires were used to gather epidemiological information from cases of campylobacter infection in the North West Region of England between 1997 and 1999. The strains of campylobacter isolated from these cases were identified and typed using serotyping and phage typing methods. Analysis of combined serotype and epidemiological data is presented. RESULTS AND CONCLUSIONS: Human campylobacter infection in the North West is seasonal and a new observation was a peak in cases in March each year. Drinking bird-pecked milk was a highly seasonal exposure that might be an indicator of environmental contamination with campylobacter. A possible environmental basis for seasonality of infection is discussed. Frequencies of risk exposures related to serotypes of cases are described and a potential association was demonstrated between Campylobacter jejuni HS6 and consumption of bird-pecked milk. Also, Campylobacter coli infections were more commonly associated with travel abroad than C. jejuni and a decreased proportion of C. jejuni HS2 and C. jejuni HS11 reported consumption of meat and unpasteurised milk (respectively). Contact with a sick animal may be a significant risk exposure in younger age groups and in those who do not consume poultry or meat. It is clear from this and other studies that the sources and vehicles of human campylobacter infection are numerous and interventions that target a single risk factor are unlikely to impact significantly on the overall burden of disease.

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Notification of tuberculosis cases is often incomplete but combining data from several sources can provide a more accurate estimate of the number of cases. Data for the city of Liverpool were collected over an eight-year period from three sources: notifications, microbiological records and in-patient discharge coding data. Capture-recapture (CR) techniques were used to estimate the total number (including unreported cases) of tuberculosis cases in the city. By creating a log-linear model from the pattern of case replication between data sets, a model of best fit was created from which the number of cases present in the population, but not identified in any of the data sets, was estimated. False positive diagnoses were found in 67/516 (13%) of notifications and in 65/241 (27%) of in-patient codings. After excluding these, the total combined number of cases from all data sources was 473. CR methods identified only twelve extra cases (2.5%) making the estimated number of true cases total 485. Of these, in-patient codings identified 36.3%, microbiological records 56.3% and notifications 92.6%. It was concluded that notification of tuberculosis is very complete in Liverpool. Capture-recapture methods can be used to assess completeness of notification data in other settings.

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The aim of this study was to identify the subtle influences of exposure and individual lifestyles on the risk of developing tuberculosis. A retrospective case-control study (with matching by sex, age, postcode and ethnicity) of all tuberculosis cases notified over a 7-yr period in Liverpool, UK, was carried out. Multiple logistic regression showed that, before diagnosis, cases were 7.4 times more likely to have had visitors from abroad; 4.0 times more likely to have been born abroad; and 3.8 times more likely to have lived with someone with tuberculosis. Subtle socioeconomic factors were also evident with cases 4.0 times less likely to have additional bathrooms. Lifestyle factors emerged with cases 2.3 times more likely to have smoked for at least 30 yrs, 3.8 times less likely to eat dairy products every week and 2.6 times less likely to have had high blood pressure. At interview, these factors were still evident, but cases, unlike controls, had reduced their smoking and alcohol consumption and were less likely to go out of the home or exercise than before their illness. Within individuals, lifestyle consequences of tuberculosis lead to a "healthier" lifestyle on the one hand (less smoking and alcohol consumption), but a reduced quality of life (social activity) on the other.

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OBJECTIVES: A reinvestigation of the relationship between the decline of tuberculosis and improvement in social conditions in England and Wales during Victorian times. DESIGN: A retrospective study using data published in the annual reports of the Registrar General from 1853 to 1910. MEASURES ASSESSED: The diseases studied, in addition to tuberculosis were dysentery and cholera, including their total and infant mortality. Social conditions were evaluated from earnings and population density per house. RESULTS: Tuberculosis mortality declined at an annual average rate of 1.71% (95% confidence interval [Cl] 0.77-2.63), whereas total mortality, infant mortality and mortality from cholera and dysentery and house population density showed no statistically significant decline over the same period. Real earnings increased by 1.05% (95% CI 0.29-1.81). CONCLUSION: Improving social conditions do not provide the total explanation for the decline in tuberculosis during Victorian times. Other factors, principally natural selection, probably played a role. Part of the current increase in tuberculosis may be caused by effective drug therapy eliminating natural selection.

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This study assessed the contribution of immigration and deprivation to the changes in tuberculosis notifications in Liverpool over the last 20 yrs. Ethnic origin was retrospectively assigned to all named cases from 1974 to 1995. Average tuberculosis rates were calculated for the 33 council wards in Liverpool for 1981-1985 and 1991-1995. Multiple regression was used to determine the independent effects of socioeconomic and population measures from the 1981 and 1991 censuses in explaining these ward-based rates. Since 1974, there has been a steady increase in the percentage of non-Caucasian cases of tuberculosis, from 8.7% in 1975-1977, 15.1% in 1981-1983, 17.5% in 1987-1989 to 28.0% in 1993-1995. Multiple regression analysis showed that in 1981 only unemployment had a significant independent relationship with tuberculosis rates, but in 1991 two indices of deprivation and ethnicity had a significant influence. The increasing proportion of non-Caucasian tuberculosis cases, both while the number of notifications was declining before 1987 and increasing afterwards, is not necessarily consistent with the concept that immigration has influenced the recent increase. However, the fact that ethnicity now independently explains some of the council ward variations but did not in the early 1980s suggests that immigration does influence the distribution of disease within the city.

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UNLABELLED: A reinvestigation of the relationship between the decline of tuberculosis and improvement in social conditions in England and Wales during Victorian times. DESIGN: A retrospective study using data published in the annual reports of the Registrar General from 1853 to 1910. The diseases studied, in addition to tuberculosis were, dysentery and cholera including their total and infant mortality. Social conditions were evaluated from earnings and population density per house. Tuberculosis mortality declined at an annual average rate of 1.71% (95%CI 0.77 to 2.63) whereas total mortality, infant mortality and mortality from cholera and dysentery and house population density showed no statistically significant decline over the same period. Real earnings increased by 1.05% (C10.29 to 1.81). Improving social conditions do not provide the total explanation for the decline in tuberculosis during Victorian times. Other factors, principally natural selection, probably played a role. Part of the current increase in tuberculosis may be caused by effective drug therapy eliminating natural selection.

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The caseload of tuberculosis in developing countries is increasingly associated with the elderly. This is possibly due to increased longevity today and a change in the lifetime risk of tuberculosis within birth cohorts. Published data for tuberculosis notifications for Hong Kong and England and Wales have been used to calculate age-specific rates of disease by different age groups for different birth cohorts. In Hong Kong, each birth cohort showed a similar pattern of disease by age, with rates peaking in the 25 to 39-yr age groups and gradually declining thereafter. After 1978, regardless of age at that time, all age cohorts showed an increase in tuberculosis rates with increasing age. This trend was more marked in males than females. A similar pattern was seen for birth cohorts in England and Wales except that the peak occurred earlier in life (before 25 yr of age) and the decline with age ceased in 1984. Thereafter, rates increased in males born before 1930 but showed only a leveling off in females. If these data represent a true increase in tuberculosis rates, rather than resulting from a change in reporting accuracy and completeness, the burden of tuberculosis in the elderly is likely to continue to increase substantially.

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The number of whooping cough notifications has declined in recent years, as vaccine coverage has recovered from the low levels seen in the 1970s and 1980s. Notification of infectious disease is often incomplete, and this study aimed to estimate the extent to which whooping cough is undernotified. We included all cases of whooping cough occurring in the North West Region between 1 April 1994 and 31 December 1996, identified by notification, hospital admission data, or laboratory reports. By combining the three sources, 1239 cases were identified, 69.6% of which were notified. The notification rate was 29.6% (131/442) for cases admitted to hospital and 45.6% (78/170) for laboratory reported cases. Completeness of notification was estimated to be 35.7% (863/2420; 95% confidence interval 30.3-43.4%) using the capture-recapture method. The study confirms that notification of whooping cough is incomplete and suggests that two thirds of cases are not notified.

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SETTING: Metropolitan areas of England, including London boroughs, in 1991. OBJECTIVE: To investigate the relative importance of deprivation, immigration and the elderly in explaining variations in tuberculosis rate. DESIGN: A retrospective study using multiple Poisson regression models to assess the interrelationship between various population parameters. RESULT: Significant differences ere observed between London and other metropolitan districts in the measures of tuberculosis, immigration and the elderly. In addition, all population parameters were significantly intercorrelated in London: areas with a high proportion of immigrants had high levels of deprivation and low proportions of elderly. In other metropolitan districts, only immigration and the Jarman index were significantly associated, and removing the immigration component from the index removed this statistical significance. Multiple Poisson regression models revealed that the immigrant index had the strongest explanatory power in explaining tuberculosis rates, but there were significant interactions between this and measures of urban deprivation indices. That is, there was a greater effect of increasing deprivation at lower levels of immigration than at higher levels. This phenomenon was more pronounced in London boroughs than other metropolitan districts. The elderly index had no significant influence on tuberculosis rates. CONCLUSION: Although the association between tuberculosis and deprivation previously reported for the city of Liverpool is confirmed across all urban areas of England, the immigrant proportion of the population has a greater statistical power in explaining variations in rates of urban tuberculosis. However, tuberculosis notifications can be most accurately predicted by combining both measures than by either one alone.

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Transmission of Pseudodiplorchis americanus is restricted to the brief period when its host, a desert toad, enters water to spawn. The parasite accumulates its entire annual reproductive output within an elongated uterus during the 10-11-month period of host hibernation. Embryos of P. americanus, at all stages of development, are retained within the uterus which eventually becomes packed with around 150 encapsulated infective larvae. Recently formed eggs, which comprise a fertilized ovum and 2-3 vitelline cells, are closely surrounded by a primary eggshell which stains positively for acidic proteins and keratin. Initially, during passage along the proximal uterus, the egg capsule is only 60 microns in diameter, but as it passes to the distal uterus it expands to 800 microns in diameter to accommodate the growing larva. Due to chemical alterations or complete replacement of the shell, the final (secondary) egg capsule is a large sac-like structure composed of elastin. The flexible nature of this shell maximizes the numbers of infective larvae which can be stored in utero. TEM studies have revealed this capsule to be composed of multi-laminate membranes with a specialized cytoplasmic lining involved in a unique mechanism for embryo nutrition. This is the first report of an elastin-type eggshell within the Monogenea.

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BACKGROUND: Tuberculin testing remains the standard method for assessing infection due to tuberculosis in the UK. However, there are no data on the incidence of tuberculin positivity among the general adult population in the UK and consequently interpretation of Heaf test results is often difficult. METHODS: During the investigation of an outbreak of tuberculosis in a Liverpool social club 198 members were interviewed and Heaf tested and 171 members of a second social club in Liverpool were similarly screened as a control group. Comparisons between the results from the two populations provided both an estimate of baseline Heaf test positivity in indigenous white adults from a British inner city population, and a measure of the effect on this baseline of recent exposure to tuberculosis. RESULTS: In both club populations the proportion of positive Heaf tests increased with age. Independent of age, the tuberculosis exposed population had a higher proportion of positive Heaf grade results (40.9%) than those in the control group (26.9%). Multivariate analysis confirmed both the differences in Heaf results between clubs and between age groups but identified no other behavioural or medical factors which affected Heaf test results. CONCLUSIONS: Heaf test positivity increases with age at least up to 54 years, and recent exposure to tuberculosis increases the proportion of positive Heaf tests in each age group. Interpretation of positive Heaf tests when assessing the effects of a tuberculosis outbreak should take account of background levels of Heaf positivity.

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