Communicable Disease and Health Protection Quarterly Review: January to March 2005
From the Health Protection Agency Centre for Infections
Keywords: communicable disease, influenza, mumps, salmonella, disease management, bloodborne viruses, chemical incidents, emergency preparedness
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Policy and practice:
- Influenza pandemic plan
Outbreaks and incidents:
- Mumps
- Heaf testing
- Salmonellosis
Publications:
- Managing meningococcal disease
- Managing invasive group A streptococcal disease
- Managing gastrointestinal infections
News from abroad:
- Polio
- Rabies
- Marburg virus
- Variant Creutzfeldt–Jakob disease
Feaures
- Surveillance of occupational exposure of healthcare workers to bloodborne viruses
- Emergency preparedness
- Surveillance of acute chemical incidents
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Policy and practice
The United Kingdom (UK) Health Departments published their influenza pandemic plan on 1 March 2005. The Health Protection Agency (HPA) plan, which was issued on the same day, is designed to operate alongside the Health Departments’ contingency plan and sets out how the agency will protect the public’s health in the event of an influenza pandemic affecting the UK. The UK Health Departments’ influenza pandemic contingency plan can be found at <http://www.dh.gov.uk/assetRoot/04/10/44/37/04104437.pdf>. The HPA flu pandemic contingency plan can be found at <http://www.hpa.org.uk/infections/topics_az/influenza/pdfs/HPAPandemicplan.pdf>.
Outbreaks and incidents
Mumps
The number of national notifications of mumps cases rose to over 1000 cases per week.1 Confirmed cases were predominantly in older teenagers and young adults. Since 1995, the HPA has been offering laboratory confirmation of all notified mumps cases using oral fluid (saliva) samples. During 2004 and the first few weeks of 2005, the number and proportion of confirmed mumps cases has increased dramatically with an overall confirmation rate of around 60 per cent. The proportion of cases confirmed as IgM positive varies by age with the highest confirmation rates (over 75 per cent) in those born between 1981 and 1986. False-negative results can also occur in a small percentage of cases particularly if the sample is taken early and, therefore, it is likely that virtually all cases in this age range are genuine mumps. On this basis the Agency recommended that during the period of increased mumps incidence, oral fluid samples should not be taken from individuals with clinical mumps who were born between 1981 and 1986, and that they should be managed as if they were a confirmed case. It was, however, recommended that samples should continue to be taken from cases in all other age groups or where it is clinically important to confirm the diagnosis (for example, where a complication has been observed).
Heaf testing device withdrawal
In March 2005, the Medicines and Healthcare Regulatory Products Agency (MHRA) issued a Medical Device Alert about the Bignell Heaf testing device.2 Bignell Surgical Instruments Ltd withdrew all Heaf testing heads in circulation at the time, following six reports of small metal fragments being found in the forearm where the test is administered with a Bignell Heaf test head. Of the six cases reported, all were detected shortly after the Heaf test had been performed. The small metal splinters, which were easily removed, were identified as swarf – fine metal filings produced by machining during the production of the needles. The Bignell Heaf test is widely used in the schools BCG programme and, following the cessation of production of the Uniheaf device in January 2005, was the only Heaf testing device on the market. The DH recommended that local BCG schools programmes be temporarily suspended until replacement stock was obtained.
Salmonella outbreaks
There was a national outbreak of Salmonella typhimurium DT104 infection at the beginning of 2005, with around 100 cases spread between England, Scotland and Wales.3,4 The phage type was resistant to ampicillin, chloramphenicol, streptomycin, sulphonamides, spectinomycin and tetracyclines (R-type ACSSuSpT). In the same period in 2004, the Laboratory of Enteric Pathogens reported on 30 human isolates of S. typhimurium DT104 R-type ACSSuSpT. Cases ranged in age from 4 months to 70 years (median 24 years) and more females (60 per cent) were affected than males. About 2000 cases of S. typhimurium infection are confirmed in Scotland, England and Wales each year,5,6 with DT104 being the most common phage type and ACSSuSpT the most common resistance pattern. The majority of these strains are also characterized by a distinctive pulsed-field gel electrophoresis profile. An unmatched national case–control study showed the consumption of lettuce outside the home to be the likely vehicle of infection. This is the second national outbreak of S. typhimurium DT104 ACSSuSpT infection associated with the consumption of lettuce in recent years. Between 1 August and 15 September 2000, 361 people in England and Wales were ill following the consumption of lettuce outside the home.7 However, the implicated strain in that outbreak differed from that reported here in that it possessed a 2.0 megadalton (MDa) plasmid in addition to the 60 MDa plasmid that is common to many strains of S. typhimurium.
North-east London Health Protection Unit investigated an outbreak of Salmonella enteritidis phage type 1 (PT1) linked to a kebab shop in north-east London in February.8 The outbreak appeared to be associated with rapid onset of what was often severe illness, and with an unusually high attack rate. Around 200 cases were reported from various sources, over 80 of which were confirmed by the Health Protection Agency’s Laboratory of Enteric Pathogens as infected with S. enteritidis PT1, with resistance to nalidixic acid and reduced susceptibility to ciprofloxacin (NxCpL). All patients reported having eaten food at the same kebab shop in north-east London. Most patients were seriously ill with diarrhoea, vomiting and fever. Some suffered from dehydration and confusion. A number of patients were admitted with possible systemic infection. The proprietors reported that three staff members had been unwell and clinical specimens were taken from all six staff, three of whom tested positive for the same salmonella strain. Assessment of the kebab shop after the outbreak identified a number of potential risk areas that could have caused cross-contamination. The incubation period was less than 12 h for two-thirds of the patients, and approximately one-quarter of 76 patients interviewed spent one or more nights in hospital. Symptoms included diarrhoea, vomiting, abdominal pain, fever, nausea and headaches. Only two other people were identified as possibly having eaten food from the restaurant and not having developed symptoms. Based on this observation, the attack rate appears to be very high. Based on an estimated 300–400 portions of food served each day and a reported 195 symptomatic cases, the attack rate currently appears to be around 50 per cent. Around 2000 cases of S. enteritidis PT1 are reported each year in the UK, some as part of outbreaks. The north-east London outbreak is the largest UK outbreak reported to date.
Publications of interest
A revised set of national guidelines Managing meningococcal disease (septicaemia or meningitis) in higher education institutions was launched in February by Universities UK, in collaboration with the HPA. The guidelines, co-written by the director of the Agency’s south-west region, are aimed particularly at university and college health services and health protection units. The guidelines update a first edition published in 1998 and are in a new format, revised to take into account new national policy and the introduction of the group C meningitis strain vaccine. The guidelines set out the reasons why students are at particular risk of infection from meningococcal disease, and summarize the issues facing students, staff, university management and health protection units. The publication provides advice on drafting plans to deal with incidents of meningococcal disease, with recommended action before and after a case of the disease occurs.
The document recommends that each higher education institution should ensure it has management protocol for dealing with such cases, which delivers:
- good channels of communication with students, staff and the public;
- effective support for students;
- strong links to health protection units and local general practitioners (GPs);
- direct access to appropriate advice on the management of meningococcal disease.
The guidelines can be found at <http://bookshop.universitiesuk.ac.uk/show/?category=9>, or via the meningococcal disease pages of the HPA website, available at <http://www.hpa.org.uk/infections/topics_az/meningo/menu.htm>.
Group A streptococci cause a wide range of illnesses from non-invasive disease such as pharyngitis to more severe invasive infections such as necrotizing fasciitis. There has been considerable debate about the risk of such invasive disease to close community contacts of an index case of invasive disease and whether this risk warrants antibiotic prophylaxis. Following a comprehensive literature review and preliminary analysis of 2003 UK data from the strep-EURO programme,9 the Health Protection Agency Group A Streptococcus Working Group published Interim UK guidelines for the management of close community contacts of invasive group A streptococcal disease in Communicable Disease and Public Health (CDPH).10
Guidelines for preventing person-to-person spread following gastrointestinal infections were also published in CDPH11 and replace those published in the CDR Review in 1995.12 They provide concise, accessible advice to public health professionals, particularly those who do not specialize in communicable disease control.
News from abroad
Two cases of polio with onset dates in late 2004 were reported from Saudi Arabia in February. One case was in Jeddah in November in a Sudanese child who had arrived 2 days earlier from the Sudan. The other case was in Mecca in December in a Nigerian child who had been living in Saudi Arabia for at least 2 years.
In February, the Deutsche Stiftung Organtransplantation (German Foundation for Organ Transplantation, http://www.dso.de/) reported possible rabies in three of six patients who received organs from a donor who died in late December 2004.13 All three patients tested positive for rabies virus by RT-PCR.14 Rabies was confirmed in the donor patient post-mortem.14 There were no clinical indications that the donor was infected with rabies prior to death from cardiac arrest in hospital. The donor is thought to have acquired the infection during a trip to India in October 2004. Person-to-person transmission of rabies has only rarely been documented following organ or tissue transplantation. Rabies transmission following corneal transplantation has been recognized as a public health risk for several years (eight cases have been described in five countries).15 The only previous reported incident of rabies transmission following solid organ transplantation (from one donor to four liver, kidney and vascular transplant recipients) occurred in the United States in 2004.16,17
An outbreak of acute haemorraghic fever in Angola, south-west Africa, was confirmed as Marburg virus disease.18 Retrospective analysis identified cases with onset dates back to October 2004. Most cases had occurred in the Uige Province, in the northern part of Angola. This has subsequently developed into the largest recorded outbreak of Marburg virus disease ever recorded and has been unusual in its largely urban nature.
The first case of variant Creutzfeldt–Jakob disease (vCJD) in a Japanese patient was announced by the Japanese Ministry of Health, Labour and Welfare on in February.19 The patient, who first experienced neurological symptoms in December 2001 and died in December 2004, was a male in his 40s. The patient was reported to have spent approximately 1 month in the UK in 1988. The possibility of exposure to the vCJD infective agent while the patient was in the UK is widely accepted at present. In February 2005, the CJD subcommittee reported that the characteristic findings of the post-mortem pathological investigation, which included a western blot, strongly indicated vCJD. There are no records of the patient ever having received a blood transfusion. Japan first reported cases of bovine spongiform encephalopathy (BSE) in farmed cows in 2001 and 14 cases of BSE were reported between 2001 and 2004.20,21 After the first case, the import, production and use of meat and bone meal was banned, and Japan implemented a programme of testing every carcass for BSE and removing specified risk materials. It also suspended beef imports from countries with BSE.
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Surveillance of significant occupational exposure to bloodborne viruses in healthcare workers
In January, the HPA Centre for Infections (CfI) published Eye of the Needle, the latest report from the surveillance of significant occupational exposure to bloodborne viruses (BBVs) in healthcare workers (HCWs).22 This report includes significant occupational exposure incidents reported to the CfI between 1 July 1996 and 30 June 2004 from reporting centres. There are currently 150 reporting centres scattered throughout England, Wales and Northern Ireland.
There have been nine reported hepatitis C (HCV) seroconversions in HCWs following occupational exposures to HCV positive source patients. Six of these transmissions were reported between July 2003 and June 2004 including three within the first 2 months of 2004. Six of the seroconversions involved source patients who were male injecting drug users (IDUs). All seroconversion cases followed percutaneous exposures mostly to fresh blood from hollowbore needles, with moderate to deep injuries. Of the nine seroconversions, six are known to have occurred after the procedure that the HCW was undertaking. Five would not have occurred if procedures for the safe handling and disposal of sharps and clinical waste had been followed. The HCV seroconversion rate was 1.5 per cent (4/264) for four of the cases exposed to a positive HCV-source patient and where complete follow-up information was available for the denominator, cases reported at the same time period as the seroconversions but HCV-negative at 6 months follow-up. There is currently no post-exposure prophylaxis (PEP) or vaccine for HCV that will prevent transmission, although appropriate follow-up and support is vital in these exposure cases since, in those infected, early referral and treatment with combination therapy, pegylated interferon and ribivirin has been shown to be effective in reducing the risk of progression to chronic HCV infection, and in most cases lead to viral clearance. Of the nine reported HCV infections, one case cleared the virus spontaneously, another is still receiving treatment, and the rest have successfully cleared their infection following treatment.
There were still a number of follow-up reports that have incomplete information, particularly in relation to post-exposure testing, and post-exposure tests being done inappropriately. Where HCWs did not receive any further follow-up at a local level, they remain unaware of the outcome of their BBV exposure and some may have been infected.
One report of HIV seroconversion in a HCW following occupational exposure23 gave an HIV seroconversion rate of 0.8 per cent (1/122), which is higher than the internationally observed seroconversion rate. The reported seroconversion rate in the surveillance programme may, however, be an overestimate caused by incomplete denominator data, as 6 month post-exposure testing for HIV exposures is poorly reported. Findings from the surveillance programme indicate that most HCWs exposed to the risk of HIV infection were started on HIV PEP within 24 h of exposure. National guidance states that HCWs should be started on HIV PEP as soon as possible after the exposure, ideally within an hour.24
Percutaneous injury was the most commonly reported type of exposure (78 per cent; 1664/2140), mainly involving hollowbore needles (63 per cent; 1056/1664). Mucocutaneous exposures accounted for 22 per cent (461/2140) of initial reports received. Injuries in nursing-related professionals represented 45 per cent (962/2140) of the initial reports with medical professions (including doctors and dentists) accounting for 37 per cent (793/2140). Overall, a larger proportion of doctors reported occupational exposures to BBVs. Two per cent (39/2140) of reports concerned exposures to ancillary staff, who do not offer direct patient clinical care. Their injuries were mainly as a result of non-compliance with universal precautions by other members of staff.
Seventy-eight per cent (1244/1597) of 6-week follow-up reports received were on exposures that occurred in a ward, theatre, intensive care and accident and emergency departments. Where reported, 37 per cent (588/1597) of exposures occurred after the procedure had been performed, but before disposal of the device, and during or after disposal. These incidents are predominately related to failure to comply with procedures for the safe handling and disposal of sharps and clinical waste, and were mostly preventable.
Emergency preparedness
The Health Protection Agency’s Centre for Emergency Preparedness and Response, based at Porton Down, has a department devoted to improving emergency preparedness and response to the threat of the deliberate release of chemical, biological, radiological or nuclear agents (CBRN). Within the department, there is a training and an exercises section.
The training section works with partner organizations to deliver specialist courses for healthcare providers and managers. These courses, funded by the Department of Health, enable delegates to respond effectively to major incidents of all kinds, including the deliberate release of chemical, biological, radiological or nuclear materials. Further details of the courses and who should apply can be found at www.hpa.org.uk/emergency/training.htm.
The exercises section is running a series of exercises to test emergency preparedness in the health service community, as part of a programme delivered on behalf of the Department of Health. These are used to test and improve current emergency health plans, helping to ensure that the health services can respond in a rapid and co-ordinated way to any deliberate release of chemical, biological or radiological agents. Each exercise involves co-ordinating a wide cross-section of organizations on a national, regional and local level including the Department of Health, other government agencies, NHS organizations, local authorities and other blue-light services.
Surveillance of acute chemical incidents
The Chemical Hazards and Poisons Division (CHaPD) of the Health Protection Agency is responsible for surveillance of acute chemical incidents. Units in Cardiff, London, Newcastle and the West Midlands provide advice to the emergency and health services in England and Wales and this information is gathered centrally by the divisional head office in Chilton, Oxfordshire.
Between 1 January and 31 March 2005 there were 137 acute chemical incidents reported to CHaPD. Products of combustion (15 per cent) were most commonly identified as being involved in an incident reported to CHaPD, followed by inorganic chemicals (11 per cent) and asbestos (10 per cent). Overall, a large range of other chemicals were released, including petroleum (9 per cent), volatile organic compounds (8 per cent), acids (6 per cent), ammonia (4 per cent), carbon monoxide (4 per cent) and various metals (4 per cent). In 10 per cent of reported incidents no chemical was identified.
Incidents were most frequently reported in London (24 per cent), followed by the west Midlands (15 per cent) and the Southeast (12 per cent), although it is recognized that there is potential for regional ascertainment bias. The location of 9 per cent of incidents was not specified. Chemical incidents commonly occurred at industrial (24 per cent), residential (18 per cent), commercial locations (14 per cent) and educational premises (6 per cent).
Of the 137 incidents logged between January and March 2005, 42 per cent of incidents were reported to involve one to 10 people and 30 per cent showed clinical symptoms. Burning sensations and irritations were the most common symptoms (11 per cent), followed by breathing complaints (9 per cent), headaches (5 per cent) and stomach aches or nausea (4 per cent). Carbon monoxide poisoning resulted in three fatalities, out of a total of seven deaths associated with, but not directly attributable to, a chemical incident.
The system is recruiting additional data providers and has developed a real time on-line data entry system to improve consistency, completeness and coverage.
The CDaHP series is prepared by the Health Protection Agency with the assistance of colleagues in partner organizations in health protection.
Reports prepared by Neil Hough (Events), Sarah Tomkins (Surveillance of significant occupational exposure to bloodborne viruses in healthcare workers), Mike Barker (Emergency preparedness), Graham Urquhart, Brett Jeffery and Patrick Saunders (Surveillance of acute chemical incidents) and edited by Neil Hough and Barry Evans.
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- HPA. Changes in laboratory testing as the increase in mumps cases in England and Wales continues. Commun Dis Rep CDR Wkly [serial online] 2005; 15: news. Available at http://www.hpa.org.uk/cdr/archives/2005/cdr0705.pdf (last accessed 9 June 2005).
- Bignell - Standard and paediatric Model 2000 single-use Heaf test heads. MDA/2005/016. London: Medicines and Healthcare Regulatory Products Agency, 10 March 2005. Available at http://devices.mhra.gov.uk/mda/mdawebsitev2.nsf/webvwSearchResults/506CEF88E10D207580256FC000403035?OPEN.
- HPA. Outbreak of Salmonella typhimurium DT104 infection in Scotland, England, and Wales: January to February 2005. Commun Dis Rep CDR Wkly [serial online] 2005; 15: news. Available at http://www.hpa.org.uk/cdr/archives/2005/cdr0705.pdf (last accessed 9 June 2005).
- HPA. Outbreak of Salmonella typhimurium DT104 infection in Scotland, England and Wales, January to February 2005 (update) – iceberg lettuce eaten outside the home implicated. Commun Dis Rep CDR Wkly [serial online] 2005; 15: news. Available at http://www.hpa.org.uk/cdr/archives/2005/cdr0905.pdf (last accessed 9 June 2005).
- Health protection Scotland website. Health Protection Scotland. Laboratory isolates of Salmonella spp in humans reported to HPS, 1993-2004. Glasgow: Health Protection Scotland, 2005. Available at http://www.show.scot.nhs.uk/scieh (last accessed 16 February 2005).
- Health Protection Agency. Salmonella in humans (excluding S. Typhi and S. Paratyphi). Faecal & lower gastrointestinal isolates. England and Wales, 1981–2003. London: Health Protection Agency, November 2004. Available at http://www.hpa.org.uk/infections/topics_az/salmonella/data_human.htm (last accessed 17 February 2005).
- Horby PW, O"Brien SJ, Adak GK, et al. A national outbreak of multi-resistant Salmonella enterica serovar Typhimurium definitive phage type (DT) 104 associated with consumption of lettuce. Epidemiol Infect 2003; 130: 169–178.[CrossRef][Medline]
- HPA. Outbreak of Salmonella enteritidis PT1 in north east London – interim report. Commun Dis Rep CDR Wkly [serial online] 2005; 15: news. Available at http://www.hpa.org.uk/cdr/archives/2005/cdr1105.pdf (last accessed 14 June 2005).
- Schalen C. European surveillance of severe group A streptococcal disease. Eurosurveillance Weekly 2002;6.
- Health Protection Agency Group A Streptococcus Working Group. Interim UK guidelines for the management of close community contacts of invasive group A streptococcal disease. Commun Dis Public Health 2004; 7: 354–361. Available at http://www.hpa.org.ok/cdph/issues/CDPHvol7/No4/guidelines1_4_04.pdf.[Medline]
- Working Group of the former PHLS Advisory Committee on Gastrointestinal Infections. Preventing person-to-person spread following gastrointestinal infections: guidelines for public health physicians and environmental health officers. Commun Dis Public Health 2004; 7: 362–384. Available at http://www.hpa.org.ok/cdph/issues/CDPHvol7/No4/guidelines2_4_04.pdf.[Medline]
- Working party of the PHLS Salmonella Committee. The prevention of human transmission of gastrointestinal infestations and bacterial intoxications. Commun Dis Rep CDR Rev 1995; 5: R158–172.
- Hellenbrand W, Meyer C, Rasch G, Steffens I, Ammon A. Eurosurveillance Weekly [serial online] 2005; 10(7). Available at http://www.eurosurveillance.org/ew/2005/050217.asp#1 (last accessed 24 February 2005).
- Informationen zu den Tollwutuebertragungen durch Spenderorgane. Epidemiologisches Bulletin 2005; 8.
- Centers for Disease Control and Prevention. Human rabies prevention – United States, 1999. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Recomm Wkly Rep 1999; 48(RR-1): 1–21. [Erratum in: MMWR Morb Mortal Wkly Rep 1999; 48(16); MMWR Morb Mortal Wkly Rep 2000; 49: 737 (last accessed 24 February 2005).]
- Centres for Disease Control and Prevention. Investigation of rabies infections in organ donor and transplant recipients – Alabama, Arkansas, Oklahoma, and Texas, 2004. MMWR Morb Mortal Wkly Rep [serial online] 2004; 53: 586–589. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5326a6.htm (last accessed 24 February 2005).[Medline]
- Centres for Disease Control and Prevention. Update: investigation of rabies infections in organ donor and transplant recipients – Alabama, Arkansas, Oklahoma, and Texas, 2004. MMWR Morb Mortal Wkly Rep [serial online] 2004; 53: 615–616. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm53d709.htm (last accessed 24 February 2005).[Medline]
- World Health Organization. Marburg virus disease in Angola – update. Disease Outbreak News [online]. Geneva: WHO, 2005. Available at http://www.who.int/csr/don/2005_03_23/en/ (last accessed 23 June 2005).
- Japanese Ministry of Health, Labour and Welfare. Kokunai ni okeru henikei Creutzfeldt-Jakob-byo (vCJD) no hassei ni tsuite. Press release, 4 February 2005. Available at http://www.mhlw.go.jp/houdou/2005/02/h0204-3.html.
- Japanese Ministry of Agriculture, Forestry and Fisheries. Countermeasures of bovine spongiform encephalopathy (BSE). MAFF Update 431, 9 November 2001. Available at http://www.maff.go.jp/mud/431.html.
- OIE. Number of reported cases of bovine spongiform encephalopathy (BSE) in farmed cattle worldwide (excluding the United Kingdom). Updated 7 February 2005. Available at http://www.oie.int/eng/info/en_esbmonde.htm.
- Health Protection Agency, National Public Health Service for Wales, CDSC Northern Ireland. Eye of the Needle. Surveillance of significant occupational exposure to bloodborne viruses in healthcare workers – seven-year report. London: Health Protection Agency, January 2005. Available at http://www.hpa.org.uk/infections/topics_az/bbv/bbmenu.htm.
- Heptonstall J, Gill ON, Porter K, Black MB, Gilbart VL. Health care workers and HIV: surveillance of occupationally acquired infection in the United Kingdom. Commun Dis Rep CDR Rev 1993; 3: R147–153. Available at http://www.hpa.org.uk/cdr/CDRreview/1993/cdrr1193.pdf.[Medline]
- Department of Health. HIV post-exposure prophylaxis: Guidance from the UK Chief Medical Officers’ Expert Advisory Group on AIDS. London: Department of Health, 2004.
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