Communicable Disease and Health Protection Quarterly Review: October to December 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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THE QUARTER AT A GLANCE... |
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 TOP THE QUARTER AT A... Events of the quarterFeaturesReferences |
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Policy and practice:
- Influenza pandemic plan
Outbreaks and incidents:
- VTEC O157
- Lymphogranuloma venereum
Surveillance:
- MRSA
Publications:
- Infections among injecting drug users
- Health protection in the 21st Century
- HIV and STI surveillance report
- Hepatitis C annual report
News from abroad:
- Salmonella Goldcoastn
- Japanese encephalitisn
- Avian flu
Features:
- HPA participation in nuclear exercise ‘Frome’
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Policy and practice
The revised Department of Health (DH) pandemic influenza plan, containing new World Health Organization (WHO) phases and health impact projections, was launched on 19 October 2005 [1]. The Department of Health (England) is the lead Government Department, in the preparation for, and response to, an influenza pandemic, supported by the Health Protection Agency. The Department of Health will: co-ordinate the UK health response; procure appropriate antiviral drugs and develop strategies for their optimal use; facilitate the development, manufacture and supply of an effective vaccine and develop strategies for its use; lead work with the devolved administrations to secure consistent public health and health service responses across the UK; lead the public health and health service responses in England (the devolved administration Health Departments will undertake this role in their countries); provide information and input to other Government Departments and other services and organisations to assist them in their response arrangements, particularly those implementing control measures and for maintaining essential services; provide information for the media and public in c provide information for the media and public in co-ordination with the Government News Co-ordination Centre. The Health Departments will be advised by a UK National Pandemic Influenza Committee and a Scientific Advisory Group.
Outbreaks and incidents
E.coli O157
Between 1 October and 21 December 2005, 79 cases of Vero cytotoxin-producing E. coli (VTEC) O157 PT8 infection throughout England and Wales were confirmed by the HPA Laboratory of Enteric Pathogens (LEP) [2]. This compares with 21 isolates received between 1 October and 31 December 2004. Thirty-five primary cases (out of a total of 44 primary cases) shared the same Xbal pulsed field gel electrophoresis (PFGE) profile (profile 1). Of these cases, 25 were female and 10 male. The median age was 20 years (range 1 to 75 years). Onset dates were available for 32 cases and ranged between 4 September and 2 December 2005. A case control study showed that infections appeared to have been associated with cooking raw beef or consuming dishes containing beef, particularly minced beef, at home in the five days before illness onset. No retail outlet was identified as being associated with beef consumption or the sale of minced beef. This was the first national outbreak of VTEC O157.
Lymphogranuloma venereum
Data to the end of September 2005 for the enhanced surveillance of lymphogranuloma venereum (LGV) programme in the United Kingdom, (UK) showed 215 cases confirmed by the Health Protection Agency Sexually Transmitted Bacteria Reference laboratory (STBRL) [3]. Of these, epidemiological and clinical reports were received for 147 confirmed cases. One hundred and forty-four cases are in men who have sex with men (MSM), with two reported in heterosexual men. Cases have been reported from across the UK , although the majority have been diagnosed in London (153, 71%) and Brighton (31, 14%). The majority of cases continue to be reported in men who have HIV infection (119/147, 81%), and most are symptomatic with proctitis.
Surveillance
The Methicillin resistant Staphylococcus aureus (MRSA) bacteraemia Enhanced Surveillance Scheme became mandatory for all NHS Acute Trusts in England on 1 October 2005 [4]. This scheme was developed by the Health Protection Agency at the request of the Department of Health. Trusts can access a website that they can use to enter details about each MRSA bacteraemia episode that is detected in their Trust. Enhanced surveillance involves collecting patient details for each MRSA bacteraemia episode such as NHS number, hospital number, date of birth, sex, as well as information concerning the patient’s location, date of admission, consultant specialty, and care details at the time the blood sample was taken.
Publications of interest
In October, the Health Protection Agency has published the third edition of Shooting Up: infections among injecting drug users [9]. Surveillance data from across the United Kingdom (UK) on a range of bacterial and viral infections that can affect injecting drug users (IDUs) were brought together with the national results for 2004 from the Unlinked Anonymous Prevalence Monitoring Programmes (UAPMP) survey of IDUs in contact with services. A key finding was that the prevalence of HIV infection among IDUs in England and Wales has probably increased in recent years. The prevalence among current IDUs participating in the UAPMP agency survey in England and Wales in 2004 was 1.5% (24 of 1574), the highest level seen among current IDUs in this survey since 1992 when the prevalence was 2.0% (40 of 2005). Although HIV infection among IDUs in the UK as a whole remains low when compared to other countries, the prevalence of HIV among IDUs has remained substantially higher in London [10], where the prevalence among current IDUs in 2004 was 4.4% (16 of 361) compared to 0.7% (8 of 1213) elsewhere in England and Wales. The report made a number of important recommendations about commissioning community-based services to reduce the harm associated with problem drug use. It recommended that primary care bodies and Drug Action Teams or local partnerships should give priority to preventing spread of infections among IDUs and reducing the harm these infections cause in line with the aims of the national drug strategies [11,12].
The Agency also published Health Protection in the 21st Century – Understanding the Burden of Disease; preparing for the future which identifed and quantified the burden of disease across the broad health protection spectrum, from infections to environmental hazards. The study built on work which quantified the burden of infectious diseases (an annual treatment cost of approximately £6 billion) applying the same principles to assessing the burden of non-infectious diseases associated with radiation, chemicals, poisons, and pollution. The report was the first stage in the process of quantifying the totality of the burden of disease, particularly in the area of environmentally linked non-infectious disease. The report full report can be accessed at the Agency’s website at: <http://www.hpa.org.uk/hpa/publications/burden_disease/default.htm>.
To coincide with World AIDS Day, the Agency published Mapping the issues, its annual surveillance report, for HIV and sexually transmitted infections in the United Kingdom (UK) [13]. The report described a worrying situation with undiminished and high levels of transmission of HIV and other sexually transmitted infections (STIs) among men who have sex with men (MSM), a steady increase in the number of HIV-infected black Africans in the UK, limited but compelling evidence that heterosexual transmission of HIV within the UK is slowly rising, and continuing high transmission of other STIs, (especially chlamydia) among young people. The report summarised current surveillance information on HIV and STIs, as well as some of the behaviours underlying transmission, and shows the distribution of the problem across different areas of the country.
In December the Agency published its first annual report on hepatitis C in England [14]. Of the estimated 200,000 individuals in England who have a chronic hepatitis C infection, a proportion will go on to develop severe liver damage. Laboratory confirmed diagnoses for hepatitis C rose from 6341 in 2003 to 7902 in 2004. This indicates that the rate of diagnoses has risen and therefore that more diagnostic testing is taking place. There are currently estimated to be around 4,500 people living with severe liver disease in England and Wales, including cirrhosis, liver failure or liver cancer, as a result of having a chronic hepatitis C infection, a figure that could rise to around 7,000 by 2010. Most individuals with chronic hepatitis C infection can be successfully treated, but the success of treatment relies on people coming forward for testing. To enable this, local health services need to provide clear pathways of referral to enable these patients to access the necessary services and be diagnosed. Injecting drug use is the dominant driver in the growth of hepatitis C in England, accounting for more than 80% of diagnosed infections. Prevalence of hepatitis C among injecting drug users is high, at around 40% and since 2000 prevalence in recent injectors has doubled to 20%, suggesting a recent increase in transmission.
News from abroad
An international outbreak of Salmonella Goldcoast infections in tourists returning from Mallorca occurred in the final quarter of 2005 [5]. One hundred and forty-eight cases of S. Goldcoast meeting the outbreak case definition were reported from around Europe between 1 October and 1 December 2005: England and Wales (66), Scotland (28), Germany (17), Sweden (12), Norway (8), Ireland (6), Denmark (4), Finland (4), and Mallorca (3). The last onset date reported was 19 October 2005. Analysis of data from the trawling questionnaires did not generate a testable hypothesis about foods, outlets, or other potential sources of infection. The international outbreak control team had its final meting on 1 December 2005 and the outbreak was declared over.
The outbreak of Japanese encephalitis (JE) that began in India and Nepal since July 2005 continued. [6] Over 7000 cases were reported in 2005 [7]. In India, the outbreak has affected the northern state of Uttar Pradesh, and the adjoining state of Bihar, and in Nepal the majority were reported in Mid-western division although the highest number were reported in Kailali district in Central division. Case fatality rates of between 11 and 23% were reported in the different regions.
During 2004, there were 93 confirmed cases of human infection with avian influenza a/H5N1 reported to WHO, including 39 deaths. Human cases were reported from Cambodia, China, Indonesia, Thailand, and Viet Nam [8].
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HPA participation in the Nuclear Emergency Exercise ‘Frome’
If a nuclear emergency were to occur would the Health Protection Agency be ready to respond? A recent major exercise demonstrates that the Agency is joined up and fully capable of providing the expert advice required.
There are statutory requirements for all nuclear licenced site operators and local authorities with a nuclear site in their area to produce emergency plans. It is also a statutory requirement that such plans are regularly tested by exercising the response to a range of credible scenarios. These exercises are classified into 3 levels depending on the level of response to be exercised. The exercise of highest grade, ‘level 3’, is held each year at one of the UK’s civil nuclear sites and during this exercise the full national multi-agency response is tested. Such an exercise would include all the key stakeholders with a role in nuclear emergency response. These include the nuclear operators, Nuclear Installations Inspectorate, Food Standards Agency, Environment Agency, the Department of Trade and Industry, the Department for Environment, Food and Rural Affairs, the Department of Health and the Health Protection Agency as well as key local responders including the emergency services and local authorities.
The most recent level 3 exercise, named ‘Frome’ and based on an accident at Hinkley Point B, an advanced gas cooled nuclear reactor power station in Somerset, was held on 19 January 2006. The HPA already has a clear emergency response plan for this type of accident scenario having developed response strategies over many years of exercise experience in this area as the former National Radiological Protection Board (NRPB), now the Radiation Protection Division of HPA and local public health arrangements.
This was an important exercise for HPA for two reasons. Firstly it was the first full national nuclear emergency exercise in England since NRPB became part of the HPA, so this exercise was used to demonstrate formalised integrated response across the Agency. Prior to joining HPA, NRPB already had significant experience in working with HPA Local and Regional Services (LARS) colleagues "at the sharp end" during exercises. Secondly, the exercise involved implementation of the HPA Strategic Emergency Response Plan, which for major emergencies provides the HPA Strategic Emergency Co-ordination Team (SECT). The SECT addressed resilience issues throughout the Agency, co-ordinated national media activity through HPA Communications Division and provided briefings to the Chief Executive Officer, Professor Pat Troop. Although used in the London Bombings and the Buncefield Fire, this was the first time these overarching HPA arrangements had been used in a nuclear exercise.
During the exercise, over 70 staff from the Agency were involved in a variety of roles addressing strategic, tactical and operational issues. HPA’s Radiation Protection Division (RPD) responded by exercising its own emergency plan. A major part of the RPD plan is to co-ordinate radiation monitoring resources made available to it. This information is important for establishing the scale and extent of the accident. In addition to RPD’s emergency operations centre being established, RPD representatives were also in attendance at off-site facilities working with LARS colleagues at the Local Emergency Centre providing input to the Health Advisory Team, Gold Command and contributing to the Recovery Working Group.
Support was provided by RPD to other national centres, namely at British Energy’s Central Emergency Support Centre, the Nuclear Emergency Briefing Room at Department of Trade and Industry in London and the Department of Health in Whitehall.
The complexities of communication within HPA, Government, with other key agencies and the introduction of an extra tier of strategic response were considered a challenge for the Agency. Exercise Frome was seen as a useful learning exercise for testing the Agency’s response to a major emergency. HPA will build upon experience from this exercise to develop further its radiological and strategic emergency response capability.
The Agency will be a key participant in future exercises in the UK for other emergencies. Lessons learned and good practice will be shared and applied to the joined up response demonstrated in responding to incidents involving other hazards. Only by fully and regularly testing our emergency response capability for a variety of emergency scenarios, can the UK Government and population be confident that we have sufficient response arrangements and resilience should a real event occur.
The CDaHP series is prepared by the Health Protection Agency with the assistance of colleagues in partner organisations in health protection.
Reports prepared by Neil Hough (Events), Martin Whild (HPA participation in the Nuclear Emergency Exercise ‘Frome), and edited by Neil Hough and Barry Evans
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References |
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TOPTHE QUARTER AT A...Events of the quarterFeaturesReferences |
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- Department of Health. UK Health Departments’ Influenza pandemic contingency plan: October 2005 edition. London: Department of Health, 2005. Available at <http://www.dh.gov.uk/assetRoot/04/12/17/44/04121744.pdf>.
- Health Protection Agency. National increase of Vero-cytotoxin producing E. coli O157 phage type 8 – case-control study. Commun Dis Rep CDR Wkly [serial online] 2006 [cited 5 May 2006]; 16(01): News. Available at <http://www.hpa.org.uk/cdr/archives/2006/cdr0106.pdf>.
- HPA.Lymphogranuloma venereum (LGV) in men who have sex with men in the UK: and update. Commun Dis CDR Wkly [serial online] 2005 [accessed 4 May 2006]; 15(40):News. Available at: <http://www.hpa.org.uk/cdr/archives/2005/cdr4005.pdf>.
- HPA. The start of the Mandatory MRSA bacteraemia Enhanced Surveillance Scheme: 1 October 2005. Commun Dis Rep CDR Wkly [serial online] 2005 [accessed 5 May 2006]; 15(40): news. Available at < http://www.hpa.org.uk/cdr/archives/2005/cdr4005.pdf>.
- HPA. Outbreak of Salmonella Goldcoast infection in tourists returning from Mallorca – final summary. Commun Dis Rep CDR Wkly [serial online} 2005 [cited 9 May 2006]; 15(49): news. Available at <http://www.hpa.org.uk/cdr/archives/2005/cdr4905.pdf>.
- Health Protection Agency. Japanese encephalitis in India and Nepal – update. Commun Dis Rep CDR Wkly [serial online] 2005 [cited 9 May 2006]; 15(46): News. Available at <http://www.hpa.org.uk/cdr/archives/2005/cdr4605.pdf>.
- WHO Regional Office for South East Asia (SEARO). Immunization and vaccine development. Japanese encephalitis [online]. Available at <http://w3.whosea.org/en/Section1226/Section2073.asp>.
- Situation updates – Avian influenza. WHO website [online] [accessed 5 May 2006]. Available at <http://www.who.int/csr/disease/avian_influenza/updates/en/index.html>.
- Health Protection Agency, SCIEH, National Public Health Service for Wales, CDSC Northern Ireland, CRDHB, and the UASSG. Shooting Up; Infections among injecting drug users in the United Kingdom 2004. London: Health Protection Agency, October 2005. Available at <http://www.hpa.org.uk/infections/topics_az/injectingdrugusers/shooting_up.htm>.
- VD Hope, A Judd, M Hickman, A Sutton, GV Stimson, JV Parry, et al. HIV prevalence among Injecting Drug Users in England & Wales 1990 to 2003: Evidence for increased transmission in recent years. AIDS 2005; 19: 1207–14.[ISI][Medline]
- The Home Office. Update Drugs Strategy. London: Home Office, 2002.
- Tackling Drugs to Build a Better Britain: The Government’s Ten-year Strategy for Tackling Drug Misuse. London: The Stationary Office, 1998.
- The UK Collaborative Group for HIV and STI Surveillance. Mapping the issues. HIV and other sexually transmitted infections in the United Kingdom: 2005. London: Health Protection Agency, 24 November 2005. Available at <http://www.hpa.org.uk/hpa/publications/hiv_sti_2005/>.
- Health Protection Agency. Hepatitis C in England. The first Health Protection Agency Annual Report 2005. London: HPA, 2005. Available at <http://www.hpa.org.uk/hpa/publications/hepC_2005/default.htm>.
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