Communicable Disease and Health Protection Quarterly Review: January to March 2006
From the Health Protection Agency, Centre for Infections
Keywords: chikungunya, CJD, communicable disease, diphtheria, measles, mumps, pneumococcal, radiation, scarlet fever, wound botulism
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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 Goldcoast
- Japanese encephalitis
- Avian flu
Features:
- HPA participation in nuclear exercise ‘Frome’
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Policy and practice
In February 2006 the Department of Health announced changes to the childhood immunisation schedule (1). Heptavalent pneumococcal conjugate vaccine (PNC-7) is being added to the schedule at 2, 4, and 13 months. There are around 5000 cases of invasive pneumococcal disease in England and Wales each year, around 530 of these in children under two years. Since the introduction of a similar programme in the United States, cases in young children caused by the strains in the vaccine have fallen by 94%, and cases in the over 65s have dropped by two thirds. Changes are also being made to the schedules for MenC and Hib vaccines. Information about the changes to the routine programme, which are due to start in September 2006, can be found on the immunisation website at http://www.immunisation.nhs.uk. Following the introduction of the vaccine, all cases of invasive pneumococcal disease in England and Wales reported to the HPA Centre for Infections in the age groups targeted for vaccination will be followed up for PNC-7 or plain pneumococcal polysaccharide (PPV- currently routinely offered to all aged 65 years and over) vaccination history and outcome.
The oral typhoid vaccine, Vivotif® (Berna Products), was re-introduced to the United Kingdom in March, having been removed from the market in 2002 (2). Typhoid vaccine is recommended for:
- travellers visiting typhoid-endemic areas, especially if sanitation and food hygiene are likely to be poor;
- persons in close contact with typhoid cases or carriers (3);
- laboratory personnel who may handle Salmonella Typhi in the course of their work.
There are now five vaccines available in the UK for prevention of typhoid fever. The other (injectable) vaccines are Typhim Vi® and Viatim® (Sanofi Pasteur MSD), and Typherix® and Hepatyrix® (GlaxoSmithKline). Details of each can be found on the typhoid vaccine information sheet from the National Travel Health Network and Centre (NaTHNaC) at http://www.nathnac.org/pro/factsheets/typhoid_vaccine.htm.
Outbreaks and incidents
In January 2006 a diphtheria toxin producing strain of Corynebacterium ulcerans was confirmed in a woman from Cheshire [4]. The woman had been recently hospitalised with a two day history of malaise, sore throat and a change in the sound of her voice.. The patient’s condition deteriorated over the next two days and a tracheostomy was carried out. During the procedure a grayish-white membrane was seen which raised the possibility of diphtheria. Given the strong probability that this could be a toxigenic strain of diphtheria it was decided to instigate control measures while laboratory confirmation was being sought. Close hospital and community contacts were identified and nose and throat swabs taken. Close contacts were offered both oral erythromycin to clear carriage, and booster Td/IPV vaccine (where appropriate).
C. ulcerans produces exactly the same toxin as C. diphtheriae and infection may present as full-blown diphtheria, as seen in this case. Eighteen cases of toxigenic C. ulcerans were documented in the UK from 2000 to 2005, including one death in an elderly female in 2000. Although exposure to raw dairy products is the most widely recognised risk factor, most cases, including the fatal case, have had no association with a farming community or through the consumption of raw dairy products. The organism has also been isolated from several domestic cats and one dog with respiratory discharges within the UK and other European countries, suggesting a possible novel reservoir for this organism. Molecular typing studies on a large collection of isolates have revealed a predominant genotype circulating within Europe, with strains isolated from some domestic cats exhibiting the same type as observed among strains causing human infections [5].
Fifty cases of scarlet fever were reported from Wiltshire in January and February 2006 [6]. There were clusters of cases in two nurseries (16 and four cases respectively) about 45 km apart. Six of the 50 cases were in adults aged 18 years and over, and the remainder were children aged between 8 months and 10 years. The 50 cases include 13 confirmed, 27 probable, and 10 possible cases, according to previously defined clinical and microbiological case definitions [7]. Eleven cases were reported during the same period in 2004, with only four reported in the same period of 2005. Cases presented with symptoms which included fever, sore throat, skin rash, strawberry tongue, and flushing of cheeks. The laboratory tests from three isolates from cases at both nurseries (two from the same town as the first nursery and one from the same town as the second) gave the same typing results. Severe forms of scarlet fever are now extremely rare in developed countries. In nursery outbreaks there are potential risks of more serious immune-mediated outcomes if cases are untreated, so outbreak management must include communications with medical practitioners and parents to emphasise the importance of adequately treating cases. In these two outbreaks, consideration was given to screening and treating children who were carriers, in an attempt to interrupt transmission. There are, however, no evidence-based guidelines in the United Kingdom to support these actions. Existing guidelines only cover the management of close community contacts of invasive group A streptococcal disease [8]. As antibiotics can have undesirable side effects it was decided to use them only if a case of invasive disease were found, because this could indicate enhanced virulence of the outbreak strain.
A new case of probable variant Creutzfeldt-Jakob Disease (vCJD) was diagnosed in a patient who received a blood transfusion from a donor who later developed vCJD [9]. This is the third case of probable transfusion transmission of vCJD infection in the UK. The case developed vCJD nearly eight years after receiving a transfusion of red blood cells from a donor who developed vCJD about 20 months after donating this blood (1). Each of the three infected recipients received blood from different donors. All three infected recipients identified to date received non-leucodepleted red blood cells. Since October 1999, leucocytes have been removed from all blood used for transfusion in the UK . The effect of leucodepletion on the reduction of the risk of transmission of vCJD from an infected donor is uncertain.
Publications of interest
New guidance published by the Health Protection Agency warns both commercial and domestic owners of spa pools about the risks of infections if they do not follow guidance on how to maintain them properly (10). Spa pools in the home are becoming more commonplace with between 14,000 and 15,000 installed in homes each year in the United Kingdom. They provide the perfect conditions for certain bacteria to survive, and cause infection because the pools have a raised water temperature and conditions that create an aerosol of water. The new guidance sets out the practical measures that can be followed to prevent users contracting infections such as legionnaires’ disease and folliculitis (inflammation of the hair follicles) and to prevent other hazards to health such as slipping. It also sets out the specific responsibilities of those who manage commercially run spa pools to ensure staff working with the pool and recreational users are protected.
Surveillance
Wound botulism in injecting drug users in the United Kingdom Wound botulism was first reported in the United Kingdom (UK) among injecting drugs users (IDUs) in 2000 [11]. Between 2000 and 2005, 112 cases of suspect wound botulism amongst IDUs were reported in the UK: five cases occurred in 2000, four in 2001, 20 in 2002, 15 in 2003, 40 in 2004 and 28 in 2005. Eighty per cent, (94) of cases occurred in England. All of the cases from England in 2005 for whom detailed information was available reported injecting heroin, and 64% reported also injecting methadone. All cases had used either vitamin C or citric acid for dissolving the drug. Injection into skin (‘skin popping’) or muscle (‘muscle popping’) was reported by all the cases and in the previous month they had all noticed swelling and tenderness of an area of skin where they inject. The majority (75%) required ventilation during their hospital admission. Wound botulism among IDUs is now the most common presentation of this disease in the UK, Seven suspect cases were reported during the first 13 weeks of 2006 (1 January to 28 March): all occurred in England.
Injection practices amongst IDUs are likely to be important since a major risk factor for soft tissue wound infections is skin or muscle ‘popping’. Clinicians should suspect botulism in any patient with an afebrile, descending, flaccid paralysis. Botulinum antitoxin is effective in reducing the severity of symptoms for all forms of botulism if administered early in the course of the disease: this should not be delayed for the results of microbiological testing. In cases of wound botulism, antimicrobial therapy and surgical debridement are important to reduce the organism load and avoid relapse after antitoxin treatment. C. botulinum is sensitive to benzyl penicillin and metronidazole. Advice for responding to suspect wound botulism is available on the HPA website [12]. As well as providing information for health professionals, the HPA website gives advice for preventative measures for IDUs.
During 2005, 56,390 cases of mumps were notified in England and Wales. The number of cases started to decline in the second half of the year and there were 3307 cases notified in the first seven weeks of 2006 (averaging around 470 cases per week compared to more than 1,600 per week in the first six months of 2005).
One hundred and eighty-one cases of measles were confirmed in England and Wales in the first quarter of 2006, compared with 78 cases in the whole of 2005 [13]. One hundred and thirty-one cases were aged under 15 years. Cases occurred in all regions apart from the North East.
News from abroad
Outbreaks of chikungunya virus that had been occurring on some islands of the Indian Ocean since March 2005 continued [14]. The majority of cases occurred since the beginning 2006, the largest outbreak being in La Réunion; outbreaks also occurred in Mauritius, The Seychelles, Mayotte, and Madagascar. Between 28 March 2005 and 26 February 2006, 2,849 cases of chikungunya virus were been reported from a general practitioner (GP) sentinel network in La Réunion [15]. A mathematical model estimated that 186,000 people (20% of the population) may have been infected in total between March 2005 and 26 February 2006. There were 77 deaths recorded with chikungunya as a diagnosis; the mean age of these deceased patients was 78 years, and most had underlying medical conditions. The possible relation between chikungunya and death is still under investigation by a scientific committee with clinicians, epidemiologists and virologists [16].
Several European countries, including the United Kingdom [17], reported cases imported in people returning from these islands [18]. The majority of these have been reported in France where 160 cases have been imported. Other countries where imported cases have been reported include Germany, Switzerland, Italy and Norway.
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Reporting of radiation events
The Health Protection Agency is committed to identifying and responding to emerging threats to health and emergencies with a potential health impact. Emergency arrangements are continually being developed and updated as new facilities are acquired and lessons learned from previous events and exercises are assimilated. It follows that the Radiation Protection Division (RPD) of HPA have an interest in any significant radiation events happening worldwide. These events could occur at nuclear power plants, research reactors, nuclear fuel facilities, involving radiation sources or the transport of radioactive materials.
So how are incidents involving radiation reported and is this information freely available in the public domain? This article describes one valuable source of such information freely available on the internet.
The International Atomic Energy Agency (IAEA), Nuclear Energy Agency (NEA) and the World Association of Nuclear Operators (WANO) maintain a web based system of reporting events associated with the civil nuclear industry known as the Nuclear Event Web-based System (NEWS). The purpose of NEWS is to provide prompt authoritative information on the occurrence of nuclear events of interest to the international community. The general public and media can access the site through the IAEA website http://www-news.iaea.org/news/. Once an individual registers with this system an automated e-mail notification is received when a new event or press release is added to the database.
The NEWS database uses the International Nuclear Event scale (INES) http://www.iaea.org/Publications/Factsheets/English/ines-e.pdf, a system devised to communicate the safety significance of any event reported. By putting events into proper perspective, INES provides a source of common understanding amongst the nuclear community, the media and the public. The INES is a broadly logarithmic scale, similar to the Richter scale for earthquakes. Events are classified on the INES scale at 8 levels; the upper levels (4–7) are termed accidents and the lower levels (1–3) incidents. Events which have no safety significance are classified below scale at level 0. Only events rated at level 2 or above or which might attract international interest are included in the NEWS database.
NEWS recently reported on an event of interest which was rated at level 4 on the INES scale .The accident took place in March 2006 at an irradiation plant in Belgium used to undertake medical device sterilisation. The devices are sterilised by irradiation from the gamma rays from a large cobalt-60 source. The source is contained within a water pool when not in use in order to shield its high dose rates.
The circumstances of the incident are reported in detail on the NEWS site and resulted in a worker being exposed to a radiation dose of nearly five grays (Gy). A dose of this magnitude delivered instantaneously to the whole body can cause death within a matter of weeks. The worker was unaware that he had received any radiation exposure and although he felt unwell the day after the incident occurred he did not attribute it to his work at the plant. He only decided to visit his company doctor three weeks later when hair loss began to occur. Following haematological examination of the worker a very low white cell blood count was observed. Confirmation of the high irradiation was made through further biological analysis of chromosomes. According to physicians observing him in a Paris hospital, the worker appears to have recovered from this exposure. This would indicate that the worker was quite a fit and robust person and the general absence of immediate prodromal effects expected from the high doses he received would seem to point to him being at the radioresistant end of the spectrum.
Why is this event of interest to the Health Protection Agency? These events are of interest, firstly from a safety perspective in that methods and procedures should be studied for possible improvements and lessons learned from this event. Secondly, case studies on people who have received high doses increase our knowledge on the effects of radiation on the human body. Information systems like NEWS bring incidents to the attention of researchers quickly and consistently.
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 (Reporting of radiation events), and edited by Neil Hough and Barry Evans
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- Department of Health. Pneumococcal vaccine added to the childhood immunisation programme; more protection against meningitis and septicaemia (press release). London : Department of Health, 8 February 2006. Available at http://www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressReleasesNotices/fs/en?CONTENT_ID=4128036&chk=PI8e57.
- National Travel Health Network and Centre. Clinical update: Re-introduction of oral typhoid vaccine: Vivotif®, 29 March 2006 [online] [cited 30 March 2006]. Available at http://www.nathnac.org/pro/clinical_updates/vivotif_290306.htm.
- Working group of the former PHLS Advisory Committee on Gastrointestinal Infections. Preventing person-to-person spread following gastrointestinal infections – a guide for public health physicians and environmental health officers. Commun Dis Public Health 2004; 7(4): 362–84.[Medline]
- Health Protection Agency. A case of diphtheria caused by toxigenic Corynebacterium ulcerans. Commun Dis Rep CDR Wkly [serial online] 2006 [accessed 3 August 2006]; 16 (4): news. Available at http://www.hpa.org.uk/cdr/archives/2006/cdr0406.pdf.
- De Zoysa A, Hawkey PM, Engler K, George R, Mann G, Reilly W, et al. Characterisation of toxigenic Corynebacterium ulcerans from humans and domestic cats. J Clin Microbiol; 2005; 43:4377–81.
[Abstract/Free Full Text] - Health Protection Agency. Scarlet fever outbreak in two nurseries in south west England Commun Dis Rep CDR Wkly [serial online] 2006 [accessed 3 August 2006]; 16 (9): news. Available at http://www.hpa.org.uk/cdr/archives/2006/cdr0906.pdf.
- Feeney KT, Dowse GK, Keil AD, Mackaay C, McLellan D. Epidemiological features and control of an outbreak of scarlet fever in a Perth primary school. Commun Dis Intell 2005; 29(4): 386–90. Available at http://www.health.gov.au/internet/wcms/Publishing.nsf/Content/cda-cdi2904h.htm.[Medline]
- Health Protection Agency, Group A Streptococcus Working Group. Interim UK guidelines for management of close community contacts of invasive group A streptococcal disease. Commun Dis Public Health 2004; 7:354–61.[Medline]
- Health Protection Agency. New case of variant CJD associated with blood transfusion (press release). London : HPA, 9 February 2006. Available at http://www.hpa.org.uk/hpa/news/articles/press_releases/2006/060209_cjd.htm.
- HPA. Management of Spa Pools – Controlling the Risks of Infection. London: Health Protection Agency, 15 March 2006. Available at http://www.hpa.org.uk/publications/2006/spa_pools/.
- PHLS. Wound botulism in an injecting drug user in London. Commun Dis Rep CDR Wkly 2000; 10 (20): 177,180. Available at http://www.hpa.org.uk/cdr/archives/CDR00/cdr2000.pdf.[Medline]
- Botulism. Health Protection Agency website [online] [cited 29 March 2006]. Available at http://www.hpa.org.uk/infections/topics_az/botulism/menu.htm.
- HPA. Laboratory confirmed cases of measles, mumps, and rubella, England and Wales: January to March 2006. Commun Dis Rep CDR Wkly [serial online] 2006 [cited 2 August]; 16(25): Immunisation. Available at http://www.hpa.org.uk/cdr/archives/2006/cdr2506.pdf.
- HPA. Chikungunya virus in the Indian Ocean. Commun Dis Rep CDR Wkly [serial online] 2006 [cited 2 August 2006]; 16(9): News. Available at http://www.hpa.org.uk/cdr/archives/archive06/News/news0606.htm.
- Institute de Veille Sanitaire. Epidemie de chikungunya a La Réunion / Ocean Indien, Point de situation au 3 Mars 2006 [online]. [cited 9 March 2006]. Available at http://www.invs.sante.fr/display/?doc=presse/2006/le_point_sur/chikungunya_030306/index.html.
- Cordel H. Chikungunya outbreak on Reunion: update. Eurosurveillance Weekly [serial online] 2 March 2006 [cited 2 August 2006]; 11(3). Available at: http://www.eurosurveillance.org/ew/2006/060302.asp#3.
- HPA. Chikungunya: increase in imported cases. Commun Dis Rep CDR Wkly [serial online] 2006 [cited 2 August]; 16(21): News. Available at http://www.hpa.org.uk/cdr/archives/archive06/News/news0606.htm#chik.
- Cases of chikungunya imported into Europe. Eurosurveillance Weekly 2006; [serial online] 11 (3); 060316. Available at http://www.eurosurveillance.org/ew/2006/060316.asp.
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