Communicable Disease and Health Protection Quarterly Review: July to September 2006
From the Health Protection Agency
Keywords: communicable disease, immunisation, salmonella, anthrax, legionnaires disease, pasteurellosis, STIs, tuberculosis, viral haemorrhagic fever
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THE QUARTER AT A GLANCE... |
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 TOP THE QUARTER AT A... Events of the quarterReferences |
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Policy and practice:
- Childhood immunisation
- Meningococcal disease
Outbreaks and incidents:
- Salmonella Montevideo
- Anthrax
- Legionnaires’ disease
- Pasteurellosis
Surveillance:
- Sexually transmitted infections
- Surgical site infections
- Tuberculosis treatment outcome
Publications:
- Prevention of healthcare-associated infections
News from abroad:
- Crimea Congo haemorrhagic fever
- Lassa fever
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Events of the quarter |
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TOPTHE QUARTER AT A...Events of the quarterReferences |
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Policy and practice
Changes to the routine childhood immunisation programme were announced in July, for implementation from 4 September 2006 [1]. The changes included the introduction of pneumococcal vaccine and the modification of the schedule for MenC and Hib vaccines, with a pneumococcal vaccination catch-up programme for children aged under two years. The detailed vaccination schedule can also be seen on the HPA website at <http://www.hpa.org.uk/infections/topics_az/vaccination/new_sched_sept2006.htm>, and details of the pneumococcal vaccine at <http://www.hpa.org.uk/infections/topics_az/pneumococcal/vaccine/vaccine.htm>.
The Health Protection Agency Meningococcus Forum reviewed and updated the UK guidelines for meningococcal disease on the HPA website in September [2]. This guidance updates the major revision published in 2002 [3] taking account of new evidence and addressing new areas where gaps have been identified. Changes are few and are highlighted in the text. In the absence of data from randomised controlled trials, the Meningococcus Forum continues to advise starting antibiotic treatment before admission to hospital. This advice is based on the potentially very rapid clinical deterioration that can occur in natural progression of illness, the established effectiveness of penicillin in hospital treatment, and the lack of increase in endotoxin levels after treatment. Rapid transfer to hospital on diagnosis of meningococcal disease remains the highest priority. The HPA endorses its advice not to give antibiotics widely in pre-school groups after a single case in such a group. The sections on vaccination and chemoprophylaxis have been updated, and examples of patient group directions for mass prophylaxis have been added. Investigation of complement deficiency is now recommended in cases of infection due to rare serogroups or of recurrent infection.
Outbreaks and incidents
From March to July 2006, the Health Protection Agency (HPA) Centre for Infections (CfI) received over 50 Salmonella Montevideo isolates fully sensitive to antibiotics, from cases of infection in England and Wales. Forty-nine were primary cases, of which 37 share the pulsed field gel electrophoresis (PFGE) profile SmvdX07 and fit a case definition [4]. The HPA CfI attempted to contact all cases and detailed food histories were obtained from 15 cases, all of which were confirmed to have the SmvdX07 profile. The analysis allowed the exclusion of a particular retailer, eating out or eating take-away food. Exposures reported by 60% or more of cases (poultry, fish and seafood, eggs, milk, cheese, other dairy products, cakes and biscuits, sauces, fruit, confectionery and drinks) were examined in greater detail. No food products or brands were identified as being common among cases with the exception of confectionery products which were reported by 14 cases. Thirteen of the cases interviewed reported eating products from Cadbury Schweppes plc. One additional case from Wales that the CfI was unable to contact, also reported consumption of products from Cadbury. After carefully considering all the available evidence the OCT concluded that consumption of products made by Cadbury Schweppes was the most credible explanation for the outbreak of S. Montevideo.
A 50 year old resident of the Borders region of Scotland, died in July 2006 after suffering from septicaemia, likely to be due to anthrax [5]. His condition deteriorated rapidly following admission to hospital in his clinical condition, he was transferred to the Edinburgh Royal Infirmary, where he died a few hours later due to septicaemia. Anthrax was diagnosed at specialist laboratories in England in August. The man is known to have made drums with untreated animal hides – working with animal hides is known to be a risk-factor for acquiring the infection, and it is possible that he acquired inhalation anthrax as a result of inhaling spores during the course of work at his home. Minute quantities of anthrax spores were detected in three drums and two imported animal skins used in the making of African drums.
A national increase in the number of cases of legionnaires’ disease was noted in August [6]. Between August and October 2006, Over 300 cases were reported between August and October 2006, nearly double that for the same period in 2005. Cases have been reported from all regions although there was no suggestion of a national outbreak occurring. The absolute number of cases in each region showed considerable variation, but rates were relatively constant with the underlying populations taken into account (from 0.38 to 1.21 cases per 100,000). The rate in the East Midlands was notably higher than their comparable rate in 2005, while London’s rate decreased despite the nationwide increase in cases.
A fatal case of Pasteurella multocida infection was been reported in a young male farmer in Suffolk in August [7]. Pasteurellosis is a zoonotic disease that occurs sporadically worldwide. Cutaneous infection following dog or cat bites, scratches or licks is the most common form of this disease in humans. Human infections are usually contracted following exposure to domestic pets such as cats and dogs, as humans have most contact with these animals. Infections have been associated with a range of other animals including cows and rabbits, although patients often report no known animal contact. There are approximately 400 laboratory confirmed cases of pasteurellosis reported in humans each year in England and Wales, of which about 70% are due to P. multocida. Fatal cases of pasteurellosis are extremely rare, and only four deaths were reported in England and Wales between 1993 and 2005, three of which were in people aged over 50 years. Previously, the most recent fatal case in England and Wales had been reported in 2003, following a cat bite.
Surveillance
Data for 2005 on sexually transmitted infections was released in July. Reports from genitourinary medicine (GUM) clinics in the United Kingdom (UK) showed that 790,387 new diagnoses were made in 2005 [8]. This represented a 3% increase from 768,339 diagnoses in 2004. There was also an increase of 9% in the total workload seen in GUM clinics between 2004 and 2005 (1,690,597 to 1,839,241), including a 13% increase (775,384 to 878,537) in sexual health screens. The gonorrhoea diagnosis rate per 100,000 decreased from 37.4 in 2004 to 32.6 in 2005 whereas the diagnosis rates of primary and secondary syphilis, genital chlamydia, genital herpes, and genital warts all increased. There was a 13% (22,350 to 19,495) decrease in gonorrhoea diagnoses between 2004 and 2005, which follows the 10% decrease seen between 2003 and 2004. A 10% decrease was seen in all male attendees, 17% (11, 721 to 9703) among heterosexual men, and 18% among women attendees. Decreases were reported in all English regions. Among men who have sex with men (MSM) diagnoses of gonorrhoea increased in Scotland, Northern Ireland, and all English regions apart from the East Midlands, East of England, and the South West. Although there was a reduction in diagnoses among MSM aged 16 to 19 years, there were increases in the 25 to 64 years age group. Genital chlamydial infection remained the most commonly diagnosed STI in GUM clinics in the UK with 109, 832 cases diagnosed in 2005, a 5% increase on 2004 (104,840 cases), 7% and 3% in males and females respectively. Highest rates of infection and highest increases in diagnoses were seen for both sexes in the 16 to 24 years age group. There was an increase of 23% in diagnoses of primary and secondary infectious syphilis from 2278 to 2807 between 2004 and 2005. The much greater increase in females compared to males was most marked in London where diagnoses rose by 61% in females (from 114 to 184) and 7% in males (from 737 to 792). Among MSM, there was a 34% increase in syphilis cases in London (from 402 to 537), and increases of 118% and 119% were seen in the North West (from 132 to 288) and South West (from 53 to 116) regions respectively.
The report Surveillance of Surgical Site Infection in England, October 1997 to September 2005 was published in August [9]. It summarises the data collected and reported by the 247 hospitals that participated in the Surgical Site Infection Surveillance Service (SSISS) between October 1997 and September 2005. It includes 240,000 records collected in 11 categories of surgical procedure and incorporates data collected as part of the mandatory surveillance of surgical site infections (SSI) in orthopaedic surgery which commenced in April 2004. All hospitals participating in the scheme are expected to adhere to a standard method of collecting and reporting data described in the SSI surveillance protocol. Hospitals must participate in the surveillance for a minimum three-month period although they can choose to collect data for more than one period. Findings included:
- The risk of SSI increased with increasing age. In eight of the 11 surgical procedures this trend was statistically significant.
- Most of the SSIs reported affected the superficial layer of the wound (skin or subcutaneous tissues). At least one fifth of infections in the major surgical categories affected the deeper tissues (fascial and muscle layers).
- Data on micro-organisms causing the SSI were available for 81% of infections. Staphylococcus aureus was the main organism reported in all 11 surgical categories, accounting for 53% of infections where a causative organism was reported.
- Sixty-four per cent of the Staphylococcus aureus reported were methicillin resistant.
- Twelve per cent of hospitals had achieved a statistically significant reduction in rate of SSI since joining the surveillance scheme. Most hospitals did not have a significant trend.
The results of treatment outcome monitoring (TOM) for tuberculosis cases reported in 2003 to Enhanced Tuberculosis Surveillance in England, Wales, and Northern Ireland was reported in July [10]. Information on outcome relates to the patient’s status 12 months after commencing treatment or notification. There were 6837 tuberculosis cases reported in 2003, of which 120 were subsequently found not to have tuberculosis. Of the remaining 6717, 90% had an outcome reported compared with 85% in 2002 and 79% in 2001. Initial analysis of the 6018 cases with a reported outcome revealed that 79% (4746/6018) of all tuberculosis cases and 79% (835/1061) of new infectious pulmonary cases completed treatment. Treatment completion was higher for foreign-born cases 82% (3233/3961) compared to cases born in the UK 74% (1200/1624). Although a higher proportion of cases had an outcome returned, the proportion completing treatment among this cohort (79%) was very similar to previous years (78% in 2002, 79% in 2001). The World Health Organization recommends at least 85% of new infectious pulmonary cases should successfully complete treatment. A substantial proportion of UK born cases derive from elderly populations aged over 65 years, in whom the risk of death from tuberculosis or other causes is much higher.
Publications of interest
The draft Code of practice for prevention and control of healthcare associated infections was published by the Department of Health website July, followed by the final version in October [11]. The Code is designed to help NHS bodies plan and implement how they can prevent and control healthcare associated infections (HCAI). It sets out criteria by which managers of NHS organisations and other health care providers should ensure that patients are cared for in a clean environment, where the risk of HCAI is kept as low as possible. The Healthcare Commission will be using this code to assess NHS performance and similar requirements will be introduced for the private and voluntary healthcare sector and care homes.
News from abroad
Between 1 January and 4 August 2006, there were 242 laboratory-confirmed cases (including 20 deaths) of Crimean Congo haemorrhagic fever (CCHF) reported in 22 out of 81 provinces in Turkey [12]. The provinces most affected were Tokat, Gümüshane, Amasya, Çorum, Yozgat, and Sivas in the central Anatolia and Black Sea regions (north east Turkey). Compared with previous years, this number may suggest increased activity of the virus in the area, although detection, diagnosis, and notification have improved. In Turkey, CCHF in humans was first documented in 2002.
In July, a patient who travelled from Freetown (Sierra Leone) to Germany via Abidjan (Ivory Coast) and Brussels was diagnosed with Lassa fever [13]. The patient had a history of a progressive neurological condition over several months in Sierra Leone and went on to develop a fever with worsening neurological symptoms. On arrival in Germany the patient was taken to a local hospital for specialist medical care. Health officials in Germany took the appropriate measures to prevent further transmission of the virus.
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, and edited by Neil Hough and Barry Evans
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References |
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TOPTHE QUARTER AT A...Events of the quarterReferences |
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- Department of Health. Important changes to the childhood immunisation programme (Letter). Chief Medical Officer: PL CMO (2006)1. London: Department of Health: 12 July 2006. Available at: <http://www.dh.gov.uk/PublicationsAndStatistics/LettersAndCirculars/ProfessionalLetters/ChiefMedicalOfficerLetters/ChiefMedicalOfficerLettersArticle/fs/en?CONTENT_ID=4137171&chk=vpwQzv>.
- Heath Protection Agency Meningococcus Forum. Guidance for public health management of meningococcal disease in the UK. London: HPA, 2006. Available at <http://www.hpa.org.uk/infections/topics_az/meningo/guidelines.htm>.
- Public Heath Service Laboratory Service Meningococcus Forum. Guidelines for public health management of meningococcal disease in the UK. Commun Dis Public Health 2002; 5:187–204.[Medline]
- HPA. National increase in human Salmonella Montevideo infections in England and Wales: March to July 2006. Commun Dis Rep CDR Wkly [serial online] 2006 [cited 15 January 2007]; 16(29): News. Available at <http://www.hpa.org.uk/cdr/archives/2006/cdr2906.pdf>.
- Health Protection Scotland. Probable human anthrax death in Scotland. HPS Weekly Report 2006; 40(33): 177. Available at <http://www.documents.hps.scot.nhs.uk/ewr/pdf2006/0633.pdf>.
- National increase in cases of legionnaires’ disease – update. Commun Dis Rep CDR Wkly [serial online] 2006 [cited 15 January 2007]; 16(46): News. Available at <http://www.hpa.org.uk/cdr/archives/2006/cdr4606.pdf>.
- HPA. Fatal case of Pasteurella multocida infection in East of England. Commun Dis Rep CDR Wkly [serial online] 2006 [cited 12 January 2007]; 16(34): News. Available at <http://www.hpa.org.uk/cdr/archives/2006/cdr3406.pdf>.
- 2005 STI data. In Health Protection Agency Website (online) December 2006 (cited 12 January 2007). London: HPA, 2006. Available at <http://www.hpa.org.uk/infections/topics_az/hiv_and_sti/epidemiology/datatables2005.htm>.
- TB epidemiology data tables. In Health Protection Agency Website (online) December 2006 (cited 12 January 2007). London: HPA, 2006. Available at <http://www.hpa.org.uk/infections/topics_az/tb/epidemiology/tables.htm#tom>.
- Health Protection Agency. Surveillance of Surgical Site Infection in England, October 1997 to September 2005. London: Health Protection Agency, August 2006. Available at <http://www.hpa.org.uk/infections/topics_az/surgical_site_infection/all_97_05_SSI.pdf>
- Department of Health. The Health Act 2006 – code of practice for the prevention and control of health care associated infection. London: DH, 1 October 2006. Available at <http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4139336&chk=6oAPfi>.
- WHO Regional Office for Europe Outbreaks of Crimean-Congo hemorrhagic fever in Turkey. Quarterly Communicable Diseases Report. Issue 42 October 2006. Available at <http://www.euro.who.int/document/CSR/CDnews42.pdf>.
- HPA. Lassa fever in Germany: follow up of possible contacts. Commun Dis Rep CDR Wkly [serial online] 2006 [cited 12 January 2007]; 16(30): News. Available at <http://www.hpa.org.uk/cdr/archives/2006/cdr3006.pdf>.
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