Communicable Disease and Health Protection Quarterly Review: January to March 2007
Keywords: avian influenza, communicable disease, corynebacterium, environmental assessment, listeriosis, malaria, ringworm
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THE QUARTER AT A GLANCE... |
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Policy and practice:
- Malaria
- Health clearance for healthcare workers
Outbreaks and incidents:
- Avian influenza
- Toxigenic Corynebacterium ulcerans
- Listeriosis
Surveillance:
- Surgical site infections
Publications:
- Tinea capitis
- Strategic environmental assessment
News from abroad:
- Malaria
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Events of the quarter |
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Policy and practice
In January, the Health Protection Agency (HPA) Advisory Committee on Malaria Prevention (ACMP) in UK travellers published new guidelines on the diagnosis and management of malaria in the UK.1 These define best practice in the UK healthcare setting where rapid diagnosis, safe medicines and high-quality medical care are available, and where the emergence of resistance is not a problem in the absence of naturally occurring disease. This completes the ABCD principles of malaria prevention promoted by the ACMP,2 which are Awareness of the risk at the traveller's destination; Bite prevention; Chemoprophylaxis and Diagnosis and treatment without delay. The aim of the ACMP malaria treatment guidelines is to increase the timeliness and safety of malaria treatment in the UK, especially in those places outside major cities where relatively few cases are seen. They have been prepared by ACMP experts, with additional input from tropical diseases specialists in the UK and overseas. They complement the treatment algorithm3 developed jointly with the British Infection Society. The treatment guidelines are available in the Journal of Infection1 and also on the HPA website at http://www.hpa.org.uk/infections/topics_az/malaria/Treat_guidelines.htm
The UK Department of Health issued new guidance to the NHS on health clearance for tuberculosis, hepatitis B, hepatitis C and HIV in new healthcare workers in March.4 This guidance related to healthcare workers new to the NHS, those who are moving to a first post or training that involves exposure-prone procedures (EPP) and returning healthcare workers who may have been exposed to serious communicable diseases while away from the health service. The guidance recommended standard health clearance checks that should be completed on appointment for all new healthcare workers, including checks for tuberculosis disease/immunity, the offer of hepatitis B immunization and testing of post-immunization response and the offer of hepatitis C and HIV tests. Additional health clearance checks are required for those healthcare workers who will be performing EPPs, and should be completed prior to confirmation of appointment. The healthcare workers must be non-infectious for HIV (antibody negative), hepatitis B (surface antigen negative or, if positive, e-antigen negative with a viral load of 103 genome equivalents/ml or less) and hepatitis C (antibody negative or, if positive, negative for hepatitis C RNA). The new guidance, which is consistent with existing policy, is intended to restrict healthcare workers infected with blood-borne viruses from working in the NHS in clinical areas where their infection may pose a risk to patients in their care. Testing is a one-off and relies on the current obligation for healthcare workers to seek confidential professional advice, if they believe that they may subsequently have been exposed to a serious communicable disease. In addition, the UK Department of Health has released new guidelines based on the recommendations from the Advisory Group on Hepatitis, allowing certain hepatitis B-infected healthcare workers to perform EPPs while on oral antiviral therapy.5
Outbreaks and incidents
On 3 February 2007, the Department for the Environment Food and Rural Affairs (Defra) reported that turkeys on a large farm near Lowestoft in north Suffolk had been confirmed by the Veterinary Laboratories Agency (VLA) to have been infected with H5N1 avian influenza virus.7 Later that day, the VLA confirmed that the influenza virus identified in the poultry was of the highly pathogenic Asian lineage and similar to the virus found in Hungary in January 2007.8 From 3 February 2007, the State Veterinary Service (SVS) enforced a Protection Zone, with a radius of 3 km, and a Surveillance Zone, with a radius of 10 km, around the premises, where poultry must be isolated from wild birds.7 The farm itself was placed under restriction on 1 February, when a health problem in turkeys on the farm was first noted. In consultation with ornithologists, a wider Restricted Zone, of 
2090 km2, was also introduced in which the isolation of poultry from wild birds is required and all bird movements must be licensed. Humane culling of turkeys at the infected farm began on 3 February and was completed by the evening of 5 February. Among the total of 159 000 turkeys on the farm, 2500 were reported to have died and the rest were culled. The level of risk to the general public from H5N1 infection as a result of this incident was assessed as extremely low, and the UK Food Standards Agency (FSA) and the World Health Organization advised that there is no risk in eating properly cooked poultry, including turkey and eggs. To facilitate the response to the incident, the HPA produced guidance (a) on the management of personnel, involved in response to the occurrence of confirmed highly pathogenic avian influenza (H5N1) in poultry in the UK, presenting with febrile respiratory illness, and (b) guidance on post-exposure prophylaxis for farm workers/residents, SVS staff and cullers involved in confirmed or suspected outbreaks of highly pathogenic avian influenza suspected or known to be due to H5N1 in poultry in the UK. Antiviral drugs were offered to 480 people. Six people who developed flu-like symptoms were tested: three met the criteria for testing, and three others were tested as a precautionary measure. All six tested negative for avian flu, and received appropriate medical care.
In February, isolation from a pharyngeal sample taken from a middle-aged man from North Yorkshire was confirmed as a toxigenic Corynebacterium ulcerans.9 His symptoms included a 5-week history of pharyngitis, laryngitis, fever and abdominal pain. He had been seen by his GP a week before when the pharyngeal swabs were taken. The index case reported no relevant risk factors in particular no history of foreign travel, or the consumption of unpasteurized dairy products or farm visits, although the family did have pets. The patient was given a 14-day course of erythromycin and will be offered booster vaccination upon full recovery. Pharyngeal swabs were taken from the household contacts; they were given a 7-day course of erythromycin and offered vaccine boosters. The contacts were excluded from school and work pending laboratory investigations. In addition, local veterinary services obtained pharyngeal swabs from the three family pets. Toxigenic C. ulcerans is a documented cause of diphtheria. Cases of diphtheria are rare in the UK since mass immunization began in 1942. Cattle are a known reservoir for C. ulcerans.10 Risk factors for people include consumption of unpasteurized dairy products or contact with cattle or farm animals. None of these risk factors have been identified for many of the recent cases of C. ulcerans in the UK, however, so questions remain about its source.11 From 2002 to date, the organism has also been isolated from several domestic cats and dogs with respiratory discharges from both the UK and other northern European countries, including France, Germany and the Netherlands, suggesting a possible novel reservoir for this organism.12,13 Although person-to-person spread of C. ulcerans hardly ever occurs, it has been a possible route of transmission in the UK12 and therefore, it is recommended that close contacts should be treated similarly to contacts of cases of infection with toxigenic C. diphtheriae.12
Also in February, routine testing of a sandwich sampled from a vending machine in Kent revealed high levels of Listeria monocytogenes contamination (160 c.f.u/g).14 The vending machine had been operating at 16°C instead of at or < 8°C. The site of manufacture of the sandwich was inspected by local authority environmental health officers 2 weeks later, in March. There was significant contamination with L. monocytogenes of sandwiches manufactured on this site (both on day of production and at end of shelf-life) and of the environment. Levels of contamination in tested sandwiches ranged from 10 to 270 c.f.u/g. The factory immediately ceased production, voluntarily, and the FSA was informed. Customers were informed by the manufacturer and advised to withdraw all sandwiches from sale. Approximately 10 000 sandwiches were produced by the manufacturer on this site each day (except Saturday); 190, 000 sandwiches between 18 February and 12 March. Approximately 40% of sandwich distribution was to hospitals in the South East and London. An uncertain proportion of this distribution was consumed by patients (sandwiches were also sold to staff and visitors). The remaining 60% were distributed to various outlets including schools and commercial organizations in the South East, London and Essex.
Surveillance
The results of the second year of the Department of Health's mandatory surveillance of surgical site infection (SSI) in orthopaedic surgery in NHS hospitals in England was published in February.15 The report presented data on the participation of hospital Trusts in the surveillance, the incidence of SSI by each of the four categories of procedure, differences between the first year (2004–05) and the second year (2005–06), the incidence by risk groups and summary data on the most common causative micro-organisms in an SSI. The key points of the report included:
- More than one-third of Trusts have undertaken surveillance in at least one category of orthopaedic procedure continuously. Most have been undertaking surveillance in the hip and knee replacement categories of procedure.
- The rates of SSI decreased between the first (2004–05) and second year (2005–06) of the mandatory surveillance for each category, although the reduction was only statistically significant for hip prosthesis surgery.
- In most Trusts, the rates of SSI in orthopaedic surgery were low.
- In both years, the rates of SSI were highest in the hip hemiarthroplasty category. This is partly explained by patients undergoing these procedures being at greater risk of infection and because they tend to have a longer post-operative stay in hospital, increasing the chance that SSIs will be detected.
- Most of the SSIs reported affected the superficial layers of the wound, but approximately a quarter involved the deeper tissues. In three categories of surgery, the proportion of SSI affecting the deeper tissues has increased in the second year.
- In 2005–06, Staphylococcus aureus continues to be a major cause of SSIs and was responsible for nearly half of all SSIs, with 65% of being methicillin resistant. Nearly one-third of the total SSIs were caused by methicillin resistant S. aureus.
- The possibility that an SSI will be detected depends on the length of time that the patient spends in hospital after operation. Some of the variation in rates may therefore be explained by differences in length of post-operative follow-up. In addition, the rates included in these tables have not been adjusted for underlying risk factors related to the patient or their operation that could affect the risk of developing an SSI, for example, age, underlying illness and complexity of the operation.
Publications of interest
In March, a working group of the HPA Advisory Committee on Fungal Infection published a report on the epidemiology, diagnosis and management of tinea capitis (scalp ringworm).16 It is a simple, concise evidence-based guide aimed at healthcare workers. The pattern of tinea capitis (scalp ringworm) in the UK has changed in the past 10 years with a significant rise in the incidence of cases of infection, mainly due to Trichophyton tonsurans.17,18 The main goals of therapy of tinea capitis are treatment of the patient and prevention of spread to other children. Although there is currently only one approved drug for tinea captitis in the UK (the tablet form of Griseofulvin), this report gives the evidence for a range of possible treatment options for cases, carriers and patients with more severe symptoms such as kerions (inflamed lesions). Advice is given on general management to avoid spread including what to do in schools. Since the clinical signs can vary widely, the authors advise that it is unreliable to depend on clinical diagnosis alone and microbiological confirmation should be sought wherever possible.
In March, the Department of Health produced draft guidance Practical Guide to the Strategic Environmental Assessment Directive.19 This was produced in close collaboration with the HPA and in consultation with the Department for Communities and Local Government. SEA has been incorporated into the sustainability appraisal for spatial plans (Regional Spatial Strategies and Local Development Documents) and is also required for other regional and local authority plans including in sectors such as economic development, transport, housing, waste management, and environmental protection and management. The guidance explains potential ways of considering the likely effects of plans and programmes covered by the SEA Regulations on the environment in relation to population and human health topics. It sets out the benefits of considering health, the requirements of the SEA Directive, and Sustainability Appraisal, what health covers and who to contact in health organisations. The relevant health input at the five stages of SEA is described with examples and links to additional resources.
News from abroad
A number of cases of malaria were reported in travellers to Goa at the end of 2006, and the beginning of 2007.20 The UK malaria guidelines20 were therefore temporarily updated to advise that travel advisors should highlight the risk of malaria, instruct on the use of mosquito bite avoidance measures and recommend malaria chemoprophylaxis to those travellers who will be visiting Goa, particularly areas north of Panaji, which will be remote from medical care. The recommended chemoprophylaxis is chloroquine plus proguanil. Alternatives are mefloquine, atovaquone plus proguanil (Malarone®), or doxycycline. All travellers to Goa should also use mosquito bite avoidance measures and be aware of the risk of malaria. This also applies to the other low-risk regions of India as listed in the guidelines.21
The CDaHP series is prepared by the HPA with the assistance of colleagues in partner organizations 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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- HPA Advisory Committee on Malaria Prevention in UK Travellers. UK malaria treatment guidelines. J Infect 2007. 54(2):111–21.
- Chiodini P, Hill D, Lalloo D, Lea G, Walker E, Whitty C, et al. Guidelines for Malaria Prevention in Travellers from the United Kingdom. (2007) London: Health Protection Agency. Available at <http://www.hpa.org.uk/publications/PublicationDisplay.asp?PublicationID=87>.
- The British Infection Society [online]. Algorithm for the initial assessment and management of malaria in adults [online]. Available at <http://www.britishinfectionsociety.org>.
- Department of Health. Health Clearance for Tuberculosis, Hepatitis B, Hepatitis C and HIV: New Healthcare Workers. (2007) 3 16. London: Department of Health. Available at <http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_073132>.
- Department of Health. Hepatitis B Infected Healthcare Workers and Antiviral Therapy. (2007) 3 16. London: Department of Health. Available at <http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_073164>.
- Department of Health. Hepatitis B Infected Healthcare Workers. Health Service Circular HSC 2000/020. (2000) 6. London: Department of Health. Available at <http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4012257.pdf>.
- H5N1 Avian Influenza Confirmed in Poultry (News release) (2007) 2 3. London: Defra. Available at <http://www.defra.gov.uk/news/2007/070203a.htm>.
- H5N1 in Poultry in Suffolk Confirmed as Asian Strain of Avian Influenza (News release) (2007) 2 3. London: Defra. Available at <http://www.defra.gov.uk/news/2007/070203b.htm>.
- HPA. Laboratory confirmed case of toxigenic. Corynebacterium ulcerans. Health Protection Report [serial online] (2007) [cited 16 July 2007]; 1(10): news. Available at http://www.hpa.org.uk/hpr/archives/2007/hpr1007.pdf>.
- HPA. General Information – Diphtheria (2006) 6 3 2007. London: Health Protection Agency. HPA Website [online] Available at <http://www.hpa.org.uk/infections/topics_az/diphtheria/gen_info.htm>.
- HPA. A case of diphtheria caused by toxigenic Corynebacterium ulcerans. Commun Dis Rep CDR Wkly [serial online] (2006) (6 March 2007, date last accessed); 16(4): news. Available at <http://www.hpa.org.uk/cdr/archives/archive06/News/news0406.htm#dip>.
- Begg NT, Bonnet JM. Control of diphtheria: guidance for consultants in communicable disease control. Commun Dis Public Health (1999) 2(4):242–9. Available at <http://www.hpa.org.uk/cdph/issues/CDPHVol2/no4/guidelines.pdf>.[Medline]
- De Zoysa A, Hawkey PM, Engler K, George R, Reilly W, Taylor D, et al. Characterization of toxigenic Corynebacterium ulcerans strains isolated from humans and domestic cats in the United Kingdom. J Clin Microbiol (2005) 43:4377–81.
[Abstract/Free Full Text] - HPA. Listeria contamination of sandwiches. Health Protection Report [serial online] (2007) [cited 16 July 2007]; 1 (12): news. Available at<http://www.hpa.org.uk/hpr/archives/2007/hpr1207.pdf>.
- HPA. Second Report of the Mandatory Surveillance of Surgical Site Infection in Orthopaedic Surgery in NHS hospitals in England. (2007) London: HPA. Available at <http://www.hpa.org.uk/infections/topics_az/surgical_site_infection/documents/SSI2ndMandatory29-01-07.pdf>.
- Health Protection Agency. Tinea Capitis in the United Kingdom: A Report on Its Diagnosis, Management and Prevention (2007) 3. London: Health Protection Agency. Available at <http://www.hpa.org.uk/publications/2007/tinea/tinea_capitis_07.pdf>.
- Hay RJ, Clayton YM, De Silva N, Midgley G, Rossor E. Tinea capitis in south-east London—a new pattern of infection with public health implications. Br J Dermatol (1996) 135:955–8.[CrossRef][Web of Science][Medline]
- Leeming JG, Elliott TS. The emergence of Trichophyton tonsurans tinea capitis in Birmingham, UK. Br J Dermatol (1995) 133:929–31.[CrossRef][Web of Science][Medline]
- Department of Health. Draft Guidance on Health in Strategic Environmental Assessment: A Consultation (2007) London: Department of Health. Available at <http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_073261>.
- HPA. Cluster of malaria cases from northern Goa – update. Health Protection Report [serial online] (2007) [cited 16 July 2007]; 1 (10): news. Available at http://www.hpa.org.uk/hpr/archives/2007/hpr1007.pdf>.
- Chiodini P, Hill D, Lalloo D, Lea G, Walker E, Whitty C. Bannister B on behalf of the Advisory Committee for Malaria Prevention in UK Travellers (ACMP). Guidelines for Malaria Prevention in Travellers from the United Kingdom (2007) London: Health Protection Agency. Available at <http://www.hpa.org.uk/infections/topics_az/malaria/guidelines.htm>.
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