Communicable Disease and Health Protection Quarterly Review: July to September 2005
From the Health Protection Agency
Keywords: communicable disease, BCG, healthcare workers, gonococci, E. coli O157, radiation
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The quarter at a glance ... |
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Policy and practice
- BCG vaccination programme
- HIV infected healthcare workers
Outbreaks and incidents
- E. coli O157 in Wales
- Rabies imported into England
Surveillance
- HPA/ONS joint initiative
News from abroad
- Marburg haemorrhagic fever
- Japanese encephalitis
- Salmonellosis in Spain
Publications
- Gonococcal Resistance to Antimicrobials Surveillance
Features
- Radiation emergency briefing packs
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Events of the quarter |
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Policy and practice
At the beginning of July, the Chief Medical Officer announced changes to the BCG (Bacillus Calmette-Guerin) vaccination programme. The new policy is based on targeted immunisation of neonates and others at high risk and will replace the schools’ programme for older children (1). Those recommended to receive BCG are:
- All infants in areas within the United Kingdom where the incidence of tuberculosis is greater than 40 per 100,000 population per year.
- Infants, wherever they live, with one or more parent or grandparent born in a country with a tuberculosis incidence of greater than 40 per 100,000.
- Previously unvaccinated new immigrants from high incidence countries.
The recommendations for immunisation of those at high risk as a result of contact with an infectious case, through occupational exposure or as a result of prolonged travel in high incidence areas of the world, remain unchanged. Further guidance was subsequently issued (2). The Department of Health also published an operational note to professions involved in BCG vaccination outlining further details on the changes to programme in England at <http://www.dh.gov.uk/PolicyAndGuidance/Health AndSocialCareTopics/Tuberculosis/fs/en>
Also in July, the UK Department of Health issued revised guidance (2) for the NHS on the management of HIV infected healthcare workers and patient notification, following consultation in 2002. The guidance replaces that previous published in 1998 (3) and the consultation guidance published in 2002 (4). In the new document, the guidance on the management of the infected healthcare worker (HCWs), or those who consider that they may have been put at risk of acquiring HIV, remains unchanged. Under this long-standing policy, HIV infected HCWs should not carry out exposure prone procedures (5) and HCWs who have any reason to believe they may have been exposed to HIV infection must promptly seek professional advice on whether they should be tested for HIV. The main change in the new guidance is in relation to patient notification following an exposure prone procedure performed by an HIV infected HCW. The new policy means that when an HCW is found to be infected with HIV it is no longer necessary to notify routinely every patient who has undergone an exposure prone procedure performed by the HCW. Instead, the risk of HIV transmission to patients will be assessed locally by the NHS on a case-by-case basis using a criteria-based risk assessment framework. To further refine the level of risk, risk of bleed-back is categorized into levels 1 to 3, with level 3 being the highest category of risk. In the very unusual case where there is evidence of HIV transmission from the infected HCW to a patient (there have been none such cases in the UK), notification of all patients who have undergone exposure prone procedures by that HCW should take place. In the absence of evidence of HIV transmission, all patients who have undergone category 3 procedures by an infected HCW should be notified. When only category 1 or 2 procedures have been carried out, patient notification will not be necessary, unless the other relevant considerations suggest that it should be done. Directors of Public Health of primary care trusts will be responsible for deciding whether patient notification is necessary. The UK Advisory Panel for Health Care Workers Infected with Blood-borne Viruses will be available to provide advice if and when needed. The extent of the patient notification exercise will depend on the level of risk of exposure. This may mean that in some instances there is no patient notification exercise, or it is limited in scope.
Outbreaks and incidents
In September 2005, staff at Prince Charles Hospital, Merthyr Tydfil, Wales, reported nine cases of bloody diarrhoea that had presented at the hospital to the National Public Health Service for Wales and local authorities (7). By the beginning of October, over 150 cases had been reported in the outbreak, with over 80 isolates confirmed as VTEC O157 (PT) 21/28 with genes for vero-cytotoxin (VT) 2. Sixty-five per cent were in school aged children, with over forty schools recording cases. A single main supplier distributed cooked meats to the affected schools. Practices that could result in contamination of cooked meat at the supplier’s premises were the subject of enforcement action by the supplier’s home local authority on 19 September 2005. The Food Standards Agency Wales also issued a food alert on 21 September 2005. E. coli O157 PT21/28, VT2 was isolated from samples of sliced cooked meat and was shown by PFGE profiles to be indistinguishable from those found in people with the infection.
A fatal case of rabies was reported in England in July (8). The person who died had been bitten by a dog while on holiday in Goa, India – India is a high-risk destination. This was the fourth case of imported rabies in England and Wales in the past ten years – all have been fatal. Previous travel destinations were Nigeria (two cases) and the Philippines.
Surveillance
The HPA and Office for National Statistics (ONS) launched a new initiative to attempt to link surveillance data on serious infections held by the HPA with mortality data held by the ONS. This data linkage programme will focus on healthcare-associated infections (HCAI), initially targeting methicillin resistant Staphylococcus aureus (MRSA) and build on previous joint work on comparing trends in mortality and morbidity from MRSA (9). It is planned to use this linkage as the framework for a two-year Department of Health funded confidential study of deaths related to MRSA and other HCAI, in response to the audit of deaths referred to in the Chief Medical Officer’s report Winning Ways: working together to reduce healthcare associated infection in England (10).
News from abroad
The final laboratory confirmed cases in the largest outbreak of Marburg haemorrhagic fever to date, that killed hundreds in northern Angola, occurred in this period (12). The outbreak started in October 2004 and peaked between 28 March and 3 April 2005; the final confirmed cases were on 27 July 2005. The final number of cases was 252, with 227 deaths, and 25 survivors, representing a case fatality rate of 90%. The outbreak was officially declared over on 7 November 2005. Despite intensive investigations extending over several years, research has failed to find an animal reservoir of the virus where it may occur between human outbreaks.
In July, an outbreak of Japanese encephalitis began (JE) in northern India and Nepal, which affected over 8500 people, mainly children, with over 1500 deaths reported (13). The outbreak affected the states of Uttar Pradesh and neighbouring Bihar in India, and most regions of Nepal; western, mid-western, and far-western regions of Nepal were most affected. JE is transmitted by the bite of the Culex spp mosquito and is endemic in many parts of India. Thousands of cases are reported each year. Peak transmission season (between May and October) in northern India occurs during and just after the monsoon season when major outbreaks coincide with heavy rains and flooding. Case numbers in the region were reported to be higher in 2005 than in previous years.
A large outbreak of salmonella gastroenteritis was reported in Spain, with over 2000 cases (14). Reported cases were been epidemiologically and microbiologically linked to a single brand of pre-cooked, vacuum-packed roast chicken which was commercially distributed throughout Spain. The National Reference Laboratory for Salmonella and Shigella (LNRSSE) confirm the identification of Salmonella Hadar, phage type (PT) 2. All implicated chicken products were recalled from commercial outlets, and a mass media campaign to ensure people avoided consuming the implicated chicken was launched throughout Spain.
Publications
The Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) 2004 report was published in August (11). The report summarised findings from the fifth year of data collection in which 1938 isolates were analysed. Twenty-four laboratories and 26 genitourinary medicine clinics participate in the project. Overall, 14% of GRASP isolates were resistant to ciprofloxacin (=1mg/L) in 2004 a significant increase from the 9% observed in 2003 (p = 0.05). As observed in previous years the prevalence of ciprofloxacin resistance varied significantly by region remaining above 5% in all regions in 2004, ranging from 6% in Yorkshire and Humberside to 36% in the North East. The prevalence of ciprofloxacin resistance in heterosexual males remained stable at 11% in 2004, but was significantly higher than the 5% prevalence observed in females. In 2004, the prevalence of ciprofloxacin resistance in men who have sex with men (MSM) rose significantly to 27%, more than double the 11% prevalence observed in 2003. Current guidelines recommend the use of third generation cephalosporins, ceftriaxone or cefixime as first line therapies. Seventy per cent of GRASP individuals were treated with a cephalosporin in 2004, of whom over half were prescribed cefixime. Despite no longer being recommended as a first-line therapy, fluoroquinolones (ciprofloxacin or ofloxacin) were prescribed to nearly a quarter of patients in 2004. In 2004 the burden of gonococcal infection remained highly concentrated within demographic and behavioural risk groups in England and Wales, with young people, MSM, and ethnic minorities, bearing a disproportionate burden of disease. As in previous years, the 2004 collection found relatively few changes in risk factors, and in clinical and behavioural presentations of gonococcal infection.
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Features |
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RPD issue Radiation Emergencies Briefing Packs for Health Protection Agency staff
The Radiation Protection Division (RPD) of the Health Protection Agency (HPA) is based at the Centre for Radiation, Chemical and Environmental Hazards (CRCE). The Emergency Response Group based there has prepared a radiation emergency briefing pack for use by of the Agency ‘at the front line’, based in Health Protection Units and elsewhere across England.
The purpose of the briefing pack document is to provide HPA staff with information on the arrangements that are in existence, some early actions and the mechanism for obtaining support from the Radiation Protection Division of HPA in the event of an emergency involving nuclear or radiological materials.
The pack provides guidance on the type of support likely to be available from the Radiation Protection Division (RPD) as an emergency scenario progresses and focuses on the first few hours of an event if radiation specialists from RPD have yet to be deployed or are en-route to the affected area. Support from local HPA units close to the scene of a radiation incident would be crucial at this time.
The briefing pack has been produced to reinforce training received by nearly 100 HPA staff during a series of one-day radiation emergencies awareness courses held this year. This training was considered to be timely and useful. Further courses for HPA staff are planned for 2006.
The pack will be distributed to HPA staff at Health Protection Units, Regional Director’s Offices, Health Emergency Planning Advisers and Regional Health Emergency Planning teams. Copies of the briefing pack will also go to HPA staff operating national on-call rotas at Chemical Hazards and Poisons Division (CHaPD) and the Centre for Emergency Preparedness and Response (CEPR).
RPD considers this a useful reference document for all HPA staff with an interest in increasing their awareness of radiation emergencies.
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 (Radiation Emergencies) and edited by Neil Hough and Barry Evans
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References |
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- Department of Health. Tuberculosis: Improvements to BCG immunisation programme (press release) (PL/CMO/2005/3). London: Department of Health, 6 July 2005. Available at <http://www.dh.gov.uk/AboutUs/MinistersAndDepartmentLeaders/ChiefMedicalOfficer/fs/en>.
- Department of Health (Letter from the Chief Medical Officer, the Chief Nursing Officer and the Chief Pharmaceutical Officer). Changes to the BCG Vaccination Programme. London: Department of Health, July 2005 [Accessed 22 August 2005]. Available at <http://www.dh.gov.uk/assetRoot/04/11/49/96/04114996.pdf>.
- Department of Health. HIV Infected Health Care Workers: guidance on management and patient notification. London: Department of Health, 28 July 2005. Available at <http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/fs/en#5325970>.
- UK Health Departments. AIDS/HIV infected health care workers: Guidance on the management of infected health care workers and patient notification. London: DH, December 1998.
- UK Health Departments. HIV Infected Health Care Workers: a consultation paper on management and patient notification. London: DH, July 2002.
- UK Health Departments. AIDS/HIV – infected health care workers: guidance on the management of infected health care workers. London: DH, March 1994.
- HPA. Vero-cytotoxin producing E. coli O157 (VTEC O157) outbreak in the south Wales valleys: update. Commun Dis Rep CDR Wkly [serial online] 2005 [cited 30 December 2005];15 (40): news. Available at <http://www.hpa.org.uk/cdr/archives/2005/cdr4005.pdf>.
- HPA. Case of imported rabies in the UK. Commun Dis Rep CDR Wkly [serial online] 2005 [cited 30 December 2005];15 (28): news. Available at <http://www.hpa.org.uk/cdr/archives/2005/cdr2805.pdf>.
- HPA. New initiative to link surveillance and mortality data. Commun Dis Rep CDR Wkly [serial online] 2005 [cited 30 December 2005];15 (37): news. Available at <http://www.hpa.org.uk/cdr/archives/2005/cdr3705.pdf>.
- Chief Medical Officer. Winning ways – working together to reduce healthcare associated infection in England. London: Department of Health, 2003.
- HPA. GRASP The Gonococcal Resistance to Antimicrobials Surveillance Programme – Annual Report 2004. London:Health Protection Agency, August 2005. Available at:<http://www.hpa.org.uk/infections/topics_az/hiv_and_sti/stigonorrhoea/publications/GRASP_2004_Annual_Report.pdf>.
- HPA. Marburg haemorrhagic fever in Angola – outbreak declared over. Commun Dis Rep CDR Wkly [serial online] 2005 [cited 30 December 2005];15 (51): news. Available at <http://www.hpa.org.uk/cdr/archives/2005/cdr4705.pdf>.
- Health Protection Agency. Japanese encephalitis in India and Nepal –update. Commun Dis Rep Weekly [serial online] 2005 [cited 30 December 2005]; 15 (45): News. Available at <http://www.hpa.org.uk/cdr/archives/2005/cdr4505.pdf>.
- Lenglet A. E-alert 9 August: Over 2000 cases so far in Salmonella Hadar outbreak in Spain associated with consumption of pre-cooked chicken, July-August, 2005. Eurosurveillance Weekly [serial online] 2005 [cited 10 August 2005]; 10 (31).
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