Communicable Disease and Health Protection Quarterly Review: April to June 2006
From the Health Protection Agency
Keywords: communicable disease, staphylococcal, acinetobacter, port health, HIV, salmonella, avian influenza, enteric fever, radiation
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Policy and practice:
- Staphylococcal infections
- Going further faster
- Multi-resistant Acinetobacter
- Review of port health
Outbreaks and incidents:
- HIV
- Salmonella Montevideo
- Avian influenza
Surveillance:
- Enteric fever
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Policy and practice
In April, the Chief Medical Officer for England published interim guidance on diagnosis and management of Panton-Valentine Leukocidin (PVL)-associated staphylococcal infections in the United Kingdom (UK), prepared by the Health Protection Agency [1]. The guidance was based on a review of the literature and experiences of colleagues in the UK, Europe, and the United States. PVL is a toxin, which destroys white blood cells and is carried by less than 2% of clinical isolates of Staphylococcus aureus. PVL can be detected in both meticillin-sensitive S. aureus (MSSA) and meticillin resistant S. aureus (MRSA). The majority of isolates causing infection in the UK have been MSSA. Community-associated MRSA are more likely to produce PVL than hospital-associated MRSA. PVL-positive S. aureus are normally associated with necrotising pyogenic cutaneous infections and occasionally with cellulitis or tissue necrosis. They can, however, cause other severe invasive infections such as septic arthritis, bacteraemia, purpura fulminans, or community-acquired necrotising pneumonia.
In May, the Department of Health launched Going further faster, new guidance on reducing meticillin-resistant Staphylococcus aureus (MRSA) infections [2]. All NHS acute Trusts in England were set specific targets for reducing their numbers of MRSA bacteraemias by March 2008. To assist Trusts in assessing the likely financial and operational impact of meeting this target, a simple spreadsheet tool was developed to estimate the current financial cost and operational cost (in terms of additional bed days incurred) of MRSA bacteraemias and, more widely, all healthcare associated infections. This shows that a Trust with ‘average’ numbers of MRSA bacteraemias (around 44 in 2003/04) could, by meeting the target reduction of 50% by 2008, make savings of over £100,000 and reduce total bed days by 0.2% if all other HCAIs remained unchanged, and realise savings of around £4m and reduced total bed days by 6.1% if all other HCAIs were reduced proportionately with MRSA bacteraemias.
Expert guidance on the control of multi-resistant Acinetobacter outbreaks developed by a working group representing the Association of Medical Microbiologists, British Society for Antimicrobial Chemotherapy, Health Protection Agency, Hospital Infection Society, Infection Control Nurses Association, and Department of Health was updated in June [3]. This was the first update of the guidance and it is the working group’s intention to review it periodically in the light of new evidence for prevention and control.
The findings of joint HPA and Home Office review of health activity at international travel terminals – known collectively as ‘port health’ was published in April [4]. The Health Protection Agency, Department of Health, and the Home Office are taking forward a number of actions to strengthen and improve current arrangements at ports and airports. These include the HPA taking the overall operational lead to ensure appropriate operation arrangements for port health, for medical examinations under the Immigration Act 1971. The HPA will also work with partners to ensure that there are clear arrangements at each international travel terminal for contacting the different health services that may need to be involved (eg, NHS emergency services), and where it thinks there is a case for this, to encourage Strategic Health Authorities and Primary Care Trusts to review and develop services. The Department of Health (DH) will continue to lead work on legislation to implement the International Health Regulations 2005 and evaluate the effectiveness of routine tuberculosis (TB) checks on immigrants who are high risk for TB. The Department will also seek an opportunity to modernise the legislation on medical examinations under the Immigration Act, and work with the HPA and Home Office to produce and publish on relevant websites a short, clear note of the accountabilities for the different health activities carried out at international travel terminals. The Home Office will take forward a proposal that the accommodation needed for medical examinations under the Immigration Act should be provided free of charge under immigration legislation. It will update the immigration directorate instructions, agreeing the health-related material with DH. It will monitor the impact that advice from those who carry out medical examinations has on the entry decisions taken by immigration officers, and set up formal arrangements for the healthcare of immigration detainees at international travel terminals. It will also be prepared to include in future legislation a provision to modernise the legislation on medical examinations under the Immigration Act.
Outbreaks and incidents
The identification of a cluster of cases of heterosexual HIV transmission in St Ives, Cornwall led to a public announcement in early May. It appeared that there had been a risk to the local population over a six to eight years period [5]. The associated awareness campaign resulted in approximately 450 calls to an NHS Direct helpline. All resultant tests were negative. The public health response to a local outbreak of heterosexually acquired HIV infection is complex. The decision to alert the public was difficult and carefully considered. The aim was to ensure that people who may have been at risk of exposure had access to an HIV test while preserving confidentiality. Issues taken into consideration when making this decision included: the inability to obtain full sexual histories and undertake complete contact tracing; the wide age range of cases (20s to 50s), the evidence that there had been a risk to the local population over an extended period, the local perception that the risk of heterosexual HIV transmission is low, and information about local sexual health networks.
From March to the end of June, the Health Protection Agency (HPA) Centre for Infections (CfI) received 56 Salmonella Montevideo isolates, fully sensitive to antibiotics, from cases of infection in England and Wales [6]. Of these, 49 were primary cases, of which 37 shared the pulsed field gel electrophoresis (PFGE) profile SmvdX07 and fitted a set case definition. Thirteen of 15 cases interviewed reported eating products from Cadbury Schweppes plc: no other common brands, retail outlets, catering chains or single food types were identified as common factors. The data collected during these investigations were presented to the S. Montevideo National Outbreak Control Team (OCT). The team included representatives from the HPA, the Food Standards Agency (FSA), the Department for Food, Agriculture and Rural Affairs (DEFRA) and selected local authorities. S. Montevideo strains isolated from samples taken from the factories of Cadbury during routine sampling in January and February were also confirmed as PFGE profile SmvdX07. The frequency of cases of S. Montevideo PFGE SmvdX07 fell following a voluntary recall of a number of chocolate products, produced by Cadbury. These were considered as potentially contaminated with S. Montevideo PFGE SmvdX07 after a risk assessment of the results of microbiological sampling and environmental investigations at a number of factory premises. 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.
On 26 April, the Department for the Environment, Food and Rural Affairs (DEFRA) reported an outbreak of A/H7 avian influenza (AI) in a 35,000-bird housed poultry flock in the county of Norfolk, eastern England [7]. As a precautionary measure, all birds on the premises were culled, and restrictions were placed on the farm. The virus was subsequently confirmed as H7N3 of low pathogenicity. On 27 April 2006, a poultry worker from the farm presented with conjunctivitis. Conjunctival and combined nose/throat swabs were taken. Infection with influenza A/H7N3 was confirmed and the patient was placed on a treatment course of oseltamivir. Serological surveillance on samples taken from other poultry workers who had contact with the birds on the farm was carried out, and conjunctival and combined nose/throat swabs for PCR testing were taken from additional workers who present with influenza-like illness or conjunctivitis. Oseltamivir and seasonal influenza vaccine was offered to all those who have had contact with birds on the farm. Over 100 people were given oseltamivir, and serological specimens were obtained from the majority of these individuals. On 29 April 2006, three workers from a processing plant serving the original premises reported eye irritation. A worker involved in the initial response at the farm and already taking prophylactic oseltamivir also reported feverishness and respiratory symptoms on 29 April 2006. On 1 May 2006, a culler taking prophylactic oseltamivir, presented with itchy eyes and a sore throat. All five of these individuals tested negative for influenza A by PCR. On 29 April 2006, two free-range poultry farms about 1.5 km from the original premises were tested by DEFRA. Results showed serological evidence of previous infection with H7N3 in the flocks, which were subsequently culled. It is not clear which of the three units was first infected or how disease may have passed between them. This is not the first reported case of conjunctivitis due to an avian influenza in the UK. In the 1990s conjunctivitis attributed to a low pathogenicity avian influenza (H7N7) from the waste products of domestic poultry was reported in a woman who had been cleaning a poultry shed [8].
Surveillance
A pilot for enhanced surveillance of enteric fever in England, Wales, and Northern Ireland was launched in May [9]. Enhanced surveillance of enteric fevers will be piloted on all cases with specimen dates on or after 1 May 2006 and will run for one calendar year. In 2005, there were 445 cases of enteric fever (typhoid and paratyphoid) reported in England, Wales, and Northern Ireland, the highest number reported in ten years. Considered against a background of changing global epidemiology of enteric fevers, ie, increasing reports – particularly of Salmonella Paratyphi A in parts of the world and antibiotic resistant disease globally – there is a need to improve epidemiological understanding of both travel associated and non-travel associated enteric fever. This will contribute to the evidence base on which pre-travel advice is given, identify particular population subgroups at risk, and inform domestic disease control.
News from abroad
A large outbreak of legionnaires’ disease was recognised in June in Pamplona in northern Spain, with over 130 cases reported [10]. All cases presented with clinical signs of pneumonia, compatible radiography and positive urinary antigen test. Most of the initial cases occurred in a neighbourhood close to the city centre, and rapid tests for Legionella antigen were positive in four cooling towers in the vicinity. Culture and PCR for Legionella have been positive in two of these cooling towers, but could not be confirmed in the other two.
Over 1000 cases of measles were linked to an outbreak in the federal state (Land) of Nordrhein Westfalen, in the west of Germany [11]. Between 1 January and 3 May 2006, 1018 cases were notified to the health authorities, and this number is believed to be an underestimate, as some cases are not notified, or are not diagnosed. School-age children represented over 60% of these reported cases. The majority of patients had not been vaccinated against measles, and about 15% required hospital admission. Two cases with serious complications (measles encephalitis) were reported. Other reported complications included lung infection middle-ear infections. About one third of cases were laboratory confirmed by detection of virus-specific antibodies or by PCR. The outbreak in Nordrhein Westfalen was caused by the D6 measles virus, which was the same strain that caused a concurrent outbreak in the Ukraine [12].
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Features |
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Accidents and Incidents Involving the Transport of Radioactive Materials in the UK
The Health Protection Agency’s Radiation Protection Division has published a report on accidents and incidents involving the transport of radioactive materials in the UK, from 1958 to 2004 [13]. The report finds that the most serious of these events involved the transport of poorly shielded industrial radiography sources, which occurred mainly in the 1970s. Some of these incidents led to radiation exposures to workers and members of the public. Better training has ensured that no similar events have occurred for 20 years. The report also details trends in other types of events; for example, a rise in incidents of excess radioactive contamination on nuclear fuel flasks in the late 1990s was reduced by better procedures at nuclear power stations. Radiological consequences from these incidents, both to workers handling the flasks and to members of the public, were negligible. The report concludes that good training of the workers involved in the transport of radioactive materials should always be a priority.
Radioactive materials are widely used in hospitals, general industry and research. It is necessary for these materials to be transported from suppliers to customers, and for some radioactive wastes to be returned from customers to suppliers or to waste facilities. All these materials are normally transported by road. Radioactive materials associated with the nuclear industry are mainly moved by road and rail. Also, exports and imports of radioactive materials are made by sea and air. Up to half a million packages are transported in the UK annually, and during these shipments events can occur. Packages that are damaged or poorly prepared can have the potential for radiological consequences for workers and members of the public in the vicinity. It is therefore important that packages are well prepared to prevent increased dose rates around the package or releases of radioactive material.
The analysis of the information on reported accidents and incidents provides an overview of the types of events that have featured throughout the period covered. For example, there was an increase in occurrences of excess contamination on flasks and rail wagons used to transport irradiated nuclear fuel (INF) from the late 1990s to the early 2000s. The occurrence of these events was reduced by improved conditions in power station storage ponds and more thorough cleaning and monitoring of INF flasks. During the 1970s there were many events involving packages being damaged at airport cargo centres, but their occurrence was greatly reduced by improvements in handling procedures. In the later years of the period, events involving contaminated items and lost sources being discovered in scrap metal were increasingly being reported.
Most of the recorded events have resulted in negligible radiological consequences to the workers involved or to members of the public. Only in 19 out of 806 cases reported were radiological exposures not negligible; almost all of those events occurred in the earlier years of the reported period, only two having occurred since the mid-1980s. There was a potentially serious accident in 2002 involving a radiotherapy source which, however, did not lead to any significant radiological exposure. The most serious radiological consequences occurred as a result of transporting improperly packaged industrial radiography sources, mainly in the 1970s.
Accidents and incidents that happen during the transport of radioactive materials, as in the transport of other types of materials, inevitably occur from time to time. The frequency of occurrence of such events, and their effects can, however, be reduced by the establishment of comprehensive radiation protection programmes and emergency procedures. Appropriate training of workers involved in these transport operations should always be a priority.
The study was funded by the Department for Transport and the Health and Safety Executive.
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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References |
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- Health Protection Agency. Interim guidance on diagnosis and management of PVL-associated Staphylococcal infections in the UK . London : Department of Health, 2006. Available at <http://www.dh.gov.uk/AboutUs/MinistersAndDepartmentLeaders/ChiefMedicalOfficer/Features/FeaturesArticle/fs/en?CONTENT_ID=4133761&chk=oW8s4w-.
- Department of Health. Going Further Faster: implementing the Saving Lives delivery programme. London: Department of Health, 2006. Available at <http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/>PublicationsPolicy And GuidanceArticle/fs/en?CONTENT_ID=4134549&chk=B8vQzg.
- Working party guidance on the control of multi-resistant Acinetobacter outbreaks. HPA website 1 June 2006 [online]. Available at <http://www.hpa.org.uk/infections/topics_az/acinetobacter_b/guidance.htm>.
- Port Health and Medical inspection review. Report from the project team. London: HPA, 2006. Available at <http://www.hpa.org.uk/porthealth/default.htm>.
- HPA. Cluster of heterosexual transmission of HIV in Cornwall – update. Commun Dis Rep CDR Wkly [serial online] 2006 [accessed 12 October 2006]; 16 (26): news. Available at <http://www.hpa.org.uk/cdr/archives/2006/cdr2606.pdf>.
- HPA. National increase in Salmonella Montevideo infections, England and Wales: March to July 2006. Commun Dis Rep CDR Wkly [serial online] 2006 [accessed 12 October 2006]; 16 (29): news. Available at <http://www.hpa.org.uk/cdr/archives/2006/cdr2906.pdf>.
- HPA. Avian influenza in poultry in Norfolk. Commun Dis Rep CDR Wkly [serial online] 2006 [accessed 12 October 2006]; 16 (18): news. Available at <http://www.hpa.org.uk/cdr/archives/2006/cdr1806.pdf>.
- Kurtz J, Manvell J, Banks J. Avian influenza virus isolated from a woman with conjunctivitis. Lancet 1996; 348: 901–2.[CrossRef][Web of Science][Medline]
- Enhanced surveillance of enteric fevers [online] [updated 11 July] London: Health Protection Agency. Available at <http://www.hpa.org.uk/infections/topics_az/typhoid/Enhanced/EnhancedSurveillance.htm>>.
- Barricarte A, García Cenoz M, Castilla J, Aldaz P Current legionellosis outbreak with 139 cases in Pamplona, Spain. Eurosurveillance [serial online] 2006; 11(3): E060608. Available at <http://www.eurosurveillance.org/ew/2006/060608.asp>.
- Masern-Ausbruch in Nordrhein-Westfalen – Update. Epidemiologisches Bulletin 2006; (18): 141–2. Available at <http://www.rki.de/DE/Content/Infekt/EpidBull/epid_bull_node.html>.
- Spika JS, Aidyralieva C, Mukharskaya L, Kostyuchenko NN, Mulders M Lipskaya G, et al. Measles outbreak in the Ukraine, 2005–2006. Eurosurveillance [serial online] 2006; 11(3): E060309.1. Available at <http://www.eurosurveillance.org/ew/2006/060309.asp>.
- Hughes JS, Roberts D, Watson SJ. Review of events involving the transport of radioactive materials in the UK, from 1958 to 2004, and their radiological consequences.RPD-014. Chilton: HPA, 2006. Available at <http://www.hpa.org.uk/radiation/publications/hpa_rpd_reports/2006/hpa_rpd_014.htm>.
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