Communicable Disease and Health Protection Quarterly Review: October to December 2006
Keywords: antimicrobial resistance chlamydia, cholera, communicable disease, hepatitis, IDU, lyssavirus, malaria, migrants, MRSA
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Policy and practice:
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Policy and practice
New practical guidelines on malaria prevention for travellers from the UK were published by the Health Protection Agency in December.1 These update and combine previous 2003 guidance issued in 2003 in a new format available on the web and as a reference manual. Updates include extensively revised advice for travellers to the Indian sub-continent, and increased emphasis on bite prevention. The guidelines also highlight that awareness needs to be raised, among those travelling back to endemic countries to visit friends and relatives. The view that this group is relatively protected is a dangerous myth and their children are particularly vulnerable. The guidelines are for use by healthcare workers (HCWs) who advise travellers, but may also be of use to prospective travellers who wish to read about the options themselves. Together with new Advisory Committee for Malaria Prevention (ACMP) malaria treatment guidelines being published in the Journal of Infection,2 it is hoped that the risk of illness and death from malaria in UK travellers can be reduced. Each year between 1500 and 2000 people are diagnosed with malaria on their return to the UK. Anyone visiting a malarious area can become infected no matter what age or sex or ethnic background. Malaria can kill very quickly if not diagnosed in time. In 2005, there were 11 deaths from malaria in the UK.3 These deaths and illness are, however, avoidable, as most people requiring medical attention for malaria in the UK have not taken the correct precautions needed for their visit.
Outbreaks and incidents
From 2004 to the end of 2006, seven cases of hepatitis B were reported to the Health Protection Agency from care and residential homes following the incorrect use of lancing devices.4 Following investigation by local Health Protections Units, 11 more cases were been identified in diabetics who were probably been infected by these means. In four patients, hepatitis B infection had contributed to their death. A further single case in a diabetic in another home is still under investigation. There have been reports that some care and residential homes have used the single patient device on more than one patient. As a small amount of blood can remain on the cap of the device, this can lead to infection being passed between patients. The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a renewed safety warning to HCWs over the use of these devices in nursing and care homes after the Agency received continued reports of infection being passed via these devices.5 The MHRA advised that care workers or healthcare professionals taking blood glucose samples in any multi-patient environment, including nursing homes and care homes must only use disposable single-use lancing devices for each resident or patient (these are used once and then the entire lancing device is discarded), or a non-disposable lancing device, but this must be one which is intended to be used to take blood samples from multiple patients, used with disposable single-use lancets.
Eight cases of Panton-Valentine leukocidin (PVL) positive community-associated MRSA (CA-MRSA) were identified among individuals in a hospital and their close household contacts in the West Midlands.6 Four individuals developed an infection, two of whom died. Transmission of the CA-MRSA strain appeared to have occurred on two separate wards and went undetected until a fatal case was examined in detail. Although the occurrence of several different clones of CA-MRSA has been reported previously,7 this was the first documented report of nosocomial transmission of PVL-positive CA-MRSA in the UK. A previously healthy HCW developed an MRSA sepsis, septic shock, pneumonia and died following non-elective surgery in September 2006 (Case 1). Screening of patients and staff on Ward A where Case 1 worked revealed another HCW carrying the same strain (Case 2). This HCW had a history of skin abscesses due to MRSA and was a social contact of Case 1. Four household contacts of Cases 1 and 2 were found to carry the same strain (Cases 3–6). One of these, Case 5, worked as a HCW on a different ward (Ward B). Subsequent screening of both patients and staff on Ward B revealed another HCW working on Ward B carrying the same strain (Case 7). This individual had a 4-month history of recurrent infection of the eyelids. One further case was identified in March 2006 through retrospective analysis of MRSA isolates kept in the laboratory. The patient (Case 8) developed a suspected hospital-acquired pneumonia while in Ward A and died within 24 h of the blood culture being taken that grew the organism. Extensive healthcare and community-based contact tracing has not identified further cases. In recent years, CA-MRSA has emerged as an important pathogen among previously healthy young people in community settings worldwide. In addition to causing sporadic disease in the community, outbreaks of CA-MRSA have occurred in individuals in close contact, particularly where skin trauma is likely, for example sporting teams, military recruits and injecting drug users (IDUs). Many strains of CAMRSA encode PVL, a poreforming cytotoxin associated with necrotic lesions or abscess formation in SSTI.8 More rarely, infection can lead to cases of serious, life-threatening disease such as necrotising pneumonia, necrotising fasciitis and purpura fulminans which may prove fatal.8
A case of toxigenic Vibrio cholerae O1 Inaba biotype El Tor was confirmed in a Spanish national returning home to Spain from India via London Heathrow airport.9 The woman developed severe vomiting and diarrhoea during her flight from Delhi to London and could not complete her ongoing flight to Barcelona due to her illness. On arrival in London, she was taken off the plane and was admitted to the intensive care unit of the local acute district general hospital with profuse diarrhoea and vomiting. The patient had rice water stools and copious fluid loss, and required intravenous fluid replacement V. cholerae was isolated from her faeces three days later. It was subsequently confirmed as a toxigenic V. cholerae O1 Inaba biotype El Tor. A family member of the index case remained with her in London and developed diarrhoea but did not require hospitalisation. Both cases were part of a group of more than 100 tourists who had toured the ‘Golden Triangle’ in India (Delhi, Agra and Jaipur) for 1 week, as part of a holiday package, and stayed in good quality hotels. It is unusual for tourists staying in such hotels to develop such serious cholera symptoms. Around 10 imported cases of cholera are diagnosed in the UK each year, mainly associated with travel to the Indian sub-continent. This small outbreak of imported cholera involving three countries demonstrates the importance of rapid international notification of suspected cases of cholera in order to review contacts, as the incubation period can be from as little as a few hours to five days.
A routine test carried out on a female Daubenton's bat (Myotis daubentonii) submitted to the Veterinary Laboratories Agency in Weybridge, Surrey, confirmed the presence of European Bat Lyssavirus type 2 (EBLV-2) (‘bat rabies’).10 The bat was found by members of the public on a path by the river Thames close to Abingdon Lock in Abingdon, Oxfordshire. In the UK, there have only been four previous cases of active infection in bats, specifically in Daubenton's bats. The first was found in Newhaven, Sussex, in 1996, with subsequent cases in Lancashire in 2002 and 2003, and Surrey in 2004.11–13 All tested positive for EBLV-2. In addition, a bat worker in Scotland, thought to have been bitten by a bat approximately six months previously, died in November 2002 from an EBLV-2 infection.14 Further information on EBLV can be found on the HPA website at < http://www.hpa.org.uk/infections/topics_az/rabies/ebl.htm >.
Surveillance
Surveillance data from across the UK on a range of bacterial and viral infections that can affect IDUs were brought together in the fourth edition of Shooting Up: infections among injecting drug users.15 The report also presented the national results for 2005 from the Unlinked Anonymous Prevalence Monitoring Programme's (UAPMP) survey of IDUs in contact with services. A key finding was that the prevalence of HIV infection among IDUs in England and Wales has continued to increase. The prevalence among current injectors (those who reported injecting in the 4 weeks prior to taking part in the survey) in England and Wales in 2005 was 2.1% (38/1833). This is the highest level ever seen among this group in UAPMP survey, and indicates that the recent increase in HIV prevalence among current IDUs in England and Wales16 has continued. In London, the HIV prevalence among current IDUs in 2005 was 4.3% (14/323), which was similar to that seen in recent years. Elsewhere in England and Wales, the prevalence was 1.6% (24/1510), which is more than twice the prevalence seen in 2004 (0.66%, 8/1213), and was the highest HIV prevalence ever seen in the UAPMP survey among current IDUs in England and Wales outside of London. More than two in five IDUs in the UK have been infected with hepatitis C. In 2005, 42% (1325/3175) of current and former injectors who took part in the UAPMP survey had antibodies to hepatitis C (anti-HCV), which is similar to that seen in 2004. The hepatitis C prevalence in England was 44% (1251/2838), although there were marked regional variations from 20% (111/552) in the North East to 55% (703/1273) in London and 58% (448/777) in the North West (data from 2004 and 2005 combined). The prevalences in Wales and Northern Ireland were lower than most of the English regions: combining data from 2004 and 2005, hepatitis C prevalence in Wales was 18% (45/253), and in Northern Ireland it was 28% (69/248). Increasing the proportion of injectors with hepatitis C who are aware of their infection is one of the aims of the Hepatitis C Action Plan for England17 and there are signs of progress. Although most IDUs who took part in the UAPMP survey in England reported having accepted the offer of a test, 29% (779/2670) reported never having had a voluntary confidential test for hepatitis C in 2005, this compares with 51% (1532/2,998) in 2000. Of those who were infected with hepatitis C in 2005, 48% (525/1098) were unaware of their infection, compared to 60% (615/1018) in 2000. Looking at participants in Wales in 2004/05, 45% (115/253) reported not having had a test for hepatitis C, and almost three-quarters (31/44) of those with hepatitis C were unaware of their infection. Thirteen per cent (33/248) of the participants in Northern Ireland in 2004/05 reported not having been tested for hepatitis C, and just over one-quarter (17/63) of the participating IDUs with hepatitis C in the province were unaware of their infection. Other data presented in the report indicate that the proportion of IDUs reporting uptake of the hepatitis B vaccine has increased markedly in recent years, with the prison vaccination programmes being an important factor in this increase. The raised level of needle and syringe sharing first seen in the late 1990s has continued with over a quarter of IDUs reporting this activity in the previous month. The sharing of other injecting equipment is more common, and few IDUs reported cleaning injecting sites prior to injecting. Injecting crack-cocaine is associated with higher prevalence of both HIV and hepatitis C infection, and with injecting risk behaviours. The underlying factors for these differences are not clear, but they are a cause for concern as crack-cocaine use has become more widespread.18 Needle exchange (NEX) schemes are a key service to reducing infections and maintaining good injection hygiene through the provision of sterile injection equipment, advice and related interventions. The data presented are considered in the context of the results of the recent National Audits of NEX.19,20 The results of these audits indicate a great diversity across the UK in the range of injecting-related equipment available, in provision of other harm reduction interventions and service accessibility.
Publications of interest
The Health Protection Agency published its third report providing a detailed overview of antimicrobial resistance in a range of pathogens (bacteria, viruses, fungi and protozoa) of public health importance.21 The majority of the data presented relate to England and Wales, although some data from other European countries are included reflecting the participation of the HPA in the European Antimicrobial Resistance Surveillance Scheme. Although this report focuses on data collected during 2004 and 2005, where possible, trend data over a longer period of time are also presented in order to put the most recent data into context.
In November, the Agency published its first report on the health of migrants Migrant health: infectious diseases in non-UK born populations in England, Wales and Northern Ireland.22 The report provides background information on migration to the UK and the general health needs of migrants, and collates data collected by the Agency on infectious diseases reported in 2004 among the non-UK born living in England, Wales and Northern Ireland. In 2001, at the time of the last UK census, 7.5% of people living in the UK were born abroad and in 2004, an estimated 582 100 people migrated to the UK for a period of 12 months or longer. Surveillance data collated from across the Agency show that in 2004, 70% of the newly diagnosed tuberculosis and HIV cases reported in England, Wales and Northern Ireland and 70% of malaria cases reported in the UK were born outside the UK. The most frequently reported countries of birth were from the South Asia and sub-Saharan Africa regions. Migrants may also be more at risk of other infectious diseases, including those that are commonly thought of as being travel related. Despite this disproportionate burden of infectious diseases, the prevalence of infection in these groups remains low. It has been demonstrated, for example, that the HIV prevalence among sub-Saharan African attendees of genitourinary medicine clinics in England, Wales and Northern Ireland is < 1%. Furthermore, there is little evidence to suggest that the general UK-born population are at risk of catching disease from migrants, although UK-born ethnic minority communities may be at increased risk.
News from abroad
An outbreak of malaria caused by Plasmodium falciparum, was been reported from the city of Kingston in Jamaica. The outbreak was believed to have started in late October 2006, and nearly 300 cases of infection had been reported by mid-February.23 Like most Caribbean countries (except for the Dominican Republic and Haiti), Jamaica is not considered endemic for malaria. The mosquitoes capable of transmitting malaria are, however, present on the island, and small localised clusters may occur from time to time as a result of the tropical climate, and its proximity to countries where malaria does occur.24 Around 160 000 UK residents travel to Jamaica every year, and malaria has not been documented in any UK travellers to date. The HPA Advisory Committee for Malaria Prevention in UK Travellers (ACMP) does not recommend preventive malaria medication for UK travellers to Jamaica. For further information about the prevention of malaria in UK travellers can be found on the HPA website at. < http://www.hpa.org.uk/infections/topics_az/malaria/default.htm > and the NaTHNaC website at < http://www.nathnac.org/pro/factsheets/malaria.htm >.
A new variant Chlamydia trachomatis strain has been isolated in Sweden.25,26 Certain commercial diagnostic platforms generate false negative results when screening specimens from patients who are infected with the new variant strain. The C. trachomatis cryptic plasmid (a nonchromosomal genetic element with unknown function found in all C. trachomatis strains) is high copy number and as such, is a popular target for commercial diagnostic platforms. This new strain has a 377 bp deletion in a portion of the plasmid that is the target area for the C. trachomatis NAAT tests most commonly used in Sweden—about 39% of UK laboratories use similar tests. The length of time that this new variant has been circulating undiagnosed in the Swedish community is, as yet undetermined, although recent decreases in C. trachomatis infections have been observed and consequently concerns are that the strain is widely distributed throughout the country. There is currently no evidence that the new C. trachomatis variant is present within the UK.
| 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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- Chiodini P, Hill D, Lalloo D, et al. Guidelines for malaria prevention in travellers from the UK (2007) January. London: Health Protection Agency. Available at <http://www.hpa.org.uk/infections/topics_az/malaria/default.htm>.
- Lalloo DG, Shingadia D, Pasvol G, et al, For the HPA Advisory Committee on Malaria Prevention in UK travellers. UK malaria treatment guidelines. In: J Infect (2007) 54(2):111–21. Available at <http://www.hpa.org.uk/infections/topics_az/malaria/pdf/mal_treat_JoI07.pdf>.[CrossRef][ISI][Medline]
- Health Protection Agency. Malaria imported into the United Kingdom in 2005: implications for those advising travellers. In: Commun Dis Rep CDR Wkly (2006) 16(23). News. Available at <http://www.hpa.org.uk/cdr/archives/2006/cdr2306.pdf>.
- HPA. Cases of hepatitis B associated with lancing devices. In: Commun Dis Rep CDR Wkly (2006) 16(49). [serial online], [cited 20 April 2007], News. Available at <http://www.hpa.org.uk/cdr/archives/2006/cdr4906.pdf>.
- Lancing devices used in nursing homes and care homes. MDA/2006/066. (2006) December 6. London: Medicines and Healthcare Products Regulations Agency. Available at <http://www.mhra.gov.uk/home/idcplg?IdcService=SS_GET_PAGE&ssDocName=CON2025400&ssSourceNodeId=389&ssTargetNodeId=365>.
- HPA. Hospital-associated transmission of Panton-Valentine leukocidin (PVL) positive community-associated MRSA in the West Midlands. In: Commun Dis Rep CDR Wkly (2006) 16(50). [serial online], [cited 20 April 2007], News. Available at <http://www.hpa.org.uk/cdr/archives/2006/cdr5006.pdf>.
- Health Protection Agency. Community MRSA in England and Wales: definition through strain characterisation. In: Commun Dis Rep CDR Wkly (2005) 15(11). [serial online], News. Available at <http://www.hpa.org.uk/cdr/archives/2005/cdr1105.pdf>.
- Robinson DA, Kearns AM, Holmes A, et al. Re-emergence of early pandemic Staphylococcus aureus as a community-acquired meticillin-resistant clone. Lancet (2005) 365(9466):1256–8.[CrossRef][ISI][Medline]
- HPA. Laboratory confirmed case of toxigenic Vibrio cholerae O1 Inaba biotype El Tor in tourists returning to Spain from India. In: Commun Dis Rep CDR Wkly (2006) 16(41). [serial online], [cited 20 April 2007], News. Available at <http://www.hpa.org.uk/cdr/archives/2006/cdr4106.pdf>.
- Confirmed case of bat rabies in Oxfordshire (Press release) (2006) October 10. London: Defra/HPA. Available at <http://www.hpa.org.uk/hpa/news/articles/press_releases/2006/061010_bat_rabies.htm>.
- CDSC. Bat brings rabies to Britain. In: Commun Dis Rep CDR Wkly. 6(24):205. Available at <http://www.hpa.org.uk/cdr/archives/1996/cdr2496.pdf>.
- PHLS. A case of bat rabies in Lancashire. In: Commun Dis Rep CDR Wkly. 12(40). News. Available at <http://www.hpa.org.uk/cdr/archives/2002/cdr4002.pdf>.
- HPA. Bat infected with a rabies-like virus identified in the south-east of England. In: Commun Dis Rep CDR Wkly. 14(40). News. Available at <http://www.hpa.org.uk/cdr/archives/2004/cdr4004.pdf>.
- HPA. Fatal infection with European bat lyssavirus rabies-related virus in Scotland. In: Commun Dis Rep CDR Wkly. 12(48). News. Available at <http://www.hpa.org.uk/cdr/archives/2002/cdr4802.pdf>.
- Health Protection Agency, Health Protection Scotland, National Public Health Service for Wales, CDSC Northern Ireland, CRDHB, and the UASSG. Shooting Up: Infections among injecting drug users in the United Kingdom 2005 (2006) October. London: Health Protection Agency. ISBN 0 901144 86 X.
- Hope VD, Judd A, Hickman M, et al. HIV prevalence among Injecting Drug Users in England and Wales 1990 to 2003: evidence for increased transmission in recent years. AIDS (2005) 19:1207–14.[ISI][Medline]
- Department of Health. Hepatitis C Action Plan for England (2004) London: Department of Health. Available at <www.dh.gov.uk/assetRoot/04/08/47/13/04084713.pdf>.
- Hope VD, Hickman M, Tilling K. Capturing crack-cocaine use: estimating the prevalence of crack-cocaine use in London using capture-recapture with covariates. Addiction (2005) 100:1701–8.[CrossRef][ISI][Medline]
- National Treatment Agency for Substance Misuse. Findings of a survey of needle exchanges in England. (2006) May. London: NTA. [Summary report] Full report will be available at <www.nta.nhs.uk>.
- Scottish Executive. Needle Exchange Provision in Scotland: a report of the National Needle Exchange Survey. (2006) July. Edinburgh: Scottish Executive. Available at <www.scotland.gov.uk/Publications/2006/06/16110001/0>.
- HPA. Trends in Antimicrobial Resistance in England and Wales: 2004 to 2005 (2006) London: Health Protection Agency. Available at <http://www.hpa.org.uk/publications/PublicationDisplay.asp?PublicationID=65>.
- Health Protection Agency. Migrant health: infectious diseases in non-UK born populations in England, Wales, and Northern Ireland (2006) London: HPA. Available at <http://www.hpa.org.uk/publications/PublicationDisplay.asp?PublicationID=53>.
- Ministry of Health, Jamaica. MOH Continues To Warn Against Malaria Re-infection. In: JIS E-Newsletter (February 20072007) February;7(07). [cited 20 April 2007]. Available at <http://www.moh.gov.jm/MOHcontinuesToWarn.htm>.
- Public Health Agency of Canada. Malaria in Kingston, Jamaica. Travel Health Notices and International Reports. (2006) December 4. [online] [cited 6 December 2006]. Available at <http://www.phac-aspc.gc.ca/tmp-pmv/2006/mal_jam061204_e.html>.
- Ripa T, Nilsson P. A variant of Chlamydia trachomatis with deletion in cryptic plasmid: implications for use of PCR diagnostic tests. In: Eurosurveillance (2006) 11(11). Available at <http://www.eurosurveillance.org/ew/2006/061109.asp#2>.
- Soderblom T, Blaxhult, Fredlund H, et al. Impact of a genetic variant of Chlamydia trachomatis on national detection rates in Sweden. In: Eurosurveillance (2006) 11(12). Available at <http://www.eurosurveillance.org/ew/2006/061207.asp>.
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