Communicable Disease and Health Protection Quarterly Review: April to June 20071
Keywords: communicable disease, HPV, salmonella, pertussis, avian influenza, wound botulism, solid radioactive waste, international health
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Policy and practice:
- HPV vaccine
- Salmonella Senftenberg
- Avian influenza
- Pertussis
- Pertussis
- Wound botulism
- Very low level solid radioactive waste
- World health statistics
- European epidemiology
- International Health Regulations
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Policy and practice
In June the Department of Health agreed, in principle, to accept advice from the Joint Committee for Vaccination and Immunisation (JCVI) that Human Papilloma Virus (HPV) vaccines should be introduced routinely for girls aged around 12-13 years, subject to independent peer review of the cost benefit analysis. Funding for this would be considered in the context of the Comprehensive Spending Review. The cervical screening programme (smear tests) would continue after an HPV vaccine was been introduced because of the gap between the age of vaccination and age of first screening. Screening would also be required as the vaccine does not protect against all HPV types that may cause cervical cancer.
Outbreaks and incidents
In the first 21 weeks of 2007, the HPA's Laboratory of Enteric Pathogens (LEP) received 45 isolates of Salmonella Senftenberg from cases of infection not reporting foreign travel, compared with ten in the same time period in 2006 [2]. Thirty-four of the isolates were received from week 15 onwards. A case was defined as a resident of England and Wales infected with a confirmed or provisionally confirmed isolate of fully sensitive S. Senftenberg received by LEP on or after the 8 April 2007. Cases reporting foreign travel or close contact with a person with gastrointestinal disease symptoms in the five days prior to the onset were excluded from the definition. Twenty-seven cases fulfilled the case definition. At a similar time, the HPA and the Local Authorities Coordinators of Regulatory Services (LACORS) had begun a UK study of the microbiological quality of retail fresh herbs. Seven samples of pre-packed fresh basil, grown and packed in Israel, had tested positive for Salmonella spp. Pulsed-field gel electrophoresis (PFGE) was carried out on two of the basil isolates which was given the PFGE profile SSFTXB.0014 [3]. This matched fourteen (50%) of the human isolates tested so far and received after week 15. The Food Standards Agency (FSA) issued a food alert on 25 May 2007 warning consumers not to eat basil from the same batches that were found to be contaminated at the time[4].
On 23 May the National Public Health Service for Wales (NPHS) was notified by Animal Health (formerly the State Veterinary Service) of confirmed H7 avian influenza virus infection in chickens that had died on a smallholding in North Wales [5]. The chickens had been bought at a market in Chelford in Cheshire on 7 May. Cases in poultry and people in the North West of England were also associated with the market in Chelford. The NPHS identified all people who had a primary or secondary contact with avian flu: Primary contact being an individual who has been in contact with affected premises or to known infected poultry (handling/within one metre) or close contact with another human case; Secondary contact being an individual not in contact with affected premises or to known infected poultry, but who has been in contact with a case, either definite or suspected. Of the 256 people fitting these criteria, 17 were symptomatic with flu-like symptoms or conjunctivitis. The public health response was to follow United Kingdom guidelines in identifying all potential contacts. Some contacts were offered prophylaxis or treatment with oseltamavir, depending on the presence of relevant symptoms and the timeline of possible exposure. Symptoms were very mild, especially in secondary contacts. This included veterinary staff dealing with the infected poultry and medical staff assessing people with symptoms who had contact with the virus. It also included staff and patients at a hospital, where a healthcare worker worked during a time when she had symptoms, and a second hospital where another possible case was admitted as a patient. Also, there were children and staff in a school with close contact with a child who was a presumed case. There were two confirmed human cases of influenza-like illness in the North West of England associated with this outbreak. These cases had laboratory confirmation of influenza A virus infection. Both had contact with diseased poultry, had symptoms compatible with H7 and were hospitalised but but subsequently discharged. Two other symptomatic cases tested negative for influenza A. Antiviral medication was given to three of the cases; one was not treated because of other clinical considerations. An investigation in the north west of England, running in parallel to that in Wales, identified 106 individuals associated with the incident. All laboratory results on these individuals were also been negative, with the exception of the two confirmed cases.
Surveillance
The HPA launched a new enhanced surveillance test for pertussis in June [6]. The test is used to estimate IgG antibody levels in oral fluid directed against Bordetella pertussis pertussis toxin (PT). Since 2002 the HPA has been providing a realtime polymerase chain reaction (PCR) service for infants admitted to hospital (now available for infants aged under 1 year) with suspected pertussis; and sero-diagnosis by detection of raised serum IgG antibodies to pertussis toxin (PT) for patients who have been coughing for two weeks or more [7]. Clinicians who are aware of these methods may still be reluctant to take blood in this patient group, so they may content themselves with notifying the infection but not confirming it by laboratory testing. To address this last group, HPA Centre for Infections Respiratory and Systemic Infection Laboratory is now providing oral fluid testing (for anti-PT IgG) to diagnose those who have been coughing for more than two weeks. The test is particularly suitable for the investigation of all notified cases of pertussis which have not already been confirmed by other methods (culture, PCR or serology) by oral fluid methods.
Cases of wound botulism continue to occur among injecting drug users (IDUs) in the United Kingdom (UK) [8]. Twenty-two suspected cases were reported to the HPA Centre for Infections in 2006, fewer than in each of the previous two years, with 28 cases reported in 2005 and 40 in 2004 [9]. A total of 134 suspected cases have now been reported since the first cases were reported in 2000 [10]. Nine of the cases in 2006 were laboratory confirmed either by detection of botulinum toxin in serum or wound tissue or by isolation of Clostridium botulinum from wound tissue. Of these, six cases were identified as type-A toxin, one as type-B and in two cases both type-A and type-B toxins were detected. Laboratory procedures are insensitive and an unconfirmed laboratory result does not exclude a diagnosis of botulism. Botulinum antitoxin is effective at reducing symptoms if given early in the course of the infection. If clinical symptoms indicate botulism, the clinician should not wait for the results of microbiological testing before administering the antitoxin. C. botulinum is sensitive to benzylpenicillin and metronidazole. Surgical debridement is important to reduce the organism load and avoid relapse after antitoxin treatment. All of the cases in 2006, where detailed patient information was provided, were admitted to hospital, the majority to intensive care. Only one individual reported that they did not have either a wound, boil or abscess present. Two individuals died, one of whom did not receive botulinum antitoxin. All of the other cases received antitoxin. All thirteen cases for whom information about drug use was available reported injecting heroin. Wound botulism among injecting drug users has been associated with ‘skin popping’ (subcutaneous injection) and ‘muscle popping’ (intramuscular injection). Of the 12 cases who provided information about their injecting practices, only seven reported skin or muscle popping as their primary or secondary method of drug use. It is possible that the individuals who did not report skin or muscle popping injected into their muscle or skin unintentionally whilst intending to inject intravenously. Even though wound botulism remains rare, it is now the most common clinical presentation of botulism in the UK. Further information and advice for health professionals and those working with injecting drug users is available on the HPA website [11].
Publications of interest
The Health Protection Agency has carried out an assessment of the potential radiological impact of the disposal of large quantities of very low level solid radioactive waste (VLLW) from the nuclear industry in sites built to conventional landfill site standards [12]. The report considered the implications of a proposed change in the definition of VLLW to include large quantities of waste with very low levels of radioactivity, such as slightly contaminated concrete rubble from the decommissioning of a nuclear power station. It also considered three different types of landfill site and assesses a number of potential exposure scenarios including the exposure of workers, the direct disposal of water from the discharge management system at the landfill site to a nearby river, and the potential radiological impact to members of the public after closure of the landfill site. Based on the dose criteria used in this study, disposal of a million tonnes of waste with very low levels of radioactivity in a site built to current landfill site standards was estimated to be acceptable, in terms of the radiological assessment, for six out of 11 of the radionuclides considered. For five radionuclides (Carbon-14, Cobalt-60, Caesium-137, Radium-226 and Thorium-232) it would be necessary to consider the exact characteristics of the site to determine the quantity which could be disposed of. The study provided a basis for the inclusion of disposal of large quantities of VLLW waste in sites similar to landfill sites in the revised government policy [13] as High Volume VLLW, and controls will be specified on the total volumes of this waste which can be disposed of to a specific site. Under the previous Low Level Waste policy small quantities of very low level radioactive waste could be disposed of, with ordinary waste, to landfill sites under a generic authorisation.
News from abroad
The World Health Organization (WHO) has published World health statistics 2007, the most complete set of health statistics from its 193 Member States, in May. It highlighted trends in ten of the most closely watched global health statistics as well as the annual reference set of 50 health indicators in countries around the world. World health statistics 2007 can be ordered or downloaded at http://www.who.int/whosis/en/index.html.
In June The European Centre for Disease Prevention and Control (ECDC) published its first epidemiological report on communicable diseases in the European Union (EU) [14]. The report contains epidemiological data on 49 communicable diseases (together with healthcare associated infections and antimicrobial resistant infections) collected from the 25 EU member states, plus Norway and Iceland for the year 2005. It includes a discussion on the main determinants of communicable diseases in the EU and their consequences, and suggests some of the main actions that are needed to deal with communicable diseases in the EU. The annual report on the communicable disease threats monitored in the EU also formed part of the document. The overall incidence of a number of the communicable diseases is low in Europe with several diseases showing clear signs of steadily declining trends (eg measles) or of remaining relatively stable (eg invasive pneumococcal disease) over the past ten years. Similarly the data show that the incidence of certain gastrointestinal infections (eg campylobacter) and certain STIs (eg HIV, Chlamydia) is increasing overall, highlighting the need to continue national prevention and control programmes.
The new International Health Regulations (IHR) came into force on Friday 15 June [15]. The IHR are a legally binding international instrument to ‘prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international trade and traffic’. The regulations, which are an update of the 1969 regulations, were adopted on 23 May 2005 at the 58th World Health Assembly. The 1969 regulations addressed only four diseases: cholera, plague, yellow fever and smallpox, and were focused on the control at borders and relatively passive notification and control measures. Under the new IHR, member states have much broader obligations to build national capacity for surveillance and response to Public Health Emergencies of International Concern (PHEIC) and share information about them, with a code of conduct for notification and response. The regulations include a list of diseases whose occurrence must always be notified to the World Health Organization (WHO) (smallpox, wild-type polio, new subtypes of human influenza and SARS), but also include an algorithm for countries to decide whether other incidents (which may be biological, radiological or chemical in nature) might constitute a PHEIC. Member states are required to designate a National IHR Focal Point (NFP) to be accessible at all times for communications with the WHO IHR Contact Point. The NFP has a duty to both assess events that may be PHEICs and to notify them to WHO. The UK Government has designated the Health Protection Agency as the UK's NFP and a joint protocol has been developed between the Department of Health and the HPA for the assessment and reporting of PHEICs by the NFP. The duty doctor system at CfI is generally the initial point of contact for public health professionals in the United Kingdom wishing to report or discuss a potential PHEIC (tel 020 8200 4400).
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The CDaHP series is prepared by the Health Protection Agency with the assistance of colleagues in partner organisations in health protection.
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Footnotes |
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1 Reports prepared and edited by Neil Hough.
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References |
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TOPTHE QUARTER AT A...EVENTS OF THE QUARTERAcknowledgementsReferences |
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- HPV vaccine. Press release GNN ref 148406P. (2007) London: Department of Health. Available at
http://www.gnn.gov.uk/environment/fullDetail.asp?ReleaseID=293322&NewsAreaID=2&NavigatedFrom Department = False. - HPA. An national outbreak of Salmonella Senftenberg in England and Wales: April to May 2007. In: Health Protection Report. 1(22). [serial online] 2007 [accessed 19 October 2007] news. Available at http://www.hpa.org.uk/hpr/archives/2007/hpr2207.pdf
. - Gatto AJ, Peters TM, Green J, et al. Distribution of molecular subtypes within Salmonella enterica serotype Enteritidis phage type 4 and S. Typhimurium definitive phage type 104 in nine European countries, 2000-2004: results of an international multi-centre study. In: Epidemiol Infect (2006) 134(4):729–36.[CrossRef][Medline]
- Food Standards Agency (FSA) [online]. Agency issues warning on salmonella in basil (2007) 5 25. London: FSA. Available at http://www.food.gov.uk/news/newsarchive/2007/may/warningbasil.
- HPR Avian influenza H7N2 in Wales and the Northwest of England. Health Protection Report. accessed 19 October 2007]. 1(22). [serial online] 2007 news. Available at http://www.hpa.org.uk/hpr/archives/2007/hpr2207.pdf.
- HPA New enhanced surveillance test for pertussis. Health Protection Report. 1(25). [serial online] 2007 [cited 18 October 2007] News. Available at http://www.hpa.org.uk/hpr/archives/2007/hpr2507.pdf.
- Crowcroft NS, Fry NK, Litt DJ, Harrison TG, George RC, Abid M, et al. Whooping cough – better methods of diagnosis are now available. In: BMJ Rapid Responses. accessed 21 June 2007]. [online] 2007 [Available at http://www.bmj.com/cgi/eletters/334/7592/532#164273.
- HPA. Wound Botulism among injecting drug users in the UK: an update. In: Health Protection Report. 1(17). [serial online] 2007 [cited 18 October 2007] News. Available at http://www.hpa.org.uk/hpr/archives/2007/hpr1707.pdf.
- Wound botulism in injecting drug users in the United Kingdom. Commun Dis Rep CDR Wkly. accessed 25 April 2007]. 16(13). [serial online] 2006 news. Available at http://www.hpa.org.uk/cdr/archives/2006/cdr1306.pdf.
- PHLS. Wound botulism in an injecting drug user in London. In: Commun Dis Rep CDR Wkly (2000) 10(20):177–180. Available at http://www.hpa.org.uk/cdr/archives/CDR00/cdr2000.pdf.[Medline]
- Botulism. Pages on Health Protection Agency website [online]. London: HPA, undated. Available at http://www.hpa.org.uk/infections/topics_az/botulism/menu.htm.
- Chen QQ, Kowe R, Mobbs SF, Jones KA. Radiological assessment of disposal of large quantities of very low level waste in landfill sites. (2007) Chilton: HPA. Available at http://www.hpa.org.uk/radiation/publications/hpa_rpd_reports/2007/hpa_rpd_020.htm.
- Defra. DTI and the Devolved Administrations. In: Policy for the long term management of solid low level radioactive waste in the United Kingdom (2007) London: Defra. Available at http://www.defra.gov.uk/environment/radioactivity/waste/pdf/llw-policystatement070326.pdf.
- European Centre for Disease Prevention and Control. European Communicable Disease Epidemiological Report (2006) Stockholm: ECDC. 2007. Available at http://www.ecdc.eu.int/pdf/Epi_report_2007.pdf.
- International Health Regulations. (2005) accessed 14 June 2007]. Geneva: WHO. online 2007. Available at http://www.who.int/csr/ihr/en/index.html.
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