key: cord-0822725-3wthbb2i authors: nan title: Communicable Disease and Health Protection Quarterly Review: April to June 2003 date: 2003-12-03 journal: J Public Health Med DOI: 10.1093/pubmed/fdg087 sha: 666e79f744cda922320ab1b2029fcee4d05a8a6c doc_id: 822725 cord_uid: 3wthbb2i nan There were two major events that dominated this quarter. The first, on an international scale, was the threat from the emerging disease known as Severe Acute Respiratory Syndrome (SARS), which is dealt with as a feature article below. The second, on a national level, was the establishment of the new Health Protection Agency (HPA), which came into operation on 1 April 2003, bringing together the functions and expertise from: the Public Health Laboratory Service, including the Communicable Disease Surveillance Centre, the Centre for Applied Microbiology and Research, the National Focus for Chemical Incidents, the Regional Service Provider Units that support the management of chemical incidents, the National Poisons Information Service, and NHS public health staff responsible for the control of infectious disease, emergency planning and other protection support. Until new legislation is enacted the HPA, which will operate in England and Wales, will work in close partnership with the National Radiological Protection Board (NRPB). Thereafter functions currently carried out by the NRPB should transfer to the HPA. The HPA is intended to deliver 10 key gains for public health: • A 'one-stop shop' to protect people from infections, poisons, chemical and radiation hazards. • A more comprehensive early warning system to pick up diseases and new threats to health, drawing on a wider network of laboratories, operating to uniformly high standards. • Better anticipation and preparation for threats to health through horizon scanning -looking ahead to the impact of forthcoming technologies and developments, nationally and internationally. • Monitoring the long-term effects of a wider range of hazards. • A dedicated resource to emergency planning. • An integrated response to emergencies involving chemicals, biological, nuclear or radiation agents. • Universal standards of response to an outbreak or incident. • Easily available, authoritative, and impartial information and advice for the public. • More knowledgeable and skilled health protection staff. • More research into health protection. A new catch-up immunization campaign against Haemophilus influenzae type b (Hib) began in England and Wales in May 2003, offering all children between 6 months and 4 years a further dose of Hib vaccine. 1 This decision was made in response to a recent increase in invasive infections caused by this organism, with 145 cases of confirmed Hib disease reported in children under 5 years in England and Wales, in 2002. Although this is still far lower than the 773 cases observed for this age group in 1990 (at a time before routine immunization was implemented) it is, however, a dramatic rise from the low point of 22, in 1998. 2 Multiple factors are believed to have contributed to this increase over time. One of these was the use of combination Hib vaccines containing acellular pertussis (DTaP-Hib) during a shortage of whole-cell pertussis-containing preparations (DTwP-Hib) in 2000 and 2001. The DTaP-Hib preparations have lower immunogenicity for the Hib component than the equivalent whole-cell pertussis-containing preparations. The anticipated effectiveness of the scheduled catch-up to halt the spread of Hib infection is based on the success of employment of this same strategy at the time of the vaccine's implementation in 1992. 3 New clinical guidelines on the prevention of healthcareassociated infections in primary and community care were published by the National Institute for Clinical Excellence (NICE). 4 Although the guidelines aim to provide a standard set of measures that can be used by anyone either giving or receiving care in primary or community care, many of the underlying principles of infection prevention and control apply equally in both hospital and community settings. The intention of these guidelines is therefore to complement the epic phase 1 Guidelines for Preventing Hospital-acquired Infections. 5 Although primarily directed at healthcare professionals based in general practice, health centres and nursing homes, these guidelines will also be of relevance to others working with patients in their own home or the community, such as the voluntary sector and social services. The Chief Medical Officer (CMO) announced the next stage of initiatives to control healthcare-associated infections (HCAIs), 6 which included the next phase of the HCAI surveillance. These initiatives form part of the HCAI developments referred to in the CMO's strategy to combat infectious disease, Getting ahead of the curve. 7 Mandatory HCAI surveillance started with the reporting of Staphylococcus aureus bacteraemias by all acute NHS hospital trusts in England in April 2001, with regular publication of the results. 8 Individual trust data from these first 2 years are also being used by the Commission of Health Improvement to derive performance indicators based on improvement scores. 9, 10 English acute NHS trusts are now required to implement the next series of developments, which include the mandatory reporting of bacteraemias caused by glycopeptide-resistant enterococci (GRE), and serious untoward incidents associated with hospital infections, which produce (or have the potential to produce) unwanted effects involving the safety of patients, staff or others. These developments are likely to be followed by mandatory reporting of Clostridium difficile associated disease and orthopaedic surgical site infections, in 2004. In addition to the GRE bacteraemia surveillance and adverse incident reporting, the CMO also announced £12 million over the next 3 years for hospital pharmacists to monitor and ensure more careful use of antibiotics in hospitals, to help contain the development of further antimicrobial resistance. This initiative will be overseen by the specialist advisory committee on antimicrobial resistance (SACAR). Between 11 April and 16 May 2003, the HPA reported 52 human isolates of Salmonella typhimurium DT193a, with resistance to ampicillin, sulphonamides, tetracyclines and trimethoprim. 11 Forty-two of these cases were reported from the South West region of England. In 2002, only three isolates were reported for the South West region. To identify the mode and vehicle of transmission and to implement appropriate control measures, an epidemiological investigation was set up on 7 May. This included case finding, case interviews and a case-control study using case-nominated controls. Some cases outside the South West were interviewed to assess any possible link with the South West outbreak. Twenty-four (57 per cent) of the 42 cases in the South West were male; the age range was between 3 and 78 years (median 42). Most (23 cases) were residents of Bristol and Bath, with others from Wiltshire, Somerset and Dorset. Ten cases were hospitalized. Preliminary findings of the case interviews and the case-control study suggested an association between illness and eating ham. From the source of ham reported by cases, two distributors were visited by local authorities, and food and environmental samples were taken. So far, cultures have been negative. Further tracing of the implicated ham distribution is being undertaken by the Food Standards Agency. A national increase in listeriosis cases was detected, predominantly in the Yorkshire and Humberside region, during January-May 2003 compared with the same months in the years 1998-2002. 12 Local and Regional Services and the consultants in communicable disease control (CCDCs) investigated the cluster in Yorkshire and Humberside. No trend is apparent for the remaining English regions, nor for Wales. Nationally, between 96 and 140 cases were ascertained annually between 1998 and 2002, with 67 cases ascertained up to 30 May 2003. The HPA's Communicable Disease Surveillance Centre released preliminary results from the 2002 collection of the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP), 13 High prevalences were also observed in the South East (13.7 per cent), East Midlands (16.5 per cent), North West (10.1 per cent), the West Midlands (12.1 per cent) and Wales (11.8 per cent). Lower increases were observed in Eastern (7.1 per cent) and South West (6.6 per cent) regions. The increases in ciprofloxacin resistance occurred irrespective of gender, sexuality and reporting recent sexual contact abroad. As ciprofloxacin is currently the recommended first line treatment for uncomplicated gonorrhoea, 14 there is considerable risk of inappropriate management of this infection and its sequelae. It is a general principle that the chosen treatment regimens should eliminate infection in at least 95 per cent of patients, and it is now clear that ciprofloxacin no longer meets this criterion. National guidelines 14 recommend alternative treatment with cephalosporins or spectinomycin. A human fatality linked to the epidemic of the highly pathogenic avian influenza (HPAI) A H7N7 was reported during this quarter. 15 The same virus had been affecting poultry flocks in the Netherlands since the end of February 2003. 16 In April 2003, a 57-year-old veterinarian who had visited an affected farm died of pneumonia. 16 A positive detection of influenza A (H7N7) was made using genomic testing methods and influenza A (H7N7) virus was also detected in post-mortem lung biopsy samples. There have been reports of human cases infected with HPAI among workers involved in the culling of chickens to control the outbreak. Eighty-three confirmed human cases of H7N7 influenza virus infections have been recorded, the majority of which have presented as conjunctivitis, with a limited number reporting symptoms of influenza-like illness. Strong evidence of person-to-person transmission has been reported in three instances, through contacts with infected poultry workers in the home environment. 16 By the end of April 2003, 212 outbreaks had been confirmed and 13.6 million birds destroyed on more than 800 holdings in the established protection, surveillance and buffer zones. This outbreak had spread across the border to Belgium and antibodies against avian influenza had also been detected in pigs in five mixed farms (chicken and pig rearing) in the Netherlands. A decision was taken by the Dutch authorities to cull pigs on infected mixed farms. Concern was centred on the potential for co-infection in humans with the avian influenza virus and any of the currently circulating human influenza viruses, with the possibility of recombination occurring to produce a virus more adapted for human-to-human transmission. Pigs have been suggested as intermediate hosts or a 'mixing vessel' between human and avian influenza viruses for such recombination events. Another possibility would be the mutation of an existing avian influenza virus more adapted for human-to-human transmission. An overall decline in rabies cases in Europe between 1990 and 2002 was reported during this quarter. 17 In other eastern European countries and many parts of southern Europe, the numbers have risen. Increases in case reporting from these countries could indicate improvements in rabies surveillance. The main animal responsible for rabies transmission is still the red fox (Vulpes vulpes), accounting for 79-90 per cent of all wildlife cases between 1990 and 2002. The proportion of rabies cases among wildlife in other species had increased considerably. Rabies in racoon dogs (Nycterautes procyonoides) increased nearly six-fold from 148 cases in 1990 to 873 in 2002. Racoon dogs also account for an increasing proportion of rabies cases among all wildlife. In 1990, fewer than 1 per cent of all wildlife cases were due to racoon dog rabies. In 2002, over 14 per cent of wildlife cases occurred in racoon dogs. Most cases of racoon dog rabies were reported from Poland and the Baltic states. Other wildlife species on average accounted for fewer than 5 per cent of all cases of rabies in wildlife. The annual number of human fatalities reported caused by rabies in Europe was between 7 and 27. In eastern Europe, cases were mostly indigenous; in countries free of rabies they were mostly imported. As a result of the success of consistent OVF, the following countries had become rabies free by 2002 according to the World Organization for Animal Health (OIE): Finland (1991), Netherlands (1991), Italy (1997), Switzerland (1998), France (2000), Belgium (2001) and Luxembourg (2001). Unlike the World Health Organization definition, the OIE definition of rabies-free status is not affected by isolation in a country of a European bat lyssavirus (EBLV). OVF campaigns have also been extremely successful in reducing rabies in the Czech Republic, Germany and Hungary. The number of cases in these countries compared with a decade ago has been reduced by 99 per cent, 97 per cent and 86 per cent, respectively. More work is needed on the surveillance, control and research of EBLV. In most parts of Europe, between 7 and 42 cases were reported in bats annually between 1990 and 2002. EBVL rarely crossed the species barrier to other mammals, although a fatal human case occurred in Scotland in 2002. 18 A House of Commons health committee report on sexual health was released, 19 20 A strong emphasis was placed on the importance of early and comprehensive sex and relationship education in schools with the establishment of a network of school-based clinics, and programmes enabling health workers to target young people in nightclubs and sports clubs. Although sexual health service delivery in primary care has considerable potential, the committee felt that general practitioners would need to receive sufficient training and support to deliver services effectively. This will need to be coupled with adequate local prioritization of sexual health within primary care trusts, as well as a mechanism to ensure that targeted funding for sexual health and HIV services is used at the local level. Some of the strongest recommendations were aimed at the development and delivery of sexual health services. An urgent review of consultant capacity within genitourinary medicine (GUM), as well as additional revenue commitment to meet the growing demands on GUM services were recommended. The report called for clinics to see patients within 48 hours, instead of the present average 10-12 day waiting time. The committee also called for a national chlamydia screening programme to be introduced 'immediately', and for a withdrawal of the use of lower sensitivity diagnostic tests for this infection. The MPs rejected compulsory HIV screening of asylum seekers. Contraceptive services were raised as an area of specific concern, with the lack of information on the organization and provision of contraceptive services, and problems with access delay receiving specific mention. The committee concluded that the current crisis in sexual health services was a consequence of a number of factors including: failure of local NHS organizations to prioritize sexual health, lack of political pressure and leadership, absent patient advocacy, lack of resources, and lack of central direction and performance management. The committee argued that the best way of ensuring that access to high-quality services is prioritized and resourced would be to launch a dedicated national service framework for sexual health, but that in the mean time the Department of Health should ensure that sexual health is tackled at the strategic health authority level by adding it to the planning and priorities framework for 2003. Revised guidelines on reducing the occupational risk of exposure to transmissible spongiform encephalopathy (TSE) were published in this quarter. 21 The guidance, which replaces that published in 1998, is aimed at employers and others, such as staff working in infection control and the reprocessing of medical devices. It is also relevant to pathologists and others handling deceased infected patients and people working with human and animal TSEs in the laboratory, including those working with diagnostic specimens potentially infected with TSEs. The format is the same as the 1998 edition but the document is significantly expanded and web based, with the main changes being: • The risk categorization of patients (definite, probable, or possible Creutzfeldt-Jakob disease (CJD) and variant Creutzfeldt-Jakob disease (vCJD) is now based on established, published, diagnostic criteria. • A new category of symptomatic patients 'with neurological disease of unknown aetiology where the diagnosis of CJD is being actively considered' has been included to encourage appropriate handling of surgical instruments, on a precautionary basis, recognizing that CJD is sometimes difficult to diagnose in the early stages of the disease. • A clearer description of the asymptomatic 'at risk' patient groups, divided into those at risk from familial forms of the disease and those at risk from iatrogenic exposure. • Abandonment of the earlier recommendation for enhanced reprocessing of certain surgical instruments in particular circumstances. The regime previously recommended is now known not to be reliably effective and may even render instruments more difficult to decontaminate. • A recommendation to quarantine instruments pending diagnosis in certain circumstances. This was recommended in an NHS circular issued in 1999. 22 The advice has now been subsumed into this guidance. A link between Chlamydia trachomatis and ovarian cancer was reported in this quarter. A major factor in the public health importance of genital C. trachomatis infection is that it is the dominant cause of pelvic inflammatory disease (PID) in developed countries. Between 10 and 40 per cent of untreated C. trachomatis cases develop PID. 23 Sequelae of PID include ectopic pregnancy, tubal factor infertility and chronic pelvic pain. PID has also been associated in some, but not all, studies with increased risk of ovarian cancer. A recent case-control study undertaken in Hawaii 24 reported evidence of a link between past C. trachomatis infection and ovarian cancer. The study included 117 women with ovarian cancer and 171 age and ethnically matched population-based controls. The analysis was adjusted for the effects of age, family history of ovarian cancer, tubal ligation, number of children and use of oral contraception. Women with ovarian cancer were significantly more likely to have high levels of IgG antibodies to C. trachomatis serovar-D elementary bodies than women who did not have ovarian cancer. The probability of having ovarian cancer was 90 per cent higher among women with high levels of IgG to chlamydial heat shock protein 60. The findings suggest that past or chronic C. trachomatis infection may be a risk factor for ovarian cancer. This year saw the international emergence of Severe Acute Respiratory Syndrome (SARS). This previously unknown respiratory infection emerged in China and spread rapidly around the world, as export of cases was aided by modern air travel. Initial reports of an outbreak of atypical pneumonia began in November 2002 in Guangdong province, China; 305 cases had been reported there by 12 February 2003. 25 The first documented case to be exported from China was a doctor from Guangdong who stayed in the Metropole hotel in Hong Kong on 21 February. During his stay at least 14 guests and visitors became infected and travelled onwards to spread the infection to Canada, Hong Kong, Vietnam and Singapore. The emergence of this new syndrome was not initially recognized, and suboptimal infection control led to hospital and community outbreaks. Transmission was predominantly to close contacts of the patients and to healthcare workers. Following the WHO global alert on 12 March, 25 the outbreaks were gradually brought under control by application of traditional public health measures such as early detection of cases and the rapid institution of control measures, including isolation of cases and quarantine of contacts. Other measures, including travel restrictions and airport screening, were introduced in many countries. Media coverage led to high levels of public awareness. Unprecedented collaboration between laboratories led to the early identification of SARS coronavirus as the causative organism, and to the development of PCR and serological assays. By 5 July 2003 the chain of transmission was broken globally. There had been 8437 reported cases and 813 deaths from SARS worldwide (see Fig.) . The situation in the United Kingdom was very different: there was anxiety about imported cases but no evidence of local transmission of SARS. The HPA established the UK SARS Taskforce, co-ordinated the operational response to SARS, issued up-to-date guidance 26 and acted as a reference laboratory. A specific SARS surveillance system, including case definitions and reporting procedures, was developed in line with WHO recommendations to ensure timely identification and follow-up of suspect and probable cases. A national SARS database was developed at CDSC to store and interrogate the surveillance data. Probable cases were reported daily on the HPA website as well as to the European Commission and WHO. A total of 424 reports were submitted to CDSC between 17 March and 20 July 2003, of which four were 'probable' and 154 'suspect' SARS cases. Serology confirmed the diagnosis of SARS in only one of the four probable cases. In addition, serology was positive in four suspect cases and in five patients with mild respiratory illness who did not meet the case definition. In cases where the clinical illness was mild, the positive serology may represent exposure to SARS as opposed to the full-blown illness. The origin of SARS is unclear. SARS-like viruses have been detected in the masked palm civet and raccoon dog, wild animals traditionally consumed as delicacies in China. 27 Close animal-human contact in Guangdong province may represent the trigger that allowed SARS to jump the species barrier. SARS appears at present to have been contained, but vigilance must be maintained. The possibility that it is circulating undetected at low level in endemic regions cannot be discounted. If it truly is a zoonosis then it may well jump the species barrier into the human population again in the future. The world needs to be prepared in case there is a 'next time'. The HPA and Department of Health have developed an integrated response, assigning different tasks to different levels within the NHS, the HPA and its partner agencies depending on the degree of SARS activity (in preparation, to be posted on the HPA website). An HPA options paper has assessed the options for making SARS a notifiable disease. 28 Research into improved diagnostic tests is continuing. The success of these efforts is due to close collaboration between local, national and international partners. New Haemophilus influenzae type b catch-up campaign commences. Commun Dis Rep CDR Wkly [serial online Rising incidence of Haemophilus influenzae type b disease in England and Wales indicates a need for a second catch-up vaccination campaign Antibody to Haemophilus influenzae type b after routine and catch-up vaccination Clinical Guideline 2. Infection control. Prevention of healthcare-associated infection in primary and community care. London: National Institute for Clinical Excellence Smith GW and the epic guideline development team. The epic project: developing national evidence-based guidelines for preventing healthcareassociated infections. Phase 1: guidelines for preventing hospitalacquired infections CMO to step up fight against hospital infection (press release) 2003/0222. London: Department of Health Getting ahead of the curve: the Chief Medical Officer's strategy for infectious disease and other aspects of health protection. London: Department of Health Press release 2002/0518. London: Department of Health PHLS. NHS performance indicators and key targets for 2002/03: new infection control indicators. Commun Dis Rep CDR Wkly Outbreak of Salmonella Typhimurium DT193a in the South West region in Yorkshire and Humberside Region Dramatic increase in ciprofloxacinresistant gonorrhoea in England and Wales. Commun Dis Rep CDR Wkly [serial online 2002 national guideline on the management of gonorrhoea in adults. London: Association for Genitourinary Medicine (AGUM), Medical Society for the Study of Venereal Diseases (MSSVD) Avian influenza in The Netherlandshuman death reported syndrome Netherlands: H7N7 in The Netherlands International Society for Infectious Diseases Summarizing the rabies situation in Europe Rabies-like infection in Scotland House of Commons health committee report on sexual health released Better prevention, better services, better sexual health: The national strategy for sexual health and HIV. London: Department of Health Guidance from the Advisory Committee on Dangerous Pathogens and the Spongiform Encephalopathy Advisory Committee. London: Department of Health Controls assurance in infection control: decontamination of medical devices. (HSC 1999/179) Effect of treatment regimens for Neisseria gonorrhoeae on simultaneous infection with Chlamydia trachomatis Serologic evidence of past infection with Chlamydia trachomatis, in relation to ovarian cancer Global alert: cases of severe respiratory illness may spread to hospital staff Severe Acute Respiratory Syndrome (SARS): guidance for health professionals Virus detectives seek source of SARS in China's wild animals (news item) Legal powers that would assist in controlling Severe Acute Respiratory Syndrome (SARS) in England and Wales: would making SARS notifiable assist? An options paper inviting comment The CdaHP series is prepared by the HPA Communicable Disease Surveillance Centre with the assistance of colleagues in partner organizations in health protection.