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Final Issue: Volume 16 Number 51
Published on: 21 December 2006
Final Issue in PDF
Last updated: Volume 14, No.3 (PDF file, 755 KB)
Outbreaks of avian influenza, due to the influenza A H5N1 virus, have been reported from South Korea in December 2003 and, on 9 January 2004, in Japan and the southern part of Vietnam. The infection, which is highly pathogenic in chickens, has caused the death of thousands of chickens and many more are being culled in order to control the outbreaks.
On 13 January 2004, the World Health Organization (WHO) published a report confirming the presence of the H5N1 avian influenza strain in samples taken from humans in an investigation of a cluster of deaths in Hanoi, Vietnam <http://www.who.int/csr/don/2004_01_13/en/>. From the end of October 2003, 14 people (13 children and one adult) with severe respiratory illness had been admitted to hospitals in Hanoi and surrounding provinces. Eleven of the children and one adult (the mother of one of the eleven children) have died. Three have been demonstrated to have been infected with the H5N1 strain, but the cause of illness in the others is not known. There is currently no evidence of human-to-human transmission. Most of those questioned reported having been in the vicinity of poultry that were ill, although outbreaks of avian influenza have not yet been reported in north Vietnam where Hanoi is located. No healthcare workers have been reported to have developed the illness.
On 14 January 2004, WHO reported that the H5N1 strain implicated in the outbreak has been partially sequenced. All genes are of avian origin, indicating that the virus that caused the death in the three confirmed human cases has not yet acquired human genes. The acquisition of human genes increases the likelihood that a virus of avian origin can be readily transmitted from one human to another. Further information is available on the WHO website at <http://www.who.int/csr/don/2004_01_14/en/>.
An outbreak of influenza among humans due to the influenza A H5N1 virus occurred in Hong Kong in 1997, and involved 18 people (six of whom died) (1). The source of infection was poultry in local markets, and a massive culling of poultry in Hong Kong was carried out. No further spread of the outbreak occurred after the cull. A further outbreak occurred in a Hong Kong family, with links to neighbouring provinces of southern China, was reported in February 2003. Two cases occurred including one death, but no evidence of further spread was found.
Human illness has not been reported in association with the outbreaks of avian influenza in South Korea or Japan. WHO has stated that the relationship between the outbreaks of avian influenza in poultry in southern Vietnam and the cluster of cases in Hanoi is not clear. Nevertheless, every case of transmission of avian influenza virus to humans is a reason for heightened vigilance. The circulation of the H5N1 avian influenza viruses in large numbers of poultry in a growing number of countries makes surveillance and vigilance even more essential.
1.CDSC. Influenza A virus subtype H5N1 infection in humans. Commun Dis Rep CDR Wkly [serial online] 1997 [cited 15 January 2004]; 7(50): news. Available at <http://www.hpa.org.uk/cdr/archives/CDR97/cdr5097.pdf>.
2.PHLS. H5N1 avian influenza virus: human cases reported in southern China Laboratory reports of Haemophilus. Commun Dis Rep CDR Wkly [serial online] 2003 [cited 15 January 2004]: 13(50): news. Available at <http://wwww.hpa.org.uk/cdr/archives/2003/cdr0903.pdf>.
Following the recent World Health Organization report of one laboratory confirmed and two suspected cases of severe acute respiratory syndrome (SARS) in Guangdong province in southern China <http://www.who.int/csr/don/2004_01_08/en/>, the Health Protection Agency (HPA) urges clinicians and other healthcare professionals to remain vigilant to the possibility of SARS even though the level of risk in the United Kingdom remains very low. Clinicians should continue to report unusual clusters of severe respiratory illness among health care workers and possible SARS infection in persons returning from China, particularly the Guangdong province. Current information on the SARS situation and case definitions in the post-outbreak period are available on the HPA website at <http://www.hpa.org.uk/infections/topics_az/SARS/casedef.htm>.
Two cases of legionnaires' disease have been diagnosed in people who were part of a group of 24 adults from the United Kingdom (UK) who stayed at a hotel in Kyrenia, in northern Cyprus between 21 December 2003 and 3 January 2004. Both cases are males aged between 50 and 59 years and one has died. A case of legionnaires' disease in August 2003 was also associated with this same hotel. Two of the three cases were diagnosed by urinary antigen detection, one of which has been confirmed as Legionella pneumophila serogroup 1 by the Health Protection Agency's Respiratory and Systemic Infections Laboratory, Colindale, and the other by direct immuno-fluorescence of the organism.
Northern Cyprus is under Turkish jurisdiction and their collaborator in the European Surveillance Scheme for Travel Associated Legionnaires' Disease (EWGLINET) is taking responsibility for organising environmental investigations and control measures at the hotel. WHO Europe, all other collaborating countries in EWGLINET, and the Department of Health, England, have been informed of the outbreak.
The remaining 22 people from the recent tour group are being contacted by the tour operator and informed of the outbreak, and advised to seek medical attention if they themselves develop symptoms suggestive of legionella infection during the relevant time period.
For further information about the outbreak please contact Carol Joseph at Health Protection Agency Communicable Disease Surveillance Centre (tel: 020 8200 6868), Roy Fey consultant in communicable disease control (CCDC), East Midlands Health Protection Unit, (tel: 01332 203102 ext 6330) or Joyshri Sarangi, CCDC Avon Health Protection Unit, (tel: 0117 900 2620).
Toxigenic Corynebacterium ulcerans has been isolated from the throat swab of a woman aged 58 years with a history of two weeks progressive sore throat, throat ulcers, cough and haemoptypsis .The throat swab was taken on 22 December. She was treated with erythromycin and her only close contact was swabbed and found to be negative. There was no history of consuming any raw milk products or rural contact.
Initially it was thought that the infection had been acquired while the patient was on holiday in Majorca, and the appropriate authorities in Spain were notified. More detailed investigation, however, indicates that the infection was most likely acquired in the UK.
Toxigenic C. ulcerans is a documented cause of diphtheria, which (similar to that caused by toxigenic C.diphtheriae), can be fatal. Thirty-nine isolates of C. ulcerans were been identified in the United Kingdom (UK) between 1993 and 2003. Exposures associated with infection include raw milk and travel, but no risk factors for infection were identified in 19 of the 39 isolates, so unknown modes of transmission could exist. Cases of C. ulcerans infection where person-to-person spread may have occurred have been reported and for this reason the management of toxigenic C. ulcerans infections in the UK is similar to those caused by toxigenic C. diphtheriae (1). Other European countries such as The Netherlands have reported occasional cases of C. ulcerans infection.
Recent isolates of toxigenic C. ulcerans from domestic cats suggest that there may also be a potential risk to human contacts of infected cats (2). The case described here owned a domestic cat.
In view of these recent documentations, and more importantly the changing epidemiology of diphtheria and related infections globally, it is important that the surveillance of corynebacteria through laboratory screening of throat swabs is maintained.
1.Bonnet JM, Begg NT. Control of diphtheria: guidance for consultants in communicable disease control. Commun Dis Public Health 1999; 2: 242-9.
2.PHLS. Toxigenic Corynebacterium ulcerans in cats. Comm Dis Rep CDR Wkly [serial online] 2002 [cited 15 January 2004]; 12(11): news. Available at <http://wwww.hpa.org.uk/cdr/archives/2002/cdr1102.pdf>.
Following meals at a 24-hour café in central London at least five people were infected with Salmonella Enteritidis. The Health Protection Agency Laboratory of Enteric Pathogens (LEP) has confirmed one patient with S. Enteritidis PT 6a, resistant to ampicillin (AmpR), and four patients with PT 6d (AmpR). The London Food, Water, and Environmental Microbiology Laboratory examined Spanish eggs obtained from the café, and Salmonella sp. was recovered from 21 of 60 pooled egg samples (comprising 360 eggs). The LEP has confirmed that one pooled sample contained Salmonella Enteritidis PT 6a (AmpR), 18 contained S. Enteritidis 6d (AmpR), and one pooled sample contained both organisms.
Salmonella Enteritidis PT 6d (AmpR) was first reported in human infections in October 2002 and the strain was isolated from Spanish eggs by the Wessex Environmental Microbiology Laboratory in Southampton in November 2002 (1,2).
1.Salmonella Enteritidis outbreaks in England and Wales, September to November 2002. Commun Disease Rep CDR Weekly [serial online] 2002 [cited 15 January 2004]; 12(49): news. Available at <http://wwww.hpa.org.uk/cdr/archives/2002/cdr4902.pdf>.
2.Public health investigation of Salmonella Enteritidis in raw shell eggs. Commun Disease Rep CDR Weekly [serial online] 2002 [cited 15 January 2004]; 12(50): news. Available at <http://wwww.hpa.org.uk/cdr/archives/2002/cdr5002.pdf>.
The outbreak of tetanus in injecting drug users (IDUs) first reported in CDR Weekly on 20 November 2003 is still ongoing (1). Since the last update (2) three more cases have been reported in England, giving a total of 10 cases in England since July 2003 (figure 1). The last onset date was 6 January 2004. The majority of cases had full-blown tetanus; one case is known to have died. Six cases were in females, and four in males. The five cases for whom information on the method of injection was available all reported subcutaneous injection of heroin ('skin popping'). Information on tetanus immunisation status was available for seven cases. Of these, only one reported to have been immunised in the past 10 years and four were probably never immunised. Three of the cases have been tested for tetanus IgG and have levels below the minimum protective level, which supports the claims that they have not/may have not had a full course of tetanus vaccination. The age of cases ranges between 20 and 47 years, with female cases being younger than male cases (median age 28 and 43 years, respectively). Nine of the cases were reported from the west of England, and one from London. In addition, two cases of tetanus in IDUs have been reported from Scotland in this time period (figure 2). There have been no reports of cases from Wales.
Figure 1 Cases of tetanus in injecting drug users by week of onset, England, Wales, and Scotland: 1/7/2003 -14/1/2004.
Figure 2 Cases of tetanus in injecting drug users by geographical location, England, Wales, and Scotland: 1/7/2003-14/1/2004
The pattern of cases over time and location suggests that a contaminated batch, or batches, of heroin are still circulating. It is unknown at what stage contamination may be occurring - it could be outside the UK or at any of several levels in the distribution, process of storage, cutting, or injecting. The national distribution of cases suggests that contamination may be occurring relatively high in the supply chain for most cases. Continued vigilance for early signs and symptoms of tetanus in IDUs is important, as early treatment with tetanus immunoglobulin, antibiotics, and wound debridement can be life saving. Information on diagnosis, treatment, and public health management of tetanus for health professionals is available at <http://www.hpa.org.uk/infections/topics_az/tetanus/tetanus_health_professionals.pdf>. Tetanus immunoglobulin for treatment of tetanus is available from Bio Products Laboratory, tel: 020 8258 2200 (with an out-of-hours service). Information for IDUs is available from <http://www.hpa.org.uk/infections/topics_az/tetanus/advice_to_idu_271103.pdf>.
Tetanus can present with local fixed muscle rigidity and painful spasms confined to the area close to the site of injury or injection. Although localised tetanus can last weeks or months, it is more commonly a precursor to generalised tetanus. The illness can progress for about two weeks. Patients with generalised tetanus can present with local tetanus, or with symptoms of generalised tetanus ranging from mild trismus ('lockjaw'), neck stiffness and/or abdominal rigidity to full-blown tetanus, including general spasticity, severe dysphagia, respiratory difficulties, severe and painful spasms, opistothonus, and autonomic dysfunction. The presentation of the cases, so far, has ranged from mild trismus to full-blown tetanus with respiratory arrest.
Five doses of tetanus toxoid containing vaccine at the appropriate intervals are considered to give lifelong protection as long as tetanus prone wounds are treated with prophylactic Tetanus Immunoglobulin (TIG) (3). The information obtained, so far, on vaccination status of the cases is consistent with this, in that none of the cases has reported to have had five doses. Health professionals in regular health care settings and drug services should ask IDUs about their tetanus immunisation status. IDUs who have not received five doses of tetanus-containing vaccine or are unsure about their vaccination status, should receive additional tetanus-low dose diphtheria (Td) vaccination.. Considering the low coverage of the school leaving boosters, many IDUs will require at least one booster. Unvaccinated IDUs should be encouraged to complete a primary course of Td vaccination followed by two further boosters.
Even individuals who have received five doses of tetanus vaccine in childhood may eventually have insufficient antibody levels to protect against heroin or a wound heavily contaminated with C. tetani. Generally, those who are exposed to risk of tetanus through injury are recommended to receive TIG even if fully vaccinated. This recommendation is impracticable for IDUs who may be at recurrent risk through regular injection. The question remains unanswered whether IDUs might benefit from regular boosters to ensure protection from ongoing contamination of heroin or from exposure through other sources.
All cases of tetanus (see case definition below) should be notified to the proper officer, normally the consultant in communicable disease control (CCDC). CCDCs are also requested to inform Joanne White at the Health Protection Agency's Communicable Disease Surveillance Centre (email: firstname.lastname@example.org) using the enhanced surveillance questionnaire, which is available at <http://www.hpa.org.uk/infections/topics_az/tetanus/tetanus_idu_quest.pdf>.
Case definition for current cluster
A case is defined as a person with clinical evidence of tetanus infection who has injected drugs in the month before onset of symptoms, and whose onset of symptoms was after 1 July 2003. Clinical evidence of tetanus infection is defined as mild to moderate trismus and one or more of the following: spasticity, dysphagia, respiratory embarrassment, spasms, and autonomic dysfunction.
1.HPA. Cluster of cases of tetanus in injecting drug users in England. Commun Dis Rep CDR Wkly [serial online] 2003 [cited 18 December 2003]; 13(47): news. Available at <http://wwww.hpa.org.uk/cdr/archives/2003/cdr4703.pdf>
2.HPA. Cluster of cases of tetanus in injecting drug users in England : update. Commun Dis Rep CDR Wkly [serial online] 2003 [cited 18 December 2003]; 13 (48): news. Available at <http://wwww.hpa.org.uk/archives/2003/cdr4803.pdf>.
3.Salisbury DM, Begg NT. Immunisation against infectious disease (The green book). London: HMSO, 1996. Available at <http://www.doh.gov.uk/greenbook/greenbookpdf/chapter-30-layout.pdf>.