Final Issue: Volume 16 Number 51	Published on: 21 December 2006	Final Issue in PDF PDF format (283 Kb)

News Archives 23 March 2006

Last updated: Volume 16, No. 12 (PDF file, 226 KB)

Archives | News Archives 2006: Page 1| News 23 March 2006

News Archives: | 2006 | 2005 | 2004 | 2003

• World TB day – 24 March 2006
• Increase in measles cases in 2006, in England and Wales
• Chikungunya outbreak in the Indian Ocean islands (and imported cases) – update
• HPA takes the initiative in immunisation training

World TB day – 24 March 2006

To mark World TB Day 2006 the Health Protection Agency has published a Tuberculosis Update newsletter which highlights some of the national and local initiatives in support of the implementation of the Chief Medical Officer’s action plan – Stopping Tuberculosis in England. <http://www.hpa.org.uk/infections/topics_az/tb/pdf/newsletter_2006.pdf>.

The newsletter was released on 22 March 2006 to coincide with the publication new clinical guidelines from the National Institute for Health and Clinical Excellence (NICE) to help the National Health Service (NHS) identify, prevent and treat people with TB in England and Wales. This guidance has been developed with input from a range of organisations involved in treating and preventing TB, including organisations representing health professionals, people with TB and their carers, local government and the voluntary sector.
<http://www.nice.org.uk/page.aspx?o=296657>.

Tuberculosis remains an important public health problem in the United Kingdom. Results of Enhanced Tuberculosis Surveillance (ETS) for 2004 have now been finalised and linked with species and drug susceptibility information from the UK Mycobacterial surveillance Network (MycobNet). Using 2000 to 2004 data, trends were examined for a number of key indicators as measures of progress in TB control.

Overall incidence
There were 7167 cases of TB reported in England, Wales, and Northern Ireland in 2004, an incidence of 13.1 cases per 100,000 population (figure 1). This represents a 5% increase in case reports when compared with the 6837 cases reported in 2003 (rate 12.6 per 100,000). The highest rate of disease was observed in London (42.1/100,000), which accounted for 44% of the total number of reported cases. The proportion of cases reported from among foreign-born population groups has increased from 63% in 2000 to 70% in 2004.

Figure 1 Tuberculosis incidence for all cases and in children aged less than 15 years old England, Wales and Northern Ireland, 2000 – 2004

Sources: Tuberculosis cases: Enhanced Tuberculosis Surveillance, ONS mid year population estimates.

Incidence in children
In 2004, there were 414 cases of TB in children aged under 15 years, giving a rate of 4.1/100,000 (figure 1).

Drug resistance
Levels of drug resistance at the start of treatment for cases reported in 2004 were
6.8% for isoniazid and 1.0% for multi drug resistance (resistance to at least isoniazid and rifampicin) compared with 6.8% and 1.3% respectively in 2003.

Treatment outcome monitoring
Provisional results of treatment outcome monitoring are available for cases reported in
2003. An outcome was reported for 88% of cases in 2003 compared with 85% in 2002 and 79% in 2001. Among all TB patients with a known outcome, the proportion of cases that have completed treatment was 79% compared with 78% in 2002 and 79% in 2001.
For new infectious cases of pulmonary TB with a reported outcome, the proportion of cases that have completed treatment was 78% compared with 76% in 2002 and 77% in 2001.

Reports of TB continue to increase annually. The observed increase is largely confined to specific subgroups of the population in major cities. The increase reflects a combination of factors, including migration from high incidence countries, homelessness, HIV co-infection and potentially improvements in case reporting following the introduction of ETS.

Tables and figures have been updated with 2004 data on the HPA TB website at <http://www.hpa.org.uk/infections/topics_az/tb/data_menu.htm>.

Increase in measles cases in 2006, in England and Wales

So far in 2006, 72 cases of measles have been confirmed in England and Wales (weeks 1 to 11), compared with a total of 77 cases in the whole of 2005. Cases have occurred in all regions apart from the North East and the ages of cases have ranged from under one to 35 years of age. Two cases had received one dose of measles, mumps, and rubella (MMR) vaccine and three others had been vaccinated with single measles vaccine (two in South Africa). Nine of the cases have been admitted to hospital and there has been one measles related death in a male aged 13 years who had an underlying lung condition and was taking immunosuppressive drugs.

An outbreak of confirmed measles was first reported on a travellers’ site in 2005 in Essex. Since then there has been a number of outbreaks of measles among the travelling community across England with the majority of the cases associated with the travelling community. Local health protections units have been working with Primary care Trust’s (PCTs) and the travelling communities to minimise the impact of this outbreak. Vaccination coverage in travelling communities has been historically low.

In line with WHO recommendations, laboratory confirmation should be performed on all suspected measles cases and all confirmed cases should be reported to the Health Protection Agency’s Centre for Infections (HPA CfI). Laboratory confirmation is usually based on virus specific IgM detection either in oral fluid or serum. Oral fluid samples are non-invasive, are easily collected from all ages, and can be taken by parents or patients themselves. Where the index of suspicion is high, or where rapid public health action may be required, oral fluid should be taken in addition to any other specimens, even in the acute phase. Public health management, however, should proceed immediately for cases that are epidemiologically-linked to the travelling community. For cases where an urgent diagnosis is required, the Virus Reference Department at CfI, Colindale, London, offers a diagnostic service by real-time PCR for oral fluid and other specimens. Oral fluid samples are positive in 80% to 90% of samples collected during the first week after onset (1); comparable with the 65% to 75% from throat swabs, and higher than other samples including serum and urine (2). Hospitals can liaise with the local HPU to obtain saliva kits for rapid diagnosis of children seen in A&E or admitted to the ward.

Where an urgent diagnosis is requested please contact the HPA Immunisation and Diagnosis Unit laboratory (tel: 020 8327 6202), or the Immunisation Department (tel: 020 8327 7084) at the Centre for Infections.

References

1. Jin L, Vyse A, Brown DW. The role of RT-PCR assay of oral fluid for diagnosis and surveillance of measles, mumps and rubella. Bull World Health Organ 2002; 80: 76-7.
2. Riddell MA, Chibo D, Kelly HA, Catton M G, Birch C J. Investigation of optimal specimen type and sampling time for detection of measles virus RNA during a measles epidemic. J Clin Microbiol 2001 39, 375-6.

Chikungunya outbreak in the Indian Ocean islands (and imported cases) – update

Situation update in the Indian Ocean
Since March 2005 several outbreaks of chikungunya infection have occurred on islands in the Indian Ocean (1). The island most affected has been La Réunion where, as of 12 March 2006, 3237 cases have officially been notified through the physicians sentinel network, although mathematical models have estimated the total number of cases to be in excess of 200,000 (2).

Other islands that have reported infections include the Seychelles (8818 suspected cases, between 1 January and 26 February 2006), Mauritius (6000 suspected cases, including 1200 confirmed cases, between 1 January and 5 March 2006), and Mayotte (3471 suspected cases, between 9 January and 12 March). An outbreak of chikungunya virus infection has recently been reported in Andhra Pradesh and Marahashtra states in India, where there also appears to be co-circulation of dengue virus, which is transmitted by the same mosquito vectors. Results confirming concurrent dengue infections are awaited (1).

Imported cases
Several European countries have reported cases in people returning from these islands. The majority of these have been reported in France, with 160 cases known to be imported between 9 April 2005 and 31 January 2006 (3). Other countries reporting imported cases include Germany, Switzerland, Italy, and Norway (4).

Since December 2005, four imported cases of chikungunya, have been identified in the United Kingdom. These have been confirmed by the Health Protection Agency’s Special Pathogens Reference Unit. Of these, two serologically confirmed cases, from the South West and London regions, were associated with travel to the Seychelles. Two further cases from the West Midlands region who had returned from Mauritius have been confirmed by both PCR and serology.

Over 7000 British tourists travel to the Seychelles and Mauritius every month (5). Health professionals need to be aware of chikungunya infection when assessing travellers who have recently returned from islands in the Indian Ocean and Indian sub-continent. All samples from suspected cases should be sent to the Special Pathogens Reference Unit for investigation. More information about this is available on the HPA website at <http://www.hpa.org.uk/srmd/other_ref_labs/spru.htm>.

There is no vaccine against chikungunya virus and, therefore, prevention relies solely on the avoidance of mosquito bites, particularly during the daylight hours (early morning and late afternoon), when the Aedes spp are most active. More information about this can be obtained from the NaTHNaC website at <http://www.nathnac.org/pro/factsheets/iba.htm>.

References
1. World Health Organization. Chikungunya and Dengue in the south west Indian Ocean 17 March 2006 [online] [cited 21 March 2006]. Available at <http://www.who.int/csr/don/2006_03_17/en/index.html>.
2. Institut de Vielle Sanitaire. Epidémie de Chikungunya à La Réunion / Océan Indien. Point de situation au 17 mars 2006 [online] [cited 21 March 2006]. Available at <http://www.invs.sante.fr/display/?doc=presse/2006/le_point_sur/chikungunya_170306/index.html>.
3. Institut de Vielle Sanitaire. Cas de Chikungunya importés en Métropole. Avril 2005-janvier 2006 [online] [cited 21 March 2006].
<http://www.invs.sante.fr/presse/2006/le_point_sur/chikungunya_cas_importes_090306/chikunguny
_cas_importes_090306.pdf>.
4. Editorial team, Pfeffer M, Löscher T. Cases of chikungunya fever imported into Europe. Eurosurveillance Weekly [serial online] 16 March 2006 [cited 21 March 2006]; 11(3).
Available at <http://www.eurosurveillance.org/ew/2006/060316.asp#2>.
5. HPA. Chikungunya virus in the Indian Ocean. Commun Dis Rep CDR Wkly [serial online] 2006[cited 21 March 2006]; 16(6): news. Available at
<http://www.hpa.org.uk/cdr/archives/2006/cdr0606.pdf>.

HPA takes the initiative in immunisation training

In the last week of March the Health Protection Agency (HPA) will, for the first time, be running a training course titled The Fundamentals of Immunisation
<http://www.hpa.org.uk/hpa/events/immunisation_course.htm>.

This course is based on several years’ experience of creating training for frontline vaccinators, trainers, and people who advise on vaccination, and has been set up to support implementation of National Minimum Standards for Immunisation Training which were published last year <http://www.hpa.org.uk/infections/topics_az/vaccination/National_immun_train_stand1.pdf>.

In a parallel and complementary initiative, the Immunisation Department at the HPA Centre for Infections has produced materials to support delivery of Immunisation Training at local level.

The first group of materials are teaching resources in the form of slide sets <http://www.hpa.org.uk/infections/topics_az/vaccination/slides.htm>.
They are designed to be used by those delivering training in immunisation, following the Core areas described in Core Curriculum for Immunisation Training <http://www.hpa.org.uk/infections/topics_az/vaccination/core_curr1.pdf> and

The content is designed to cover the more theoretical aspects; they do not address the need for other types of learning including supervised practice, reflective learning, communication exercises, and practical workshops.

The slides have been created as a resource to be used by trainers. They assume a significant degree of knowledge and are designed to be used by individuals who already have a strong background in immunisation. The slides are not intended to be used as a distance learning course. Anyone is welcome to make use of the slides and adapt them for local purposes as long as their source is fully acknowledged.

The second resource is an on-line self assessment facility built upon a bank of multiple choice questions on immunisation contributed by HPA staff. This can be found at <http://www.hpa.org.uk/infections/topics_az/vaccination/training_menu.htm>.

Feedback is welcomed on the resources that have been developed, so far, on ancilliary training materials or methods, or on possible additional multiple choice questions to add to the HPA database. Please email comments and suggestions to <immunisationtraining@hpa.org.uk>.