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

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• Eye of the needle: surveillance of significant occupational exposure to bloodborne viruses in healthcare workers
• Health Protection Agency publishes its first migrant health report
• Guidelines for Hajj pilgrims 2006
• Survey of Salmonella contamination of non-UK produced shell eggs on retail sale in the north west of England and London
  
  

Eye of the needle: surveillance of significant occupational exposure to bloodborne viruses in healthcare workers

The latest report on surveillance of significant occupational exposures to bloodborne viruses in healthcare workers has been published by the Health Protection Agency Centre for Infections. Titled Eye of the Needle, the report details surveillance data on significant occupational exposures to bloodborne viruses in healthcare workers in England, Wales, and Northern Ireland [1]. Unless otherwise stated in the text, the data are based on a subset of 40 reporting centres which consistently reported to the surveillance scheme.

Occupational exposures to bloodborne viruses in the healthcare setting are an increasing public health concern. The report highlights that in 2005, there were two documented cases of hepatitis C seroconversion in healthcare workers. Eleven healthcare workers have now been reported as having contracted hepatitis C via this route, including the latest reported cases. Healthcare workers who initiated treatment within the eight months following the date of exposure have all achieved viral clearance.

Following reported occupational exposure to hepatitis C positive source patients, less than half (46%; 112/242) of healthcare workers reported follow-up at six months post-exposure. For the reports on exposures to hepatitis C positive source patients received in 2005, only 20% (49/242) of healthcare workers returned for all the appropriate follow-up tests at the correct time points after first being exposure. This finding is worrying since the majority of hepatitis C infected cases show no symptoms of their infection. Symptoms of infection can take up to 30 years before the infection manifests itself, when chronic damage to the liver has already occurred. It is therefore essential that healthcare workers are made aware of the need to attend follow-up appointments and ensure they know the outcome of their exposure.

The report found that in the majority of cases of HIV occupational exposures, national guidance on the use of HIV post-exposure prophylaxis guidelines was followed. In 2005, 65% (62/94) of healthcare workers who initiated HIV post-exposure prophylaxis (PEP) following exposure to an HIV positive source patient, were prescribed the current recommended starter pack regimen of AZT (Zidovudine), 3TC (Lamivudine), and Nelfinavir. Guidelines from the Expert Advisory Group on AIDS, recommend that HIV PEP should be started as soon as possible after the exposure, ideally within an hour [2]. Thirty-four per cent (64/189) of healthcare workers exposed to HIV who initiated HIV PEP, did so within an hour of their exposure, and cumulatively 89% (169/189) started HIV PEP within 24 hours. There were no new HIV seroconversions in 2005 reported to the scheme; with the total number of UK documented HIV seroconversions remaining at five.

Percutaneous injuries, the majority of which involved hollowbore needles, were the most commonly reported type of exposure. Reports of exposures increased by 49% from 206 in 2002 to 306 in 2005. Reports of percutaneous injuries to source patients infected with hepatitis C have also seen an increase of 37% over the same time period, from 81 in 2002 to 111 in 2005. The number of reports involving medical professionals have increased by 78%, from 73 in 2002 to 130 in 2005; a greater percentage increase in reports over time than for nursing professionals (47%; from 102 to 150 between 2002 and 2005 respectively). Although doctors and dentists comprise a much smaller group of healthcare workers, they reported a similar number of injuries, which suggests they have a higher injury rate.

The report highlights that preventable injuries are still occurring. Between 1997 and 2005, nearly half the incidents that occurred in the ward (45%; 425/954) were after the procedure had taken place. A lot of these incidents could have been prevented with proper adherence to the safe handling and disposal of sharps and clinical waste. There is guidance in place that details the recommended procedures for the prevention of exposure to bloodborne viruses in the healthcare setting [3] and Trusts should ensure that healthcare workers are aware and adequately trained on the implementation of these precautions in order to protect themselves from exposures. Employers should also have adequate systems in place, 24 hours 7 days a week; for the reporting and management of occupational exposures, and ensure that all staff members know how to report such incidents, in line with current guidance [2]. Primary Care Trusts working with local Health Protection Units should ensure that arrangements are in place for managing occupational exposures to healthcare workers occurring outside the hospital environment. In addition, Microbiologists and Virologists working with Occupational Health, Infectious Disease, and GUM colleagues are encouraged to ensure that appropriate and timely testing and follow-up arrangements are available and consistent with national guidance.

Incidents of healthcare workers occupationally exposed to bloodborne viruses in England, Wales and Northern Ireland, should be reported to Jane Aston/Sarah Tomkins at the Centre for Infections (tel: 020 8327 7152/7095).

References
1. Health Protection Agency Centre for Infections, National Public Health Service for Wales, CDSC Northern Ireland and Health Protection Scotland. Eye of the Needle. United Kingdom Surveillance of Significant Occupational Exposures to Bloodborne Viruses in Healthcare Workers. London: HPA, November 2006. Available at:
<http://www.hpa.org.uk/publications/PublicationDisplay.asp?PublicationID=54>.

2. HIV Post-Exposure Prophylaxis: Guidance from the UK Chief Medical Officers’ Expert Advisory Group on AIDS. London: Department of Health, February 2004.

3.Expert Advisory Group on AIDS and the Advisory Group on Hepatitis. Guidance for clinical health care workers: protection against infection with bloodborne viruses. London: UK Health Departments; 1998.

 

Health Protection Agency publishes its first migrant health report

The Health Protection Agency has published its first report on the health of migrants Migrant health: infectious diseases in non-UK born populations in England, Wales, and Northern Ireland. The report provides background information on migration to the United Kingdom (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. The report aims to be a useful resource for health professionals and others with an interest in migrant health.

Migration affects virtually every country worldwide and is increasing globally. 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. The migrants who arrive in the UK are very diverse in terms of their reason for migration and their country of origin. Most are young adults who have voluntarily chosen to come to the UK, mainly to work or study, and many arrive from countries with a low prevalence of infectious disease. Some arrive from countries with a high prevalence of infections and may therefore have additional health needs compared with UK born people.

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 less than four per cent. 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.

The increased burden of infection in some non-UK born populations is in large part related to the higher prevalence of infection in the countries from which they originate, and many infections are probably acquired prior to migration. The report shows, however, that some migrants are at ongoing risk of infectious diseases after arrival, either through travel to visit family and friends in their countries of origin, or as a result of exposure in the UK. It is therefore important to identify risk factors that may be amenable to public health action in the UK.

The report makes recommendations for addressing the increased burden of infectious disease in migrant populations including: strengthening provision of culturally appropriate and language-supported health services, increasing awareness of disease in migrant communities and their health care practitioners, and improving surveillance to better understand the prevalence of infections in people born abroad. Many organisations could have a role to play in implementing the report’s recommendations, and the Agency will be taking this work forward with relevant partners, particularly in the NHS, to identify the most effective public health response.

References

1. Health Protection Agency. Migrant health: infectious diseases in non-UK born populations in England, Wales, and Northern Ireland. London: HPA, 2006. Available at <http://www.hpa.org.uk/publications/PublicationDisplay.asp?PublicationID=53>.

 

Guidelines for Hajj pilgrims 2006

 

The National Travel Health Network and Centre (NaTHNaC) have, this week, issued guidance detailing all the health requirements that Hajj pilgrims need to consider before they leave for their trip, some of which are required by the Ministry of Health of Saudi Arabia in order to enter the country [1]. This is available on the NaTHNaC website at http://www.nathnac.org/pro/clinical_updates/Hajj151106.htm. Guidance has also been published in the World Health Organization Weekly Epidemiological Record [2]. The Foreign and Commonwealth Office has also published an informational leaflet with more general advice for pilgrims, which is available at http://www.fco.gov.uk/Files/KFile/6pp%20Hajj%20Guide06.pdf [3].

Hajj, the Muslim pilgrimage to Mecca, is the largest annual gathering of its kind in the world. All adult Muslims who are physically and financially able to do so have a religious obligation to make the pilgrimage once in their lifetime, and each year, over two million Muslims from around the world gather in Mecca [4]. The Hajj takes place between the eighth and thirteenth day of the last month of the Islamic lunar calendar, and therefore falls at different dates each year. The next Hajj will take place between 29 December 2006 and 3 January 2007.

On 16 November 2006, the Agency organised a conference on ‘Health at Hajj and Umrah’ in association with the Muslim Council of Britain, and Queen Mary, University of London, which brought together experts from Saudi Arabia, Australia, Singapore and the UK to share information on providing effective health advice and support to pilgrims.

 

References

1. The National Travel Health Network and Centre (NaTHNaC). Clinical update: Guidelines for Hajj pilgrims. London: NaTHNaC; 15 November 2006. Available at <http://www.nathnac.org/pro/clinical_updates/Hajj151106.htm>

2. World Health Organization. Health conditions for travellers to Saudi Arabia for the pilgrimage to Mecca (Hajj). WER 2006; 81 (44); 422-3. Available at <http://www.who.int/wer/2006/wer8144.pdf>.

3. Advice to British Hajjis. London: Foreign and Commonwealth Office, 2006. Available at <http://www.fco.gov.uk/Files/KFile/6pp%20Hajj%20Guide06.pdf>.

4. Shafi S, Memish Z, Gatrad A, Sheikh A. Hajj 2006: communicable disease and other health risks and current official guidance for pilgrims. Euro Surveill 2005; 10 (12): E051215.2. Available at <http://www.eurosurveillance.org/ew/2005/051215.asp#2>.

 

Survey of Salmonella contamination of non-UK produced shell eggs on retail sale in the north west of England and London

The Food Standards Agency (FSA) has published its findings of a survey of salmonella contamination in eggs produced outside the United Kingom (UK) and on retail sale in England [1]. The consumption level of eggs in the UK exceeds the national supply, resulting in the need to source eggs from outside the UK. This is the first survey to provide information on Salmonella contamination of non-UK eggs on retail sale, and was carried out against a backdrop of a change in the epidemiology of S. Enteritidis in England and Wales [2,3] and elsewhere in Europe [4]. The survey was carried out over a period of 16 months, between March 2005 and July 2006.

Shell and contents of 1744 samples of six pooled eggs from targeted retail premises in the north west of England and London were analysed for Salmonella during the course of the survey. The overall finding was that 157 (9.0%) samples were contaminated with Salmonella spp on the shell of the egg. When egg import data is taken into account, this results in an estimated prevalence of 3.3%; this is equivalent to 1 in every 30 ‘boxes’ of six eggs. Of these 157 samples, S. Enteritidis were detected in 136, with a prevalence estimate of 2.6%, equivalent to 1 in every 40 ‘boxes’ of six eggs.

Eggs sampled were produced in eight European Countries (Spain, France, The Netherlands, Germany, Portugal, Republic of Ireland, Belgium, and Poland), with most (66.3%) originating from Spain. Salmonella spp. was detected from 13.3% and 0.6% of eggs sampled that were produced in Spain and France, respectively. Most of the Salmonella contaminated eggs from Spain were linked with just one packing station and three producers. This finding could indicate problems of contamination within the layer flock or cross-contamination at the packing station.

Of the 157 Salmonella shell-positive samples, ten were also contents-positive (six samples also contained two separate Salmonella isolates), making a total of 173 distinct Salmonella isolates recovered from the survey. The isolates comprised eight different serotypes, of which most were
S. Enteritidis (84.9%; 147/173). Other serotypes included S. Mbandaka (8.1%), S. Rissen (1.2%),
S. Braenderup (0.6%), S. Infantis (0.6%), S. Panama (0.6%), and S. Weltevreden (0.6%). The remainder (3.4%) of serotypes were unnamed (S. Unnamed). There were nine different phage types (PTs) of S. Enteritidis, with PT1 predominating (81.6%). S. Enteritidis PT4 was not detected.

Eighty-three per cent of the Salmonella isolates were resistant to at least one antimicrobial drug; mostly resistant to nalidixic acid with concomitant reduced susceptibility to ciprofloxacin (NxCpL) (78.6%). Resistance to NxCpL was also found in S. Enteritidis isolates from Spanish eggs associated with multiple common source outbreaks of S. Enteritidis infection in England and Wales during 2002 to 2004 [1,2]. The subtype S. Enteritidis PT 1 NxCpL was also commonly reported as the causative organism in outbreaks linked to the use of Spanish eggs [1,2]. Previous egg surveys have shown that antimicrobial resistance is uncommon in isolates of S. Enteritidis from UK-produced eggs [5,6].

It is not unusual for Salmonella to be present in the environment and therefore contributing to the contamination of the egg shell. Ten shell-positive samples were also contents-positive, which suggests that systemic infection with Salmonella in laying flocks may be an issue in some EU Member States. The findings from the FSA survey are supported by the recent European Food Safety Authority survey of salmonella in layer flocks across Europe, in which Spain had among the highest prevalence on its farms [7].

Eggs are a commonly consumed food that may occasionally be contaminated with Salmonella at different rates according to their place of origin. Consumers and caterers need to be aware of this continuing hazard, adopt appropriate control measures and follow advice provided by the Food Standards Agency [8,9] in order to reduce the risk of infection. Salmonella contamination of eggs has been one of the main microbiological food safety issues in the last 20 years, with outbreaks of Salmonella Enteritidis infection associated with raw shell eggs continuing to be a common cause of food borne illness.

The FSA survey was carried out by the Health Protection Agency (HPA) Centre for Infections Department of Gastrointestinal Infections, HPA London Food, Water, and Environmental Microbiology Services Laboratory, Chester Food and Environmental Microbiology Services, and Local Authorities

The final report for the non-UK retail egg survey can be found at <http://www.food.gov.uk/news/newsarchive/2006/nov/eggs>.

Referenes

1. Food Standards Agency. FSA surveys non-UK eggs for salmonella. (Press release). London: FSA, 15 November 2006.Available at: <http://www.food.gov.uk/news/newsarchive/2006/nov/eggs>. Accessed 10 November 2006.

2. Health Protection Agency. Salmonella Enteritidis infection in England and Wales – update from a multi-Agency national outbreak control team. Commun Dis Rep CDR Wkly [serial online] 2005 [accessed 10 November 2006].; 15(42): News. Available at: http://www.hpa.org.uk/cdr/archives/archive05/News/news4205.htm#S_ent.

3. Health Protection Agency. Public Health Investigation of Salmonella Enteritidis in raw shell eggs in England and Wales. Eurosurveillance Weekly [serial online] 2002 [Accessed 31 October 2006];
6(50): 021212. Available at: http://www.eurosurveillance.org/ew/2002/021212.asp#4

4. Fisher ISF.. Dramatic shift in the epidemiology of Salmonella enterica serotype Enteritidis phage types in Western Europe, 1998-2003 – Results from the Enter-net International Salmonella Database. Euro Surveill 2004; 9: 43-5.

5. ElsonR , Little, CL.Mitchell, RT. Salmonella spp. and raw shell eggs: results of a cross-sectional study of contamination rates and egg safety practices in the United Kingdom catering sector in 2003.
J Food Prot 2005; 68: 256-64.

6. Food Standards Agency. Report of the Survey of Salmonella Contamination of UK Produced Shell Eggs on Retail Sale. London: Food Standards Agency; 2004. Available at: http://www.food.gov.uk/multimedia/pdfs/fsis5004report.pdf

7. European Food Safety Authority. Preliminary report on the analysis of the baseline study on prevalence of Salmonella in laying hen flocks of Gallus gallus. The EFSA Journal 2006; 81:1-71.

8. Food Standards Agency. Eat well, be well – Eggs. In: Food Standards Agency website [online] [Accessed 10 November 2006]. London. Available at http://www.eatwell.gov.uk/healthydiet/nutritionessentials/eggsandpulses/eggs/

9. Food Standards Agency. Eggs – what caterers need to know. In: Food Standards Agency website [online]. London. Available at http://www.food.gov.uk/multimedia/pdfs/eggleaflet.pdf