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  Laboratory confirmed case of toxigenic Corynebacterium ulcerans
  
• Cluster of malaria cases from northern Goa – update

 

Laboratory confirmed case of toxigenic Corynebacterium ulcerans

On 15 February 2007, the Respiratory and Systemic Infection Laboratory confirmed isolation of a toxigenic Corynebacterium ulcerans from a pharyngeal sample taken from a middle-aged man from North Yorkshire. His symptoms included a five week history of pharyngitis, laryngitis, fever, and abdominal pain. He had been seen by his GP a week previously when the pharyngeal swabs were taken.

The North Yorkshire HPU undertook contact tracing, liaison with the family, the GP, and HPA Centre for Infections. The index case reported no relevant risk factors in particular no history of foreign travel, or the consumption of unpasteurised dairy products or farm visits, although the family did have pets. The patient was given a 14 day course of erythromycin and will be offered booster vaccination upon full recovery. Pharyngeal swabs were taken from the household contacts; they were given a seven day course of erythromycin and offered vaccine boosters. The contacts were excluded from school and work pending laboratory investigations. In addition, local veterinary services obtained pharyngeal swabs from the three family pets.

Samples from the human and animal contacts of the index case were negative. The index case and three contacts had no further symptoms and have remained well. Further investigation (molecular typing) of the original isolate is currently being undertaken by the Streptococcus and Diphtheria Reference Unit (SDRU). Current evidence is inconclusive as to the exact origin of this case.

Toxigenic C. ulcerans is a documented cause of diphtheria. Cases of diphtheria are rare in the United Kingdom (UK) since mass immunisation began in 1942. Cattle are a known reservoir for C.ulcerans (1). Risk factors for people include consumption of unpasteurised dairy products or contact with cattle or farm animals. None of these risk factors have been identified for many of the recent cases of C. ulcerans in the UK, however, so questions remain about its source [2]. From 2002 to date the organism has also been isolated from several domestic cats and dogs with respiratory discharges from both the UK and other northern European countries, including France, Germany, and the Netherlands, suggesting a possible novel reservoir for this organism [3,4]. Although person to person spread of C. ulcerans hardly ever occurs, it has been a possible route of transmission in the UK [3] and therefore, it is recommended that close contacts should be treated similarly to contacts of cases of infection with toxigenic C. diphtheriae [3].

References
1. General Information – Diphtheria. HPA Website [online] .London: Health Protection Agency, 2006. [accessed 6 March 2007]. Available at <http://www.hpa.org.uk/infections/topics_az/diphtheria/gen_info.htm>.

2. HPA. A case of diphtheria caused by toxigenic Corynebacterium ulcerans. Commun Dis Rep CDR Wkly [serial online] 2006 [accessed 6 March 2007]; 16(4): news. Available at <http://www.hpa.org.uk/cdr/archives/archive06/News/news0406.htm#dip>

3. Begg NT, Bonnet JM. Control of diphtheria: guidance for consultants in communicable disease control. Commun Dis Public Health 1999; 2(4): 242-9. Available at<http://www.hpa.org.uk/cdph/issues/CDPHVol2/no4/guidelines.pdf>.

4. De Zoysa A, Hawkey PM, Engler K, George R, Reilly W, Taylor D, et al. Characterization of toxigenic Corynebacterium ulcerans strains isolated from humans and domestic cats in the United Kingdom. J Clin Microbiol, 2005; 43: 4377-81.

Cluster of malaria cases from northern Goa – update

On 26 January 2007 the Health Protection Report reported a malaria case diagnosed on 29 December 2006 in a traveller from the United Kingdom (UK) who had visited Northern Goa [1]. A cluster of cases was also seen in European travellers to Goa which coincided with increased rainfall in Goa [2]. The UK malaria guidelines [3] were therefore temporarily updated to advise that travel advisors should highlight the risk of malaria, instruct on the use of mosquito bite avoidance measures, and recommend malaria chemoprophylaxis to those travellers who will be visiting Goa, particularly areas north of Panaji, who will be remote from medical care.

Since this update there have been four more reported cases of Plasmodium falciparum malaria in UK travellers returning from Goa. These were confirmed by the Malaria Reference Laboratory (MRL) between 4 January and 15 February 2007. The cases were seen in one male and three females, ranging from 16 to 68 years of age. They all travelled separately and stayed in a range of accommodation from a holiday resort, to one staying with friends and relatives. None of the cases had taken chemoprophylaxis. Insect repellent was known to have been used by one patient who was mainly based in a resort.

In 2006 the MRL received reports of 11 cases of falciparum malaria imported from India (one from each of Goa and Assam, and nine with state unspecified); in 2005 there were nine reports, all with state unspecified. Since late 2006, when the updated ACMP guidelines [3] were published online, the MRL has been undertaking enhanced surveillance of malaria cases imported from India to determine the state(s) visited.

The situation will continue to be monitored closely for any change in transmission which should decrease after the period of increased rainfall ends.

The current advice for travellers to Goa from the UK is stated below:
Based on the additional cases of falciparum malaria reported from Goa, the Advisory Committee on Malaria Prevention in UK travellers now advises that travel health advisors should highlight the risk of malaria, instruct on the use of mosquito bite avoidance measures [4], and consider recommending malaria chemoprophylaxis to those travellers who will be visiting Goa.

The recommended chemoprophylaxis is chloroquine plus proguanil. Alternatives are mefloquine, atovaquone plus proguanil (Malarone ®), or doxycycline.

All travellers to Goa should also use mosquito bite avoidance measures and be aware of the risk of malaria. This also applies to the other low-risk regions of India as listed in the guidelines [3].

All travellers should seek medical attention promptly if they become unwell and inform their doctor that they have been in a malarious area. The healthcare worker should consider malaria in every ill patient who has recently returned from the tropics. For those with a fever on return from the tropics, the illness should be considered to be malaria until proven otherwise.

References

1. Health Protection Agency. Cluster of malaria cases from northern Goa. Health Protection Report 2007 [accessed 6 March 2007]; 01(02): news.. Available at <http://www.hpa.org.uk/hpr/archives/2007/hpr0207.pdf>.

2. Jelinek T, Behrens R, Bisoffi Z, Bjorkmann A, Andersen P, Blaxhult A, et al. Recent cases of falciparum malaria imported to Europe from Goa, India, December 2006-January 2007. Eurosurveillance [serial online] 2007 [accessed 12 January 2007];12(1):E070111.1. Available from <http://www.eurosurveillance.org/ew/2007/070111.asp#1>.

3. Chiodini P, Hill D, Lalloo D, Lea G, Walker E, Whitty C, Bannister B on behalf of the Advisory Committee for Malaria Prevention in UK Travellers (ACMP). Guidelines for malaria prevention in travellers from the United Kingdom. Health Protection Agency: London; 2007. Available at <http://www.hpa.org.uk/infections/topics_az/malaria/guidelines.htm>.

4. The National Travel Health Network and Centre (NaTHNaC). Insect bite avoidance [online] [accessed 9 January 2007]. London: NaTHNaC, 2006. Available at <http://www.nathnac.org/pro/factsheets/iba.htm>.