News Archives |
Volume 2 No 17; 25 April 2008
-
France declares loss of rabies free status: implications for British travellers
- Mandatory MRSA bacteraemia and C. difficile infection data published
Malaria imported into the United Kingdom in 2007: implications for those advising travellers
Latest data on malaria imported into the United Kingdom (UK), based on figures for 2007 reported to the Health Protection Agency (HPA) Malaria Reference Laboratory, indicate that a significant cause of infections is UK travellers' failure to take prophylaxis. There was, nevertheless, a small fall in reported cases in 2007 compared with the previous year.
A full, more-detailed analysis of the data will be provided in the biennial travel report, to be published later in the year. (Details of methods of data collection for malaria are presented in the HPA 2002 baseline report [1]).
Figure 1. Imported malaria cases (with P. falciparum cases) in the UK: 1987- 2007
There were 1548 cases of malaria reported in 2007, a slight decline on the 1758 cases of malaria reported by this stage in 2006. (It is possible that a few cases have still to be reported). This may be random variation, but there is evidence of a recent decline in malaria transmission in some malaria-endemic countries visited by travellers, especially in East Africa, which could have an impact on UK imported cases [2]. Over 70% of malaria cases are caused by (the potentially fatal) Plasmodium falciparum and the high proportion of falciparum malaria has been sustained over many years, reflecting the fact most malaria imported to the UK is acquired in Africa. The overall trend towards an increase in malaria numbers over the last 20 years is likely to be due mainly to a steady increase in travel to malaria-endemic countries over this period rather than increased risk per travel episode. The breakdown of malaria cases reported by region of travel and parasite species is shown in table 1.
Table 1. Cases of malaria by species of parasite and primary region of travel, United Kingdom: 2007
Geographic Area |
P.falciparum. |
P.vivax |
P.malariae |
P.ovale |
Pf/Pv |
Pf/Pm |
Pf/Po |
Pm/Pv |
Total |
North Africa |
- |
- |
- |
- |
- |
- |
- |
- |
0 |
Central Africa |
23 |
- |
2 |
2 |
- |
- |
- |
- |
27 |
East Africa |
92 |
8 |
10 |
11 |
- |
1 |
- |
1 |
123 |
Southern Africa |
31 |
1 |
1 |
1 |
- |
- |
- |
- |
34 |
West Africa |
719 |
2 |
11 |
67 |
1 |
3 |
5 |
- |
808 |
Africa - unspec. |
12 |
1 |
- |
1 |
- |
- |
|
- |
14 |
Middle East |
1 |
- |
- |
- |
- |
- |
- |
- |
1 |
| Asia | 22 |
168 |
- |
1 |
2 |
- |
- |
- |
193 |
Asia -unspecified |
- |
1 |
- |
- |
- |
- |
- |
- |
1 |
Far East/SE Asia |
1 |
3 |
- |
- |
- |
- |
- |
- |
4 |
Far East - unspec. |
- |
1 |
- |
- |
- |
- |
- |
- |
1 |
Central/S. America |
2 |
11 |
- |
1 |
- |
- |
- |
- |
14 |
Oceania |
1 |
14 |
- |
- |
- |
- |
- |
- |
15 |
Not given |
235 |
46 |
6 |
24 |
1 |
1 |
- |
- |
313 |
| Total | 1139 |
256 |
30 |
108 |
4 |
5 |
5 |
1 |
1548 |
Five deaths from malaria in 2007 have been reported to date, one from India, the rest from Africa. Vivax malaria deaths are rare, and are often associated with co-morbidity. There is a small variation in the number of deaths from malaria in the UK every year but the number for 2007 is broadly similar to the annual average since 2000.
Among patients with malaria where the history of prophylaxis was obtained, 704/844 (83%) had not taken prophylaxis, and a high proportion of the remainder took prophylaxis not recommended for their travel destination by the HPA Advisory Committee on Malaria Prevention in UK Travellers (ACMP) [3]. This high proportion is similar to recent years. It is clear that some groups are at particular risk of acquiring malaria and are not being reached by health messages about the importance of antimalarial prophylaxis. The burden of falciparum malaria falls heavily on those of African and south Asian ethnicity [4]. Of those who had malaria diagnosed in the UK, where ethnicity was known, 144 were reported as white British, compared with 1001 who were reported as African or of African descent and 190 reported as south Asian or of south Asian decent. The overall trend has been for the proportion of malaria both in those of south Asian descent and travelling to south Asia to decrease, whilst the proportion in those of African descent to increase over time.
Among those who were travellers from the UK (rather than normally resident in an endemic area) where reason for travel was known, 549/770 (72%) were visiting friends and relatives (table 2). The ratio of malaria in UK residents visiting friends and relatives compared with malaria cases acquired in holiday travellers was 5.1:1. As with all routinely collected data, exact figures should be treated with caution. It seems likely that those travelling to visit friends and relatives are either not seeking or able to access medical advice on malaria prevention before they travel, or they are not being given good advice, or are not adhering to it as they do not perceive the risk to be as great to them as to the holidaying public; probably all these contribute. Targeting these groups, and their healthcare providers, should be considered a priority for health promotion and education.
Table 2. Cases of malaria by stated reason for travel, UK: 2007
Population group |
P.f. |
P.v. |
P.m. |
P.o. |
Pf/Pv |
Pf/Pm |
Pf/Po |
Pm/Pv |
Total |
New entrant |
40 |
25 |
2 |
10 |
- |
- |
- |
1 |
78 |
Visiting family in country of origin |
455 |
51 |
10 |
29 |
- |
1 |
3 |
- |
549 |
UK citizen living abroad |
14 |
4 |
- |
1 |
1 |
- |
- |
- |
20 |
Civilian sea/air crew |
2 |
- |
- |
- |
- |
- |
- |
- |
2 |
British armed services |
- |
4 |
- |
1 |
- |
- |
- |
- |
5 |
Business/professional travel |
35 |
8 |
2 |
5 |
- |
- |
- |
- |
50 |
Foreign student studying in UK |
24 |
6 |
1 |
3 |
- |
- |
1 |
- |
35 |
Holiday travel |
58 |
41 |
2 |
7 |
- |
- |
- |
- |
108 |
Foreign visitor ill while in UK |
56 |
27 |
4 |
7 |
1 |
1 |
- |
- |
96 |
Children visiting parents living abroad |
- |
- |
- |
1 |
- |
- |
- |
- |
1 |
Not stated |
455 |
90 |
9 |
44 |
2 |
3 |
1 |
- |
604 |
Malaria, an almost completely preventable disease but one which can be fatal, remains a significant issue UK travellers. Failure to take prophylaxis is associated with most cases of malaria in UK residents travelling to malarial areas. There is continuing evidence that those of African or Asian ethnicity going to visit friends and relatives are at increased risk and those providing advice should engage with these travellers wherever possible. Recently updated guidelines [5] should assist clinicians in helping travellers to make rational decisions about protection against malaria.
References
1. Health Protection Agency (HPA). Illness in England, Wales, and Northern Ireland associated with foreign travel – a baseline report to 2002. London: HPA; 2004. Available at: http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1203496904956?p=1158945066450.
2. Bhattarai A, Ali AS, Kachur SP et al. Impact of artemisinin-based combination therapy and insecticide-treated nets on malaria burden in Zanzibar. PLoS Med. 2007 Nov 6;4(11):e309.3. See http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1195733830209.
4. Health Protection Agency. Migrant Health: Infectious diseases in non-UK born populations in England , Wales and Northern Ireland. A baseline report 2006. London: Health Protection Agency Centre for Infections. 2006.
5. Chiodini P, Hill D, Lalloo D, Lea G, Walker E, Whitty C and Bannister B. Guidelines for malaria prevention in travellers from the United Kingdom. London, Health Protection Agency, January 2007. Available at http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1195733823080?p=1191942128258.
France declares loss of rabies free status: implications for British travellers
Following the recent rabies incident in France [1] involving an illegally imported dog, with transmission to two indigenous dogs, the French Ministry of Agriculture has declared that France has lost its rabies-free status.
French officials have confirmed that there is a low but increased risk of rabies in three previously identified areas of France (Gers, Grandpuits and Calvados) [2]. Elsewhere the risk of rabies is considered to be extremely small, but cannot be completely ruled out.
Implications for British travellers to France
All travellers to France are reminded of the need to avoid contact with animals where possible.
Implications for travellers to the affected regions
• For travellers to Gers (Auch city and surroundings), Seine-et-Marne (environs of Grandpuits) and Calvados (Lisieux city and Thury Harcourt village and their surroundings)
There is a low but increased risk of exposure to rabies from animal exposures (bites, scratches and licks around the eyes, mouth or on open wounds) in these areas. Those individuals exposed as above should seek prompt medical assessment to determine whether post-exposure prophylaxis (PEP) is required, either from the local rabies clinic in France [3] or, in the case of British travellers, from their GP on their return to the UK .
• For travellers to other parts of France
The risk of rabies is considered to be extremely low however exposed travellers are advised to seek advice from the local rabies clinic as above, or, in the case of British travellers, if not possible from their GP on return to the UK .
References
1. HPA. Canine rabies in France, Health Protection Report [serial online] 2008; 2 (10, 7): news. http://www.hpa.org.uk/hpr/archives/2008/news1008.htm
2 . French Ministry of Agriculture guidance for vets following the recent canine cases (in French), 19 March 2008 [accessed 24 April 2008], http://agriculture.gouv.fr/sections/publications/bulletin-officiel/2008/bo-n-12-du-21-03-08/note-d-information-dgal6060/downloadFile/FichierAttache_1_f0/DGALO20088008Z.pdf?nocache=1206087673.53
3. Addresses of French rabies clinics are available at:http://cmip.pasteur.fr/cmed/voy/Car2007.pdf
Mandatory MRSA bacteraemia and C. difficile infection data published
The latest healthcare-associated infections quarterly report, for the final quarter of 2007, was published by the HPA on 24 April, suggesting a plateauing of case reports following steady falls achieved in the previous quarters of 2007 [1].
The new data comprises quarterly reports for both MRSA bacteraemia and Clostridium difficile infection collected through the mandatory surveillance systems [2].
MRSA bacteraemia
There were 1,080 episodes of MRSA bacteraemia in July-September 2007 and 1,087 in October-December. This represents a levelling out against the significant decreases in numbers seen in recent quarters. The tables and commentary also indicate special circumstances, for instance cases which had been ‘double counted' by different Trusts.
Clostridium difficile
This week also saw the publication of the October-December 2007 figures for C. difficile infection. Over this period there were 9,872 episodes of C. difficile infection in patients aged 65 years and over and 2,211 episodes of infection in patients aged 2-64 years. This is only the third quarter in which C. difficile infections in the latter age group have been published. The number of infections in the 65 years and over age group represents an 8% decrease on the previous quarter and 23% decrease on the same period in 2006.
Trusts are required to report all C. difficile positive diarrhoeal specimens processed by their laboratories, including samples taken in the community (e.g. at GP surgeries, nursing homes and PCT hospitals). Data representing specimens taken in the reporting Trust and other settings are presented separately. This indicates the patient's location when the specimen was taken and does not necessarily reflect where the infection was acquired.
Recent changes to the Department of Health's surveillance requirements will have impacted on the accuracy of the published data for C. difficile infections as the data for this scheduled publication had to be extracted before Trusts had fully completed reviewing their data. Changes were identified in the Chief Medical Officer letter dated January 2008 [3] and include changes to the episode definition; Trusts were also encouraged to add NHS number and admission date to any incomplete records. Trusts were given until by 10 March 2008 to review all their data from April 2007 in the light of these changes, but data had to be extracted for this publication before 10 March. Consequently not all reviews would have been completed. The effects of this review on the data will be more accurately reflected in the next quarterly publication in July.
References
1. Latest figures show MRSA bloodstream infections plateau, HPA press release, 24 April 2008, http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1209023435298?p=1204186170287
2. These data are available, together with commentaries and historical annual data for both organisms, and six-monthly data for MRSA bacteraemia at http://www.hpa.org.uk/infections/topics_az/hai/Mandatory_Results.htm
France declares loss of rabies free status: implications for British travellers
Following the recent rabies incident in France [1] involving an illegally imported dog, with transmission to two indigenous dogs, the French Ministry of Agriculture has declared that France has lost its rabies-free status.
French officials have confirmed that there is a low but increased risk of rabies in three previously identified areas of France (Gers, Grandpuits and Calvados) [2]. Elsewhere the risk of rabies is considered to be extremely small, but cannot be completely ruled out.
Implications for British travellers to France
All travellers to France are reminded of the need to avoid contact with animals where possible.
Implications for travellers to the affected regions
• For travellers to Gers (Auch city and surroundings), Seine-et-Marne (environs of Grandpuits) and Calvados (Lisieux city and Thury Harcourt village and their surroundings)
There is a low but increased risk of exposure to rabies from animal exposures (bites, scratches and licks around the eyes, mouth or on open wounds) in these areas. Those individuals exposed as above should seek prompt medical assessment to determine whether post-exposure prophylaxis (PEP) is required, either from the local rabies clinic in France [3] or, in the case of British travellers, from their GP on their return to the UK .
• For travellers to other parts of France
The risk of rabies is considered to be extremely low however exposed travellers are advised to seek advice from the local rabies clinic as above, or, in the case of British travellers, if not possible from their GP on return to the UK .
References
1. HPA. Canine rabies in France, Health Protection Report [serial online] 2008; 2 (10, 7): news. http://www.hpa.org.uk/hpr/archives/2008/news1008.htm
2 . French Ministry of Agriculture guidance for vets following the recent canine cases (in French), 19 March 2008 [accessed 24 April 2008], http://agriculture.gouv.fr/sections/publications/bulletin-officiel/2008/bo-n-12-du-21-03-08/note-d-information-dgal6060/downloadFile/FichierAttache_1_f0/DGALO20088008Z.pdf?nocache=1206087673.53
3. Addresses of French rabies clinics are available at:http://cmip.pasteur.fr/cmed/voy/Car2007.pdf
Mandatory MRSA bacteraemia and C. difficile infection data published
The latest healthcare-associated infections quarterly report, for the final quarter of 2007, was published by the HPA on 24 April, suggesting a plateauing of case reports following steady falls achieved in the previous quarters of 2007 [1].
The new data comprises quarterly reports for both MRSA bacteraemia and Clostridium difficile infection collected through the mandatory surveillance systems [2].
MRSA bacteraemia
There were 1,080 episodes of MRSA bacteraemia in July-September 2007 and 1,087 in October-December. This represents a levelling out against the significant decreases in numbers seen in recent quarters. The tables and commentary also indicate special circumstances, for instance cases which had been ‘double counted' by different Trusts.
Clostridium difficile
This week also saw the publication of the October-December 2007 figures for C. difficile infection. Over this period there were 9,872 episodes of C. difficile infection in patients aged 65 years and over and 2,211 episodes of infection in patients aged 2-64 years. This is only the third quarter in which C. difficile infections in the latter age group have been published. The number of infections in the 65 years and over age group represents an 8% decrease on the previous quarter and 23% decrease on the same period in 2006.
Trusts are required to report all C. difficile positive diarrhoeal specimens processed by their laboratories, including samples taken in the community (e.g. at GP surgeries, nursing homes and PCT hospitals). Data representing specimens taken in the reporting Trust and other settings are presented separately. This indicates the patient's location when the specimen was taken and does not necessarily reflect where the infection was acquired.
Recent changes to the Department of Health's surveillance requirements will have impacted on the accuracy of the published data for C. difficile infections as the data for this scheduled publication had to be extracted before Trusts had fully completed reviewing their data. Changes were identified in the Chief Medical Officer letter dated January 2008 [3] and include changes to the episode definition; Trusts were also encouraged to add NHS number and admission date to any incomplete records. Trusts were given until by 10 March 2008 to review all their data from April 2007 in the light of these changes, but data had to be extracted for this publication before 10 March. Consequently not all reviews would have been completed. The effects of this review on the data will be more accurately reflected in the next quarterly publication in July.
References
1. Latest figures show MRSA bloodstream infections plateau, HPA press release, 24 April 2008, http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1209023435298?p=1204186170287
2. These data are available, together with commentaries and historical annual data for both organisms, and six-monthly data for MRSA bacteraemia at http://www.hpa.org.uk/infections/topics_az/hai/Mandatory_Results.htm