News Archives |
Volume 2 No 19; 9 May 2008
Death in a child infected with toxigenic Corynebacterium diphtheriae in London
On 2 May 2008 an isolate of Corynebacterium diphtheriae var mitis, from a school age child, was reported to the Health Protection Agency in London. The child had died on 30 April. The isolate was confirmed as toxigenic on 4 May by the HPA's Respiratory and Systemic Infection Laboratory.
The child had been admitted to hospital on 27 April after a three to four day illness and did not have a classical presentation of diphtheria. A diagnostic bronchoalveolar lavage was carried out from which C.diphtheriae was grown, the result being known only after the death of the child. The most likely explanation for the child's death is the infection with diphtheria.
The child was not immunised against diphtheria and had moved to the UK from Europe in late 2007. One family member had travelled to Africa earlier this year, returning to the UK about one month before the child was unwell. There was no other history of travel since late 2007.
The full public health investigation was initiated on the afternoon of 4 May, although preliminary information was available from a public health assessment conducted following the original report two days earlier.
Close contacts were identified and included:
- family contacts;
- a small number of school classmates and teachers with very close contact;
- hospital staff with prolonged close contact, or undertaking droplet-producing procedures;
- other inpatients with prolonged close contact, for example sharing the same hospital bay for several hours or overnight.
In line with current guidance, all close contacts had nasal and pharyngeal swabs, were offered erythromycin chemoprophylaxis and diphtheria immunisation. Swabs, received to date, from family and hospital contacts are negative.
Diphtheria became rare in England and Wales following the introduction of mass immunisation in 1942 when the average number of notifications of diphtheria was about 60,000 with 4,000 deaths. Between 1986 and 1997 there were eight cases of classical respiratory diphtheria caused by toxigenic C. diphtheriae, all of whom had a history of travel to endemic countries, and none since caused by this organism. The last death from C. diphtheriae in 1994 was in a child who became infected in Pakistan [1].
Classical respiratory diphtheria can also be caused by Corynebacterium ulcerans and cases which have occurred in England and Wales since 1997 have all been due to this organism rather than C. diphtheriae. There were two deaths from respiratory diphtheria caused by C. ulcerans ; one in 2000 and one in 2006 [2,3].
Primary immunisation coverage (three doses) in the UK for children aged two has been 94% since 2001, just below the World Health Organization target of 95%. However, there is regional variation and coverage in London is lower than elsewhere in the UK with 86% coverage for 2006/07.
References
1. PHLS. A case of diphtheria from Pakistan. Comm Dis Rep Wkly 1994;4(27):173. Available at http://www.hpa.org.uk/cdr/archives/1994/cdr3794.pdf
2. PHLS. Three cases of toxigenic Corynebacterium ulcerans infection. Comm dis Rep Wkly 2000;10(6):49,52. Available at http://www.hpa.org.uk/cdr/archives/2000/cdr0600.pdf
3. HPA. A case of diphtheria caused by Corynebacterium ulcerans. Health Protection Report 2006;16(5). Avaiable at http://www.hpa.org.uk/cdr/archives/archive06/News/news0406.htm#dip
Further information
Diphtheria Q&As on HPA website
Update on the investigation of Hepatitis E on a cruise ship
The occurrence of four cases of hepatitis E on a cruise ship was reported previously [1]. This is a very unusual event and a cross-Agency investigation led by CfI and coordinated through the regional hepatitis leads is underway to identify additional cases of hepatitis E.
Letters were sent to all passengers who were on the cruise asking them to participate in the investigation whether they were ill or not. Those who agreed to participate were asked to give a sample of blood and to complete a questionnaire. There was an overwhelming response with more than 1100 passengers volunteering to participate before recruitment was closed. Time was limited because blood samples had to be taken within a few weeks of exposure in order to reliably detect specific IgM. Blood samples and questionnaires are currently being analysed at CfI.
To date seven cases (the four original cases and three others through case finding) of hepatitis E have been identified. All these are in older patients (aged 68-81 years) with onset dates between 8 and 23 March 2008. All were serologically confirmed by the laboratory at CfI as acute Hepatitis E. Viral RNA was recovered from three cases and all were genotype 3. This virus clusters with European strains and is distinguishable from the majority of isolates from indigenously acquired infections and from UK pigs.
References
1. http://www.hpa.org.uk/hpr/archives/2008/news1408.htm#hepE
Reminder on vaccination requirements for those working with imported animals
Following the incident of rabies in an imported puppy held in a UK quarantine centre reported here last week [1], the HPA has taken the opportunity to remind animal rescue charity, quarantine and animal reception centre workers of the importance of immunisation.
The Agency has written to all quarantine centres, border inspection posts, live animal reception centres and animal rescue charities in England reminding them of the need for their workers to be immunised against rabies.
The HPA letter [2] stresses the need for those working in these areas to receive public health education and be made aware of the risks associated with this type of work. It sets out details of the immunisation schedule which should be followed by those at regular risk of exposure to rabies and which has been contained for many years in the Department of Health's immunisation guide, the Green Book [3].
2. HPA letter to quarantine centres
3. Immunisation against infectious disease - "The Green Book"