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Volume 2 No 38; 19 September 2008

A case of toxigenic Corynebacterium diphtheriae in London

In 12 September 2008 an isolate of Corynebacterium diphtheriae var mitis, from a school age child, was reported to the Health Protection Agency (HPA) in London. The isolate was confirmed as toxigenic on 13 September by the HPA's Respiratory and Systemic Infection Laboratory.

The case had become unwell with fever, sore throat and generalised muscle aches after a recent travel to Asia. He was seen by his GP on 8 September. Throat swabs were taken and sent to the local laboratory. The patient was started on penicillin V and advised to be isolated at home. The patient had travelled with other members of his family, who were well.

Following the identification of a toxigenic strain, a public health investigation was initiated on the afternoon of 13 September. The immunisation status of the case and the family members could not be confirmed although the child was thought to have received some diphtheria vaccinations as a young child.

Close contacts were identified as the family members and their family doctor. In line with current guidance, close contacts had nasal and pharyngeal swabs taken, were offered erythromycin 500 mg four times a day for seven days as chemoprophylaxis, and diphtheria immunisation. All swabs from family contacts have since tested negative.

Diphtheria became rare in England and Wales following the introduction of mass immunisation in 1942 when the average number of notifications was about 60,000, with 4,000 deaths. Between 1986 and 1997 there were eight cases of classical respiratory diphtheria (with pseudomembrane) caused by toxigenic C. diphtheriae, all of whom had a history of travel to endemic countries. No further cases had been caused by this organism until the death, earlier this year, from C. diphtheriae, of an unimmunised child who had moved to the UK from Europe in late 2007 [1].

The current case presented with mild respiratory symptoms, compatible with partial immunisation. It is important to raise awareness among clinicians that mild diphtheria can present without a pseudomembrane and to include diphtheria in differential diagnoses for travellers to or from epidemic or endemic areas. Individuals travelling to such areas should ensure they are fully immunised with diphtheria-containing vaccine before travelling.

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%. There is, however, regional variation and coverage in London is lower than elsewhere in the UK with 86% coverage for 2006/07.

References
1. HPA. Death in a child infected with toxigenic Corynebacterium diphtheriae in London. Health Protection Report HPR Wkly [serial online] 2008 [cited 18 September 2008]; 2(19): news. Available at: http://www.hpa.org.uk/hpr/archives/2008/news1908.htm#diph.

Further information
HPA website: Frequently asked questions about diphtheria.

New guidelines on HIV testing in high-prevalence areas

New guidelines from the British HIV Association (BHIVA), the British Association for Sexual Health and HIV (BASHH) and the British Infection Society (BIS) [1] aim to increase the offer of HIV testing that was recommended by the Chief Medical Officer in September 2007 [2]. On the assumption that the prevalence of HIV infections that have already been diagnosed is a good indicator of the prevalence of undiagnosed HIV infection in a particular place, the new guidelines state that consideration should be given to offering HIV testing to all men and women aged 15 to 59 registering in general practice as well as to all general medical admissions in areas where the prevalence of diagnosed HIV infections is greater than two in 1,000.

To assist local discussions about implementing the guideline, the Health Protection Agency has used the latest available data (from the Survey Of Prevalent HIV Infections that have been Diagnosed (SOPHID) [3]) to show the primary care trusts (PCTs) in England where the prevalence of diagnosed HIV infection exceeded two adults per 1,000 population (aged 15-59 years) in 2007. Table 1 lists the PCTs with an overall prevalence above this threshold. In addition, table 2 shows other PCTs in which the prevalence is below the two per 1,000 threshold overall, but is above it in a constituent local/unitary authority of the PCT.

The 42 PCTs listed in the two tables account for 20% of the English population aged 15-59 years and 60% of all persons accessing HIV-related care in England in this age group. The majority of these PCTs are in London. PCTs outside London include Brighton and Hove, Manchester, Blackpool, Salford, Bournemouth and Eastbourne, which have historically had a relatively high prevalence of diagnosed HIV infection. Also included are PCTs which have experienced more recent increases. In areas around London, this includes: Luton, Watford, Harlow, Southend-on-Sea, Reading, Slough and Crawley; in the Midlands: Birmingham, Leicester, Nottingham and Northampton.

A universal offer of HIV testing is estimated to be cost-effective where the diagnostic rate of HIV is greater than one per 1,000 [4-7]. However, the evidence on the cost effectiveness of expanding HIV testing in the population of England is sparse. Therefore, local innovations to expand HIV testing should be the subject of formally designed service evaluations and be sufficiently large so as to better inform the implementation of the guidelines and the development of national policy.

Table 1. Primary care trusts in England where the prevalence of diagnosed HIV infection exceeded two adults per 1,000 population (aged 15-59 years) in 2007.

Primary Care Trust
Residents accessing HIV-related care (15-59)

Resident population*
(1000s) (15-59)

Diagnosed HIV
prevalence per 1,000
Rate
Rank

London

 

 

 

 

Barking and Dagenham

427

101.7

4.20

19

Barnet

507

205.5

2.47

31

Brent Teaching

676

179.8

3.76

21

Camden

1,181

169.0

6.99

9

City and Hackney Teaching

1,132

147.1

7.70

5

Croydon

824

214.4

3.84

20

Ealing

549

204.5

2.68

28

Enfield

587

178.0

3.30

23

Greenwich Teaching

711

144.2

4.93

14

Hammersmith and Fulham

906

122.6

7.39

6

Haringey Teaching

1,024

155.0

6.61

11

Hillingdon

336

157.6

2.13

32

Hounslow

516

147.2

3.51

22

Islington

1,110

136.1

8.16

3

Kensington and Chelsea

943

121.4

7.77

4

Lambeth

2,339

196.2

11.92

1

Lewisham

1,098

176.5

6.22

12

Newham

1,175

166.6

7.05

8

Redbridge

404

159.4

2.53

29

Southwark

1,830

194.5

9.41

2

Sutton and Merton

619

249.9

2.48

30

Tower Hamlets

836

152

5.50

13

Waltham Forest

654

145.1

4.51

16

Wandsworth

880

204.4

4.31

18

Westminster

1,155

170.0

6.79

10

Out of London

 

 

 

 

Blackpool

272

82.4

3.30

24

Bournemouth and Poole §

354

176.3

2.01

34

Brighton and Hove City

1,236

167.5

7.38

7

Heart Of Birmingham ¶

493

171.2

2.88

26

Leicester City

535

189.0

2.83

27

Luton

513

118.2

4.34

17

Manchester

1,459

312.8

4.66

15

Nottingham City

412

197.1

2.09

33

Salford

427

137.0

3.12

25

* Office for National Statistics population estimates for local/unitary authorities aggregated where appropriate to match primary care trust boundaries.
Numbers accessing care, population estimates and diagnosed HIV prevalence in the City of London UA were 45, 5,700 and 7.89 per 1,000, and in Hackney UA were 1,087, 141,400 and 7.69 per 1,000.
Numbers accessing care, population estimates and diagnosed HIV prevalence in the Sutton UA were 208, 116,000 and 1.79 per 1,000, and in Merton UA were 411, 133,700 and 3.07 per 1,000.
§ Numbers accessing care, population estimates and diagnosed HIV prevalence in the Bournemouth LA were 257, 98,500 and 2.61 per 1,000, and in Poole LA were 97, 77,800 and 1.25 per 1,000.
¶ Office for National Statistics 2006 population estimate for Heart of Birmingham Teaching PCT.

Table 2. Primary care trusts in England where the prevalence of diagnosed HIV infection exceeded two adults per 1,000 population (aged 15-59 years) in a constituent local/unitary authority but not in the primary care trust overall in 2007.

Primary care trust

Local authority

Residents accessing HIV-related care (15-59)

Resident population* (1,000s)(15-59)

Diagnosed HIV prevalence per 1,000

Berkshire East

Slough

282

77.4

3.64

Berkshire West

Reading

252

95.9

2.63

East Sussex Downs & Weald

Eastbourne

119

52.3

2.28

Northamptonshire

Northampton

281

128.2

2.19

South East Essex

Southend-on-Sea

259

93.8

2.76

West Essex

Harlow

101

48.0

2.10

West Hertfordshire

Watford

127

50.7

2.50

West Sussex

Crawley

126

62.8

2.01

* Office for National Statistics population estimates for local/unitary authorities.

There are over 77,000 people living with HIV in the UK , a third of whom remain unaware of their infection, potentially putting their sexual partners at risk of HIV [8]. Furthermore, a third of all newly diagnosed individuals each year are diagnosed late (CD4 cell counts <200 cells per cubic mm) and are at increasing risk of early death [8-10]. The expected benefits of increased HIV testing are a reduction in late HIV diagnoses (and in consequent mortality) and a reduction in the number of people unaware of their HIV infection and consequent HIV transmission [9-11].

In addition to considering wider HIV testing policies in areas of high prevalence, the new guidelines also recommend:

A. Universal offer of an HIV test in each of the following settings:
•  Genitourinary medicine (GUM) or sexual health clinics,
•  Antenatal services,
•  Termination of pregnancy services,
•  Drug dependency programmes,
•  Healthcare services for those diagnosed with tuberculosis, hepatitis B, hepatitis C or lymphoma.

B. HIV testing should be also offered and recommended as part of routine care to the following patients:
•  Any patient presenting for healthcare where HIV, including primary HIV infection, enters the differential diagnosis,
•  All men and women diagnosed with a sexually transmitted infection,
•  All sexual partners of HIV-infected men and women,
•  All men that have disclosed sexual contact with other men,
•  All female sexual contacts of men who have sex with men,
•  All patients reporting a history of injecting drug use,
•  All men and women known to be from a country of high HIV prevalence (>1% [12])
•  All men and women who report sexual contact abroad or in the UK with individuals from countries of high HIV prevalence [12].

C. For the following groups in accordance with existing Department of Health guidance:
•  Blood donors,
•  Dialysis patients,
•  Organ transplant donors and recipients,
•  All patients requiring immunosuppressant therapy.

References
1. BHIVA website: http://www.bhiva.org/; BASHH website: http://www.bashh.org; BIS website: http://www.britishinfectionsociety.org/
2. Chief Medical Officer, Professor Sir Liam Donaldson. Improving the detection and diagnosis of HIV in non-HIV specialties including primary care, 2007. London: Department of Health, 2007. http://www.medfash.org.uk/publications/documents/Improving_the_detection_&_diagnosis
_of_HIV_13_09_07.pdf.
3. HPA SOPHID website: http://www.hpa.org.uk/web/HPAweb&Page&HPAwebAutoListName/Page/1201094588844
4. Walensky RP, Weinstein MC, Kimmel AD, Seage GR, III, Losina E, Sax PE et al. Routine human immunodeficiency virus testing: an economic evaluation of current guidelines. Am J Med 2005; 118: 292-300.
5. Paltiel AD, Weinstein MC, Kimmel AD, Seage GR, III, Losina E, Zhang H et al. Expanded screening for HIV in the United States - an analysis of cost-effectiveness. N Engl J Med 2005; 352: 586-95.
6. Sanders GD, Bayoumi AM, Sundaram V, Bilir-S-Pinar, Neukermans CP, Rydzak CE et al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. N Engl J Med 2005; 352: 570-85.
7. Walensky RP, Freedberg KA, Weinstein MC, Paltiel AD. Cost-effectiveness of HIV testing and treatment in the United States. Clin Infect Dis 2007; 45 Suppl 4: S248-S254.
8. The UK Collaborative Group for HIV and STI Surveillance. Testing Times - HIV and other sexually transmitted infections in the United Kingdom: 2007. London: Health Protection Agency Centre for Infections.
9. Chadborn TR, Baster K, Delpech VC, Sabin CA, Sinka K, Rice BD et al. No time to wait: how many HIV-infected homosexual men are diagnosed late and consequently die? (England and Wales, 1993-2002). AIDS 2005; 19: 513-20.
10. Chadborn TR, Delpech VC, Sabin CA, Sinka K, Evans BG. The late diagnosis and consequent short-term mortality of HIV-infected heterosexuals (England and Wales, 2000-2004). AIDS 2006; 20: 2371-9.
11. Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS 2006; 20: 1447-50.
12. UNAIDS website: Latest epidemiology data http://www.unaids.org/en/KnowledgeCentre/HIVData/Epidemiology/latestEpiData.asp.

Latest figures show MRSA bloodstream infections falling

The latest data from the mandatory surveillance of MRSA bloodstream infections show that there were 836 cases reported in England during the April to June quarter of 2008 [1]. This is a 14% decrease on the previous quarter (January to March 2008) when 969 reports were received and a 36% reduction in the corresponding quarter of 2007 (April to June) when 1,306 reports were received.

There was a 30% decrease in the number of reported MRSA bacteraemias received in the financial year 2007/08 compared to the financial year 2006/07, with a decease in the rate from 1.67 to 1.16 cases per 10,000 bed-days.

Quarterly reports of MRSA bacteraemia: April 2006 to June 2008

Quarter

Number of MRSA bloodstream infection reports

April 2006 June 2006

1,742

July 2006 September 2006

1,651

October 2006 December 2006

1,543

January 2007 March 2007

1,447

April 2007 June 2007

1,306

July September 2007

1,082

October December 2007

1,091

January 2008 March 2008

969

April 2008 June 2008

836

References
1. Quarterly figures for MRSA bacteraemia derived from mandatory surveillance (April to June 2008). Available at: http://www.hpa.org.uk/web/HPAweb&Page&HPAwebAutoListName/Page/1191942126541.