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Volume 2 No 43; 24 October 2008

Identification in the UK of the first oseltamivir-resistant influenza A(H1N1) virus of the 2008/09 season

Since week 34/08, several sporadic, laboratory-confirmed influenza infections have been detected in the United Kingdom (UK): isolates have included influenza A(H3N2), A(H1N1) and influenza B. The first oseltamivir resistant influenza A(H1N1) for the 2008/09 season has also been identified in the UK through the HPA sentinel GP virological surveillance scheme. The virus contains the H274Y mutation but remains sensitive to zanamivir and amantadine, and is antigenically similar to the H1N1 reference strain A/Brisbane/59/2007, which is included in this season's influenza vaccine. Antiviral susceptibility tests on A(H3) isolates showed that they are sensitive to oseltamivir and zanamivir.

With laboratory-confirmed sporadic influenza infections of various strains in circulation at the start of this autumn season, it is important to emphasise that people in the defined influenza risk groups should take up the recommendation of influenza vaccination. It is too early in the season to predict the course of the 2008/09 influenza season, and whether it will be dominated by the circulation of H1N1, H3N2, or influenza B. The Agency will be closely monitoring the characteristics of circulating isolates in order to determine the overall prevalence of drug resistant influenza A and B isolates.

Influenza virus detections across Europe have been low so far in the 2008/09 influenza season (13 to date) and the above-mentioned H1N1 oseltamivir-resistant influenza isolate is, to the Agency's knowledge, the first detected in Europe. Influenza A oseltamivir resistance first emerged last season with a number of circulating influenza A(H1N1) isolates with the H274Y mutation, which confers resistance to oseltamivir, but not to zanamivir. By the end of the 2007/08 season, 26 out of 33 reporting European countries reported H1N1 oseltamivir resistance ranging from 4% in Spain to 67% in Norway, with 11% (38/347) in the UK [1,2]. The epidemiological evidence from the 2007/08 season suggested no reported increase in morbidity associated with these confirmed oseltamivir-resistant cases.

Reports between the second quarter 2008 and September 2008 from WHO showed high prevalence of resistance in the southern hemisphere with 100% (129/129) of H1N1 strains oseltamivir resistant in South Africa, and 96% (25/26) strains in Australia [2].

References
1. Centre for Disease Prevention and Control. Antivirals and antiviral-resistant influenza – resistance to oseltamivir (Tamiflu) in some influenza A(H1N1) virus samples. ECDC website [online] September 2008 [cited 24 October 2008]. http://ecdc.europa.eu/Health_topics/influenza/antivirals.html
2. WHO. Epidemic and Pandemic Alert Response: influenza A(H1N1) virus resistance to oseltamivir. WHO website [online] 13 October 2008 [cited 24 October 2008].http://www.who.int/csr/disease/influenza/h1n1_table/en/index.html.

European Bat Lyssavirus type 2 in a bat – Shropshire, October 2008

A Daubenton's bat found dead at a heritage site in Shropshire has tested positive for European Bat Lyssavirus type 2 (EBLV-2). This is the eighth confirmed EBLV-2 case in United Kingdom (UK) bats since 1996, and the second case in Shropshire [1, 2].

The bat was found dead by a member of staff early in the morning before the area was opened to the public. It was placed in a sealed box, using protective gloves. Risk assessment confirmed that no members of the public could have come into contact with the bat as it had not been present when the area was checked the previous evening.

The routine checking of the site for bats, along with other recommendations [1], which were fully implemented by staff after the previous incident, ensured that the bat was safely handled and nobody else had contact with it. The carcass was subsequently examined by a bat worker from the Shropshire bat group and placed in container for transfer to the Veterinary Laboratories Agency.

EBLV is a rabies-like virus found in insectivorous bats across northern Europe. It comes from the same family of viruses as rabies, but is a different strain from that which causes 'classical' rabies in dogs and many other domestic and wild animals. Humans are not at risk from EBLV unless they have been exposed to the saliva or nervous tissue of an infected bat or have been scratched or bitten.

The HPA, Defra, and Department of Health work closely with the Bat Conservation Trust and Natural England on bat issues. All those licensed to handle bats or who regularly handle bats in Great Britain should ensure that they have up to date rabies vaccination and should always wear protective gloves when handling bats. Anybody who is potentially at risk from EBLV but is given prompt protective treatment will not develop the infection.

Anyone finding a sick or ailing bat is advised not to approach or handle it but to seek advice from a conservation group or the Bat Conservation Trust Helpline on 0845 1300 228.

References
1. Duggal H. European bat lyssavirus type 2: human exposure in England. Euro Surveill. 2007;12(36):pii=3264. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=3264
2. HPA. European Bat Lyssavirus: Frequently asked question. http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1215157152257?p=121515715225.

Rabies in Italy, October 2008

 

 


On 21 October 2008 the national reference laboratory for rabies in Italy confirmed a case of rabies in a fox in the Friuli-Venezia Giulia Region of north-eastern Italy (marked in red on the map below). This fox was euthanized on 10 October after it attacked a person who was out walking in a forest in Resia district, close to the borders with Austria and Slovenia. The results were positive for ‘classical' rabies virus by PCR testing [1].

Figure 1 Map of Italy showing the Friuli-Venezia region

Italy has been rabies free since 1995, although rabies has been found in foxes in this area previously, most recently in 1992. In previous cases foxes appear to have crossed the border from Slovenia and Austria, although the risk of rabies in the northern and eastern border regions of Italy has long been recognised. Local routine preventive policies in Italy reflect the ongoing risk across the borders, and include compulsory vaccination of domestic animals and livestock which graze outside in those districts close to the border.

Local controls put in place in response to the present case include vaccination and restriction of movement of dogs in the Chiusaforte, Resiutta, Resia, and Venzone districts, enhanced surveillance of wildlife, and oral vaccination of wild foxes.

This area is alpine and forested and not a major tourist destination. However the following advice has been given for travellers from the UK:

Those who are travelling to the northern and eastern border regions of Italy should avoid contact with wild and domestic animals. However, if they are licked, scratched or bitten by a wild or domestic animal they should wash the area thoroughly with soap and water and seek urgent medical advice either in Italy, or on their return from their GP or NHS Direct.

Expert advice for health professionals is available from the HPA Centre for Infections (CfI) Virus Reference Department (0208 200 4400) or the CfI duty doctor at (0208 200 6868).

Reference
1. Rabies, Italy: Report to OIE [World Organisation fro Animal Health], 22/10/08. Available at:
http://www.oie.int/wahid-prod/public.php?page=single_report&pop=1&reportid=7444.

Mandatory C. difficile infection data published

The HPA's second quarterly report on C. difficile infections in England, published on 23 October, indicates significant falls in the level of infections since the previous quarter, and since the same period in 2007 [1, 2]. There were 8,683 C. difficile cases recorded in patients aged 65 years and over between April and June 2008, representing a fall of 18% in this age group from the previous quarter (10,608 cases); compared with the number reported for same quarter of 2007 (13,924 cases), the fall was 38%.

Under the mandatory reporting regime, Trusts are required to report all C. difficile positive diarrhoeal specimens processed by their laboratories, including samples taken in the community (eg at GP surgeries, nursing homes and PCT hospitals). The HPA's third annual report on healthcare-acquired infections, which focused on those infections subject to mandatory surveillance – MRSA and C. difficile, was published in July 2008 [3]. The next set of quarterly C. difficile data will be published on 15 January 2009. 

Table 1. C. difficile infections  in England, April – June 2008

Quarter
C. difficile reports in patients aged 2-64 years
C. difficile reports in patients aged
over 64 years
C. difficile reports in patients aged
less than 2 years

January – March 2006

–

15,349

–

April – June 2006

–

14,689

–

July – September 2006

–

12,821

–

October – Dec 2006

–

12,776

–

January – March 2007

–

15,644

–

April – June 2007

2,944

13,924

16,868

July – September 2007

2,538

10,884

13,422

October – Dec 2007

2,239

10,009

12,248

January – March 2008

2,356

10,608

12,964

April – June 2008

2,183

8,683

10,866

References
1. Clostridium difficile infections fall significantly, HPA press release, 23 October 2008. http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1224745719153?p=1204186170287
2. Epidemiological Data: Healthcare Associated Infections: C. difficile infection: October 2008.http://www.hpa.org.uk/web/HPAweb&Page&HPAwebAutoListName/Page/1191942126541.

3. Surveillance of healthcare associated infections report: 2008.http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1216193832294.