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Volume 2 No 44; 31 October 2008

 

A single case of inhalation anthrax in a drum maker in London

On 21 October 2008 a patient presented to a London hospital with respiratory symptoms and feeling generally unwell. They rapidly deteriorated and were transferred to ITU on 23 October with respiratory failure and later multiple organ failure. The chest X-ray showed widening of mediastinum and bilateral pleural effusion. Further investigations included a blood culture on 22 October.

Gram positive, encapsulated, non-motile rods were isolated from blood on 24 October. The organism was sensitive to penicillin and the primary identification was Bacillus anthracis. The results were reported to North East and North Central London Health Protection Unit that day and an incident was declared. Diagnosis was confirmed later that day by the HPA Novel and Dangerous Pathogens in Porton Down . Further molecular and microbiological investigations the following day confirmed the identification of the organism and drug sensitivities.

Following preliminary diagnosis of anthrax on 24 October the antibiotic regimen was changed from tazocin and ciprofloxacin to rifampicin, ciprofloxacin and clindamycin. The patient is also being treated for multiple organ failure due to septicaemia. After consultation with CDC, Atlanta , anthrax immunoglobulin (AIG) was flown in from United States (US) on 27 October and administered on the same day. It was well tolerated. Their condition has improved slightly but they remain critically ill.

The patient makes and plays animal hide drums. It is likely that the infection was acquired by making drums from imported hides. The main supplier of animal skins reported importing hides from the Gambia . Review of previous similar cases of inhalation anthrax suggested that the main risk would be during processes of drum making, particularly shaving hair from infected animal skin which may result in aerosolised anthrax spores being inhaled [1].

A risk assessment of individuals who might have been present when the case was making drums in the 60 days before onset of symptoms has been made.. The patient's immediate family, the main supplier of the skins, and a person who assisted them with drum making were offered prophylaxis with ciprofloxacin. A staff member at the hospital was also concerned about potential exposure to aerosolised spores and started prophylaxis. No one else has been identified as being at risk.

Environmental sampling of the studio where drum making activities took place will be carried out by a team from HPA, Novel and Dangerous Pathogens, with support from local Emergency Services and the local authority . This will include testing animal skins left in the properties, drums, drum making equipments and surfaces of the flat.

Environmental Health Officers and Health Protection Unit staff have interviewed the main skin supplier to assess the risk at their premises. The Incident Control Team decided that the remaining skins should be tested but extensive sampling of the property would not be required.

Between 1981 and 2006, 18 possible cases of anthrax were notified in England and Wales . All cases were cutaneous anthrax, with bacteria isolated in only one case and serological confirmation in another two. The last case of pulmonary anthrax in England and Wales was reported in 1974 which was linked to bonemeal fertilizer and proved fatal. This was the first case of pulmonary anthrax reported since 1965 [2].

A death from anthrax occurred in Scotland in 2006; this was a case of disseminated anthrax following exposure to untreated imported animal hides used for drum making [3]. One case of naturally acquired inhalation anthrax was also reported from US in 2006 in a drum maker who used animal skins imported from Cote D'Ivoire [1]

References

1.CDC. Inhalation Anthrax Associated with Dried Animal Hides-Pennsylvania and New York City, 2006 MMWR 2006: 55(10);280-282. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5510a4.htm.

2 .Epidemiological data: Human anthrax in England and Wales. Health Protection Agency website [online] 2008 [Cited 31 October 2008] Available at www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListDate/Page/1191857565963?p=1191857565963

3. Riley A. Report on the management of an anthrax incident in the Scottish boarders. July 2006 to May 2007. NHS Boarders, 2007. Available at: http://www.nhsscotland.com/nhsborders/view_item.aspx?item_id=18647.

 

 

 

 

Tuberculosis in the UK: annual report on tuberculosis surveillance in the UK 2008

 

 

 

The 2008 UK wide annual report Tuberculosis in the UK has been published by the Health Protection Agency (HPA) in collaboration with our partners in Wales, Northern Ireland, and Scotland [1]. The report provides an update on the epidemiology of tuberculosis in the United Kingdom (UK) and an assessment of whether measures outlined in the Chief Medical Officer's (CMO) Action Plan [2] are being met . Latest surveillance information on the occurrence of tuberculosis and anti-tuberculosis drug resistance in 2007, and treatment outcome results for cases reported in 2006 are presented. The report also provides a summary of published research and development work carried out by the Health Protection Agency since its inception in 2003.

A total of 8417 cases of tuberculosis was reported in the UK in 2007, a rate of 13.8 per 100,000 population. This represents a small decrease of 0.9% on the number of cases reported in 2006 (8495). This is the second consecutive year without a rise in the incidence of tuberculosis after nearly two decades of increase. While this is encouraging, rates remain high with the UK having one of the highest incidence rates in western Europe.

Most cases occurred in England (92%), with London having the highest regional rate of 43.2 per 100,000 (figure). The majority of cases were among young adults (60%) and the non-UK born population (72%, rate 85 per 100,000). The rate of tuberculosis in the UK born population has remained low at 4 cases per 100 000 but has not declined. Where site of disease was reported, 56% of cases had pulmonary disease. In England the proportion of cases with pulmonary disease has declined from 60% in 2000 to 55% in 2007.

Figure. Tuberculosis case reports and rates by country/region, UK: 2007

Figure. Tuberculosis case reports and rates by country/region, UK: 2007

Among initial isolates with drug susceptibility testing results, 7.4% were resistant to at least one first line drug, 6.8% were resistant to isoniazid and 1.2% were multi-drug resistant (resistant to at least isoniazid and rifampicin). Levels of drug resistance have also been stable and are at the lower end of the range observed for multi-drug resistant tuberculosis in the European Union.

Treatment outcomes were returned for 93% of cases reported in 2006, the highest yet achieved. Despite this, the level of treatment completion, at 79%, has remained stable and below the level of 85% suggested by the CMO. Reasons for the latter include high levels of mortality from causes other than tuberculosis among elderly cases, and patients undergoing planned courses of treatment which exceed 12 months.

An assessment of current progress against the measures of success suggested in the CMO's Action Plan is summarised in the table. While a number of these goals have been achieved, there is still much work to be done and efforts to prevent and control tuberculosis on all fronts need to be sustained and further strengthened.

Table. Current progress against the measures of success suggested in the CMO's Action Plan

Indicator

Status

A progressive decline (of at least 2% per year) in rates of tuberculosis in population groups born in England .

Not met

No more than 7% of new cases resistant to the anti-tuberculosis drug isoniazid

Met

No more than 2% of new cases multi-drug resistant.

Met

At least 70% of patients with pulmonary tuberculosis have the diagnosis confirmed by laboratory culture of the organism.

Met

All patients diagnosed with tuberculosis have the outcome of their treatment recorded

Not met

At least 85% successfully complete their treatment.

Not met

The HPA, in collaboration with a wide range of partners, also contributes to the prevention and control of tuberculosis through research and development. Current activity includes work on vaccine development, strengthening surveillance, molecular diagnostic methods, mechanisms of drug resistance and modelling and economics.

References

1. HPA. Tuberculosis in the UK: Annual report on tuberculosis surveillance in the UK 2008. London : Health Protection Agency, October 2008. Available at <http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1225268885969?p=1158945066450>

2. Department of Health . Stopping tuberculosis in England : an action plan from the Chief Medical Officer. London: Department of Health, 2004.

Shooting Up: infections among injecting drug users in the United Kingdom 2007

The sixth report on infections among injecting drugs users (IDUs) in the UK, Shooting Up [1], was released on the 27 of October. IDUs are vulnerable to a wide range of infections, including those caused by viruses such as HIV and hepatitis C, and bacteria such as Clostridium botulinum and group A streptococci, and these infections can cause significant morbidity and mortality among IDUs. The latest Shooting Up report summarises surveillance data from across the United Kingdom (UK) and presents the latest results from the Unlinked Anonymous Prevalence Monitoring Programme (UAPMP) survey of IDUs in contact with specialist services in England, Wales and Northern Ireland. The main findings from UAPMP survey are summarised below:

  • Levels of reported needle and syringe sharing have declined in recent years following an increase in the late 1990s. In 2007, almost a quarter (23%, 487 of 2,093) of current injectors reported sharing injecting equipment in the previous month.
  • Transmission of HIV and HCV infection through injecting drug use remains higher than in the late 1990s, with a fifth (21%, 103 of 484) of recent initiates* having hepatitis C and one in 100 (1%, 5 of 484) having HIV. Overall in 2007, 39% (1,412 of 3,580) injecting drug users were infected with hepatitis C and about 1.1% (41 of 3,580) with HIV.
  • Uptake of testing for HCV among IDUs in contact with drug services, after increasing markedly, now appears to be levelling off. In England only 25% of IDUs (732 of 2,906) reported never having had a voluntary confidential testing (VCT) for HCV in 2007 compared with 51% (1,532 of 2,998) in 2000. Of participants from Wales 39% (187 of 471) reported never having a VCT for hepatitis C in 2006/07, whilst less than one in ten (8.8%, 27 of 307) of the participants from Northern Ireland in 2006/07 reported not having had a VCT for hepatitis C.
  • Most IDUs in contact with services report having had a VCT for HIV at some point with 32% (1,092 of 3,410) reporting never having had such test in 2007 .
  • There has been a marked increase in the number of IDUs receiving the hepatitis B vaccine, with two-thirds (66%, 2,299 of 3,491) now reporting uptake of the vaccine.
  • Around one third (34%, 803 of 2,330) of IDUs reported having had an abscess, sore or open wound at an injecting site in the last year. A recent report has shown that these infections may place considerable burden on the NHS [2].

The findings presented in the report indicated a continuing need to develop in line with published guidelines services to reduce injecting related harms and to support those who want to stop injecting [3,4,5,6,7].

Infections caused by injecting drug use can cause significant morbidity and mortality among IDUs. Public health surveillance of the diseases and behaviours associated with injecting drugs continues to be an important tool in developing policies and services to reducing infections among IDUs.

References

1. Health Protection Agency, Health Protection Scotland, National Public Health Service for Wales, CDSC Northern Ireland, and the CRDHB. Shooting Up: Infections among injecting drug users in the United Kingdom 2007. London: Health Protection Agency, October 2008. Available at http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1224833091685

2 Hope V et al. Frequency, factors and costs associated with injection site infections: findings from a national multi-site survey of injecting drug users in England. BMC Infectious Diseases 2008, 8:120

3 Drug misuse and dependence - guidelines on clinical management: update 2007. London: Department of Health, 2007

4 Drug misuse: psychosocial interventions. NICE, Clinical Guideline, CG51, July 2007. Available athttp://guidance.nice.org.uk/CG51

5 Drug misuse: opioid detoxification. NICE, Clinical Guideline, CG52, July 2007. Available at http://guidance.nice.org.uk/CG52

6 ; Models of care for the treatment of adult drug misusers MOC3 . London: National Treatment Agency for Substance Misuse, 2006.

7 (Guidance still in development) Needle and syringe programmes: providing injecting equipment to people who inject drugs. NICE, Public Health Interventions Guideline, February 2009. Available at http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11829