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Published on: 5 December 2008 |
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National Influenza Immunisation Monitoring Programme – 2008/09
The annual monitoring of influenza vaccine uptake in England is co-ordinated by the Health Protection Agency (HPA) on behalf of the Department of Health (DH). Recommendations for who should be immunised are set out in the CMO Letter [1]; this includes every person aged 65 years and over and those aged under 65 years falling in a clinical risk group.
The 2008/09 campaign consists of four monthly collections allowing GP practices to submit cumulative vaccine uptake data with the final collection taking place in February 2009. Vaccine uptake data is collected electronically via the DH Health Protection Informatics, a web-based reporting system. Provisional vaccine uptake results from the first monthly collection (which covers vaccinations administered from 1 September 2008 to 31 October 2008 inclusive) are now available to view on the NHS Immunisation website [2].
Provisional data derived from 86% of GP practices in England (7139 out of 8330 making an electronic return) shows that by the end of October 2008, 55.9% of patients aged 65 years and over had received their flu vaccination (uptake ranged by PCT from 41.9% to 66.2%). For those aged under 65 years and falling in a risk group, 30.6% of patients had received their flu vaccination by the end of October 2008 (uptake ranged by PCT from 17.5% to 38.9%). The equivalent figure for the same month in 2007 for both risk groups was 54.7% and 28.4% respectively.
1. Chief Medical Officer, Professor Sir Liam Donaldson. The influenza immunisation programme 2008/09. London: Department of Health, 31 March 2008, http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Professionalletters/
Chiefmedicalofficerletters/DH_083812.
2. http://www.immunisation.nhs.uk/Vaccines/Flu/Resources/vaccine_uptake_2008_2009.
Malaria associated with travel to The Gambia
A recent increase in the number of UK malaria cases caused by Plasmodium falciparum has been reported in those who have travelled to, or arrived from, The Gambia, West Africa. In 2000 there were 129 such cases reported to the Health Protection Agency Malaria Reference Laboratory and numbers decreased in subsequent years to a low of 20 in 2006. There were 21 cases reported in 2007, and in 2008 there have been 28 reported up to the end of November. The recent cases coincide with clusters of cases acquired in The Gambia that have been reported in other European countries such as the Netherlands, Finland, Denmark, Spain, and Norway [1, 2]. There have so far been no reported deaths in the UK from malaria associated with travel to The Gambia in 2008. The continued reporting of avoidable disease in travellers highlights the need for reinforcement of health messages that all travellers to the country and other parts of West Africa should use effective malaria prevention methods, including chemoprophylaxis.
Of the 28 total cases reported in the UK to the end of November 2008, 23 had information about reason for travel, of which six were new entrants or foreign visitors and 17 were travellers departing from and returning to the UK. The majority of travel-associated cases (13) travelled for holidays, three were visiting friends and relations (VFR), and one travelled for business. Eleven of the holiday travellers were of White British ethnicity and most had stayed in The Gambia for a relatively short period (seven to 14 days). The VFR cases were of Black African ethnicity, of which one had stayed in The Gambia for 21 days; no information on duration of stay was available for the other two. Of all 17 travel-associated cases, only two cases had reported taking malaria chemoprophylaxis recommended for The Gambia by the HPA Advisory Committee for Malaria Prevention in UK travellers (ACMP) [3].
Clusters of falciparum malaria are often reported in travellers returning from The Gambia during the winter months [4, 5] with lower numbers reported at other times of the year. The majority of malaria cases in the UK, however, occur as a result of travel to West Africa as a whole, one of the most malarious regions in the world, and mainly in those visiting friends and relatives in their own or their family's country of ethnic origin (eg in 2007, 808 cases in total were acquired in West Africa, of which 424 (52%) were associated with VFR travel). Most travel related cases are known not to have taken appropriate chemoprophylaxis.
The clustering of cases from The Gambia in the winter months may reflect both transmission and travel patterns. Transmission of malaria in The Gambia is seasonal with peak transmission occurring between September and December, whereas for most other areas of West Africa, it is year round. Similarly, data from the Federation of Tour Operators indicate that there are around 40,000 UK holiday travellers that go to The Gambia in the winter season (November to April) compared to around 5,000 in the summer [6]. In contrast the majority of visits to West Africa as a whole are made between April and September [7].
There is no evidence to suggest that travel to The Gambia has increased in 2008 and a recent study showed that there has been a decrease in the burden of indigenous malaria in certain parts of The Gambia over the last 10 years, due in part to the increased use of insecticide-treated bednets in many regions of the country [8]. This decrease has coincided with the observed decrease in travel-associated cases reported in the UK since 2000 (figure 1). The small increase in cases reported so far in 2008 in the UK may represent chance fluctuation year on year, but the situation will continued to be monitored as the winter season proceeds.
Figure 1. Malaria cases known to be associated with travel to The Gambia by reason for travel: 2000 - 2008*
The appropriate chemoprophylaxis recommended for The Gambia by the HPA ACMP, is atovaquone/proguanil (Malarone), or doxycycline, or mefloquine (Lariam) [3]. Travellers should also avoid mosquito bites from dusk through dawn, but especially at night, by using repellents and sleeping under a mosquito net [8], especially during the period of heaviest transmission in the second half of the year.
The three effective chemoprophylactic options for The Gambia are prescription-only medicines. All travellers to West Africa, including The Gambia, need to be made aware of malaria risk and of the need to seek appropriate pre-travel medical advice from their GP or a travel clinic at least six weeks in advance. The importance of completing the prescribed course of chemoprophylaxis must also be emphasised to all travellers. Health care practitioners should consider opportunistically asking those who may undertake future VFR travel to West Africa about their travel plans, to try to ensure that they receive pre-travel advice. Those booking travel to malarious areas at short notice should be advised by their travel agents of the need to seek pre-travel health advice as soon as possible, and that it is still possible to receive appropriate chemoprophylactic prescriptions, even for last minute travellers.
Further information about malaria prevention and other possible health risks of travelling to countries in West Africa is available from the National Travel Health Network and Centre Country Information Pages at http://www.nathnac.org/ds/map_africa.aspx.
All travellers should seek medical attention promptly if they become unwell and inform their doctor if they have been in a malarious area. The healthcare worker should consider malaria in every ill patient who has recently returned from the tropics and for those with a fever, the illness should be considered to be malaria until proven otherwise. In these circumstances, blood film examination should be performed without delay.
Clinicians should ensure that any cases of imported malaria are reported to the HPA Malaria Reference Laboratory. The standard reporting form can be downloaded from http://malaria-reference.co.uk/.
References
1. ProMED-mail. Malaria - Europe, USA ex Gambia, 1 December 2008. Available at: http://www.promedmail.org/pls/otn/f?p=2400:1001:1770362615062596::NO::F2400_P1001_BACK_PAGE, F2400_P1001_PUB_MAIL_ID:1000,74978
2. ProMED-mail. Malaria, imported - Europe ex Gambia, 28 November 2008. Available at: http://www.promedmail.org/pls/otn/f?p=2400:1001:1770362615062596::::F2400_P1001_BACK_PAGE, F2400_P1001_ARCHIVE_NUMBER,F2400_P1001_USE_ARCHIVE:1001,20081128.3752,Y
3. Chiodini P, Hill D, Lalloo D, Lea G, Walker E, Whitty C, Bannister B. Guidelines for malaria prevention in travellers from the United Kingdom. London: Health Protection Agency; 2007. Available online at: http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1195733823080?p=1191942128258
4. Health Protection Agency. Consequences of failure to use malaria prophylaxis in The Gambia. CDR Weekly 2003; 13(49): news. Available at: http://www.hpa.org.uk/cdr/archives/2003/cdr4903.pdf
5. Health Protection Agency. Malaria deaths in travellers returning from The Gambia. CDR Weekly 2005; 15(49): news. Available at: http://www.hpa.org.uk/cdr/archives/2005/cdr4905.pdf
6. Andy Cooper, Director General, Federation of Tour Operators, personal communication, 27 November 2008.
7. Data from the International Passenger Survey 2000 - 2007, Office for National Statistics.
8. Ceesay SJ, Casals-Pascual C, Erskine J, Anya SE, Duah NO, Fulford AJC et al. Changes in malaria indices between 1999 and 2007 in The Gambia: a retrospective analysis. Lancet 2008; 372: 1545-54.
9. National Travel Health Network and Centre (NaTHNaC) Health Information Sheet. Insect bite avoidance . Available online at: http://www.nathnac.org/pro/factsheets/iba.htm.