• Group A streptococcal infections: update on seasonal activity, 2008/09
  
• Follow-up related to the human rabies case in Northern Ireland
  
• Clostridium difficile infections continue to fall
  
• Migrant workers health status reviewed
  
  

 

Group A streptococcal infections: update on seasonal activity, 2008/09

National surveillance data for group A (Streptococcus pyogenes) streptococcal infections continue to show increases in incidence above the seasonally expected levels for England. Further to the previous report of 19 December 2008 [1], scarlet fever notifications are now showing an increase across the country, whilst routine laboratory reports and isolate referrals are indicating high numbers of invasive group A streptococcal (iGAS) disease in several regions.

Scarlet fever

Overall, the scarlet fever notifications during the 2007/08 season were the highest recorded in the last few years, higher than the last peak in 2002/03 (2462). The notifications made for the last four weeks of 2008 (49-52), at 220, were higher still than 2007 (135).

Notifications of scarlet fever for weeks 49-52 of 2008 were higher than in the previous six years in all regions, with the exception of Yorkshire and the Humber (26 notifications), where an upsurge was noted in the first quarter of 2008 [2], and the South West (22 notifications) where unusually high numbers of notifications were reported during the 2005/06 season. Provisional notifications for the other regions (weeks 49-52) are as follows: North West (32), East Midlands (18), East of England (16), London (37), North East (18), South East (33) and West Midlands (25). Of these regions, the highest numbers of notifications relative to the range for 2003-07 were received for the East Midlands (18 vs range of 2 to 14, weeks 49-52, 2003-07), West Midlands (25 vs range of 7 to 14) and North East (18 vs range of 6 to 10).

In contrast to notifications of scarlet fever, clinical incidence data for pharyngitis/scarlet fever derived from the QSurveillance® GP surveillance system shows no substantial rise at present compared to 2007/08 [3].

Invasive group A streptococcal infection

A total of 88 reports of GAS bacteraemia were received from laboratories across England, Wales and Northern Ireland for November 2008, a slight increase on November 2004-07 (50-80 reports), but lower than for 2003, the last peak year. Reports received thus far for December (127) exceed the December 2004-07 range and are just above the total for December 2003 (123) and likely to rise as further reports are made. Several regions have reported numbers of cases in November/December as high as, or higher than, 2003 as follows: East Midlands (24 vs range of 5 to 17 for 2004-07), North West (39 vs range of 11 to 19) and South West (26 vs range of 13-18). The age and sex distribution of cases reported so far for November/December 2008 is similar to previous years.

Figure 1. Weekly routine laboratory reports of group A streptococcal bacteraemia, England, Wales and Northern Ireland

* Number of reports likely to increase.

Invasive GAS isolates (defined as isolation of GAS from a normally sterile site, most commonly blood culture) referred to the Respiratory and Systemic Infection Laboratory at CfI from laboratories in England, Wales and Northern Ireland showed a substantial increase in November/December 2008 (235) over the same period in 2007 (142). The most common emm /M-type identified in November/December 2008 was emm /M1, followed by emm /M89, emm /M3, emm /R28 and emm/M75.

Analysis of scarlet fever notifications over the last century suggest cyclical patterns in incidence, with resurgences occurring on average every four years [4]. The last peak year for scarlet fever was 2002/03, although notifications were also high in 2003/04, with superficial manifestations of GAS infection tending to mirror those of invasive disease [5]. The current increases being seen in some regions in particular may be attributable to a natural cycle in disease incidence, although the potential for changes in virulence of circulating strains or increased incidence in particular risk groups, as seen during the early 2000s [6], remains possible and as such continued vigilance remains essential. It is also possible that the significant influenza activity this winter may be contributing directly or indirectly by increasing transmission of GAS and/or rendering individuals with influenza more susceptible to secondary infection with GAS. Analysis of isolates submitted to the national reference laboratory has not identified any unusual serotypes to be circulating. Re-establishment of enhanced surveillance nationally for iGAS is currently under consideration.

Further seasonal updates will be published in the Health Protection Report. Clinicians, microbiologists and HPUs should be mindful of these indications of increases in iGAS and maintain a high index of suspicion in relevant patients as early recognition and prompt initiation of specific and supportive therapy can be life-saving. Invasive disease isolates and those from suspected clusters or outbreaks should be submitted to the Respiratory and Systemic Infection Laboratory at the Health Protection Agency, Centre for Infections, 61 Colindale Avenue, London NW9 5HT. Guidelines for the management of close community contacts [7] of invasive group A streptococcal disease are available on the Agency's website at: http://www.hpa.org.uk/cdph/issues/CDPHvol7/No4/guidelines1_4_04.pdf.

References

1. HPA. Group A streptococcal infections: seasonal activity 2008/09. Health Protection Report [serial online] 2008; 2(51): news.

2. HPA. Yorkshire and the Humber scarlet fever update. Health Protection Report [serial online] 2008; 2(15): news.

3. QSurveillance® Weekly Bulletin No 217, Week commencing 12 January 2009 (Week 2, 2009). Data extracted from version 1 of the QSurveillance® database. QSurveillance® 2009; http://www.hpa.org.uk/hpr/infections/Qresearch.pdf.

4. Lamagni T, Dennis J, George R, Efstratiou A. Analysis of epidemiological patterns during a century of scarlet fever. Paper presented at the European Scientific Conference on Applied Infectious Disease Epidemiology, 18 November 2008, Berlin, Germany.

5. Dennis JN, Lamagni TL, Smith GE, Elliot AJ, Loveridge P, George RC et al. Use of primary care syndromic data to forecast rises in invasive group A streptococcal disease. Paper presented at the Health Protection 2008 conference; 15 September 2008, Warwick, UK.

6. Lamagni TL, Neal S, Keshishian C, Hope V, George RC, Duckworth G et al. Epidemic of severe Streptococcus pyogenes infections in UK injecting drug users, 2003-04. Clin Microbiol Infect 2008; 14(11):1002-1009.

7. Health Protection Agency Group A Streptococcus Working Group. Interim UK guidelines for management of close community contacts of invasive group A streptococcal disease. Commun Dis Public Health 2004; 7(4):354-361.

Follow-up related to the human rabies case in Northern Ireland

The Health Protection Agency is working with colleagues in South Africa and Northern Ireland to trace volunteers who have worked at the Riverside Wildlife Rehabilitation and Environmental Education Centre in Limpopo province, South Africa. This follows the recent death from imported rabies of a young woman in Northern Ireland who had worked at the Centre in December 2006 [1].

The woman is thought to have acquired rabies following a bite from a dog whilst working at the animal sanctuary. As a precautionary measure, a letter has been sent by the Centre to all those who have volunteered there since July 2006. This includes approximately 220 UK citizens, some of whom made multiple visits.

Volunteers are being advised that if they have been bitten, scratched or licked on the face or on an open wound, by a dog or mongoose, within the Centre or in the surrounding area, they should seek medical advice from a health professional to determine whether they require preventive treatment with rabies vaccine.

Pre-exposure prophylaxis is highly effective at preventing rabies infection. Travellers to rabies endemic countries should seek travel health advice well in advance of their departure (ideally 4-6 weeks before) regarding their need for pre-exposure immunisation against rabies, particularly if they are planning on working with animals.

Following a bite, scratch or lick by a warm blooded animal in a rabies endemic country, the wound or site of exposure (eg mucous membrane) should be washed with plenty of soap and water and medical advice sought without delay, even for those who have been vaccinated. If medical advice is not received whilst abroad, this should still be sought on return to the UK, even if this is some time after the event.

Following exposure, an individual risk assessment should be undertaken to determine the need for post-exposure prophylaxis (PEP) with rabies vaccine and/or immunoglobulin. PEP is highly effective in preventing rabies and most effective when given promptly. There have been no cases of rabies in the UK in people who have received PEP for rabies.

Detailed information is available in the Green Book chapter on rabies, available at http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1216022456494

Further information on rabies prevention for the traveller including country-specific rabies advice is available from the National Travel Health Network and Centre at http://www.nathnac.org/pro/factsheets/rabies.htm.

Reference

1. HPA. Case of imported rabies in the UK. HPR 2(51): news. Available at: http://www.hpa.org.uk/hpr/archives/2008/hpr5108.pdf.

Clostridium difficile infections continue to fall

C. difficile infections in hospital patients in England are continuing to fall, the latest quarterly total of reported cases - 8,947 infections between July and September 2008 (patients aged two years and over) - indicating a 33% reduction compared to the same quarter last year and an 18% reduction compared with the previous quarter. The improvement applies across all age groups for the quarter.

The national target is for a reduction of C. difficile infections by 30% by 2010/11 against the 2007/08 baseline.

C. difficile infection reports : a summary of cases reported under mandatory surveillance in England

Quarter	Number of C. difficile reports in patients aged 2-64 years	Number of C. difficile reports in patients aged ≥65 years	Number of C. difficile reports in patients aged ≤2 years
January - March 2006	–	15,349	–
April - June 2006	–	14,689	–
July - September 2006	–	12,821	–
October - December 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 - December 2007	2,239	10,009	12,248
January - March 2008	2,356	10,609	12,965
April - June 2008	2,192	8,696	10,888
July - September 2008	1,886	7,061	8,947

The next set of quarterly C. difficile data will be published on 16 April 2009. This publication will include the 2007/08 baseline targets for C. difficile.  (Quarterly figures for MRSA infections (July to September 2008) will be published on March 19 2009.)

Reports of C. difficile infections for individual Trusts are available on the Healthcare Associated Infections page of the HPA website [1].

New best practice guidance on prevention and management of C. difficile infections has also been published [2]. This replaces Clostridium difficile infection: prevention and management, published in 1994, and describes up-to-date approaches to infection control and environmental hygiene taking into account the national framework for clinical governance which did not exist in 1994.

References

1. Epidemiological Data: Healthcare Associated Infections - Quarterly Reporting Results for Clostridium difficile infections, MRSA bacteraemia and GRE bacteraemia. Available at: http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1191942126522?p=1191942126522.

2. DH/HPA. Clostridium difficile infection: how to deal with the problem, 2009. Available at: http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1232006607827.

Migrant workers health status reviewed

A new Agency report provides a demographic overview of migrants from east and central Europe who live and work in England and Wales and compares the various infectious disease and immunisation rates in their host countries with those in the UK [1].

The report presents data relating to the 10 countries that joined the EU in 2004 (the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia and Slovenia, plus Cyprus and Malta) and the two that joined in 2007 ( Bulgaria and Romania ). Overall, many of these countries report higher levels of immunisation coverage and lower rates of infectious diseases than the UK. The report notes, however, that UK healthcare workers should ensure that all those living or working in the UK, irrespective of origin, should be offered full immunisation according to the relevant HPA algorithm [2]. It also notes the National Institute for Health and Clinical Excellence (NICE) recommendation that new migrants from a country with a TB incidence of 40 cases/100,000 or more (which currently includes Lithuania and Romania) should be screened for active TB [3]. Additionally, that anyone with the following symptoms suggestive of TB should be tested appropriately and treated where necessary: fever and night sweats, persistent cough, weight loss, or blood in sputum (phlegm or spit) at any time.

References

1.HPA. Migrant workers from the EU Accession countries: a demographic overview of those living and working in England and Wales and a comparison of infectious disease and immunisation rates in the Accession countries with those in the UK. Available at: http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1191942172859?p=1191942172859.

2. HPA. Vaccination of Individuals with uncertain or incomplete immunisation status. Available at: http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947406156.

3. National Institute for Health and Clinical Excellence. Clinical diagnosis and management of tuberculosis, and measures for its prevention and control. December 2008. Available at: http://www.nice.org.uk/page.aspx?o=CG033.