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Volume 3 No 23; 12 June 2009

Influenza A/H1N1 (‘swine-lineage’): UK and international situation at 12 June 2009

Following the raising of the World Health Organization pandemic alert level to phase 6 [1], the HPA stated that the United Kingdom's approach to management of the UK outbreak would continue to be to delay, by all reasonable measures available, the spread of the infection for as long as possible, to minimise the impact of the disease and to allow time to improve preparedness, a policy that has allowed scientists time to find out more about the characteristics of the virus through gathering crucial virological, clinical and epidemiological information [2].

Because reports of swine flu cases are increasing globally, the Agency anticipates there will be more cases in the UK in the coming weeks. Although to date the disease is proving severe in a small minority of UK cases, for the majority it has been generally mild. This increases the options in terms of how the UK can respond in the next phase of managing the outbreak.

European situation

A first epidemiological review of the situation across the European Union (and in three non-EU countries), as at 8 June, was published by the European Centre for Disease Control (ECDC) [3].

Confirmed UK cases update

On Friday 12 June, the number of confirmed cases of swine-lineage influenza A/H1N1 in the United Kingdom rose to 921. The total of confirmed cases in England was 574, in Northern Ireland seven, and in Wales three. Total confirmed cases in Scotland more than doubled compared with the previous week to 337 (see table 1) [4].

Table 1: Confirmed cases by Region and Devolved Administration, United Kingdom as reported by 12 June 2009

Region*

Confirmed cases 12 June
(5 June)

East of England

47 (36)

East Midlands

13 (8)

London

140 (108)

North East

18 (2)

North West

19 (14)

South East

79 (61)

South West

14 (13)

West Midlands

229 (113)

Yorkshire & Humberside

15 (4)

Total England

574 (363)

Northern Ireland

7 (2)

Scotland

337 (119)

Wales

3 (2)

TOTAL UK

921 (486**)

* New testing arrangements mean that the regional breakdown of figures reflects the regional laboratory where samples are tested, which may not always be in the region where the patient lives.
** Four of the cases in last week's regional totals had not been allocated to a region.

Scotland situation

During the previous week, in view of the disproportionately high day-on-day rise in confirmed cases in Scotland (most new cases being in the NHS Greater Glasgow and Clyde regions), in comparison to the rest of the UK, the Scottish Chief Medical Officer issued a letter on 3 June giving further information and guidance to the NHS in Scotland [5].

Assumed mode of transmission in the UK

A third out-of-season Weekly National Influenza Report [6] for the UK was published, indicating that at 10 June (week 24), of the 750 cases confirmed in the UK at that time:

  • 139 were assumed to have acquired the virus abroad;
  • 380 were assumed to have acquired the virus in the UK of which 30 were thought to be sporadic cases (no known travel history or contact with a known case); and
  • the determination of the route of transmission was pending in 370 cases.

 

References

1. WHO. “World now at the start of 2009 influenza pandemic”. Transcript of statement by Margaret Chan, Director-General of World Health Organization (pdf), 11 June 2009. Available at: http://www.who.int/mediacentre/influenzaAH1N1_presstranscript_20090611.pdf
[accessed 12 June 2009].

2. "World Health Organization (WHO) raises pandemic alert phase", (HPA press release of 12 June 2009). HPA website: National Press Releases.

3. ECDC, "Preliminary analysis of influenza A(H1N1)V – individual and aggregated case reports from EU and EFTA countries", Euro Surveill. 14(22), 11 June 2009. Available at: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19238.

4. "Update on confirmed swine flu cases", (HPA press release of 12 June 2009). HPA website: National Press Releases.

5. The Scottish Government. Update on inlfuenza A(H1N1) in Scotland (SGHD/CMO(2009)05), 3 June 2009. Available at: http://www.sehd.scot.nhs.uk/cmo/CMO(2009)05.pdf.

6. "HPA Weekly National Influenza Report", 10 June 2009 (week 24). HPA website: Swine Influenza Epidemiological Data.

Un-seasonal increase in Salmonella Oranienburg in England and Wales

The Laboratory of Gastrointestinal Pathogens (LGP) has reported 17 non-travel associated isolates of Salmonella Oranienburg in May 2009. Although reported numbers of this serotype remain within the expected cumulative range for the time of year, the reporting of these isolates is significantly higher than expected for the month. Between 2004 and 2008, an average of 2.5 cases were reported in May. All isolates are fully susceptible to anti-microbials, and represent five English regions - East of England, South East, Yorkshire and the Humber, East Midlands, London and Wales - with the majority reported from East and South East regions (table 1). Thirteen cases are male (54%) with most cases in adults. Cases range in age from under one year of age to 75 years of age (mean 42, median 43). Specimen collection dates range from 30 April to 28 May.

Salmonella Oranienburg is a relatively uncommon serotype of salmonella, with an average of 42 reports per year (2000-2008) in England and Wales. Although no outbreaks have been reported in England and Wales, S. Oranienburg has been reported in outbreaks associated with dairy products (Tyrolean cheese [1] fruit salad [2], black pepper [3] and chocolate [4]).

The outbreak has been reported to the European Centre for Disease Control for dissemination across European member states and the Centre for Disease Control in the United States. Early reports from Health Protection Scotland (HPS) and the Republic of Ireland indicate a similar increase in Scotland, but no increase in Eire.

Staff at the Centre for Infections are investigating cases to determine a likely source of these infections.

Table 1 . Regional distribution of fully sensitive non travel associated Salmonella Oranienburg reported in May 2009

Region

Cases

East Midlands

2

East of England

4

London

1

North East

-

Northern Ireland

-

North West

-

South East

11

South West

-

West Midlands

-

Wales

1

Yorkshire and the Humber

4

Total

23

References

1. Allerberger F, Kreidl P, Dierich MP, Klingsbichel E, Jenewein D, Mader C, et al. Salmonella enterica serotype Oranienburg infections associated with consumption of locally produced Tyrolean cheese. Euro Surveill. 2000; 5(11). Available at: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=27.

2. Anon. Salmonella Oranienburg [in] Ontario. Canada Communicable Disease Report. Vol 24-22, 15 November 199. Available at: http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/98vol24/dr2422ea.html.

3. Anon. International notes: Outbreak of Salmonella Oranienburg Infection – Norway. MMWR 1982: 31(48); 655-6. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00001205.htm.

4. Werber D, Ammon A, Dreesman J, Feil F, van Treeck U, Fell G, et al. International outbreak of Salmonella Oranienburg, October-December 2001, Part 1: Germany. Euro Surveill . 2002; 6(3). Available at: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=27.

vCJD-related abnormal prion protein in a person with haemophilia – an update

Following the finding of evidence of the abnormal prion protein that causes variant Creutzfeldt-Jakob Disease (vCJD) in a haemophilia patient at post mortem, a risk assessment of the possible routes of exposure for this individual has been published by the Department of Health [1].

The vCJD-related abnormal prion protein was detected only in the individual's spleen but the finding was the first of the agent in a haemophilia patient [2].

To date, no haemophilia or bleeding disorder patients have been diagnosed with or died from clinical vCJD.

The investigations into the possible routes of infection considered, assuming that the abnormal prion protein did indicate vCJD infection, four possible infection routes: dietary exposure to BSE; surgical procedures; transfusions with several units of red cells; and treatment with large amounts of UK sourced Factor VIII. This included two batches of Factor VIII 8Y that were sourced from plasma pools which included plasma from a single donor who later developed clinical vCJD.

The calculations involved in this risk assessment depend on the likely prevalence of subclinical vCJD infections among the UK population, the infectivity of plasma products and blood components - both of which are subject to great uncertainties - and the number of donors contributing to the plasma pools. The risk assessment concludes that in scenarios based on current evidence, the most likely source of this patient's infection was treatment with UK sourced clotting factors.

This haemophilia patient had been treated in the 1990s with over 390,000 units of UK-sourced Factor VIII, including over 9,000 units from two implicated batches of Factor VIII 8Y (linked to a donor who later developed clinical vCJD).

The risk assessment concluded that, based on plausible assumptions, the patient was more likely to have been infected by a batch of Factor VIII that was not sourced from a pool containing plasma from the donor known to have vCJD (a non-implicated batch), than by one of the two implicated batches that were linked to this donor.

This is because far more units of non-implicated than implicated batches were administered to this patient. Each batch of plasma product is sourced from many thousands of donors (around 20,000), any one of whom could have had an asymptomatic abnormal prion protein infection. The relative risks from implicated and non-implicated batches will only be clarified further by long-term follow-up of patients.

The CJD Incidents Panel considered the risk assessment, together with other information, and concluded that this evidence confirms its existing advice to patients already notified as at increased risk of vCJD. There is therefore currently no reason to change that advice, nor to notify any new groups of patients. There is no change in the public health vCJD "at risk" status of any patients with bleeding disorders.

All patients with bleeding disorders [3] who have been treated with UK-sourced pooled factor concentrates or antithrombin [4] between 1980 and 2001 [5] are classified as "at risk of vCJD for public health purposes". Special infection control precautions and other safety measures apply to these patients.

All haemophilia centre doctors were informed of the Panel's decision on Tuesday, 9 June, 2009 and were asked to send a letter to their patients who have been notified as at increased risk of vCJD. Further information is available at http://www.hpa.org.uk/vcjdplasmaproducts.

Notes

1. vCJD risk assessment calculations for a patient with multiple routes of exposure. Department of Health, 9 June 2009. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_100357

2. HPA. Post mortem finding of asymptomatic variant Creutzfeldt-Jakob Disease abnormal prion protein in a person with haemophilia, Health Protection Report [serial online] 2009; 3 (10): news. Available at: http://www.hpa.org.uk/hpr/archives/2009/news0709.htm#vcjd.

3. Defined here as congenital and acquired haemophilia (Haemophilia A and Haemophilia B), Von Willebrand Disease, other congenital bleeding disorders and congenital antithrombin III deficiency.

4. ie clotting factors and antithrombin made from pooled plasma. These include factor VIII, factor IX, factor VII, factor XI, factor XIII and prothrombin complex concentrates as well as antithrombin.

5. The start date of 1980 is when BSE is thought to have entered the human food chain. The end date of 2001 is the last possible expiry date of any product manufactured by the UK fractionators that was sourced from UK donors until 1998.