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Volume 3 No 47; 27 November 2009

HIV in the United Kingdom: 2009 report



The number of deaths among HIV-infected people in the UK has remained stable over the past decade but the number of people living with the disease continues to rise, according to the HPA's latest annual HIV report [1]. The number of people estimated to be living with the infection increased to 83,000 in 2008, compared with 77,000 the previous year. In 2008, 7,298 adults were newly diagnosed with the infection, a slight decrease compared with previous years.

Among the successes noted in the report -- prepared by the HPA Centre for Infections' Microbiology and Epidemiology of STIs and HIV (MESH) Department - is that of the antenatal screening programme that helps identify infected mothers early, offering them treatment and limiting the possibilities for perinatal transmission. The estimated proportion of exposed infants (born to either diagnosed or undiagnosed HIV-infected women) who have become infected has decreased in the UK from 12% in 1999 to approximately 2% in 2007.

In contrast, the problem of late diagnosis in adults is highlighted in the 2009 report [2]. Of the 7,298 new diagnoses in 2008, an estimated 32% (2,310) of adults over 15 years were diagnosed at a point after which treatment should already have begun (ie when their CD4 cell count has fallen to below 200 per cubic millimetre [3]), resulting in their missing out on the benefits that come from early diagnosis, including improved life expectancy.

Other key points of the report are that:
  • New diagnoses among men who have sex with men remained high in 2008, and four out of every five probably acquired their infection in the UK.
  • New HIV diagnoses among those who acquired their infection heterosexually within the UK have risen, from an estimated 740 in 2004 to 1,130 in 2008.
  • Preliminary data for the first six months of 2009 indicate that one in five men who have sex with men, and one in ten heterosexuals newly diagnosed with HIV were likely to have acquired their infection within the last six months.
  • Uptake of HIV testing in antenatal and genitourinary medicine clinics continued to improve in 2008, reaching 95% and 93%, respectively.
  • Forty-three English local authorities (35 primary care trusts) had a prevalence of diagnosed HIV greater than 2 per 1,000 population in 2008, at which threshold it has been recommended to expand HIV testing in the local population.
  • Preventing the 3,550 HIV infections that were probably acquired in the UK, and subsequently diagnosed in 2008, would have reduced future HIV-related costs by more than £1.1 billion.

References

1. HPA. HIV in the United Kingdom: 2009 report. Downloadable at: http://www.hpa.org.uk/HPA/Publications/InfectiousDiseases/HIVAndSTIs/.

2. "A third of HIV patients diagnosed late", HPA press release, 27 November 2009, http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1259151920246?p=1231252394302.

3. According to British HIV Association guidelines introduced last year, patients with HIV should now be considered for treatment when their CD4 cell count reaches <350 per cubic millimetre rather than waiting until it falls further to <200 per cubic millimetre. If these guidelines were used when interpreting the latest figures, it would mean more than half (55%) of all individuals diagnosed in 2008 would have been diagnosed "late".

National increase in Salmonella Enteritidis phage type 14b NxCpl infections in England – an update

This report provides an update on the upsurge that has been noted since mid-August in the number of non-travel human isolates of Salmonella Enteritidis PT 14b with resistance to nalidixic acid and low level resistance to ciprofloxacin (NxCpl) [1]. A standard national protocol and guidance for the management and investigation of S. Enteritidis PT 14b outbreaks by the HPA National Outbreak Control Team (led by the Centre for Infections) is in use across the Agency (by the Centre for Infections, Local and Regional Services Division and the Regional Microbiology Network).

Over 400 cases (443) of S. Enteritidis PT 14b NxCpl have been reported by the Laboratory of Gastrointestinal Pathogens to week 46 in 2009 compared to 137 cases in 2008. Investigation of sporadic human cases of infection started 12 October 2009. To date, out of all the Salmonella case forms that have been returned, 53 are indigenous and confirmed with S. Enteritidis PT14b NxCpl. An analytical (case-control) study is currently being conducted nationally to investigate any common sources.

Concurrently, 13 S. Enteritidis PT 14b NxCpl outbreaks have occurred between August and November in England, and one in Wales in September. The earliest date of onset for these outbreaks was 17 August 2009. Seven of the 14 outbreaks were linked to oriental restaurants (Chinese or Thai), six to other food service establishments (three cafes, one Italian restaurant, one kebab shop and one mobile vendor), and one took place in a care home. A total of 144 cases have been associated with the 14 outbreaks, which have ranged in size from two to 68 cases. Eighty eight of the 144 cases have been confirmed as having S. Enteritidis PT 14b NxCpl infection, five of which were hospitalized. During one outbreak (in a care home) two elderly people died; although post mortem investigations were conducted the results were inconclusive. Inquests have been ordered into both deaths. In addition, other foodborne outbreaks of S. Enteritidis of different phage types (eg PT 1 and 59 with NxCpl) are being investigated to determine if these are linked by a common cause to the PT 14b NxCpl outbreaks. S. Enteritidis PT 14b NxCpl isolates obtained from environmental and food samples tested in the outbreak investigations and also from eggs produced in Spain (as described below) are indistinguishable by molecular diagnostic testing to isolates obtained from human cases both from the outbreaks and as sporadic cases of infection.

Cumulative incidence (weekly) and epidemic curve of non-travel related NxCpl resistant Salmonella Enteritidis PT 14b to week 46, 2009

From investigations of supply chains, eggs collected from catering premises in five of the outbreaks (three oriental restaurants, two cafes) were produced from the same approved establishment in Spain (as indicated by the distinguishing egg stamp mark on shell eggs). Subsequent sampling of 480 eggs supplied by this egg producer from a UK distributor took place on 3 November. S. Enteritidis PT 14b NxCpl was detected in two (2.5%) of the 80 pooled samples of six eggs. In addition, eggs supplied by the same producer in Spain and sampled during one of the aforementioned outbreaks were found to be contaminated with S. Enteritidis PT 1 NxCpl (5.0%; 1/20 pooled samples of six eggs).

The Food Standards Agency has notified the European Commission (EC) and other Member States through the Rapid Alert System for Food and Feeds (RASFF) of these contaminated eggs sourced from Spain. Investigations are currently underway to identify the source of contamination of the eggs.

Poultry are subject to a number of statutory and voluntary testing programmes for Salmonella within the EU. As part of the requirements laid out in EU legislation for the Salmonella National Control Programme ( NCP) [2], from January 2009, eggs from flocks testing positive for S. Enteritidis or S. Typhimurium need to be treated in a manner that guarantees the elimination of Salmonella, eg eggs from contaminated farms will be sent for heat processing and will not be allowed to enter the fresh table egg market (EC Regulation 1237/2007) [3]. This requirement applies in all Member States. The UK Salmonella NCP for laying flocks also sets out the monitoring and controls that primary producers should follow for laying flocks kept for the commercial production of eggs for human consumption. There have been no reports of S. Enteritidis PT14b NxCpl in poultry (broiler, layer) flocks in Great Britain (England, Scotland and Wales).

Food poisoning risks associated with food preparation of eggs and egg dishes in the food service industry, and especially those serving Chinese cuisine, have included high-risk practices such as pooling and mixing shelled eggs, and storing at ambient temperature for use during the day [4, 5]. Eggs are a commonly consumed food that may occasionally be contaminated with Salmonella. The rates of contamination have been linked to the origin of the eggs. Consumers and caterers still need to be aware of this continuing hazard, adopt appropriate control measures and follow advice provided by the Food Standards Agency in order to reduce the risk of infection [6]. Advice on pasteurized egg use for raw egg dishes, together with further advice on refrigerated storage of eggs and measures to prevent cross-contamination needs to be followed.

References

1. National increase in Salmonella Enteritidis PT14b infections in England. Health Protection Report 3(42); 23 October 2009, http://www.hpa.org.uk/hpr/archives/2009/news4209.htm%20#pt14b.

2. Defra. Zoonoses: National Control Programmes for the Reduction of Salmonella. Defra website: http://www.defra.gov.uk/foodfarm/farmanimal/diseases/atoz/zoonoses/ncp.htm.

3. European Commission. Commission Regulation 1237/2007 of 23 October 2007 amending Regulation 2160/2003 of the European Parliament and of the Council, and Decision 2006/696/EC, as regards placing on the market of eggs from Salmonella infected flocks of laying hens. Official Journal of the European Union, L 280, 5-9. Available at: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2007:280:0005:0009:EN:PDF.

4. Little CL, Rhoades JR, Hucklesby L, Greenwood M, Surman-Lee S, Bolton FJ, et al. (2008). Survey of Salmonella contamination of raw shell eggs used in catering premises in the United Kingdom, 2005 to 2006. Journal of Food Protection 71: 19-26.

5. Gormley FJ, Little CL, Murphy N, de Pinna E and McLauchlin J (2009). Pooling raw shell eggs: Salmonella contamination and high risk practices in the UK food service sector. Journal of Food Protection: In press, October 2009.

6. Food Standards Agency (2009). Advice for caterers on handling eggs safely. Available at: http://www.food.gov.uk/news/newsarchive/2009/oct/eggssafe.

Pandemic influenza: UK situation at 26 November 2009



The Health Protection Agency's Weekly National Influenza Report of 26 November (week 48) [1] described the UK (and international) situation as follows:
  • Pandemic influenza activity was variable across the UK;
  • In week 47 (ending 22 November), the weekly influenza/influenza-like illness (ILI) consultation rates increased slightly in England while it decreased or remained stable in Scotland, Wales and Northern Ireland;
  • The National Pandemic Flu Service (NPFS) continued to issue antiviral drugs to people in England with the number of assessments and antiviral collections increasing slightly over the past week;
  • Interpretation of data to produce estimates on the number of new cases continued to be subject to a considerable amount of uncertainty with the move to NPFS. HPA modelling gave an estimate of 46,000 (range 23,000 - 99,000) new cases in England in week 47. The estimated number of new cases decreased in most regions and age groups;
  • The main influenza virus circulating in the UK continued to be the pandemic (H1N1) 2009 strain, with few influenza H1 (non-pandemic), H3 and B viruses detected. Twenty-two of 3732 pandemic viruses tested have been confirmed to carry a mutation which confers resistance to the antiviral drug oseltamivir; three are phenotypically resistant to the drug but retain sensitivity to zanamivir. Possible person-person transmission of resistant virus has occurred in an outbreak on a hospital ward;
  • The majority of pandemic influenza cases continued to be mild. The cumulative number of deaths reported due to pandemic (H1N1) 2009 in the UK was 240. There was a total of 1463 new patients hospitalised with suspected pandemic influenza in the week from 19 to 25 November, an increase from 1483 in the previous week. The hospitalisation rates have increased in the under-5-year age group but have decreased in most other age groups recently;
  • The UK pandemic influenza vaccination programme continues in people at high risk for severe disease and in health-care workers. For further information see the Department of Health website;
  • According to the European Centre for Disease Prevention and Control (ECDC), by 25 November, 7909 deaths due to pandemic influenza had been reported globally; according to the World Health Organisation (20 November), pandemic influenza activity continues to intensify across parts of North America and much of Europe. However, there are signs that the disease may have peaked in some areas of the northern hemisphere. Virus mutations have been detected in Norway in two fatal cases and one severe case but investigations suggest that the mutation is not widespread. Canada has withdrawn a batch of pandemic vacine due to higher than expected adverse reactions.

Reference

1. HPA. Weekly National Influenza Report: week 48 (26 November 2009, PDF 429 KB), HPA website: www.hpa.org.uk/swineflu/surveillance&epidemiology.

Outbreak of E. coli O157 linked with travel to Spain

The Health Protection Agency is investigating a number of cases of the gastrointestinal infection E. coli O157 associated with travellers returning from the resort of Benidorm in Spain. To date, the Agency has been made aware of 14 confirmed cases among returning UK travellers with onset dates between 12 and 21 November, including four who were hospitalised. All confirmed cases reported so far are adults.

Health authorities in Spain have been formally notified of the situation and have commenced local investigations. Cases stayed in a number of different hotels with a small number of individuals using self-catering accommodation. No specific source has yet been identified but the Agency is working with the Spanish health authorities to assist in their investigation, conducting interviews with people affected in the UK to help identify a possible source.

Advice for travellers recently returned from this resort are contained in an HPA press release [1].

Reference

1."E. coli O157 associated with travel to Benidorm in Spain", HPA press release, 27 November 2009, http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1259151936550?p=1231252394302.