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Volume 3 No 49; 11 December 2009

HPR Home | Archives | 2009 news

• Hepatitis C diagnoses increasing across the UK
  
  
• Interim report on first year of the norovirus in hospitals reporting scheme
  
  
• Food-borne outbreaks of Campylobacter (associated with poultry liver dishes) in England
  
  
• Pandemic influenza: UK situation at 3 December 2009
  
  

Hepatitis C diagnoses increasing across the UK

Increased public awareness of hepatitis C infection may have been partly responsible for the 6% increase in new laboratory-reported diagnoses of the infection in England (to 8,196) in 2008 compared with 2007. However, awareness campaigns need to be not only sustained but further enhanced if they are to have major impact on the numbers of people suffering from liver disease in the future, the HPA's 2009 report on hepatitis C (HCV) [1] stresses.

The report records several routine data sources - including HCV-related deaths, liver transplants and hospital admissions - that confirm that HCV-related morbidity and mortality continues to rise across the UK. In the case of hospitalisations of individuals with end-stage liver disease, there has been a steady year-on-year increase in England and Wales for more than a decade (see figure 1).

Annual number of individuals in England, Scotland and Wales hospitalised with hepatitis HCV-related end-stage liver disease (ESLD) and HCV-related hepatocellular carcinoma (HCC)


1. Refers to individuals in England and Wales hospitalised with HCV-related ESLD and HCV-related HCC.
2. Refers to individuals diagnosed with hepatitis C and admitted to hospital for the first-time with either ESLD or HCC (including cases both with and without mention of hepatitis C on the hospital record).
Data sources: Hospital Episode Statistics, England; Health Protection Scotland, in association with the Information Services Division; Patient Episode Database for Wales (PEDW) 2009.


It is estimated that currently around 185,000 individuals in the UK are chronically infected with the virus (142,000 in England and Wales, 39,000 in Scotland and 4,000 in Northern Ireland) – all at risk of developing serious liver disease. Much of the prevalent infection is concentrated in marginalised populations – with injecting drug users (IDUs) at greatest risk of acquiring infection. More recent evidence suggests that some minority ethnic populations are also at increased risk of infection.

The report summarises the progress of UK action plans that are in place to help tackle HCV infection in England, Scotland and Northern Ireland (a Welsh Action Plan is due to be implemented). These all comprise activities under four main headings: preventing new infections; increasing awareness of the infection amongst the public and healthcare professionals; increasing diagnosis; and getting diagnosed individuals into treatment and care.

The future HCV-related burden on the health service will be substantial if awareness, diagnosis and treatment do not increase, the report notes.

The work of the Health Protection Agency includes monitoring trends in hepatitis C at a national level and working with other agencies through a network of local leads to improve services for the prevention, diagnosis and treatment of hepatitis.

Reference

1. Hepatitis C in the UK - 2009 report. Downloadable at: www.hpa.org.uk/hepC2009.

Interim report on first year of the norovirus in hospitals reporting scheme

Since 1 January 2009 the HPA has been coordinating a reporting system for norovirus outbreaks in hospitals. The scheme, developed in consultation with the Infection Prevention Society, has now been running for nearly a year. Infection control teams based in acute trusts enter data directly into a web based system, accessed via the web address: http://www.hpa-bioinformatics.org.uk/noroOBK/. Reporting to the system is voluntary; however, there has been a good response. The first report published data from the first six months of reporting to the end of June, showed that 350 outbreaks were reported between January and June this year. Norovirus activity increases during the winter months coinciding with increased activity in respiratory infections and childhood diarrhoea, increasing pressures on acute services and competing demand for beds. The mainstay of norovirus outbreak control is ward closure which is highly disruptive and in itself leads to increased pressures on bed demand. This interim report is to update users of the system to the current situation on norovirus outbreaks reported in trusts to the beginning of December (to the end of week 48), and to heighten awareness of the reporting system.

Outbreak reporting pattern

Four hundred and fifty eight outbreaks were reported by 61 trusts in England since the beginning of January. Sixty percent of outbreaks reported occurred between January and March this year and declined during the spring and summer months. Outbreak reports are now beginning to rise again. Figure 1 shows outbreaks and laboratory reports in each month as a proportion of the annual total reported in each system.

Figure 1. Proportion of all outbreak and laboratory reports by month of outbreak occurrence

Trusts from all regions in England reported outbreaks, the highest numbers were reported from the North West and South West regions (see table 1). Eighty three percent of outbreaks involved ward closures with wards being closed on average for seven days (range 0-54 days) leading to a total of 6352 reported bed days lost (range 0-173 average 24 per outbreak). Sixty nine percent of reported outbreaks were laboratory confirmed as norovirus.

Table 1. The number of suspected and confirmed norovirus outbreaks reported by region 01/01/2009-01/12/2009

HPA Region	Outbreaks reported (n)
East	23
East Midlands	33
London	10
North East	47
North West	102
South East	59
South West	89
West Midlands	47
Yorkshire and Humberside	48
Total	458

Outbreaks affected a range of wards, the most commonly affected are general medicine (32%) and care of the elderly (15%) other wards including stroke, oncology and cardiac care wards were also affected (see figure 2). A total of 4481 patients and 1265 staff were affected, on average, each outbreak affected ten patients (range 0-34) and three staff (range 0-21) per outbreak.

Figure 2. Breakdown of wards affected by outbreaks

Discussion

The previous report highlighted that the outbreaks reported to this scheme were likely to be an underestimate. We have not estimated the scale of under-reporting for the purpose of this update. The data from laboratory reports does indicate that there is now an upturn in norovirus infections and the data on reported outbreaks correlates very well with this. The reporting system does not record how long affected staff are off ill. However, it is possible to make estimates based on the usual clinical pattern of norovirus. Assuming illness lasts two days and staff are off sick from day one, and allowing for 48 hours after symptoms subsided before staff can return to work, we can assume that illness lasts for four days. Allowing for a working week of 37.5 hours and staff working 5/7 days per week: days of work lost = 4 x 5/7 = 2.86. Given that there were a reported 1265 staff involved in outbreaks, this would have led to around 2.86 x 1265 = 3618 working days lost to the NHS in England due to norovirus outbreaks.

In summary norovirus continues to be a common cause of outbreaks in hospitals in England with considerable impact to both patients and staff. In order to continue to be able to provide accurate estimates of this impact we would encourage people to report outbreaks to the reporting scheme.

Food-borne outbreaks of Campylobacter (associated with poultry liver dishes) in England

Campylobacter is the most common bacterial cause of food poisoning in England and Wales. While the incidence of Salmonella infections has steadily declined since the late 1990s those caused by Campylobacter are showing an upward trend with a marked increase observed during 2009 [1]. The epidemiology of campylobacteriosis is complex, with meat, unpasteurised milk, and untreated water all contributing. There is however strong evidence that the handling of raw chicken, and eating undercooked chicken is the most common cause of illness [2].

Of note there have been 11 foodborne outbreaks of Campylobacter in England reported to the Health Protection Agency (HPA) so far this year. Ten of these were associated with catering premises (restaurants, functions), one with a school, and in all a total of 259 persons were affected. Nine (82%) of the 11 outbreaks at catering premises were linked to poultry liver parfait or pâté consumption (8 and 1 prepared from chicken and duck livers, respectively) and the school outbreak linked to chicken curry consumption. Evidence from the catering outbreaks showed that poultry liver parfait or pâté were prepared by deliberate undercooking (searing by flash frying) of chicken livers or inadequate cooking of the blended duck livers in a bain marie used in the preparation of this dish. The proportion of foodborne outbreaks of Campylobacter linked to poultry liver parfait or pâté reported to the HPA has increased since 2007 (2007-2009 to date, 75% (15/20); 1992-2006, 9.5% (9/95)) (P<0.0001). Campylobacter outbreaks linked to pâté consumption have also been recently reported in Scotland [3, 4].

The widespread contamination of raw poultry meat and animal livers with Campylobacter is well documented [5, 6, 7]. Studies have also shown that pathogens such as Campylobacter may be present both on the outside and the inside of chicken liver and inadequate cooking can result in viable pathogens remaining in the end product [8]. This reinforces the need to cook poultry livers and other varieties of animal offal until a safe internal temperature is reached. Pâté dishes made from meat have also been associated with Salmonella and Listeria infections. Caterers and consumers need to be aware of these hazards, adopt appropriate control measures, and follow advice provided by the Food Standards Agency in order to reduce the risk of infection, ie preventing cross-contamination when handling raw meats, cooking thoroughly all animal offal, including poultry livers, before consumption (to a core temperature of 70°C for at least two minutes or equivalent) [9], and keeping foods properly refrigerated.

References

1. Health Protection Agency. Increased Campylobacter cases in 2009. Health Protection Report 3(31); 7 August 2009. http://www.hpa.org.uk/hpr/archives/2009/news3109.htm#camp09.

2. Advisory Committee on the Microbiological Safety of Food (2005). Second Report on Campylobacter. http://www.food.gov.uk/multimedia/pdfs/acmsfcampylobacter.pdf.

3. Forbes KJ, Gormley FJ, Dallas JF, Labovitiadi O, MacRae M, Owen RJ, et al (2009). Campylobacter immunity and coinfection following a large outbreak in a farming community. Journal of Clinical Microbiology 47: 111-116.

4. Health Protection Scotland (2009). Surveillance Report. Gastro-intestinal and foodborne infections (General outbreaks of infectious intestinal disease reported to HPS in the third quarter of 2009). http://www.hps.scot.nhs.uk/giz/wrdetail.aspx?id=43393&wrtype=6.

5. Kramer JM, Frost JA, Bolton FJ, Wareing DRA (2000). Campylobacter contamination of raw meat and poultry at retail sale: identification of multiple types and comparison with isolates from human infection. Journal of Food Protection 63: 1654-1659.

6. Food Standards Agency (2009). FSA report for the UK survey of Campylobacter and Salmonella contamination of fresh chicken at retail sale. http://www.foodbase.org.uk/admintools/reportdocuments/351-1-676_B18025.pdf

7. Little CL, Richardson JF, Owen RJ, de Pinna E, Threlfall EJ (2008). Prevalence, characterization and antimicrobial resistance of Campylobacter and Salmonella in raw poultrymeat in the United Kingdom, 2003 to 2005 . International Journal of Environmental Health Research 18: 403-414.

8. Whyte R, Hudson JA, Graham C (2006). Campylobacter in chicken livers and their destruction by pan frying. Letters in Applied Microbiology 43: 591-595.

9. Food Standards Agency (2009). Eat Well, Be Well - Cooking. http://www.eatwell.gov.uk/keepingfoodsafe/cooking/.

Pandemic influenza: UK situation at 10 December 2009

The Health Protection Agency's Weekly National Influenza Report of 10 December (week 50) [1] described the UK (and international) situation as follows:

• Pandemic influenza activity is decreasing across the UK;
• In week 49 (ending 6 December), the weekly influenza/influenza-like illness (ILI) consultation rate increased slightly in England, Wales and Northern Ireland and remained stable in Scotland;
• The National Pandemic Flu Service (NPFS) continued to issue antiviral drugs to people in England with the number of assessments and antiviral collections The number of assessments and antiviral collections through this service have decreased 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. HPA modelling gave an estimate of 11,000 (range 6,000 - 24,000) new cases in England in week 49. The estimated number of new cases decreased in all regions and age groups;
• An increase in respiratory syncytial virus detections has been observed in recent weeks, which may account for increases in some respiratory indicators for children aged less than five years.
• 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-five of 4229 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;
• 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 282. There was a total of 1223 new patients hospitalised in England with suspected pandemic influenza in the week from 3 to 9 December, a decrease from 1384 in the previous week. The hospitalisation rates have decreased in most age groups, including the under-5's;
• 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 World Health Organisation (4 November), pandemic influenza activity continues to intensify across central Europe and parts of central, eastern and southern Asia. In North America and much of western and northern Europe, activity has peaked. Many tropical areas are reporting declining activity  and there is evidence of continued co-circulation of pandemic and seasonal (H3N2) influenza viruses in parts of Africa.

Reference

1. HPA. Weekly National Influenza Report: week 50 (10 December 2009, PDF 445 KB), HPA website: www.hpa.org.uk/swineflu/surveillance&epidemiology.