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Volume 4 No 26; 2 July 2010

Hine review of the UK response to the 2009 influenza pandemic

The Cabinet Office review of the UK response to the 2009 influenza pandemic has endorsed most aspects of the national pandemic preparedness arrangements that were in place before the arrival of the 2009 (H1N1) influenza virus in the UK at the end of April 2009 [1].

The Health Protection Agency welcomes the review, led by Dame Deirdre Hine, which assesses the work done by the Agency, the Department of Health and other agencies both in the preparation for, and throughout the course of, the pandemic.

The HPA contributed significantly to the UK pandemic plan in addition to being at the forefront of the swine flu response when the first cases were seen in England. The Agency welcomes the report's finding that the UK's response was "proportionate and effective" and its recognition that there is much good practice on which to build.

The report also commended many other areas including the scientific advice given to the government as the infection spread, the response from the NHS and other health protection bodies, the communications management arrangements and the calm public reaction. These, together with the unexpectedly mild nature of the virus itself led to the pandemic having a much smaller impact in the UK than had been feared, notwithstanding the 457 related UK deaths up to 18 March 2010.

Most of the review's 28 recommendations are concerned with how the national framework plan [2], and some of the ancillary emergency preparedness arrangements, might be revised to take account of the lessons learned; the review recommends that a revised national framework plan should be re-issued before March 2011.

Other recommendations cover: the central government response; the scientific advice received by officials and ministers; antiviral treatment and vaccination strategies.

The HPA also welcomes the report's acknowledgement of the rapidity with which health protection staff and front-line healthcare services established new ways of working in order to implement the containment policy and the "dedication and professionalism" of health protection staff.

During the development of the national pandemic flu plan HPA experts gave advice and guidance to government on a wide range of topics including the use of school closures to stop the spread of disease, advice on infection control measures, travellers' health and the use of antivirals to reduce the spread and the severity of flu symptoms, all of which were fundamental in the UK response. The pre-existing guidance was adapted during the summer of 2009 as more information became available on the new virus. Other key activities carried out by the HPA included surveillance of the flu virus, virology, modelling, communications, epidemiological data, vaccine development and a local response delivered through the Health Protection Units.

References

1. Cabinet Office. An independent review of the UK response to the 2009 influenza pandemic, 1 July 2010. Available at: http://www.cabinetoffice.gov.uk/ukresilience/ccs/news/100701-flu-pandemic-review.aspx.

2. Department of Health. Pandemic flu: A national framework for responding to an influenza pandemic. Available at: http://www.dh.gov.uk/en/
Publicationsandstatistics/Publications/PublicationsPolicyandGuidance/DH_080734.

Surveillance of travel-related Legionnaires Disease in Europe

In a recent paper, the results of investigations into more than 100 clusters of travel-related Legionnaires Disease (LD) cases with an onset date in 2008, identified through the European surveillance mechanism established in 1987, are reported [1].

A feature of the European surveillance scheme is that, by collating information about cases reported through the network at a European level, travel-related clusters involving residents of more than one country can be identified that could not have been picked up by any single national surveillance scheme. Of the 108 "new clusters" (see below) covered in the recent paper, 38 were in this category, involving no more than one case from any single reporting country.

The European surveillance system for travel-related LD comprises a web-based network of collaborating public health centres currently coordinated by the European Centre for Disease Prevention and Control in Stockholm.  (ECDC took over management of the network, now known as ELDSNet - the European Legionnaires' Disease Surveillance Network in April 2010 [2].  It had previously been known as EWGLINET - European Surveillance Scheme for Travel-associated Legionnaires' Disease, previously co-ordinated from the HPA Centre for Infections, London.) In 2008, 30 European countries were covered by the European scheme.

The collation of reports of travel-associated cases reported through the network is now carried out by ELDSNet.  Clusters are investigated - under the direction of ECDC - in those countries that are signed up to the relevant European guidelines [3]. Site operators are required to implement post-incident remedial measures or face "publication" on ELDSNet website [4].

The recent paper is an analysis of data from a total of 144 site investigations carried out by EWGLI related to 866 travel-associated cases reported through the network with an onset date in 2008. The 144 investigations were associated with 108 "new clusters" of cases while 35 related to clusters associated with sites that had been the subject of an investigation in the preceding two years and were therefore classified as not new, being associated with "re-offending" sites.

The paper notes that the increasing availability and use of sequence-based typing techniques, although as yet only in a small minority of investigations, provides a rapid means of matching clinical and environmental cultures during cluster investigations and improving the quality of evidence in cases where a particular accommodation site is suspected of being the source of infection.

References

1. Ricketts K, Joseph CA and Yadav R, on behalf of EWGLI. Travel-associated Legionnaires' disease in Europe in 2008, Euro Surveill, 15(21). Available at: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19578.

2. http://ecdc.europa.eu/en/activities/surveillance/ELDSNet/Pages/Index.aspx.

3. European guidelines for control and prevention of travel-associated legionnaires' disease [283 KB PDF]. Downloadable via the HPA website at: Home › Topics › Infectious Diseases › Infections A-Z › Legionnaires' Disease ›Guidelines › European Advice and Guidance.

4. When a traveller who has contracted legionnaires' disease has stayed (during the two to 10-day incubation period) at a hotel participating in the ELDSNet scheme, the hotel is sent a checklist to ensure it is following the best practice for control of risk of legionella contamination of its water systems. This is a precautionary measure as there may be no connection between the illness and the hotel. When a cluster is identified as being associated with a particular hotel, however, the guidelines require more detailed investigation, including a risk assessment, sampling and control measures. Progress with the investigation has to be reported and if these reports are incomplete or are not received on time, details of the cluster site are published on the ELDSNet public website, indicating that there is uncertainty about whether the risk of legionella infection is under control at the site. In respect of the cases covered by the paper reported here, the names of 12 such sites were published.