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Volume 6 No 32; 10 August 2012

HSE consultation on sharps regulations

The Health and Safety Executive (HSE) has published a consultation document containing draft "health and safety (sharp instruments in healthcare) regulations" with a view to implementing the European Union council directive 2010/32/EU on the prevention of sharps injuries in the hospital and healthcare sector, which is due to come into force in member states in May 2013 [1].

The proposed regulations would introduce explicit provisions relating to the prevention of sharps injuries in healthcare, including: safe use and disposal; information and training of healthcare workers; and actions to be taken by employers following injury, including post-injury investigation and post-exposure prophylaxis where appropriate.

The regulations would apply to all "healthcare employers" (ie those whose main activity is managing, organising or providing healthcare), which would include hospitals, GPs, dental surgeries ambulance services and care homes, and in some cases their sub-contractors if they are involved in providing laundry, cleaning or waste disposal services.

Significantly they would introduce the same "hierarchy of control" as exists in other health and safety legislation requiring, as far as reasonably practicable, that alternative, safer devices are used.  The consultation document's impact assessment includes a presentation of the evidence base underpinning proposals for implementing the directive. This stresses that "safer sharps" are  "one control measure in the Directive that is intended to be considered alongside others (such as elimination and prevention through safer working practices) when assessing the risk". HSE has amended the wording of the directive, in the process of transposition, so as to make clear that measures such as use of safer devices and banning of recapping would not be absolute requirements of the proposed regulations.

Reference

1. Consultation on proposed regulations to implement Council Directive 2010/32/EU on preventing sharps injuries in the hospital and healthcare sector (CD244), see HSE website at: http://www.hse.gov.uk/consult/condocs/cd244.htm.  Further information: Martin Dilworth, HSE, 5S2 Redgrave Court, Merton Road, Bootle, Liverpool L20 7HS; tel: 0151 951 4335; email: sharpsconsultation@hse.gsi.gov.uk. The consultation began on 8 August 2012 and ends on 8 November 2012.

Increase in hepatitis E cases in England and Wales

Hepatitis E virus infections in the past have been associated with travel to endemic areas. More recently, indigenous cases have been increasingly recognised in developed countries, including in England and Wales [1,2].

The number of reference laboratory confirmed cases in England and Wales, which was stable prior to 2010/11, has substantially increased since then (see table); non-travel associated cases account for most of the increase and are now in the majority (56%) (of which more than 60% are male and over 50 years of age, with no geographical clustering).

Enhanced surveillance for hepatitis E in England and Wales: reference laboratory* confirmed cases

Year

2007

2008

2009

2010

2011

Number

162

176

175

274

454

Non-travel** (%)

62 (38%)

78 (44%)

78 (44%)

152 (56%)

253 (56%)

*Birmingham Regional HPA Laboratory and VRD Microbiology Services Colindale.
** "No travel" stated on laboratory request form or, where no information Caucasian name used as a proxy.

As in mainland Europe, the genotype 3 virus found in human infections in England and Wales is very similar to that found in swine [3]. Food sources and risk factors, including consumption of pig products and contact with pigs, have been reported [4,5]. With evidence of a similar virus circulating in pigs, routes of transmission to humans in England and Wales are likely to be zoonotic. In addition, a recent study has shown 10% of pork sausages sampled at point of sale from UK retailers were positive for hepatitis E [6], suggesting that these products could be a potential vehicle for hepatitis E virus transmission.

HPA is currently investigating with colleagues in the Department for Environment, Food and Rural Affairs, the Food Standards Agency and the Animal Health and Veterinary Laboratories Agency.

References

1. Ijaz S, Arnold M, Bendall RP, et al. Non-travel-associated hepatitis E in England and wales: demographic, clinical and molecular epidemiological characteristics. J Infect Dis 2005; 192: 1166-72.

2. Lewis HC, Boisson S, Ijaz S, et al Hepatitis E in England and Wales. Emerg Infect Dis 2008; 14: 165-7.

3. Banks M, Bendall R, Grierson S, et al. Human and porcine hepatitis E virus strains, United Kingdom. Emerg Infect Dis 2004; 10: 953-5.

4. Lewis HC, Wichmann O, Duizer E. Transmission routes and risk factors for autochthonous hepatitis E virus infection in Europe: a systematic review. Epidemiol Infect. 2010; 138: 145-66.

5. Wilhelm BJ, Rajic A, Grieg J, et al. A systematic review/meta-analysis of primary research investigating swine, pork or pork products as a source of zoonotic hepatitis E virus. Epidemiol Infect2011; 139: 1127-44.

6. Berto A, Martelli F, Grierson S, Banks M. Hepatitis E virus in pork food chain, United Kingdom, 2009-10. Emerg Infect Dis  2012; 18(8): 1358-60.

Legionnaires’ disease outbreak in Stoke-on-Trent

Public and environmental health experts in the West Midlands are continuing to investigate a legionnaires' disease outbreak at Stoke-on-Trent after identifying the probable source as a hot tub on display in a store in the town.  Appropriate control measure have now been put in place. As at 10 August, the number of confirmed cases associated with the outbreak was 21, including two fatal cases.

In the meantime, the Health and Safety Executive (HSE), having reviewed significant outbreaks in Great Britain over the past 10 years [2], has issued a safety notice reminding operators of cooling towers and evaporative condensers - the most common source of such events - of the need for effective and consistent monitoring of water quality and the importance of responsibilities being assigned to named individuals with proper management oversight of such facilities [3].  

References

1. "Media update on legionnaires' disease in Stoke-on-Trent", HPA press notice, 3 August 2012.

2. Legionella outbreaks and HSE investigations; an analysis of contributory factors (Health and Safety Laboratory report HEX/12/07), HSE website: http://www.hse.gov.uk/research/hsl_pdf/2012/hex1207.pdf.

3. Management of the risks from legionella in cooling towers and evaporative condensers (27 July), HSE website: http://www.hse.gov.uk/safetybulletins/coolingtowers.htm.

Summary results of the second national survey of abnormal prion prevalence in archived appendix specimens

In April 2008, the Spongiform Encephalopathy Advisory Committee (SEAC) considered available prevalence data for variant Creutzfeldt-Jakob Disease (vCJD) in the British population and advised that a second appendix survey, using the same approach as a previous appendix tissue survey [1] on samples from the 1941 to 1985 birth cohort, be undertaken to further refine the estimate for the prevalence of subclinical infection [2].The second unlinked anonymous survey of the prevalence of abnormal prion protein in archived appendix tissues has now been completed and this summary provides an update to the interim results published in September 2011 [3,4].

The survey examined appendices by immunohistochemistry from operations conducted between 2000 and 2012 and collected from 41 hospitals throughout England. Abnormal prion accumulation was detected within the follicular dendritic cells of 16 appendices out of 32,441 suitable samples examined. None of the positive appendices have come from the 176 known vCJD cases in the UK. In line with the interim findings, the final overall prevalence estimate, 493 per million (95% Confidence Interval (CI): 282 to 801 per million), remained statistically consistent with results from the earlier appendix survey (237 per million, 95%CI 49 to 692 per million) which examined samples from operations performed between 1995 and 1999 [1]. The prevalence estimates by birth cohort were 733 per million (95% CI: 269 to 1596 per million) in those born between 1941 and 1960 and 412 per million (95% CI: 198 to 758 per million) in those born between 1961 and 1985: these results were also in line with the interim findings [3,4].

The survey was conducted by a collaboration of the HPA, the Department of Neurodegenerative Diseases at the UCL Institute of Neurology, the Animal Health and Veterinary Laboratories Agency, the National Creutzfeldt-Jakob Disease Research and Surveillance Unit, the Histopathology Department of Derriford Hospital in Plymouth, and the MRC Prion Unit.

The final survey results have been considered by the Transmissible Spongiform Encephalopathies Risk Assessment Sub-Group of the Advisory Committee on Dangerous Pathogens, the successor to SEAC [5]. In summary, the estimated prevalence range largely overlaps that from the first survey, but is narrower with a higher central estimate (around 1 in 2000 compared with around 1 in 4000). The new survey also demonstrates the presence of prion protein across a wider birth cohort than previously.

The hypothesis that the prevalence of abnormal prions found in both appendix surveys to date is linked to the epidemic of BSE in cattle in Britain can be tested directly by studying further appendix samples archived prior to the BSE outbreak and samples from those born in 1996 or later by which time measures had been put in place to protect the food chain [5].

References

1. Hilton DA, Ghani AC, Conyers L, Edwards P, McCardle L, Ritchie D, et al. Prevalence of lymphoreticular prion protein accumulation in UK tissue samples. J Pathol 2004; 203: 733-9.

2. Spongiform Encephalopathy Advisory Committee (SEAC). Position Statement. Prevalence of subclinical variant Creutzfeldt-Jakob Disease infections. August 2008. SEAC position statement.

3. HPA. Interim data from the current national survey of abnormal prion prevalence in archived appendix specimens. September 2011. Health Protection Report 5(36). Available at: http://www.hpa.org.uk/hpr/archives/2011/news3611.htm#cjd.

4. HPA. Creutzfeldt-Jakob disease (CJD) biannual update (2012/1). February 2012. Health Protection Report 6(6). Available at: http://www.hpa.org.uk/hpr/archives/2012/hpr0612.pdf.

5. Advisory Committee on Dangerous Pathogens (ACDP) TSE Risk Assessment Subgroup. Position Statement on occurrence of vCJD and prevalence of infection in the UK population. July 2012. Available at: http://www.dh.gov.uk/ab/ACDP/TSEguidance/DH_125868.