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• Imported infections, England and Wales: January to March 2009

Imported infections, England and Wales: January to March 2009

The data presented in this report should be interpreted in conjunction with the report Illness in England, Wales and Northern Ireland associated with foreign travel – a baseline report to 2002 [1], especially the content under the section ‘Sources of data on travel-associated illness and their limitations for analysis'. All data presented are provisional and subject to change; the confirmed final data will be presented on an annual basis. All data presented in table 1 are for laboratory reports with specimen dates within the first quarter of 2009 unless specified otherwise. Travel-associated infections are generally under-reported as information on travel history is incomplete through routine reporting mechanisms. For some infections listed in table 1 such as malaria, the arboviruses, leishmaniasis, schistosomiasis, filariasis, trypanosomiasis, and Rickettsia spp, it is assumed that although no country of travel is given in the laboratory report, they are all foreign travel-related as they are not known to occur in the UK.

 

Table 1. Laboratory confirmed reports of infections associated with foreign travel, England and Wales: first quarter 2009

Organism	Total reports for Q1 (Jan - Mar)				Cumulative totals for Jan - Mar
	2009*		2008		2009*		2008
	Travel-related	All reports	Travel-related	All reports	Travel-related	All reports	Travel-related	All reports
Gastrointestinal Infections
Bacterial
Salmonella spp	320	1222	390	1701	320	1222	390	1701
Campylobacter spp	225	9953	233	8272	225	9953	233	8272
Shigella flexneri	17	93	11	94	17	93	11	94
Shigella dysenteriae †	10	13	7	12	10	13	7	12
Shigella sonnei	18	207	14	96	18	207	14	96
Shigella boydii †	15	21	17	27	15	21	17	27
Other (species unknown)	1	39	2	47	1	39	2	47
Salmonella Typhi	29	60	34	65	29	60	34	65
Salmonella Paratyphi (A,B,C)	23	51	39	62	23	51	39	62
Vibrio cholerae O1†	–	–	–	–	–	–	–	–
Vibrio parahaemolyticus	1	2	–	5	1	2	–	5
Protozoal
Entamoeba histolytica	1	28	3	33	1	28	3	33
Giardia lamblia	44	661	61	671	44	661	61	671
Cryptosporidium	15	578	10	397	16	579	10	397
Cyclospora spp	2	3	2	4	2	3	2	4
Intestinal helminths
Strongyloides spp	–	5	–	6	–	5	–	6
Hookworm	1	2	3	8	1	2	3	8
Ascaris spp (round worm)	1	10	2	13	1	10	2	13
Trichuris spp (whip worm)	1	3	1	5	1	3	1	5
Hymenolepis spp	–	2	–	–	–	2	–	–
Taenia spp (tape worm)	3	17	1	17	3	17	1	17
Gnathostoma spp	–	1	–	–	–	1	–	–
Diphyllobothrium latum (fish tape worm)	–	5	–	1	–	5	–	1
Arthropod-borne infections
Malaria - total ‡	283	283	241	241	283	283	241	241
Plasmodium falciparum	229	229	194	194	229	229	194	194
Pl. vivax	26	26	25	25	26	26	25	25
Pl. malariae	10	10	5	5	10	10	5	5
Pl. ovale	17	17	15	15	17	17	15	15
Pl. unspecified	–	–	–	–	–	–	–	–
Mixed	1	1	2	3	1	1	2	3
Arboviruses
Dengue virus ‡‡	19	19	31	31	19	19	31	31
Chikungunya virus ‡‡	3	3	2	2	3	3	2	2
Ross river virus ‡‡	–	–	–	–	–	–	–	–
Sandfly fever virus ‡‡	–	–	–	–	–	–	–	–
Eastern Equine Encephalitis ‡‡	–	–	–	–	–	–	–	–
West Nile virus ‡‡	–	–	–	–	–	–	–	–
Leishmaniases
Cutaneous	–	–	–	8	–	–	–	8
Visceral	–	2	–	3	–	2	–	3
Unspecified	–	1	1	3	–	1	1	3
Filariases
Loa loa	–	1	–	–	–	1	–	–
Wuchereria bancrofti	–	–	–	–	–	–	–	–
Mansonella perstans	–	1	–	1	–	1	–	1
Onchocerca volvulus	–	–	–	–	–	–	–	–
Unspecified	–	1	–	–	–	1	–	–
Trypanosomiasis	–	–	–	–	–	–	–	–
Miscellaneous
Schistosome infections
Schistosoma mansoni	–	–	–	2	–	–	–	2
Schistosoma haematobium	5	22	2	7	5	22	2	7
Schistosoma spp	1	6	–	8	1	6	–	8
Other infections
Legionnaires' disease**	17	48	19	56	17	48	19	56
Rickettsia spp ‡‡	17	17	10	10	17	17	10	10
Lassa fever ‡‡	3	3	–	–	3	3	–	–

All data extracted from Labbase 02.06.09 unless otherwise specified.
* All data for 2009 are provisional and may be subject to change.
† Data on cholera, S.boydii and S.dysenteriae supplied by the CfI Laboratory of Enteric Pathogens.
‡ Data for malaria, for whole of UK, supplied by the HPA Malaria Reference Laboratory and are provisional. Trends are best interpreted on an annual basis.
** Data on legionnaires' disease supplied by the Legionella Section of the Respiratory Diseases Department of CfI.
‡‡ Data from the Special Pathogens Reference Unit, Centre for Emergency Preparedness and Response.

 

Gastrointestinal infections

Gastrointestinal infections are the most common travel-associated infection, affecting travellers worldwide. “Travellers' diarrhoea” affects between 20% and 60% of overseas travellers [2] and may be viral, bacterial or protozoal in origin; the risk of illness usually depends on the country visited.

Salmonella spp (non-typhoidal)

There were 1222 laboratory reports of Salmonella spp, of which 320 (26%) were associated with recent travel abroad. Salmonella serovar Enteritidis was the most common serotype associated with travel abroad (104/320, 33%), of which phage type (PT) 1 was the most commonly reported (22/104, 21%), followed by S. Typhimurium (49 reports, 15%) and S. Virchow (21 reports, 7%). The 10 most reported countries of travel for Salmonella are listed in table 2.

Table 2. Laboratory reports of other Salmonella spp associated with foreign travel, England and Wales: first quarter 2007

Country of travel	S Enteritidis	S Typhimurium	S Virchow	Other Salmonella spp	Total
India	7	8	1	29	45
Egypt	30	2	1	8	41
Thailand	4	3	3	15	25
Kenya	4	2	1	7	14
The Gambia	–	–	5	8	13
Pakistan	–	1	1	9	11
Morocco	5	3	–	2	10
Tunisia	8	1	–	–	9
Bangladesh	–	1	3	5	9
Mauritius	4	3	–	1	8
Other countries (N=47)	32	17	4	41	94
Country not stated	10	8	2	21	41
Total	104	49	21	146	320

 

Campylobacter spp

There were 9953 laboratory reports of Campylobacter spp, of which 225 (2%) were associated with recent travel abroad (table 3).

Table 3. Laboratory reports of Campylobacter spp associated with foreign travel, England and Wales: first quarter 2009.

Country of travel	Campylobacter spp
India	60
Thailand	21
Morocco	20
Spain	19
Egypt	11
Pakistan	9
France	5
South Africa	4
Sri Lanka	4
Mexico	4
Other countries (N=39)	57
Country not stated	11
Total	225

 

 

 

 

 

 

 

 

 

 

 

Shigella spp

In total, there 373 reports of shigella infection in the first quarter of 2009, of which 61 (16%) were associated with foreign travel. Travel history information was available for 74% for both S. boydii and S. dysenteriae reports, but for only 22% for S. sonnei and S. flexneri. Countries of travel are listed for each species in table 4.

Table 4. Laboratory reports of Shigella spp associated with foreign travel, England and Wales: first quarter 2009

Country of travel	Shigella species					Total
	S. flexneri	S. sonnei*	S. boydii	S. dysenteriae	Shigella sp
Egypt	6	7	2	–	–	15
India	2	3	6	3	–	14
Pakistan	2	1	4	4	–	11
Bangladesh	1	–	1	–	–	2
Sub-Saharan Africa	5	2	2	3	1	13
Spain	1	–	–	–	–	1
United Arab Emirates	–	2	–	–	–	2
Kuwait	–	1	–	–	–	1
Papua New Guinea	–	1	–	–	–	1
Country not stated	–	2	–	–	–	2
Total	17	19	15	10	1	62

* One case of S. sonnei had more than one country of travel so is included twice in table.

Cryptosporidium

There were 578 reports of cryptosporidium infection, of which 15 (3%) were associated with recent foreign travel. Countries of travel reported were India (three), Pakistan (two), and Egypt, Chile, Kenya, Cyprus, USA, Asia (unspecified), Cameroon, Malawi and Syria (one each); one report had no country stated. Sentinel surveillance submission forms to the UK Cryptosporidium Reference Unit (CRU) during the same time frame included 13 (8% of total) travel abroad-related cases [3]. Countries of travel reported to CRU were Bulgaria (one Cryptosporidium parvum), Burma (one Cryptosporidium hominis), Chile (one C. hominis), Egypt (one C. hominis), India (three C. hominis, one C. meleagridis), Malawi and Ethiopia (one not typable), Pakistan (one C. hominis), South Africa (one C. parvum), Spain (one C. parvum) and one had no country of travel stated (C. parvum).

Giardia lamblia

There were 661 giardia infections reported, of which 44 (7%) were associated with recent foreign travel. Countries of travel reported were India (17), Egypt (five), Pakistan (three), Nepal (three); 13 other countries (spread worldwide) were reported (17 reports; some travelled to more than country) and two reports had no country stated.

Other intestinal protozoa

Other intestinal protozoa reported were Entamoeba histolytica; one out of a total of 28 was associated with recent foreign travel to Singapore. There were three reports of Cyclospora, of which one was associated with travel to Peru and one had been on a cruise (destinations not stated).

Enteric fever

During the first quarter of 2009, there were 60 reports of S. Typhi and 51 reports of S. Paratyphi A.

Forty-eight percent (29/60) of S. Typhi and 45% S. Paratyphi (23/51) reports were associated with recent foreign travel. Countries of travel are listed in table 5. The Indian sub-continent remains the most reported region of travel for cases of enteric fever and is mainly associated with those visiting friends and relatives in their country of ethnic origin [4].

Table 5. Laboratory reports of enteric fever associated with foreign travel, England and Wales: first quarter 2009

Resort country	Salmonella spp		Total
	S. Paratyphi A	S. Typhi
India	10	10	20
Pakistan	6	10	16
Bangladesh	1	2	3
Nigeria	–	2	2
Angola	–	1	1
Egypt	–	1	1
Panama	1	–	1
Philippines	1	–	1
South Africa	–	1	1
South America unspecified	1	–	1
Sri Lanka	1	–	1
Country not stated	2	2	4
Total	23	29	52

 

Intestinal helminths

In the first quarter of 2009 there were 47 reports of intestinal helminth infections, of which six were reported to be associated with recent foreign travel. Three cases of infection with Taenia saginata stated recent travel to India (one), Thailand (one), and one had no country stated. One case of hookworm infection was associated with travel to Papua New Guinea; one case of Ascaris lumbricoides was associated with travel to Viet Nam and one case of Trichuris trichiura had no country stated. Helminth infections can persist in the body for months and it may not be possible to say for certain where these infections were acquired; they are probably associated with new entrants to the UK as well as short-term travellers.

 

Arthropod-borne infections

Malaria
During the first quarter of 2009, there were 283 cases of malaria reported in the United Kingdom, a 17% increase compared to the same period in 2008. The majority (81%, 229 cases) were caused by the parasite, Plasmodium falciparum and 9% (26 cases) were caused by P. vivax. Where region of travel was known (139/187), 74% of malaria cases caused by P. falciparum were reported to be acquired in West Africa, and 65% (15/23) of P. vivax cases were reported to be acquired in Asia.

Dengue
Nineteen cases (all probable) were reported by the HPA Special Pathogens Reference Unit (SPRU) in the first quarter. All but one had information about foreign travel. Six cases were associated with travel to Thailand, three to India; the remaining cases had travelled to Australia, Brazil, Cambodia, Fiji, French Guiana, Indonesia, Malaysia, Singapore, and Trinidad and Tobago (all one case each).

Chikungunya
Three cases of chikungunya (one probable and two suspected) were reported by SPRU during the first quarter. Countries of travel reported were India, Malaysia and Pakistan.

Leishmaniasis
There were three cases of leishmaniasis reported in the first quarter, two presumed to be visceral leishmaniasis and one of unknown type; none of them had a country of travel stated.

Other infections

Schistosomiasis
Of 28 reports of infection with Schistosoma spp, 22 were S. haematobium and six were unknown. Only six reported recent travel abroad of which two had been to Africa (one S. sp and one S. haematobium), the remainder were S. haematobium with reported travel to Malawi (one), Tanzania (one) and one had no country stated.

Rickettsial infections
There were 17 cases of rickettsial infection reported by the SPRU in the first quarter. Fifteen were spotted fever (one confirmed, eight probable, and six suspected) of which five cases had no country of travel, seven had travelled to South Africa (one also to Mozambique); other countries reported were India, Senegal and Afghanistan (one report each). There were two reports of epidemic typhus (one confirmed, one suspected) and both had no country of travel stated.

Legionnaires' disease
There were 48 cases of Legionnaires' disease reported in the first quarter, of which 17 (35%) were associated with foreign travel. Three of the 17 cases were associated with travel to the United Arab Emirates and one case was part of an outbreak in Italy.

 

References
1. Health Protection Agency. Illness in England, Wales, and Northern Ireland associated with foreign travel – a baseline report to 2002. London: HPA, 2004. Available at: http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1203496904956?p=1158945066450.

2. National Travel Health Network and Centre. Prevention of food and waterborne diseases (information sheet): London: NaTHNaC, November 2006. Available at: http://www.nathnac.org/pro/factsheets/food.htm.

3. Personal communication. Rachel Chalmers, Head of UK Cryptosporidium Reference Unit, NPHS Wales, 24 June 2009.

4. Health Protection Agency. Foreign travel-associated illness – a focus on those visiting friends and relatives, 2008 report. London : HPA, 2008. Available at: http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1231419800356.