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Volume 3 No 13; 3 April 2009

Group A streptococcal infections: third update on seasonal activity, 2008/09

National surveillance data for group A (Streptococcus pyogenes) streptococcal infections continued to show levels of seasonal activity above the expected based on comparison with the past five seasons (2002/03 onwards) throughout December, January, and February. Scarlet fever notifications have remained consistently above the levels seen since the mid to late 1990s. Numbers of invasive disease cases appear to have fallen since the high incidence towards the end of December 2008 and into January 2009, although increases have subsequently been seen in March. In light of this continued increase in invasive group A streptococcal disease, a letter via the Chief Medical Officer for England's Central Alerting System was issued to general practitioners and hospital doctors reminding them of the importance of early detection and rapid initiation of treatment in suspect cases [1].

Scarlet fever

From week 48 of 2008 onwards, notifications of scarlet fever in England have been above the average for the past decade (1998/99 to 2007/08) and currently above the average for the previous decade (1988/89 to 1997/98). A total of 1739 unconfirmed notifications of scarlet fever were made for weeks 48 of 2008 to week 12 of 2009, the highest since 1995/96 (2143). The highest weekly number of notifications for this season so far were for the most recent week, week 12, with 233 notifications made across England.

Figure 1 Weekly scarlet fever notifications; England: 1988/89 to 2008/09*


*up to week 12 of 2009

Notifications of scarlet fever in Wales so far this season (weeks 37 of 2008 to week 12 of 2009) were within the range seen in the previous five seasons. Within England, notifications were higher for weeks 37 of 2008 to week 12 of 2009 than the previous five years in all regions, although more elevated in London, the South East, East of England and West Midlands than elsewhere. The age distribution of scarlet fever cases is similar to previous years, with 83% of cases being children aged less than 10 years, with an age range from 0 to 99 (mode of 4 years).

Clinical incidence data for pharyngitis/scarlet fever derived from the QSurveillance® GP surveillance system shows a slight increase for 2008/09 compared to 2007/08 [2].

Invasive group A streptococcal infection

Routine laboratory reports of invasive group A streptococcal (iGAS) infection, defined as the isolation of GAS from a normally sterile site, from across England, Wales, and Northern Ireland continued to show an increase throughout December, peaking in week 52 (48 reports). In total, 156 reports were received in December, compared to a range of 80 to 127 for the same period in 2002 to 2007. Reports for January (143) and February (121) were just below the same months in 2004 (163 and 122 respectively), 2003/04 being the last peak season for iGAS, but above all other years between 2002 and 2008. Numbers of reports for February in particular may rise as further reports are made.

Several English regions have reported high numbers of cases in December 2008 to February 2009 in comparison to the past four seasons (2004/05 to 2007/08), although generally similar to numbers for 2003/04, as follows: East Midlands, North East, North West, South East, South West, and West Midlands. Reports for the East of England, London and Yorkshire and the Humber were within the range seen since the last peak year. In contrast to England, numbers of iGAS reports for Northern Ireland and Wales have not shown any particular elevation during December to February.

Figure 2. Weekly count of sterile site GAS isolates referred to the Streptococcus and Diphtheria Reference Unit (SDRU) by specimen date; England: week 37 2008, to week 12 2009

Numbers of iGAS isolates referred to the Respiratory and Systemic Infection Laboratory at CfI from laboratories in England showed a similar trend to routine laboratory reporting, peaking in week 1 of 2009. Although numbers of isolates have fluctuated since week 5, with a marked increase over the last 2 weeks (week 11 to 12), they have generally remained above the corresponding period during the 2007/08 season. The emm /M-type distribution shifted between December 2008 and January 2009 with a relative increase in emm /M3 from 24% to 40%, although subsequently dropping to 31% in February. Other common types were emm /M1, emm /M89, emm /R28 and emm /M6.

Since the launch of the enhanced surveillance for severe group A streptococcal infections diagnosed since 1 January 2009, 263 records have been submitted by Health Protection Units across England [3]. Preliminary analysis of patient risk factors has not identified any increase in cases in any particular risk group. A common and diverse range of clinical presentations have been reported, including skin/soft tissue infections and lower respiratory tract infections. There are indications of an increased case fatality rate from the preliminary data reported, with 25% of cases reported to have died within seven days of diagnosis, although outcome information is still awaited on 105 cases, and as such may fall within the usual range for these diseases (15-20%).

Preliminary results from the enhanced surveillance suggest a generalised increase in invasive group A streptococcal diseases, over and above that normally expected in the winter and spring months, and as such it remains unclear why this increase, along with increases in scarlet fever, should have arisen. As the highest incidence of invasive disease was seen around the new year, this may be connected to the increase influenza activity this winter which peaked in week 51 of 2008 [4]. However, the continued elevation in notifications of scarlet fever and invasive disease since the new year suggest that other factors may underpin the current high season. The increased circulation of GAS may be due to a natural cycle in incidence [5].

Although analysis of isolates submitted to the national reference laboratory has not identified any unusual serotypes to be circulating, a significant increase in emm /M3 has been seen during this early part of 2009. This increase is of concern given the association between this emm type and more severe clinical presentations compared to other emm types [6,7].

Further seasonal updates will be published in the Health Protection Report. Microbiologists and HPU staff are requested to help complete questionnaires for all cases meeting the case definition for severe GAS infection diagnosed from specimens taken since the 1 January 2009. The enhanced surveillance protocol and questionnaires can be downloaded from the Group A Streptococcal Infections pages on HPA web site (follow the links to "Epidemiological Data" and "National enhanced surveillance of severe group A streptococcal disease").

Clinicians, microbiologists and HPUs should be mindful of the recent increases in iGAS and maintain a high index of suspicion in relevant patients as early recognition and prompt initiation of specific and supportive therapy can be life-saving [1]. Invasive disease isolates and those from suspected clusters or outbreaks should be submitted to the SDRU, Respiratory and Systemic Infection Laboratory at the Health Protection Agency, Centre for Infections, 61 Colindale Avenue, London NW9 5HT. Guidelines for the management of close community contacts of invasive group A streptococcal disease are also available on the Agency's website [8].

References

1. Department of Health. Increase in invasive group A streptococcal infections in England. CEM/CMO/2009/05: London: DH, 1 April 2009. Available at: https://www.cas.dh.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=101179.

2. QSurveillance ® Weekly Bulletin No 227, week commencing 16 March 2009 (week 12, 2009). Data extracted from version 1 of the QSurveillance® database. QSurveillance® 2009 [cited 1 April 2009]. Available at: http://www.hpa.org.uk/hpr/infections/Qresearch.pdf.

3. HPA. Enhanced surveillance initiated for group A streptococcal infections. Health Protection Report [serial online] 2009 [cited 03 April 2009]; 3(8): news. Available at: http://www.hpa.org.uk/hpr/archives/2009/news0809.htm#enhancd.

4. HPA. Influenza activity is increasing across the UK. Health Protection Report [serial online] 2008[cited 03 April 2009]; 2(51): news. Available at:http://www.hpa.org.uk/hpr/archives/2008/news5108.htm#flu.

5. Lamagni T, Dennis J, George R, Efstratiou A. Analysis of epidemiological patterns during a century of scarlet fever. In: European Scientific Conference on Applied Infectious Disease Epidemiology; 18 November 2008; Berlin, Germany; 2008.

6. O'Loughlin RE, Roberson A, Cieslak PR, Lynfield R, Gershman K, Craig A et al. The epidemiology of invasive group A streptococcal infection and potential vaccine implications: United States, 2000-2004. Clin Infect Dis 2007; 45(7): 853-862.

7. Lamagni TL, Neal S, Keshishian C, Alhaddad N, George R, Duckworth G et al. Severe Streptococcus pyogenes Infections, United Kingdom, 2003-2004. Emerg Infect Dis 2008; 14 (2): 201-209.

8. Health Protection Agency Group A Streptococcus Working Group. Interim UK guidelines for management of close community contacts of invasive group A streptococcal disease. Commun Dis Public Health 2004; 7(4): 354-361. Available at: http://www.hpa.org.uk/cdph/issues/CDPHvol7/No4/guidelines1_4_04.pdf.

Wound botulism in injecting drug users in England: an update

Since the beginning of 2009, 13 cases (11 males and two females) of wound botulism in injecting drug users (IDUs) have been reported to the Health Protection Agency Centre for Infections, from six regions in England. Clostridium botulinum Type B has been laboratory confirmed in five of these cases and C botulinum Type A in one case. The ages of these cases ranged from 28 to 57 years.

Six of the cases (five males and one female) have been reported since our first report on 6 March 2009 [1]. These new cases, were all heroin injecting IDUs, and were reported from West Yorkshire, East of England, East Midlands, London, and the South East. The cases were aged between 35 and 50. Clostridium botulinum Type B has been laboratory confirmed in two of these cases.

Cases of wound botulism are thus continuing to occur among IDUs. Clinicians should suspect botulism in any patient with an afebrile, descending, flaccid paralysis, with a history of injecting drug use. Specialist advice should be urgently sought from an Infectious Diseases Physician. Botulinum antitoxin is effective in reducing the severity of symptoms if administered early in the course of the disease. C. botulinum is sensitive to benzyl penicillin and metronidazole. In cases of wound infection, antimicrobial therapy and surgical debridement should reduce the organism load and therefore toxin production, but circulating toxin can only be neutralised by the early administration of antitoxin. Where there is definite clinical suspicion of botulism, treatment with antitoxin should not be delayed for microbiological testing.

Further information on wound botulism among IDUs can be found on the HPA website: www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1195733795383?p=1191942152230.

Reference

1. HPA. Increase in reported cases of wound botulism associated with injecting drug use in Southern England. Health Protection Report [serial online] 2009 [accessed 3 April 2009]; 3(9) news. Available at: http://www.hpa.org.uk/hpr/archives/2009/news0909.htm#wbot.

Confirmed measles cases in England and Wales, January 2008 to February 2009

Two hundred and twenty laboratory confirmed cases of measles have been reported in the first two months of this year: 104 in January and 116 in February. Following a brief decline in reported cases in the latter part of 2008, London is once again the region where most cases are confirmed. Outside London, the South East and West Midlands regions have the highest incidence and continue to identify clusters of cases linked to the travelling communities and to schools/nurseries (see table).
Around 20% of notified measles cases tested with an oral fluid test in the period were confirmed nationally.

Confirmed cases of measles by region and month of onset, England and Wales:
January 2008 to February 2009

Month

Lond-on

East Mids

East of Engl'd

North East

North West

South East

South West

West Mid's

Wales

York & Humb

N/k

Jan 08

53

1

6

1

1

1

-

3

-

6

-

Feb 08

48

-

6

3

-

4

-

-

1

8

-

Mar 08

71

1

1

-

-

8

1

1

1

5

-

Apr 08

74

-

7

3

-

6

14

2

-

13

-

May 08

117

1

6

-

21

4

7

3

-

5

-

June 08

106

-

11

1

24

7

4

5

-

3

-

July 08

63

1

10

-

19

13

2

8

-

1

-

Aug 08

35

7

6

-

17

21

1

6

-

3

-

Sep 08

31

5

4

-

7

2

-

9

21

-

-

Oct 08

41

13

4

2

31

8

1

9

14

1

1

Nov 08

14

7

9

3

36

27

2

33

1

2

-

Dec 08

11

12

20

4

22

28

10

34

1

2

-

Total
2008

664

48

90

17

178

129

42

113

39

49

1

Jan 09

39

7

3

1

9

20

4

13

-

8

-

Feb 09

38

-

3

-

2

48

1

19

-

5

-

 

Figure 1: Number of laboratory confirmed cases in England and Wales by month of onset: January 2007 to February 2009

Cases are still occurring in the age groups targeted by the MMR catch-up campaign announced in August 2008 (fig 2). So far in 2009, the majority of cases are confirmed in nursery and primary school aged children (three and a half to 11 years), the group with the highest number of cases in 2008.

Figure 2: Confirmed cases by age groups targeted by the MMR catch-up programme, England and Wales: total 2008, January and February 2009*

*excludes one case with unknown age.

Merger of the National Institute for Biological Standards and Control (NIBSC) with HPA

The National Institute for Biological Standards and Control (NIBSC) [1,2] merged with the Health Protection Agency with effect from 1 April 2009, significantly extending the Agency's range of expert services.

NIBSC is a world renowned institute and a world leader in the standardisation and control of biological medicines such as vaccines and other products made from blood and tissues. It prepares, evaluates and distributes International Biological Standards and other biological reference materials and distributes them globally. It is the source of 90% of such international biological standards produced worldwide.

NIBSC is also the UK's Official Medicines Control Laboratory, responsible for independent testing of biological medicines produced by the pharmaceutical industry to make sure they meet the required specifications, and the home of the UK Stem Cell Bank, the CJD and Influenza Resource Centres and the Centre for AIDS reagents. It has a vital role in supporting global research and development into innovative medicines for the prevention and treatment of some of the world's most dangerous and debilitating diseases.

Notes
1. Further information about the Institute can be found at www.nibsc.ac.uk.
2. The Health and Social Care Act 2008 required that the National Biological Standards Board be abolished and its functions, carried out since 1976 by NIBSC, transferred to the Health Protection Agency (HPA).

New Water and Environmental Microbiology Network established


The Health Protection Agency's newly restructured Food, Water and Environmental (FW&E) Microbiology Network was officially launched on 1 April 2009, enabling the Agency to achieve greater capacity and resilience in responding to health threats from food, water and the environment.

The network's laboratories play an important role in protecting the public from any threats to health through food, water and the environment - for example salmonella, listeria, E. coli and Legionnaires' disease.

The aim of the new arrangements is to create a network of 12 enlarged laboratories at strategic locations across England, bringing together a critical mass of expertise and replacing the previous structure of 26 smaller laboratories. All of the laboratories are fully accredited. Ten will be managed by the HPA while those based in Stoke-on-Trent and Leicester will remain under the management of local health trusts.

The network's new structure has been designed in close consultation with stakeholders including environmental health departments, port health authorities, LACORS and the Food Standards Agency to ensure that their needs are fully met.

The 12 enlarged laboratories are based in the following regions and towns:

  • East of England: Chelmsford and Norwich Laboratories;
  • East Midlands: Leicestershire Laboratory;
  • London: Colindale Laboratory;
  • North East: Newcastle Laboratory;
  • North West: Preston Laboratory;
  • South East: Southampton and Ashford Laboratories;
  • South West: Bristol Laboratory;
  • West Midlands: Birmingham and Stoke-on-Trent Laboratories;
  • Yorkshire and the Humber: Leeds Laboratory.