Research and analysis

HPR volume 11 issue 24: news (14 July)

Updated 15 December 2017

1. Updated guidance on public health management of hepatitis A

PHE has issued temporary hepatitis A vaccination recommendations for adults [1] and children [2] in the light of the ongoing hepatitis A outbreak primarily affecting men who have sex with men (MSM) and the shortage of global hepatitis A vaccine that has severely impacted UK supply [3]. The temporary recommendations include updated travel vaccine recommendations and dose sparing advice to preserve adult monovalent hepatitis A vaccine stock for those with the greatest ability to benefit.

At the same time, pre-existing public health guidance on prevention and control of hepatitis A infection has been updated. ‘Public health control and management of hepatitis’ [4] aims to reduce the occurrence of secondary infections and to prevent and control outbreaks. The updated guidance follows a review of the epidemiology of the infection in England and Wales and includes revised evidence-based advice on the use of hepatitis A vaccine and Human Normal Immunoglobulin (HNIG) for post-exposure prophylaxis.

1.1 References

1. PHE website. Hepatitis A vaccination in adults: temporary recommendations.
2. PHE website. Hepatitis A vaccination in children: temporary recommendations.
3. “Hepatitis A outbreak in England under investigation”, HPR 11(17), May 2017.
4. PHE website. Public health control and management of hepatitis A.

2. Legionnaires’ disease in Europe, 2011 to 2015

An analysis of annual data submitted by 29 EU/EEA countries to the European Legionnaires’ Disease Surveillance Network (ELDSNet) – covering the period 2011 to 2015 – has been published in the journal Eurosurveillance [1]. Notwithstanding the variable levels of surveillance operating in participating countries, tentative conclusions are drawn about trends in incidence, age and gender of cases, probable setting of infection, fatality rates and changes in microbiological techniques used for diagnosis.

Four countries, France, Germany, Italy and Spain, accounted for 70.3% of all reported cases, although their combined populations represented only 49.9% of the study population, the 20 lowest-reporting countries make up only 10.2% of all cases, while their combined populations represented 28.8% of the study population.

The main purpose of ELDSNet, operated by ECDC, is detection of travel-related LD clusters involving residents of Europe that could not otherwise be detected by any national surveillance scheme. Of the total 30,532 LD cases reported to ECDC between 2011 and 2015 11.5% (3098) were deemed to be foreign travel-related, whereas 71% (21,618) were community/sporadic, 4.9% (1322) nosocomial, and 8.4% (2259) domestic travel-related). (By comparison, during the period 2013-2015, 46.3% of confirmed cases in England and Wales residents were deemed to have been foreign travel-related (177 of 387 cases) [2].)

The report’s overall conclusion is that the burden of LD appears to be growing in Europe, displaying an epidemiology very similar to that observed in the United States, with a comparable notification rate and similar settings of infection.

In the EU/EEA, although the case fatality rate fell between 2011 (10.4%) and 2015 (8.1%), the age-adjusted notification rate increased steadily over the period to 1.3 cases per 100,000 population, the highest rate ever recorded. The report recommends that, ‘In countries with persistently low notification rates, ad hoc studies should identify reasons for under-ascertainment [and] all countries should endeavour to develop and maintain appropriate control measures in man-made water systems to prevent LD cases’.

2.1 References

1. Beauté J, et al on behalf of ELDSNet (2017). Legionnaires’ disease in Europe, 2011 to 2015. Euro Surveill. 22(27), 6 July.
2. PHE (2016). Legionnaires’ disease in residents of England and Wales: 2015.

3. Mandatory MRSA, MSSA and E. coli bacteraemia and C. difficile infection data (England): up to and including financial year 2016 to 2017

PHE’s latest annual data, and latest Annual Epidemiological Commentary, on trends in reports of Staphylococcus aureus (MRSA and MSSA) and Escherichia coli bacteraemia, and of Clostridium difficile infections, mandatorily reported by NHS acute Trusts in England up to financial year (FY) 2016/17, have been published on the GOV.UK website [1,2].

The data and commentary, including tabular and graphical information, update the previous report published on 7 July 2016. Some key facts are listed below.

3.1 MRSA MSSA and E. coli bacteraemias

A total of 823 cases of MRSA bacteraemia were reported by NHS acute trusts in England between 1 April 2016 and 31 March 2017. This equates to no change from 2015 to 2016 (823 cases), and a decrease of 81.5% from 2007 to 2008 (4,451 cases).

The PIR data show a consistent decline in the rates of CCG-assigned cases from 0.8 cases per 100,000 population in 2013 to 2014 to 0.4 cases per 100,000 population in 2016/17. In contrast, rates of trust-assigned MRSA bacteraemias fell from 1.2 cases per 100,000 bed days in 2013 to 2014 to 0.9 in 2014 to 2015, after which trust-assigned rates remained steady at 0.9 each year to 2016 to 2017. The rate of Third Party assigned cases has increased from 0.2 per 100,000 population to 0.5 per 100,000 population. It is important to note that some of the decline seen in the rates of CCG- and trust-assigned cases will have been due to the introduction of third party assignment.

A total of 11,486 cases of MSSA bacteraemia were reported by NHS acute trusts in England between 1 April 2016 and 31 March 2017. This is an increase of 8.3% from 2015/16 (10,606 cases) and an increase of 31% from 2011 to 2012 (8,767 cases). The rate of all MSSA cases per 100,000 population, per year, has risen from 16.4 in 2011 to 2012 to 20.9 in 2016 to 2017. The incidence rate for trust-apportioned MSSA cases has increased steadily (from 7.8 in 2012/13 to 8.8 in 2016 to 2017, a change of 12.6%).

A total of 40,580 cases of E. coli bacteraemia were reported by NHS trusts in England between 1 April 2015 and 31 March 2016. This is an increase of 6.1% from 2015 to 2016 (38,251 cases) and an increase of 25.6% from 2012 to 2013 (32,309 cases). The rate of E. coli cases per 100,000 population has risen 22% from 60.4 in 2012 to 2013 to 73.9 in 2016 to 2017. Unlike the interventions for MRSA that were hospital- and device-related, effective interventions for MSSA and E. coli bacteraemia will need to include the community setting if the same magnitude of reductions are to be achieved as with MRSA.

3.2 Clostridium difficile infections

A total of 12,840 cases of Clostridium difficile infection were reported by NHS trusts in England between 1 April 2016 and 31 March 2017. This translates to a decrease of 9.2% from 2015/16 (14,143 cases) and a decrease of 76.9% from 2007 to 2008 (55,498 cases). The rate of all CDI cases per 100,000 population, per year, has fallen from 107.6 in 2007 to 2008 to 23.4 in 2016 to 2017. Of the 12,840 total cases reported in FY 2016 to 2017, 4,618 (36%) were trust-apportioned (13.2 per 100,000 bed days).

The incidence rate for trust-apportioned CDI cases mirrors the trends in incidence for all cases, with declining rates from 2007/08 to 2013 to 2014 which then remained approximately stable to 2015 to 2016. The rate of trust-apportioned CDI cases decreased slightly from 14.9 in 2015 to 2016 to 13.2 in 2016 to 2017, a change of 11.6%.

3.3 References

1. PHE (July 2017). Quarterly counts by acute Trust and CCG, and financial year counts and rates by acute Trust and CCG, up to financial year 2016/17: * MRSA bacteraemia * MSSA bacteraemia * E. coli bacteraemia * C. difficile infections

2. PHE (6 July 2017). Annual Epidemiological Commentary: MRSA, MSSA and E. coli bacteraemia, and C. difficile infection data, up to and including financial year 2016/17.

3. NHS England (2014). Zero tolerance – guidance on the post infection review.

4. Infection reports in this issue of HPR

The following reports are published in this issue of HPR. The links below are to the relevant webpage collections:

• Salmonella and shigella infections from faecal specimens (England and Wales): laboratory reports, May-June 2017
• General outbreaks of foodborne illness in humans (England and Wales): weeks 22-26/2017
• Common GI infections (England and Wales): laboratory reports, weeks 22-26/2017
• Suspected and laboratory-confirmed reported norovirus outbreaks in hospitals: outbreaks occurring in weeks 22 to 26, 2017
• Respiratory infections (England and Wales): laboratory reports, weeks 22-26, 2017