Research and analysis

HPR volume 12 issue 6: news (16 February)

Updated 21 December 2018

Avian flu advice for travellers going to China

PHE and NaTHNaC have reminded travellers to Lunar New Year celebrations in China to avoid contact with live poultry, and not to visit live bird or animal markets, because of the small but ongoing risk of contracting avian influenza [1]. Human cases are being reported in the region and numbers are expected to increase [1].

Advice for public health professionals investigating putative cases among returning travellers has also been published [2].

Human cases of avian influenza arise following close contact with infected poultry or other birds and the majority of human cases in China were infected in this way. Human cases have occurred across mainland China and Taiwan, and small numbers from Hong Kong SAR residents who had travelled to mainland China.

The PHE advice is to:

• avoid visiting live bird and animal markets and poultry farms
• avoid contact with animal waste or untreated bird feathers
• not to eat or handle undercooked or raw poultry, for example, duck dishes
• not to pick up or touch dead or dying birds
• no to bring any poultry products back to the UK
• to wash hands regularly with soap, or to use alcohol-based hand rubs

UK-based travellers experiencing flu-like illness within 10 days of returning from these areas are advised to mention their recent travel when contacting their GP or NHS 111. PHE has produced clinical guidance for health professionals in England on the assessment and investigation of patients with severe flu-like illness who have recently returned from China [2].

Comprehensive travel health advice – including vaccine and antimalarial recommendations – for the region, ie China, Hong Kong, Macao, Taiwan and Tibet, is available from the Country Information pages of the NaTHNaC TravelHealthPro website.

Chinese New Year celebrations in 2018 take place over a fortnight from 16 February.

References

1. Avian flu advice for travellers going to China, PHE news website story (12 February 2018).
2. PHE (12 February 2018). Investigation and management of possible human cases of avian influenza A(H7N9) in returning travellers, see Avian influenza: guidance and algorithms for managing human cases.

Two recent cases of infant botulism in England

Infant botulism is a very rare disease in the UK and as such may not always be considered as a diagnosis leading to possible delays in treatment. There have only been a total of 17 cases since the first reported case in 1978 until the end of 2013 and no reported cases from 2014 until September 2017. However, two recent cases have been reported in England: one in September 2017 and the second in January 2018.

The first of these was in a previously healthy five month old female initially presenting at hospital with hypotonia, reduced feeding, lethargy and a four-day history of constipation. The infant received empirical antimicrobial therapy for sepsis and was intubated and ventilated in paediatric intensive care (PIC). The infant had a history of travel to the southwestern area of the USA including several National Parks, Canyons and Lakes in the preceding six weeks. The infant had been exclusively breastfed. Clostridium botulinum neurotoxin was detected in a faecal specimen collected from the infant on day 5 of admission and C. botulinum type B isolated from the same faecal specimen following extensive enrichment. On laboratory confirmation of diagnosis the infant was treated with human derived botulinum immunoglobulin (BabyBIG®) obtained from the California Department of Public Health’s Infant Botulism Treatment and Prevention Program (IBTPP). The infant subsequently stabilised and went on to make a full recovery.

The second recent case of infant botulism occurred in a seven-month-old male infant who was admitted to hospital at the end of January 2018 with a one-day history of coryza, poor feeding, reduced urine output and a four-day history of constipation. The infant was also treated empirically with antibiotics and antivirals for suspected encephalitis and was subsequently intubated and ventilated for respiratory support. The infant had commenced weaning, consisting of home prepared boiled vegetables, toast with dairy-free spread and commercially prepared sweet potato puree, three weeks prior to symptom onset. A faecal specimen collected eight days after onset of illness produced classic symptoms of botulism in a bioassay although there was insufficient material to perform neutralisation tests for confirmation. The causative organism was not isolated from the infant’s faecal specimen possibly due to the effects of antibiotics. This infant was also treated with BabyBIG [1] and is showing gradual signs of improvement.

Infant botulism occurs when infants, less than one year old, ingest spores of C. botulinum which germinate and produce botulinum neurotoxin in the infant’s gut. The neurotoxin blocks release of the neurotransmitter, acetylcholine, leading to a characteristic, flaccid paralysis.

Infant botulism should be suspected in infants who present with symptoms and signs including constipation, poor feeding, lethargy, ptosis, bulbar palsies, hypotonia, weakness and loss of head control.

The differential diagnosis of infant botulism includes sepsis, meningitis, myasthenia gravis and Guillain Barré syndrome. Treatment for infant botulism includes administration of BabyBIG [1]. together with meticulous intensive care support. As with all antitoxin treatment for botulism, BabyBIG treatment should be started as early as possible in order to neutralise circulating neurotoxin and prevent further progression of the illness. Treatment with BabyBIG has been demonstrated to improve the rate of recovery thereby reducing the length of time in paediatric intensive care and the overall length of hospital stay. Laboratory examination for detection of botulinum toxin in faeces or detection and isolation of C. botulinum from faeces confirms the clinical diagnosis of botulism. Prompt laboratory diagnosis is important for patient management and for ruling out the possibility of fatal degenerative neuromuscular diseases.

The source of spores in infant botulism is usually not identified. Spores are widely distributed in the environment and thought to be ingested from the atmosphere. Honey is a known dietary risk factor and should not be fed to infant less than one year of age [2]; pet terrapins have also been linked to infant botulism [3]. Whilst most infants are believed to be exposed to C. botulinum spores only a small minority develop infant botulism. It is thought that, in a very small minority, a perturbation in the immature gut flora provides a window of opportunity for the spores to germinate and produce toxin.

Clinical advice on infant botulism including diagnosis and patient management can be obtained from Dr Gauri Godbole (07826 859 642), and enquiries on laboratory testing including specimen collection can be directed to either Dr Corinne Amar (0208 327 7341) or Dr Kathie Grant (020 8327 7117) at the Gastrointestinal Bacteria Reference Unit, National Infections Service, Colindale. Information on the supply of BabyBIG® is available from the Infant Botulism Treatment and Prevention Programme, California http://www.infantbotulism.org/.

Further information about symptoms and epidemiology of botulism is available at: Botulism: diagnosis, data and analysis.

References

1. Arnon S, Schechter R, Maslanka S, Jewell N, Hatheway C (2006). Human botulism immune globulin for the treatment of infant botulism. N Engl J Med 354: 426-47.
2. Grant KA, McLauchlin J, Amar C (2013). Infant botulism: advice on avoiding feeding honey to babies and other possible risk factors. Commun Pract 86: 44-46.
3. Shelley EB, O’Rourke D, Grant K, McArdle E, Capra L, Clarke A, et al (2015). Infant botulism due to C. butyricum type E toxin: a novel environmental association with pet terrapins. Epidemiol Infect 143: 461–469.

Seasonal influenza vaccination uptake in Europe

Influenza vaccination coverage among high-risk groups has dropped in the European Region over the last seven years, and half the countries report a decrease in the number of vaccine doses available.

These are the results of the first joint ECDC / WHO Regional Office for Europe comprehensive overview of seasonal influenza vaccine coverage in the WHO European Region between 2008 and 2009 and 2014 and 2015 [1]. The two organisations have warned that low uptake of seasonal influenza vaccination in Europe jeopardises the capacity to protect people during annual epidemics and the next pandemic.

The overview appears in a peer-reviewed scientific article published in Vaccine in January 2018, based on data from the Vaccine European New Integrated Collaboration Effort (VENICE III) and WHO surveys.

Reference

1. ECDC news release (7 February 2018). Low uptake of seasonal influenza vaccination in Europe may jeopardise capacity to protect people in next pandemic.

BSMT annual scientific conference, 18 May

The theme of the upcoming annual scientific meeting of the BSMT is rapid diagnostics.

Programme includes presentations on:

• optimising the recovery of bacteria from blood cultures
• device-related orthopaedic infections and new technologies
• epidemiology of MSSA in the ICU and other areas
• molecular diagnostics for enteric infections
• relevance for clinical diagnosis and public health
• next generation sequencing for detection of pathogens direct from the specimen
• rapid diagnostics: bad bugs and antibiotics

Venue: PHE Colindale, NW9 5EQ.

Programme and registration: http://www.bsmt.org.uk.

Infection reports in this issue

• Laboratory reports of hepatitis A and C (England and Wales): July to September 2017.