Research and analysis

HPR volume 13 issue 2: news (11 January)

Updated 20 December 2019

ECDC guidance on screening and vaccination for newly arrived migrants in Europe

The European Cente for Disease Prevention and Control (ECDC) has published guidance on screening and vaccination for infectious diseases in newly-arrived migrants in Europe, intended to support member states in the development of national strategies [1]. The guidance takes account of the results of systematic evidence reviews, the opinions of an ad hoc scientific panel comprising 21 EU and EEA experts, and the recommendations of an advisory group on which PHE and other UK scientists were represented.

Questions asked by ECDC included whether newly arrived migrants should be offered screening for key infections – including tuberculosis, HIV, and hepatitis B and C – who should be targeted and how, and whether vaccination should be offered.

The report presents a number of evidence-based statements on screening, and vaccination for the key infections – all predicated on evidence of a clear public health benefit, arising from enrolment of migrants in relevant screening and vaccination programmes, in each case taking account of the prevailing burden of disease in a migrant’s country of origin.

Primary care

The report notes that the implementation of its recommendations relies on the provision of primary healthcare services that are responsive to the needs of migrants, and the ability of migrant populations to access key services. ECDC’s ad hoc scientific panel of experts strongly supported free screening, vaccination and care for key infectious disease for all migrants in the EU and EEA, including irregular migrants.

The report concludes “[T]here is a need to ensure that health professionals [in primary care] have sufficient knowledge of migrant health needs and that they have skills in culturally sensitive health education, as well as access to culturally and linguistically appropriate information materials and interpretation support services”.

The report goes on to state, “Improvements in surveillance are required to increase the completeness and quality of data and inform more accurate estimates of disease, morbidity, and mortality among migrant populations”. The need for more research into multiple-disease screening, and the roles for screening in community-based primary healthcare services, is also noted in the report.

Reference

1. ECDC website (December 2018). Public health guidance on screening and vaccination for newly arrived migrants in the EU/EEA: executive summary.

New measles and rubella elimination strategy for the UK

PHE has published a new measles and rubella elimination strategy, that maps out how the UK can sustain elimination of measles, rubella and congenital rubella syndrome (CRS) in the future [1].

The strategy builds on the experience and success of 50 years of measles vaccination and 30 years of the national measles, mumps and rubella (MMR) immunisation programme.

Since the introduction of the measles vaccine, an estimated 20 million cases and 4,500 deaths have been prevented in the UK. In addition, it is estimated that rubella vaccination has prevented an estimated 1.4 million cases of rubella, 1,300 cases of CRS-related birth defects, and averted 25,000 terminations.

The World Health Organization confirmed that the UK eliminated rubella in 2015 and measles in 2016, acknowledging that measles and rubella are no longer native to the UK. However, both infections remain endemic in many countries, and the risk of imported infections remains a very real threat to the UK’s achievements.

On measles, new analyses conducted by PHE suggest that immunity levels in some age groups, especially young people aged 15-to-20 years, are well below the levels needed to prevent measles from spreading.

The new strategy makes a number of recommendations for actions required to sustain measles and rubella elimination, with four goals:

• to achieve and sustain over 95% coverage with two doses of MMR vaccine in the routine childhood immunisation programme (a target not currently met in the UK)
• to achieve over 95% coverage with two doses of MMR vaccine in older age groups
• to strengthen measles and rubella monitoring
• to ensure easy access to high-quality, evidence-based information for health professionals and the public

Reference

1. PHE website. UK Measles and Rubella Elimination Strategy 2019.

Multi-drug resistant Shigella sonnei circulating in UK and USA

Whole genome sequencing (WGS) has identified links between 17 cases of Shigella sonnei in England, Wales and Scotland between March and November 2018. Case isolates fall within the 10-SNP cluster CC 152 1.3.197.460.1360.% on WGS. The majority of cases are male, and initial data collection on exposures and clinical outcomes indicates that three cases identify as men who have sex with men (MSM).

International spread has been demonstrated, with the USA Centers for Disease Control, identifying a number of cases of S. sonnei falling within this 10-SNP cluster from residents across multiple states who also identify as MSM.

This strain is of concern due to its multi-drug resistant genotype and the potential risk of treatment failure. Resistance markers include bla _CTX-M-27, associated with extended-spectrum beta-lactamase production, a single gyrA mutation associated with reduced susceptibility to fluoroquinolones and the plasmid-mediated macrolide resistance markers erm(B) and mph(A). This macrolide resistance profile has been associated with sexual transmission amongst MSM in the UK. Standard treatment with first-line agents such as quinolones, azithromycin and ceftriaxone may not be effective.

In response to these concerns, new guidance has been published targeted at microbiologists assessing the susceptibility of Shigella sonnei isolates.

Two cases of extensively drug-resistant gonorrhoea diagnosed in the UK

PHE is investigating 2 cases of gonorrhoea in heterosexual, UK-resident females [1], each with extensively-drug-resistant (XDR) Neisseria gonorrhoeae [2].

Isolates in each case are resistant to ceftriaxone (MIC 1.0mg/L) and have intermediate susceptibility to azithromycin (MIC 0.5mg/L). They are also both resistant to cefixime, penicillin, ciprofloxacin and tetracycline, but are susceptible to spectinomycin.

Both cases were successfully treated and PHE is undertaking contact tracing to minimise the risk of onward transmission.

The pattern of resistance of these cases (which are linked to another European country) is different to that of a case of extensively drug-resistant gonorrhoea with high-level resistance to azithromycin (in a UK national acquired in south-east Asia) reported in 2018 [3], which is therefore unrelated to the new cases.

PHE actively monitors, and acts on, the spread of antibiotic resistance in gonorrhoea and potential treatment failures, and has introduced enhanced surveillance to identify and manage resistant strains promptly.

Primary diagnostic laboratories have been reminded to continue to refer gonorrhoea isolates with resistance to ceftriaxone (MIC >0.125 mg/L) or high-level resistance to azithromycin (MIC >256mg/L) to the reference laboratory at PHE Colindale for confirmation. General practitioners should refer all suspected cases of gonorrhoea to sexual health services, for appropriate management according to PHE guidance [4].

References

1. Two cases of resistant gonorrhoea diagnosed in the UK, PHE 9 January 2019.
2. Tapsall JW, Ndowa F, Lewis DA and Unemo M (2009). Meeting the public health challenge of multidrug- and extensively drug-resistant Neisseria gonorrhoeae. Expert Rev. Anti Infect. Ther. 7(7), 821 to 834.
3. PHE (2018). Multi-drug resistant gonorrhoea in England (2018).
4. PHE (2014). Guidance for the detection of gonorrhoea in England.

Infection reports in this issue of HPR

This issue includes the following report:

• Routine reports of foodborne illness in humans, England and Wales: November to December 2018.