Research and analysis

HPR volume 8 issue 48: news

Updated 23 December 2014

1. Rising seasonal flu activity triggers CMO advice on antivirals for treatment and prophylaxis

Latest surveillance data [1] has indicated that influenza is now circulating in the community in England and on 16 December the Chief Medical Officer and Chief Pharmaceutical Officer issued a letter to signal the use of antivirals for the prophylaxis and treatment of influenza, according to NICE guidance [1,2].

A number of different indicators of influenza activity in week 49 were used to inform the decision, as follows:

1.1 Clinical indicators

• the weekly influenza-like illness (ILI) consultation rate in the PHE GP practice sentinel surveillance scheme increased from 6.9 to 9.5 per 100,000 in week 49
• syndromic surveillance indicators for ILI have started to increase across all systems (cold/flu calls through NHS 111, ILI emergency department attendances and GP Out of Hours ILI consultation rates)
• twelve acute respiratory outbreaks have been reported in the past seven days, seven in schools (two virologically tested), one in a nursery (not tested) and four in care homes (none tested)
• the UK Severe Influenza Sentinel Hospital Surveillance Scheme reported 20 new hospitalised cases of confirmed influenza infection admitted in the previous week (18 due to A(H3) or FluA untyped) and the ICU mandatory Surveillance Scheme reported 13 new admissions of confirmed influenza (11 of which were due to Flu A untyped).

1.2 Virological surveillance

• the proportion of samples positive for influenza in the PHE DataMart scheme (representing mainly persons hospitalised with acute respiratory illness) has increased to 8.1% from 4.6% the previous week (PHE baseline threshold is 6%). The highest age-specific positivity was in 5-14 year olds (18.8%) and 15-44 year olds (15.0%).

Taken together these findings indicate an increased likelihood that people presenting with an ILI are infected with influenza virus and provide the basis for using antivirals for appropriate patients presenting with ILI in the community. Full details on current flu activity are in Public Health England’s weekly flu report on the GOV.UK website [1].

PHE has reiterated that, although not life-threatening for most people, seasonal flu can be far more serious for those in “at-risk” groups. People aged 65 and over, and people aged under 65 in clinical risk groups (which includes all pregnant women), should be vaccinated against flu.

1.3 References

1. PHE weekly national flu report.

2. NICE guidance on the use of antivirals for prophylaxis for influenza.

2. Ebola virus disease: international epidemiological summary (at 14/12/2014)

Up to the end of 14 December (9 December for Liberia), a total of 18,603 clinically compatible cases (CCC) of Ebola virus disease (EVD) have been reported in the five currently affected countries (Guinea, Liberia, Sierra Leone, the USA and Mali) and three previously affected countries (Nigeria, Spain and Senegal) since December 2013. There have been at least 6,915 deaths, but the true numbers are not known due to continued under-reporting. Case fatality rates remain high across Guinea, Liberia and Sierra Leone where for cases with a definitive outcome the case fatality rate is 70%. For hospitalised patients, the case fatality rate is lower at 60% in Guinea and Sierra Leone, and 58% in Liberia.

The trends in national incidence continue to vary across Guinea, Liberia and Sierra Leone. In Guinea, the trend nationally has fluctuated since September without clear evidence of either upward or downward change. From the latest information available from Liberia (three days of data compared to seven days for Guinea and Sierra Leone), case incidence continues to decline. In Sierra Leone there is some initial evidence that incidence may no longer be increasing. However, transmission remains intense in the northern and western districts. Freetown and the Western Rural area remain the worst affected areas. An operation to intensify efforts to halt disease in these areas has begun with the aim to eradicate disease here within 42 days.

The total number of EVD CCC reported in Mali stands at eight. The last patient tested negative on 6 December, and was discharged from hospital on 11 December. All contacts of infected patients have passed the 21 day observation period. If no new cases arise, Mali will be declared EVD-free on 18 January 2015. The situation in Mali looks encouraging but given the porous nature of the Mali-Guinea border, the risk of further importation of cases is recognised.

To date, a total of 23 EVD cases have been cared for outside of Africa; 18 repatriated cases (hospitalised in USA, Spain, UK, Germany, France, Norway, Switzerland, Italy and the Netherlands), two imported cases (both diagnosed in USA) and three incidents of local transmission (in Spain and USA).

The table below summarises Ebola virus disease international epidemiological information as at 14 December 2014 (9 December for Liberia)

Country	Total CCCs	Total deaths	Current status
Guinea	2416	1525	Ongoing transmission
Liberia	7797	3290	Ongoing transmission
Sierra Leone	8356	2085	Ongoing transmission
Mali	8	6	Awaiting EVD free status
Nigeria	20	8	EVD free
Senegal	1	0	EVD free
Spain	1	0	EVD free
USA	4	1	Awaiting EVD free status
TOTAL	18,603	6915	–

Further information on the international epidemiological situation can be found in PHE’s weekly ebola epidemiological update.

3. Trends in mandatory MRSA/MSSA and Escherichia Coli bacteraemia, and in CDI data (England): data to end-September

PHE’s latest quarterly epidemiological commentary on trends in reports of Staphylococcus Aureus (MRSA and MSSA) and E. Coli bacteraemia, and of Clostridium Difficile infections (CDI), mandatorily reported by NHS acute Trust hospitals in England up end-September 2014, has been published on the GOV.UK website [1].

The report, including tabular and graphical information, provides data for the July-September 2014 quarter to update the previous report published on 19 September 2014 [1,2]. Some key facts are listed here:

• in the July-September 2014 reporting period, the total number of MRSA bacteraemia reports decreased by 9.4% compared to the same quarter in the previous year, from 201 to 182, continuing the steady decline in MRSA reports over the last eight years

• since the July-September 2013 quarter there has been a 20.7% decrease in the total number of Trust-assigned MRSA bacteraemias (from 92 to 73 reports) and a 17.4% decrease in CCG-assigned bacteraemias (from 109 to 90 reports)

• there was a corresponding decrease in Trust-assigned rates of MRSA bacteraemia (ie reports per 100,000 bed-days) compared to the same quarter in the previous year (from 1.09 to 0.86 per 100,000 bed-days). The CCG-assigned rate – per 100,000 population – decreased from 0.80 to 0.66 over the same time period

• overall, there was a 7.1% increase in the rate of MSSA bacteraemia reports between July-September 2011 and July-September 2014. However, over the same time period was a 6.2% decrease in the rate of Trust-apportioned reports (from 8.54 to 8.01 per 100,000 bed days)

• Trust-apportioned of MSSA bacteraemia rates remained relatively consistent (ranging from 7.7-8.3) between October-December 2012 and July-September 2014, except for the October-December 2013 when the rate dipped to 7.0 per 100,000 bed days. Therefore the increase seen in overall reports was not due to increases in Trust-apportioned reports

• since the start of mandatory E. Coli bacteraemia surveillance in June 2011, the total number of reported E.Coli bacteraemias has increased steadily, with seasonal peaks between July-September each year

• the highest rate was in the most recent quarter (July-September 2014) when the rate reached 69.77 per 100,000 population, an increase of 4.3% compared to the same quarter last year

• the first quarter of 2014 saw the lowest number of Clostridium Difficile infections (CDI) recorded since mandatory reporting began in 2007

• since then, the total number of CDI has increased 32.2%, from 3,006 in January-March to 3,973 in July-September. The total number of CDI for the July-September 2014 quarter has increased by 302 reports (8.2%) compared to the same quarter in the previous year and accounts for the highest number of cases reported in a quarter since October-December 2011; an increase is also observed in the all-reports rate per 100,000 population

• overall, Trust-apportioned CDI decreased by 854 (38.7%) between April-June 2011 and the current quarter (2,206 to 1,352, respectively). But compared with the same quarter the previous calendar year, increased in the two most recent quarters (by 11.1% and 5.8%, respectively)

• the percentage increase in non-Trust apportioned reports between July-September 2013 and July-September 2014 was sharper, with nearly double the percentage increase compared to Trust-apportioned reports (9.5% vs. 5.8%, respectively)

• Trust-apportioned rates of CDI also increased in the July-September 2014 quarter compared to the same quarter in the previous year.

3.1 References

1. PHE (11 December 2014). Quarterly epidemiological commentary: mandatory MRSA, MSSA and E. coli bacteraemia, and C. difficile infection data (up to July to September 2014), [500 KB PDF]

2. See HPR 8(37), 26 September 2014.

4. New CIDSC information system underpins national AMR strategy

Collection and collation of laboratory reports on human infections – respiratory, enteric, sexually transmissible, healthcare-associated, etc – is a principal activity of the Centre for Infectious Disease Surveillance and Control (CIDSC) at PHE Colindale. In recent years three principal electronic laboratory data repositories have operated – LabBase (the principal database), Amsurv (for antimicrobial resistance reports) and Cosurv (an infectious disease notification system) – which allowed data on particular infections to be centrally collated at CIDSC but was costly to maintain and difficult to quality assure.

After a period of development and testing, these databases have been amalgamated into, and replaced by, a single, web-based system that further automates infectious disease reporting but also opens up new possibilities for health protection professionals and participating laboratories to make fuller use of the data they collect and submit to CIDSC.

SGSS (Second Generation Surveillance System), commissioned on 1 December, comprises a single entry point for the collection of data from all England, Wales and Northern Ireland laboratories and is expected to lead to improved ascertainment of infections, and of infectious disease outbreaks, and to improved quality and speed of data collection.

This applies to most infections of public health significance – from long-surveilled diseases, such as syphilis and TB, to the more-recently recognised hazards of hospital-acquired infections and infections resistant to treatment by antibiotics. In the field of antimicrobial resistance (AMR) in general, and implementation of the government’s five year AMR strategy in particular, SGSS/AmSurv will play a key role.

Because SGSS significantly expands CIDSC’s capability to capture both infection reports and antibiotic susceptibility test results, it will allow analysis of trends in resistance from a much wider range of clinical sources than previously. In addition SGSS allows analysis that previously was impossible, for instance exceedance alerting to help identify outbreaks.

In future SGSS will be expanded to allow for antimicrobial prescribing data to be collated alongside the infections and AMR data that are available at present. The system will therefore play a key role in implementation of the recently launched English Surveillance Programme for Antimicrobial Utilization and Resistance (ESPAUR) [1]. Consumption of antibiotics is a major driver for the development of resistance in bacteria and SGSS will be in due course provide information not only on antibiotic resistance trends but also on trends in useage/prescribing, at national and regional level.

4.1 Reference

1. English Surveillance Programme for Antimicrobial Utilisation and Resistance first report, HPR 8(39): news, 10 October 2014.