Research and analysis

HPR volume 9 issue 20: news (12 June)

Updated 29 December 2015

1. Malaria imported into the UK, 2014

Public Health England (PHE) has published its annual malaria report for the UK for 2014 [1].

In 2014, 1586 cases of imported malaria were reported in the UK, 5.7% higher than reported in 2013 (1501) and just 0.25% below the mean number of 1590 cases reported between 2004 and 2013. The majority of cases (74%) continue to be caused by, the potentially fatal, Plasmodium falciparum parasite.

Of those with travel history/country of residence information available (1264/1586, 80%), the majority of malaria cases reported in the UK were UK residents who had travelled abroad (1000/1264, 79%), with most having travelled to visit friends and relatives in West Africa.

Three deaths from malaria were reported in 2014 compared to seven in 2013, all from falciparum malaria acquired in Nigeria.

This latest report shows that malaria remains an important issue for UK travellers, particularly for those of African or Asian ethnicity who are non-UK born and going to visit friends and family in their country of origin. Failure to take chemoprophylaxis is associated with the majority of cases. Those providing advice should engage with these population groups wherever possible, including using potential opportunities to talk about future travel plans outside a specific travel health consultation, such as during new patient checks or childhood immunisation appointments [2].

The PHE Advisory Committee on Malaria Prevention guidelines [3] and resources available from the National Travel Health Network and Centre should also assist clinicians in helping travellers to make rational decisions about protection against malaria.

Useful resources for travellers, including translated advice leaflets, are also available via the PHE Malaria: Guidance, Data and Analysis health protection collection webpage [4].

1.1 References

1. PHE (12 June 2015). Malaria imported into the United Kingdom: 2014, Implications for those advising travellers.
2. PHE Migrant Health Guide (online).
3. Chiodini PL, Field VK, Whitty CJM and Lalloo DG. Guidelines for malaria prevention in travellers from the United Kingdom.
4. PHE. Malaria: guidance, data and analysis.

2. MERS-CoV in South Korea

The largest outbreak of MERS-CoV outside the Arabian Peninsula has led PHE to temporarily add South Korea to the list of affected countries in its management algorithms.

The outbreak in South Korea followed the importation of a confirmed case who acquired their infection in the Middle East, with subsequent limited person-to-person transmission in health care settings.

PHE advice for health professionals for the management of suspect cases returning from affected countries includes primary care and public health investigation algorithms. These state that in cases where “a history of travel to, or residence in [the respective countries is indicated] in the 14 days prior to symptom onset” further clinical risk assessment, management and/or microbiological testing may be appropriate [1,2].

The updating of advice for health professionals follows the notification to WHO during the past month of an escalating number of confirmed cases in South Korea (125 as at 12 June [3]).

Despite the change to the testing algorithms, the implications of the South Korean outbreak for UK travellers is minimal. PHE’s latest risk assessment [4] notes that: “Although the MERS-CoV cluster in South Korea is the largest that has so far been observed outside of the Arabian Peninsula, the cluster remains limited to patients, visitors to patients and healthcare workers in a few healthcare facilities, and close relatives of the cases. The outbreak does not represent an increased risk of infection for travellers or visitors to South Korea.”

Current PHE guidance is therefore that testing is now recommended for suspect cases hospitalised with an acute respiratory illness with a history of travel to the following countries:

• Bahrain
• Iraq
• Iran
• Jordan
• Kingdom of Saudi Arabia
• Kuwait
• Oman
• Qatar
• South Korea
• United Arab Emirates
• Yemen

Further related information is available via the PHE MERS-CoV Clinical Management and Guidance health protection collection webpage [4].

2.1 References

1. PHE (9 June 2015). Primary care initial management and assessment algorithm (MERS-CoV or avian influenza A).
2. PHE (9 June 2015). Public health investigation and management algorithm.
3. WHO MERS-CoV webpages.
4. PHE. Middle East respiratory syndrome coronavirus (MERS-CoV): clinical management and guidance.

3. Guidance for cardiothoracic providers on mycobacterial infections

PHE in partnership with the Society for Cardiothoracic Surgery and the Association of Cardiothoracic Anaesthetists have issued joint guidance for providers of cardiothoracic surgery in England following a field safety notice (FSN) regarding infection risks potentially associated with heater cooler devices used in cardiopulmonary bypass [1]. The manufacturer’s FSN recommends enhanced decontamination procedures and/or removal from service of some contaminated machines, a measure with potential for significant disruption to cardiothoracic surgical services given the widespread use of this brand in the UK.

The FSN follows investigations in Switzerland, the Netherlands, Germany and the UK which have identified a small number of patients with post-surgical infection due to M. chimaera, potentially associated with contaminated heater cooler units [2,3].

PHE advice to hospitals includes a preliminary assessment of the potential additional infection risk posed by contamination of heater cooler equipment based on the 13 cases of mycobacterial infection identified to date in patients undergoing cardiothoracic surgery since 2007 [4]. Given the approximately 56,000 surgical procedures involving cardiopulmonary bypass performed on NHS patients in England annually, and the background risk of infection following this type of surgery, the additional risk posed by this threat appears to be very low. The Society for Cardiothoracic Surgery advises that the risk to patients of delaying surgery is likely to be significantly greater than the risk of infection in most cases.

The PHE advice recommends that – where patients develop endocarditis, surgical site infection or systemic illness suggestive of infection after cardiothoracic surgery – diagnostic testing for mycobacterial infection should be considered. The guidance also includes background information about the clinical and microbiological aspects of such investigations. All related documents are available via the Mycobacterial infections associated with heater cooler units health protection collection.

3.1 References

1. PHE, Society for Cardiothoracic Surgery, Association of Cardiothoracic Anaesthetists (9 June). Mycobacterial infections associated with heater cooler units used in cardiothoracic surgery: advice for providers of cardiothoracic surgery.
2. Investigation of M. chimaera infection associated with cardiopulmonary bypass: an update, HPR 9(18), 21 May 2015.
3. ECDC (30 April 2015). Invasive cardiovascular infection by Mycobacterium chimaera potentially associated with heater-cooler units used during cardiac surgery.
4. Mycobacterial infections associated with cardiopulmonary bypass surgery, PHE news story, 11 June 2015.