Research and analysis

HPR volume 9 issue 25: news and travel (17 July)

Updated 29 December 2015

1. Mandatory MRSA, MSSA and E. Coli bacteraemia and C. Difficile infection data (England): up to financial year 2014 to 2015

PHE’s latest annual data, and latest annual epidemiological commentary, on trends in reports of Staphylococcus Aureus (MRSA and MSSA) and E. Coli bacteraemia, and of Clostridium Difficile infections, mandatorily reported by NHS acute Trusts in England up to financial year 2014 to 2015, have been published on the GOV.UK website [1,2].

The data and commentary, including tabular and graphical information, cover the 2014 to 2015 Financial Year (updating the previous report published on 10 July 2014). Some key facts are listed below.

1.1 MRSA MSSA and E. Coli bacteraemias

A total of 801 cases of MRSA bacteraemia were reported by English NHS acute Trusts between 1 April 2014 and 31 March 2015 (FY 2014 to 2015). This represents a reduction of 7.1% in the number of cases reported in 2013 to 2014 when 862 cases were reported, and an overall reduction of 82.0% from the number of cases reported in 2007 to 2008 (4,451 cases).

Of the 801 cases in FY 2014 to 2015, 320 MRSA bacteraemias were assigned to an acute Trust (0.9 per 100,000 bed days) through the Post Infection Review (PIR) process [3] and 384 were assigned to a Clinical Commissioning Group (CCG ) (0.71 per 100,000 population) while the remaining 97 MRSA bacteraemias were assigned to a Third Party, equivalent to 0.2 per 100,000 population.

A total of 9,827 cases of MSSA bacteraemia were reported across the NHS in England in 2014 to 2015. This represents an increase of 5.8% on the number of cases reported in 2013 to 2014 when 9,290 cases were reported, and an increase of 12.1% on the number of cases reported in 2011 to 2012 (8,767 cases). The associated national rate also increased from 16.5 to 18.2 cases per 100,000 population over this time period.

A total of 2,795 (28.4% of 9,827 total reported MSSA bacteraemias) were Trust apportioned across the NHS in 2014 to 2015. This represents a 3.7% increase compared to the number of Trust apportioned cases in 2013 to 2014 (n=2,696) and is the first increase in Trust apportioned MSSA bacteraemias since its inclusion in the mandatory surveillance scheme. Similarly, the rate of Trust apportioned MSSA bacteraemia has also increased between 2013 to 2014 and 2014 to 2015 from 7.9 per 100,000 bed days to 8.1 per 100,000 bed days, respectively.

A total of 35,676 cases of E. Coli bacteraemia were reported across the NHS 2014 to 2015. This represents an increase of 4.1% on the number of cases in 2013 to 2014 when 34,275 cases were reported and an overall 10.4% increase from 2012/13 (n=32,309 cases), which was the first full financial year of mandatory surveillance data on E. Coli bacteraemias. The associated national rate also increased from 60.4 to 66.2 cases per 100,000 population over this time period.

Observed increases in MSSA and E. Coli bacteraemia numbers have been apparent for some time and is in fact why Public Health England (PHE), the Department of Health and the NHS initiated more in-depth surveillance on these infections. PHE are currently working with the Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) to identify suitable healthcare interventions to reduce these infections.

1.2 C. Difficile infections

A total of 14,165 cases of C. Difficile infection (CDI) were reported across the NHS in 2014 to 2015. This represents an increase of 6.0% on the number of cases reported in 2013 to 2014 when 13,361 cases were reported. This is the first increase in CDI since the enhanced mandatory surveillance of CDI was initiated in 2007. However, the 2014 to 2015 data is not yet at 2012 to 2013 levels and even with the recent increase in 2014 to 2015, there remains a 74.5% overall reduction in the number of CDI between 2007 to 2008 and 2014 to 2015 (from 55,498 in 2007/08). The associated national rate decreased from 108.0 in 2007 to 2008 to 24.8 cases per 100,000 population in 2013 to 2014, with a slight increase in the rate to 26.3 per 100,000 population in 2014 to 2015.

There has also been an increase in the number of Trust apportioned cases in 2014 to 2015. Of the 14,165 cases reported in patients aged 2 years and over in 2014 to 2015, 5,213 (36.8%) were Trust apportioned. This represents a 3.6% increase on the 5,033 Trust apportioned CDI reports received in 2013 to 2014; however, the number of Trust apportioned cases have still declined by 84.4% overall since 2007/08 (from 33,442 in 2007 to 2008).

Of note, the increase in non-Trust apportioned cases was greater, with a 7.5% increase over the same time period from 8,328 non-Trust apportioned C. Difficile infections in 2013 to 2014 to 8,952 in 2014 to 2015; resulting in a lesser percentage of all reported C. Difficile infections which were Trust apportioned in 2014 to 2015 than ever before (36.8% in 2014 to 2015).

Like the number of Trust apportioned C. Difficile infections, the rate of Trust apportioned cases per 100,000 bed days has decreased overall between 2007 to 2008 and 2014 to 2015, from 89.7 per 100,000 bed days in 2007 to 2008 to 15.1 per 100,000 bed days in 2014 to 2015; however, there has been a 2.9% increase since 2013 to 2014 (14.7 per 100,000 bed days).

The observed increases in Clostridium Difficile infection are currently under investigation and Public Health England is working closely with the NHS and the wider health service to look for any underlying reasons. In particular, the proportion of infections that detected in the community that maybe associated with recent hospital stays.

1.3 References

1. PHE (July 2015). Quarterly counts by acute Trust and CCG, and financial year counts and rates by acute Trust and CCG, up to financial year 2014 to 2015: * MRSA bacteraemia; * MSSA bacteraemia; * E. Coli bacteraemia; * C. Difficile infections.

2. PHE (9 July 2015). Annual Epidemiological Commentary: MRSA, MSSA and E. Coli bacteraemia, and C. Difficile infection data, up to and including financial year 2014/15.

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

2. Travel advice for Hajj and Umrah pilgrims

The National Travel Health Network and Centre (NaTHNaC) has updated its guidance for UK-based Hajj and Umrah pilgrims, for the upcoming Hajj season in September 2015 (1436H), following the publication of health-related requirements and recommendations by the Ministry of Health in the Kingdom of Saudi Arabia (MOH-KSA) [1,2].

The NaTHNaC guidance includes general precautionary advice, and recommends that UK-based pilgrims should be up-to-date with routine immunisations and have a pre-travel consultation with a healthcare provider at least 4 to 6 weeks before travel for advice on their fitness to travel, malaria prophylaxis, other risks from insect bites and contact with animals, food and water precautions, and injury prevention. A single dose of quadrivalent conjugate meningococcal vaccine administered between three years and 10 days before arrival in KSA is a mandatory requirement for Hajj pilgrims.

There is currently an ongoing outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) in KSA, with a small number of cases also reported in other countries of the Middle East. The risk to UK residents travelling to the Middle East of contracting MERS-CoV during travel remains very low [3]. MOH-KSA and PHE advise a number of precautions to prevent the spread of respiratory diseases, including good hand hygiene and mask wearing in crowded places. See the NaTHNaC information sheet [1] for the full details of all recommendations.

In response to international outbreaks of disease, the MOH-KSA recommends that vulnerable groups – those over 65 years of age, those with chronic diseases (eg heart, kidney or respiratory disease, diabetes or immune deficiency), malignancy and terminal illness, pregnant women and children – should postpone their pilgrimage this year for their own safety.

2.1 References

1. National Travel Health Network and Centre clinical update (17 July 2015). Advice for pilgrims: Hajj and Umrah 1436 (2015).
2. Ministry of Health, Kingdom of Saudi Arabia (15 July). Health requirements and recommendations for Hajj and Umrah performers and those working in Hajj areas.
3. PHE (June 2015). Risk assessment of Middle East Respiratory Syndrome coronavirus (MERS-CoV).