Research and analysis

HPR volume 9 issue 3: news (23 January)

Updated 29 December 2015

1. Ebola virus disease: international epidemiological summary (at 18 January 2015)

As of 18 January 2015, WHO reports a total of 21,724 clinically compatible cases (CCC) of Ebola virus disease (EVD), including 8,641 deaths, associated with the west African outbreak (table 1). Provided case totals and particularly deaths are known to still under-represent the true impact of the outbreak in west Africa. While the majority of cases have been reported from Guinea, Liberia and Sierra Leone, cases have also been reported from Mali, Nigeria, Senegal, Spain, the United Kingdom (UK) and the United States of America (USA).

Current reports indicate an overall improving epidemiological situation in Guineau, Liberia and Sierra Leone continues to improve.

In Guinea, reported case incidence showed a decrease again this week to the lowest level nationally since early August 2014, and in the capital Conakry since early November 2014. However, the geographical distribution of cases continues to vary and shift. The resurgence of cases in Boffa in the last week (last cases reported here in June 2014) is characteristic of the variable nature of EVD transmission in Guinea. Incidents of community resistance remain an issue and may impede progress in EVD control.

In Liberia reported case incidence remains at a low level level with eight confirmed cases reported in the last week. Currently only two districts are reporting active transmission: Montserrado county and Grand Cape Mount. As in Guinea, community resistance to EVD control measures, particularly in Grand Cape Mount, may hinder progress.

While Sierra Leone remains the worst affected country (with nearly three times as many new confirmed cases reported in the last 21 days than in Guinea and Liberia combined), a decrease in national case incidence has been reported for the third consecutive week. This week’s total is the lowest weekly total of new confirmed cases reported since July 2014. Significant transmission continues in the western districts, particularly in Freetown, Port Loko and the Western Rural Area, where a combined total of 78 confirmed cases were reported in the last week.

The average case fatality rate among hospitalised patients for Guinea, Liberia and Sierra Leone is 58%, with no detectable improvement since the onset of the epidemic.

To date, a total of 24 EVD cases have been cared for outside of Africa. Of these, 18 repatriated cases (hospitalised in USA, Spain, UK, Germany, France, Norway, Switzerland, Italy and the Netherlands), three imported cases (diagnosed in the USA and the UK) and three incidents of local transmission (in Spain and the USA).

The table below summarises Ebola virus disease international epidemiological information as at 18 January 2015.

Country	Total CCCs	Total deaths	Current status
Guinea	2871	1876	Ongoing transmission
Liberia	8478	3605	Ongoing transmission
Sierra Leone	10,340	3145	Ongoing transmission
Mali	8	6	Awaiting EVD free status
Nigeria	20	8	EVD free
Senegal	1	0	EVD free
Spain	1	0	EVD free
UK	1	0	Single imported case
USA	4	1	Awaiting EVD free status
TOTAL	21,724	8641	–

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

2. Collaborative tuberculosis strategy for England published

The collaborative tuberculosis strategy for England, jointly launched by NHS England and PHE this month [1,2], follows an extensive consultation exercise in 2014 during which more than one hundred respondents participated. Alongside the 45-page strategy document itself, a report on the consultation exercise has been published describing how responses were analysed, highlighting key comments made and indicating how the draft strategy was amended as a result [3].

Approximately one quarter of responses to the consultation were from local authorities, a quarter from the NHS, a quarter from PHE (including collective responses of local stakeholders made up of PHE, NHS, clinical commissioning groups (CCGs), local government, the third sector and others) and a quarter from other stakeholder groups including the National Institute for Health and Care Excellence, the British Thoracic Society, local government, the Association of Directors of Public Health and third sector organisations.

The collaborative strategy, which will co-ordinate action by local government, the NHS and the voluntary sector, was developed by a PHE-managed National TB Oversight Group on which NHS England, the British Thoracic Society, TB Alert, local government and NICE were represented. It aims to achieve sustained, year-on-year reduction of TB incidence by 2020 and thus reverse the recent trend that has led to England now having the second highest TB rate in Western Europe.

The 10 key intervention areas specified in the draft strategy are carried forward into the final document, ie:

• improving access to services and ensuring early diagnosis
• providing universal access to high-quality diagnostics
• improving treatment and care services
• ensuring comprehensive contact tracing
• improving BCG vaccination uptake
• reducing drug-resistant TB
• tackling TB in under-served populations
• systematically implementing new entrant latent TB (LTBI) screening
• strengthening surveillance and monitoring
• appropriate workforce development to deliver TB control.

Following the consultation exercise, questions about how the proposed local control boards would operate, and how implementation of the strategy would be funded, have been clarified.

Nine TB control boards – coterminous with PHE Centre areas – will be established, responsible for planning, overseeing, supporting and monitoring all aspects of local TB control, including clinical and public health services and workforce planning, with support from the national TB programme. The terms of reference of the control boards, and the roles and responsibilities of individuals involved, are currently being developed. Control boards will be funded through PHE and enable establishment of a dedicated core management team in addition to stakeholder representation. The consultation report also includes reference to an impact assessment which analysed costs and benefits of the strategy.

A formal monitoring framework is being put in place to track implementation progress at control board and national level. The monitoring framework will use existing surveillance systems, including current enhanced tuberculosis surveillance arrangements, but will collect additional data, where necessary. Currently available data cover incidence, treatment outcomes, antimicrobial resistance trends and treatment delays.

It is accepted that socioeconomic deprivation and recent migration from a country where TB is common are important risk factors for TB. A key component of the strategy is to improve early access to detection and treatment of TB, particularly amongst hard to reach populations. To this end, it is planned to expand the successful Find and Treat service, which provides diagnosis and care for persons with social risk factors, including homelessness, imprisonment, drug and alcohol use. The strategy also supports the screening and treatment of recent migrants with dormant (latent) TB, and almost all respondents to the consultation were very supportive of this intervention.

2.1 References

1. PHE/NHS England policy paper. Collaborative tuberculosis strategy for England 2015-2020 [1.23 MB PDF].

2. “PHE and NHS England launch joint £11.5m strategy to wipe out TB”, PHE press release, 19 January 2015.

3. Consultation on the collaborative tuberculosis strategy for England 2015-2020: summary report [425 KB PDF].