Research and analysis

HPR volume 9 issue 36: news (9 October)

Updated 29 December 2015

1. Alert on 2,4-dinitrophenol deaths

A reduction in reported cases of poisoning associated with the industrial chemical 2,4-dinitrophenol (DNP) – often illegally marketed as a weight-loss and body-building food supplement – were achieved after warnings were issued by the FSA (in 2012 and 2013), and the CMO in 2013. However, ongoing surveillance by the PHE-commissioned National Poisons Information Service (NPIS) has indicated a resurgence of such poisonings, including an increase in fatal cases, continuing into 2015.

According to the latest NPIS annual report for 2014/15 [1], the rate of enquiries from health professionals to NPIS about DNP fell from peaks of more than 150 per quarter in 2013/14 (for both online enquiries to the NPIS TOXBASE database, and for telephone enquiries to NPIS toxicology specialists, respectively) to below 30 per quarter in late-2013/early-2014 in each case [1].

The most recent surveillance data, however, indicate that more than 30 complex cases were referred to NPIS specialists between 1 January and 17 September 2015, compared with nine such cases during the whole of 2014. Five of the cases in 2015 were fatal.

Those affected have been for the most part teenagers and young adults. Symptoms of poisoning include high fever, gastro-intestinal disturbances, chest and abdominal pain, headache, confusion and convulsions. PHE has issued a new alert advising general practitioners to refer suspect cases to hospital for assessment and observation, and accident and emergency departments to obtain further information from TOXBASE or from NPIS specialists.

1.1 References

1. PHE (September 2015). National Poisons Information Service annual report 2014/2015, ISBN 978-0-85951-774-4.

2. MERS, influenza and respiratory illness in travellers returning from the Hajj

Following the recent Hajj annual pilgrimage to Mecca in the Kingdom of Saudi Arabia (KSA), UK clinicians have been reminded to be vigilant for suspect Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV) cases among returning travellers presenting to hospital with acute respiratory symptoms – so as to ensure early detection, respiratory isolation and testing with the aim of limiting onward spread [1].

The Hajj festival, a mass gathering that draws more than two million pilgrims from around the world, is well recognised as an amplifying event for respiratory pathogens [2]. Respiratory illness is common amongst travellers returning from the Hajj, with increased rates of acute respiratory illness and infection observed in previous studies [2,3,4].

Since the first recognition of MERS in September 2012, there have been concerns about transmission of this infection linked to this mass gathering event, and of associated exportations as pilgrims return home. No Hajj-related MERS cases have been reported over the seasons since [5]. Taking account of recent reports of MERS transmission in Riyadh, however, the UK has raised awareness of the potential of MERS acquisition [1].

The UK has an established enhanced surveillance system for suspect MERS cases in travellers returning from the Middle East and hospitalised with an acute respiratory illness [6]. In the period 1 September 2015 to 7 October 2015, there have been a total of 19 possible MERS cases reported in travellers returning from KSA, who required admission to hospital with acute respiratory illness. All cases were tested and were negative for MERS-CoV. To date nine (47%) have been diagnosed as influenza A positive (including one co-infection with RSV, one with paraflu-3 and one with rhinovirus), four (21%) as rhinovirus positive (single infection) and one (5%) adenovirus positive.

The picture in 2015 is very similar to that seen in the two previous Hajj/Umrah periods during which MERS surveillance has been operational in the UK. In 2013, from 1 September until 1 November, a total of 24 possible cases were reported and investigated. All were negative for MERS-CoV on laboratory investigation, but 11 (46%) were positive for influenza A and seven (29%) for rhinovirus (although six of these were co-infections with influenza). Similarly in 2014, in the period from 1 September until 1 November, a total of seven MERS-CoV cases were investigated. All were negative for MERS-CoV, but three (43%) were positive for rhinovirus, three (42%) for influenza. All cases were hospitalised, including admissions to critical care units. Information on influenza vaccine status and antiviral treatment of these cases are not known.

Clinicians should remain vigilant for MERS-CoV in travellers returning from the Middle East and who present with a recent acute respiratory illness that has resulted in hospitalisation. It is important that strict respiratory infection control measures are put in place and MERS-CoV testing is expedited [7]. However, particularly for Hajj returnees, clinicians should be aware that influenza may be a more likely explanation for the patient’s symptoms and they should not hesitate to start empirical antiviral treatment for influenza on admission if indicated, pending the results of laboratory investigations for influenza, MERS-CoV and other respiratory pathogens. In addition, these findings reinforce the MOH-KSA recommendation that pilgrims be vaccinated against seasonal influenza, especially those at increased risk of severe disease.

2.1 References

1. CMO alert to the NHS (21 September 2015). Middle East Respiratory Syndrome coronavirus (MERS-CoV) in the Kingdom of Saudi Arabia and the upcoming Hajj pilgrimage.
2. Memish ZA, Assiri A, Turkestani A, Yezli S, Al Masri M, Charrel R, et al (2015). Mass gathering and globalization of respiratory pathogens during the 2013 Hajj. Clin Microbiol Infect. Jun 21(6): 571.
3. Gautret P, Yong W, Soula G, Gaudart J, Delmont J, Dia A, et al (2009). Incidence of Hajj-associated febrile cough episodes among French pilgrims: a prospective cohort study on the influence of statin use and risk factors. Clin Microbiol Infect. Apr. 15(4): 335-40.
4. Rashid H, Shafi S, Booy R, El Bashir H, Ali K, Zambon MC, et al (2008). Influenza and respiratory syncytial virus infections in British Hajj pilgrims. Emerg Health Threats J. 1: e2.
5. Gardner LM, MacIntyre CR (2014). Unanswered questions about the Middle East respiratory syndrome coronavirus (MERS-CoV). BMC Res Notes. June 7: 358.
6. Thomas HL, Zhao H, Green HK, Boddington NL, Carvalho CF, Osman HK, et al (2014). Enhanced MERS coronavirus surveillance of travelers from the Middle East to England. Emerg Infect Dis. Sept. 20(9): 1562-4.
7. PHE guidance for management of a possible case of MERS

3. Antimicrobial resistance testing included in SMIs

In order to support antimicrobial stewardship programmes in healthcare, PHE is increasingly including testing for antimicrobial susceptibility as a component of new (and newly updated) microbiological laboratory test procedures promulgated by its Microbiology Services Standards Unit. Two recently promulgated Standards for Microbiology Investigations (UK SMIs) – covering test methods for investigation of skin and superficial soft tissue infections (B11) [1], and for urinary infections (B41) [2] – were the first to include recommendations on AMR testing.

(Consultations on the new these two SMIs is now closed; however, the documents can be viewed on the gov.uk website [1,2], where a Review of User’s Comments will published in due course.)

Antimicrobial testing and reporting tables included in the SMIs indicate which “drug-bug” combinations are recommended for testing: in all cases for some antimicrobials, only in specific clinical scenarios for others, taking account of local circumstances.

Recommendations on antimicrobial testing in SMIs are drafted in conjunction with the British Society for Antimicrobial Chemotherapy. They are intended to support and complement local antimicrobial testing guidance.

3.1 References

1. SMI B 11: Investigation of skin, superficial and non-surgical wound swabs.

2. SMI B 41: Investigation of urine.

4. Defra consultation on air quality (nitrogen dioxide) improvement plans

The Department for Environment, Food and Rural Affairs (Defra), which has lead responsibility for air quality in the UK, has published a public consultation document setting out draft plans to improve air quality in England, Wales and Northern Ireland [1]. The document is specifically concerned with compliance with EU limit values for nitrogen dioxide (NO2) and sets out actions being planned or implemented at local, regional and national levels in the UK to move towards compliance. The consultation document invites comments – before 6 November 2015 – particularly from local authorities (who have statutory duties for managing local air quality), environmental groups, those operating in the transport and public health sectors, and other organisations with an interest in air quality.

Following the consultation – and after the independent Committee on the Medical Effects of Air Pollutants (COMEAP) publishes its assessment of how reductions in NO2 concentrations could impact on mortality in the UK, due in December – an Air Quality Plan for the UK will be submitted to the European Commission before the end of 2015.

Of the 43 zones and agglomerations into which the UK is divided for monitoring and reporting purposes, 38 do not currently comply with EU NO2 limit values, including eight that are projected to still be non-compliant in 2020.

Defra’s proposed air quality action plans focus on reducing NO2 levels in towns and cities and include measures that primarily target urban road traffic because, on average, around 80% of emissions of oxides of nitrogen in areas where the UK is exceeding NO2 limits is due to transport (although non-transport sources are also significant). The largest source is emissions from diesel light duty vehicles (cars and vans) where emissions standards have had least impact and there has been significant growth in vehicle numbers over the last 10 years.

Levels of action included in Defra’s draft Air Quality Plans include the following:

• local action, ie: “Interventions identified seek to improve air quality by promoting a modal shift from private cars to active travel and integrated public transport; reducing congestion and employing restrictions to change fleet mixes in cities via Low Emissions Zones and parking restrictions”;
• national action, ie: “The plans propose that cities consider the role of access restrictions for certain types of vehicles on the basis of a national framework for new Clean Air Zones. Other actions include electrification of the vehicle fleet and other ultra-low emission technologies”;
• international action, ie: “While the UK is taking action locally, regionally and nationally to reduce NO2 concentrations, there is also a need for action at European level to ensure that relevant standards and regulations support reductions in NO2 concentrations …”

The Defra consultation has particular significance for local authorities in England, Wales and Northern Ireland whose statutory duties include assessing priority health issues for their local communities. PHE Centres are being actively encouraged to liaise with their LAs to raise local awareness of air pollution, promote local action to improve air quality and respond to the Defra consultation.

4.1 Reference

1. Defra (September 2015). Consultation on draft plans to improve air quality: tackling nitrogen dioxide in our towns and cities website.