Corporate report

UKHSA Advisory Board: Update on preparedness and response for infectious diseases

Updated 28 January 2025

Date: January 2025

Sponsor: Susan Hopkins

Presenter: Richard Pebody

1. Purpose of the paper

To update on UKHSA activities to support preparedness and response for infectious diseases.

2. Recommendations

The Advisory Board is asked to note this update on activities that have occurred or under development to prepare for and respond to infectious diseases threats in particular:

• delivery of actions for the Antimicrobial Resistance National Action Plan;

 - development supporting implementation of Sexually Transmitted Infections (STIs) Prioritisation Framework and implementation and evaluation of STI vaccines (for mpox and gonorrhoea, where policy agreed);

• monitoring and evaluation of current HIV Action Plan 2022-2025 and development of evidence-based interventions for the next HIV action plan to support elimination of domestic transmission of HIV by 2030;

• working with NHSE to determine the optimal cost-effective interventions to maintain the UK as a low tuberculosis (TB) incidence country

• continue to prepare and build functions and systems to enable effective responses to new and emerging threats, epidemics and pandemics

• working with NHSE to meet national and global commitments for elimination of viral hepatitis as a public health threat (i.e. reducing harmful impacts of hepatitis B and C infection)

3. Background

The Board previously received an overarching report on related to Infectious Diseases preparedness, response and control in January 2024 (Ref: AB/23/005). This report updates on key activities that have occurred over the last 12 months and highlight the ongoing work in this area.

Infectious diseases impact on, and is impacted by, all six strategic priorities in the UKHSA strategic plan 2023 to 2026. Preparing for infectious diseases ensures we are ready to respond to all hazards. The statistical and research outputs ensure that we provide evidence for interventions (e.g. vaccines, pre-exposure prophylaxis for HIV, harm reduction strategies for preventing hepatitis C infection in people who inject drugs, blood-borne virus opt-out testing in Emergency Departments, antimicrobial stewardship) to reduce the impact of infectious diseases and evaluate the effectiveness and uptake of policy decisions to improve health outcomes. Horizon scanning, vector surveillance and work on mitigating the impact of climate change with partners protects from threats in the environment. Data and insights, including data on inequalities [including groups and settings most impacted] improves action across the health, public health, and government to improve health security for all. Bringing together the range of skills and expertise across the organisation through implementing of our science strategy including the pathogen genomics strategy will help us make faster and greater progress towards our priorities.

The work outlined is delivering government policy and national action plans for a range of endemic infectious diseases. It also delivers components of the Government Biological Security Strategy, responds to threats on the national risk register including for emerging infection and for future pandemics. The work is underpinned by an evidence base with cost effective policy implementation, robust evaluation, and the production of statistical reports.

4. Summary of Infectious Diseases impacting on the UK

A number of factors altered endemic and epidemic infectious diseases in the UK over recent years. The COVID-19 pandemic and associated social restrictions and alterations in healthcare delivery reduced the transmission of almost all infectious diseases. The return of social mixing and international travel and migration has been associated with rises in endemic and epidemic infectious diseases since 2022/23. UKHSA has been at the forefront of tackling these increases working with NHS and local systems to provide rapid responses. In addition, UKHSA is developing the evidence base for new interventions to support policy development to reduce transmission and mitigate the impact on human lives and livelihoods.

5. Endemic disease

Respiratory

The 2023/24 winter season saw co-circulation of influenza, respiratory synctical virus (RSV) and SARS-CoV-2. Following initial spread of RSV in early autumn 2023, there was circulation of influenza with influenza A(H3N2), A(H1N1)pdm09 and B/Victoria viruses all detected (1). To improve effectiveness, the influenza vaccine programme has seen the introduction of a number of newly licensed vaccines in recent years - including adjuvanted, cell-based and recombinant vaccines. Influenza vaccine VE monitoring found moderate to good protection for the 23/24 seasonal influenza season in both children and adults (3). However, influenza vaccine uptake in children, pregnant women, under-65 olds at risk and health care workers was low and ranged from 30-40% (2). COVID-19 continued to circulate though out the 23/24 season, with the JN.1 variant becoming dominant.

The 2024/25 season has also seen the introduction of the new RSV vaccination programme targeting both women who are at least 28 weeks pregnant (to protect their infants) and adults 75-79 years of age with the Abrysvo® RSV vaccine (Pfizer Limited) (5). UKHSA will be evaluating these new and existing programmes and early outputs from the RSV vaccine programme in older adults shows it has had significant impact in this population. The impact of the RSV vaccination in pregnant women to protect neonates and babies under 1 year old will take longer to assess. During the 2024/25 season to date, both RSV and influenza have had severe impacts on hospital admissions.

Mycoplasma pneumoniae epidemic peaks tend to happen every 4 to 7 years. Laboratory reports from the winter season of 2023 to 2024 indicated there was an epidemic period of Mycoplasma pneumoniae infections, with laboratory detections in January 2024 exceeding detections in the previous epidemic in 2019 to 2020 three-fold. While this increase could be partially explained by changes in testing methods that have occurred around the COVID-19 pandemic, from October 2023 to February 2024, hospital admissions of Mycoplasma pneumoniae increased by 461% (from 110 to 617 admissions), primarily driven by an increase in admissions in children aged 0 to 14 years old (6).

The annual legionella report showed that in 2023 there were 604 cases reported in England and Wales, the highest since 2017. It is likely that the observed increase is multifactorial, with some genuine changes in the epidemiology likely linked in part again to the impact of the pandemic, but also improvements in detection and awareness (7). The data was released as official statistics for the first time.

Finally, the TB annual report for 2023 was released with 4855 cases notified, an 11% increase compared to 2022, with a further 13.7% increase in the first three-quarters of 2024; if this rate of increase continues then the UK will lose its low incidence status by 2028. 80% of notifications are in those born outside of the UK, with a strong association with inequalities. There is a strong association between the increase of TB incidence and rise in migration (to more than 1m) from high or very high incidence countries despite a doubling in the number of people screened before entry to the UK. The number of eligible new entrant migrants tested through the NHSE Latent TB Infection programme was more than 35,000 (the highest number tested) but was only 11% of the total eligible cohort (8). Work is underway to identify the optimal strategies to tackle this increase.

Healthcare Associated Infection and Antimicrobial Resistance

In 2023, the burden of antimicrobial resistance (AMR), surpassed 2019 levels by 3.5%. The rise in AMR burden followed an initial reduction at the beginning of the pandemic, but with year-on-year increases of resistant bacteraemia reported since 2021. As in previous years, the AMR burden varied markedly across the regions of England, with the highest rate in the London region. Variation in burden was also seen by ethnicity, with the highest percentage resistant reported in the Asian ethnic groups (39.4%). Antibiotic resistance also increased across most major antibiotic classes for Klebsiella pneumoniae between 2019 and 2023 and since 2021, the rates of reported carbapenemase-producing organisms (CPO) from all sample types have doubled.

Total antibiotic consumption also increased by 2.4% between 2022 and 2023 in part linked to a national surge in group A Streptococcus (GAS) cases.

The UK 2024 to 2029 AMR National Action Plan was published in May 2024. It builds on the earlier programme and aims to further strengthen surveillance, antimicrobial stewardship, diagnostics and infection prevention and control interventions to reduce the impact of AMR on the population (9).

Blood-borne viruses

In 2023, there were 6,008 HIV diagnoses in England, an increase of 51% from 2022; 53% of diagnoses were reported as being previously diagnosed abroad (12). Although the HIV action plan for England sets challenging targets to reduce HIV transmission by 80% between 2019 and 2025 – this report highlights a rise in the number of people first diagnosed with HIV, with evidence of widening inequalities across the care pathway. In December 2024, on world AIDS Day, the Prime Minister announced the extension of Emergency Department (ED) opt out testing to HIV high prevalence areas. DHSC, UKHSA and stakeholders are developing the next HIV Action Plan for 2026-2030, to be published during summer 2025, which will include refreshed and new actions, underpinned by evidence, that meet the needs of the changing epidemic and address inequities in access and outcomes.

In relation to Hepatitis B and C, the UK government has adopted the World Health Organization’s (WHO) updated Global Health Sector Strategies to eliminate viral hepatitis by 2030. The latest Hepatitis C (HCV) report with data to the end of 2022 shows continued progress towards achieving these goals. From 2015 to 2022, the number of people living with chronic HCV infection in England has fallen dramatically in the general adult population by 51.6% and is now estimated at 62,600 due to improved testing and access to treatment. People who inject drugs are the main risk group for HCV infection and significant progress has been made to reduce chronic prevalence which is now at 11.8%. Interventions have reduced HCV-related mortality to 0.44 per 100,000 population, the lowest mortality rate for a decade (13). Focus is now being turned to determining what levels of prevention, testing and treatment interventions are required to maintain elimination status.

For hepatitis B (HBV), UKHSA currently estimates in 2022 there were around 270,000 people living with HBV, 0.6% of the population, increasing to 1.5% in London. England has met and exceeded WHO absolute targets on HBV-related mortality, incidence of new infections, elimination of mother to child transmission and universal vaccine coverage among infants. Robust public health programmes and surveillance systems provide a strong platform for these achievements, however, there are areas at risk of not being achieved by 2030. These include increasing the proportion of people living with HBV who are aware of their infection being diagnosed, referred and engaged in care, and tackling declining vaccine coverage in groups at high risk of infection e.g. people who inject drugs. WHO and European clinical guidelines will widen the criteria for treatment and combined with the high number of new diagnoses of HBV from the ED opt out testing sites are expected to increase demands on NHS hepatology services so different models of care, and improvements to the treatment and care pathway are being considered (14).

5.1 Sexually transmitted infections

The 2023 annual STI report showed reductions in reported incidence of a number of STIs during the pandemic. There was, however, an increase seen in 2023 in the numbers of gonorrhoea (7.5%, from 79,268 to 85,223), and infectious syphilis (primary, secondary and early latent stages) diagnoses (9.4%, from 8,693 to 9,513) compared to 2022. The number of gonorrhoea diagnoses in 2023 was the largest reported since records began in 1918, with the number of syphilis diagnoses the largest since 1948. The impact of STIs remains largest in those aged 15 to 24 years; GBMSM (gay, bisexual and men who have sex from men); and some minority ethnic groups (15) .

In 2023 and 2024 (up to 30 November 2024), there have been a total of 409 cases of mpox clade IIb reported in the UK – much lower than seen in 2022. Clade IIb transmission at low levels continues to be mainly among GBMSM  without documented history of travel to endemic countries in Africa (16).

There are novel interventions on the horizon for STIs. In November 2023, the JCVI also advised two routine STI vaccination programmes to be delivered in sexual health services:  a routine mpox vaccination programme for GBMSM at higher risk of infection using MVA-BN vaccine and a routine gonorrhoea programme using the 4CMenB vaccine for GBMSM at high risk, but also including transgender women, gender diverse people assigned male at birth, and heterosexuals, at equivalent risk of gonorrhoea. While mpox policy was agreed in September 2024, gonorrhoea vaccine policy was agreed in January 2025 and the programme implementation for both mpox and 4CMenB vaccines is being supported by a UKHSA led UKHSA/DHSC/NHSE/MHRA (Medicines and Healthcare products Regulatory Agency) vaccine programme board. UKHSA has worked with the British Association for Sexual Health and HIV to develop an evidence-based guideline for the use of doxycycline post-exposure prophylaxis to prevent bacterial STIs; this is currently out for public consultation. To address syphilis, UKHSA published a Syphilis Action Plan which focuses on key interventions such as more frequent testing for GBMSM at higher risk of syphilis, partner notification, raising awareness, and maintaining high uptake of antenatal screening for syphilis (the screening programme in pregnancy also includes HIV and HBV).

Gastro-intestinal infections

During 2023, 177 Listeria cases were reported in England and Wales, an increase from 2022. Listeriosis is a high impact infection with the highest incidence in >80 year olds. One sixth of infections were pregnancy associated, of which almost one-quarter resulted in still-birth or miscarriage. Seven outbreaks were detected over this period linked to consumption of smoked fish, soft cheese and beef products (17). Similarly, Shiga toxin-producing E. coli (STEC), whose reservoir is in cattle, can be responsible for clusters and outbreaks. An outbreak of STEC t5:206 occurred in summer 2024, resulting in over 200 cases of whom 7 developed HUS. Investigation linked the outbreak to consumption of contaminated salad sandwiches (18). Awareness of high-risk products for vulnerable groups for both Listeria and STEC is essential. It is vital clusters and outbreaks of these pathogens are rapidly detected and investigated so that prompt control measures can be implemented in partnership with the Food Standards Agency (FSA) and the food industry to protect public health.

Finally, norovirus – another virus linked to winter-pressures – has seen an earlier increase than usual in autumn 2024, with activity at a 5-year high. This increased activity may be linked to the emergence of the new genogroup GII.17. Simple measures such as washing your hands thoroughly with soap and water and staying home at least 48 hours after recovery can help to reduce spread (19). The start of a new phase 3 clinical trial for a norovirus vaccines also highlights other potential future prevention strategies.

There was also detection of Vaccine Derived Poliovirus type 2 in environmental samples, genetically linked to a VDPV2 circulating in west Africa and now seen in a number of European countries. This later observation is a timely reminder of the importance of ensuring eligible groups are fully up to date with polio vaccination (26).

5.2 Vaccine Preventable infections

Measles started to resurge in 2023 with 362 laboratory confirmed cases reported in England. Activity earlier on was mainly focused in the London region, and then in autumn 2023, it was dominated by an outbreak in the West Midlands (20). In 2024, a total of 2836 measles cases were reported – mainly in the first 6 months of the year – with the majority of cases in children <10 years of age. The outbreak highlighted the critical importance of ensuring eligible groups are fully vaccinated with Measles, Mumps, and Rubella (MMR) vaccine.

Pertussis is cyclical disease with the last increase in 2016 and major increase in 2012. Following the COVID-19 pandemic, a further outbreak has now been seen starting in 2023 with 856 pertussis cases reported in England that year and then 14,453 laboratory confirmed cases between January and October 2024 (21). The number of cases in infants under 3 months of age, the group at highest risk of severe disease, was 427 in 2024 of whom 10 died. The outbreak highlights the importance of ensuring optimal uptake of pertussis vaccine in eligible pregnant women, babies and children.

5.3 Emerging Infections

 UKHSA continued to work with the Animal and Plant Agency (APHA), Department for environment, Food and Rural Affairs (Defra) and FSA to monitor and reduce the risk to human health from emerging influenza viruses. As part of the UKs routine influenza surveillance, a case of swine influenza - A(H1N2)v virus genetically belonging in clade 1B 1.1. – was detected in November 2023 (23). No onward spread was found. Avian influenza A(H5N1) clade 2.3.4.4b has resulted in many human exposures in infected poultry holdings across the UK over the 2023/24 season. As part of the public health response, there were a small number of detections of A(H5N1) in largely asymptomatic exposed workers.

In Spring 2024, the US reported the detection of A(H5N1) in dairy cattle, which has affected herds across several US states, but also involved poultry, wild birds and other mammals in North America. There have been a number of human cases reported – largely exposed dairy workers. The UK has been undertaking regular situational assessments as part of contingency planning. Although no human-to-human transmission has been demonstrated to date, UKHSA’s work in this area forms a critical part of the UK’s broader respiratory epidemic and pandemic preparedness activities (22).

In August 2024, WHO declared Mpox a Public Health Emergency of International Concern under the International Health Regulations. This followed the identification and rapid spread of clade Ib in the Eastern Democratic Republic of Congo together with some neighbouring countries. The UK has seen two travel-related case of clade Ib linked to this region in 2024; one of which led to onward transmission to household contacts (23), but no further spread. This outbreak continues to evolve and will likely lead to further exports outside of the African region.

A wide range of other emerging infections have been detected, assessed and managed. These range from Brucella canis (24) where a small number of human cases have been diagnosed linked to recently imported dogs; a variety of vector borne diseases such as five cases of locally acquired Tick-Borne encephalitis since 2019 (25), as part of monitoring rapidly shifting patterns of vector epidemiology across Europe.

6. Epidemic and Pandemic Preparedness and Response

A range of activities are underway by UKHSA working with the Department of Health

and Social Care (DHSC) and other key stakeholders to develop and refresh strategic and response plans as part of pandemic and epidemic preparedness across all routes of transmission. This includes the ongoing development of a refreshed Pandemic Preparedness Strategy for the healthcare sector and supporting response plans, the first of which will be a published Respiratory Pandemic Response Plan. As part of this work, UKHSA has been supporting DHSC led capabilities assessments of core health protection capabilities that are scalable in response to incidents and will be required for future pandemics and major epidemics. Updates and progress are as follows:

6.1 Prepare

The current UKHSA surveillance systems are highly dependent on NHS laboratories and clinicians identifying and reporting infectious diseases in individual patients and clusters of unusual disease. Progress has been made in strengthening surveillance by delivering the following:

• UKHSA provided evidence to demonstrate the importance of adding additional infectious diseases to become notifiable under the Health Protection regulations in 2024 including Candida auris, Middle East respiratory syndrome (MERS), novel influenza, chickenpox (varicella) and acute flaccid paralysis or acute flaccid myelitis (AFP or AFM). This will commence on 2 April 2025 and enable improved data ascertainment from clinicians to support control measures;

• a UKHSA-wide workshop supported by WHO to review national respiratory surveillance capabilities according to the Mosaic respiratory surveillance framework (27) has supported the development of the respiratory pandemic surveillance plan and associated protocols and operational plans;

• development of a UK-wide infectious disease reporting capability (UKCOPS) with a four nation platform for common reporting to enable better data sharing and the capacity to stand up urgent four nation surveillance and reporting at short notice;

• publication of the UKHSA pathogen genomics strategy (25), with a programme of priority work focused on emerging infections; AMR and VPD has ensured that we are capable of delivering laboratory and analytical pathways to inform public health risk assessments;

• piloting of pathogen-agnostic methods using metagenomics to detect new and emerging pathogens through the mSCAPE programme in association with the NHS – this has been developed with an initial 6 Trusts and with a planned rollout to a further 20 over the next 12 months;

• use of new technology and infrastructure using the CLIMB-TRE resource to collect metagenomics data and associated metadata generated from NHS and research facilities to ensure that there are data analysis capabilities with robust data security.

6.2 Respond

Analysis, including risk assessments, and the ability to share data with professionals, requires a modern data analysis platform and agility to deliver rapidly when necessary with a skilled workforce. Progress has been made in the following areas working across Chief Medical Advisor, Chief Data Officer and Chief Scientific Officer groups:

• development of a priority pathogen family R&D tool list for vaccine and drug development (based on the threat assessment) which supports internal and cross-government  prioritisation of resources;

• as part of pandemic and epidemic preparedness development of special study protocols to improve knowledge on transmission routes, secondary attack rate and severity using approaches such as the FFX for new and emerging pathogens which is essential to enable rapid insights and data sharing with academic communities for modelling new and emerging threats;

• Developed national security accredited function in UKHSA demonstrating that we have right standards and quality assurance processes to use intelligence assessment to support policy and operational decision-making for all hazard threat assessments;

• developing scenarios for planning such as for avian influenza and mpox which have been used across government to support planning for emerging incidents with close working with the Cabinet Office.

6.3 Build

As an organisation, UKHSA needs the ability to scale the operational delivery of interventions to protect the population from public health threats. Progress in this area includes:

• development of a new strategic cloud platform which optimizes our data on secure data platforms and is part of the work to ensure that we are resilient to cyber attacks;

• the successful launch of the Case and Incident Management system to assess and manage enquiries and cases across all-hazards for local Health Protection Teams that allows more flexible, modular data systems to collect, curate and analyse data;

• developed and rolled out new eNOIDs notification system which saves health protection team time and improves data quality allowing rapid response time to infectious disease case management and data delivery;

• development of a unified data platform across the agency including a number of key products (1) launch of UKHSA data dashboard in 2023 and (2) development of first phase of the Surge Response Service which will enable surge high throughput testing, contact tracing to support control of infectious disease outbreaks

• the announcement of academic partnerships for the HPRU3 with a variety of partners for priority areas such as Immunisation, Emerging Infections, Respiratory, AMR and Genomics;

• provided the evidence to DHSC to strengthen UK vaccine and medical countermeasures as part of epidemic and pandemic preparedness, including the purchase of a H5 pre-pandemic vaccine stockpile and an increase to the MVN-BN stock.

7. Co-ordination and Leadership

UKHSA has been co-ordinating a range of activities. Examples include:

• development of an Emerging Infections Disease Plan under the EPRR framework;

• planning for a Tier 1 pandemic exercise in autumn 2025 (ex Pegasus);

• development of the UK 5-year action plan for antimicrobial resistance 2024 to 2029, building on the 2019 to 2024 national action plan;

• support to the ongoing COVID-19 public enquiry.

8. Conclusions

The COVID-19 pandemic not only disrupted the epidemiology of a wide range of infectious pathogens – but also their surveillance, control and prevention programmes. This report highlights the on-going impact, but also some evidence of normalisation. Some of the response deployed during the pandemic are providing opportunities to review and strengthen our systems. Using this learning, UKHSA is delivering on a wide range of preparedness activities over the past 12 months working across the breath of expertise in the Agency and with key stakeholders in the United Kingdom and internationally. This work has been coupled with extensive, simultaneous response work to a wide range of acute incidents. The threat from wide-range of infections with epidemic and pandemic potential from avian influenza to mpox to vector-borne disease will continue to evolve and UKHSA will need to redouble their preparedness work in the next year and beyond.

Richard Pebody

Director, Epidemic & Emerging Infections

January 2025

With input from Susan Hopkins, Sema Mandel, Gauri Godbole, Meera Chand, Isabel Oliver, Will Cook

9. References

1. Flu/RSV/COVID 2023/24 report Weekly_flu_and_COVID-19_report_w20.pdf

2. Flu vaccine uptake 2023/24 Seasonal influenza vaccine uptake in GP patients in England: winter season 2023 to 2024 - GOV.UK

3. 2023/24 Flu VE https://onlinelibrary.wiley.com/doi/full/10.1111/irv.13284

4. Flu, RSV, COVID, 2024/25 National flu and COVID-19 surveillance report: 12 December (week 50) - GOV.UK

5. RSV vaccination Respiratory syncytial virus (RSV) vaccination programme - GOV.UK

6. Mycoplasma Eurosurveillance Persistent elevation in incidence of pneumonia in children in England, 2023/24

7. Legionella Legionellosis in residents of England and Wales: 2017 to 2023 report - GOV.UK

8. TB  Tuberculosis in England, 2024 report - GOV.UK

9. ESPAUR report for 2023 ESPAUR report 2023 to 2024

10. CDI quarterly report 2024 Quarterly epidemiological commentary: mandatory Gram-negative bacteraemia, MRSA, MSSA and C. difficile infections (data up to April to June 2024) - GOV.UK

11. Candida auris https://www.microbiologyresearch.org/content/journal/jmm/10.1099/jmm.0.001820

12. HIV HIV testing, PrEP, new HIV diagnoses and care outcomes for people accessing HIV services: 2024 report - GOV.UK

13. Hepatitis C  Hepatitis C in England 2023 - GOV.UK

14. Hepatitis B Hepatitis B in England 2024 - GOV.UK

15. STIs Sexually transmitted infections and screening for chlamydia in England: 2023 report - GOV.UK

16. Mpox clade 2 Mpox outbreak: epidemiological overview, 12 December 2024 - GOV.UK

17. Listeria Listeriosis in England and Wales: summary for 2023 - GOV.UK

18. STEC Shiga toxin-producing Escherichia coli: guidance, data and analysis - GOV.UK

19. Norovirus National norovirus and rotavirus report, week 50 report: data to week 48 (1 December 2024) - GOV.UK

20. Measles Confirmed cases of measles in England by month, age and region: 2023 - GOV.UK

21. Pertussis Confirmed cases of pertussis in England by month - GOV.UK

22. H5 avian influenza Influenza A(H5N1) 2.3.4.4b B3.13: US cattle outbreak: human health risk assessment

23. Swine influenza UKHSA detects human case of influenza A(H1N2)v - GOV.UK

24. Brucella canis Brucella canis: information for the public and dog owners - GOV.UK

25. Vector Borne disease AB-24-045_Core_preparedness_for_vector_borne_diseases.pdf

26. VDPV HPR volume 18 issue 11: news (10 December) - GOV.UK

27. Mosaic framework WHO Mosaic Respiratory Surveillance Framework

28. Pathogen genomic strategy UKHSA Pathogen Genomics Strategy - GOV.UK

*[DEFRA]; Department for Environment, Food and Rural Affairs