Drug resistant gonorrhoea surveillance (GRASP) annual report Public health impacts of shale gas extraction reviewed in CRCE draft report

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1 Volume 7 Number 44 Published on: 1 November 2013 Current News Drug resistant gonorrhoea surveillance (GRASP) annual report 2012 Chemicals, poisons and environmental hazards Public health impacts of shale gas extraction reviewed in CRCE draft report Infection reports Respiratory Laboratory reports of respiratory infections made to CIDSC from PHE and NHS laboratories in England and Wales: October, 2013 HIV-STIs Recent epidemiology of infectious syphilis and congenital syphilis

2 News Volume 7 Number 44 Published on: 1 November 2013 Drug resistant gonorrhoea surveillance (GRASP) annual report 2012 Antimicrobial resistant gonorrhoea is of global public health concern. In England and Wales, GRASP is the national sentinel surveillance programme that is run between July and September each year. The programme monitors patterns of susceptibility of Neisseria gonorrhoeae to antimicrobial agents used for treatment of gonorrhoea and informs clinical guidelines. In 2012, 25 GUM clinics and 23 laboratories participated in GRASP and 1518 gonococcal isolates were included in the programme. The 2012 GRASP study found that there was a continued increase in the number of patients receiving the recommended first-line treatment of ceftriaxone (500mg) and azithromycin (1g), from 79.4% in 2011 to 86.2% in Decreased susceptibility (MIC 0.125mg/L) to cefixime fell significantly for the second year from 10.8% in 2011 to 5.6% in 2012, predominantly among men who have sex with men (MSM) (see figure). Patients infected with isolates exhibiting decreased susceptibility to cefixime were more likely to be older and have reported sex abroad. Three isolates (0.2%) exhibiting decreased susceptibility to the currently recommended first line agent, ceftriaxone, were detected for the first time since Azithromycin resistance increased slightly from 0.5% in 2011 to 0.7% in 2012 with evidence of a steady increase in the female population. Spectinomycin resistance was not detected. The proactive change in first-line therapy in 2011 has resulted in the majority of GRASP patients receiving the recommended treatment of ceftriaxone and azithromycin which, in turn, may have increased the useful life of the cephalosporins. However, evidence of emerging decreased susceptibility and higher MICs to ceftriaxone and azithromycin is of concern and attempts to find new treatments should continue. The epidemiology of infection with isolates exhibiting decreased susceptibility to cefixime may be evolving as shown by a change in the risk factors associated with infection with these isolates. Isolates exhibiting decreased susceptibility to cefixime continue to decline, particularly from infection seen in MSM, which is consistent with the increased use of the recommended first-line treatment. The continued drift towards decreased susceptibility to ceftriaxone and azithromycin highlights the need to remain vigilant for treatment failures. Continued compliance with recommended therapies is essential to maintain gonorrhoea as a treatable infection. Percentage of isolates exhibiting decreased susceptibility to cefixime (MIC 0.125mg/L) by gender and sexual orientation; GRASP

3 Chemicals, poisons and environmental hazards Volume 7 Number 44 Published on: 1 November 2013 Public health impacts of shale gas extraction reviewed in CRCE draft report The extraction of natural gas from sedimentary rock using hydraulic fracturing commonly referred to as fracking is at an early exploratory stage in the UK, with fracturing operations having taken place at only one site to date. Nevertheless, in anticipation of further exploratory drilling activity, and in view of public concern about the potential public health impact, PHE's Centre for Radiation Chemical and Environmental Hazards (CRCE) established a working group in May 2012 to consider the potential public health impact of direct emissions from such operations. The working group's report, Review of the potential public health impacts of exposures to chemical and radioactive pollutants as a result of shale gas extraction: Draft for Comment, has now been published [1,2]. It is based on the examination of the scientific literature and data from countries which already have commercial scale shale gas extraction operations, taking account of UK conditions. The currently available evidence indicates that the potential risks to public health from exposure to the emissions associated with shale gas extraction are low if the operations are properly run and regulated. Most evidence suggests that contamination of groundwater, if it occurs, is most likely to be caused by leakage through the vertical borehole. Contamination of groundwater from the underground fracking process itself (ie the fracturing of the shale) is unlikely. However, surface spills, of fracking fluids or waste water, may affect groundwater; and emissions to air also have the potential to impact on health. Where potential risks have been identified in the literature, the reported problems are typically a result of operational failure and a poor regulatory environment. Therefore, good on-site management and appropriate regulation of all aspects including exploratory drilling, gas capture, use and storage of fracking fluid, and postoperations decommissioning are essential to minimise the risk to the environment and public health. In the UK, shale gas developers and operators will be required, through the planning and environmental permitting processes, to satisfy the relevant regulators that their proposals and operations will minimise the potential for pollution and risks to public health. PHE and other public health bodies will provide support by responding to requests to assess the potential impact on health in specific circumstances. The report makes the following recommendations: Public Health England needs to continue to work with regulators to ensure all aspects of shale gas extraction and related activities are properly risk assessed as part of the planning and permitting process. Baseline environmental monitoring is needed to facilitate the assessment of the impact of shale gas extraction on the environment and public health. There should also be consideration of the development of emission inventories as part of the regulatory regime. Effective environmental monitoring in the vicinity of shale gas extraction sites is needed throughout the lifetime of development, production and post-production. It is important to ensure that broader public health and socioeconomic impacts such as increased traffic, impacts on local infrastructure and worker migration are considered. Chemicals used in fracking fluid will be publicly disclosed and risk assessed prior to use. It is useful to note that any potential risk to public health and the environment from fracking chemicals will be dependent on the route of exposure, total amount and concentration, and eventual fate of any such chemicals. It is expected that these aspects will be considered as part of the regulatory environmental permitting process. The type and composition of the gas extracted is likely to vary depending on the underlying geology and this necessitates each site to be assessed on a case by case basis. Evidence from the USA suggests that the maintenance of well integrity, including post-operations, and appropriate storage and management of fracking fluids and wastes are important factors in controlling risks and appropriate regulatory control is needed. Characterisation of potentially mobilised natural contaminants is needed including naturally occurring radioactive materials (NORM) and dissolved minerals. References 1. Review of the potential public health impacts of exposures to chemical and radioactive pollutants as a result of shale gas extraction: Draft for Comment (October 2013), ISBN [425 KB PDF]. Downloadable from the legacy HPA website: Home Publications Environment PHE CRCE scientific and technical report series. 2. Shale gas extraction emissions are a low' risk to public health, PHE press release, 31 October 2013,

4 Infection reports Volume 7 Number 44 Published on: 1 November 2013 Respiratory HIV-STIs Laboratory reports of respiratory infections made to the Centre for Infectious Disease Surveillance and Control (CIDSC) from Public Health England and NHS laboratories in England and Wales: October, 2013 Recent epidemiology of infectious syphilis and congenital syphilis Laboratory reports of respiratory infections made to the Centre for Infectious Disease Surveillance and Control (CIDSC) from Public Health England and NHS laboratories in England and Wales: October, 2013 TData are recorded by week of report, but include only specimens taken in the last eight weeks (ie recent specimens). Table 1. Reports of influenza infection made to PHE Colindale, by age group Week Week 39 Week 40 Week 41 Week 42 Week 43 Week ending 29/09/13 06/10/13 13/10/13 20/10/13 27/10/13 Influenza A Isolation DIF * PCR Other Influenza B Isolation DIF * 1 1 PCR Other * DIF = Direct Immunofluorescence. Other = "Antibody detection - single high titre" or "Method not specified". Total Table 2. Respiratory viral detections by any method (culture, direct immunofluorescence, PCR, four-fold rise in paired sera, single high serology titre, genomic, electron microscopy, other method, other method unknown), by week of report Week Week 39 Week 40 Week 41 Week 42 Week 43 Week ending 29/09/13 06/10/13 13/10/13 20/10/13 27/10/13 Adenovirus * Coronavirus Parainfluenza Total Rhinovirus RSV* * Respiratory samples only. Includes parainfluenza types 1, 2, 3, 4 and untyped.

5 Table 3. Respiratory viral detections by age group: weeks 39-43/2013 Age group (years) <1 year 1-4 years 5-14 years years years 65 years Unknown Adenovirus * Coronavirus Influenza A Influenza B Parainfluenza Rhinovirus Respiratory syncytial virus Total * Respiratory samples only. Includes parainfluenza types 1, 2, 3, 4 and untyped. Table 4 Laboratory reports of infections associated with atypical pneumonia, by week of report Week Week 39 Week 40 Week 41 Week 42 Week 43 Week ending 29/09/13 06/10/13 13/10/13 20/10/13 27/10/13 Coxiella burnettii Respiratory Chlamydia sp. * Mycoplasma pneumoniae Total Legionella sp *Includes Chlamydia psittaci, Chlamydia pneumoniae, and Chlamydia sp detected from blood, serum, and respiratory specimens. Table 5 Reports of Legionnaires Disease cases in England and Wales, by week of report op Week 40 Week 41 Week 42 Week 43 Week ending 06/10/13 13/10/13 20/10/13 27/10/13 Nosocomial 1 1 Community Travel Abroad 4 8 (1*) Travel UK Total Male Female (*) Non-pneumonic case. Thirty cases were reported with pneumonia and one case was reported with non-pneumonic infection. Twenty males aged 32-88yrs and 11 females aged 44-78yrs. Twenty-one cases had community-acquired infection. Total Ten cases were reported with travel association: Cuba (1), Greece (1), Indonesia/Malaysia (1), Poland (1), Spain (2) and the United Kingdom (4).

6 Table 6. Reports of Legionnaires Disease cases in England and Wales, by PHE Centre: weeks 40-43/2013 Region/Country North of England Nosocomial Community Travel Abroad Travel UK Total North East 2 2 Cheshire & Merseyside 1 1 Greater Manchester 1 1 Cumbria & Lancashire 1 1 Yorkshire & the Humber South of England Devon, Cornwall & Somerset 3 3 Avon, Gloucestershire & Wiltshire Wessex 1 1 Thames Valley 1 1 Sussex, Surrey & Kent 4 3 (1*) 7 Midlands & East of England East Midlands South Midlands & Hertfordshire Anglia & Essex West Midlands London Integrated Region London Public Health Wales Mid & West Wales North Wales 1 1 South East Wales Miscellaneous Other 2 2 Not known 0 Total (*) Non-pneumonic case.

7 Infection reports Volume 7 Number 44 Published on: 1 November 2013 HIV-STIs Recent epidemiology of infectious syphilis and congenital syphilis Recent epidemiology of infectious syphilis in England Over the decade 2003 to 2012 diagnoses of infectious syphilis (primary, secondary and early latent) made at genitourinary medicine (GUM) clinics in England increased by 61% (from 1688 to 2713) in men (figure 1). In contrast diagnoses in women decreased by 16% (from 317 to 265). In 2012, 2978 cases of infectious syphilis were diagnosed in GUM clinics, 2713 in men of which 2061 were in MSM, and 265 in women. Figure 1. Diagnoses of infectious syphilis by gender, England: 2003 to 2012 Data source: GUMCAD Rates of infection with primary and secondary syphilis were highest in the year age group for men (25.1/100,000) and the year age group for women (3.8/100,000)(figure 2). Health Protection Report Vol 7 No November 2013

8 Figure 2. Diagnoses of infectious syphilis by age and gender, England: 2012 Data source: GUMCAD Increased incidence has been focussed on urban areas, such as central London, Manchester and Brighton, where a high proportion of the population are men who have sex with men (MSM) (figure 3). Sexual networks within these areas have driven the syphilis epidemic and other sexually transmitted infections including gonorrhoea, lymphogranuloma venereum, Hepatitis C and, more recently, sexually transmissible infections such as Shigella flexneri [1]. Figure 3. Diagnoses of infectious syphilis by Local Authority of residence, England: 2012 Health Protection Report Vol 7 No November 2013

9 These overlapping epidemics have been influenced by the HIV epidemic and associated behavioural change in MSM. For example, recreational drug use in MSM has recently been identified as an important factor driving infection transmission within high risk sexual networks [1]. Progression of the infectious syphilis epidemic has been analysed using data from enhanced surveillance and returns from GUM clinics [2]. This showed that the general profile of the epidemic is one of white MSM aged many of whom are co-infected with HIV and had high numbers of sexual partners, a profile that has been seen consistently since the re-emergence of infectious syphilis in the late 1990s. Outbreaks Outbreaks of infectious syphilis have become a feature of the epidemic as infection is transmitted between sexual networks. Whilst many of these have been focussed on MSM, several have been seen amongst heterosexuals who typically have been less than 19 years of age, and may be socially vulnerable [3,4]. The outbreaks provide an insight into the complexity of the evolving syphilis epidemic and highlight the associated public health challenges. The responses to outbreaks seen in Rochdale, Teeside, south east Hampshire, Ipswich and more recently in Hereford were co-ordinated by multidisciplinary outbreak control teams (OCT) using HPA and BASHH guidelines [5]. STI outbreaks may take months to develop as transmission is heavily influenced by sexual network density and structure. In common with diagnoses in MSM a high proportion of sexual partners were anonymous which reduces the effectiveness of partner notification (PN). Finding and treating cases and their partners has been a control priority and has been achieved by rolling out syphilis testing to young people s clinics, and contraceptive and termination of pregnancy services and by strengthening support for PN in local GUM services. Health promotion campaigns have also been used to target sexually active young people, promote awareness to reducing sexual risk-taking behaviours and encouraging testing. Successful outcomes are achieved as the result of a prompt, multifaceted public health response coordinated by an OCT formed as soon as the outbreak is detected. Congenital syphilis in the UK Congenital syphilis (CS) occurs when syphilis is transmitted from a woman to her unborn baby during pregnancy. This can lead to miscarriage, stillbirth, neonatal death, or disorders such as deafness and bone deformitie [6]. As such, congenital syphilis is a distressing condition, which is costly to health care systems [7]. Control methods are highly cost effective but are dependent on well-structured healthcare pathways. Cases can be prevented through antenatal screening and appropriate treatment. In England the uptake of antenatal screening for infectious syphilis has been >95% over the past five years (2005 to 2012) [8]. Of those screened, 0.15% had an initial positive result but less than a third of these had an active infection that required treatment [9]. In 2010, the HPA (now PHE) in collaboration with the UCL Institute of Child Health and the British Paediatric Surveillance Unit (BPSU) initiated a study of congenital syphilis in children less than two years of age. The study aimed to estimate the incidence of infection and investigate determinants of incidence, information which has been used as an evidence base to improve clinical pathways and patient management systems. Details of the study protocol are available at Preliminary analysis indicates that the incidence of CS for each year studied was: per 1000 live and still births (2010) and /1000 (2011). Cases were seen throughout England, except the South West SHA and were mainly of white ethnicity. The influence of the eastern European syphilis epidemic was also observed. Cases have generally been seen in the mothers who were unable to access healthcare service due to cultural barriers or chaotic lifestyles, and who experienced high levels of socioeconomic deprivation. Consequently the mothers generally accessed clinical services around the time of delivery in the third trimester. The occurrence of CS indicates gaps within the coverage of prenatal care delivery systems and syphilis intervention strategies aimed at adults. Identifying women at high risk of infection and encouraging attendance at clinical services in early pregnancy is challenging. Local, proactive multi-agency interventions aimed at improving service access for women, their children and sexual partners in communities that have low rates of GP registrations and antenatal screening could play a vital role in increasing case ascertainment. Clinicians also need to be able to identify vulnerable women, who tend to be late bookers and could have been concealing their pregnancy, who are at risk of missing out on appropriate levels of care. Health Protection Report Vol 7 No November 2013

10 Conclusions Whilst numbers of infectious syphilis diagnoses are at their highest since the mid-1950 s the character of the underlying epidemics has changed substantially. The current syphilis epidemic has a high proportion of primary and secondary cases which indicates that infection is detected and managed at an earlier stage of infection. In turn this has led to the virtual elimination of sequelae and vertical transmission [6]. Nevertheless, the re-establishment of syphilis as an endemic infection reflects a failure of control strategies. Sustained, intensive, targeted efforts to interrupt further transmission need to be maintained and intensified. Locally based interventions that penetrate sexual networks identified through partner notification and surveillance initiatives will probably be the most effective method of controlling infection. References 1. Gilbart VL, Simms I, Gobin M, Oliver I, Hughes G. High-risk drug practices in men who have sex with men. Lancet 2013; 381(9875): Jebbari H, Simms I, et al. Variations in the epidemiology of primary, secondary and early latent syphilis, England and Wales: 1999 to Sex Transm Infect 2011; 87: Simms I, Fenton KA, Ashton M, Turner KME, Crawley-Boevey E, Gorton R, et al. The re-emergence of syphilis in the UK: the new epidemic phases. Sex Transm Dis 2005; 32: Simms I, Hughes G, Bell G. Infectious syphilis in young heterosexuals: responding to an evolving epidemic. Int J STD AIDS 2011; 22(9): Annan T, Hughes G, Evans B, et al. Guidance for Managing STI Outbreaks and Incidents. Health Protection Agency. See (last checked 28 July 2011). 6. Goh BT. Syphilis in adults. Sex Transm Infect 2005; 81: Simms I, Broutet N. Congenital Syphilis Re-emerging. J Dtscg Dermatol Ges 2008; 6: UK National Screening Committee. Infectious Diseases in Pregnancy Laboratory Survey Townsend CL, Tookey PA. Syphilis screening in pregnancy: results from a UK-wide surveillance study. Poster at PHE Annual Conference 2013, Warwick University. Health Protection Report Vol 7 No November 2013