HPS Weekly Report CURRENT NOTES CONTENTS. international Jamboree. Chikungunya diagnosis in Spain

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1 HPS Weekly Report 18 August 2015 Volume 49 No. 2015/33 ISSN (Online) CONTENTS CURRENT NOTES Meningococcal disease in Scouts returning from international Jamboree 302 Chikungunya diagnosis in Spain 302 National decontamination guidance on loan devices 303 Air quality - sampling height study 303 Engineered nanomaterials - workplace exposure and control measures 304 SURVEILLANCE REPORT VTEC in Scotland 2014: enhanced surveillance, reference laboratory and clinical reporting data 305 CURRENT NOTES Meningococcal disease in Scouts returning from international Jamboree 49/3301 On 13 August 2015, HPS reported two confirmed cases of meningococcal disease in Scouts from Scotland who had returned from an international Scout jamboree in Japan. A further case has since been reported, bringing the total to three. The 12-day event in Kirara-hama was attended by around 33,000 teenagers from across the globe, including around 180 from Scotland. Cases have been treated in hospital and are recovering well. All close contacts were identified and given antibiotics and immunisation as a precautionary measure, in line with standard guidance. The onset of illness of the cases was 8-12 August following the return journey on 8 August. An Incident Management Team has been led by HPS and NHS boards have arranged chemoprophylaxis and vaccination for close contacts. Serogrouping has confirmed the bacteria as serogroup W, ST11, the same as that which has been emerging across the UK, leading to the MenACWY vaccination programme for year olds and university freshers. HPS also sent an advise and inform letter to the participants from other units in Scotland who attended the Jamboree, and approximately 4000 letters were also issued to other participants in the rest of UK alerting them to the signs and symptoms of disease. The Public Health Agency of Sweden has since (17 August) reported three suspected cases of meningococcal infection in Swedish participants who have returned after attending the Jamboree in Japan. None is yet confirmed. Chikungunya diagnosis in Spain 49/3302 For the first time, an individual with no history of travel to a chikungunya-endemic area has tested positive for the disease in Spain. On 3 August 2015, WHO/Europe was notified of a case of chikungunya infection in the city of Gandia, Valencian Community. A 60-year-old man developed symptoms on 7 July in France and sought care. He was hospitalized on 11 July in Spain upon his return and discharged on 16 July. He tested positive for chikungunya on 31 July.

2 Both Spanish and French health authorities are establishing vector control measures and carrying out relevant investigations. [Source: WHO Regional Office for Europe, 13 August news/news/2015/08/first-case-of-chikungunya-diagnosed-in-spain] More information about the chikungunya case in Spain is available at don/10-august-2015-chikungunya/en/. Further advice is available for clinicians on TRAVAX (at and for the general public on fitfortravel (at fitfortravel.nhs.uk). National decontamination guidance on loan devices 49/3303 Further to Current note 48/3006 (at aspx?id=59737), Health Facilities Scotland Decontamination Services has recently published the first edition of GUID 5002 National Decontamination Guidance on Loan Medical Devices (Reusable): Roles & Responsibilities. Healthcare facilities are using reusable loan medical devices to provide needed inventory to perform procedures. An obligation of healthcare facilities is to ensure these loan medical devices have minimal contamination and are appropriately processed at time of use. Additionally national initiatives exist to minimise Healthcare Associated Infections (HAIs) and harm to patients and staff. The effective control of loan medical device decontamination presents challenges to theatres, clinics, sterile services, manufacturers and suppliers. Loan medical devices must be managed in a consistent way to ensure patient and staff safety. Clear national guidance is required to define roles and responsibilities required in the decontamination process of loan medical devices. The Sterile Service Department Consultative Group (SSDCG) requested the development of such guidance. The new guidance should reduce risks associated with loan medical devices and deliver positive health impacts. Contained within the guidance are roles and responsibilities for theatres/clinics, Central Decontamination Units (CDUs) and manufacturers/suppliers. The guidance encompasses the entire loan cycle from the decision to order a loan medical device to the returning of the loan medical device to the supplier. The guidance should ensure loan medical devices are delivered to theatre fit for purpose, in a timely manner and returned safely to the supplier. [Source: HFS News, 23 July hfs.scot.nhs.uk/news/?item=297] Air quality - sampling height study 49/3304 The Scottish Government commissioned a study to undertake a mobile air quality monitoring study. The two key aims of the study were: determine the relationship between height from pavement and air quality under a range of conditions; and investigate the relationship between concurrent air quality sampling obtained from mobile and fixed sampling stations. HPS WEEKLY REPORT Volume 49 No.2015/33 18 August

3 The study primarily focussed on particulate matter with mean aerodynamic diameters of 2.5 μm (PM 2.5 ) and 10 μm (PM 10 ), ultrafine particles (UFP) between the sizes of 10 nm and 300 nm and black carbon (BC). In addition, the following pollutants were monitored: nitrogen dioxide (NO 2 sulphur dioxide (SO 2 carbon monoxide (CO benzene (C 6 H 6 particulate matter with a mean aerodynamic diameter of 0.5 μm (PM 0.5 particulate matter with a mean aerodynamic diameter of 1.0 μm (PM 1.0 particulate matter with a mean aerodynamic diameter of 5.0 μm (PM 5.0 total particulate matter (TPM). The study was carried out in Glasgow city centre with a total of 11 co-location exercises to evaluate agreement between samplers; and eight mobile monitoring exercises to evaluate potential concentration gradients between 0.80 m and 1.68 m. All monitoring exercises were carried out between February 2014 and September Overall, the study (accessible at provided valuable insights into spatial (vertical and horizontal) variations of concentrations of key air pollutants in Glasgow city centre. The study is thought to have generated numerous interesting findings which, with further research, could help to inform and guide future air quality research and policy in Scotland. Engineered nanomaterials - workplace exposure and control measures 49/3305 Nanotechnology is moving from the focused research environment to wider application in the workplace. Across Great Britain (GB) there are companies, small and large, manufacturing or using nanomaterials. As yet the scientific community does not have a good understanding of whether working with nanomaterials poses a risk to the health of workers as is suggested by some stakeholders. The Health and Safety Executive (HSE) commissioned a project with the Health and Safety Laboratory (HSL) to improve understanding of the nanomaterials industry across GB and its employees potential exposure to materials at the nanoscale. HSE and HSL made attempts to identify and engage with companies which manufactured or used nanomaterials, but only four volunteered to take part in this project. The project therefore only represents a very small sample of the industry and a finite selection of nanomaterials. The observations presented here represent a limited data set; they need to be understood in this context and not over-generalised. The full report RR1068 Summary of work undertaken to assess workplace exposure and control measures during the manufacture and handling of engineered nanomaterials can be accessed at HPS WEEKLY REPORT Volume 49 No.2015/33 18 August

4 VTEC in Scotland 2014: enhanced surveillance, reference laboratory and clinical reporting data Surveillance Report Prepared by: Lynda Browning 1, Lesley Allison 2, Mary Hanson 2, Gill Hawkins 1 1. Health Protection Scotland, 2. Scottish E. coli O157/VTEC Reference Laboratory Introduction Reported rates of Escherichia coli O157 (E. coli O157) infection in Scotland rose substantially in the mid-1990s and remain consistently high compared to other countries within the UK and Europe. Although large foodborne outbreaks have occurred in Scotland, 1,2 sporadic infection predominates. Serious outcomes of infection can include haemolytic uraemic syndrome (HUS) which is a major cause of acute renal failure in children in Scotland. The potential for E. coli O157 to cause both secondary spread 3 and large outbreaks is exacerbated by its low infectious dose 1,2 and asymptomatic infection can also occur. 4 FIGURE 1: E. coli O157: rates per 100,000 population culture positive cases, UK * 12 Rate per 100,000 population Year England Scotland Wales Northern Ireland UK *Data outwith Scotland courtesy of Public Health Wales, Public Health Agency (NI) and Public Health England. Data for Wales, N Ireland and England include verotoxin positive cases only. All data for 2014 are provisional. Although E. coli O157 is the only serogroup of verotoxin-producing E. coli (VTEC) routinely detected by diagnostic laboratories in Scotland, in recent years verotoxigenic strains of non-o157 serogroups (non-o157 VTEC) have also been identified in Scotland, and can be associated with significant morbidity including HUS. 4 Health Protection Scotland (HPS) has established enhanced surveillance of E. coli O157 in close collaboration with the Scottish E. coli O157/VTEC Reference Laboratory (SERL). This surveillance was extended in 2003 to include non-o157 VTEC. Data is also integrated with other surveillance functions at HPS, in particular with ObSurv, 5 the system for surveillance of all general outbreaks of infectious intestinal disease. HPS WEEKLY REPORT Volume 49 No.2015/33 18 August

5 Methods HPS defines a case as a single person-infection episode with laboratory confirmation of infection by one or more of the following: culture positive (isolates of E. coli O157 or other serogroups cultured from faeces) or faecal PCR positive for verotoxin genes, and/or an E. coli O157 specific gene, but not confirmed by culture or serum positive (antibodies detected in blood serum). This includes identifications by SERL from samples forwarded by local laboratories from cases with symptoms suggesting VTEC, but without local laboratory confirmation. National forwarding criteria were first established in 2001 by the national E. coli O157 Task Force 2 and most recently revised in In summary, local laboratories are advised to forward locally negative stool samples from clinically suspicious cases to SERL for more sensitive testing methods. Both symptomatic and asymptomatic cases are included. HPS surveillance systems collect information about general outbreaks i.e. those affecting members of more than one household, or residents of institutions. 5 Other cases are therefore either sporadic or occur amongst members of a single household. Put simply, cases in general outbreaks will be termed outbreak cases, while cases or clusters restricted to single households will be termed sporadic cases, irrespective of whether they are secondary or primary cases. Imported infections are defined as those cases from whose onset date, incubation period, and travel and other exposure histories, local investigators judge that the infection was more likely to have been acquired outside the UK than from any other identifiable source. This report presents analyses of the main variables for VTEC infections reported to HPS in Cases identified by serodiagnosis or PCR without culture confirmation were excluded from analyses of incidence rates, geographical distribution and other variables, for reasons of historical consistency. All data for 2014 will be provisional until 31 December Results E. coli O157 In 2014, a total of 275 reports of E. coli O157 were made to HPS. The methods of identification of these are described in Table 1. TABLE 1: Laboratory confirmed reports of E. coli O157. Method of laboratory confirmation Total Culture positive (faeces) 263 PCR positive, culture negative 6 Serum positive only 6 To allow comparison with previous years, only faecal culture positive cases were included in the following analyses. HPS WEEKLY REPORT Volume 49 No.2015/33 18 August

6 There were 263 faecal culture positive cases of E. coli O157 notified to HPS in This represented an increase on the 167 cases reported in The reasons for the increase observed in 2014 compared to 2013 will be discussed later (see Discussion and conclusion), but were due in part to the fact that the number of cases reported in 2013 was the lowest annual total for five years and substantially below the annual average for that period (221 cases per annum). FIGURE 2: E. coli O157: Faecal culture positive laboratory reports in Scotland, Number of laboratory reports Year Geographical distribution and incidence rates TABLE 2: E. coli O157: NHS board, rates per 100,000 faecal culture positive cases. NHS board Ayrshire & Arran Borders Dumfries & Galloway Fife Forth Valley Greater Glasgow & Clyde Grampian Highland Lanarkshire Lothian Orkney Shetland Tayside Western Isles Scotland HPS WEEKLY REPORT Volume 49 No.2015/33 18 August

7 The rate of faecal culture positive cases per 100,000 population for the whole of Scotland in 2014 was 4.9, compared to 3.2 in 2013, 4.5 in 2012 and a five-year average ( ) of 4.3. Incidence rates varied across Scotland, as they have done historically. The overall rates increased in 11 of the 14 NHS boards compared with the previous year. The rates for NHS boards with small populations should be interpreted with caution as the numbers disproportionately affect the incidence rates. Age and sex The age distribution of the 263 faecal culture positive cases ranged from seven months to 90 years. The mean age was 30 years. Children under 16 accounted for 33% of cases. An age of over 65 was reported in 9% of cases. As seen in previous years, children under five years of age had the highest rate of infection. The age stratified rates per 100,000 population for males and females are shown in Figure 3. FIGURE 3: Age stratified rates per 100,000 population. 20 Rate per 100,000 population Age range Male Female Scotland Seasonality The number of cases per month is shown in Figure 4. Seasonality in 2014 varied from the fiveyear average but this is not uncommon in any given year in Scotland. The peaks observed at the start of the year and in May include cases that were part of two outbreaks that occurred in Scotland in ,8 Cases tend to peak in the summer months every year. HPS WEEKLY REPORT Volume 49 No.2015/33 18 August

8 FIGURE 4: E. coli O157: month infection occurred faecal culture positive cases in Scotland, Number of cases Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month 2014 Five-year average per month Clinical presentation and hospitalisation In 2014, information on 230 cases of E. coli O157 was provided to HPS following case interviews by the local NHS board health protection teams. Of these, 88 cases (38%) were admitted to hospital for at least one night during their illness, which is slightly lower than the historical average of 43%. Bloody diarrhoea was reported in 61% of cases and a further 27% reported diarrhoea with no blood observed, while 12% of cases were asymptomatic. Sporadic or outbreak cases During 2014, nine general outbreaks of VTEC were reported to HPS compared to three in Of these nine, seven were identified as serogroup O157, one was serogroup O125 and one was both serogroup O157 and O103. Further information on these outbreaks is contained in the HPS Weekly report on general outbreaks of infectious intestinal disease in Of the 263 faecal culture positive cases of E. coli O157 reported in 2014, 73 (28%) were reported to be part of outbreaks. This compares to 23 (14%) of cases in As has historically been the case in Scotland, 1,2 the majority of cases in 2014 were apparently sporadic cases. Imported infections Of the 230 cases for whom information was available, 31 (13%) were reported as having acquired their infection outside the UK. Reference Laboratory data Isolates of E. coli O157 identified by local diagnostic laboratories are routinely sent to SERL for further typing. This includes phenotypic characterisation phage typing, antimicrobial sensitivity testing as well as genotypic typing PCR, MLVA and PFGE. This additional typing facilitates the identification of outbreaks as well as monitoring the trends and emergence of new strain types. Phage type (PT) results for culture positive E. coli O157 isolates are reported to HPS by SERL. As seen in previous years, PT 8 and PT21/28 accounted for the majority of cases. In 2014, these phage types accounted for over 56% of cases. HPS WEEKLY REPORT Volume 49 No.2015/33 18 August

9 TABLE 3: E.coli O157, Phage Type results. Phage type 2014 (% of total) 2013 (% of total) PT 8 79 (30%) 35 (21.0%) PT21/28 74 (28.1%) 66 (40.7%) PT31 21 (8.0%) 1 (0.6%) RDNC 19 (7.2%) 13 (7.8%) PT32 17 (6.5%) 14 (8.3%) PT1 12 (4.6%) 1 (0.6%) PT54 11 (4.2%) 1 (0.6%) PT2 11 (4.2%) 2 (2.4%) PT4 6 (2.3%) 2 (1.2%) PT34 5 (1.9%) 9 (5.4%) PT Untypable 4 (1.5%) 8 (4.8%) PT14 3 (1.1%) 7 (4.2%) PT 87 1 (0.4%) 0 Although most isolates from culture positive cases in 2014 were verotoxigenic, 19 (7.2%) had no identifiable verotoxin-producing genes. Non-O157 VTEC As previously stated, E. coli O157 is the only serogroup of verotoxin-producing E. coli (VTEC) routinely detected by diagnostic laboratories in Scotland. Identification of non-o157 VTEC therefore requires submission of faecal samples to SERL for further investigation. In 2014, 75 isolates of non-o157 VTEC were cultured and reported by SERL to HPS. This compares to 52 non-o157 isolates reported in In addition, there were two serum positive non-o157 VTEC cases reported in The observed increase in non-o157 isolates reported in 2014 is largely due to a change in the referral pattern from laboratories sending samples to SERL resulting in an increase in identification of non-o157 cases. In total, 27 different non-o157 serogroups were identified in 2014, of which 19 were reported on one occasion only. VTEC O26 was the most common serogroup reported as was the case in previous years and accounted for 15 (18%) of non-o157 cases. While 12 isolates were O-unidentifiable, the next most common serogroups were O103 (eight cases) and O146 (seven cases). Discussion and conclusions The number of E. coli O157 cases reported in Scotland increased in However it should be recognised that this followed a year where the number of cases reported was unusually low and, as described in the VTEC Annual Report for substantial decreases in previous years have generally been followed by a return to higher incidence rates. It should also be noted that the number of outbreak cases reported in 2014 was higher than in previous years (73 cases in 2014 compared with 23 in 2013 and 25 in 2012). This increase was driven by two large foodborne outbreaks which occurred in Scotland in ,8 which, taken together, accounted for 41 of the outbreak cases reported that year. After taking the increase in outbreak cases into account, the number of cases of E. coli O157 cases reported in Scotland in 2014 is comparable to the average number of cases reported in previous years and within the normal variation expected from year to year. The consistently high rates of VTEC infection reported in Scotland as compared to other UK countries, and indeed the increase in outbreak cases observed in 2014, underlines the need for the continued and comprehensive application of the wide range of existing control measures embedded in food safety and other guidance in Scotland. In addition it highlights the importance of a comprehensive multi-agency approach to tackling VTEC in Scotland as set out in the VTEC Action Plan for Scotland. More information on the Action Plan can be accessed at: HPS WEEKLY REPORT Volume 49 No.2015/33 18 August

10 Acknowledgements HPS and SERL particularly wish to thank those patients and their families who have provided information; and also the following groups across Scotland: HP Teams in NHS boards; environmental health officers; consultant microbiologists and diagnostic laboratory staff; participating clinicians and general practitioners; and Scottish Agricultural College (now part of SRUC). We also thank Susan Brownlie, Kevin Pollock, Alison Smith-Palmer, Genna Drennan, Mary Locking and other present and past participants at HPS and SERL. References 1. Scottish Government. VTEC/E. coli O157 action plan for Scotland Available from: (accessed 14 August 2015). 2. Scottish Executive Health Department/Food Standards Agency (Scotland). Report of the E. coli O157 Task Force Available from: (accessed 14 August 2015). 3. Locking ME, Pollock KGJ, Allison LJ, Rae L, Hanson MF, Cowden JM. Escherichia coli O157 infection and secondary spread, Scotland, Emerg Inf Dis. 2011;17( Available from: (accessed 14 August 2015). 4. Pollock KGJ, Locking ME, Cowden JM. Clinical surveillance of haemolytic uraemic syndrome surveillance in Scotland, 2010: emergence of highly virulent Escherichia coli O26. HPS Weekly Report. 2011;45(16): Available from: aspx?id= (accessed 14 August 2015). 5. Health Protection Scotland. General Outbreaks of Infectious Intestinal Disease reported to HPS in HPS Weekly Report. 2015;49(25): Available from: nhs.uk/ewr/redirect.aspx?id= (accessed 14 August 2015). 6. Health Protection Network. Guidance for the public health management of infection with verotoxigenic Escherichia coli (VTEC). Health Protection Network Scottish Guidance 3 (Second Edition) Available from: aspx?id= (accessed 14 August 2015). 7. NHS Greater Glasgow and Clyde; Glasgow City Council. E. coli O157 cases at SSE Hydro associated with consumption of burgers Available from: ecoli0157report. (accessed 14 August 2015). 8. NHS Fife. E. coli O157 cases reported in Dunfermline area. Available from: nhsfife.org/nhs/index.cfm?fuseaction=nhs.newsdisplay&objectid=3dcfcd8b-cae9-f7bd- 535E669210BA3FC4. (accessed 14 August 2015). 9. Health Protection Scotland. VTEC and HUS in Scotland, 2013: enhanced surveillance, reference laboratory and clinical reporting data HPS Weekly Report. 2014;48(19): Available from: (accessed 14 August 2015). The last Gastro-intestinal and foodborne infections Surveillance Report was in Issue 15/25 The next Gastro-intestinal and foodborne infections Surveillance Report will be in Issue 15/37 NHS BOARD ABBREVIATIONS AA Ayrshire & Arran BR Borders DG Dumfries & Galloway GGC Greater Glasgow & Clyde FF Fife FV Forth Valley GR Grampian HG Highland LO Lothian LN Lanarkshire OR Orkney SH Shetland TY Tayside WI Western Isles Correspondence to: The Editor, HPS Weekly Report, Health Protection Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, Scotland T F E NSS.HPSWReditor@nhs.net W Printed in the UK. HPS is a division of the NHS National Services Scotland. HPS Registered WEEKLY as a newspaper REPORT at the Post Office. Volume Health 49 Protection No.2015/33 Scotland August