HSE co-ordination of UK response to recasting of Euratom directives. Pandemic (H1N1) 2009 influenza: UK situation at 20 August 2009

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1 Volume 3 Number 33 Published on: 21 August 2009 Current News Update on rabies free status of France, August 2009 HSE co-ordination of UK response to recasting of Euratom directives Pandemic (H1N1) 2009 influenza: UK situation at 20 August 2009 Infection Reports Bacteraemia Escherichia coli bacteraemia in England, Wales, and Northern Ireland, 2004 to 2008 Zoonoses Common animal associated infections, England and Wales: laboratory reports, weeks 14-26/2009 Med-Vet-Net, a European Union network for zoonotic research John Threlfall, project director, Med-Vet-Net, Gastrointestinal, Emergency and Zoonotic Infections Department, HPA Centre for Infections.

2 News Volume 3 Number 33 Published on: 21 August 2009 Update on rabies free status of France, August 2009 HSE co-ordination of UK response to recasting of Euratom directives Pandemic (H1N1) 2009 influenza: UK situation at 20 August 2009 Update on rabies free status of France, August 2009 Since France lost its rabies free status in 2008 [1] current HPA guidance on animal exposures in France had been to treat these as low risk with vaccine only. Although France has not officially regained its rabies-free status, detailed surveillance has not detected any further cases of rabies in animals and French authorities believe that there is no increased risk from animal bites, scratches and licks occurring within France. Therefore, on the basis of advice from French colleagues, the HPA guidance has been revised such that animal bites, scratches and licks occurring within France should be treated as no risk (ie no post-exposure prophylaxis required). The Rabies Country Risk table has been updated accordingly [2]. According to the OIE (World Organisation for Animal Health), a country may be considered rabies free when two years have elapsed since the last indigenous transmission of classical rabies infection to any animal species, including human. Six months must elapse following a case in an imported animal if this occurred outside a quarantine establishment. Status is unaffected by isolations of Bat Lyssaviruses [3]. References 1. France declares loss of rabies free status: implications for British travellers, HPA website, 26 April Rabies Country Risk Table, August Available at: 3. OIE Terrestrial Animal Health Code: Rabies, Article Available at: HSE co-ordination of UK response to recasting of Euratom directives The Health and Safety Executive (HSE), having convened internal and cross-government groups of officials to coordinate the UK response to a forthcoming European Commission proposal to recast the Euratom radiological protection directives, has published a bulletin on the current state of play of the recasting process on its website [1]. It invites views from other UK stakeholders to inform the development of the UK position on the directives. The bulletin notes that stakeholder groups have begun to examine the issues raised by the review process so as to determine the sectors affected and the likely impacts. The contributions from these groups will be analysed, and thereafter, form the evidence base for the UK Impact Assessment and negotiating position. Reference 1. HSE. UK response to the forthcoming European Commission (EC) proposal to recast the Basic Safety Standards (96/29) (and other Euratom) Directives. HSE website, 13 August 2009,

3 Pandemic (H1N1) 2009 influenza: UK situation at 20 August 2009 The HPA Weekly National Influenza Report of 20 August 2009 (week 34) [1] has summarised the UK (and international) situation as follows: Pandemic influenza activity continues to decrease across all regions of the UK and in all age groups, though remains at levels higher than expected for this time of year. In week 33 (week ending 16 August), the GP consultation rates decreased in England and Wales to below the normal winter seasonal baseline thresholds. In Northern Ireland the rate decreased (thresholds not yet set in Northern Ireland ) and the rate in Scotland decreased, remaining below the baseline level. The National Pandemic Flu Service (NPFS) continues to issue antiviral drugs to people in England with an influenza-like illness who call or log onto the internet site. There has been a general decrease in the number of assessments, and antiviral collections, over the past week. Interpretation of data to produce estimates on the number of new cases continues to be subject to a considerable amount of uncertainty with the move to the NPFS. HPA modelling gives an estimate of 11,000 (range ,000) new cases in England in week 33 compared to an estimated 25,000 cases in the previous week. The estimated number of new cases has decreased in all regions and age groups. The main influenza virus circulating in the UK continues to be the pandemic (H1N1) 2009 strain, with few influenza H1 (non-pandemic), H3 and B viruses detected through sentinel and nonsentinel surveillance. To date, in the UK, no pandemic viruses have been found to be resistant to the antiviral drugs oseltamivir or zanamivir. The majority of pandemic influenza cases continue to be mild. The cumulative number of deaths reported due to pandemic (H1N1) 2009 in the UK is 59. There was a total of 609 new patients hospitalised with suspected pandemic influenza in week 33 (up to 0800 hrs, Monday 17 August); a decrease of 299 from the previous week. The highest hospitalisation rates have consistently been in the under five-year age group. Hospitalisation rates have decreased over the past week in all age groups. According to the European Centre for Disease Prevention and Control (ECDC), by 18 August, 237,129 laboratory confirmed cases of pandemic influenza (H1N1) had been reported globally with 2144 deaths. In week 32 all European countries reported low or moderate levels of influenza activity. Reference 1. HPA Weekly National Influenza Report: week 34 (20 August 2009, PDF 106 KB), HPA website:

4 Infection reports Volume 3 Number 33 Published on: 21 August 2009 Bacteraemia Escherichia coli bacteraemia in England, Wales, and Northern Ireland, 2004 to 2008 Zoonoses Common animal associated infections, England and Wales: laboratory reports, weeks Med-Vet-Net, a European Union network for zoonotic research John Threlfall, project director, Med-Vet-Net, Gastrointestinal, Emergency and Zoonotic Infections Department, HPA Centre for Infections.

5 Bacteraemia Escherichia coli bacteraemia in England, Wales, and Northern Ireland, 2004 to 2008 Introduction and summary This report covers voluntary reports of bacteraemia due to Escherichia coli (E. coli) made to the Health Protection Agency between 2004 and 2008 from participating laboratories in England, Wales and Northern Ireland. Data were extracted on 24 July 2009 and are provisional; reports for 2008 may increase due to late reporting. There was an 8% increase in the total number of reports of E. coli bacteraemia via the voluntary surveillance scheme in 2008 (23,974 reports) compared to 2007 (22,132 reports) (figure 1). Since 2004 there has been a 38% increase in E. coli bacteraemia reports, greater than the 16% increase in reports for all bacteraemias ( 80,890 to 94,093 ) via the voluntary surveillance scheme for the same time period (data extracted 17 June 2009). E. coli bacteraemia is more frequent among males than females among those aged under one year, and among those aged 65 years and over; however E. coli bacteraemia is more frequent among women in the 15 to 44 year age group (figure 2). The overall reported incidence of E. coli bacteraemia for England, Wales and Northern Ireland in 2008 is 42.9 per 100,000 population (figure 3). Although there has been little change in the rates of non susceptibility to key antimicrobials (cephalosporins, quinolones, and gentamicin) from , rates are still higher in 2008 than in 2004 (table 1) The percentage of isolates testing non-susceptible to either ciprofloxacin or gentamicin remains very similar to 2007 at 21% and 8%, respectively. While the percentage of isolates testing non-susceptible to the extended-spectrum cephalosporins ceftazidime and cefotaxime remains similar to 2007 at 11-12% this rate is still twice that reported in 2004 (6%). All isolates tested for either imipenem or meropenem remained fully susceptible. Trends in reports E. coli is one of the two most common causes of bacteraemia in England, Wales and Northern Ireland, having recently overtaken Staphylococcus aureus as the most frequently reported cause [1]. In 2008 there were 23,974 voluntary reports of E. coli made to the Health Protection Agency (figure 1). This represents an 8% increase compared to 2007 (22,132 reports). In the five years since 2004 (17,411 reports were received in 2004) there has been a greater increase (38%) in E. coli bacteraemia reports than for all bacteraemias (16%; 80,890 to 94,093 [data extracted 17 June 2009]). The increase in reports of E. coli bacteraemia may be due to either increased incidence and/or increased ascertainment. Furthermore reports for 2008 are provisional as of 24 July 2009 and the number of reported cases of bacteraemia may increase slightly as late reports are received.

6 Figure 1. E. coli bacteraemia reports, England, Wales and Northern Ireland: 2004 to 2008* * Data extracted 24 July 2009 Completeness of laboratory reports The number of laboratories voluntarily reporting data for E. coli bacteraemia has decreased marginally from 196 in 2004 to 183 in 2008 (table 1). The percentage of laboratories reporting drug susceptibility data increased from 90% in 2004 to 95% in The decreased number of reporting laboratories is probably due to consolidation of laboratories at trust level. Table 1. Laboratories reporting E. coli bacteraemia, England, Wales and Northern Ireland: 2004 to 2008* Number of E. coli bacteraemia reports 17,411 18,597 19,989 22,132 23,974 Number of reporting laboratories Laboratories reporting susceptibility data 90% 91% 95% 95% 95% * Data extracted 24 July 2009

7 Age and sex distribution Figure 2 shows the age and sex distribution (rate per 100,000 population) of E. coli bacteraemia reported to the Health Protection Agency in The distribution among the sexes differs by age group; E. coli bacteraemia is more frequent among males than females in those aged under one year, and those aged 65 years and over; whilst it is more frequent among women in the 15 to 44 year age group. Figure 2. E. coli bacteraemia reports in 2008, England, Wales and Northern Ireland, by age and sex* * Data extracted 24 July 2009 Antimicrobial susceptibility Trends in non-susceptibility to key antimicrobials are presented in table 2. The trend for no increase in non-susceptibility to any of the key antimicrobials (cephalosporins, quinolones, and gentamicin) has been sustained since 2006 however, rates were still significantly higher in 2008 than they were in In comparison with 2007 data, the percentage of isolates testing non-susceptible to the cephalosporins cefotaxime and ceftazidime remained very similar at 11-12%, and rates for ciprofloxacin and gentamicin also remain similar at 21% and 8%, respectively. The increased resistance to cephalosporins most likely reflects the emergence and spread, since 2002/03, of strains producing extended-spectrum ß-lactamases (ESBLs), particularly CTXM-15, which is now the dominant type [2,3]. All isolates tested for either imipenem or meropenem remained fully susceptible. Nevertheless a few E. coli samples (and rather more Klebsiella pneumoniae ) with acquired carbapenemases are now being received by the HPA reference lab, which UK microbiologists should be aware of. Most have an enzyme called NDM-1, which is epidemiologically linked to India and Pakistan [4].

8 Table 2. Antibiotic susceptibility data for reports of E. coli bacteraemia, England, Wales and Northern Ireland: 2004 to 2008* E. coli Total reports 17,411 18,597 19,989 22,132 23,974 Cefotaxime % non-susceptible 6% 9% 11% 12% 11% Reports with susceptibility data ,465 11,727 Ceftazidime % non-susceptible 6% 9% 12% 12% 11% Reports with susceptibility data ,306 14,595 15,980 Ciprofloxacin % non-susceptible 16% 19% 23% 23% 21% Reports with susceptibility data 13,170 13,949 15,912 18,421 19,535 Gentamicin % non-susceptible 7% 8% 9% 9% 8% Reports with susceptibility data 14,165 14,651 16,094 19,190 21,128 Imipenem % non-susceptible 0% 0% 0% 0% 0% Reports with susceptibility data Meropenem % non-susceptible 0% 0% 0% 0% 0% * Data extracted 24 July 2009 Distribution by region Reports with susceptibility data ,732 Figure 3 shows regional distribution of E. coli bacteraemia in Regions/countries with high incidence include West Midlands (54.8/100,000), North East (53.8 per 100,000 population), and Northern Ireland (50.8/100,000). Regions/countries with lower incidence include London (37.5/100,000) and South West (33.5/100,000). The overall reported incidence for England, Wales and Northern Ireland is 42.9 per 100,000 population. As data collection is based on a voluntary reporting system, it is important to note that regional incidence rates are affected by completeness of regional reporting. Figure 3. Region-specific rates of E. coli bacteraemia: England, Wales and Northern Ireland: 2008* * Data extracted 24 July 2009

9 References 1. HPA. Surveillance of Healthcare Associated Infections Report London: Health Protection Agency, HPA. Investigations into multi-drug resistant ESBL-producing Escherichia coli strains causing Infections in England: September London: Health Protection Agency, Potz N, Hope R, Warner M, Johnson A, Livermore D. CTX-M-producing Escherichia coli now the dominant cephalosporin-resistant Enterobacteriaceae. Clin Microbiol Infect 2005; 11(Suppl 2): HPA. Multi-resistant hospital bacteria linked to India and Pakistan. Health Protection Report, 2009; 3(26). Acknowledgements These reports would not be possible without the weekly contributions from microbiology colleagues in laboratories across England, Wales and Northern Ireland, without whom there would be no surveillance data. The support from colleagues within the Health Protection Agency, Antibiotic Resistance Monitoring and Reference Laboratory, in particular, is valued in the preparation of the report. Feedback and specific queries about this report are welcome and can be sent to

10 Zoonoses Common animal associated infections, England and Wales: laboratory reports, weeks 14-26/2009 Organism Total reports for weeks Cumulative totals for weeks * * 2008 Borrelia burgdorferi *,# Leptospira hardjo **,## Leptospira icterohaemorrhagiae **,## Leptospira other **, ## Pasteurella haemolytica Pasteurella multocida Pasteurella pneumotropica Pasteurella other/ spp Toxocara canis Toxocara other/ spp Toxoplasma gondii Toxoplasma other/ spp Coxiella burnetii Chlamydia (Chlamydophila) psittaci Capnocytophaga spp Mycobacterium marinum Orf virus Echinococcus granulosus Brucella melitensis Brucella spp * Provisional data; ** By specimen date; # Lyme Diagnostic Unit and CDSC; ## Leptospira Reference Unit and CDSC; Toxoplasma reports to LabBase only.

11 Commentary Borrelia burgdorferi (Lyme borreliosis): (127) weeks 01-26/2009 < Not stated Cum. total weeks 01-26/ Country visited (Second quarter reports) Number of cases France 3 Germany 1 Sweden 2 Czech Republic 1 USA (Eastern seaboard) 2 Finland - Poland 1 Slovenia - Slovakia - Austria - Leptospirosis: (2) Indigenous cases (2): weeks 01-26/2009 < Not stated Cum. total weeks 01-26/ Infections were reported from regions throughout England and Wales. Reported serovars were: not determined (2).

12 Overseas acquired infections (0): weeks 01-26/2009 < Not stated Cum. total weeks 01-26/ The following table lists countries visited during 2009 by patients diagnosed with overseas-acquired leptospirosis. Country visited Number of cases** Antigua 1 Grenada 1 Samoa 1 ** Some patients may report visiting more than one country During this reporting period, 2 cases (2 indigenous infections) were reported by NHS laboratories to the national surveillance system and 3 statutory notifications (NOIDS). Pasteurella: (119) Pasteurella haemolytica: (1) Pasteurella multocida: (87) Pasteurella pneumotropica: (4) Pasteurella aerogenes: ( ) Pasteurella spp: (27) weeks 01-26/2009 < Not stated Cum. total weeks 01-26/ Toxocara: Nil report Toxoplasmosis: Refer to Toxoplasma Reference Laboratory.

13 Coxiella burnetii: (8) weeks 01-26/2009 < Not stated Cum. total weeks 01-26/ Over 85% or reports were from laboratories in the south west of England. Chlamydia (Chlamydophila) psittaci: (21) weeks 01-26/2009 < Not stated Cum. total weeks 01-26/ Over 60% of reports were from south-west England. Capnocytophaga spp: (4) weeks 01-26/2009 < Not stated Cum. total weeks 01-26/ No clinical or epidemiological details were reported.

14 Mycobacterium marinum: (5) weeks 01-26/2009 < Not stated Cum. total weeks 01-26/ Orf: Nil report Echinococcus granulosus: Nil report Brucellosis: (5) weeks 01-26/2009 < Not stated Cum. total weeks 01-26/

15 Med-Vet-Net, a European Union network for zoonotic research John Threlfall, project director, Med-Vet-Net, Gastrointestinal, Emergency and Zoonotic Infections Department, HPA Centre for Infections. Med-Vet-Net (MVN), an EU-funded network of zoonotic disease researchers in which the Health Protection Agency plays a leading scientific role, has recently secured continued funding for its activities. The overall aims of the Med-Vet-Net network of excellence are to improve the understanding, prevention and control of zoonotic diseases in Europe by promoting strategic and integrated high-quality collaborative research: raising awareness of zoonotic diseases in policy makers, the general public, and others concerned with food safety; and enhancing the skills and knowledge base of European researchers in the field. The project has involved 15 independent EU organisations seven public health institutes and eight veterinary institutes, in 10 member states all having national reference laboratory-based responsibilities for prevention and control of zoonoses. A further partner is the Society for Applied Microbiology (SfAM) (fulfiling an EU requirement for the inclusion of a small-to-medium enterprise) tasked with the dissemination of scientific knowledge. The network's project management team is based at the Agency's Centre for Infections, Colindale (CfI), as is the overall scientific direction of the network. Coordination of the network together with financial and legal administration is handled by France 's National Agency for Food Safety (AFSSA) in Paris. The scientific activities are broken down into four thematic areas Epidemiology, Host-Microbe Interactions, Detection and Control, and Risk Research, within which there are a series of independent Workpackages (WPs). To date there have been 25 scientific WPs, 17 of which have involved HPA scientists. Organisms studied both in the laboratory and in terms of their epidemiology have included bacteria (salmonella, campylobacter, Vero cytotoxin-producing Escherichia coli (VTEC) and Coxiella burnetti), viruses (European bat Lyssaviruses, hepatitis E, Anellovirus and Encephalomycarditis virus in swine), and parasites (Trichinella, Cryptosporidium and Giardia). Several of the WPs have resulted in the formation of Europe-wide networks, with repositories of strains, DNA and databases, which have been made publicly-available. The outputs of one WP targeted at the development of a linked molecular surveillance database system for foodborne infections caused by salmonella, VTEC and listeria have been taken up by the European Centre for Disease Control and Prevention (ECDC). Antimicrobial drug resistance has been given high priority, with three WPs encompassing resistance to beta-lactam antibiotics, multiple drug resistance in salmonella, and the emergence and spread of new resistance determinants of importance to public health. In the field of risk research there have been a series of WPs encompassing risk assessment to support decision making in food safety, pre-harvest microbiological risk assessment and prioritisation of foodborne and zoonotic hazards at the EU level, in tandem with the current second study of Infectious Intestinal Disease in the community (IID2) in the United Kingdom [1]. As well as the scientific work packages described above, the network has also supported the formation of special interest groups in overarching areas or in areas with relatively low critical mass. These have included work on host-pathogen interactions, European bat Lyssaviruses, and wildlife-related emerging diseases and zoonoses. Recent and future developments The first phase of the MVN network's activities - funded under the European Union's 6th Framework Programme within the Quality and Safety of Food priority area draws to a close this Autumn. During this period, developments have included the integration of activities of some of WPs. For example, epidemiological and laboratory-based WPs are now working together in such areas as geographical information systems, antimicrobial resistance, seroepidemiology and campylobacter control. Extensive training activities, particularly the sponsoring of exchanges of young scientists between institutes, have also been supported. More than 200 young scientists participated in 20 training workshops over the last 12 months and an annual scientific meeting is also organised at which MVN member institutes are funded to participate. The value of these activities has been recognised both within and outwith the EU. Funding for continuation of the network, albeit at a lower level than under the 6th Framework Programme, has recently been secured in the short-term by the formation of the Med-Vet-Net Association, which will be launced in October This is selffunded by existing institute partners of the present network, and further funding is currently being actively pursued through a variety of fora. This means that one of the MVN network's primary objectives that of establishing an integrated and sustainable virtual institute for zoonoses research within the EU has been successfully achieved. Reference 1. Second [UK] study of infectious intestinal disease in the community. See: Second UK-wide, community-based infectious intestinal disease study, Health Protection Report 2(21),