HPS Weekly Report. Contents CURRENT NOTES. 22 June 2011 Volume 45 No. 2011/25 ISSN (Online) E. coli outbreak Germany

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1 HPS Weekly Report 22 June 2011 Volume 45 No. 2011/25 ISSN (Online) Contents CURRENT NOTES E. coli outbreak Germany Cholera outbreak in Haiti and Dominican Republic HFS cleaning compliance report Zearalenone in food Solar ultraviolet radiation in Great Britain ( ) SEPA s new environmental protection regime Road casualty statistics 2010 SURVEILLANCE REPORT Gastro-intestinal and foodborne infections pages pages CURRENT NOTES E. coli outbreak Germany 45/2501 On June 14, Eurosurveillance published further information on the characteristics of the German outbreak strain of Escherichia coli and the sharing of these microbiological findings by public health microbiology experts to disseminate best laboratory practice for case detection and public health investigations across Europe and beyond. In the same issue (at eurosurveillance.org/public/articles/archives.aspx?publicationid=11597), a collaborative group of investigators report several findings on the nature and possible origin of the epidemic strain. The E. coli strain causing a large outbreak of haemolytic uraemic syndrome and bloody diarrhoea in Germany in May and June 2011 possesses an unusual combination of pathogenic features typical of enteroaggregative E. coli together with the capacity to produce Shiga toxin. The article goes on to describe simple diagnostic screening tools for detecting the outbreak strain in clinical specimens and a novel real-time PCR for its detection in foods. In addition, the European Centre for Disease Prevention and Control (ECDC) has published an updated rapid risk assessment Outbreak of Shiga toxin-producing E. coli (STEC) in Germany (at revised.pdf) as part of its monitoring and surveillance work. Specifically, the risk assessment looked into the unusual increase in Shiga toxin-producing Escherichia coli (STEC) infections in Germany, with patients presenting with haemolytic uremic syndrome (HUS) and bloody diarrhoea. [Source: ECDC News Release, 16 June The ECDC risk assessment reports that Raw (bean) sprouts retrieved in an open bag from the household of a family with EHEC infection were found to harbour the outbreak EHEC strain O104:H4. NOTIFIABLE TABLE to 10/6/2011 pages Food safety advice in the UK continues to be available from the FSA at news/newsarchive/2011/june/ecoli10jun. No further Scottish cases with E. coli O104 have been reported to HPS since the confirmed case described in Current Note 45/2410 (at Cholera outbreak in Haiti and Dominican Republic 45/2502 The Health Protection Agency (HPA) has noted that the cholera outbreak which began in Haiti in October 2010 and spread to the Dominican Republic in November 2010, is continuing. Cases of cholera reported in the UK are rare and are usually associated with travel to the Indian subcontinent and Africa, where outbreaks frequently occur in the local population. A case of laboratory-confirmed cholera caused by Vibrio cholerae O1 El Tor Ogawa has however recently been reported in a UK traveller returning from the Dominican Republic. While the risk of cholera in travellers to Haiti and Dominican Republic is low, travellers should nonetheless practise food and water hygiene precautions. They should, in particular, avoid eating shellfish unless sure that it has been thoroughly cooked. Correspondence to: The Editor, HPS Weekly Report HPS, Clifton House, Clifton Place Glasgow, G3 7LN Scotland T F E NSS.HPSWReditor@nhs.net HPS is a division of the NHS National Services Scotland Registered as a newspaper at the Post Office HPS 2011 Clinical suspicion for cholera should be high for anyone presenting in the UK with a profuse diarrhoeal illness and with a history of having been in an area affected by a cholera outbreak or epidemic. Specimens should be immediately sent to the laboratory for testing along with any relevant travel history including the potential of exposure to cholera [Source: Health Protection Report, 17 June Health Protection Scotland s travel team has updated its related advice on TRAVAX ( travax.nhs.uk). HFS cleaning compliance report 45/2503 On 17 June, Health Facilities Scotland (HFS) published a report providing data on compliance with the requirements set out in the NHSScotland National Cleaning Services

2 Specification for January 2011 to March The report includes data on the 18 Scottish NHS boards that offer inpatient services or deal directly with patients, as follows: the 14 NHSScotland operational boards. These results are shown in two forms; the overall result for each Board and results for A1 (Acute Teaching) and A2 (Acute - Non-Teaching hospitals); four special health boards - Golden Jubilee National Hospital, The State Hospitals Board for Scotland, Scottish Ambulance Service and the Scottish Blood Transfusion Service (part of NHS National Services Scotland). The report indicates the status of each NHS board using a traffic light system as follows: Green: compliance above 90% Amber: compliance between 70% and 90% Red: compliance below 70% The report also highlights any issues regarding non-compliance with the National Cleaning Specification as it relates to estates issues. NHS boards or major sub-units which receive an amber or red compliance rating must develop an action plan to address the issues identified through the monitoring process (to be submitted to Health Facilities Scotland). [Source: HFS Cleaning Compliance Report, 17 June Zearalenone in food 45/2504 On 21 June, the European Food Safety Authority (EFSA) published a report on the public health risks related to the presence of zearalenone in food. Zearalenone is a mycotoxin produced by several Fusarium species and is commonly found in maize but can also be found in other crops such as wheat, barley, sorghum and rye. A total of 13,075 analytical results obtained on food samples and 9,877 results on unprocessed grains sampled by 19 European countries in were used in the evaluation. The highest concentrations of zearalenone were reported for wheat bran, corn and products thereof (e.g. corn flour, cornflakes). Grains and grain-based foods, in particular grains and grain milling products, bread and fine bakery wares, made the largest contribution to the estimated zearalenone exposures. Vegetable oils also made an important contribution to the zearalenone exposure. The critical effects of zearalenone result from its oestrogenic activity. Based on recent data in the most sensitive animal species, the pig, and taking into account comparisons between pigs and humans, EFSA s Panel on Contaminants in the Food Chain (CONTAM) established a tolerable daily intake (TDI) for zearalenone of 0.25 μg/kg b.w. Estimates of chronic dietary exposure to zearalenone based on the available occurrence data are below or in the region of the TDI for all age groups and not a health concern. A potential increase in the maximum level (ML) for zearalenone in breakfast cereals from 50 µg/kg to 75, 100, 125 or 150 µg/kg was considered unlikely to result in a chronic dietary exposure exceeding the TDI. In a worst case scenario it was however possible that an individual could consume the same batch of breakfast cereal containing zearalenone at the ML every day for two to four weeks, in which case exposures might exceed the TDI. [Source: EFSA Scientific Opinion, 21 June Solar ultraviolet radiation in Great Britain ( ) 45/2505 A recent report from the Health Protection Agency investigates a long-term trend demonstrated by an ongoing survey of solar radiation levels at the six different latitude sites in Great Britain (GB). The network consists of three HPA sites at Chilton, Leeds and Glasgow and three Meteorological Office stations at Camborne, Kinloss and Lerwick. At each site in the network, measurements of solar ultraviolet radiation (UVR), including erythemally effective ultra violet radiation exposure (UVR eff, nm), UVA ( nm) and photopically weighted visible radiation, have been measured simultaneously using a three detector measurement system. Overall, it has been found that UVR eff and UVA measurements have indicated a statistically significant increasing linear trend between 1989 and 2008 in the UK with a mean rate of 0.23 kj/m2 eff /year (95% CI: ) or 1.68% per year for the UVR eff and 0.15 MJ/m 2 /year (95% CI: ) or 1.36% per year for the UVA. Changes in UVR solar radiation in relation with eff eff ozone depletion and sunshine hours in GB have been investigated. Although an increase in UVR eff in response to decreasing ozone and increasing sunshine hours has been detected in GB, it has not been statistically feasible to draw any conclusion regarding an underlying dependence of ozone concentration and sunshine hours on changes in UVR eff in GB. HPA-CRCE-020: Solar Ultraviolet Radiation in Great Britain ( ), published on 15 June, can be accessed at

3 SEPA s new environmental protection regime 45/2506 In December 2010, the Scottish Environment Protection Agency (SEPA) launched a consultation on its proposals for what it hoped would prove to be a new, simpler and more effective way forward for environmental regulation in Scotland. The consultation closed in February 2011 and generated significant interest from a wide range of stakeholders, with 105 responses received from over 30 sectors. The findings are summarised in Response to the Better Environmental Regulation: SEPA s Change Proposals Consultation (at There was a high level of support for the main principles in the consultation, particularly in relation to: reducing the complexity and improving the effectiveness of environmental regulation; simplifying permits (including working up proposals for single site, operator or network licences); placing an assessment of risk to the environment, and the performance of operators, at the centre of SEPA s approach; targeting environmental harms and working with partner organisations and local communities to solve these; dealing with non-compliance through stronger and swifter forms of enforcement, where necessary. SEPA is now working with respondents and others on the details of the proposed changes, how these will work in practice, and the funding model that will support them. [Source: SEPA News Release, 20 June news/2011/support_for_changes_to_sepa s.aspx] Road casualty statistics /2507 Statistics published on 20 June ( show that Scotland s roads casualties continue a downward trend and are at their lowest since records began. Compared to 2009, the reported number of deaths on Scotland s roads fell in 2010 by 4% to 208 and the number of serious injuries fell by 14% to 1,960. Scotland s Road Safety Framework (accessible at sets distinct and challenging targets for reductions in road casualties in Scotland over the decade from January 1, These are the first ever Scottish road safety targets - for a 40% reduction in fatalities; 55 % reduction in serious injuries; a 50% reduction in children killed and 65% reduction in children seriously injured based on the average. [Source: Scottish Government New Release, 20 June

4 Surveillance Report Gastro-intestinal and foodborne infections: overseas outbreaks of infectious intestinal disease Prepared by: Alison Smith-Palmer and Mary Locking This report presents information on the surveillance system that HPS uses to collect and disseminate information on potential outbreaks of infectious intestinal disease believed to have been acquired abroad. A potential outbreak of infectious intestinal disease occurring abroad is defined as two or more confirmed cases of infection or at least one confirmed case where others are alleged to have been ill. Such outbreaks are usually reported to HPS by NHS board public health teams. They may also, however, be identified by the reference laboratories. This is particularly the case where phage types or molecular profiles rarely seen in Scotland are involved and/or where the individuals affected are resident in disparate regions of Scotland. Information on the organism responsible, number positive, number of others suspected to be affected, country, town/resort, hotel or other accommodation, catering (full board/half board/ self catering) holiday start and end dates, date of first onset, tour operator, flight details (if applicable) and any other relevant information is disseminated by HPS to the NHS board public health teams in Scotland, so that other linked cases can be identified. Where possible information is also sent directly to the national surveillance centre in the country where infection is thought to have been acquired, enabling them to facilitate any investigations or control measures they believe to be necessary. Where HPS does not have direct contacts with the country concerned, information is copied to the Foreign and Commonwealth Office for onward circulation to the relevant country. A copy of the information is also sent to the European Centre for Disease Prevention and Control (ECDC) in order that the outbreak can be linked to any others that may have been identified in other ECDC countries due to infected persons returning from the same resort. After the initial information has been disseminated, when additional cases are identified in Scotland and additional information becomes available, this information is passed to the relevant national surveillance centre in order to facilitate local investigations. In 2010, information was circulated concerning 108 potential outbreaks of infectious intestinal disease in persons returning to Scotland from abroad; this is an increase on 2009 when information was circulated on 71 such outbreaks. In 2010, Egypt was the country most frequently reported and was associated with 36 (33%) outbreaks. This was higher than 2009 when Egypt was associated with 15 (21%). In 2009 Turkey had been the most frequently reported country reported with 19 (27%) outbreaks but in 2010 it was the second most frequently reported country, associated with 22 (20%) outbreaks. Spain, including the Balearic Islands, was associated with 12 outbreaks compared to 15 the previous year. Eleven outbreaks were associated with Tunisia. Five outbreaks were associated with Morocco. The USA, Cuba and cruises were each associated with three outbreaks. India and Kenya were each associated with two outbreaks. There were nine countries which were each reported on just one occasion in 2010 (Table 1). Salmonella was the most frequently identified pathogen associated with overseas outbreaks in 2010 and was reported from 62 (57%) outbreaks. Cryptosporidium was the second most common aetiological agent associated with 21 (19%) outbreaks. Ten outbreaks were associated with Shigella, five outbreaks with E. coli, two with norovirus, one each of Giardia, cholera and Vibrio parahaemolyticus. One reported outbreak was associated with a case of haemolytic uraemic syndrome, and in one outbreak the responsible agent was unknown at the time of report. There were three outbreaks of mixed aetiology. FIGURE 1: Organisms reported in potential overseas outbreaks of infectious intestinal disease Cryptosporidium Cholerae Mixed Vibrio parahaemolyticus Shigella Table 1: Countries reported as associated with potential overseas outbreaks of infectious intestinal disease Country Number of outbreaks Cruise 3 Cuba 3 Cyprus 1 Egypt 36 Honduras 1 India 2 Jordan 1 Kenya 2 Mexico 1 Morocco 5 Nepal 1 Sri Lanka 1 Slovenia 1 Spain 12 Sudan 1 Tanzania 1 Tunisia 11 Turkey 22 USA 3 Total 108 E.coli Giardia HUS N/K Norovirus Salmonella Within the 62 outbreaks of Salmonella, S. Enteritidis was the most frequently identified serotype, associated with 14 outbreaks. Of the total, 19 (31%) of the outbreaks were associated with travel to Egypt, 13 with travel to Turkey, and nine with travel to Tunisia. 229

5 Seven of the ten outbreaks of Shigella were associated with S. sonnei, two with S. flexneri and one with S. dysenteria. Seven of the Shigella outbreaks were associated with travel to Egypt, two with Cuba and one with Sudan. There were 21 outbreaks of Cryptosporidium, seven (33%) being associated with travel to Egypt, six with Turkey, four Spain, two USA and one each with Jordan and Morocco. To date in 2011 information has been circulated on six outbreaks of infectious intestinal disease in persons returning to Scotland from abroad, three involved persons returning from Egypt, and one each with India, Dominican Republic and Vietnam and Cambodia. Two of the six outbreaks so far in 2011 have been of Salmonella, and one each of Cryptosporidium, Shigella, Giardia and one of mixed infection. Verotoxigenic E. coli infection believed to have been acquired outside Scotland. Due to the potentially serious complications associated with infection with E. coli O157 and other verotoxigenic serogroups of E. coli, HPS operates a similar system to that for outbreaks of TABLE 2: Selected gastrointestinal infections, Scotland: laboratory reports, weeks 2011/17-20 Organism 11/17 11/18 11/19 11/20 Total for period Cumulative total to: 11/ /20 10/20 Campylobacter E. coli O Listeria Shigella Yersinia enterocolitica Cryptosporidium Giardia Hepatitis A Rotavirus Norovirus TABLE 3: Salmonella (excl. S.typhi & S.paratyphi), Scotland: laboratory reports, weeks 2011/17-20 Salmonellas 11/17 11/18 11/19 11/20 infectious intestinal disease for single cases of VTEC infection who report travel outside Scotland in the 14 days prior to the onset of symptoms. During 2010, HPS circulated information on a total of 31 cases (29 of E. coli O157, one of E. coli O26 and one E. coli non-o157 serogroup currently unknown). Six cases reported travel to Turkey, four to England, three to France, two each to Malta, Morocco and Spain, and one each to Austria, Bulgaria, Egypt, Indonesia, Jamaica, Kazakhstan, Maldives, New Zealand, Qatar, Tunisia, UAE and one case with travel to more than one country. To date in 2011, information has been circulated on eight cases of E. coli O157, two with a history of travel to Egypt, and one each with a history of travel to Australia, Mexico, Morocco, Netherlands and Tunisia, and one case of E. coli O104 who had returned from Germany. HPS would like to thank all the members of the public health teams, environmental health officers and microbiologists who contribute to these systems. Further information on the overseas outbreak surveillance system can be obtained from John Cowden or Alison Smith-Palmer. Total for period Cumulative total to: 11/ /20 10/20 S.Enteritidis S.Enteritidis PT S.Typhimurium S.Typhimurium DT Other Salmonellas Total The last Gastro-intestinal and foodborne infections Surveillance Report was in Issue 11/21 The next Gastro-intestinal and foodborne infections Surveillance Report will be in Issue 11/29 230

6 Notifiable diseases Part 2 (Notifiable Diseases, Organisms and Health Risk States) of the Public Health etc.(scotland) Act came into effect on 1 January 2010 and sets out new duties for registered medical practitioners, NHS boards and directors of diagnostic laboratories. GP practices should familiarise themselves with the Scottish Government guidance on the new notification requirements at: Registered medical practitioners report notifiable diseases based on clinical suspicion. As such, notifications may not be subject to laboratory report confirmation. The published figures will record therefore how many diseases have been clinically suspected. Patient notifications can, however, be reclassified. When, for example, a suspected (and notified) tuberculosis case is subsequently reported as negative by a laboratory (and found not to be a health protection risk) it would subsequently be removed from the disease totals. Diseases to be notified by registered medical practitioners with effect from 1 January 2010: Notifiable Diseases which come into effect on 1 January 2010 *Anthrax *Meningococcal disease *Severe Acute Respiratory Syndrome (SARS) *Botulism Mumps *Smallpox Brucellosis *Necrotising fasciitis Tetanus *Cholera *Paratyphoid Tuberculosis (respiratory or non-respiratory) (see Note 2) *Clinical syndrome due to E. coli O157 infection (see note 1) *Pertussis (Whooping Cough) *Tularemia *Diphtheria *Plague *Typhoid *Haemolytic Uraemic Syndrome (HUS) *Poliomyelitis *Viral haemorrhagic fevers *Haemophilus influenzae Type b (Hib) *Rabies *West Nile fever *Measles Rubella Yellow Fever It is recommended that those diseases above marked with an * require urgent notification, i.e. within the same working day. Note 1: Escherichia coli O157 Clinical suspicion should be aroused by (i) likely infectious bloody diarrhoea or (ii) acute onset non-bloody diarrhoea with a biologically plausible exposure and no alternative explanation. Examples of biologically plausible exposures include: contact with farm animals, their faeces or environment; drinking privately supplied or raw water; eating foods such as undercooked burgers or unpasteurised dairy products; contact with a confirmed or suspected case of VTEC infection. Further guidance is available at: coli0157.aspx. Where a case is notified as HUS (Haemolytic Uraemic Syndrome) it should NOT also be notified as Clinical syndrome due to E. coli O157 infection. Note 2: Tuberculosis For the purposes of notification, respiratory TB or non-respiratory TB should be taken to have the same meanings as the World Health Organisation definitions of pulmonary TB and non-pulmonary TB respectively: Pulmonary TB is tuberculosis of the lung parenchyma and/or the tracheobronchial tree. Non-pulmonary TB is tuberculosis of any other site. Where tuberculosis is clinically diagnosed in both pulmonary and non-pulmonary sites, this should be treated as pulmonary TB. Registered medical practitioners have been advised to contact their local NHS Board Health Protection Team for advice should they have any doubts about the diagnosis of suspected cases. Non-notifiable diseases Registered medical practitioners are no longer required to notify the diseases listed below. Bacillary dysentery Chickenpox Food poisoning Scarlet fever Viral hepatitis These diseases are now covered by a list of notifiable organisms details of which will be reported by laboratories to health protection teams. 231

7 A National Statistics release Infectious Disease Statutory Notification of Infectious Diseases (by age) Week ended 10 June 2011 Age Group All ages Under & over Not known M F M F M F M F M F M F M F M F M F M F Anthrax Botulism Brucellosis Cholera Clinical Syndrome E.coli Diphtheria Haemolytic Uraemic Syndrome (HUS) Haemophilus Influenzae Type B (Hib) Measles Meningococcal Infection Mumps Necrotizing Fasciitis Paratyphoid Fever Pertussis Plague Poliomyelitis Rabies Rubella Severe Acute Respiratory Syndrome (SARS) Smallpox Tetanus Tuberculosis: Respiratory Tuberculosis: Nonrespiratory Tularemia Typhoid Fever Viral Haemorrhagic Fevers West Nile Fever Yellow Fever TOTAL

8 Infectious Disease Statutory Notification of Infectious Diseases (by board) Week ended 10 June 2011 Health board area Current week Previous week Current week last year Total from first week of year AA BR DG FF FV GR GG HG LN LO OR SH TY WI Anthrax Botulism Brucellosis Cholera Clinical Syndrome E.coli Diphtheria Haemolytic Uraemic Syndrome (HUS) Haemophilus Influenzae Type B (Hib) Measles Meningococcal Infection Mumps Necrotizing Fasciitis Paratyphoid Fever Pertussis Plague Poliomyelitis Rabies Rubella Severe Acute Respiratory Syndrome (SARS) Smallpox Tetanus Tuberculosis: Respiratory Tuberculosis: Nonrespiratory Tularemia Typhoid Fever Viral Haemorrhagic Fevers West Nile Fever Yellow Fever TOTAL Amendments: Add 1 Measles (1 x LO wk 22); 2 Tuberculosis : non-respiratory (2 x GR wk 18) Source: Health Protection Scotland, NHS National Services Scotland NHS BOARD ABBREVIATIONS AA Ayrshire & Arran GG Greater Glasgow & Clyde LN Lanarkshire SH Shetland TY Tayside BR Borders FF Fife GR Grampian LO Lothian WI Western Isles DG Dumfries & Galloway FV Forth Valley HG Highland OR Orkney 233