HPS Weekly Report. Contents CURRENT NOTES. 17 February 2010 Volume 44 No. 2010/07 ISSN (Online)

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1 HPS Weekly Report 17 February 2010 Volume 44 No. 2010/07 ISSN (Online) Contents CURRENT NOTES. Advice to pregnant women during lambing season. Consultation on sustainable use of pesticides. Equine infectious anaemia detected in horses. Research funding - global livestock diseases. Managing our climate water and soil - SAC/SEPA Conference. Sunbeds in breach of UV radiation safety limits SURVEILLANCE REPORT Respiratory infections NOTIFIABLE TABLES to 5/2/2010 pages pages pages CURRENT NOTES Advice to pregnant women during lambing season 44/0701 The Scottish Chief Medical Officer has issued seasonal advice highlighting a potential risk for pregnant women at this time of year. Pregnant women who come into close contact with sheep during lambing may be risking their health and the health of their unborn children. This is because infections such as chlamydiosis (enzootic abortion of ewes - EAE), toxoplasmosis and listeriosis - all common causes of abortion in ewes - can be passed on to them. Although these infections are uncommon, and the number of human pregnancies affected by contact with sheep is extremely small, it is important that pregnant women are aware of the potential risks and take appropriate precautions. If they do become ill - experience fever or influenza-like symptoms, and are concerned that they could have acquired infection from a farm environment, they should seek immediate medical advice. To avoid the possible risk of infection, pregnant women are advised that they should: not help to lamb or milk ewes avoid contact with aborted or new-born lambs or with the afterbirth, birthing fluids or materials (e.g. bedding) contaminated by such birth products avoid handling (including washing) clothing, boots or any materials that may have come into contact with ewes, lambs or afterbirth ensure partners attending lambing ewes take appropriate health and hygiene precautions, including the wearing of personal protective equipment and adequate washing to remove any potential contamination Farmers have a responsibility to minimise the risks to pregnant women, including members of their family, the public and professional staff visiting farms. If a ewe aborts, farmers are advised to ask their veterinary surgeon to take a sample to their local Veterinary Investigation Centre to determine the cause. In the interests of hygiene, farmers should dispose of all afterbirths promptly and safely via an approved route such as rendering or incineration. [Source: Scottish Government News Release, 9 February Releases/2010/02/ ] Consultation on sustainable use of pesticides 44/0702 A UK-wide consultation seeks views on the approach to be taken in implementing a European Directive on the sustainable use of pesticides (Directive 2009/128/EC) which came into force in November The Directive covers areas including training for those using pesticides, inspecting spraying equipment, aerial spraying and minimising the risk of pollution from pesticides. Correspondence to: The Editor, HPS Weekly Report HPS, Clifton House, Clifton Place Glasgow, G3 7LN Scotland T F E NSS.HPSWReditor@nhs.net Views are also sought on two provisions in a Regulation on Plant Protection Product Authorisations (Regulation (EC) No 1107/2009) on options on access to information about pesticides used near homes, and ways individuals could be provided with it. The Regulation will apply from June 14, The consultation is being carried out by the Chemicals Regulation Directorate of the Health and Safety Executive on behalf of the Scottish Government, Defra, the Welsh Assembly Government, and the Northern Ireland Assembly. Responses to the consultation should be submitted by May 4, [Scottish Government News Release, 9 February Printed in the UK HPS is a division of the NHS National Services Scotland Registered as a newspaper at the Post Office HPS 2010

2 Equine infectious anaemia detected in horses 44/0703 On 19 January, Defra confirmed that equine infectious anaemia (EIA) had been detected in two horses in Wiltshire following importation from Romania via Belgium. EIA is a lentivirus disease of horses causing intermittent fever, anaemia, emaciation and death. It can be transmitted by the exchange of blood by biting insects and occurs typically in low-lying swampy areas. EIA has a worldwide distribution. Early in the twentieth century serious outbreaks occurred in France, Japan and America. The disease has been reported in many other parts of the world and is endemic in parts of Romania. The UK applies special import conditions to address this. The premises in Wiltshire were placed under restriction and the two infected horses humanely destroyed in line with existing regulations, the other horses on the premises being subject to epidemiological investigation in the following weeks. A further two horses were investigated and test results proved negative. The remaining horses on the premises will continue to be under restriction until a second official test is negative 60 days after the slaughter of the infected ones. The animals arrived in a group of 10 horses, nine of which originated from Romania and one from Belgium. This is the first case of equine infectious anaemia infected animals being imported into Great Britain since On 8 February, Defra issued a qualitative risk assessment - Equine Infectious Anaemia - Potential risk factors for the introduction of the virus to the United Kingdom from the EU member states. EIA is not a zoonotic disease and has no human health implications. [Source: Defra News Release, 19 January defra.gov.uk/foodfarm/farmanimal/diseases/atoz/eia/latest/index.htm] Research funding - global livestock diseases 44/ M of new research was launched on 15 February to tackle the significant and growing threat posed by livestock diseases to global food security and livelihoods in developing countries. More than 900 million people in the developing world live below the poverty line in rural areas. Just one animal can meet a whole family s needs, offering individuals a way out of poverty. But deadly and debilitating livestock diseases jeopardise this and lead to an increase in food prices. The Biotechnology and Biological Sciences Research Council (BBSRC) and the Department for International Development (DFID), with a contribution from the Scottish Government, have joined forces to fund 16 new projects that bring together UK researchers with institutions in the developing world. The projects aim to find sustainable solutions to the animal disease threat to improve food security and help to build scientific capacity in the developing world to meet future challenges. Each project has a UK and an international partner, bringing together scientists in 15 UK institutions with researchers in countries including India, Ethiopia and Kenya. As animal diseases do not respect international frontiers, it is hoped the research will also have significant benefits for UK farmers and consumers. Livestock diseases such as foot and mouth disease, bluetongue, African swine fever and peste des petits ruminants virus are a global concern. Over the past 15 years livestock diseases are estimated to have cost the UK economy over 15Bn. [Source: BBSRC Media Release, 15 February Managing our climate water and soil - SAC/SEPA Conference 44/0705 With the future of our climate, our water and our soil all under the microscope, the eighth SAC & SEPA biennial conference is dedicated to the science and policy surrounding these combined challenges. On 31 March - 1 April at Pollock Halls, Edinburgh, experts in the field will address key issues linked to climate change, the management of our river catchments and water supply and the maintenance of healthy, productive soils. They will review the science and discuss the role of land managers and government. The conference programme, organised by SAC and the Scottish Environment Protection Agency, is split into four sessions. The first will consider the big picture and look at how global issues and policies affect Scotland. In the afternoon attention will turn to issues on a catchment scale putting water quality and flood control in particular focus. The second day begins by highlighting more local projects and studies linked to soil and water management, biodiversity and Nitrate Vulnerable Zones. In the final session, speakers will look forward to what is required in future and what land mangers want to know. There will be presentations on what we do and don t yet know about climate change, the effects of soft engineering options for flood control and what that means for landowners. On the second day attention focuses on the conflicts and compromises of achieving farmland biodiversity and how the lowlands, the uplands and forestry can rise to future challenges. [Source: SAC News Release, 11 February Sunbeds in breach of UV radiation safety limits 44/0706 On 12 February, the European Commission published he results of a market surveillance check of sunbeds and sunbed services which highlighted the potential risks associated with using sunbeds. Market surveillance authorities in 10 member states inspected more than 500 sunbeds at over 300 locations (mostly tanning salons and wellness centres) between September 2008

3 and September 2009, and found three main problems: UV radiation limits for sunbeds were violated in one in seven sunbeds made available at tanning services; consumer guidance, including on the hazards of UV radiation or prohibiting their use by under 18s was not provided; there were insufficient warnings on the sunbeds themselves (e.g. that UV radiation may cause injury). Authorities are intensifying their work to ensure compliance with all relevant safety legislation and the results of the 2008/2009 check will feed into a follow up project launched today by authorities in 12 member states to train more inspectors and improve information to consumers. Authorities are also working more with the sunbed industry, which is itself developing training material for service providers such as tanning studios. The joint project was carried out by market surveillance authorities in 10 member states (led by the Dutch Food and Consumer Product Safety Authority), and concentrated on the safety information and advice provided to consumers, the labelling of the sunbeds, the availability of eye protection and the UV radiation emitted by the sunbeds. The European Commission is co-financing a follow up joint project, launched by member states today, to: support industry which is keen to develop training material and code of good conduct for tanning studios and information, especially to young consumers; and to discuss with Member States the application of the product safety rules in the interest of consumer safety. The outcome of this project should be available at the end of Further information is available at [Source: European Commission Press Release, 12 February &format=HTML&aged=0&language=EN&guiLanguage=en] In Scotland, sunbed use is subject to the Public Health etc. (Scotland) Act 2008 which banned the use of sunbeds by and the sale or hire of a sunbed to anyone under 18 and requires sunbed operators to provide users with information about the health risks of sunbed use (see Current note 43/2903 at

4 Surveillance Report The following report describes the most recent quarterly surveillance data on meningococcal disease, invasive pneumococcal disease and Haemophilus influenzae in Scotland. Meningococcal disease Meningococcal disease (MD) is a notifiable disease caused by infection with the bacterium Neisseria meningitidis. MD is a significant cause of morbidity and mortality in children and young people. Meningococcal Invasive Disease Augmented Surveillance (MIDAS 1 ) was introduced in 1999 to monitor the impact of the meningitis C vaccine and data from this informs the following report. During the fourth quarter of 2009 (weeks 40-52), reports submitted to MIDAS indicate a provisional total of 25 meningococcal disease cases giving a total of 139 cases in 2009, and representing an annual incidence of 2.69 cases per 100,000 population. This compares with 125 cases reported in the same period of 2008 and 157 cases in 2007 and is the second lowest total since enhanced surveillance began in Serogroups have been determinable for 74 cases (53.2%) reported in 2009: 66 were infected with serogroup B, four with serogroup Y, three with serogroup W135 and one with serogroup 29E (confirmed by PCR). Four isolates were non-groupable. There have been no reported cases of serogroup C since the four cases reported in 2007, indicating the effectiveness of the meningitis C vaccine campaign. Figure 1 shows the serogroups of meningococcal disease cases reported from The clinical presentation of the 139 cases was as follows: 47 Figure 1: Meningococcal disease cases reported to HPS by serogroup, * (*2009 data provisional) Number of cases Respiratory and immunisation quarterly report Quarter four: 1 October to 31 December 2009 Prepared by: Prepared by: Eisin McDonald (HPS), Barbara Denham (SHLMPRL) and Jim McMenamin (HPS) Clincal Diagnosis Other * Year (33.8%) had a recorded diagnosis of meningitis, 40 (28.8%) had septicaemia, 31 (22.2%) had meningitis and septicaemia, nine (6.5%) had other diagnoses (of which seven were eye infections, one joint infection, one not stated) while 12 (8.6%) had no recorded diagnosis. Meningococcal disease occurred more frequently in younger age groups: 46.0% (64 cases) were aged less than five years, 28.8% (40 cases) were aged 5-24 years and 25.2% (35 cases) were aged 25 years and over. Four deaths from meningococcal disease have been provisionally reported in 2009: three were serogroup B and one was a clinical diagnosis. Two of these cases were aged under one year and Y W135 Group C Group B 1 For more details on MIDAS and SPIDER, see HPS website at two were aged over 25 years. This compares to six deaths in the same period of 2008 and ten deaths in the same period of The number of deaths reported by serotype from is shown in Figure 2. Figure 2: Meningococcal deaths by serotype reported to HPS * (*2009 data provisional) Number of deaths Invasive pneumococcal disease (IPD) Clincal Diagnosis Other Invasive pneumococcal disease (IPD) is caused by infection of a normally sterile site (e.g. blood, cerebrospinal fluid) with the bacterium Streptococcus pneumoniae. IPD is a major cause of morbidity and mortality. It particularly affects the very young, the elderly and those with impaired or absent immunity. Streptococcus pneumoniae Invasive Disease Enhanced Reporting (SPIDER 1 ) was introduced in 1999 and data from this informs the following report. During the fourth quarter of 2009, 165 cases of IPD were provisionally reported to the SPIDER scheme taking the total number of cases reported in 2009 to 580. This compares with 606, 629 and 753 cases reported in the same time period of 2008, 2007 and 2006 respectively, and is the lowest total reported since Information on 579 of the 580 cases provisionally reported in 2009 indicates that 37.8% (219 cases) were aged 65 years and Y Non groupable W135 Group C Group B * Year Figure 3: Cases of IPD reported to SPIDER by quarter and by age group * (*2009 data provisional) Number of cases Year (by quarter) <5 years 5-14 years years years 65+ years

5 older, 44.2% (256 cases) were aged 35 to 64 years, 8.1% (47 cases) were aged 15 to 34 years, 3.1% (18 cases) were aged 5 to 14 years, 2.8% (16 cases) were aged two to four years, and 4.0% (23 cases) were aged under two years. Figure 3 shows IPD cases reported to SPIDER by quarter and by age group from IPD in children aged under five years Pneumococcal conjugate vaccine (PCV-7) has been part of the routine childhood immunisation schedule since September Earlier this year, the Department of Health announced that PCV-7 will be replaced with PCV-13 in late spring The new vaccine will follow the same three dose immunisation schedule at two and four months of age followed by a booster at 13 months. PCV-13 will include the existing seven serotypes contained within PCV-7 (see below) and six new additional serotypes: 1, 3, 5, 6A, 7F and 19A. PCV-7 offers protection against the following seven serotypes of Streptococcus pnemoniae: 4, 14, 6B, 9V, 18C, 19F and 23F. To coincide with the introduction of PCV-7, enhanced surveillance was established for pediatric cases aged less than five years which is described below. Of IPD cases provisionally reported in 2009, 39 were in children aged under five years. This compares with 34 cases in the same time period of 2008, 26 in 2007, 61 in 2006 and 95 in Clinical diagnosis was recorded for 30 (75.0%) of these cases: ten had a diagnosis of septicaemia, eight had pneumonia, two had meningitis, one had pneumonia and septicaemia, and nine had other diagnoses. Nine cases (22.5%) were known to have an underlying medical condition. Outcome is known for 24 cases (58.3%): 16 were discharged alive, seven were still ill at the time of reporting and one died. It is anticipated that more will be known about the outcome of these cases as surveillance forms continue to be received. Twenty-three cases were aged under two years and eligible for vaccination. This compares to 22, 17 and 41 cases reported in the same period of 2008, 2007 and 2006 respectively. Of the 23 cases reported in 2009 who were aged under two years, serotypes detected so far include serotypes 1 (two cases), 3 (two cases), 6A, 7F (six cases), 12F, 15A, 19A (four cases), 19F (two cases), 20, 27, 33F and 38 (Table 1). The majority of these cases (16; 69.6%) were caused by serotypes that are included in PCV-13. There were three cases aged five years or under who were infected with a serotype of Streptococcus pneumoniae covered by PCV-7: one serotype 6B and two serotype 19F. One case was aged <2 months and not yet eligible for vaccination. The remaining two cases (aged 3-11 months and two years) had not received the full entitlement of PCV-7 vaccine and are therefore not classified as vaccine failures. Of the 580 cases provisionally reported in 2009, the most common serotypes reported were serotypes 7F (76 cases), 1 (52 cases), 19A (45 cases), 3 (44 cases), 8 (42 cases), 22F (36 cases), and 12F (24 cases). A total of 67 cases (11.6%) were caused by serotypes covered by PCV-7. Figure 4 shows a continued reduction in the cumulative PCV serotypes reported to SPIDER from 2004 to The full impact of the vaccine will become apparent in time. Figure 4: Cumulative IPD cases caused by pneumococcal vaccine (PCV-7) serotypes reported to SPIDER * (*2009 data provisional) Number of cases * Week number Haemophilus influenzae Up to the end of 2009, HPS received reports on 63 cases of invasive Haemophilus influenzae, less than the 68 reported in Of the cases reported in 2009, nine were in children aged one year or under, one was a child aged nine years while the remainder were in adults aged over 16 years. Six cases were type f, five type b and two type e, while 37 cases were nontypeable and 13 cases were not sent for typing. This compares to ten cases of type b, three cases of type f, 32 non-typeable cases and 23 cases not sent for typing from in Of the 63 invasive cases reported in 2009, 60 had Haemophilus influenzae isolated from blood, two from cerebrospinal fluid and one from pleural fluid. There have been 11 deaths among Haemophilus influenzae cases in 2009, all in adult cases. Of these, eight were nontypeable, two were not sent for typing and one was type e while five had a known underlying risk factor. This compares to six deaths reported in the same period of 2008 (two paediatric and four adult cases: all non-typeable, while three had a known underlying risk factor). Figure 5: Laboratory reports of invasive Hib disease in Scotland 1990 to 2009* (*2009 data provisional) number of reports Hib vaccine introduced, Hib booster campaign, from June In 2009 there have been no paediatric and five adult (aged 19, 37, 39, 41 and 64 years) invasive Haemophilus influenzae type b (Hib) cases reported to HPS. This compares with five paediatric cases (aged less than one month, three months, one year and two aged two years) and five adult cases (aged 34, 56, 64, 68 and 77 years) in Clinical presentation is known for three of the 2009 Hib cases: two presenting with bacteria and pneumonia and one with bacteraemia and pharyngitis. One of the cases had an underlying risk factor indicating vaccination years by quarter 2002 Under 5 years of age All ages (incl. under 5 years) Routine Hib booster, from Sept

6 Figure 5 shows the laboratory reports of invasive Hib disease in Scotland from Acknowledgements The authors would like to thank the microbiologists, consultants in public health medicine, clinicians, nurses and other staff who TABLE 2: Selected respiratory viruses* 09/Qtr 1 09/Qtr 2 09/Qtr3 09/Qtr4 Q Q Influenzavirus Influenzavirus A # Influenzavirus B Influenzavirus C Para-influenza virus Para-influenza virus Para-influenza virus Para-influenza virus Para-influenza virus RSV Picornavirus & Rhinovirus # Influenza A virus should NOT include H1N1v reports however Q2 - Q4 may contain both A and H1N1 reports, steps are being taken to address this in ECOSS. These figures will be subject to change. *Data provisional TABLE 3: Atypical pneumonias & tuberculosis* 09/Qtr 1 09/Qtr 2 09/Qtr3 09/Qtr4 Q Q Mycobacterium tuberculosis 0 Pulmonary Non-pulmonary Legionella sp Mycoplasma pneumoniae *Data provisional assist in the submission of samples to the Scottish Haemophilus, Legionella, Meningococcus and Pneumococcus Reference Laboratory (SHLMPRL) and in the completion of surveillance forms. The authors would also like to acknowledge Fiona Johnston and Hazel Littler for managing the Haemophilus influenzae database. TABLE 1: S. pneumoniae serotypes in paediatric IPD cases reported to SPIDER in 2009* (*2009 data provisional) <=2 mths 3-11 mths 1 yr 2 yrs 3 yrs 4 yrs Total <5 Not known PNE PNE PNE004 0 PNE014 0 PNE06A PNE06B 1 1 PNE07F PNE09V 0 PNE12F 1 1 PNE15A 1 1 PNE15B PNE18C 0 PNE19A PNE19F PNE PNE23F 0 PNE PNE33F 1 1 PNE Total

7 TABLE 4: Upper respiratory tract infections* 09/Qtr 1 09/Qtr 2 09/Qtr3 09/Qtr4 Q Q Grp A streptococci Grp B streptococci Grp C streptococci Grp F streptococci Grp G streptococci *Data provisional TABLE 5: Blood isolates of respiratory / meningitis pathogens* 09/Qtr 1 09/Qtr 2 09/Qtr3 09/Qtr4 Q Q Haemophilus influenzae type b N. meningitidis Strep. pneumoniae *Data provisional *includes non CSF sterile sites eg. Pleural fluid, joint aspirates TABLE 6: Meningitis (CSF specimens only)* 09/Qtr 1 09/Qtr 2 09/Qtr3 09/Qtr4 Q Q Allococcus otitis C-n Staphylococcus Coxsackievirus Echovirus Enterovirus E. coli Enterobacter cloacae Enterococcus faecalis H. influenzae type b Herpes simplex virus Kl. oxytoca L. monocytogenes Listeria sp N. meningitidis Polyomavirus Staph. aureus Strept. mitis Strept. pneumoniae Strept. sp Varicella-zoster virus *Data proisional *one case also isolated from blood #MRSAs not included for 2007 and The last Respiratory infections Surveillance Report was in Issue 09/50 The next Respiratory infections Surveillance Report will be in Issue 10/19 60

8 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: 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. 61

9 A National Statistics release Statutory Notification of Infectious Diseases (by age) Week ended 5 February 2010 Age Group Infectious Disease 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 : non-respiratory Tularemia Typhoid fever Viral haemorrhagic fevers West Nile Fever Yellow Fever TOTAL

10 Infectious Disease Statutory Notification of Infectious Diseases (by NHS board) Week ended 5 February 2010 NHS BOARD AREA AA BR DG FF FV GR GG HG LN LO OR SH TY WI Amendments: add 2 Mumps (2 x LO wk 4), 1 Rubella (1 x LO wk 4), 1 Tuberculosis : respiratory (1 x LO wk 4) NHS BOARD ABBREVIATIONS Current week Previous week Current week last year Source: Health Protection Scotland, NHS National Services Scotland 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 Total from1st week of year Anthrax Botulism Brucellosis Cholera Clinical Syndrome E.coli O 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 : non-respiratory Tularemia Typhoid fever Viral haemorrhagic fevers West Nile Fever Yellow Fever TOTAL