Volume 5 Number 47 Published on: 25 November 2011 Current News New guidelines for the management of norovirus outbreaks in acute and community health and social care settings Surveillance of haemolytic uraemic syndrome in children Measles cases in Europe: update to end-october 2011 Infection Reports Immunisation Laboratory confirmed cases of measles, mumps and rubella, England and Wales: July to September 2011 Laboratory confirmed cases of pertussis reported to the enhanced pertussis surveillance programme during April to June 2011
News Volume 5 Number 47 Published on: 25 November 2011 New guidelines for the management of norovirus outbreaks in acute and community health and social care settings A new report on the management of outbreaks of vomiting and/or diarrhoea in hospitals, and in other community health and social care settings, aims to achieve a balance between the prevention of spread of infection and the need to minimise disruption of services while outbreak control measures are in place [1]. Developed following a Department of Health workshop held in July 2010, the title of the guidance reflects the fact that, while there are other causes of vomiting and/or diarrhoea outbreaks (and its recommendations will therefore apply to all viral gastroenteritides), the principal and most common cause is norovirus, which is one of the most infective agents seen in health and social care establishments [2]. The guidance, published on the HPA website [3], was developed by a multi-agency working party (the members of which acted as representatives of their respective organisations) and involved a number of stakeholder consultation exercises [4]. There was also the full involvement of NHS management representation through the NHS Confederation. It is therefore anticipated that the resulting joint ownership of the guidance between infection prevention and control (IPC) practitioners on the one hand, and the managerial sector on the other, will reduce conflicts of interest and tensions within organisations. This is important because, an introduction/methodology section of the guidance notes, differing patterns and dynamics of outbreaks will require different, tailored IPC responses which may be misconstrued as inconsistency of approach and it is, therefore, important that the underlying principles are understood by all sections and levels of an affected organisation. The introduction continues: This guidance is based on a principle of minimising the disruption to important and essential services and maximising the ability of organisations to deliver appropriate care to patients safely and effectively. There is a shift of focus towards a balance between the prevention of spread of infection and maintaining organisational activity. In effect, this means a move away from the traditional approach of early, complete ward closure and an adoption of a pragmatic, escalatory system of isolation using single rooms and cohort nursing without compromising patient care both for norovirus itself and other essential healthcare. This is a key difference to previous guidance of the Public Health Laboratory Service Working Party published in 2000. The guidance draws on current practice that shows that cases should be managed in single rooms and bays in the first instance if this is possible. This will allow some flexibility in the response and also for cleaning to take place allowing smaller wards to be able to re-open more quickly. Other recommendations cover closure of affected bays to admissions/transfers, use of signage, restriction of access to affected areas, deep cleaning, etc. There are separate recommendations for healthcare workers in outbreak situations, including the need to ensure staff are aware of work exclusion policy, the need for staff to be allocated staff to duties in either affected or non-affected areas but not both, etc.
References 1. "New guidelines for the management of norovirus". HPA press release, 25 November 2011. 2. The guidance applies to nursing and residential homes. It is not specifically intended to cover schools, colleges, prisons, military establishments, hotels or shipping but it enshrines generalisable principles that will be of use in managing outbreaks in those institutions. 3. Guidelines for the management of norovirus outbreaks in acute and community health and social care settings, November 2011 [1.2 MB PDF]. Downloadable from the HPA website: Home Publications Infectious diseases Infection control. 4. The working party comprised representatives of the following organisations: the HPA; the NHS Confederation; the British Infection Association; the Healthcare Infection Society; the Infection Prevention Society; the Sowerby Centre for Health Informatics Newcastle; and National Concern for Healthcare Infections. Observers from UK departments of health and the Community Care Sector also participated. Other external stakeholders are listed in an appendix to the guidance. Surveillance of haemolytic uraemic syndrome in children A study aiming to better define the incidence of haemolytic uraemic syndrome (HUS) in children in the UK and Ireland has been jointly launched by the British Paediatric Surveillance Unit (BPSU) and HPA. The study also involving paediatric nephrologists and public health bodies in the Devolved Administrations and the Republic of Ireland will provide valuable data on the incidence of HUS, clinical progression and management of cases, and outcomes of disease one year after presentation. By linking incidence, exposure and clinical data with laboratory reports, the study aims to determine which strains of VTEC are causing HUS. The results will be compared with those of a previous BPSU-HUS study (1997-2001) to allow changes in epidemiology and any necessary changes to clinical management to be determined. HUS is a rare but serious condition that can develop following diarrhoeal illness caused by vero cytotoxin-producing Escherichia coli (VTEC). The peak incidence of HUS is in children under five of age. Patients generally develop HUS a week or more after their symptoms have disappeared, by which time they present a minimal risk to other people, which means the previous regular connection with the HPA may have ceased. Cases of HUS are therefore not often identified through the existing VTEC enhanced surveillance system for England. HUS was included in the notifiable disease list (Schedule 1) of the Health Protection (Notification) Regulations 2010. However, it is known that data collected through the Notifications of Infectious Disease system is incomplete and this study will allow a more complete understanding of the epidemiology of the disease. Clinicians in England, Wales, Northern Ireland and the Republic of Ireland will be asked to report cases of HUS under the age of 16 through the BPSU. Scottish clinicians will continue to report through the existing HUS surveillance system run by Health Protection Scotland, and data from this system will be included in the study. The study will run for 13 months with a one year follow-up questionnaire. Together with the national surveillance system for VTEC, data collected will help identify factors associated with an increased risk of developing HUS, in the hope that, in the future, it may be possible to prevent at-risk children from developing HUS after a VTEC infection. Further information is available at: VTEC@hpa.org.uk.
Measles cases in Europe: update to end-october 2011 The fifth European monthly measles monitoring (EMMO) surveillance report has been published by the European Centre for Disease Prevention and Prevention (ECDC) [1]. Although no new outbreaks were reported in the 29 EU and EEA/EFTA countries during October, over 1,000 new measles cases were detected through epidemic intelligence, bringing the total number of cases for 2011 to more than 30,200. Two cases of sub-acute sclerosing panencephalitis (SSPE), one of whom died, were reported in October. Between January and September eight measles-related deaths and 23 cases of acute measles encephalitis were reported. WHO Regional Office for Europe published it's Epidemiological Brief in October covering the measles outbreaks and preventative measures taken across 53 member countries [2]. The report highlights the nearly three-fold increase in cases compared to the same period in 2007. The wider impact of the outbreaks in Europe was also examined and in particular the link between the resurgence in measles in South America and its connection with Europe. Confirmed measles cases in England and Wales to the end of October 2011 In England and Wales, 956 laboratory confirmed measles cases have been reported to the end of October 2011 (see table 1 and figure). Following the peak in April 2011, the monthly total of confirmed cases has been falling with between 53 and 68 confirmed cases reported in the last three months. The majority of cases are in unvaccinated individuals (92% total). Outbreaks in schools and small family clusters are continuing to occur, particularly in London (401 cases) and the South (255 cases) regions where most cases have been diagnosed. A history of travel abroad or contact with someone who had travelled was the source for infection for 150 confirmed cases this year. Table 1. Confirmed cases of measles by region and month of onset, England and Wales: January-October 2011 Month London Mids of England North North South South Mids Wales York & Humber Jan-11 7 1 2 10 9 1 1 31 Feb-11 6 1 1 17 1 2 4 32 Mar-11 39 5 2 10 35 8 6 31 136 Apr-11 61 3 2 12 48 13 14 1 13 167 May-11 80 2 11 2 7 44 13 2 8 5 174 Jun-11 53 1 8 5 4 28 20 7 5 1 132 Jul-11 60 1 6 28 3 1 3 1 103 Aug-11 35 1 7 1 8 2 5 1 60 Sep-11 32 2 2 3 1 13 53 Oct-11 28 1 3 2 24 5 1 1 3 68 Total Total to October 401 14 40 15 40 255 74 39 19 59 956
Table 2. Number of confirmed cases of measles by region and age, England and Wales: January-October 2011 Month London Mids of England North North South South Mids Wales York & Humber Total Under 1 year 1-4 5-9 10-14 22 3 1 2 7 8 1 5 2 3 54 79 2 6 2 6 27 4 4 2 8 140 59 2 8 3 8 51 17 7 4 2 161 65 3 7 3 7 73 22 9 4 5 198 15-19 43 2 8 3 3 53 16 5 3 18 154 20-24 21 3 6 11 4 5 2 15 67 25-29 30-34 35 Total, all age groups 37 1 1 2 6 7 1 2 57 32 1 1 1 6 1 2 44 43 2 5 20 2 2 1 6 81 401 14 40 15 40 255 74 39 19 59 956 Number of confirmed measles cases by month of onset, England and Wales: January 2006 to October 2011 References 1. European Centre for Disease Prevention and Control (ECDC). European measles monthly monitoring, October 2011. Stockholm: ECDC; 2011. Available from: http://ecdc.europa.eu/en/publications/publications/forms/ecdc_dispform.aspx?id=778. 2. World Health Organisation, Regional Office for Europe (WHO Europe). WHO Epidemiological Brief: a monthly publication on vaccine-prevantable diseases and immunisation data and analysis, No.18 (October 2011). Available from: http://www.euro.who.int/ data/assets/pdf_file/0006/153195/epi_brief_issue_18.pdf.
Infection reports Volume 4 Number 47 Published on: 25 November 2011 Immunisation Laboratory confirmed cases of measles, mumps and rubella, England and Wales: July to September 2011 Laboratory confirmed cases of pertussis reported to the enhanced pertussis surveillance programme during April to June 2011 Laboratory confirmed cases of measles, mumps and rubella, England and Wales: July to September 2011 Data presented here are for the third quarter of 2011 (ie July to September 2011). Cases include those confirmed by oral fluid testing (IgM antibody tests and/or PCR) at the Virus Reference Department, Colindale and national routine laboratory reports (table 1). Analyses are by date of onset. Regional breakdown figures relate to Government Office Regions rather than regional health authorities (pre-april 2002 definitions). Quarterly figures for cases confirmed by oral fluid antibody detection only from 1995 and annual total numbers of confirmed cases by health region and age are available from: http://www.hpa.org.uk/web/hpaweb&hpawebstandard/hpaweb_c/1195733778332. http://www.hpa.org.uk/web/hpaweb&hpawebstandard/hpaweb_c/1195733841496. http://www.hpa.org.uk/web/hpaweb&hpawebstandard/hpaweb_c/1195733752351. Table 1 Total confirmed cases of measles, mumps and rubella, and oral fluid IgM antibody tests in notified cases: weeks 27-39/2011 Cases reported to Health Protection Units in England* Notified cases in England and Wales Number tested % of notified cases tested Oral fluid testing Total positive Recently vaccinated Confirmed cases Confirmed infections Other samples Total Measles 1041 477 604 126* 160 7 153 59 212 Mumps 1651 1117 874 78 184 2 182 153 335 Rubella 177 116 105 91 4 2 2 1 3 * This figure represents the number of infections reported as possible cases and investigated by individual HPUs in England.
Measles There were 212 cases of measles confirmed with onset dates in the third quarter of 2011, compared to 472 cases in the previous quarter [1]. As in the previous quarter, the majority of cases identified between July and September were in London (124 cases, 59%), although all regions in England and Wales reported cases (see table 1, news item this week). Clusters in schools and communities in London (number of affected individuals ranging between 2 and 25) accounted for the increased level of reporting in this region. The majority (165/212, 77%) of the confirmed cases this quarter were in children and adolescents: 12 (6%) under one year; 43 (20%) aged 1 to 4 ; 40 (19%) aged 5 to 9 year, 37 (17%) aged 10 to 14 ; 33 (16%) aged 15 to 18. The remaining 47 (22%) cases were aged 19 to 46. Less than four percent (8/212 cases) of the confirmed measles cases reported receiving one dose of a measles containing vaccine although only 5 (2%) were confirmed based on GP records. A history of recent travel to Europe continued to be a source of infection with 22 cases (10%) known to have acquired their infection abroad: Italy (five cases), France (three cases), Greece (two cases), Ireland (two cases), Romania (two cases) and in Kenya, Georgia, Poland, Belgium, Spain, Cyprus, Switzerland and US (one case each). Mumps There were 335 laboratory confirmed cases of mumps with onset in the third quarter reported compared to 799 in the previous quarter [1]. Cases continue to occur predominantly in individuals born between 1980 and 1990 (see figure), many of whom either were not routinely offered MMR vaccination in childhood, or have only received one dose. The majority of reports were from the London, South and North regions although cases were identified in all regions of England and Wales (table 2). Table 2: Confirmed cases of mumps by age group and region, England and Wales: weeks 27-39/2011 Region <1 1-4 5-9 10-14 15-19 20-24 25+ Total North 1 6 7 North 1 1 8 16 17 43 Yorks & Humber 1 3 5 4 4 7 24 Midlands 1 1 4 4 10 Midlands 1 5 9 9 24 of England 3 9 10 22 London 4 6 6 8 20 48 92 South 2 2 10 19 29 62 South 1 2 3 4 7 8 25 Wales 1 1 1 7 11 5 26 Total 10 14 20 49 99 143 335
Distribution (as a percentage of total number) of laboratory confirmed mumps cases in England and Wales by year of birth and quarter Rubella Three cases of rubella were confirmed this quarter, compared to a single case the previous quarter [1]. These were aged between 23-29 and all three cases were born outside the UK. Only one case reported a history of recent travel. Reference 1. HPA. Laboratory confirmed cases of measles, mumps and rubella, England and Wales: April to June 2011. Health Protection Report HPR 2011; 4(34): immunisation. Available at: http://www.hpa.org.uk/hpr/archives/2011/hpr3411.pdf.
Laboratory confirmed cases of pertussis reported to the enhanced pertussis surveillance programme during April to June 2011 There were 211 laboratory confirmed cases of pertussis (culture, PCR, serology) reported to the pertussis enhanced surveillance programme in the second quarter of 2011 (see table). This is double the number of cases reported in the previous quarter (106 in January to March 2011 [1]). Cases reported in the second quarter of 2011 are higher than the same quarter last year (104 cases between April and June 2010 see figure). This is consistent with increased levels of pertussis activity observed in some areas and fits the recognised epidemiological pattern of 3-4 yearly cyclical peaks in pertussis, with the last peak occurring in 2008. Laboratory-confirmed cases of pertussis by age and testing method, England and Wales, April to June 2011 Age group Culture tested PCR tested Serology tested <3 months 39 13 3-5 months 4 1 6-11 months 1 1 1-4 2 1 5-9 2 3 10-14 1 21 15+ 1 119 Age not known 1 1 All ages 50 15 144 Total number of laboratory-confirmed cases of pertussis per evaluation quarter in England and Wales since 2005
There has been a background increase in laboratory confirmed cases, largely in older age groups, subsequent to the introduction of new laboratory methods in 2001. More detailed explanations were provided in previous HPR articles [2]. Although a greater number of notified cases are being confirmed in older age groups, rates of confirmed cases in these age groups remain relatively low [2]. Bordetella pertussis PCR (for hospitalised cases <1 year old) and serological investigation by estimation of anti-pertussis toxin (PT) IgG antibody levels for older children and adults are provided by the Respiratory and Systemic Infection Laboratory (RSIL) at the HPA Microbiology Services Division Colindale. The laboratory also encourages submission of all Bordetella pertussis isolates for confirmation and national surveillance purposes. Further information is available on the HPA website at http://www.hpa.org.uk/cfi/rsil/bordetella.htm. References 1. HPA. Laboratory-confirmed cases of pertussis reported to the enhanced surveillance programme, England and Wales: January to March 2011. Health Protection Report 2011; 4(34): immunisation. Published on: 26 August 2011. Available at: http://www.hpa.org.uk/hpr/archives/2011/hpr3411.pdf. 2. HPA. Laboratory-confirmed cases of pertussis reported to the enhanced pertussis surveillance programme in 2009. Health Protection Report 2010; 4(25): immunisation. Available at: http://www.hpa.org.uk/hpr/archives/2010/hpr2510.pdf..