HPS Weekly Report 26 July 2016 Volume 50 No. 2016/30 ISSN 1753-4224 (Online) CONTENTS CURRENT NOTES World Hepatitis Day 28 July 2016 235 Candida auris emerging fungal pathogen 235 Public health risks of the Bacillus cereus group 236 Environmental incidents - SEISS reports (Falkirk industrial unit major fire) 237 SURVEILLANCE REPORT Surveillance of known hepatitis C antibody positive cases in Scotland: results to 31 December 2015 239 CURRENT NOTES World Hepatitis Day 28 July 2016 50/3001 This Thursday (28 July) marks World Hepatitis Day (http:// worldhepatitisday.org/), which aims to raise awareness of the disease and encourage better access to treatment. The disease is one of the top 10 causes of global death, costing 1.4 million lives every year. There are more than 400 million people chronically infected with hepatitis B and C worldwide. The theme for this year s global campaign is ELIMINATION. This year sees the first ever World Health Organization s Global Strategy for Viral Hepatitis, which sets a goal of eliminating viral hepatitis as a public health threat by 2030. The draft text of the strategy is available at http://www.who.int/hepatitis/strategy2016-2021/draft_ global_health_sector_strategy_viral_hepatitis_13nov.pdf. To the end of 2015, it is estimated that 36,000 people were living with chronic hepatitis C infection in Scotland; of these 60% had been diagnosed. In financial year 2015/2016, 1,735 hepatitis C infected individuals were initiated onto antiviral therapy. In this issue, the number of newly diagnosed hepatitis C antibody positive people are presented. Candida auris emerging fungal pathogen 50/3002 Since April 2015 a critical care unit in England has been managing an outbreak of Candida auris with over 40 patients either colonised or infected. 1 Around 20% of these patients have had candidaemia. The hospital outbreak has been difficult to control, despite enhanced infection control interventions, including regular patient screening, environmental decontamination and ward closure. Candida auris is an emerging fungal pathogen - a yeast species first isolated from the external ear of a patient in Japan in 2009. 2 Since then C. auris has been associated with bloodstream infections, wound infections and otitis. It has also been cultured from urine and the respiratory tract, although it is not known if positive cultures from these sites represent infections or colonisations. One of the most important features of C. auris is that it is commonly resistant to the first-line antifungal drug fluconazole, and may also be resistant to other classes of antifungal drugs (including amphotericin B and the echinocandins). The strains currently circulating in England appear to be susceptible to the echinocandin group but it should be noted that this species can evolve rapidly to develop further resistance.
Microbiologists need to be aware that any Candida spp isolates associated with invasive infections and isolates from superficial sites in patients transferred from an affected hospital (UK or abroad) should be analysed to species level. Most routinely used identification systems may misidentify C. auris. If Candida haemulonii,candida famata, Candida sake, Saccharomyces cerevisiae or Rhodotorula glutinis (the latter species is pink on Sabouraud s agar and is easily distinguished) are identified, further work should be undertaken to ensure that they are not C. auris. This would involve either (a) MALDI-TOF Biotyper analysis (NB: microbiologists with access to MALDI-TOF Biotyper must ensure that C. auris is either already present or added to their local database) or (b) molecular sequencing of the D1/D2 domain which can be offered at the PHE Mycology Reference Laboratory. The PHE Mycology Reference Laboratory in Bristol is keen to review any suspicious isolates. Please send pure isolates on Sabouraud s slopes accompanied by the appropriate form (accessible from https://www.gov.uk/government/publications/mycology-identification-andsusceptibility-testing-request-form). Further Guidance for the Laboratory Investigation, Screening, Management and Infection Prevention and Control of cases of C. auris is available at https://www.gov.uk/government/ publications/candida-auris-laboratory-investigation-management-and-infection-prevention-andcontrol. References 1. Public Health England News story, 1 July 2016. PHE responds to cases of Candida auris in England. Available from: https://www.gov.uk/government/news/phe-responds-to-cases-ofcandida-auris-in-england. (accessed 22 July 2016). 2. Satoh K, Makimura K, Hasumi Y, et al. Candida auris sp.nov., a novel ascomycetous yeast isolated from the external ear canal of an inpatient in a Japanese hospital. Microbiology and immunology. 2009;53(1):41-4. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1348-0421.2008.00083.x/abstract. (accessed 22 July 2016). Public health risks of the Bacillus cereus group 50/3003 A panel of scientific experts set up by the European Food Safety Authority (EFSA) has updated a 2005 scientific opinion on the risks to public health related to Bacillus cereus and other Bacillus species in food. The Bacillus cereus group comprises eight species. One of these, Bacillus thuringiensis, is used as a biopesticide for insect control. These naturally occurring, soil-borne bacteria can cause foodborne illnesses which usually result in vomiting and diarrhoea. The panel have stated that the only way to identify strains of Bacillus cereus group unambiguously is to determine their complete genome sequence. They recommend the use of whole genome sequencing techniques to collect relevant information as a pre-requisite for further risk assessment. The experts also recommend control options to manage risks caused by these bacteria. One of the most important options is to keep food refrigerated at a maximum temperature of 7 C. From 2007 to 2014, EU member states reported 413 strong-evidence foodborne outbreaks associated with Bacillus cereus, which affected 6,657 people and caused 352 hospitalisations. Risks for public health related to the presence of Bacillus cereus and other Bacillus spp. including Bacillus thuringiensis in foodstuffs can be accessed at http://www.efsa.europa.eu/en/efsajournal/ pub/4524. [Source: EFSA News Release, 20 July 2016. http://www.efsa.europa.eu/en/press/ news/160720] HPS WEEKLY REPORT Volume 50 No.2016/30 26 July 2016 236
Environmental incidents - SEISS reports (Falkirk industrial unit major fire) 50/3004 The Scottish Environmental Incident Surveillance System (SEISS) recorded the following incident in the past week: A fire broke out at an industrial unit storing tanks of highly flammable acetylene gas in Falkirk. More than 30 firefighters were called to the unit at Bankside Industrial Estate shortly after midnight on 18 July. Additional crews from across central Scotland had to be called in due to the protracted nature of the blaze. The Scottish Fire and Rescue Service said the fire was extinguished and made safe by about 05:00. Two crews were initially sent to the site of the fire before further crews were dispatched due to the severity of the incident. A total of 35 firefighters were involved in the operation (http://www.bbc.co.uk/news/uk-scotland-taysidecentral-36824055). For more detailed information on SEISS, go to http://www.hps.scot.nhs.uk/enviro/ssdetail. aspx?id=107 or contact either Ian Henton or Colin Ramsay at HPS on 0141 300 1100. HPS WEEKLY REPORT Volume 50 No.2016/30 26 July 2016 237
Surveillance Report Surveillance of known hepatitis C antibody positive cases in Scotland: results to 31 December 2015 Prepared by: Glenn Codere, Amanda Weir, Andrew McAuley, Allan McLeod, Cameron Watt, Sharon Hutchinson, David Goldberg In Scotland During January to December 2015, 1821 new cases of hepatitis C antibody-positivity were diagnosed. This figure compares to 1857, 1941, and 2024 for 2012, 2013 and 2014 respectively. An average of 1866 cases were diagnosed per annum in the years 2007-2011, compared with 1911 from 2012-2015. The number newly diagnosed in previous years has been revised following improvements in de-duplication methodologies and quality checks of the data. FIGURE 1: Persons in Scotland reported to be hepatitis C antibody positive by year and quarter of earliest positive specimen, to 31 December 2015. 2500 Annual number of diagnoses 2000 1500 1000 500 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year of earliest positive specimen 2011 2012 2013 2014 2015 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Of new (2015) cases, 33% (593) resided in Greater Glasgow & Clyde NHS Board area, 17% (307) in Lothian, 11% (192) in Tayside, 7% (135) in Grampian, and < 7% each in the other NHS board areas. 69% (1255) were male and 31% (560) female. Gender was not reported in fewer than 1% (6) of cases. At the time of diagnosis, 16% (295) were aged 20-29 years, 36% (652) were aged 30-39 years, 28% (509) were aged 40-49 years, 12% (219) were aged 50-59 years, and 6% (108) were aged 60+ years. Source of referral was known in 77% (1397) of cases, 30% (425) being diagnosed in the hospital setting (including infectious disease and gastroenterology units) and 28% (391) were diagnosed by general practitioners. 19% (261) were known to have been diagnosed in specialist drug services, where dry blood spot testing for hepatitis C was introduced in 2009 (diagnoses made on dry blood spot samples were confirmed at NHS testing laboratories). HPS WEEKLY REPORT Volume 50 No.2016/30 26 July 2016 238
A cumulative total of 38577 cases of hepatitis C antibody-positivity had been diagnosed as at 31 December 2015. 38% (14718) resided in Greater Glasgow & Clyde NHS Board area, 14% (5371) in Lothian, 10% (4016) in Grampian, 8% (3236) in Tayside, and < 8% each in the other NHS board areas. 67% (25852) were male and 32% (12337) female, gender was not known in 1% (388) of cases. At the time of diagnosis, 31% (12010) were aged 20-29 years, 36% (13857) were aged 30-39 years, 19% (7167) were aged 40-49 years, 7% (2581) were aged 50-59 years, and 4% (1421) were aged 60+ years. Age was not known in 1% (448) of cases. 66% (20987) of diagnosed individuals not known to be dead are currently aged between 30 and 49 years, 20% (6306) between 50 and 59 years, 8% (2537) are aged 60+, and 6% (1742) aged under 30 years. 17% (6559) are known to have died. Risk group was known in 56% (21657) of cases. Of those where risk group was known, 91% (19607) of infections were among persons who inject drugs (PWID). Source of referral was known in 78% (30198) of cases: 34% (10263) were diagnosed in the hospital setting (including infectious disease and gastroenterology units), 29% (8746) by general practitioners, 8% (2348) in genito-urinary medicine clinics, 8% (2309) in prison, and 7% (2222) in specialist drug services. Methods For details of methods see SCIEH Weekly Report vol.33 no.99/29 (at http://www.hps.scot.nhs.uk/ ewr/redirect.aspx?id=14870). In collaboration with the Scottish National Blood Transfusion Service (SNBTS), records of hepatitis C antibody positive cases diagnosed through their screening programme have been added to the national surveillance database. Acknowledgements HPS thanks collaborators and contributors to national HCV surveillance throughout Scotland for their assistance in the compilation and production of these data. HPS WEEKLY REPORT Volume 50 No.2016/30 26 July 2016 239
TABLE 1: Persons in Scotland reported to be hepatitis C antibody positive; Number and rate/100000 population 1 by NHS board and year of earliest positive specimen, to 31 December 2015. NHS board 2007 2008 2009 2010 2011 2012 2013 2014 2015 Total 2 AA Number 101 122 143 175 146 135 188 150 128 2582 Rate/100000 27.5 33.2 38.9 47.7 39.1 36.2 50.5 40.4 34.5 - BR Number 24 24 24 20 23 28 32 27 19 395 Rate/100000 21.5 21.3 21.3 17.7 20.2 24.6 28.1 23.7 16.7 - DG Number 44 53 49 53 35 38 35 30 30 892 Rate/100000 29.7 35.7 33.0 35.8 23.1 25.2 23.3 20.0 20.0 - FF Number 86 51 54 49 31 65 98 105 100 1258 Rate/100000 23.9 14.1 14.9 13.4 8.5 17.7 26.7 28.6 27.2 - FV Number 79 65 97 101 131 139 125 113 122 1850 Rate/100000 27.4 22.4 33.3 34.4 43.9 46.5 41.7 37.6 40.3 - GR Number 143 169 202 162 253 161 169 178 135 4016 Rate/100000 26.7 31.3 37.1 29.4 44.4 28.1 29.2 30.5 23.0 - GGC Number 582 577 794 809 777 585 592 657 593 14718 Rate/100000 48.8 48.3 66.2 67.2 64.0 48.1 52.0 57.5 51.6 - HG Number 33 57 77 48 58 65 80 88 68 1161 Rate/100000 10.7 18.4 24.8 15.4 18.0 20.3 24.9 27.4 21.2 - LN Number 101 129 150 145 188 166 158 150 121 2982 Rate/100000 18.0 23.0 26.7 25.8 32.8 29.0 24.2 23.0 18.5 - LO Number 204 196 186 261 306 245 232 317 307 5371 Rate/100000 25.2 24.0 22.5 31.2 36.6 29.0 27.3 36.9 35.4 - TY Number 116 117 179 226 272 224 225 204 192 3236 Rate/100000 29.4 29.5 44.8 56.1 66.3 54.4 54.6 49.3 46.3 - Scotland 3 Number 1516 1567 1960 2053 2236 1857 1941 2024 1821 38577 Rate/100000 29.5 30.3 37.7 39.3 42.2 34.9 36.4 37.8 33.9-1. Based on population at 30 June of indicated year. 2. Includes persons diagnosed prior to 2007. 3. Includes persons diagnosed in island boards (NHS Orkney, NHS Shetland and NHS Western Isles). NHS board refers to the persons NHS board of residence, or where this is not known, the NHS board of source of referral. HPS WEEKLY REPORT Volume 50 No.2016/30 26 July 2016 240
TABLE 2: Persons in Scotland reported to be hepatitis C antibody positive by NHS board and risk group, to 31 December 2015. NHS board PWID Blood Factor Other Not known Total Ayrshire & Arran 892 29 74 1587 2582 Borders 143 6 20 226 395 Dumfries & Galloway 565 5 26 296 892 Fife 684 12 38 524 1258 Forth Valley 613 15 49 1173 1850 Grampian 2319 25 142 1530 4016 Greater Glasgow & Clyde 8166 103 716 5733 14718 Highland 396 18 53 694 1161 Lanarkshire 1355 33 123 1471 2982 Lothian 2674 75 302 2320 5371 Tayside 1759 32 138 1307 3236 All Islands 41 6 10 59 116 Scotland 19607 359 1691 16920 38577 Notes: Other includes sexual contact, tattoo/body piercing, needlestick, bite, blood spillage, blood transfusion, or perinatal risk. Persons who acquired their hepatitis C infection In Scotland through blood factor will have become infected prior to the time, in the mid 1980 s, when heat treatment was introduced to prevent blood borne infection. NHS board refers to the persons NHS board of residence, or where this is not known, the NHS board of source of referral. All Islands refers to NHS Orkney, NHS Shetland and NHS Western Isles. HPS WEEKLY REPORT Volume 50 No.2016/30 26 July 2016 241
TABLE 3: Persons in Scotland reported to be hepatitis C positive and not known to be dead by NHS board, gender, and current age group, to 31 December 2015. Age range Gender <30 30-39 40-49 50-59 60+ Total AA Male 63 440 579 244 75 1401 Female 63 331 227 86 41 748 Total 127 788 819 336 119 2189 BR Male 18 79 80 55 25 257 Female 12 18 21 17 19 87 Total 31 97 103 72 44 347 DG Male 30 178 155 68 52 483 Female 25 121 64 31 20 261 Total 56 307 231 101 73 768 FF Male 28 265 232 125 40 690 Female 45 161 88 46 28 368 Total 74 426 321 172 69 1062 FV Male 73 336 318 163 69 959 Female 76 211 211 88 47 633 Total 154 552 540 251 116 1613 GR Male 100 801 852 358 176 2287 Female 100 480 353 156 88 1177 Total 200 1291 1213 517 267 3488 GGC Male 161 1709 3576 1738 465 7649 Female 162 1155 1630 758 267 3972 Total 330 2895 5236 2515 739 11715 HG Male 36 158 206 169 97 666 Female 27 92 84 77 37 317 Total 70 257 298 250 135 1010 LN Male 39 451 702 352 116 1660 Female 57 268 244 112 81 762 Total 96 720 950 464 198 2428 LO Male 135 690 907 729 353 2814 Female 147 352 371 341 206 1417 Total 284 1048 1289 1078 565 4264 TY Male 168 529 557 387 125 1766 Female 143 295 180 140 63 821 Total 311 826 739 529 191 2596 Scotland Male 856 5646 8181 4405 1605 20693 Female 861 3489 3481 1856 906 10593 Total 1742 9222 11765 6306 2537 31572 Notes: Excludes 446 cases with age not known. NHS board totals include cases with gender not known. Scotland totals include 92 cases from Orkney, Shetland, and Western Isles NHS Boards. Data for these boards cannot be featured separately due to confidentiality issues. HPS WEEKLY REPORT Volume 50 No.2016/30 26 July 2016 242
TABLE 4: Persons in Scotland reported to be hepatitis C antibody positive by gender, age group at diagnosis and year of earliest positive specimen, to 31 December 2015. Sex Age 2007 2008 2009 2010 2011 2012 2013 2014 2015 Total 1 Male <20 12 11 11 14 15 10 16 16 14 542 20-29 262 249 312 269 283 177 196 184 168 7486 30-39 385 385 500 599 556 452 512 483 449 9714 40-49 263 261 352 357 411 334 328 390 389 5244 50-59 88 100 117 132 133 123 143 165 151 1780 60+ 26 29 38 33 47 58 63 59 70 837 NK 0 5 5 5 8 21 4 5 14 249 Total 1036 1040 1335 1409 1453 1175 1262 1302 1255 25852 % 68% 66% 68% 69% 65% 63% 65% 64% 69% 67% Female <20 19 17 18 17 19 13 17 8 8 533 20-29 160 189 178 197 245 189 173 143 124 4418 30-39 152 143 223 212 250 221 254 250 202 4051 40-49 82 91 123 129 156 132 126 162 120 1873 50-59 38 42 42 50 56 57 63 67 67 791 60+ 22 26 20 24 41 33 31 42 38 570 NK 2 2 1 1 2 10 2 4 1 101 Total 475 510 605 630 769 655 666 676 560 12337 % 31% 33% 31% 31% 34% 35% 34% 33% 31% 32% Total 2 <20 31 29 29 31 35 24 34 25 23 1093 20-29 424 442 495 469 529 373 372 332 295 12010 30-39 538 532 732 817 811 681 771 736 652 13857 40-49 347 353 479 489 571 470 456 557 509 7167 50-59 126 143 159 184 189 182 206 232 219 2581 60+ 48 57 59 57 89 93 94 102 108 1421 NK 2 11 7 6 12 34 8 40 15 448 Total 1516 1567 1960 2053 2236 1857 1941 2024 1821 38577 1. Includes persons diagnosed prior to 2007. 2. Includes 388 persons with gender not known. HPS WEEKLY REPORT Volume 50 No.2016/30 26 July 2016 243
TABLE 5: Persons in Scotland reported to be hepatitis C antibody positive by source of referral and year of earliest positive specimen, to 31 December 2015. Source of referal 2007 2008 2009 2010 2011 2012 2013 2014 2015 Total 1 GP 437 409 404 368 490 397 468 454 391 8746 Hospital patients 394 400 384 382 412 361 568 541 425 10263 GUM Clinic 90 110 131 102 110 110 153 122 117 2348 Prison 71 54 92 93 99 91 93 123 153 2309 Drug Service 18 11 182 429 427 262 287 226 261 2222 Other 2 131 133 94 66 52 55 84 62 50 4310 Not Known 375 450 673 613 646 581 288 496 424 8379 Total 1516 1567 1960 2053 2236 1857 1941 2024 1821 38577 1. Includes persons diagnosed prior to 2007. 2. Other includes those diagnosed in counselling clinics, renal units, haemophilia clinics, occupational health and Scottish National Blood Transfusion Service donor screening. The last hepatitis C Surveillance Report was in Issue 15/28 The next hepatitis C Surveillance Report will be in Issue 17/TBC NHS BOARD ABBREVIATIONS AA Ayrshire & Arran BR Borders DG Dumfries & Galloway GGC Greater Glasgow & Clyde FF Fife FV Forth Valley GR Grampian HG Highland LO Lothian LN Lanarkshire OR Orkney SH Shetland TY Tayside WI Western Isles Correspondence to: The Editor, HPS Weekly Report, Health Protection Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, Scotland T 0141-300 1100 F 0141-300 1172 E NSS.HPSWReditor@nhs.net W http://www.hps.scot.nhs.uk/ewr/ Printed in the UK. HPS is a division of the NHS National Services Scotland. HPS Registered WEEKLY as a newspaper REPORT at the Post Office. Volume Health 50 Protection No.2016/30 Scotland 2014 26 July 2016 244