HPS Weekly Report

9 June 2015Volume 49 No. 2015/23ISSN 1753-4224 (Online)

CONTENTS

CURRENT NOTES

•Botulism among people who inject drugs – update 189

•Ongoing cholera outbreak in Tanzania 189

•Diphtheria detected in Spain 190

•Scotland’s Bathing Water season starts 190

•SRUC consultation on veterinary disease surveillance 191

•FSA information on Maggi noodles 191

•EFSAscientificopinion on acrylamide in food 192

•Mortality risk attributable to high and low temperatures 192

•LiDAR volcanic ash detection system 193

SURVEILLANCE REPORT

Respiratory bacteria quarterly report: Quarter one: 1 January to 31 March 2015 194

CURRENT NOTESBotulism among people who inject drugs – update

49/1301 The outbreak of botulism in people who inject drugs (PWID) (see previous Current notes 49/0801 and 49/0802 at http://www.hps.scot.nhs.uk/ewr/redirect.aspx?id=62841 and http://www.hps.scot.nhs.uk/ewr/redirect.aspx?id=62842) is still ongoing. The source of the infection is believed to be heroin contaminated with Clostridium botulinum spores. To date, 47 people in Scotland have been admitted to hospitals between 21 December 2014 and 5 June 2015,withillnesswherebotulismhasbeensuspected.Infiveofthe47 cases botulism was thought not to be the cause of the illness, these cases having now been discounted. Of the remaining 42 cases,17havebeenconfirmedmicrobiologicallytobebotulismand14havebeenconfirmedastypeB.In23cases,thereisclinicalevidence to support a diagnosis of wound botulism, these cases havingbeenclassifiedasprobablecases.Theremainingtwocasesareunderinvestigationandhavebeenclassifiedaspossiblecases.Five of the 42 cases have died, with botulism being considered a contributory factor in four.

Ongoing cholera outbreak in Tanzania

49/2302 The ongoing cholera outbreak in Tanzania started last month, primarily among Burundian refugees entering Tanzania. More than 50,000 Burundian refugees are still being sheltered in Tanzania’sNyarugusurefugeecamp.Thesuddeninfluxofpeople,combinedwithovercrowdingandpoorsanitation,intensifiedthetransmission of the ongoing cholera outbreak.

As of 2 June 2015, a total of 4578 suspected cholera cases had been reported, with fewer and fewer cases being reported on a daily basis among displaced Burundians. But worryingly, some cases are now emerging in Tanzanian communities, including more than 10 suspected cholera cases in Kigoma, the region straddling the shared border of both countries, and the main entry point for many Burundians seeking safety here. Cholera’s entry into the local population has come as a surprise as arriving Burundians had been quicklytransferredtospecialdesignatedareas.Anyfleeingrefugeeshowing cholera symptoms was taken to one of the three cholera treatment centres set up to respond to the outbreak.

To better understand the dynamics of how the disease was transmitted into the local population, a WHO surveillance team, togetherwithrepresentativesoftheKigomaRegionalOfficeoftheMinistry of Health, visited the affected Uvinza district, a two-hour drive southwards from Kigoma town. The WHO surveillance team

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revieweddata,interviewedcholerapatientsandgatheredspecificsontheoutbreakwiththehelpof the local health facilities and staff. Two clusters of around a dozen sporadic suspected cholera cases were found in isolated locations at Kibirizi Beach, Kigoma, and Uvinza District.

The team also discovered that a number of Burundians had crossed Lake Tanganyika and reached as far as Karago village. Suspected cholera cases among the local population were possibly linked to these refugees, since they came from Kigoma, one of the main hot spots of the cholera outbreak.

WHO is continuing to support the Ministry of Health in strengthening local health facilities along Lake Tanganyika’s shores by stocking them with enough medical supplies to treat any new cholera cases. If needed, WHO stands ready to continue supporting the deployment of additional health staff to these health facilities in the event of a possible, unmanageable caseload. [Source: WHORegionalOfficeforAfricaPressRelease,4June2015.http://www.afro.who.int/en/tanzania/press-materials/item/7728-ongoing-cholera-outbreak-in-tanzania-puts-local-population-at-risk.html]

Diphtheria detected in Spain

49/2303WHOhasbeeninformedofaconfirmedcaseofdiphtheriainSpain,detectedon30May2015. A young child who had not been immunized against the disease is very ill and is currently being treated with an antitoxin.

Diphtheria is a serious bacterial infection, usually spread through coughing or sneezing. Once in the respiratory system, the bacteria that cause diphtheria produce a poison (toxin) that can cause weakness, a sore throat, a fever and swollen glands in the neck. Even with treatment, the disease can lead to serious complications, including death in approximately 10% of cases.

There has not been a case of diphtheria in Spain for 28 years, primarily due to the very high vaccination coverage (over 95%) in the country.

TheWHORegionalOfficeforEuropeisincontactwiththeSpanishMinistryofHealthandthenational immunization programme and providing support, as required. [Source: WHO Regional OfficeforEuropeNewsRelease,5June2015.http://www.euro.who.int/en/health-topics/disease-prevention/vaccines-and-immunization/news/news/2015/06/diphtheria-detected-in-spain]

Scotland’s Bathing Water season starts

49/2304 As in previous years, staff from the Scottish Environment Protection Agency (SEPA) have initiated the collection of hundreds of samples from 84 designated Bathing Waters between 1 June and the end of the season on 15 September. Electronic message signs will also display live water quality predictions at 23 locations, ensuring beach visitors are informed if bathing is not advised.

However,therearesomesignificantchangesasthiswillbethefirstfullyearofthenewBathingWaterDirective.Thefinalwaterqualityassessmentswillnowbebasedontheagency’smonitoring results over four years, indicating the quality status of the normal condition for each location, rather than the previous system which relied on single day samples.

The end of season outcome report will also be very different. In previous years Scotland’s bathing waters would be designated as ‘guideline’, ‘mandatory’ or ‘fail’. This year they will be in ‘excellent’, ‘good’,‘sufficient’or‘poor’classes-basedonthefour-yeardatasetandusingtighterperformancecriteria, as standardised across the EU.

Probablythefirstchangethepublicmaynoticeduringtheseasonishowmonitoringresultsare displayed on the SEPA website. All samples are tested for the water quality indicator

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bacteria Escherichia coli(EC)andintestinalenterococci(IE),andthesefigureswillbedisplayedthroughout the season as results are analysed. Single sample results above 500 EC and 200 IE are indicative that water was probably of low quality when the sample was taken. For inland waters the low quality boundaries are higher at 1000 EC and 400 IE. [Source: SEPA News Release, 1 June 2015. http://media.sepa.org.uk/media-releases/2015/scotland-s-bathing-water-season-starts/]

SRUC consultation on veterinary disease surveillance

49/2305 Scotland’s Rural College (SRUC) has announced proposals for changes to the network of veterinary disease surveillance centres (DSCs) it runs in Scotland on behalf of the Scottish Government.

The DSCs are operated by SRUC’s SAC Consulting Veterinary Services. SRUC has begun consultationwithstakeholdersonwhatcouldbesignificantchangestoservicedeliveryattheInverness and Ayr DSCs. Meanwhile the centres at Thurso, Perth, St Boswells, Dumfries, Aberdeen and Edinburgh will continue as usual, although there are plans to relocate the Aberdeen and Edinburgh operations to new premises near their current locations.

The plans have been announced in the wake of the Kinnaird Review of Veterinary Surveillance published in 2011 (and available at http://www.gov.scot/Topics/farmingrural/Agriculture/animal-welfare/Diseases/VetSurv) and after consultation with the Strategic Management Board (SMB) subsequently appointed by Ministers. The proposed developments are intended to ensure that SRUCmaintainsanefficient,sustainableandrobustdiseasesurveillanceserviceforScotlandandthe UK

The consultation period will run for six weeks until 10 July 2015, after which time SRUC will submit areporttotheSMB.SRUCwillthenliaisewiththeScottishGovernmenttofinaliseplans,andstartemployee consultation.

Those wishing to comment on the proposals are invited to contact Brian Hosie, Head of SAC Consulting Veterinary Services at mailto:brian.hosie@sac.co.uk or on 0131 535 3139. [Source: SRUC News Release, 3 June 2015. http://www.sruc.ac.uk/news/article/1259/sruc_to_consult_on_veterinary_disease_surveillance]

FSA information on Maggi noodles

49/2306 The Food Standards Agency (FSA) has noted recent events in India involving Maggi Noodles and is currently working with Nestlé UK and the European Commission to investigate a report of higher than expected levels of lead and undeclared monosodium glutamate (MSG) in Maggi Noodles.

The batch of noodles originally tested by the authorities in India, which was found to contain lead, was not sold in the UK. Nestlé UK has informed the FSA that they currently only import masala flavour‘Maggi2MinuteNoodles’fromIndia.OtherflavourMagginoodlesarenotimportedbyNestlé UK from India, but from Nestlé factories in other countries.

Following the incident in India, the agency has taken the decision to test for levels of lead in a selection of Maggi noodles as a precaution. [Source: FSA News Release, 5 June 2015. http://www.food.gov.uk/news-updates/news/2015/14042/further-information-for-consumers-on-maggi-noodles]

The news release points to further information on this incident available from Nestlé UK on 00800 6378 5385, or in the Q&A available on its website: http://www.nestle.com/aboutus/ask-nestle/answers/maggi-noodles-india.

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EFSA scientific opinion on acrylamide in food

49/2307 Following a comprehensive review, the European Food Safety Authority (EFSA) has publisheditsscientificopiniononacrylamideinfood.ExpertsfromEFSA’sPanelonContaminantsintheFoodChain(CONTAM)havereconfirmedpreviousevaluationsthatacrylamideinfoodpotentially increases the risk of developing cancer for consumers in all age groups. This conclusion has not changed since the draft opinion was made available for an open public consultation in July 2014.

Evidence from animal studies shows that acrylamide and its metabolite glycidamide are genotoxic and carcinogenic: they damage DNA and cause cancer. Evidence from human studies that dietary exposure to acrylamide causes cancer is currently limited and inconclusive.

Since acrylamide is present in a wide range of everyday foods, this health concern applies to all consumers but children are the most exposed age group on a body weight basis. The most important food groups contributing to acrylamide exposure are fried potato products, coffee, biscuits, crackers, crisp bread and soft bread.

AlthoughnotthefocusofEFSA’sriskassessment,thescientificopinionincludesanoverviewof data and literature summarising how the choice of ingredients, the storage method and the temperatureatwhichfoodiscookedcaninfluencetheamountofacrylamideindifferentfoodtypes and therefore the level of dietary exposure.

EFSA’sscientificadvicewillinformEUandnationaldecision-makerswhenweighinguppossiblemeasures for further reducing consumer exposure to acrylamide in food. These may include, for example, advice on eating habits and home-cooking, or controls on commercial food production, though EFSA plays no direct role in deciding such measures.

EFSAhaspreparedanon-technical(or‘lay’)summaryofitsscientificopinionforeaseofunderstanding and addresses additional aspects of this work in its Frequently Asked Questions on acrylamide in food. [Source: EFSA Press Release, 4 June 2015. http://www.efsa.europa.eu/en/press/news/150604.htm]

Mortality risk attributable to high and low temperatures

49/2308 Although studies have provided estimates of premature deaths attributable to either heat or cold in selected countries, according to a recent MRC-funded study published in the Lancet (at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)62114-0/fulltext), none had so far offered a systematic assessment across the whole temperature range in populations exposed to different climates. This research therefore aimed to quantify the total mortality burden attributable to non-optimum ambient temperature, and the relative contributions from heat and cold and from moderate and extreme temperatures.

The researchers collected data for 384 locations in Australia, Brazil, Canada, China, Italy, Japan, SouthKorea,Spain,Sweden,Taiwan,Thailand,UK,andUSA.Theyfittedastandardtime-seriesPoisson model for each location, controlling for trends and day of the week. They then estimated temperature-mortality associations with a distributed lag non-linear model with 21 days of lag, and then pooled them in a multivariate meta-regression that included country indicators and temperatureaverageandrange.Attributabledeathsforheatandcoldwerecalculated,definedas temperatures above and below the optimum temperature, which corresponded to the point ofminimummortality,andformoderateandextremetemperatures,definedusingcut-offsatthe2·5th and 97·5th temperature percentiles.

The researchers analysed 74,225,200 deaths in various periods between 1985 and 2012. In total, 7·71% (95% empirical CI 7·43-7·91) of mortality was attributable to non-optimum temperature in the selected countries within the study period, with substantial differences between

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countries, ranging from 3·37% (3·06 to 3·63) in Thailand to 11·00% (9·29 to 12·47) in China. The temperature percentile of minimum mortality varied from roughly the 60th percentile in tropical areas to about the 80-90th percentile in temperate regions. More temperature-attributable deaths were caused by cold (7·29%, 7·02-7·49) than by heat (0·42%, 0·39-0·44). Extreme cold and hot temperatures were responsible for 0·86% (0·84-0·87) of total mortality.

Most of the temperature-related mortality burden was found to be attributable to the contribution of cold. The effect of days of extreme temperature was substantially less than that attributable to milder but non-optimum weather. This evidence may prove to have important implications for the planning of public health interventions to minimise the health consequences of adverse temperatures, and for predictions of future effect in climate-change scenarios.

The researchers acknowledge some limitations. First, although the investigation includes populations with markedly different characteristics and living in a wide range of climates, the findingscannotbeinterpretedasgloballyrepresentative.Theydidnotincludeentireregions,suchas Africa or the Middle East, and the assessment was mainly restricted to urban populations. Although the results suggest substantial inter-country variation in attributable risk for both heat and cold, the analysis did not characterise these differences to identify determinants of susceptibility or resilience to the effects of temperature. They suggest that these limitations might be addressed in future research by extension of the dataset to populations living in other regions, andbycollectionofstandardisedmeasuresofmeta-variablesforlocation-specificcharacteristicsto be included in the second-stage meta-regression.

LiDAR volcanic ash detection system

49/2309 A network of particle-sensing Light Detection and Ranging Systems (LiDARs) has been installed across the UK to improve detection and aid forecasting of volcanic ash in the event of futureeruptions.TheMetOfficeisinstallingtenLiDARs(includingamobileversion)specificallydesigned to sense atmospheric particles around the country as part of a £3m Department for Transport funded project.

The new network will provide observations to the UK’s Volcanic Ash Advisory Centre (VAAC), run bytheMetOffice,toprovidemoredetailedinformationonthelocationandcharacteristicsofashthatcouldimpactaircraftflightpaths.Duringthe2010volcanicashincident,anetworkofolderlaser-basedequipment,originallysetuptomeasurecloudheights,wasreconfiguredtoprovideash observations. The new LiDAR network will be more advanced and will include the capability to distinguish ash from other types of suspended aerosols.

The project is currently under way and is expected to be completed and operational by the spring of2016.[Source:MetOfficeNewsRelease,1June2015.http://www.metoffice.gov.uk/news/releases/archive/2015/lidar-volcanic-ash]

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Surveillance Report

Respiratory bacteria quarterly report: Quarter one: 1 January to 31 March 2015

Report prepared by: the vaccine preventable diseases team and the Scottish Haemophilus, Legionella, Meningococcus and Pneumococcus Reference Laboratory (SHLMPRL)

The following report describes the most recent quarterly surveillance data on meningococcal disease, invasive pneumococcal disease and Haemophilus influenzae in Scotland.

Meningococcal disease

Meningococcaldisease(MD)isanotifiablediseasecausedbyinfectionwiththebacteriumNeisseria meningitidis.MDisasignificantcauseofmorbidityandmortalityinchildrenandyoungpeople.Meningococcal Invasive Disease Augmented Surveillance (MIDAS - further details at http://www.hps.scot.nhs.uk/resp/surveillancesystems.aspx) was introduced in 1999 to monitor the impact of the meningococcal C vaccine and data from this informs the following report.

In March 2015, the Scottish Government announced that a vaccine targeted against meningococcal serogroup B was to be introduced into the childhood immunisation programme. More details are available at http://news.scotland.gov.uk/News/Meningitis-B-vaccine-to-be-introduced-in-Scotland-1807.aspx. The Joint Committee on Vaccination and Immunisation also recommended a programme of vaccination with the MenACWY vaccine for 14-18 year olds to combat the increase in the number of cases of meningococcal serogroup W disease.

Duringthefirstquarterof2015(weeks1-13),reportssubmittedtoMIDASindicateaprovisionaltotal of 21 meningococcal disease cases, which is higher than the numbers reported in the same period of 2014 (19 cases) but lower than the number of cases reported during quarter one of 2010-2013 (range 27-44 cases) (Figure 1). Meningococcal disease continues to occur more frequently in youngeragegroups:52.4%(11cases)ofcaseswereagedunderfiveyears,28.6%(sixcases)wereaged 5-24 years and 19.0% (four cases) were aged 25 years and over (Figure 2).

FIGURE 1: Cumulative number of meningococcal disease cases reported to MIDAS, 2008-2015*.

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FIGURE 2: Meningococcal disease cases reported to MIDAS by age group and quarter, 2001-2015*.

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Serogroups have been determinable for 18 cases (85.7%) reported thus far in 2015: 14 being infected with serogroup B, one with serogroup C and three with serogroup W. This compares toonecaseofgroupWinthefirstquarterof2014andatotaloffivecasesofgroupWin2014(Figure 3). Information on clinical presentation was available for all cases (21/21; 100%): 10 cases (47.6%)presentingwithmeningitis,fivecases(23.8%)withsepticaemia,fivecases(23.8%)withboth meningitis and septicaemia, and one case (4.8%) with a joint infection.

FIGURE 3: Meningococcal disease cases reported to MIDAS by serogroup, 1999-2015*.

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Thus far in 2015, one death from meningococcal disease has been reported, equating to a 4.8% case fatality ratio (CFR). The death was a serogroup B infection. This compares with one death during the same period of 2012, 2013 and 2014 (3.7%, 3.6%, and 5.3% CFR, respectively). The number of deaths reported by serogroup and case fatality ratio from 2002-2015 is shown in Figure 4.

FIGURE 4: Meningococcal deaths by serotype reported to HPS 2002-2015*.

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Invasive pneumococcal disease (IPD)

Invasive pneumococcal disease (IPD) is caused by infection of a normally sterile site (e.g. blood, cerebrospinalfluid)withthebacteriumStreptococcus 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 - further details at http://www.hps.scot.nhs.uk/resp/surveillancesystems.aspx) was introduced in 1999. Pneumococcal conjugate vaccine (PCV-7) was introduced into the routine childhood immunisation schedule in September 2006. In spring 2010, PCV-7 was replaced with PCV-13 to provide broader protection against more serotypes of S. pneumoniae. The new vaccine follows the same three-dose immunisation schedule at two and four months of age followed by a booster at 12-13 months. PCV-13 offers protection against the following 13 serotypes of S. pneumoniae; 1, 3, 4, 5, 14, 6A, 6B, 7F, 9V, 18C, 19A, 19F and 23F. To coincide with the introduction of PCV-7,enhancedsurveillancewasestablishedforpaediatriccasesagedunderfiveyears.DatafromSPIDER informs the following report.

Duringthefirstquarterof2015(weeks1-13),aprovisionaltotalof206casesofIPDwerereportedto SPIDER. This is higher than the number of cases reported during quarter one of 2010, 2011, 2012, and 2014 (range 133-185 cases); however it is the same as 2013 (Figure 5).

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FIGURE 5: Cumulative number of IPD cases reported to SPIDER 2008-2015*.

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Information on cases reported thus far in 2015 indicates that IPD continues to occur more frequently in older age groups: 53.4% (110 cases) were aged 65 years and older, 32.5% (67 cases) were aged 35 to 64 years, 5.3% (11 cases) were aged 15 to 34 years, 2.4% (5 cases) were aged5to14yearsand6.3%(13cases)wereagedunderfiveyears(eightofwhomwereagedunder two years). Figure 6 shows IPD cases reported to SPIDER by quarter and by age group from 1999 to 2015.

FIGURE 6: Cases of IPD reported to SPIDER by quarter and by age group 1999-2015*.

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Circulating serotypes of Streptococcus pneumoniaeTyping results were available for 93.7% (193 /206) of cases reported thus far in 2015. The most common serotypes reported were serotypes 3 (22 cases), 8 (21 cases), 22F (19 cases), 19A (17 cases), 1 (14 cases), and 12F (11 cases). A total of 48 cases (23.3%) were caused by serotypes includedinPCV-13,47ofwhichwereincasesagedfiveyearsorolder.Onecasewasagedlessthan 5 years and infected with serotype 7F. This case was not recorded as receiving any doses of the vaccine and therefore does not represent a vaccine failure.

IPD in children aged under five yearsOftheIPDcasesreportedthusfarin2015,13wereinchildrenunderfiveyearsofageandeligiblefor PCV vaccination. This is comparable to the number of cases reported in this age group in the same periods of 2010-2014 (range 7-14 cases) but less than the number of cases in the same period of 2005 (i.e. before the introduction of PCV) when 37 cases were reported. Serotypes detectedinchildrenagedunderfiveyearsthusfarin2015areshowninTable1.

TABLE 1: S. pneumoniae serotypes in paediatric IPD cases reported to SPIDER in 2015*.

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yrs15B 1 121 1 122F 1 1 223B 1 124F 1 133F 1 17F 1 18 1 19N 1 1Not Known 1 1 1 3Grand Total 2 3 2 1 2 3 13

*2015 data to quarter one only.

Ofthe13casesagedunderfivereportedsofarin2015,enhancedsurveillancequestionnaireshave been returned for four (30.8% - less than a third). The four cases presented with the following clinical presentations: meningitis (one case), septicaemia (one case) and pneumonia (two cases). All four cases were discharged alive and one case has recorded as having an underlying medical condition (malignancy).

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Haemophilus influenzae

Duringthefirstquarterof2015(weeks1-13),HPSreceivedreportson23casesofinvasiveHaemophilus influenzae, which is higher than the number of cases reported in the same period of 2013 and 2014 (range 11 and 21 cases) but the same as in 2012 (Figure 7). Of the cases reported thus far in 2015, 20 (87.0%) cases were in adults aged over 16 years and three (13.0%) werepaediatriccasesagedlessthanfiveyears.Thiscompareswithten(90.9%)casesinadultsaged over 16 years and one paediatric case (9.1%) in the same period of 2014. Information on the clinical presentation was available for two out of three paediatric cases. One presented with bacteraemia and the other with meningitis.

FIGURE 7: Cumulative number of H. influenzae cases reported to HPS 2008-2015*.

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NHS BOARD ABBREVIATIONSAA Ayrshire & Arran BR Borders DG Dumfries & Galloway GGC Greater Glasgow & ClydeFF 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, ScotlandT 0141-300 1100 F 0141-300 1172 E NSS.HPSWReditor@nhs.net W http://www.ewr.hps.scot.nhs.uk/Printed in the UK. HPS is a division of the NHS National Services Scotland. RegisteredasanewspaperatthePostOffice.©HealthProtectionScotland2015

Thus far in 2015, two cases were type f, 14 were non-typeable and seven isolates were not sent for typing. This compares with two type b, one type f, seven non-typeable and one isolate not sent for typing in the same period in 2014. No cases of invasive H. influenzae type b (Hib) have been reported to HPS during this period of 2015. Figure 8 shows the laboratory reports of invasive Hib disease in Scotland from 1999 to 2015.

FIGURE 8: Laboratory reports of invasive Hib disease in Scotland 1988 to 2015*.

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Of the 23 invasive cases reported thus far in 2015, all had H. influenzae isolated from blood, and none were known to have died. These numbers are comparable to quarter one 2014, whereas during the same period of 2010-2013 an average of one death was reported each year (5.6% CFR).

Acknowledgements

The authors would like to thank the microbiologists, consultants in public health medicine, clinicians, nurses and other staff who assist in the submission of samples to SHLMPRL and in the completion of surveillance forms.

The last Respiratory bacteria quarterly Surveillance Report was in Issue 15/10 The next Respiratory bacteria quarterly Surveillance Report will be in Issue 15/35