Document 6430192

CDR WEEKLY
Volume 10
Number 39
29 September 2000
ISSN 1350-9357
Communicable Disease Report
Outbreaks of Salmonella typhimurium DT204b infection in
England and Wales and elsewhere in Europe
One hundred and twenty-five isolates of Salmonella typhimurium definitive phage
type (DT) 204b from humans in England and Wales have been characterised by the
PHLS Laboratory of Enteric Pathogens (LEP) between 1 and 27 September 2000.
Most of the cases are from the north east, but 20% have occurred in other regions,
particularly Wessex. Forty-five per cent of cases are male and 55% female; most are
young adults. Four are known to have travelled abroad – to Germany, Greece,
Holland, and Mexico. All the isolates are resistant to ampicillin (A), chloramphenicol
(C), gentamicin (G), kanamycin (K), neomycin (Ne), streptomycin (S), spectinomycin
(Sp), sulphonamides (Su), tetracyclines (T), trimethoprim (Tm), nalidixic acid (Nx),
ciprofloxacin (CpL) [MIC: 0.125mg/L] (R-type ACGNeKSSuSpTTmNxCpL). Until
this month LEP had reported on only 43 human isolates of S. typhimurium DT204b
since 1999, none of which had this R-type.
An outbreak of multiresistant S. typhimurium infection has arisen in Iceland,
mainly in the vicinity of Reykjavik. One hundred and twenty-six cases were
identified between 9 and 26 September 2000, most of them teenagers and young
people who reported eating ‘fast food’. Both sexes have been affected – 54% male and
46% female. Epidemiological evidence suggests that imported iceberg lettuce is the
vehicle of infection. The outbreak’s peak date of onset of illness was 9 September,
and is now declining. Seventeen isolates sent from Iceland were identified by LEP
as S. typhimurium DT204b with the same R-type as the isolates from England and
Wales. Plasmid analysis has shown the isolates from England and Wales and Iceland
to be indistinguishable.
Similar multiresistant strains of S. typhimurium with the same R-type have also
been reported by Germany (11), Holland (20)1, and Scotland (12). Enhanced case
ascertainment has been initiated using the international surveillance network Enternet2 to see if other countries are also being affected by this salmonella strain.
1. van Pelt W, Widdowson M. Outbreak of S. typhimurium PT204 (Dutch phage type)
infection: the Netherlands. Eurosurveillance Weekly 2000; 4: 000928
<www.eurosurv.org/2000/000928.htm>
2. Desenclos JC, Fisher IST, Gill N in collaboration with all Enter-net participants.
Management of the investigation of international foodborne outbreaks of
gastrointestinal organisms. Eurosurveillance 1999; 4: 58-62. <www.ceses.org/
eurosurveillance/v4n5/en33-22.htm>
Active surveillance of rare and serious diseases in children
The British Paediatric Surveillance Unit’s (BPSU) 14th annual report, which was
published recently, includes reports of its studies on congenital rubella,
encephalitis in children aged 2 months to 3 years, haemolytic uraemic syndrome
(HUS), HIV infection and AIDS in childhood, invasive Haemophilus influenzae
infection, progressive intellectual and neurological deterioration, subacute
sclerosing panencephalitis (SSPE), and several non-infectious conditions 1. It also
describes a new study of neonatal group B streptococcus disease. The BPSU and
similar active surveillance systems in other countries (also described in the
report) send paediatricians reply-paid cards each month on which to report
whether they have seen any cases from a list of, say, ten or 12 conditions under
investigation. Positive replies generate enquiries by the investigators and negative
replies enable the BPSU to monitor response rates, which are very high.
continued on page 352
Correspondence to:
Editor CDR,
PHLS Communicable Disease Surveillance Centre,
61 Colindale Avenue, London NW9 5EQ
Tel: 020 8200 6868 Fax: 0208 200 7868 Email: [email protected]
Outbreaks of Salmonella
typhimurium DT204b
infection in England and
Wales and elsewhere in
Europe
349
Active surveillance of rare
and serious diseases in
children
349,52
Sexually transmitted
disease quarterly report:
anogenital warts and
anogenital herpes
simplex virus infection in
England and Wales
350-2
Correction
352
Notifications of infectious
diseases:
weeks 23/00
353-6
AIDS and HIV infeection:
monthly report
357-8
29 Sep 2000
Communicable Disease Report
Vol 10 No 39
Sexually transmitted infections quarterly report: bacterial vaginosis, Trichomonas vaginalis and
candidiasis in England and Wales
The following data are based on reports (KC60) from
genitourinary medicine (GUM) clinics to the PHLS
Communicable Disease Surveillance Centre (CDSC) and
CDSC Wales. Age group data are not collected for these
conditions on the KC60 return, which limits the
interpretation.
There are three main types of vaginal infection: bacterial
vaginosis, vulvovaginal candidiasis, and trichomoniasis.
Factors that predispose the vagina to infection include
hormonal and immunological factors, antimicrobial
therapy, the use of vaginal douches, and aspects of sexual
behaviour, such as multiple sexual partners.
Figure 1 New cases of anogenital bacterial vaginosis: 1990 to
1999
60000
Female
50000
40000
30000
Bacterial vaginosis
Bacterial vaginosis (BV) is a polymicrobial syndrome
associated with a change in the vaginal flora in which
normal hydrogen peroxide producing lactobacilli are lost
and anaerobic bacteria and mycoplasmas appear. Common
aetiological agents include Gardnerella vaginalis,
Mobiluncus sp, Bacteroides sp, and Mycoplasma hominis 1 .
BV is often associated with sexually transmitted
infections (STI) such as Chlamydia trachomatis and Neisseria
gonorrhoeae, but it also occurs in monogamous and sexually
abstinent women and consequently cannot to be considered
a STI. BV has been associated with a considerable
burden of morbidity in women of reproductive age.
Complications associated with BV include miscarriage
in the first trimester of pregnancy, preterm birth, low
birth weight, post-abortive endometritis, intra-amniotic
infection, and post partum endometritis 2. In non-pregnant
women, BV has been linked with pelvic inflammatory
disease and HIV transmission2,3.
20000
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
BV is the commonest cause of abnormal vaginal
discharge in women in their reproductive years. Diagnoses
of BV increased by 110% between 1990 and 1999, (from
27 252 to 57 294). BV accounted for 18% of female
attendances at GUM clinics in 1999 (figure 1); the highest
rates of diagnoses were in the London (605 per 100 000
population) and South East regions (172/100 000). This is
similar to the geographic variation seen for bacterial and
viral STIs. The KC60 data set is likely to underestimate the
true burden of disease in the population as up to 50% of
infections may be asymptomatic. Prevalences of between
12% and 28% have been reported from studies of antenatal
and termination of pregnancy clinics, respectively, and a
recent study in general practice reported a prevalence of
9%4-6. These studies suggest that a substantial burden of
disease exists in the population.
Figure 2a Estimated numbers of new cases (prevalence%) of Trichomonas vaginalis: geographical distribution in males aged 15
to 49 years, 1995
350
Communicable Disease Report
29 Sep 2000
Vol 10 No 39
Figure 2b Estimated numbers of new cases (prevalence %) of Trichomonas vaginalis: geographical distribution in females aged
15 to 49 years, 1995
Trichomoniasis
Trichomonas vaginalis, a flagellate protozoon, is the cause of
one of the commonest STIs worldwide, responsible for an
estimated 167 million cases of trichomoniasis each year, in
both the developed and developing world (figures 2a and
2b)7. T. vaginalis has been associated with premature
labour, low birth weight, prostatitis, and HIV transmission8.
The only prevalence study undertaken in the UK in the
past 10 years detected a prevalence of 0.1% among women
requesting cervical smears8. In other countries, studies
undertaken in settings such as STI clinics have detected
prevalences of between 6% and 46% 8.
Over the past ten years, diagnoses of trichomoniasis in
GUM clinics have remained relatively constant in both
males and females, fluctuating more in females than males
(figure 3). For females in 1999, the highest rates of diagnosis
Figure 3 New cases of Trichomonas vaginalis infection by
sex: 1990 to 1999
were seen in the London (77/100 000) and West Midland
(22/100 000) regions. The numbers of diagnoses were
lower in males than females but the highest numbers
were seen in London (14/100 000) and the West Midlands
(1/100 000). The striking difference in the number of
diagnoses seen in males and females probably reflects
the fact that most infections in males are asymptomatic5.
Proactive partner management is essential for disease
prevention and control.
Candidiasis
Candidiasis (thrush) is a fungal infection, most commonly
caused by Candida albicans and Torulopsis glabrata. Vaginal
candidiasis does not cause serious illness or death, but can
be distressing. Systemic antibiotic treatment for other
conditions is an important risk factor for disease
Figure 4 New cases of candidiasis by sex: 1990 to 1999
80000
8000
Female
Female
7000
70000
60000
6000
50000
5000
4000
40000
3000
30000
2000
20000
1000
10000
0
1990
Male
Male
1991
1992
1993
1994
1995
1996
1997
1998
1999
0
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
351
29 Sep 2000
Communicable Disease Report
development; sexual transmission plays a limited part in
the epidemiology of candidiasis. Among females in 1999,
the highest rates of diagnoses were seen in the London
(646/100 000) and Eastern (259/100 000) regions. Diagnoses
of candidiasis have risen steadily in the past 10 years. In
1999, candidiasis accounted for 25% of diagnoses in females
attending GUM clinics (figure 4). This rise could reflect
increased use of antibiotics or increased GUM clinic
attendance and screening.
4.
5.
6.
References
1. Holst E, Wathne B, Hovelius B, Mårdh P-A. Bacterial
vaginosis: microbiological and clinical findings. Eur J Clin
Microbiol 1987; 6: 536-41.
2. Eschenbach D, Hillier S, Critchlow C, Stevens C, de Rouen
T, Holmes K. Diagnosis and clinical manifestations of
bacterial vaginosis. Am J Obstet Gynecol 1988; 158: 819-28.
3. Laga M, Manoka A, Kivuvu M, Malele B, Tuliza M, Nzila
N, et al. Non-ulcerative sexually transmitted diseases as
7.
8.
Vol 10 No 39
risk factors for HIV-1 transmission in women: results from
a cohort study. AIDS 1993; 7: 95-102.
Hay P, Lamont RF, Taylor-Robinson D, Morgan D, Ison C,
Pearson J. Abnormal bacterial colonisation of the genital
tract and subsequent preterm delivery and late miscarriage.
BMJ 1994; 308: 295-8.
Blackwell AL, Thomas P, Wareham K, Emery S. Health
gains from screening for infection of the lower genital tract
in women attending for termination of pregnancy. Lancet
1993; 342: 206-10.
Lamont RF, Morgan DJ, Wilden SD, Taylor-Robinson D.
Prevalence of bacterial vaginosis in women attending one
of three general practices for routine cervical cytology. Int
J STD AIDS 2000; 11: 495-8.
Gerbase AC, Rowley JT, Heymann DHL, Berkley SFB, Piot
P. Global prevalence and incidence estimates of selected
curable STDs. Sex Transm Infect 1998; 74 (suppl 1): S12-6.
Bowden FJ, Garnett GP. Trichomonas vaginalis
epidemiology: parameterising and analysing a model of
treatment interventions. Sex Transm Infect 2000; 76: 248-56.
Active surveillance of rare and serious diseases in children (continued from page 349)
One case of congenital rubella was ascertained by the BPSU in 1999, the first since 1996, when 12 were identified1. A
total of 46 cases have been ascertained in the ten years from 1990 to 1999. The study of encephalitis in children aged 2
months to 3 years has identified human herpesviruses 6 and 7 in the cerebrospinal fluid of affected children as commonly
as herpes simplex and herpes zoster viruses and more commonly than enteroviruses and adenovirus. Reports of 310
children conformed to the case definition for HUS. Most of them were aged 3 years or under, and girls outnumbered boys,
especially between 1 and 2 years of age. Most of the cases (205) were associated with Escherichia coli O157 infection, but
campylobacter, pneumococci, and shigella were responsible for a few cases. Almost 90% of children appear to recover,
but 2.5% of those who outcome was known died. Reports of HIV infected children are increasing; most cases represent
mother to child transmission, but some children are diagnosed with AIDS before their mother’s HIV infection is
diagnosed. Fewer than 40 cases of H. influenzae type b (Hib) disease have been ascertained in each of the past four years:
the risk of Hib disease in an unvaccinated child is 23 times higher than in a vaccinated child. The study of progressive
intellectual and neurological deterioration is intended to provide surveillance of variant Creutzfeldt-Jakob disease
(vCJD), but most of the children identified in the study have other diagnoses: three of the 655 cases discussed by the Expert
Neurological Advisory Group have definite/probable vCJD. One new case of SSPE has been reported with onset in 1999.
A wild type measles virus was identified in brain tissue. None of the ten cases investigated has been related to a vaccinelike strain. Earlier reports of these studies were summarised in CDR Weekly last year2.
Group B streptococcal (GBS) disease is the commonest cause of severe neonatal infection in developed countries and
strategies for its prevention – screening women for infection, identifying risk factors, intra/post partum antibiotic
prophylaxis – continue to be debated. The estimated incidence of GBS disease in Britain (0.3/1000 live births) is much
lower than that quoted for the United States (1.4/1000). This has prompted the BPSU to set up a study, which should yield
the data needed to make robust recommendations about policies and practices.
Organisations similar to the BPSU have been set up in Australia, Canada, Germany, Latvia, Malaysia, the Netherlands,
New Zealand, Papua New Guinea, Switzerland, and Wales. Together they are conducting studies on 66 conditions. Their
activities are described briefly in the BPSU report and fostered by the International Network of Paediatric Surveillance Units.
1. Lynn R, Nicoll A, Rahi J, Verity C (editors). British Paediatric Surveillance Unit 14th annual report 1999-2000. London: Royal
College of Paediatrics and Child Health, 2000. (pdf files of the report and a limited number of paper copies are available from
BPSU, 50 Hallam Street, London W1W 6DE; tel: 020 7306 5680; fax: 020 7307 5690; email [email protected])
2. CDSC. British Paediatric Surveillance Unit: annual report for 1998/99. Commun Dis Rep CDR Wkly 1999; 9: 363,6.
Correction: Case control study links salad vegetables to national increase in multiresistant
Salmonella typhimurium DT104 (Commun Dis Rep CDR Wkly 2000; 10: 333,6 [15 September])
Sentence one of paragraph one of this article referred to the organism as ‘Salmonella typhimurium definitive phage type
(DT) 120 (R-type ACSSuSpT)’, rather than correctly, as ‘Salmonella typhimuriData are for England and Wales only, unless
otherwise stated. Weekly numbers are provisional and should not be used to indicate trends.Registered as a newspaper.um
definitive phage type (DT) 104 (R-type ACSSuSpT)’.
Data are for England and Wales only, unless otherwise stated.
Weekly numbers are provisional and should not be used to indicate trends.
Registered as a newspaper.
352
Communicable Disease Report
29 Sep 2000
Vol 10 No 39
Notifications of infectious diseases
General of the number of cases of each disease that have
been notified. The responsibility for collating the weekly
returns from proper officers, and publishing analyses
of local and national trends has been transferred to
CDSC from ONS (CDR Weekly 1997; 7: 145). An expanded
form of table 2 with data to district level is available on
a quarterly basis on the PHLS website
<www.phls.co.uk/facts/noid.htm>.
Doctors in England and Wales have a statutory duty to
notify a ‘proper officer’ of the local authority (usually
the consultant in communicable disease control) of cases
of certain infectious diseases (CDR Review 1993; 3: R1925). Notifications of infectious diseases, not all of which
are microbiologically confirmed, prompt local
investigation and action to control the diseases. Proper
officers are required each week to inform the Registrar
Table 1 Notifications of infectious diseases* in the past 6 weeks, with totals for the current year compared with
corresponding periods of the two preceding years
Cumulative totals to week 37†
Week
1998 (i)
1999 (ii)
2000 (iii)
Cumulative totals from midyear to week 37‡
32/00
33/00
34/00
35/00
36/00
37/00
Tuberculosis
Cases¶
98/99 (a) 99/00 (b) 00/01 (c)
131
134
157
108
117
113
4222
4563
4982
1288
1399
1460
Scarlet fever
Cases
21
23
15
7
22
12
2671
1651
1463
464
283
262
Malaria
Cases
15
31
29
12
60
30
801
702
747
256
329
302
Leptospirosis
Cases
1
1
–
1
1
1
21
13
21
9
1
8
Food poisoning
formally notified
ascertained
Cases
Cases
Cases
2144
1102
1042
2239
1113
1126
2193
1122
1071
1968
1039
929
2246
1116
1130
2149
1049
1100
65020
37085
27935
63539
36177
27362
60989
31311
29678
25036
14188
10848
24525
13636
10889
23902
12015
11887
Typhoid fever
presumed contracted
Cases
abroad§
GB
1
1
–
6
5
1
3
2
1
2
2
–
9
8
1
1
1
–
86
74
12
127
114
13
100
93
7
28
23
5
40
40
–
36
32
4
Paratyphoid fever
presumed contracted
Cases
abroad§
GB
–
–
–
1
1
–
2
1
1
2
2
–
4
3
1
1
1
–
82
75
7
93
89
4
57
51
6
27
23
4
30
29
1
16
13
3
Dysentery
Cases
35
28
21
36
28
40
1139
1069
1041
458
343
335
Viral hepatitis
hepatitis A
hepatitis B
hepatitis C
other and unknown
Cases
Cases
Cases
Cases
Cases
77
32
25
12
8
87
23
33
27
4
59
16
25
15
3
43
16
6
19
2
70
25
16
23
6
42
22
14
3
3
2162
1039
594
411
118
2372
1177
612
479
104
2522
967
720
710
125
665
260
203
174
28
738
346
226
148
18
770
255
235
230
50
Meningitis
meningococcal
influenzal (Haemophilus
influenzae)
other specified
unspecified
Cases
Cases
51
24
63
18
58
22
37
17
45
10
46
16
1464
824
1524
833
1918
927
343
169
327
154
616
222
Cases
Cases
Cases
–
22
5
2
38
5
–
30
6
–
14
6
1
31
3
–
23
7
18
442
180
17
471
203
30
731
230
4
116
54
6
120
47
8
318
68
Meningococcal septicaemia
(without meningitis)
Cases
29
18
12
14
17
19
1082
1396
1298
230
268
255
Acute encephalitis
infective
post-infectious
Cases
Cases
Cases
–
–
–
–
–
–
1
1
–
–
–
–
2
–
2
1
1
–
19
14
5
15
11
4
9
5
4
8
5
3
3
3
–
4
2
2
Whooping cough
Cases
21
16
14
11
23
22
1127
853
490
336
306
203
Tetanus
Cases
–
1
–
–
–
–
7
1
1
7
–
1
Measles
Cases
49
32
33
38
26
34
2924
1833
1920
667
489
483
Mumps
Cases
45
53
26
32
34
27
1150
1230
1608
304
375
436
Rubella
Cases
30
24
25
8
21
18
2620
1529
1354
558
389
332
Ophthalmia neonatorum
Cases
3
1
5
3
1
4
141
119
120
39
32
32
Cholera
Cases
1
1
1
1
–
2
39
21
22
13
7
11
Anthrax
Cases
–
1
–
–
–
–
–
1
1
–
–
1
Diphtheria
Cases
–
–
1
–
–
1
15
19
11
6
3
2
Special cases
All figures include late returns
* includes notifications from Port Health Authorities
† Cumulative totals commencing week ended (i) 2 Jan (ii) 8 Jan (iii) 7 Jan
‡ Cumulative totals from mid-year commencing week ended (a) 5 July (b) 4 July (c) 9 July
§ Includes cases of unstated origin
¶ Excluding chemoprophylaxis
353
29 Sep 2000
Communicable Disease Report
Vol 10 No 39
Table 2 Notifications of infectious diseases in week 37/00 (health regions, counties, and unitary authorities)
Area
Measles
Mumps
Rubella
Dysentery
Scarlet
Whooping
Viral
TB all
fever
cough
hepatitis
forms*
Meningitis✝
Food poisoning
notified§ ascertained# Malaria
. orthern and Yorkshire
N
Cumbria
Durham
North Yorkshire
Northumberland
Tyne and Wear ¶
West Yorkshire¶
City of Kingston upon Hull
Darlington
East Riding of Yorkshire
Hartlepool
Middlesbrough
Redcar and Cleveland
Stockton-on-Tees
York
7
–
–
–
1
1
4
–
1
–
–
–
–
–
–
6
–
–
–
–
1
5
–
–
–
–
–
–
–
–
2
–
–
–
–
–
2
–
–
–
–
–
–
–
–
6
–
–
–
1
–
4
–
–
1
–
–
–
–
–
2
–
–
–
–
–
–
1
–
–
–
1
–
–
–
5
–
–
–
–
2
1
1
–
–
–
1
–
–
–
6
–
–
–
–
1
4
–
–
–
–
1
–
–
–
4
–
–
1
–
–
3
–
–
–
–
–
–
–
–
3
–
–
–
–
–
2
–
–
1
–
–
–
–
–
109
5
18
14
1
16
39
–
1
–
4
6
–
5
–
116
9
10
16
16
24
32
–
9
–
–
–
–
–
–
1
–
–
–
–
–
1
–
–
–
–
–
–
–
–
Trent
Derbyshire
Leicestershire
Lincolnshire
Nottinghamshire
South Yorkshire ¶
Derby
Leicester
North East Lincolnshire
North Lincolnshire
Nottingham
Rutland
6
–
–
–
3
1
–
1
–
1
–
–
–
–
–
–
–
–
–
–
–
–
–
–
6
–
–
2
–
2
2
–
–
–
–
–
3
–
–
–
–
3
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
2
–
–
1
1
–
–
–
–
–
–
–
4
–
1
–
1
1
–
1
–
–
–
–
25
–
5
–
–
6
1
13
–
–
–
–
3
–
–
–
2
–
1
–
–
–
–
–
115
23
29
11
20
18
5
4
–
1
2
2
109
11
1
21
22
19
3
10
4
5
13
–
1
–
–
–
–
–
–
–
–
–
1
–
Eastern
Bedfordshire
Cambridgeshire
Essex
Hertfordshire
Norfolk
Suffolk
Luton
Peterborough
Southend-on-Sea
Thurrock
3
–
–
1
1
1
–
–
–
–
–
4
1
–
–
–
1
1
1
–
–
–
–
–
–
–
–
–
–
–
–
–
–
2
–
–
–
–
–
2
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
4
–
–
–
–
–
4
–
–
–
–
4
–
1
–
2
–
–
1
–
–
–
4
1
1
–
–
1
–
1
–
–
–
106
6
22
22
18
6
17
5
4
–
6
144
23
9
17
49
26
13
7
–
–
–
1
–
–
–
–
–
–
1
–
–
–
London
Greater London
1
1
3
3
1
1
13
13
3
3
1
1
7
7
43
43
7
7
200
200
23
23
19
19
South East
Buckinghamshire
East Sussex
Hampshire
Kent
Northamptonshire
Oxfordshire
Surrey
West Sussex
Bracknell Forest
Brighton and Hove
Isle of Wight
Medway Towns
Milton Keynes
Newbury
Portsmouth
Reading
Slough
Southampton
Windsor and Maidenhead
Wokingham
5
–
1
–
2
–
–
–
–
–
–
–
1
–
–
–
–
–
–
1
–
2
–
–
2
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
1
–
–
–
1
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
12
1
1
1
1
3
3
–
–
–
–
–
–
1
1
–
–
–
–
–
–
2
–
–
1
–
–
–
–
1
–
–
–
–
–
–
–
–
–
–
–
–
4
–
–
1
1
–
–
1
–
–
–
–
–
–
–
–
–
–
–
1
–
6
–
–
–
2
1
–
2
–
–
1
–
–
–
–
–
–
–
–
–
–
9
1
1
–
1
2
–
–
–
–
1
–
–
–
–
–
–
2
1
–
–
7
2
–
–
–
1
–
–
–
–
–
–
1
1
–
–
–
–
1
1
–
168
6
7
26
25
7
3
32
20
2
4
–
13
–
6
7
1
–
1
5
3
178
15
12
41
16
20
25
8
19
–
–
–
–
8
2
–
–
2
6
1
3
4
–
–
2
–
–
1
–
–
–
–
–
–
–
–
–
–
1
–
–
–
South West
Cornwall and Isles of Scilly
Devon
Dorset
Gloucestershire
Somerset
Wiltshire
Bath and NE Somerset
Bournemouth
Bristol
North Somerset
Plymouth
Poole
South Gloucestershire
Swindon
Torbay
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
2
–
1
–
–
1
–
–
–
–
–
–
–
–
–
–
1
–
–
–
1
–
–
–
–
–
–
–
–
–
–
–
1
–
–
–
–
–
–
–
–
–
–
–
–
1
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
3
2
–
–
–
–
–
1
–
–
–
–
–
–
–
–
4
–
1
–
–
–
–
–
3
–
–
–
–
–
–
–
5
–
–
–
2
–
–
–
–
–
–
–
3
–
–
–
5
1
1
–
–
1
–
–
–
1
1
–
–
–
–
–
76
11
22
3
7
22
–
4
–
2
1
–
3
1
–
–
142
18
26
22
6
–
–
7
2
23
14
–
6
13
–
5
2
–
–
–
–
–
–
–
1
1
–
–
–
–
–
–
354
Communicable Disease Report
29 Sep 2000
Area
Measles
Mumps
Rubella
Vol 10 No 39
Scarlet
Whooping
Viral
TB all
Dysentery
fever
cough
hepatitis
forms*
Meningitis✝
Food poisoning
notified§ ascertained# Malaria
West Midlands
Shropshire
Staffordshire
Warwickshire
West Midlands ¶
Worcestershire
Hereford
Stoke-on-Trent
Telford and Wrekin
1
–
–
–
1
–
–
–
–
5
–
1
–
4
–
–
–
–
2
–
–
–
–
2
–
–
–
–
–
–
–
–
–
–
–
–
3
–
–
1
1
1
–
–
–
2
1
–
–
1
–
–
–
–
3
–
–
–
3
–
–
–
–
18
–
–
–
17
1
–
–
–
5
–
1
–
2
1
–
–
1
110
3
29
8
49
15
–
4
2
190
19
14
19
93
14
1
17
13
2
–
1
–
–
–
–
–
1
North West
Cheshire
Cumbria
Greater Manchester ¶
Lancashire
Merseyside
Blackburn
Blackpool
Halton
Warrington
8
–
–
1
1
4
–
–
2
–
4
–
–
1
1
2
–
–
–
–
4
–
–
1
1
2
–
–
–
–
3
–
–
–
1
1
–
–
–
1
1
–
–
–
–
1
–
–
–
–
1
–
–
–
–
1
–
–
–
–
4
–
–
2
1
–
1
–
–
–
2
–
–
1
–
–
1
–
–
–
7
3
–
2
1
–
–
–
–
1
121
19
8
33
36
18
1
4
2
–
145
24
15
43
10
36
4
9
–
4
–
–
–
–
–
–
–
–
–
–
Wales
Blaenau Gwent
Bridgend
Caerphilly
Cardiff
Carmarthenshire
Ceredigion
Conwy
Denbighshire
Flintshire
Gwynedd
Isle of Anglesey
Merthyr Tydfil
Monmouthshire
Neath and Port Talbot
Newport
Pembrokeshire
Powys
Rhondda, Cynon, Taff
Swansea
Torfaen
Vale of Glamorgan
Wrexham
3
–
–
–
1
–
–
–
–
–
–
2
–
–
–
–
–
–
–
–
–
–
–
1
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
1
–
–
–
1
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
1
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
1
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
1
–
–
–
4
–
–
–
–
–
1
–
–
–
2
–
–
–
–
–
–
–
1
–
–
–
–
4
–
–
–
1
2
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
1
3
1
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
1
1
–
–
–
5
–
–
–
–
–
1
1
–
–
–
–
–
–
–
–
–
–
1
2
–
–
–
44
–
6
3
3
1
1
1
4
1
1
1
2
–
5
–
–
–
6
9
–
–
–
53
2
–
1
10
2
1
–
2
4
–
–
1
1
–
6
–
–
–
11
2
3
7
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
* Excluding prophylaxis.
† All forms.
§ Formally notified.
# Ascertained by other means.
¶ Metropolitan county.
Unitary authorities are shown in italics.
Notifications in week 37/00 of infectious diseases not shown in table 2
Acute encephalitis: one infectious case; in Nottinghamshire.
Cholera: two cases; in Northumberland and in West
Midlands.
in each of Bracknell Forest, Buckinghamshire, Cardiff,
Flintshire, Greater London, Hertfordshire, Lancashire,
Merseyside, Northamptonshire, Northumberland, Poole, Tyne
and Wear, West Midlands, and West Sussex.
Diphtheria: one case; in Greater London (known to be a nontoxigenic strain).
Ophthalmia neonatorum: four cases; three in Greater London
and one in Staffordshire.
Leptospirosis: one case; in Greater London.
Paratyphoid fever: one case; presumed to have been contracted
abroad – from Oxfordshire.
Meningitis (meningococcal): 16 cases; three in Greater
London, two in Buckinghamshire and in Swansea, and one in
each of Bedfordshire, Cambridgeshire, Cornwall and Isles of
Scilly, Lancashire, North Somerset, Somerset, West Midlands,
Windsor and Maidenhead, and Worcestershire.
Meningococcal septicaemia (without meningitis): 19 cases;
three in Greater Manchester, two in West Yorkshire, and one
Typhoid fever: one case; presumed to have been contracted
abroad – from Greater London.
No cases of acute poliomyelitis, anthrax, meningitis influenzal
(Haemophilus influenzae), plague, rabies, relapsing fever,
smallpox, tetanus, typhus, viral haemorrhagic fever, or yellow
fever were notified.
355
29 Sep 2000
Communicable Disease Report
Vol 10 No 39
Food poisoning (all)
Bolton
Ellesmere Port and Neston
Exeter
Fylde
Gedling
Greenwich
Harborough
Horsham
Ipswich
Merton
South Cambridgeshire
South Lakeland
South Ribble
South Shropshire
Stoke-on-Trent
Swansea
Telford and Wrekin
Tynedale
Watford
Wirral
Greater Manchester
Cheshire
Devon
Lancashire
Nottinghamshire
Greater London
Leicestershire
West Sussex
Suffolk
Greater London
Cambridgeshire
Cumbria
Lancashire
Shropshire
Stoke-on-Trent
Swansea
Telford and Wrekin
Northumberland
Hertfordshire
Merseyside
0.15
0.30
0.06
0.20
0.05
26.64
10.01
32.50
14.64
56.87
24
10
12
9
12
21
13
14
12
16
13
19
14
9
21
20
15
10
10
26
11.03
3.36
4.43
3.10
4.63
8.78
3.00
4.83
4.74
7.44
5.25
4.17
4.28
1.65
10.57
9.58
6.01
2.40
3.21
13.77
2.18
2.97
2.71
2.91
2.59
2.39
4.34
2.90
2.53
2.15
2.48
4.56
3.27
5.44
1.99
2.09
2.50
4.17
3.12
1.89
Food poisoning (Formally notified)
Ashford
Kent
10
Braintree
Essex
9
Carrick
Cornwall and Isles of Scilly 9
Chesterfield
Derbyshire
9
Crewe and Nantwich
Cheshire
8
East Hampshire
Hampshire
8
East Staffordshire
Staffordshire
10
Epsom and Ewell
Surrey
6
Fylde
Lancashire
9
Greenwich
Greater London
21
Harborough
Leicestershire
13
Ipswich
Suffolk
12
Medway Towns
Medway Towns
13
Merton
Greater London
16
Mid Devon
Devon
6
Mole Valley
Surrey
8
Richmond upon Thames Greater London
11
Sedgefield
Durham
7
Shepway
Kent
9
South Cambridgeshire
Cambridgeshire
13
South Lakeland
Cumbria
8
South Ribble
Lancashire
14
Sutton
Greater London
14
Three Rivers
Hertfordshire
7
Walsall
West Midlands
14
Wyre Forest
Worcestershire
8
1.95
2.54
1.71
2.05
2.30
2.23
2.04
1.40
1.51
4.29
1.46
2.31
4.87
3.63
1.34
1.61
3.56
1.84
1.97
2.56
2.04
2.09
3.54
1.70
5.33
1.97
5.12
3.55
5.25
4.40
3.47
3.59
4.91
4.28
5.96
4.90
8.89
5.19
2.67
4.40
4.48
4.97
3.09
3.80
4.57
5.07
3.93
6.70
3.96
4.11
2.63
4.07
* excluding prophylaxis
356
0.12
0.05
0.08
32.63
41.00
24.61
Measles
Halton
Isle of Anglesey
Shepway
Halton
Isle of Anglesey
Kent
2
2
2
0.09
0.04
0.06
21.44
45.00
33.29
Meningitis (all)
Bassetlaw
Nottinghamshire
2
0.09
21.10
Meningitis (meningococcal)
Southwark
Greater London
Swansea
Swansea
2
2
0.07
0.07
27.87
28.04
Mumps
Bradford
West Yorkshire
3
0.29
10.33
Rubella
Derby
North Kesteven
Rotherham
Worcester
Derby
Lincolnshire
South Yorkshire
Worcestershire
2
2
2
2
0.08
0.03
0.09
0.03
23.82
73.57
21.68
63.19
Scarlet fever
Barnet
Greater London
2
0.07
27.31
Tuberculosis*
Birmingham
City of Westminster
Hillingdon
Leicester
Newham
Poole
Tower Hamlets
Walsall
West Midlands
Greater London
Greater London
Leicester
Greater London
Poole
Greater London
West Midlands
10
5
4
13
4
3
4
4
2.22
0.43
0.54
0.65
0.50
0.30
0.38
0.57
4.50
11.72
7.46
20.13
8.02
9.89
10.60
6.97
Viral hepatitis (all)
Bournemouth
Bradford
Mid Suffolk
Tandridge
Bournemouth
West Yorkshire
Suffolk
Surrey
3
4
3
2
0.13
0.39
0.06
0.06
22.96
10.21
46.42
31.98
Whooping cough
Gwynedd
Gwynedd
2
0.05
41.85
Coun
Obse
r
num ved
ber
4
2
2
ty
Greater London
Hampshire
Greater London
ict
Malaria
Greenwich
Hart
Kingston upon Thames
Distr
Ratio
obse
r
expe ved/
cted
Expe
c
num ted
ber
4
3
2
3
3
Ratio
obse
r
expe ved/
cted
Greater London
West Yorkshire
Suffolk
Greater London
Northamptonshire
Expe
c
num ted
ber
Dysentery
Hackney
Kirklees
Mid Suffolk
Wandsworth
Wellingborough
Obse
r
num ved
ber
ty
Coun
Distr
ict
Table 3 Weekly analysis report of notifications above expected rates in week 37/00
Note: This table shows those districts from which the rates of notifications reported
this week were significantly higher than expected (P<0.005). The number of
notifications in each district is shown in the third column (observed). The number
expected if the national rate is applied to the district population is shown in the fourth
column (expected). The fifth column shows by how many times the number of
notifications exceeds the expected number (ratio observed/expected). Caution must
be exercised when interpreting this table, as listing is wholly dependent on
comparable reporting of notifiable infectious diseases from all districts of England and
Wales and on local patterns of disease.
29 Sep 2000
Communicable Disease Report
Vol 10 No 39
AIDS and HIV infection in the United Kingdom: monthly report
United Kingdom data from the PHLS AIDS and STD Centre, Scottish Centre for Infection and Environmental Health, Institute of
Child Health, London, and Oxford Haemophilia Centre (on behalf of UK Haemophilia Centre Directors' Organisation)
Soon after the first cases of AIDS were recognised in
homosexual men in the United States it was realised that
the causative agent could be transmitted with clotting
factor concentrates and transfused blood. Until that agent
was identified and laboratory tests for its presence were
developed, donor selection was the only means by which
the collection of infectious units could be limited. The
implementation of heat treatment to inactivate infectious
agents in clotting factor concentrates and the introduction
of donation screening for HIV antibody in the mid 1980s
has virtually eliminated blood and blood products as
vehicles for HIV infection in the UK.
HIV infection attributed to treatment with
clotting factor concentrates (blood products)
Clotting factor production is a batch process involving the
pooling of plasma from several thousand donations. Each
batch is used to treat many patients. This means that the
inclusion of one donation infectious for HIV could result in
the transmission of HIV to many patients through blood
product treatment. Patients with haemophilia, who form
the great majority of those exposed to HIV infection
through blood product treatment, have been monitored
throughout the epidemic by the UK Haemophilia Centre
Directors’ Organisation (UKHCDO).
Because the risks of clotting factor treatment were well
recognised when the tests for HIV infection became
available most of those infected by this route were
diagnosed during the mid 1980s (figure 1). Some, however,
have chosen not to be tested until they develop HIV related
symptoms. Retrospective testing of stored specimens after
the tests became available has established that transmission
occurred from the late 1970s onwards. No transmission of
HIV through the use of clotting factor concentrates in the
UK has been recorded since the introduction of heat
treatment was completed in 1985.
By the end of June 2000, 1351 people (1339 male and 12
female) had been reported in the UK as infected with HIV
through treatment with blood products. Of the 1351, 1328
(1321 male and 7 female) were recorded through the
UK CDO as having been treated for coagulation disorders,
usually haemophilia A or B. The other 23 reports (18 males
and 5 females) relate either to people whose coagulation
disorders that have not been treated regularly in the UK, or
to people treated with blood products to control excessive
bleeding from some other cause.
As HIV infections associated with blood product treatment
are related to the need for treatment rather than to behaviour
that may be related to age, the age distribution of these cases
differs from that of those exposed to infection by most other
routes. Thirty-five per cent were under 20 years of age when
diagnosed with HIV infection, compared with 0.5% for the
other risk categories combined. Survival with HIV infection
has been shown to be age related1, and this effect is still
apparent in the UK cohort of those who acquired HIV infection
through blood products (figure 2). Only 9% of those diagnosed
as infected at 40 years or over were recorded as still alive at
the end of June 2000, compared with 56% of those under 20
years of age when diagnosed. Twenty-nine per cent of those
reported to have died (242/844) have done so without having
had an AIDS defining condition. This is much higher than the
5% for deaths without reported AIDS in individuals HIV
infected by other routes2. Of the 181 deaths without AIDS for
which a cause of death was recorded, the majority were
attributed to liver disease (58), cardiovascular disease (41),
and malignancies (38). Before the introduction of heat
treatment of clotting factor concentrates their use was often
associated with the transmission of hepatitis and other viruses
as well as HIV.
The introduction of multi-antiretroviral therapy in the
mid 1990s has been associated with a decline in the number
of deaths in patients infected through clotting factor
treatment as it has in other groups. Of 993 patients with
HIV infection in this group who were alive at the beginning
of 1992, 356 (36%) died in the next four years. In the four
years from the beginning of 1996, 120 of 637 (19%) died.
Figure 2 Survival of patients infected with HIV through
blood product treatment by age group: UK data
to end of June 2000
Figure 1 HIV infection through blood or blood products by
year of diagnosis
357
29 Sep 2000
Communicable Disease Report
Figure 3 Transfusion associated HIV infections: age at
HIV diagnosis
Vol 10 No 39
blood transfusion. Of the 236 for whom the country of
transfusion has been recorded 73 (31%) were transfused in
the UK, 65 (27%) in Africa, 49 (21%) in Asia, 33 (14%) in
Europe, and 18 (8%) in the Americas.
As with blood product associated infections the age
distribution at diagnosis for transfusion associated HIV
infections differ from that of most infections, with a greater
proportion in the under 20 and over 50 age groups (figure
3). It is also different for males and females, with 48% of the
males and 73% of the females in the 20 to 49 age group at
diagnosis. This reflects the greater likelihood of transfusion
of women during their childbearing years.
Heterosexual spread from those infected
through blood product treatment or blood
transfusion
This is despite the fact that all the individuals infected
through this route had been infected for ten or more years
before the therapies came into use, and despite their higher
rates of deaths from causes not directly related to HIV.
HIV infection attributed to blood transfusion
Since 1983 individuals in recognised risk groups in the UK
have been instructed not to donate blood and, since suitable
tests became available in October 1985, all donations have
been screened for HIV antibody. Between the introduction
of screening and the end of June 2000 two instances have
been recorded of the passing for donation of units of blood
infectious for HIV. In both cases the blood had been
donated during the ‘window’ period between infection
and the appearance of antibody 3,4. Components from these
two units were transfused to five patients, two of whom
died soon afterwards from causes unrelated to HIV
infection. The other three patients were shown to be HIV
infected. One other person, transfused on multiple
occasions for a genetic blood disorder is considered as
possibly infected through blood transfused in the UK since
the introduction of donation screening. No positive donor
has been identified but it has not been possible to trace and
test all those involved.
The risk of HIV infection associated with transfusion of
unscreened blood is much lower than that of treatment
with blood products that have not been heat treated. As a
result many of those infected have not had their infection
recognised until they became symptomatic. Transfusion
in countries with a high prevalence of HIV may still be
associated with a considerable risk of HIV infection. For
these reasons transfusion associated infections have been
identified in greater numbers than blood product infections
since the mid 1980s (figure 1). By the end of June 2000 291
individuals were recorded as probably infected through
358
Eighty-three people (82 female and 1 male) have been reported
as infected through heterosexual contact with a person infected
through blood product treatment. Some of them may have
acquired infection from patients who did not at the time of the
transmission know of their HIV infection. Thirty heterosexual
transmissions (8 to females and 22 to males) have been
reported as associated with transfusion acquired infections.
Most of these have occurred when the transfused partner’s
infection was unrecognised.
Tissue and organ transplant
Tissue and organ transplants are much less common than
blood transfusions and very few HIV infections due to this
route of transmission have occurred. Only four have been
reported to have taken place in the UK; the donor of the
organs transplanted in three of these incidents was
transfused with unscreened HIV infected blood after a
road accident in 1984 from which he subsequently died.
The fourth transmission was reported after a skin graft.
Since laboratory tests became available and the hazards
were fully understood HIV has, in effect, ceased to be a risk
in transplantation in the UK.
1. Darby SC, Ewart DW, Giagrande PLF, Spooner RJD, Rizza
CR. The importance of age at infection with HIV-1 for
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