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Health in Scotland 2003

CHAPTER 3 HEALTH PROTECTION

A healthy environment

Health protection arrangements

Health Protection in Scotland: A Consultation Paper was issued by the Scottish Executive in November 2002. It is the main plank of a programme to strengthen health protection functions in Scotland, designed to ensure that effective arrangements are in place to monitor, address and respond to a widening spectrum of environmental, biological, chemical and infectious threats.

Views were sought on options for structural change, which took account of the spectrum of risks, the current health protection structures in Scotland and the establishment of the Health Protection Agency (HPA) in England and Wales.

The option most favoured by respondents envisaged the restructuring of current arrangements in Scotland, with the HPA's assumption of responsibility in Scotland for the functions at present discharged by the National Radiological Protection Board and the National Focus for Chemical Incidents and for the commissioning of an integrated UK poisons service, which would include the Scottish Poisons Information Bureau.

When the Minister for Health and Community Care announced the outcome of the consultation in October 2003, he indicated that, in line with the favoured option:

• it was the intention that radiation protection and some aspects of chemical and poison functions, as outlined above, should be brought within the remit of the Health Protection Agency, subject to the passage of the necessary legislation

• the health protection functions of NHS Boards and Local Authorities in Scotland would be unaffected

• there would be a new Scottish health protection organisation, which would form a discrete division within the Common Services Agency (CSA), bringing together a number of services which have up to now been separately discharged across the Agency.

These plans will simplify the structures for the delivery of health protection in Scotland and the rest of the UK and will provide greater coherence and clarity in responding to the new demands and challenges of the 21st century in this increasingly important field.

Setting the agenda for a healthier indoor environment in Scotland

For various reasons, including climate and the increase in indoor leisure activities, the people of Scotland, particularly the young, the old and those with pre-existing illness, spend a large proportion of their lives indoors. The indoor environment is therefore an important determinant of health and presents a challenge for health improvement in people of all ages.

High smoking rates, particularly in Scottish women, result in many children being exposed to environmental tobacco smoke in the home. The combined effects of cold climate, a significant (though diminishing) legacy of energy-inefficient housing and poor ventilation contribute to a less healthy indoor environment. Damp, cold homes promoting mould growth and increased concentrations of house dust mites can also promote allergic illnesses such as asthma and rhinitis. The latest quinquennial Scottish House Conditions Survey, which reported in November 2003, found that there is a correlation between poor self-assessed health and the existence of problems caused by dampness and condensation in the dwelling.

The fuel used for domestic heating and cooking, cleaning materials and even hobbies can influence indoor air quality. Increasing volumes of traffic on Scottish roads and other outdoor pollution sources can also impact negatively on the quality of the air inside buildings.

Indoor exposure to radon gas makes a significant contribution to the incidence of lung cancer throughout the UK. Areas with high concentrations of uranium in the local strata, such as Deeside, have been identified. During 2003, the Scottish Executive commissioned the National Radiological Protection Board to complete a survey of radon concentrations in Scottish homes. This will identify any further regions of Scotland where the proportions of houses that have radon concentrations above a defined action limit is in excess of that required for classification as a radon-affected area. Houses in these areas are subject to special provisions for protection against radon.

The indoor environment is relevant to many policy initiatives within Scotland. Improving the quality of the indoor environment in Scotland's homes, schools and recreational facilities supports the delivery of the Health Improvement Challenge and of Environmental Justice. The Health Department continues to work with NHS Health Scotland on various initiatives aimed at lessening the public health impact of exposure to tobacco smoke in indoor air. It also supports current initiatives in Europe that address the effects of the environment on the health of children, with a particular focus on respiratory illnesses such as asthma.

The Scottish Executive Health Department (SEHD) has recently commissioned the Scottish Centre for Infection and Environmental Health (SCIEH) and NHS Health Scotland jointly to examine the evidence linking the indoor environment to health in Scotland. This initiative will focus on evidence about the effects of the quality of domestic, educational and leisure environments on the health of children and will set out the policy context for further action in this important area.

Quality of Scotland's environment

In terms of its effect on public health, the quality of Scotland's environment is generally getting better. For example, changes to the patterns of industry and the development of environmental control legislation have ensured that present-day exposures of the people of Scotland to many pathogenic industrial pollutants are well below those experienced in the nation's industrial past. Scotland's air and water quality now rival the best in Europe, yet the state of the nation's health ranks with Europe's poorest. There is, therefore, a need to reassess the focus of attention on the environmental determinants of health in order to address 21st century priorities.

Aspirations for an environment that promotes and sustains human health are in keeping with those that seek sustainability and biodiversity. Therefore, it is wholly appropriate to work in partnership with environmental interests nationally and internationally, both within and outwith government, to ensure that this generation takes full responsibility for bequeathing a healthy environment to the next.

Over the past year, the Health Department has collaborated with the other UK government departments representing health and the environment in developing the UK approach to the forthcoming Ministerial Conference on Environment and Health. This will be held in Budapest in June 2004 and is the fourth in a series of quinquennial conferences organised by World Health Organization (WHO)/Europe. The central theme is 'The Future for Our Children.'

The World Health Organization defines health as 'a complete state of physical, mental and social well-being and not simply the absence of disease'. A healthy environment will not of itself deliver such a complete state for the current generation of Scots against a background of unhealthy behaviours including smoking, poor diet, lack of exercise, drug misuse and excessive consumption of alcohol. The challenge is therefore to work towards a 21st century environment that not only continues to reduce public exposure to environmental pathogens but also provides the next generation of Scots with surroundings that encourage the healthy behaviours that will allow them to achieve their full potential.

Vaccine-preventable diseases of childhood

Through immunisation, millions of children have been protected against previously feared vaccine-preventable diseases of childhood. Over 96% of children reaching their second birthday in January to September 2003 had received three doses of vaccines against diphtheria (D3), tetanus (T3), pertussis (P3), polio (Pol3), Haemophilus influenzae type b (Hib3) and Meningococcal serogroup C (MenC).

Figure 3.1: Vaccine uptake at 24 months

The uptake of measles, mumps and rubella (MMR) vaccine was lower at 86.1%, 85.8% and 86.4% for the three-quarters respectively but the figures in Scotland continue to compare favourably with those for elsewhere in the UK (Figure 3.2).

Figure 3.2: MMR vaccine uptake

Pre-school vaccine uptake rates indicate that around 95% of children continue to receive four doses of diphtheria, tetanus and polio vaccines by their sixth birthday and over 90% receive at least one dose of MMR.

There were no reports of diphtheria or poliomyelitis in Scotland in 2003, continuing to represent long-term successes in immunisation. There were two reports of clinically diagnosed tetanus in injecting drug users (IDUs) during December 2003. The cases were part of an ongoing outbreak of tetanus among IDUs in the UK that is believed to be a consequence of contamination of heroin with tetanus spores. Because the responsible organism, Clostridium tetani, is present in soil, eradication is impossible and therefore vaccination against tetanus must continue.

The number of notifications for whooping cough has decreased, as has the number of laboratory reports. An acellular booster for pre-school children was introduced into the routine immunisation schedule from January 2002.

The incidence of measles, mumps and rubella in Scotland is monitored through notifications, salivary surveillance of notified cases and other laboratory reports. There were 15 laboratory reports (provisional) for measles in 2003. Seven cases were linked to virus imported from other countries. Of the other eight, four were in one family, who travel during the year, and four were in a prison.

There were 42 laboratory reports (provisional) for mumps, across ten NHS Boards, indicating that mumps is circulating in Scotland. The mean age of 19 years highlights the potential for mumps in the teenage years and young adults who are too old to have been offered MMR vaccine as children. There has been one laboratory-confirmed case of rubella in a child, where virus was imported.

Twenty-eight laboratory reports (provisional) were received for invasive Haemophilus influenzae type b in 2003. This increase in cases was reflected throughout the UK and led to a Hib booster campaign for children aged six months to four years from June 2003. The impact of the campaign is being assessed in Scotland and across the UK.

It should be noted that the notifications in Table 3.1 do not necessarily equate to the actual number of cases of disease.

Table 3.1: Notifications and laboratory reports of vaccine-preventable diseases in Scotland in 2002 and 2003

Meningococcal disease

Invasive infections due to Neisseria meningitidis are the most common cause of bacterial meningitis in the UK and are an important cause of morbidity and mortality around the world. In 2003 enhanced surveillance of meningococcal disease, which is undertaken jointly between SCIEH and the Scottish Meningococcus and Pneumococcus Reference Laboratory, has seen evidence of the continued success of the UK-wide meningococcal group C immunisation campaign. The vaccination programme, which began in late 1999, offered vaccine protection against group C initially to all those aged under 20 and was extended to include all those aged under 25 from January 2001.

From early provisional totals for 2003, group C meningococcal disease has been virtually eliminated from all those within the target age range (with only one case in a patient under 20, who was not fully immunised) and dramatically reduced overall. Of 87 cases of meningococcal disease in which grouping was carried out, only three cases were group C. Further, it is encouraging that there were no deaths attributable to group C meningococcal disease and overall case fatality rates fell to their lowest level in 10 years (2.5% in 2003). (Figure 3.3).

Figure 3.3: Case Fatality Ratios (CFR) by serogroup 1998-2003

While B is now by far the predominant group (Figure 3.4), accounting for 87% of those cases which have been grouped, the overall burden of disease has continued to decline steadily (Figure 3.5).

Figure 3.4: Meningococcal breakdown by serogroup 1998 to 2003 (as percentage of confirmed groups)

Figure 3.5: Meningococcal disease by confirmed group status 1998 - 2003

Tuberculosis

Since 2000, data on Mycobacterium tuberculosis (TB) has been provided from the Enhanced Surveillance of Mycobacterial Infection (ESMI) scheme run by SCIEH. This supplements the information derived from the Statutory Notification of Infectious Diseases collated by ISD. The ESMI scheme provides additional information on epidemiology, including ethnicity, asylum seeker/refugee/immigrant background, microbiology, treatment and outcome information.

Differences in total numbers are explained by the effects of case de-notification (removal of cases initially notified as TB once an alternative diagnosis has been established). Summary information from 2000 to date is presented in Table 3.2. TB grows very slowly in the laboratory, hence figures for 2003 are provisional. A similar final total is expected for 2003, since the provisional total of 363 cases will increase once more clinical and laboratory information is gathered.

Table 3.2: Tuberculosis in Scotland 2000-2003

* Country of birth and risk information is provided on ESMI Form B. The denominator for each year is the number of such forms completed to date.

Scotland continues to have an unusual position within the UK: the rest of the UK and London in particular have seen an increasing number of cases of TB but in Scotland the number of cases has been fairly constant, at around 400 each year. About half of these occur in the Greater Glasgow area.

Most cases of TB in Scotland occur in people born in the UK, with 18-24% of all cases in previous years having been identified in individuals who were not born in the UK. This contrasts with the situation in England where between 70 and 80% are born outwith the UK (Source: HPA _ Respiratory Division). A small but important number are seen in the refugee/asylum seeker group. In line with the increased number of asylum seekers resident in Scotland, this number has increased over recent years but it is uncertain whether the total observed in 2003 will yet exceed that for 2002.

The most important consistent risk group recorded across the period 2000 to 2003 are people with an alcohol problem. They come predominantly from lower socio-economic groups and it is difficult to separate the relative contribution of alcohol from the often co-existing problems of malnutrition and homelessness.

Severe Acute Respiratory Syndrome (SARS)

The identification of the Severe Acute Respiratory Syndrome (SARS) in March 2003 caused by a newly emerged virus, the SARS coronavirus, led to the first global outbreak of a new illness in the new century. Due to the rapid response of the global health network, co-ordinated by the World Health Organization, the threat to the public health was contained but not before more than 8000 patients had developed the illness and 800 deaths had occurred.

No probable or confirmed cases of SARS were identified in Scotland but a number of travellers to areas of risk were investigated. SCIEH, working in co-operation with the Health Protection Agency, acted as an information and advice resource for healthcare workers and the general public, initiated and ran educational events for healthcare workers and provided operational support to NHS Boards in the investigation and management of suspected cases in returning travellers.

A national contingency plan for managing SARS was produced and reflects the UK approach. In the absence of a vaccine and the uncertainty about whether an animal reservoir exists, SARS can be thought of as controlled rather than eliminated. Contingency plans remain in force to deal with the threat of SARS, should it recur.

Influenza

The expected winter flu season occurred earlier than usual in 2003/04 (Figure 3.6) and was heralded by the identification of the H3N2 Fujiian strain in three children who died from influenza. Children and young adults were differentially affected with relative sparing of the elderly. It is uncertain what contribution was made by the success of the flu immunisation campaign, which has exceeded its target, with over 70% of patients over the age of 65 being vaccinated. Influenza rates have dropped to baseline levels, having peaked in November 2003 without having approached epidemic levels.

Figure 3.6: Fluspotter rates per 100,000

Avian flu

As this report went to press, an outbreak was being monitored of a new virulent strain of influenza, H5N1, in poultry in a number of countries in South East Asia. Several deaths have occurred in humans who may have acquired the disease from contact with live poultry. To date, human to human transmission has not been verified. Contingency plans for this eventuality are
in hand.

Gastro-intestinal infections

Escherichia coli O157

From the mid-1990s, background incidence of laboratory-confirmed infection with Escherichia coli serogroup O157 ( E. coli O157) in Scotland averaged 200 to 250 cases per year. Numbers affected rose during two large outbreaks of E. coli O157, in Lothian in 1994 and in central Scotland between late 1996 and early 1997, but have otherwise remained consistent. (Figure 3.7) Scotland continues to have higher rates of E. coli O157 infection per 100,000 population than other parts of the UK or Europe. Figures fell from 229 cases in 2002 to 148 cases in 2003, a decrease of 35%.

Figure 3.7: E. coli O157: laboratory-confirmed infections (faecal isolates) reported to SCIEH 1984 to mid-December 2003

Enhanced surveillance of E. coli O157 now provides data on secondary and asymptomatic cases, imported cases and health outcomes. Secondary spread accounts for 13% of infections and 11% of cases appear to be asymptomatic. Enhanced surveillance found that 14% of patients had travelled outwith Scotland prior to infection. Hospital admission was reported for 37% of all cases and 58% of those admitted were under 16 years old.

A total of 37 cases of non-O157 E. coli were reported in 2003, of which seven possessed verotoxin genes, compared with two of the 31 cases of non-O157 E. coli reported in 2002.

Enhanced Surveillance of Haemolytic Uraemic Syndrome and Other Thrombotic Microangiopathies (ENSHURE)

Haemolytic Uraemic Syndrome (HUS) is a triad of haemolytic anaemia, thrombocytopaenic purpura and acute renal impairment. Other presentations of HUS may involve neurological complications such as thrombotic thrombocytopaenic purpura (TTP). Various studies have shown the potential seriousness of HUS/TTP, with kidney failure being reported in up to 10% of cases and as many as 40% of those affected developing long-term renal impairment. In 2003, ENSHURE identified 30 cases of HUS/TTP, with a fatality rate of 17%, demonstrating how devastating this illness can be. The results highlight the importance of E. coli O157 in the development of HUS/TTP: two-thirds of cases were associated with E. coli O157 infection.

Salmonella Bareilly

During a national outbreak of S. Bareilly infection, 27 cases were identified in Scotland and 160 from England and Wales. The age range was from under one to 93 years. An outbreak control team consisting of representatives from SCIEH, the Scottish Salmonella Reference Laboratory, Scottish NHS Boards, Health Protection Agency and Food Standards Agency was convened to co-ordinate investigations.

In the statistical analysis, illness was independently associated with the consumption of egg and cress sandwiches, egg mayonnaise sandwiches, mayonnaise and other food from a particular chain of stores. A total of 23 out of 27 cases (85%) who reported consumption of pre-packed egg and cress sandwiches and 5 out of 13 cases (38%) who reported consumption of egg mayonnaise sandwiches had bought their sandwiches from this company.

While the study identified these items as important vehicles of infection, environmental and microbiological investigations failed to pinpoint the cause of their contamination.

Norovirus

In 2003, 212 outbreaks of norovirus (confirmed or suspected), representing 70% of all general outbreaks of infectious intestinal disease, were identified. This is an increase of 11%, compared with the number of outbreaks of norovirus reported in 2002. They have occurred predominantly in healthcare associated settings, with 43% reported from hospitals and 52% from residential institutions, principally care homes for the elderly. A further 39 outbreaks of viral aetiology and 23 of unknown aetiology were identified during 2003, some of which may also have been norovirus. During 2003, 1442 reports of laboratory isolates of norovirus were received by SCIEH, a slight decrease of 2% on the corresponding period in 2002.

Blood borne viruses

Hepatitis C Virus

In 2003, an estimated 1,600 people in Scotland were diagnosed with Hepatitis C virus (HCV) infection, bringing the total since 1991 to 17,000. It is estimated that this figure represents about one-third of the total number of people in Scotland who have been infected. Preliminary estimates indicate that approximately 20,000 may have progressed to moderate or severe hepatitis, disease stages which, according to the latest NICE and NHS QIS guidelines, should trigger the offer of Pegylated Interferon and Ribavirin therapy unless there are contraindications, such as current injecting drug use.

The majority of this group are past injecting drug users (IDUs) who are undiagnosed or lost to follow-up. The currently available antiviral regime achieves a sustained viral clearance rate of 61% and is considered cost-effective. The challenges are to identify persons eligible for treatment and to provide appropriate treatment and care resources. Unless these needs are met, the numbers of infected persons presenting with end-stage liver disease will increase considerably over the next 10 to 20 years.

As HCV infection constitutes a major public health risk, SEHD has supported several initiatives including the establishment of a National Clinical HCV Database and a managed clinical network for HCV. A programme of work has begun to design a strategy for HCV testing, to estimate the future burden of HCV disease and to evaluate the effectiveness of increasing the number of needles and syringes made available to IDUs, in order to reduce needle and syringe sharing behaviour.

Hepatitis A and B and serious bacterial infections among IDUs

In late 2003, an outbreak of Hepatitis A among IDUs in a town in Ayrshire and Arran resulted in the implementation of a Hepatitis A (and B) vaccination programme for IDUs living there. No outbreaks of Hepatitis B among IDUs were identified in 2003. IDUs continue to be at risk of serious clostridial infections which arise through the injection of contaminated drugs, usually heroin. Three cases of botulism (Glasgow) and two cases of tetanus (Aberdeen and Edinburgh) occurred in 2003.

Sexually Transmitted Infections

HIV infection

In 2003, 252 diagnoses of HIV were reported to SCIEH, the highest annual total since the mid 1980s. The distribution of cases among risk groups is similar to that observed in 2002, with men who have sex with men accounting for 36% (90) and people who are presumed to have been infected outside the UK for 29% (74) of the total (Figures 3.8 and 3.9).

HIV transmission among gay men is a continuing problem: during 2003, over 10% of the new diagnoses were in men under the age of 25. The dramatic increase in syphilis and rectal gonorrhoea, observed during 2001/02, among gay men in central Scotland has been maintained in 2003. The problem is particularly pronounced in Glasgow. More gay men are undergoing HIV testing than ever before. However, Scotland's unlinked anonymous HIV testing programme indicated that the majority of those infected who do not know their status, and who attend Genito-urinary medicine (GUM) clinics with a sexually transmitted infection (STI) problem, remain undiagnosed after their clinic visit.

The recently published consultation document Enhancing Sexual Well-being in Scotland: a Sexual Health and Relationships Strategy recommends that "HIV testing is offered to all GUM clinic attendees not known to be HIV infected who present with a new STI. This offer should be made in the context of the HIV test being presented as a routine, recommended test." If this recommendation is accepted, it is hoped that the proportion of HIV infected gay men remaining undiagnosed after attendance at GUM clinics will decrease considerably.

Figure 3.8: Reports of heterosexually acquired HIV infection in Scotland, 1989-2003

Figure 3.9: Presumed region of infection

Table 3.3: Diagnoses of HIV acquired in Africa

In 2003, two-thirds of diagnoses among heterosexuals were made in people who acquired their HIV abroad, mainly in sub-Saharan Africa, and were themselves of African origin. Table 3.3 shows the epidemiological characteristics of Africans diagnosed during 2001/03. For 2003, it is estimated that of the 1,650 HIV infected people in specialist care in Scotland, 13% (220) originated from African countries. This compares with 6% (72/1,218) in 1999 and 5% (44/992) in 1995.

Despite this increase, there is no evidence that infected people from African countries receive sub-optimal care. For both Africans and indigenous Scots, 80% access specialist care within 30 days of their diagnosis and 80% of those who have severe disease and are eligible for antiretroviral therapy are administered it. With the overall numbers of people requiring HIV clinical and social care increasing by 100 to 150 per year, it is essential that HIV services continue to be developed to meet the demand.

In April 2003, the policy of offering every pregnant woman an HIV test was implemented. This intervention is particularly timely in the context of the increasing number of infected women of childbearing age originating from Africa.

SEHD issued a consultation document on new proposals to reduce further the risk of patients acquiring infections from staff in healthcare settings. Of particular note is the recommendation that all new healthcare workers must test HIV antibody negative if they are to enter training or a post which involves exposure-prone procedures.

STIs other than HIV

Appreciable increases in the numbers of chlamydia and herpes simplex diagnoses (9% and 38% respectively) were observed in 2003. The increase in chlamydia diagnoses might have been accounted for by increased testing. Just over half of the 12,600 cases were in women under the age of 25. The rise in herpes simplex diagnoses from 940 in 2002 to 1,300 (estimated) in 2003, the first appreciable increase since the mid to late 1990s, is likely to reflect an actual increase in the incidence of this infection, and thus higher risk behaviour, among heterosexual men and women. At a regional level, a 275% increase in chlamydia diagnosis in the Borders (48 to 183) and a 100% increase in herpes simplex in Forth Valley (31 to 60 (estimated)) are worthy of note.

The incidence of gonorrhoea among females is a good marker of especially high-risk sexual behaviour among heterosexuals. The 17% decline in the numbers of diagnoses from 205 in 2002 to 170 (estimated) in 2003 is inconsistent with the above chlamydia and herpes simplex findings.

As indicated above, the incidences of syphilis (35 diagnoses (estimated)) and rectal gonorrhoea (80 diagnoses (estimated)) among gay men in 2003 were similar to those observed in 2002.

Healthcare Associated Infection (HAI) continues to be a priority patient safety issue. The prevention and control of HAI is important both in terms of the safety and well-being of patients and of the resources consumed by potentially avoidable infections. HAI includes infections acquired in hospital (apparent before and after discharge), those contracted in healthcare facilities by staff and those picked up while receiving healthcare outwith hospitals.

Last year's report detailed the launch of the Ministerial Action Plan for Preventing HAI and the establishment of the HAI Task Force which has the remit to co-ordinate implementation of the Action Plan, to monitor progress, to monitor levels of HAI and to report on progress to the Minister. Progress has been substantial in the first year of working, with interim/consultation guidance documents issued, including a Code of Practice for the Management of HAI and Hygiene and a National Cleaning Services Specification.

Work is well advanced on many other fronts, including a framework for mandatory induction training on HAI for all staff, development of risk-based methodologies for prioritising and focusing on measures to reduce the risk of HAIs, guidance on management of HAI outbreaks, including staff screening, development of a best practice statement on urinary catheterisation and national standards for infection control in adult care homes. Public involvement and effective communications are at the heart of the working philosophy for the HAI Task Force.

Reviews of compliance with national standards for control of HAI and for cleaning were published in January 2003 by NHS QIS and Audit Scotland respectively. Both reports identify significant progress in meeting standards but also identified areas where further improvements could be made. Each Trust received its own detailed evaluation, highlighting areas for further improvement.

Surveillance of Healthcare Associated Infections

National surveillance of HAI is co-ordinated by SCIEH. The Scottish Surveillance of HAI Programme (SSHAIP) Steering Group has met quarterly since December 2001. SSHAIP is developing further surveillance systems which support the HAI Action Plan and is monitoring progress in implementation. Since April 2001, quarterly reports on rates of methicillin resistant Staphylococcus aureus (MRSA) bacteraemia in Scotland have allowed Trusts to examine their own trends in relation to Scottish rates and to take appropriate steps to contain the spread of MRSA. Quarterly rates have been broadly stable over 2003, in contrast to the continuing increase in incidence of MRSA seen in many other countries.

Surveillance of surgical site infections (SSI) has been implemented in all acute Trusts in Scotland and a preliminary report was published during 2003. Although numbers are still too small for robust analysis, this early information shows infection rates which are broadly consistent with English and US data. Other HAI surveillance projects being progressed include:

• SSIs following neurosurgical procedures

• respiratory syncytial virus infection and bacteraemias in paediatric hospitals

• HAIs in intensive care units

• HAI outbreaks.

In December 2003, SEHD supported a successful national conference organised by SSHAIP on 'Confronting the Challenge of HAI'.

Resistance to antimicrobial agents such as antibiotics remains an increasing and serious problem worldwide. Resistant organisms transmitted within healthcare settings pose a particular problem. Work on implementing the SEHD Antimicrobial Resistance Strategy and Scottish Action Plan (2002) now forms part of the broad strategic plan for the HAI Task Force.

During 2003, SEHD has funded a study to develop teaching materials for the undergraduate medical curriculum. A working group on national guidance for prudent antimicrobial prescribing has been set up under the Scottish Medicines Consortium and is expected to complete its work in 2004. Surveillance of antibiotic resistance in Scotland (notably MRSA but including other organisms) is one of the responsibilities of SSHAIP.

The various forms of CJD belong to a group of diseases known as Transmissible Spongiform Encephalopathies (TSEs) which also includes Bovine Spongiform Encephalopathy (BSE) in cattle and Scrapie in sheep. There were 18 deaths in the UK from variant CJD (the human form of BSE) recorded in 2003, compared with 17 in 2002 and 21 in 2000: the cumulative total to the end of 2003 stands at 139 deaths. The indications are that the number of new vCJD cases is currently levelling off or is even in decline. While this is encouraging, too little is understood of this disease to know if the outbreak is over or if this was the first wave of cases in highly susceptible individuals.

There is well-recognised evidence of transmission of TSEs through tissue transplantation (notably corneal and dura mater transplants), the use of natural human growth hormone and via contaminated surgical instruments used in neurosurgery. New evidence suggests that there may be risks from olfactory epithelium (the smell-sensitive part of the lining of the nose), blood and other tissues not previously thought to harbour TSE agents.

Evolving knowledge of TSEs reinforces the need to continue the precautionary approach to minimising risks of transmission. The suspected case of transmission of vCJD via blood transfusion in England in 2003 was the first of its kind in the world and has reinforced the need to continue with precautionary measures such as leucodepletion (removal of white cells from donated blood) and external sourcing of plasma for the UK.

Decontamination is the combination of processes (including cleaning, disinfection and sterilisation) employed to make a re-useable item safe for both staff and patients. In recent years, the need to address risks associated with transmission of TSEs such as variant CJD, in addition to the well-recognised infection hazards posed by bacteria, viruses and fungi, has reinforced the importance of adequate decontamination.

An incident in an English neurosurgical unit in 2003, where several patients were potentially put at risk of transmission of CJD, has strongly reinforced the need to sustain rapid progress in the upgrading of Scottish decontamination facilities. This is a major programme of work which has been directed for SEHD since 2001 by the Glennie Group. Much progress has been made in meeting the planned programme for Glennie Technical Requirements and deadlines have been set for full compliance in 2004 for both acute and primary care settings.

Each month around 15,000 registered users log on to TRAVAX, the NHS database of travel health information www.travax.nhs.uk. Nearly all Scottish Health Centres are registered, Wales has become involved through the NHS Intranet service 'HOWIS' and English Primary Care Trusts are being encouraged to register collectively. The companion website for the public 'Fit for Travel' www.fitfortravel.nhs.uk receives around one million 'hits' a month and was recently named one of 50 best websites in a survey by the Daily Mail.

The quality of these websites depends upon sound surveillance of both imported illnesses and risks that may affect visitors in the host countries. This complicated and time-consuming process is helped by SCIEH having a scientist/epidemiologist dedicated to the task.

Possibly as a result of increasingly sound travel health advice, Hepatitis A and malaria in returning travellers continue to decline in incidence. Severe illnesses imported into Scotland which result in referral to hospital are monitored. International surveillance through 'geo-sentinel', an initiative developed by the International Society of Travel Medicine in collaboration with Centre for Disease Control and Prevention (Atlanta), aims to link cases of serious infection affecting international travellers and to identify early outbreaks that may be the result of terrorist attacks involving biological weapons.

The Travel Medicine Courses begun by SCIEH in collaboration with Glasgow University in 1995 are now managed within SCIEH, with the Royal College of Physicians and Surgeons of Glasgow conducting the examination and awarding the Diploma to successful candidates. From 2004, the second year Masters degree component of this course will be awarded as a Master of Philosophy (MPhil) through St Andrews University. Twenty-eight students are currently completing the first diet of the new style Diploma and 30 have been accepted for the next course, starting in March 2004.

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