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chapter 10 communicable disease and environmental health
Significant incidents in 2006
Highly Pathogenic Avian Influenza ( HPAI) - Cellardyke Harbour, Scotland
In April 2006 a dead Whooper swan found floating in Cellardyke harbour, Scotland, was submitted for routine testing as part of the ongoing UK wild bird survey. The H5N1 virus was isolated and characterised as HPAI by the national reference laboratory at Veterinary Laboratory Agency, Weybridge. The single incident generated significant media and public interest and lead to many reports of dead swans, ducks and geese, which were collected by the State Veterinary Service and tested at Veterinary Laboratory Agency, Weybridge. There were no further detections of HPAI H5N1 in wild birds or domestic poultry. Since that time the number of reports of dead wild birds has significantly declined.
Anthrax incident in the Scottish Borders
In August 2006 a 50 year old man living in a rural part of the Scottish Borders died due to infection with anthrax. This was the first fatal case of human anthrax in the U.K for over 30 years. This individual had developed a sudden severe illness, which progressed rapidly over 3 days leading to his death from septicaemia. Bacillus species identified in blood cultures taken on hospital admission were later confirmed as Bacillus anthracis by the Health Protection Agency ( HPA) Novel and Dangerous Pathogens Laboratory at Porton Down. Subsequent investigations by agencies including the US Centres for Disease Control and Prevention in Atlanta ( CDC) confirmed that inhalational anthrax was the most likely cause of death. The deceased was a craftsman wood-worker and musician known to have used animal skins obtained from road kills, including deer and badger, in making musical instruments including African-style drums. Intensive investigations were carried out at his home to try to identify a source. Investigations of home and workshop did not identify any Bacillus anthracis spores. Further investigation of African drums to which he had been exposed during drumming classes did identify contamination with Bacillus anthracis spores.
Viable spores were also identified at a number of locations where the drums had either been stored or used at classes, both in Scotland and in England. Locations in Scotland identified as being contaminated were subsequently decontaminated using gaseous Chlorine Dioxide, by a specialist contractor from the USA, previously involved in the anthrax decontamination of the US Capitol complex and other buildings contaminated in 2001. Post decontamination sampling verified that the agreed standard of "no detectable viable spores" set by a local Clearance Committee for publicly accessible locations had been attained.
Previous non-fatal cases of human anthrax infection implicated drums and goatskins from Haiti and West Coast African countries, leading the US to ban the importation of goat hides from Haiti. This case highlights risk of exposure within the UK to Bacillus anthracis from imported West African drums made using goat hides in particular.
E.coli O157
In April and May 2006 an outbreak of infection with an extremely rare strain of E.coli O157 occurred in a nursery in Fife. The strain was a sorbitol fermenting E.coli O157 with a particular genetic fingerprint or Pulse Field Gel Electrophoresis ( PFGE) pattern. Six children from the nursery were affected, and five suffered the serious complication of Haemolytic Uraemic Syndrome. The infection appears to have been passed from child to child, although how the first child became infected is unknown. Seven further cases were identified in family contacts of the nursery cases. At around the same time, seven more cases of this unusual form of E.coli O157 occurred throughout Scotland, bringing the total to 20. Health Protection Scotland also became aware that four cases of this unusual type had also occurred in England earlier in the year. The most diligent investigation by NHS Fife health protection team working with Health Protection Scotland failed to find any links between these cases or the nursery, despite the extreme rarity of this particular strain of E.coli O157. No further cases of sorbitol fermenting E.coli O157 have occurred in Scotland since the outbreak ended in July 2006.
Epidemic curve of symptomatic Q fever cases - confirmed and probable
Outbreak of Q Fever in a meat-processing plant in Bridge of Allan
At the start of July 2006, an unusual illness was reported in workers in a meat processing plant in Bridge of Allan, Scotland. The plant, which slaughters and processes up to 2,000 cattle and 10,000 sheep per week, had a workforce of 228 people with many more people visiting the site. Symptoms included fever, dry cough, muscle/joint pain and headache. In total 49 people were symptomatic, 9 of whom had more serious symptoms and were admitted to hospital with atypical pneumonia or neurological symptoms. Initial investigations confirmed Q Fever as the cause of the outbreak. An outbreak control team lead by the NHS Forth Valley health protection team was given very strong support from Health Protection Scotland ( HPS) professionals.
Subsequent work included screening of all staff working at the plant. By May 2007, 111 confirmed cases, 28 probable and 5 possible cases were identified. Q fever or "Queensland Fever" is considered to be endemic in sheep and cattle and human infection is often associated with contact with sheep or cattle. This is now recorded as the UK's largest ever outbreak of Q Fever.
New challenges
Health protection framework for pandemic influenza
HPS produced an updated version of the Health Protection Framework in December 2006 for use by health protection teams in Scotland. This document summarises the roles and responsibilities for health protection teams during the phases of the pandemic and aligns the Scottish health protection response to that of the other countries in the UK.
New strain of verocytotoxin producing E.coli O157
As mentioned earlier an outbreak of infection with a new strain of E.coli O157 occurred in 2006 centred on a nursery in Fife. The strain is more difficult to identify and potentially more serious than the verocytotoxin producing E.coli ( VTEC) usually seen in Scotland. The Scottish Health Protection Network Steering Group has asked HPS to update the existing guidance on the management of incidents of VTEC. HPS is currently convening a group of experts to complete this task by the spring of 2008.
Epidemic curve of symptomatic Q fever cases - confirmed and probable
Healthcare Associated Infection ( HAI)
Health Protection Scotland is working on a coordinated programme approach to the reduction of HAI, focusing on those Hospital Associated Infections where there is the most potential for prevention. Programmes have been developed for Staphylococcus aureus bacteraemia reduction, surgical site infection reduction and Clostridium difficile reduction. These programmes take quality improvement approaches to clinical practice in order to improve outcomes. A programme has also been developed to address the important issue of decontamination of medical and dental instruments and work to achieve the highest practicable standard for decontamination of re-usable medical devices in Scotland.
Tackling antimicrobial resistance to antibiotics is also an important challenge and joint working between HPS and the reference laboratories for Meticillin Resistant Staphylococcus aureus ( MRSA) and Clostridium difficile is progressing to enhance our understanding of the epidemiology of these organisms.
A key element of preventing the spread of healthcare associated infections is good hand hygiene. The Scottish Government's Healthcare Associated Infection Task Force provided funding to NHS Boards to employ the local Hand Hygiene Co-ordinators who are working to improve hand hygiene practice and compliance amongst healthcare workers, patients and visitors. This campaign will continue until at least March 2008. The important messages on hand hygiene have also been conveyed to the general public through successful TV and media advertising campaigns during January 2007. These will be repeated in early 2008.
The Deputy First Minister and Cabinet Secretary for Health and Wellbeing also launched good hand hygiene packs for school children in September 2007, as part of a campaign to instill a culture of good hand hygiene in young children that should last through their lives.
"A key element of preventing the spread of healthcare associated infections is good hand hygiene."
Hepatitis C ( HCV)
Following an extensive public consultation in 2005, the Health Minister and Chief Medical Officer launched Scotland's Action Plan for Hepatitis C in September 2006. Its aims are:
(i) to prevent the spread of HCV, particularly among intravenous drugs users
(ii) to diagnose HCV infected persons, particularly those who would most benefit from treatment
(iii) to ensure that those infected receive optimal treatment care and support.
The Plan is in two phases:
Phase 1 during September 2006 - August 2008 comprises 41 actions spread across the three areas of prevention, testing, treatment, care, support and education, training, awareness-raising. The Scottish Executive Health Department ( SEHD) provided an additional £4 million to NHS Boards to support the implementation of local action during Phase 1. One key action for NHS Boards is preparing costed proposals for developing Phase 2 services within the three above areas.
The Action Plan is being co-ordinated by HPS and a Scottish Action Plan Co-ordinating Group, comprising representatives of key stakeholder groups, is overseeing the implementation.
Organisational developments in health protection
Establishment of a Health Protection Advisory Group for Scotland
A Health Protection Advisory Group ( HPAG) was established in August 2005 to advise the Chief Medical Officer and NHS National Services Scotland (the parent body of HPS) on health protection priorities and on the effectiveness and efficiency of the health protection function across Scotland. It also supports the continued corporate development of Health Protection Scotland. The group has a very senior multidisciplinary multi-agency membership. This includes representatives of NHS Boards, Local Authorities, Health Protection Scotland and other national organisations with an interest in health protection and relevant professional and staff bodies. It is chaired by Professor James McEwen, former Henry Mechan Chair of Public Health, Glasgow University and former President of the UK Faculty of Public Health.
International developments in health protection
New European Centre for health protection
In 2005, the European Community established the European Centre for Disease Prevention and Control ( ECDC), based in Stockholm, to co-ordinate member states' public health agencies, principally on health protection issues. Scotland's lead health protection organisation, Health Protection Scotland, is working in partnership with the Health Protection Agency ( HPA) for England, Wales and Northern Ireland to ensure effective working within this new European approach.
New international health regulations established
Communicable diseases do not recognise any country's boundaries. Following the outbreak of SARS which resulted in 810 deaths in 29 countries, and increasing concern about pandemic influenza, the World Health Organisation ( WHO) acted to strengthen international co-operation to combat the global spread of new and emerging infections. These International Health Regulations ( IHR 2005) put in place a framework to allow this cooperation to take place. These regulations aim to prevent the international spread of disease while also seeking to limit the disruption of international traffic and trade. They require countries to report all events that could result in public health emergencies of international concern. They are a welcome development in the drive to protect public health of the people of Scotland.
"Communicable diseases do not recognise any country's boundaries."
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