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1999 Health in Scotland

Figure 2.8 Campylobacter reports in 1999 in various Health Board areas in Scotland. Rates expressed per 100,000 population. 1998 figures in parentheses

Campylobacter

In 1999, reports to SCIEH of Campylobacter identifications declined by 7%, the first fall in six years (Figure 2.7). Although the rate of infection for the whole of Scotland fell, rates rose in four of the 12 mainland Health Board areas. The greatest rise was in Fife (24%), where the rate still remained below the national average. The greatest falls on the mainland were in Highland (25%), and in Ayrshire an Aran (16%) (Figure 2.8). Preliminary data indicate that 6 outbreaks of infection with campylobacter affecting more than one family occurred during 1999, compared with 7 in 1998.

Figure 2.7 Campylobacter reports to SCIEH

Other bacterial and bacterial toxin gastroenteritis

In 1999 reports of other bacterial pathogens and toxins has remained very low compared to reports of salmonella, campylobacter, and E.coli O157. For example, only 69 reports of Shigella sonnei were received. There were no reports of any general outbreaks of gastroenteritis caused by any bacterium other than salmonella, E.coli O157 or campylobacter, nor was there any outbreak due to intoxication due to Staph. aureus, Bacillus cereus, or Clostridium perfringens.

Viral gastroenteritis

In 1999, Rotavirus remained the most commonly reported viral cause of gastroenteritis. There were 1880 identifications, almost all in children under 5 years old, in whom infection remains the commonest cause of diarrhoea. Only 2 outbreaks of rotaviral gastroenteritis were reported in 1999, reflecting the fact that, although common, this disease is almost always sporadic.

There were 160 reports of Small Round Structured Virus in 1999 compared to 108 in 1998. SRSV remains under-reported in Scotland compared to the rest of the UK. In 1999 there were 2005 reports of SRSV in England & Wales where the population is approximately 10 times larger than that of Scotland. Reports of Astrovirus, Calicivirus and Adenovirus type 40/41 are rare.

In 1999 there were 36 general outbreaks of SRSV infection reported to SCIEH compared to 10 in 1998. This rise may well reflect improvements in ascertainment. Confirmation of the pathogen in outbreaks of viral gastroenteritis is however still uncommon. In 1999, 48 outbreaks reported were described as 'viral' but were unconfirmed, and in another 9 the pathogen was unknown.

Protozoal gastroenteritis

Reports of both cryptosporidium and giardia infection declined between 1998 and 1999. Cryptosporidium reports fell from 879 to 607, and giardia reports from 360 to 298. Only one outbreak of cryptosporidiosis was reported, and none of giardiasis.

Tuberculosis

One of the main themes of the 1998 Scottish Office Department of Health document The Control of Tuberculosis in Scotland was a commitment to improve the surveillance of tuberculosis. In the course of 1999, a Working Group addressed the development and implementation of an Enhanced Surveillance of Mycobacterial Infections (ESMI) scheme. Following extensive multidisciplinary consultation, ESMI was piloted in Greater Glasgow Health Board in November 1999 and launched in January 2000. A fundamental principle of ESMI was that it should be of practical use for all stakeholders; in addition to regular feedback, this has been achieved by designing an information gathering system which provides summary data on each case for clinicians, tuberculosis nurses, and public health physicians. The augmented national database is thereafter based on an extract of these local datasets, rather than existing in isolation. It is hoped that ESMI will provide a model for enhanced surveillance requirements for other diseases.

Tuberculosis incidence over the past 10 years in Scotland has been relatively stable (Figure 2.9), unlike some other areas of the UK and Europe. This stability offers an opportunity to consider the possibility of eliminating indigenous tuberculosis. Multi-drug resistant tuberculosis (MDRTB, defined as resistance to at least isoniazid and rifampicin) continues to be a concern, but annual numbers remain low. Three cases of MDRTB were recorded in 1999, involving infections acquired in Hong Kong, Ghana and Ecuador. One of these cases subsequently died, the first death from MDRTB in recent years. Another case was a student with several university contacts showing evidence of infection on the basis of tuberculin skin testing, but no cases of person to person spread of MDRTB disease were found.

Figure 2.9 Notifications of respiratory and non-respiratory tuberculosis, Scotland, 1980-99

The application of molecular epidemiology techniques was instrumental in the discovery and characterisation of a cluster of 38 cases of tuberculosis occurring over a 9 year period across five Health Board areas. Genetic fingerprinting carried out by the Department of Medical Microbiology at the University of Aberdeen in collaboration with the Scottish Mycobacteria Reference Laboratory identified 28 indistinguishable archived mycobacterial isolates, and in the subsequent investigation a further 10 cases with plausible epidemiological links were identified. The core of the cluster was a group of hostel-dwellers, although there were also two family groups, a healthcare worker and others with plausible epidemiological links. The cluster had been previously assigned to 19 separate incidents, and the bringing together of these cases by molecular fingerprinting offered an opportunity to revise local approaches to control.

Respiratory & Airborne Infections

Legionellosis

Thirty-five cases of legionellosis were diagnosed in Scotland in 1999 compared with 44 and 27 for 1998 and 1997 respectively. Two of the 35 cases were reported to have died but both had other significant health problems which may have contributed to death. The age and sex distribution was as expected, with males and those 55 years or older being most commonly affected. Twenty-eight cases in 1999 (80%) were associated with travel abroad. The countries implicated were Spain (10 cases), Turkey (5), France (2), Portugal (2), USA (2) and Canada, Germany, Greece, Indonesia, Italy, Mexico and Thailand (one case each) Figure 2.10 shows the countries implicated in travel-associated cases in recent years: incidence rates, however, largely reflect the volume of tourist traffic to particular countries (notably Spain and Turkey) rather than the intrinsic risk of infection.

Figure 2.10 Countries associated with travel-associated legionellosis diagnosed in Scotland, 1995-1999

Hospital-acquired (nosocomial) cases of legionellosis remain a concern, with an Ayrshire hospital being associated with three cases of legionellosis in the winter of 1998-99. An extensive programme of disinfection of the water supply was undertaken, and continuous treatment plant installed. While undeniably an expensive exercise for the hospital, the propensity for Legionella to cause large outbreaks within hospitals, hotels and in recreational settings is well known. One notable example of the last of these was the outbreak of around 233 cases with 22 deaths associated with commercial spa bath displays at an international flower show in the Netherlands in March 1999. Although no Scottish cases were identified, spa bath displays have been identified in the recent past as sources of legionellosis in the UK. Active intervention following ascertainment of even a single case is vital in minimising the consequences of such real or potential outbreaks, and there is a close collaborative surveillance and control network involving consultants in public health medicine, SCIEH, the Scottish Legionella Reference Laboratory, and the European Legionellosis Surveillance Scheme.

Influenza

The Scottish "flu spotter" system collates reports of "flu-like illness" each year, and currently involves some 90 practices in 12 Health Board areas covering around 10% of the Scottish population. It is part of a group of early warning systems operating throughout Europe which contribute data from clinical consultations and laboratory tests to the European Influenza Surveillance Scheme (EISS).

Compared with the unusually small 1997-98 influenza outbreak, the 1998-99 season was notable for a higher level of activity and an earlier peak (Figure 2.11). At its peak, the 1998-99 outbreak generated reporting rates for Scotland within the mid-range of the "normal seasonal activity" band of 50-600 consultations per 100,000 population. Extrapolation from spotter practice data allows the estimate that some 135,000 people consulted their general practitioner with flu-like illness during the season; this was substantially higher than the 1997-98 flu season estimate (108,000 consultations) but was again very much in the mid-range in comparison with historical data.

Figure 2.11 Laboratory reports of influenzavirus infections and influenza "spotter" rates, 1997-99

The great majority of laboratory diagnoses were of influenza A. Typing of virus isolates at the virus reference laboratory at Colindale showed that Scottish isolates were A/Sydney/5/97(H3N2)-like, which was a component of the 1998-99 influenza vaccine formulation. There was a late, smaller outbreak of influenza B, which again was of a vaccine-like strain. By the end of 1999 it was apparent that a very substantial influenza outbreak was in progress, with the cases once more being almost entirely due to an A/Sydney/5/97(H3N2)-like strain.

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