UK PHE Reports Imported Case Of CCHF

Photo Credit- CDC

 

# 8805

 

A recurring theme in public health is just how quickly, and easily, that `exotic’ diseases can cross vast oceans or borders, given our modern air travel industry and our penchant for international travel (see The Global Reach Of Infectious Disease). 

 

The introduction of Chikungunya to the Caribbean last fall, and the ensuing (and ongoing) epidemic, are almost certainly the result of an infected traveler coming from an endemic region of the world.

 

Similarly the reintroduction of Dengue to South Florida in 2009, and the arrival of West Nile Virus in New York in 1999, are both thought to have arrived via infected international travelers, and both (probably after multiple introductions) have managed to gain a foothold in the United States.

 

More dramatically, but with less public health impact, earlier this year we saw the first North American importation of H5N in a nurse returning from China (see H5N1 In Canada: A Matter Of Import), while a few months later we saw Minnesota: Rare Imported Case Of Lassa Fever.

 

The good news is - despite their fearsome reputations - neither of these two diseases are easily spread between humans, and no secondary infections were reported.

 

The continual importation of measles has seen us go from the near-elimination of the virus in this country in 2000 to this year’s CDC Telebriefing: Worst US Measles Outbreak In 20 Years.  And the most recent Arbovirus surveillance report lists thus far for 2014  the detection of 24 imported cases of Dengue, 52 imported cases of Chikungunya, and 20 imported cases of Malaria . . . in Florida alone.

Given this track record, no one should be terribly surprised to learn that the Public Health England reported yesterday their second known case of imported CCHF (Crimean-Congo Hemorrhagic Fever).   While CCHF can be transmitted from one human to another, it requires contact with infected blood or bodily fluids, and so it isn’t easily done.

 

 

Crimean-Congo haemorrhagic fever case identified in UK

From: Public Health England

History: Published 3 July 2014

Part of: Public health

PHE is aware of a laboratory-confirmed case of CCHF in a UK traveller who was bitten by a tick while on holiday in Bulgaria.

The patient is responding well to treatment and there is no risk to the general population.

As a precautionary measure, close contacts of the patient, including hospital staff involved in the patient’s care, will be given health advice and encouraged to contact their GP if they experience symptoms.

Although Crimean-Congo haemorrhagic fever (CCHF) can be acquired from an infected person, this would require direct contact with their blood or body fluids and the risk even for close contacts is considered very low.

This is the second laboratory-confirmed case of CCHF in the UK, following the diagnosis in 2012 of CCHF in a UK resident who had recently returned from Afghanistan.

CCHF is the commonest viral haemorrhagic fever worldwide. It is not found in the UK but is endemic in many countries in Africa, the Middle East, Asia and Eastern Europe, including Turkey and Bulgaria.

People most at risk are agricultural workers, healthcare workers and military personnel deployed to endemic areas. CCHF is most often transmitted by a tick bite but can also be spread through contact with infected patients or animals.

Dr Tim Brooks, Head of Public Health England’s (PHE’s) Rare and Imported Pathogens Laboratory (RIPL) said:

It’s extremely rare to see a case of Crimean-Congo haemorrhagic fever in the UK, and it’s important to note there is no risk to the general population. As a precaution, close contacts of the patient will be contacted and monitored, but the risk of transmission is very low and would require direct contact with bodily fluids.

 

 

The first imported case of CCHF in the UK, mentioned above, was a 38-year old man who flew into Glasgow, Scotland from the Middle East (see Update: CCHF Patient In Scotland Dies).

 

While uncommon in Western Europe, this tickborne virus is widely distributed across parts of Eastern Europe, the former Soviet Union, the Mediterranean, central Asia, southern Europe, Africa, the Middle East, and the Indian subcontinent.

Credit WHO

 

CCHF is a Nairovirus in the family Bunyaviridae, and was first described in the Crimea in 1944.  Later it was also isolated in the Congo (1969) – hence the name.

 

CCHF is normally transmitted to humans via the bite of a tick, or via contact with the blood of infected animals, although there have been reports of nosocomial (in hospital) transmission as well (see 2010  WHO report on Pakistan).

 

Today’s story isn’t so much about one rare imported case of CCHF, but about how important it is that we anticipate, and prepare for, the inevitable arrival of many more imported diseases. 

 

Which is why the CDC, along with other international public (and animal) health agencies are involved in a series of initiatives to improve global health surveillance & emergency response in this age of rising infectious diseases.  The rationale for which is explained on the CDC’s Global Health Website at:

 

Why Global Health Security Matters

Disease Threats Can Spread Faster and More Unpredictably Than Ever Before

(Excerpt)

A disease threat anywhere can mean a threat everywhere. It is defined by

• the emergence and spread of new microbes;
• globalization of travel and trade;
• rise of drug resistance; and
• potential use of laboratories to make and release—intentionally or not—dangerous microbes.

(Continue . . .)

Public Health England Launches Airport MERS Advisory Campaign

 

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With the Holy month of Ramadan less than a month away, and the Hajj coming up in early October, the number of people passing through London airports traveling to or from the Middle East is only going to increase over the next few months. As the MERS outbreak continues unabated on the Arabian peninsula, concerns run high over its potential to spread.

 

Already, at least two known MERS-CoV infected passengers have transited through Heathrow, sparking intensive contact tracing and follow up of airline passengers (see  Public Health England Press Release On MERS Case Transiting London).

In an attempt to mitigate the risks of travelers unwittingly carrying the virus on air flights, or spreading it once they arrive at their destinations,  PHE (Public Health England) has issued two new informational posters on MERS for placement at airports, and is advising up their 999 and 111 systems on how to handle possible enquires. 

The first poster (at top of post) deals with passengers headed to the Middle East.  A number of US airports posted a similar notice a couple of weeks ago (see MERS Advisories Go Up In Some U.S. Airports) – although  unlike the new PHE posters - those did not specifically warn about contact with camels.

 

The second (below) is for returning passengers.

 

 

PHE has issued a press release on this campaign, with quotes from experts on the risks of MERS infection:

 

Posters featuring advice for travellers to and from the Middle East have been distributed to UK airports and airlines.

Public Health England (PHE) is providing two posters to major UK airports to warn about the risks of Middle East respiratory syndrome coronavirus (MERS-CoV). The first poster gives general advice for travellers to the Middle East, while the second issues advice for travellers returning to the UK.

 

MERS-CoV is a new type of coronavirus, first identified in a Middle Eastern citizen in 2012. Although cases continue to be reported from the Middle East, no new cases of MERS-CoV have been detected in the UK since the cases linked to the Middle East in February 2013.

 

PHE scientists recently met to review the current risk assessment and concluded the risk to UK residents and travellers to the Middle East remains very low. Travellers, particularly people with underlying or chronic medical conditions, are advised to avoid contact with camels in the Middle East, avoid drinking raw camel milk and handling raw camel meat, and adhere to good general food and hand hygiene measures.

 

After diagnosing one of the first cases of MERS-CoV in the world at the health protection laboratories in Colindale in September 2012, PHE remains at the forefront of providing public health advice and information on MERS-CoV.

Professor Nick Phin, Head of Respiratory Diseases for PHE, said:

There is growing evidence of the possible role of camels in transmitting MERS-CoV to humans. We advise travellers, particularly those with underlying or chronic medical conditions, to avoid contact with camels in the Middle East and practice good hand and respiratory hygiene to reduce the risk of respiratory illnesses.

 

Healthcare professionals are advised to remain vigilant for severe unexplained respiratory illness occurring in anyone who has recently travelled in the Middle East, as well as any unexplained cluster of severe respiratory illness or healthcare worker with unexplained severe respiratory illness.

 

PHE will continue to provide advice on infection control, urgent diagnostic investigation and identification of contacts of suspected cases who may need to be followed up to check on their health.

Dr Brian McCloskey, Director of Global Health at PHE, said:

The recent reports of cases in travellers visiting the region and the rise in global cases we’ve seen is concerning, and we will continue to monitor the global situation and adjust our risk assessment as appropriate.

 

The risk of UK residents contracting infection in the UK remains very low. The risk to UK residents travelling to Middle Eastern countries may be slightly higher than within the UK, but is still very low.

 

PHE will maintain its current enhanced levels of surveillance and continue to liaise with WHO and ECDC colleagues to ensure we have the best available information so that our advice is accurate and up to date.

Contact: infections-pressoffice@phe.gov.uk

 

Meanwhile, NHS Pathways has issued the following guidance to those who must respond to calls from the public regarding possible infection.

 

MERS Coronavirus – General Advice for responding to calls from the public

Important information for anyone taking calls within a 999 or NHS 111 service.  Please print and circulate copies of this instruction sheet to all staff handling 111 and 999 calls

Public Health England are planning to publish posters at airports in the UK on 29th May 2014 regarding Middle East Respiratory Syndrome Coronavirus (MERS-CoV).

There have been various public health alerts relating to passengers travelling by air from MERS--CoV affected countries in the Middle East.  Public Health England is issuing general guidance for members of the public travelling to and from the Middle East, which includes advice to call NHS 111. The countries covered by this travel advice include: Syria, Iraq, Lebanon, Palestinian Territories, Israel, Jordan, Saudi Arabia, Kuwait, Bahrain, United Arab Emirates, Oman, Yemen or Saudi Arabia.

If a caller identifies themselves as having been to a known MERS-CoV affected region within the 14 days before their symptoms started:

• AND they have shortness of breath or cough with a fever
• Triage their symptoms as normal
• BUT if the final disposition is less urgent than ‘Contact a Primary Care Service within 12 hours’, you MUST upgrade the disposition to ‘Contact a Primary Care  Service within 12 hours’

It is vital that these callers are seen within this time frame They MUST tell the Primary Care Service that they have been to the Middle East when  they are seen.

Do not alter the disposition if it is more urgent than Contact Primary Care Service within 12 hours.
If an AMBULANCE has been dispatched to a caller who has declared travel to an affected area, ensure that the crew is made aware to enable them to follow the Public health guidance regarding MERS – CoV

If a caller identifies themselves as having travelled to the affected areas, but they DO NOT have any of the above symptoms:

• Triage the presenting symptoms

If a caller identifies themselves as having travelled to the affected areas, but they DO NOT have ANY symptoms and are just concerned:

• Pass the call to the NHS Pathways clinician for advice

FOR NHS Pathway’s Clinician

Reassure them that the risk of infection is low

1. Give the following advice “If you develop shortness of breath or cough with a fever in the 2 weeks after return then”:

• During normal working hours, contact a Primary Care Service within 12 hours.
• Out of normal surgery hours, call 111
  

They MUST tell the Primary Care Service that they have been to the Middle East when they are seen.

Public Health England Press Release On MERS Case Transiting London

Credit PHE

 

# 8610

 

For the second time in two weeks a MERS infected traveler has flown from Saudi Arabia to London, and then on to the United States (see CDC : 2nd Imported MERS Case Confirmed In Florida), prompting Public Health England to begin their own epidemiological investigation.

This is a press statement, release in concert the CDC’s press conference this afternoon.

 

Second case of MERS-CoV detected on flight through London

Published 12 May 2014

PHE advised of a case of MERS-CoV in a person flying from flying from Jeddah to the USA and transiting through London on 1 May 2014.

 

Public Health England (PHE) was today (12 May 2014) advised of a case of Middle East Respiratory Syndrome (MERS-CoV) in a person flying from Jeddah to the USA and transiting through London on Thursday 1 May 2014.

 

The passenger was on Saudi Airlines flight 113 from Jeddah to London, and transferred at Heathrow for onward travel to the USA, where they were later confirmed positive for MERS-CoV.

 

This is the second incident involving a passenger transiting via Heathrow, following a case of MERS-CoV in the US from a passenger who travelled from Riyadh to Chicago and transited through London on Thursday 24 April 2014. Follow up with passengers on that flight found no cases of MERS-CoV.

 

Risk of transmission is considered extremely low but as a precautionary measure, PHE is working with the airline to be able to contact UK passengers who were sitting in the vicinity of the affected passenger to provide health information.

 

Any UK based passengers travellers on flight SV113 on 1 May who have since become unwell or experienced respiratory symptoms, such as shortness of breath, are advised to seek medical advice.

 

The period between exposure and when symptoms might develop (the incubation period) for MERS-CoV is currently considered to be up to 14 days. Any illness that passengers might experience more than 14 days after the flight (i.e. starting on or after Wednesday 14 May), would not be considered to be related.

 

MERS-CoV is a new type of coronavirus, first identified in a Middle Eastern citizen in 2012. Although cases continue to be reported from the Middle East with an increase in reported cases in recent weeks, no new cases of MERS-CoV have been detected in the UK since the cases linked to the Middle East in February 2013.

Professor Nick Phin, Head of Respiratory Diseases for Public Health England said:

 

As with the incident earlier this month, the risk is very low. We will be following up with any UK passengers who were sitting in the vicinity of the passenger with MERS-CoV, as a precautionary measure.

 

Any UK based travellers who become unwell with a fever, cough or shortness of breath within 14 days of being in the Middle East, should make sure they call their doctor and tell them where they have travelled.

 

Although the source of MERS-CoV is currently unknown, there is growing evidence of the possible role of camels in transmitting MERS-CoV to humans. We advise travellers, particularly those with underlying or chronic medical conditions, to avoid contact with camels in the Middle East. All travellers should practice good hand and respiratory hygiene to reduce the risk of respiratory illness.

PHE: Transmission Of Bovine TB From Felines To Humans - UK

 

 

# 8410

 

Readers with good memories will recall that back in 2010 I wrote a blog called Badgers? We Don’t Need No Stinkin’ Badgers!, that looked at a controversial plan to cull badgers in the UK in an attempt to reduce the wildlife reservoir of Mycobacterium bovis which is the cause of tuberculosis in cattle (known as bovine TB).

 

M. bovis is also capable of infecting humans (mainly through unpasteurized milk), although famers in contact with infected cattle are at risk as well.

 

In fact, of the three type of Tuberculosis bacteria (Mycobacterium bovis, M. avium, and M. tuberculosis – the most prevalent strain in humans), M. bovis has the largest host range – being capable of infecting just about all warm-blooded vertebrates.

 

Last year, a study appeared in the CDC’s EID Journal that attempted to estimate the global burden of M. bovis infection in humans (see Zoonotic Mycobacterium bovis–induced Tuberculosis in Humans), and found that while the number was small (roughly 1 per 100,000 pop.) - it was not insignificant – particularly in areas of the world where unpasteurized milk is still widely consumed.

 

DEFRA calls Bovine TB one of the biggest challenges facing UK cattle industry, and cites the following key facts:

• 5.5 Million – total number of TB tests on cattle in England in 2011.
• 28,000 – approximate number of cattle slaughtered for TB control in England in 2012.
• 3,900 – approximate number of new TB incidents in 2012 (herds where at least one animal tests positive for bovine TB, when the herd had previously been TB free).
• 11.5% of cattle herds in England were under cattle movement restrictions at some point in 2011 (the 2012 statistics will be published once additional quality assurance checks have been completed).
• 23.6% of cattle herds in the South-West were under cattle movement restrictions at some point in 2011 (the 2012 statistics will be published once additional quality assurance checks have been completed).
• £500 million – the amount it has cost the taxpayer to control the disease in England in the last 10 years.
• £1 billion – estimated cost of TB control in England over the next decade without taking further action.
• £34,000 – the average cost of a TB breakdown on a farm, of which around £12,000 falls to the farmer.

 

While many farmers see badgers as the primary source of their bovine TB woes, and blame them for reintroducing the disease into their herds each year, conservation and animal rights groups strongly disagree, and argue that the badger is the victim here.

 

They maintain that cow-to-cow transmission is the primary route of infection, and that badgers usually get the disease from cattle – not the other way around.

 

Four years, and a pilot culling program later, and the controversy still reigns. Recent media coverage has run the gamut from TB strategy about much more than badger culling – Paterson -Farmers Guardian to MPs vote overwhelmingly to halt badger cull in England – The Guardian.

 

Adding a new dynamic to an already complex and contentious debate, yesterday Public Health England released a report on two rare human infections with M. bovis – both associated with an outbreak in cats – which likely became infected via contact (directly or indirectly) with badger setts (dens). 

 

The feline outbreak is described in a letter published in the BMJ’s Veterinary Journal called Mycobacterium bovis infection in cats by Nigel Gibbens, which prompted a full epidemiological investigation.  A brief excerpt:

 

BETWEEN December 2012 and March 2013, a veterinary practice in Newbury (west Berkshire) diagnosed nine cases of Mycobacterium bovis infection in domestic cats. In seven of those cases the diagnosis was confirmed by bacteriological culture. The nine affected cats belonged to different households and six of them resided within a 250 metre radius. The animals presented with mycobacterial disease of variable severity including anorexia, non-healing or discharging infected wounds, evidence of pneumonia and different degrees of lymphadenopathy. The latest information is that six of the cats have been euthanased or have died. The three surviving animals are undergoing treatment and are reported to be responding. At the time of writing, no new cases had been detected in local cats since March 2013.

 

PHE published the following press release on their website yesterday regarding the epidemiological investigation that turned up two probable cases where humans contracted M. bovis from cats.

 

Cases of TB in domestic cats and cat-to-human transmission: risk to public very low

Published 27 March 2014

Two people in England have developed tuberculosis after contact with a domestic cat infected with ‘Mycobacterium bovis’ (‘M. bovis’), Public Health England (PHE) and the Animal Health and Veterinary Laboratories Agency (AHVLA) have announced.’‘M. bovis’ is the bacterium that causes tuberculosis (TB) in cattle (bovine TB) and in other species.

Nine cases of ‘M. bovis’ infection in domestic cats in Berkshire and Hampshire were investigated by AHVLA and PHE during 2013. PHE offered TB screening to 39 people identified as having had contact with the infected cats as a precautionary measure. 24 contacts accepted screening. Following further investigations, a total of 2 cases of active TB and 2 cases of latent TB were identified. Latent TB means they had been exposed to TB at some point but they did not have active disease. Both cases of active TB disease have confirmed infection with ‘M. bovis’ and are responding to treatment.

There have been no further cases of TB in cats reported in Berkshire or Hampshire since March 2013. PHE has assessed the risk of transmission of ‘M. bovis’ from cats to humans as being very low.

Dr Dilys Morgan, head of gastrointestinal, emerging and zoonotic diseases department at PHE, said:

“It’s important to remember that this was a very unusual cluster of TB in domestic cats. ‘M. bovis’ is still uncommon in cats - it mainly affects livestock animals. These are the first documented cases of cat-to-human transmission, and so although PHE has assessed the risk of people catching this infection from infected cats as being very low, we are recommending that household and close contacts of cats with confirmed ‘M. bovis’ infection should be assessed and receive public health advice.”

The findings of the animal health aspects of this investigation are published in The Veterinary Record today, 27 March 2014.

 

Molecular analysis at AHVLA showed that ‘M. bovis’ isolated from the infected cats and the human cases with active TB infection were indistinguishable, which indicates transmission of the bacterium from an infected cat. In the other cases of latent TB infection, it is not possible to confirm whether these were caused by ‘M. bovis’ or the source of their exposure.

 

Transmission of ‘M. bovis’ from infected animals to humans can occur by inhaling or ingesting bacteria shed by the animal or through contamination of unprotected cuts in the skin while handling infected animals or their carcasses.

 

Professor Noel Smith, Head of the Bovine TB Genotyping Group at AHVLA, said:

“Testing of nearby herds revealed a small number of infected cattle with the same strain of ‘M. bovis’ as the cats. However, direct contact of the cats with these cattle was unlikely considering their roaming ranges. The most likely source of infection is infected wildlife, but cat-to-cat transmission cannot be ruled out.”

Cattle herds with confirmed cases of bovine TB in the area have all been placed under movement restrictions to prevent the spread of disease.

 

Local human and animal health professionals are remaining vigilant for the occurrence of any further cases of disease caused by ‘M. bovis’ in humans, cats or any other pet and livestock animal species.

(Continue . . . )

 

The PHE also released a HAIRS Risk Assessment, where they characterized the risk to public health as:

 

A Very low risk of transmission of M. bovis from cats to humans.

 

Although the risk of acquiring TB from a domestic cat in the UK is exceedingly low, and even less likely here in the United States, this report illustrates how animals – both wild and domestic – can carry and transmit zoonotic infections to humans.

 

This intersection of man and other species, and their sharing of viruses (zoonotic transmission), has increasingly been recognized as a driving factor in emerging infectious diseases, and even the creation of pandemics.

 

The age of emerging infectious diseases in humans really began in earnest about 10,000 years ago when humans began to domesticate – and live in close proximity to – other animals (see The Third Epidemiological Transition).

   

Measles probably evolved from canine distemper and/or the Rinderpest virus of cattle. Tuberculosis, which now infects 1/3rd of humanity, likely jumped from domesticated goats and cattle.  And influenza’s all seem to have an origin in waterfowl.

 

Other zoonotic nasties include Babesiosis, Borrelia (Lyme), Nipah, Hendra, Malaria, Hantavirus, Ebola, Leptospirosis, Q-Fever, bird flu . . . the list is long and growing.

 

Roughly 70% of the infectious diseases that afflict man today are believed to have begun in some other species, and new ones (think MERS-CoV, H7N9, H5N1, SFTS, etc. ) continue to show up each year. We live in an amazingly complex and interconnected world, where what happens in a live poultry market in China, a camel stable in Saudi Arabia, or a pig farm in Mexico can ultimately impact the health of people around the world.

 

So we watch these spillovers of diseases from animals to humans – no matter how rare, or small they may be – with considerable interest.