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Health Protection: Infectious Diseases
Executive Summary
Control of infectious diseases is particularly important, as they have the
possibility of affecting large numbers of people and can make then very ill. In
England, infectious diseases account for £1 in every £10 spent in the NHS.
Infectious diseases are also a major cause of days lost to the workforce.
In the three year period 2007-2009, there were 90 deaths from infectious or
parasitic diseases in North Somerset. The North Somerset mortality rate is lower
than the England average but not significantly different. The mortality rate has
fluctuated over the last 17 years. The number of deaths peaked in 2006 but has
since fallen. 26% of these deaths occur in those aged under 75. With the
exception of food poisoning, the number of notifiable diseases is low, although
there were peaks of infection in 2009 for measles and in 2005 for mumps.
Groups at high risk of infection include pregnant women; young children; over
65’s; those with pre-existing medical conditions; homeless; and substance
misusers. Those in nurseries, residential and nursing homes are at increased risk
of gastro-intestinal and other infectious diseases.
Food Poisoning
The most common notifiable disease in North Somerset is food poisoning, with
423 reported cases in 2009. Many cases of food poisoning are unreported. In
2009, the rate of food poisoning in North Somerset (202.2) was substantially
higher than the national (134.2). This may reflect a higher level of reporting and
demography. North Somerset Council’s Food and Safety Team investigates
complaints of food and water borne infection and provides guidance to caterers.
In 2010, 93% of establishments were broadly compliant with food hygiene
standards locally compared to 92% nationally.
Tuberculosis
Although the rate of new cases of tuberculosis (TB) in North Somerset is low (5
per 100,000 compared to 15.4 nationally), it has been increasing broadly in line
with the South West rates over the last 9 years. The PCT, Weston Area Health
Trust and the local Health Protection Unit work jointly to ensure monitoring,
control and treatment of TB in North Somerset. There is also provision to provide
the BCG vaccination to babies at increased risk.
Health Care Associated Infections
Health Care Associated Infections (HCAI) are infections resulting from medical
care or treatment in hospital (in- or out-patient), nursing homes, or even the
patient's own home. Increased focus and vigilance have resulted in rates of
Methicillin-resistant Staphylococcus aureus (MRSA) decreasing nationally and
locally. Weston Areas Health Trust has seen a steady decline of cases since
2004. Between April 09 and March 10, there were 9 cases of MRSA and 95 of
Clostridium Difficile in North Somerset patients attending any hospital. Local
rates for PCT patients attending any hospital were similar to national rates.
Blood Bourne Viruses.
There has been a year on year increase in the number of Hepatitis C cases, but
this may be due to improved laboratory reporting. The North Somerset Locally
Enhanced Service for drug misusers specifies testing for blood borne viruses
including HIV, Hepatitis A, B and C.
Flu
Immunisation is highly effective in preventing illness and hospital admissions
from flu. Vaccination is available to the over 65’s and other high risk groups. In
2010/11 vaccination uptake in the over 65’s was 75.4% and 49.6% in the under
65’s at risk.
In 2009/10, uptake locally was higher (75.5%) than the national average (72.4%)
for the over 65’s and slightly lower (50.2%) for the under 65’s at risk (51.6%
nationally). In 2009/10 50.2% of carers had the vaccine, above the national
average of 42.3%. In the at risk disease groups, uptake was highest in those with
diabetes and lowest in those with degenerative/neurological disease. There was
a particularly low rate for those with chronic liver disease (37.7%). Uptake in
pregnant women in 2010/11 was 48.3% compared with 37.7% nationally. There
was a wide range of uptake by practice.
Recommendations for consideration
1. Food Safety: Focus on businesses that are non-compliant with food hygiene;
continue provision of level 2 food handling training; and provide targeted
events in response to new legislation.
2. Tuberculosis: Ensure local service specification for treatment and
management of TB conforms to recent NICE guidance.
3. Health Care Associated Infections: Maintain vigilance in infection control in
health care establishments; increase control awareness and training in the
community.
4. Blood Bourne Viruses: Improve surveillance of hepatitis B and C,
particularly screening of pregnant women and monitoring of vaccination
programmes for infants; CSDAT to look at surveillance of hepatitis with the
drug and alcohol service.
5. Flu: Working with primary care to understand how vaccines are being
delivered to different groups and reduce variations in uptake; improve
communication with the public about flu vaccination.
6. Surveillance: Improve the timeliness and accuracy of infectious disease
surveillance information
Authors: Rosanne Sodzi, Public Health Specialist, North Somerset PCT
(secondment) and Chris Gwenlan, Food Safety, North Somerset Council:
Date: September 2011
Why is it important?
Health protection covers a wide range of “threats” to our health. These include
many diverse areas such as infectious diseases, “superbugs”, flooding, radiation,
poisons and food safety. It is important that the health, safety and protection of
the population from all external threats to health is rigorously maintained.
Control of infectious diseases are particularly important, as they not only have
the possibility of affecting large numbers of people, but often make people who
contract them, very ill. In England, for example, infectious diseases account for
£1 of every £10 spent on the NHS and are a major cause of days lost to the
workforce.(source : HPA). Despite improvement in the general standards of
living, broadened scope of vaccination programmes and refined used of
antibiotics and other therapeutics, infectious diseases remain a major health
threat.
Mortality from infectious and parasitic disease
Infectious diseases account for significant numbers of deaths, and rates vary
over time.
The data in table 1 shows mortality rates in North Somerset, and
compares them with the surrounding areas and regional and national averages.
Table 1: Mortality from infectious disease and parasitic disease in all ages:
2007-09 (pooled)
Area
No
North Somerset
Bristol
South Gloucestershire
BANES
South West Region
ENGLAND
90
202
88
71
1947
18,863
Directly
Standardise
Rate per 100,000
7.03
11.56
6.96
7.00
6.34
7.61
95% CI
Lower
95% CI
Upper
5.40
9.84
5.45
5.18
6.02
7.49
8.66
13.28
8.47
8.82
6.65
7.72
Source : The NHS Information Centre for health and social care
There were 90 deaths due to infections or parasitic disease in North Somerset
between 2007-09. It is likely that some of these could have been prevented with
appropriate control of infection measures.
This data shows that the rate of deaths due to infections in North Somerset does
not differ significantly from the rates in the surrounding area, with the exception
of Bristol where the rate is significantly higher. The rate is not significantly
different from the national or regional rate.
Graph 1: Mortality from infections and parasitic diseases (1993-2009)
North Somerst : Mortality from Infections & Parasitic diseases
1993-2009 trend Rates per 100,000 Pop
14
12
10
8
Males
Females
6
4
2
0
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Source : The NHS Information Centre for health and social care
This trend data on rates of death from infections over the last 17 years,
demonstrates that rates do fluctuate, with generally rates being higher in men
than women.
As can be seen from the chart below, the numbers of people dying in North
Somerset varies substantially in different years. There was a significant increase
in deaths in 2003-2008, which has only recently reduced again.
Graph 2: Number of deaths from infectious and parasitic diseases (1993 –
2009)
North Somerset : Number of deaths from infections and parasitic diseases (1993 -2009)
50
45
40
35
30
25
20
15
10
5
0
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Source : The NHS Information Centre for health and social care.
Deaths from infectious disease affect those in younger age groups as well as the
elderly. Nationally about 30% of deaths from infectious disease occur in the
under 75s (see table 2 below). In North Somerset only 26% of deaths are in the
under 75s, suggesting that locally, infectious diseases in the elderly are a
significant concern.
Table 2: Numbers of deaths from infectious diseases: Under 75s (2007-09)
(Pooled)
Area
North Somerset
Bristol
South Glos
BANES
SW Region
England
Total
No
deaths
90
202
88
71
1947
18,863
of Deaths in under % of deaths in
75s
under 75s
23
26%
61
30.2%
24
27.3%
17
23.9%
512
26.3%
5930
31.4%
Source : The NHS Information Centre for health and social care
There is therefore no room for complacency in the continued fight against
infection. The challenge is that there are so many different areas which require
constant attention.
They range from ever-present threats such as
gastrointestinal infections, through to bloodborne viruses such as hepatitis,
sexually transmitted infections including chlamydia, syphilis and HIV/AIDS, and
emerging infections such as meticillin-resistant Staphylococcus aureus (MRSA)
to re-emerging infections such as tuberculosis. For many infections resistance to
antibiotics continues to evolve.
Nationally, the Health Protection Agency provide a specialist services to
diagnose, monitor and evaluate the impact of infections. Locally, both within the
NHS, and via the council, prompt action needs to be taken to limit the impact of
outbreaks on the public.
The needs of the population
In a local area, the population face risks of many diverse threats each day,
however, due partly to the work of those involved in health protection, these risks
remain minimal most of the time. Health protection is carried out via the NHS
and by specific directorates within the local council. Although the “threats” are
diverse, the common theme of this type of work is to reduce the “threat” and
address the “treat” if it arises. The work of health protection is about preparation,
active prevention and rapid response when incidents arise. There is an
important role in surveillance of disease and ensuring the spread of infection is
minimised.
High risk groups/inequalities
All the above threats can affect the whole population at different times, however,
there are particular vulnerable groups who are more prone to be affected by both
infections and hazards, and any control systems need to take particular care to
ensure their needs are met. These particular groups have particularly high
needs:






Pregnant women
Infants and young children
People over 65
People with pre-existing medical conditions
Homeless people
Drug and Alcohol misusers.
Table 3: Notifications of Infectious Diseases (NOIDS) (2004-2009)
Disease
Whooping
cough
Viral
hepatitis
Disease Type
2004
3
2005
1
2006
3
2007
0
2008
4
2009
0
Hep A
0
1
0
0
0
0
4
20
1
4
119
0
13
9
4
10
7
2
1
6
5
417
7
41
0
1
10
0
7
4
3
7
7
0
0
0
7
473
3
76
0
0
4
0
6
4
2
2
1
1
0
2
10
449
0
2
0
0
3
5
0
0
0
0
0
0
0
0
1
10
9
1
1
1
1
0
0
0
0
1
403
423
0
1
1
0
7
1
0
4
Hep B
Hep C
Hep E
2
7
0
Measles
1
Mumps
40
Rubella
1
Tuberculosis
5
Pulmonary
4
Other forms
1
Meningitis
5
Meningoccal
1
Pneumococcal 2
Viral
2
Septicaemia
0
Shigella
6
Food
431
Poisoning
Malaria
0
Dysentery
Scarlet
Fever
Source : NOIDS
Table 3 above show the notifiable diseases reported in North Somerset in the
years 2004-9. The recording of diseases on this system is entirely reliant on
doctors reporting cases to the HPA. This may account for some of the variation
in rates of diseases recorded. Doctors in England and Wales have a statutory
duty to notify a 'Proper Officer' of the Local Authority of suspected cases of
certain infectious diseases. There are currently 31 notifiable diseases in the UK.
For
a
full
list
see
http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/NotificationsOfInfe
ctiousDiseases/ListOfNotifiableDiseases/.
The HPA publish weekly reports of all notifiable diseases. Most have very low
incidence both locally or nationally, although there are some noted variations in
some years e.g. measles and mumps. . The most common notifiable disease in
food poisoning, and how this is addressed in North Somerset is described in the
next section.
Current Service Provision
Health protection is managed nationally, regionally and locally. This section
looks specifically at local level health protection issues for North Somerset. It
includes sections on the following infections:





Food Safety and Food Poisoning
Tuberculosis
Seasonal flu vaccination
Healthcare associated infections
Blood bourne viruses
Food Safety and Food Poisoning
Food Safety and Food Poisoning
In North Somerset, in 2009, no cases of proven food borne outbreaks were
reported to the Health Protection Agency, there were however, 432 notifications
of food poisoning. It is considered that not all those suffering from food poisoning
will contact their GP and therefore the number of official notifications is likely to
be an underestimate of the total number of food poisoning cases within the
district.
Food poisoning impacts not only on the health of the individual but also on local
health services and local economies due to lost working days. Through
increasing the awareness of the potential sources of food poisoning and the
hygiene standards within food businesses the public can make better choices
about where to eat and how to prepare food hygienically thus and reduce their
risk of food poisoning.
Reporting suspected food poisoning is important even if the symptoms are not
serious, as vulnerable groups ,ie the elderly, young or immuno-compromised ,
could become seriously ill if they eat contaminated food.
Current service provision
North Somerset Council‘s Food and Safety Team investigate complaints of food
and water borne infectious diseases in North Somerset. This particularly applies
to any infectious disease where the illness is caused by eating contaminated
food or drink. They act on reports passed to them by GPs, members of the
public, businesses, hospitals and other local authorities.
Health practitioners are required to notify the Proper Officer for North Somerset
Council via the Food and Safety Team of any suspected cases of food poisoning,
which are then reported to the Health Protection Agency. Dependant on risk and
provision of positive laboratory results individual cases and outbreaks are then
subject to investigation.
Table 4: No of food poisoning per 100,000 population for 2008 and 2009 for
North Somerset, and surrounding areas & England.
N Somerset
England
Bristol
S Glos
BANES
2008
195.7
125.7
150.2
113.2
153.6
2009
202.4
135.2
193.1
186.6
171.6
Source : HPA Local Profiles using NOIDS data
North Somerset has the highest rate of food poisoning in the area, and the rate is
substantially higher than the English average in both 2008 and 2009. This value
does not mean that food safety standards are any poorer in North Somerset than
elsewhere, it may just reflect a higher level of reporting and the make up of the
population. Certain people are more likely to present to their GP with food
poisoning than others such as mothers with small children and older people. Also
those with confirmed food poisoning may have acquired the illness in another
part of the country or abroad and not necessary from businesses in North
Somerset.
Food Safety
In addition to the consumption of food at home, the public can be exposed to
foodstuffs from a variety of sources such as restaurants, takeaways, school and
work canteens, supermarkets, delicatessens, butchers and bakers.
There is an increased risk of acquiring a food borne illness from food businesses
that exhibit lower standards of food hygiene. In order to reduce the risk of food
poisoning, North Somerset Council Food and Safety Officers take measures to
ensure that food businesses operators who manufacture, prepare, cook and
serve food to the public do so safely. Food safety officers carry out interventions
to ensure that food is prepared in a safe and hygienic environment, and that
those involved are suitably trained and have systems in place to support food
safety.
The food and safety team are able to provide advice and guidance on crosscontamination, temperature control, cleaning and disinfection, pest control, and
food poisoning. They work in partnership with the Trading Standards team
whose role is to ensure that food is labeled correctly, properly described and
meets quality standards.
Each food inspection will generate a rating for the quality of food hygiene
witnessed by the officer, which is put onto a national database. Through
increased awareness of the hygiene standards the public are empowered to
make informed choices about which establishments they use and therefore
reduce their risk of food poisoning.
Table 5: Establishments broadly compliant with food hygiene standards
N Somerset
England
Bristol
S Glos
BANES
2009
87.3%
92.1%
97%
99.3
97%
2010
93%
92.1%
97%
99.5
96.7%
HPA Health Protection Profiles
Current and Future Initiatives
Future initiatives will primarily focus on those businesses that are deemed to be
non compliant with food hygiene standards and a range of enforcement
interventions will be used to drive up their compliance.
Alternative enforcement initiatives include a comprehensive programme of food
hygiene training for food handlers as well as sector specific events designed to
support businesses in achieving compliance with their statutory duties. For
example recent seminars have provided bespoke guidance for diverse groups as
butchers and over 50% of North Somerset’s registered child minders. The
intention is to extend this supportive approach to other client groups in future.
Areas of Inequity in service provision
Service provision is focused on achieving compliance with non-compliant
businesses and our evidence is that non-compliance is not area specific. In North
Somerset the gastro-enteritis outbreaks which were investigated in 2009 were
due to viral infection such as, the noro-like virus. These tend to be more
prevalent in semi-closed environments such as residential and nursing homes
and amongst children who attend nurseries. This is because these
establishments where people are in close proximity to one another provide ideal
conditions for person-to-person spread. Noro-like viruses are highly contagious
and as few as 10 viral particles may be sufficient to contaminate an individual.
Information about food safety, North Somerset Council training courses, food
poisoning and business compliance with food hygiene standards is available to
the community via the North Somerset website: http://www.n-somerset.gov.uk/
Contact with the community and business is also achieved via our occassional
magazine Food Safety News which is issued in response to matters of food
concern. The preference is to provide this information portal via email and webbased contact in future. Established internal structures, such as exist in CYPS,
will now be developed to disseminate information to client groups such as childminders.
Food hygiene training is available via routine monthly courses or bespoke client
group courses by request. Improvements in food hygiene have been noted
following previous projects to facilitate food hygiene training for a number of
ethnic minority food businesses including for Bengali, Turkish and Cantonese
speakers. The outcome of these projects was to enable these groups to
understand and comply with the legal requirements for documented procedures,
which is a vital part of legal compliance. Achieving legal compliance vastly
improves the food hygiene rating of the premises for which the outcomes are
improved food hygiene and public choice.
Recommendations
1. That food hygiene interventions focus on those businesses that are noncompliant with food hygiene requirements with the express intention of
ensuring that a minimum of 50%` of these premises become broadly
compliant
within
any
12
month
period.
2. That the North Somerset Council officers continue to provide Level 2 food
hygiene training for food businesses to ensure that food handlers are
competent to handle, prepare and cook food hygienically.
3. That North Somerset Council officers provide targeted events for food
businesses in response to emerging problems/new legislative
requirements.
References/data
Food
Safety
Act:
http://www.opsi.gov.uk/acts/acts1990/ukpga_19900016_en_1.htm
European
Communities
Act:
http://www.opsi.gov.uk/Acts/acts1972/ukpga_19720068_en_1
Food
Standards
Agency
Code
of
Practice
and
Guidance:
http://www.food.gov.uk/enforcement/enforcework/foodlawcop/copengland/copen
gland
North Somerset Council Food Safety Service Plan
Food Standards Agency – Food Hygiene Rating Scheme
http://ratings.food.gov.uk/
http://ratings.food.gov.uk/
Tuberculosis
Tuberculosis (TB) is caused by the bacterium Mycobacterium tuberculosis. It can
cause disease in the lungs as well as other sites such as the lymph nodes and
bones.
Why is it important?
TB, although curable with antibiotics, has re-emerged as a major Public Health
problem and is the leading cause of death worldwide among curable infectious
diseases. In England cases fell progressively until the mid-1980s but started to
rise again in the early 1990s.
What are the needs of the population?
Case numbers in the UK are at their highest for nearly thirty years and now
exceed 9,000 per year. Much of this rise affects disadvantaged communities
including certain ethnic minority groups and those with social risk factors such as
homelessness and drug/alcohol misuse. This concentration in particular sections
of the community provides unequivocal evidence for a need to strengthen efforts
to control the disease through a range of measures targeted at key risk groups
and in particular urban areas. NICE are currently working on guidance on the
management of TB in hard to reach groups. TB is a disease associated with
poverty, specific groups of the population are at heightened risk:
•
•
•
•
•
•
Close contacts of infectious cases
Those that have lived in, travel to, or receive visitors from places where
TB is still very common
Those that live in ethnic minority communities originating from places
where TB is very common
Those with immune systems weakened by HIV infection or other medical
problems
The very young and the elderly as their immune systems are less robust
Those with chronic poor health and malnutrition because of lifestyle
problems such as homelessness, drug abuse or alcoholism.
Tuberculosis in North Somerset
Table 6: Average no of new cases (3 year rolling average)
North Somerset
2001 – 03
5
2004 – 6
7
2007-9
10
Source : HPA Health Protection Profiles
Table 7: Average incidence rate per 100,000 population
North Somerset
South West
England
2001-3
3
4.4
13.1
2004-6
4
5.3
14.7
2007-9
5
5.6
15.4
Source : HPA Health Protection Profiles
Table 8: Average incidence rates per 100,000 population in surrounding
areas 2007/09
North Somerset
Bristol
S Glos
BANES
2007-09
5
19
6
4
Source : HPA Health Protection Profiles
Although rates in North Somerset are low, they are also increasing, and the rate
is broadly in line with the South West rates over the last 9 years. A low indicator
value should not mean that action is not needed as TB is preventable and any
case of tuberculosis needs to be treated.
Current Service Provision
The PCT, Weston Area Health Trust and the local Health Protection Unit are
working together to ensure that nationally approved systems for monitoring,
control and treatment of tuberculosis are in place across North Somerset. There
is a GP Referral pathway developed for suspected TB which is available at
http://www.northsomersetpathways.co.uk/documents/other/clinical_policies_and_
guidelines/infection_control/tuberculosispolicy.pdf
There is provision to provide BCGs to infants at risk of infection.
Future Developments
TB is curable if detected and treated early but the longterm nature and
associated side effects of the antibiotic therapy can sometimes result in failure to
complete treatment, leading to possible relapse and emergence of
drug-resistant strains. The current six-month treatment regime was developed
nearly half a century ago, and there is now an impetus (e.g. by the Global
Alliance for TB DrugDevelopment) to modernise TB treatment.
Antibiotics and inhibitors that are more effective and which could reduce
treatment times are in phase II and phase III clinical trials. Other drugs are at the
discovery phase or are in preclinical development.
What works : the evidence base
NICE has recently updated its guidance on the management and control of TB
and this contains the most up to date guidance on treatment.
NICE guidance : Clinical diagnosis and management of TB, and measures for its
prevention and control. (March 2011) http://www.nice.org.uk/CG117
Recommendations
To ensure that local service specification for treatment and management of TB
conform to the recent updated NICE guidance.
Health Care Associated Infections
Why is it important?
Health Care Associated Infections (HCAI) are infections resulting from medical
care or treatment in hospital (in- or out-patient), nursing homes, or even the
patient's own home.
Previously known as 'hospital acquired infection' , the current term reflects the
fact that a great deal of healthcare is now performed outside the hospital setting.
Healthcare associated infection (HCAI) can affect any part of the body, including
the urinary system (urinary tract infection), the lungs (puenmonia or respiratory
tract infection), the skin, surgical wounds (surgical site infection), the digestive
(gastrointestinal) system and even the bloodstream (bacteraemia).
What type of infections are associated with healthcare?
This chart shows a breakdown of healthcare associated infections by body
system for the United Kingdom:
Graph 3: Site of HCAI
Source: Summary of Preliminary Results of the Third Prevalence Survey of Healthcare Associated
Infections in Acute Hospitals 2006, England, Hospital Infection Society and Infection Control Nurses
Association, 27 February 2007.
There are a number of factors that can increase the risk of acquiring an infection,
but high standards of infection control practice minimise the risk of occurrence.
Often infections which occur in hospital are however contracted outside the
hospital in the community. The HPA make the distinction of hospital and
community acquired infection. An infection is not classed as hospital acquired
unless it is evident after 48 hours in hospital.
The Health Protection Agency assists infection control and the control of
antibioctic resistance in the healthcare setting by monitoring infections with
mandatory and voluntary surveillance schemes covering:





methicillin-resistant Staphylococcus aureus (MRSA),
Clostridium difficile infection (C. diff/CDI),
glycopeptide-resistant enterococci (GRE),
bacteraemia (blood stream infection),
surgical site infections (of which some orthopaedic categories are
mandatory) via the surgical site infection surveillance scheme (SSISS).
Information on two of these conditions is presented here: MRSA and C Difficile
which have presented particular challenges locally in recent years.
MRSA
Why is it important?
Staphylococcus aureus is a bacterium that commonly colonises human skin and
mucosa (e.g. inside the nose) without causing any problems. It can also cause
disease, particularly if there is an opportunity for the bacteria to enter the body,
for example through broken skin or a medical procedure.
If the bacteria enter the body, illnesses which range from mild to life-threatening
may then develop. These include skin and wound infections, infected
escema, abcesses or joint infections, infections of the heart valves (endocarditis),
pneumonia and bacteraemia (blood stream infection).
Most strains of S. aureus are sensitive to the more commonly used antibiotics,
and infections can be effectively treated. Some S. aureus bacteria are more
resistant. Those resistant to the antibiotic meticillin are termed meticillin-resistant
Staphylococcus aureus (MRSA) and often require different types of antibiotic to
treat them.
Both locally and nationally rates of MRSA have been decreasing, mainly due to
increased vigilance within hospitals around infection control.
This follows a
period when rates of infection where very high. The renewed vigilence against
these infections, meant that infection control became a top priority for Trust
Boards, and Trusts had to mandatorily report rates.
Below are the cases by quarter in Weston Area Health Trust as an example,
showing a steady decline in numbers of cases since 2004.
Graph 4: Number of cases of MRSA in Weston Hospital (2004 – 2010)
Weston Area Health Trust : MRSA Cases by Quarter (Jan 2004 - Dec 2010)
October to December 2010
July to September 2010
April to June 2010
January to March 2010
October to December 2009
July to September 2009
April to June 2009
January to March 2009
October to December 2008
July to September 2008
April to June 2008
January to March 2008
October to December 2007
July to September 2007
April to June 2007
January 2007 - March 2007
October 2006 - December 2006
July 2006 - September 2006
April 2006 - June 2006
January 2006 - March 2006
October 2005 - December 2005
July 2005 - September 2005
April 2005 - June 2005
January 2005 - March 2005
October 2004 - December 2004
July 2004 - September 2004
April 2004 - June 2004
January 2004 - March 2004
0
2
4
6
8
Source : HPA : HCAI mandatory surveillance
Rates for North Somerset PCT are shown below, and these include cases not
only from Weston Hospital, but any cases from other hospitals used by North
Somerset residents.
Table 9: Number of MRSA infections at Weston Area Health Trust (2007 –
March 2011).
PCT
North
Somerset
– Rate
per
100,000
population
Totals cases
15
7.3
April 08
March 09
April 09 – Rate
per
March 2010
100,00
population
Total cases
9
4.4
10
12
South Glos
Bristol
BANES
8
39
10
3.1
9.3
5.5
National rate
11
25
10
4.3
5.9
5.5
5.7
3.7
Source : HPA mandatory surveillance
Although numbers of cases during the last three years has been decreasing, and
this is seen in the reducing rates above, not only in North Somerset, but in the
surrounding areas, rates are still above the national average. This may be due to
the demographics of the local population, who are older than the national
average. The rates are not adjusted to give a standardised rate which considers
factors such as demographics or case mix.
C. Difficile
Like MRSA, rates of C Difficile have declined both locally and nationally. This is
mainly due to increased vigilance within hospitals around infection control.
Below are the cases by quarter in Weston Area Health Trust as an example,
showing a steady decline in numbers of cases since 2007.
Graph 5: Number of C. Difficile infections at Weston Area Health Trust
(2007 – March 2011).
Nos of C.Diff infections at Weston Area Health Trust in patients aged 2 and over
by quarterApril 2007 to March 2011
January - March 2011
October - December 2010
July - September 2010
April - June 2010
January - March 2010
October - December 2009
July - September 2009
April - June 2009
January - March 2009
October - December 2008
July - September 2008
April - June 2008
January - March 2008
October - December 2007
July - September 2007
April - June 2007
0
10
20
30
40
50
60
70
80
90
Source : HPA HCAI Mandatory Surveillance
Rates for North Somerset PCT are shown below, and these include cases not
only from Weston Hospital, but any cases from other hospitals used by North
Somerset residents. Again this shows much progress in reducing rates, with the
overall rate in North Somerset in 09/10 the lowest in the area, and well below the
national average, having been much higher, the previous year.
Table 10: C. Difficile hospital acquired infections in North Somerset PCT
patients (2008/09 – 2009/10).
PCT
North
Somerset
South Glos
Bristol
BANES
– Rate
per
100,000
population
Totals cases
215
106.4
April 09 – Rate
per
March 2010
100,00
population
Total cases
95
47.0
137
473
213
145
265
138
April 08
March 09
National rate
54.5
115.4
120.6
72.0
57.6
64.6
78.1
51.1
Source : HPA Mandatory Surveillance
Recommendations
To maintain the current vigilance in infection control within healthcare
establishments to ensure rates of HCAI remain low.
To increase infection control awareness and training in the community, including
across primary care and social care services in North Somerset.
Blood Bourne Viruses
The most common serious viruses carried in people's bloodstreams are hepatitis
B, hepatitis C and HIV. HIV is not covered here, see section on sexual health for
information.
Hepatitis B
Hepatitis B is not very common in the UK: approximately one in 1,000 people are
thought to have the virus. However, in some inner-city areas with a high
percentage of people from parts of the world where the virus is common, as
many as one in 50 pregnant women may be infected. Worldwide, the occurrence
of hepatitis B is highest in sub-Saharan Africa, south-east Asia and the Pacific
islands.
Early symptoms of the hepatitis B virus are flu-like, and infection can lead to liver
disease and liver cancer. The virus circulates in the blood and body fluids of
infected people, and spreads by sexual contact, other close contact and the
sharing of needles and razors. Babies with infected mothers can also become
infected during birth. However, a vaccination is available. The vast majority of
people who are infected with hepatitis B are able to fight off the virus and fully
recover from the infection within a couple of months.
However, most babies infected with hepatitis B have a poorer outlook, as their
infection usually becomes chronic.
It is important therefore locally that pregnant women are screened for Hepatitis B,
and those with positive results are followed up, so that their babies can be
vaccinated at birth, and complete a full course of vaccinations over the first year.
90% of infected babies will develop resistent Hepatitis B infections and be at risk
of serious liver disease in later life.
Hepatitis C
People infected with hepatitis C virus often show no symptoms initially, but long
term effects can include liver damage and cancer. The virus is transmitted by
infected body fluids, and needle sharers are at particular risk. It is estimated that
about 92% of cases are as a result of drug users sharing dirty needles. Babies
can also be infected by their mothers during birth, though this is rare. No vaccine
exists to prevent hepatitis C infection, but treatments are available that are
effective in over 50% of cases.
There has been a year on year increase in the number for Hepatitis C cases, but
closer scrutiny of the data suggests that this may be due to improved reporting
from the laboratory. The data does not necessarily represent newly acquired
disease, it may be that the infection was acquired many years ago and has only
now been diagnosed.
The North Somerset Locally Enhanced Service for drug misusers includes
ensuring that all problem drug users being treated under this service are tested
and vaccinated for blood borne viruses, including HIV, Hepatitis A, B and C.
Recommendations
Improve the surveillance of Hepatitis B & C locally, particularly the screening of
pregnant women, and the monitoring of vaccination programmes for infants.
CSDAT to look at surveillance of Hepatitis within the drug and alcohol service.
There is a specific problem obtaining hepatitis data as it is received from the HPA
from laboratories, with often the PCT field not completed. It is therefore not
possible to ascertain precise local figures.
Taking laboratory figures (for
example from Weston Hospital), as a proxi for PCT, is not accurate. There is also
an issue about the laboratories releasing their data, as it is owned by them, not
the HPA.
Seasonal Flu Vaccination Programme
Seasonal flu occurs every year, usually in the winter. It’s a highly infectious
disease caused by a virus. Illnesses resembling influenza that occur in the
summer are usually due to other viruses.
Rates of seasonal flu vary each year, and within the year. Levels for 2010, for
example, were generally lower than 2009.
For example in the last week of
November in 2009, the rate of primary care consultations for flu like illness in
Avon was 38 per 100,000 population, a year later it was 6 per 100,000.
The annual flu immunisation is the best protection against flu for people with
underlying health problems that put them at risk of complications from influenza
(flu), and for all those aged 65 and over.
Why is it important?
For most people under 65, who do not have underlying medical conditions,
having flu, is unpleasant, but is not life-threatening. Most people need to stay in
bed for a few days, and then recover. It is, however, much worse than a bad
cold.
Some people however are more susceptible to the effects of seasonal flu. For
them it can increase the risk of developing more serious illnesses such as
bronchitis and pneumonia, or can make existing conditions worse. In the worst
cases, seasonal flu can result in a stay in hospital, or even death.
For these groups, an annual vaccine against seasonal flu is recommended and
available via GP practices.
Immunisation is one of the most effective healthcare interventions available and
flu vaccines are highly effective in preventing illness and hospital admissions
among these groups of people. Increasing the uptake of flu vaccine among high
risk groups should also contribute to easing winter pressure on primary care
services and hospital admissions.
High risk groups/inequalities
Government policy is to recommend immunisation for people aged 65 years and
over. The vaccination is recommended also for those who live in a residential or
nursing homes, carers of an older or disabled person, or for women who are
pregnant. Even if healthy, a free seasonal flu vaccination is available from GP
practices if you are under 65 and have:
• a heart problem
• a chest complaint or breathing difficulties, including bronchitis or emphysema
• a kidney disease
• lowered immunity due to disease or treatment (such as steroid medication or
cancer treatment)
• a liver disease
• had a stroke or a transient ischaemic attack (TIA)
• diabetes
• a neurological condition, for example multiple sclerosis (MS) or cerebral palsy
• a problem with your spleen, for example sickle cell disease, or you have had
your spleen removed.
Current Service Provision
The seasonal flu vaccination programme for the population of North Somerset is
delivered through GP practices, and managed by NHS North Somerset. North
Somerset Community Services carry out the vaccination programme to frontline
health care workers and housebound patients. Information on uptake rates are
given below.
Table 11: Uptake rates for the seasonal flu vaccine in North Somerset:
(2006/07 to 2010/11)
Group
2006/07
People
76%
aged
65
and over
Under 65s 42%
at risk
2007/08
75.6%
2008/09
77.2%
2009/10
75.5%
2010/11
75.4%
42.4%
46.2%
50.2%
49.6%
Source : ImmForm web based reporting : DH/HPA
Uptake rates are good for those 65 or over, the most recent figures for
neighbouring areas and England are shown below. These are for 2009/10. North
Somerset have uptake rates which are higher than both the regional and national
average. For the under 65s at risk, rates are much lower, in all areas with only
around 50% of those eligible, receiving the vaccination. The rate in North
Somerset is slightly under the regional and national average.
Table 12: Flu Vaccination Uptake (2009/10)
PCT
Uptake in over 65s
North Somerset
South Glos
Bristol
BANES
South West SHA
National rate
75.5%
78.2%
74.8%
74.0%
72.9%
72.4%
Source : ImmForm web based reporting : DH/HPA
Uptake in Under 65s at
risk
50.2%
53.7%
50.5%
49.4%
51.8%
51.6%
For the first time, in 2009/10 uptake rates for carers were available. In North
Somerset, 50.2% of eligible carers had the vaccine. These are carers who look
after an elderly or disabled person and are under 65 and not in an at risk group,
and hence would not be covered by the main programme. This is well above the
national average of 42.3%. The most recent figures available for carers show
that there was a slight decrease in the carers rate of 48.8% in 2010/11.
There are some differences in the uptake rates in the “at risk” groups. See rates
for North Somerset and national rates below:
Table 13: Seasonal Influenza vaccine uptake in those aged 6 months to
under 65 years, at risk, by disease : NHS North Somerset and England
(2009/10)
At risk group
Chronic heart disease
Chronic
respiratory
disease
Chronic kidney disease
Chronic liver disease
Diabetes
Diabetes on medication
Immuno-suppression
Stroke/TIA
Chronic
degenerative/neurological
disease (include MS)
North Somerset
51.8%
50.2%
England
56.5%
51.8%
49.7%
37.7%
66.5%
68.4%
55.7%
54.8%
41.2%
53.4%
42.1%
68.8%
71.9%
50.1%
59.0%
38.7%
Source : ImmForm web based reporting : DH/HPA
The pattern of uptake by disease is broadly similar to the England average, with
the greatest uptake in people with Diabetes and the lowest rates in those with
degenerative/neurological disease. Uptake rates by disease are mostly slightly
lower in North Somerset than nationally. There is a particularly low rate for those
with chronic liver disease. (37.7%).
Another important at risk group is pregnant women. In 2010/11, there was an
average uptake rate of 48.3%. Pregnant women at risk, had a slightly higher
uptake rate of 56.1%. The overall national rate in 2010/11 for pregnant women
was 37.7%, and hence North Somerset, have achieved a higher rate.
Variation in uptake rates
A concern is that when looking across North Somerset, there is a wide range in
uptake rates by GP practice. The table below shows the range of uptake rates
for each key group, showing the lowest uptake and the highest uptake rates.
There is a particular issue with variation in rates for pregnant women and carers.
Table 14: Uptake rates of the flu vaccination in 2010/11
Group
Over 65s
Clinical at risk
Pregnant women
Pregnant women at risk
Carers
North
Somerset
delivery range
67.1% – 82.3%
39.7% - 59.8%
7.1% - 74.1%
0 – 100%
9.1% - 100%
% North
Average
75.4%
49.6%
48.3%
56.1%
48.8%
Somerset
Source : NHS North Somerset
Future planning
The Chief Medical Officer sent a letter out in March 2011 detailing the seasonal
flu vaccination uptake requirements for 2011/12. A suggested uptake delivery
improvement trajectory, which will affect all General Practices within North
Somerset over the coming years is as follows:
1.
2.
3.
Reach or exceed 75% uptake for people aged 65 years or over.
Reach or exceed 75% uptake for people under age 65 with clinical
conditions.
Reach or exceed 75% uptake for pregnant women.
Given that North Somerset is already achieving the 75% uptake for the over 65s,
the challenge here will be maintaining it, and improving rates in practices which
are currently not achieving 75%.
A suggested trajectory for uptake increases in clinical risk groups and pregnant
women might be:
Table 15: Suggested trajectory for increased uptake in clinical risk groups
and pregnant women (2010/11 – 2013/14).
Actual
2010/11
Under 65s at 49.6%
risk
Pregnant
48.3%
woman
Source : NHS North Somerset
2011/12
2012/13
2013/14
60%
70%
75%
60%
70%
75%
These are very challenging targets, given current uptake rates in the under 65s
and pregnant woman.
Recommendations
To have strong engagement with practice managers and understand on a
monthly basis how GP practices are delivering the vaccinations to various groups
and reduce variation in uptake between practices.
To improve communications locally with the public over the availability and
importance of the seasonal flu vaccination, particularly to high risk groups.