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Eurosurveillance Weekly: Thursday 24 May 2001. Volume 5, Issue 21
Contents:
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Increased cases of invasive Group A streptococcal infections in Sweden
Imported cases of polio in Bulgaria – vaccination campaign postponed***
Influenza A(H5N1) virus in poultry in Hong Kong
Carriage of antibiotic resistant bacteria by healthy children
“Clostridium novyi and co” – the drug injector outbreaks: meeting announcement
Dip into The Lancet Infectious Diseases
Increased cases of invasive Group A streptococcal infections in Sweden
During the period January-April 2001 a total of 133 isolates from patients with invasive Group
A streptococcal (GAS) infection have been reported to Smittskyddsinstitutet (the Swedish
Institute of Infectious Disease Control, SMI). The increase in the total number of reported
cases of invasive GAS is restricted to the centre and south west of the country (figure 1). This
represents an incidence of 1.5 per 100 000 population, 15% higher than in January-April 1999
(115 cases, 1.3/100 000) and 58% higher than in the same period for 2000 (84 cases, 0.9/100
000) (figure 1). Forty-nine cases were reported in March 2001, and between 27 and 29 cases
were reported during each of the other three months.
Figure 1. Left: number of isolates of invasive GAS infections from January to April 2001 by
county of infection. Right, highlighted: counties with an incidence above the average
incidence calculated for the same periods of 1999 and 2000
Of the 133 isolates reported, 64 (48%) were serotyped, and 30 were found to be T1,
compared with 18 in 1999 and 13 in 2000. Other strains isolated more often during this year’s
January-April period included T3.B3264 (10 isolates compared with six in both 1999 and
2000) and T13.28 (four isolates compared with none in 1999 and one in 2000).
The proportion of serotyped specimens identified as T1 rose from 34% in 1999 to 47% in
2001. The increase in reported T1 isolates is not due to an increased proportion of specimens
being serotyped during this period. Similar proportions were serotyped in the same periods of
2001 (64/133, 48%), 1999 (52/115, 45%), and 2000 (36/84, 43%).
Figure 2. Number of isolates from cases of GAS reported to SMI from January 1999 to April
2001
Of the 133 patients with invasive GAS, 61 (46%) were female and 72 (54%) were male.
The median age of cases in 2001 is 55, compared with 64 and 71 during the equivalent
periods of 1999 and 2000, respectively. The fall in age is largely due to data from the month
of February, when five cases of infection in children aged 2 to 7 years were reported. Fifteen
cases aged 0 to 15 years have been reported in 2001, compared with seven for the
equivalent periods of both 1999 and 2000. Twenty-two infections among women of
childbearing age (20 to 49 years) have been reported during this period, compared with 19
and 8 for the equivalent periods of 1999 and 2000, respectively.
The data must be interpreted with caution, as invasive GAS infection is not a notifiable
disease in Sweden. Infections are reported on a voluntary basis by microbiological
laboratories. They notify all GAS isolates recovered from blood, spinal fluid, or other normally
sterile sites. Preliminary consultations do not suggest that any changes in laboratory methods
or in the reporting system have occurred to explain the observed changes.
The reported GAS isolates originate from cases with different clinical presentations. There is
concern that the epidemiology of GAS infections is changing, with more cases of necrotising
fasciitis and streptococcal toxic shock syndrome (STSS), with a high case fatality. Previous
studies have shown an association between serotype T1 and STSS in Sweden (1).
A descriptive study of the cases of invasive GAS during 2001 is under way, with emphasis on
the occurrence in children and women who have just given birth. We would like to learn
whether this increase is also affecting other European countries. This might justify the
initiation of a collaborative epidemiological study.
Reference:
1.
Svensson N, Öberg S, Henriques B, Holm S, Källenius G, Romanus V, Giesecke J.. Invasive Group A
Streptococcal infections in Sweden in 1994 and 1995: Epidemiology and clinical spectrum. Scand J Infect
Dis 2000; 32: 609-14.
Reported by Juan J Carrique-Mas ([email protected]), EPIET fellow, Karin
Nygård, and Victoria Romanus, Smittskyddsinstitutet, Stockholm, Sweden.
Imported cases of polio in Bulgaria –vaccination campaign postponed***
The first two cases of poliomyelitis in Europe since 1998 have been diagnosed in Bulgaria,
according to the World Health Organization (WHO) and Bulgarian officials (1,2). The virus
was identified on 17 April in a 13 month old Romany child in the Black Sea city of Burgas. The
child develped acute flaccid paralysis on 24 March (3). Other Romany children were
immediately vaccinated, and WHO was notified six days later.
Despite this the virus was detected on Tuesday 15 May 2001 in a 2 year old Romany girl in a
location 90 km west of Burgas, whose legs and left arm were reportedly paralysed.
Laboratories at the Institut Pasteur in Paris, France, the Istituto Superiore di Sanità in Rome,
Italy, and the Centers for Disease Control and Prevention in Atlanta, USA used genetic
sequencing to identify the infectious agent as poliovirus type 1 of a subtype associated with
northern India, according to WHO's European Region Headquarters in Copenhagen,
Denmark (3).
In response to the discovery of the two cases a national vaccination campaign in Bulgaria –
where about 5% of children have never been vaccinated –was planned to take place on 28
May but had to be postponed on 18 May owing to lack of vaccine. According to Bulgaria’s
health ministry, however, some 800 000 doses of polio vaccine are to be imported within days
with the help of UNICEF (the United Nations Children's Fund).
The two cases of infection are the first cases of poliomyelitis in Bulgaria since 1991,
according to official statistics. The recent cases are the first cases of polio recorded in Europe
since November 1998, when the virus was found in a Turkish province on the Iranian border.
The occurrence of wild poliovirus circulation in Bulgaria may be a setback for the European
region, which was on track for certification of poliomyelitis eradication. A region is certified as
polio free when there has been no circulation of wild poliovirus in the region for three years.
The WHO campaign for a world certified polio free by 2005 was reported to be on track in
April (4).
The occurrence of two cases, geographically separated but among the same ethnic group
that may have social interactions, suggests circulation of wild poliovirus in communities. In
recent years, most poliovirus isolates were of subtypes associated with northern India and the
subcontinent. The European Certification Committee will assess the current situation in
Bulgaria, Tajikistan, Turkey, Turkmenistan and Uzbekistan on 27-28 September 2001 in
Ankara, Turkey.
Editorial comment
As paralytic polio only occurs in fewer than 1 in 100 infections, the occurrence of two cases in
separate communities separated by several weeks suggests that widespread circulation of
poliovirus occurred in the Romany community. Although national coverage of polio vaccine is
95%, coverage in the Romany community is thought to be lower.
About 5% of Bulgarian children have not apparently been vaccinated, and the immediate
priority of the Bulgarian authorities is to interrupt transmission of the virus by vaccinating
widely. This is another example of how the poliovirus needs only an 'attic window' of
opportunity to take advantage of the vulnerable.
References:
1.
2.
3.
4.
Imported cases of poliomyelitis in Bulgaria. ProMED-mail 2001; 18 May. (Click here)
Poliomyelitis, imported - Bulgaria ex India (02). ProMED-mail 2001; 22 May. (Click here)
World Health Organization Europe. Polio case reported in Bulgaria. National authorities and WHO act
quickly to keep polio eradication on track. WHO Press release EURO 05/2001. Copenhagen 17 May 2001
(http://www.who.dk/cpa/pr01/pr0005e.htm)
Twisselmann B. Polio eradication: final 1% poses greatest challenge. Eurosurveillance Weekly 2001; 5:
010419. (http://www.eurosurv.org/2001/010419.html)
Editorial comment by Norman Noah and Mary Ramsay, Public Health Laboratory Service
Communicable Disease Surveillance Centre, London, England. Reported by Birte
Twisselmann ([email protected]), Eurosurveillance editorial office.
***Correction from WHO Europe, 30 May 2001
The vaccination campaign was not postponed, as incorrectly reported in the news last week,
but started in all children aged 0-7 years on 28 May, with an accelerated programme in
Romany children taking place on 14-18 May. A second wave is planned for 25-29 June.
Influenza A(H5N1) virus in poultry in Hong Kong
An increase in the number of deaths of poultry from influenza A(H5N1) virus in additional
retail live bird poultry markets in Hong Kong Special Administrative Region (SAR) has been
reported by the World Health Organization (WHO) (1,2).
As a result, the Hong Kong authorities on Monday 21 May initiated a two week operation to
slaughter more than a million poultry at local farms (3). All wholesale and retail markets
selling chickens will be closed, and the birds will be destroyed (4). Retail outlets for live
chickens will remain closed for four weeks. Farms with live chickens ready for slaughter will
be depopulated within the next two weeks. Importation of chickens from mainland China has
been stopped.
No human cases of influenza A(H5N1) virus have been detected. The strains isolated from
the birds differ genetically from the H5N1 virus that caused human disease in 1997 (5-11).
References:
1.
2.
3.
4.
5.
6.
World Health Organization. Isolation of influenza A(H5N1) virus in poultry in Hong Kong Special
Administrative Region of China (SAR) – Update. Disease outbreaks reported. 18 May 2001.
(http://www.who.int/disease-outbreak-news/n2001/may/18may2001.html)
World Health Organization. Isolation of influenza A(H5N1) virus in poultry in Hong Kong Special
Administrative Region of China. Disease outbreaks reported. 17 May 2001. (http://www.who.int/diseaseoutbreak-news/n2001/may/17may2001.html)
Hong Kong begins preemptive poultry cull to halt avian influenza outbreak. ProMED-mail 2001; 23 May.
(Click here)
Hong Kong Special Administrative Region of the People’s Republic of China. Secretary for the
Environment and Food announces measures to prevent spread of avian flu. Press release. 18 May 2001.
(http://www.info.gov.hk/gia/general/200105/18/0518293.htm)
Watson J. Four cases of H5N1 influenza in Hong Kong. Eurosurveillance Weekly 1997; 1: 971211.
(http://www.eurosurv.org/1997/971211.html)
Begg N. Influenza A H5N1 in Hong Kong: update from WHO 17 December. Eurosurveillance Weekly 1997;
1: 971218. (http://www.eurosurv.org/1997/971218.html)
7.
Begg N. Influenza A H5N1 in Hong Kong: update 23 December. Eurosurveillance Weekly 1997; 1: 971223.
(http://www.eurosurv.org/1997/971223.html)
8. Handysides S. Influenza A H5N1 infection in Hong Kong: update 31 December. Eurosurveillance Weekly
1997; 1: 971231. (http://www.eurosurv.org/1997/971231.html)
9. Begg N, Joseph C. Influenza A H5N1 in Hong Kong: update 7 January. Eurosurveillance Weekly 1998; 2:
980107. (http://www.eurosurv.org/1998/980107.html)
10. Joseph C. Influenza A H5N1 in Hong Kong: update 14 January. Eurosurveillance Weekly 1998; 2: 980114.
(http://www.eurosurv.org/1998/980114.html)
11. Lavanchy D. The WHO update on influenza A (H5N1) in Hong Kong. Eurosurveillance 1998; 3: 23-5.
(http://www.ceses.org/eurosurveillance.htm)
Reported by Birte Twisselmann ([email protected]), Eurosurveillance editorial office.
Carriage of antibiotic resistant bacteria by healthy children
A study reported recently showed that many children – and possibly even more adults – in the
population carry bacteria that are resistant to one or more antibiotics (1). The study population
comprised 539 children aged 7 and 8 years in Bristol, England (1). Carriage was estimated
using mouth and stool specimens. None of 105 children about whom information was
available had received tetracycline, chloramphenicol, ciprofloxacin, or an extended spectrum
cephalosporin in the previous year.
Staphylococcus aureus was isolated from mouthwashes from 200 (37%) of 539 children
sampled. Six (3%) of the isolates were resistant to chloramphenicol or tetracycline, and four
(2%) to methicillin. Haemophilus spp. were isolated from 369 (72%) of 513 samples, and 63
(17%) of the 369 were resistant to ampicillin, 49 (13%) to erythromycin, and seven (2%) to
tetracycline. Branhamella catarrhalis was isolated from 333 (74%) of 450 samples. Twentyeight (8%) of these 333 were erythromycin resistant and 14 (4%) were resistant to
tetracycline. Group A ß-haemolytic streptococci were isolated from 17 of 507 children
sampled. One of these was tetracycline resistant. Stool specimens were returned by 335
(62%) of the 539 children from whom they were requested. Eleven per cent of specimens
yielded Gram negative bacilli with high level resistance to chloramphenicol, which was often
linked to resistance to ampicillin, spectinomycin, and streptomycin. Isolates showing
resistance to the third generation cephalosporin ceftazidime were recovered from 17 subjects.
Six of the 17 isolates possessed extended spectrum ß-lactamases.
The levels of resistance illustrate the extent to which antibiotic resistant bacteria may be
circulating within the healthy childhood population. No distinction was made in the study
between inherent and acquired resistance.
Reference:
1.
Millar MR, Walsh TR, Linton CJ, Zhang, Leeming JP, Bennett PM, et al. Carriage of antibiotic resistant
bacteria by healthy children. J Antimicrob Chemother 2001; 47: 605-10.
(http://jac.oupjournals.org/cgi/content/abstract/47/5/605?maxtoshow=&HITS=&hits=&RESULTFORMAT=&f
ulltext=antibioticresistant+bacteria&searchid=QID_NOT_SET&stored_search=&FIRSTINDEX=&volume=47&issue=5)
Reported by Birte Twisselmann ([email protected]), Eurosurveillance editorial office.
“Clostridium novyi and co – the drug injector outbreaks”: meeting
announcement
An international scientific meeting about the outbreaks of illness among drug injectors that
occurred in Scotland, Ireland, and England in spring and summer 2000 (1-12) is being held on
15 and 16 October 2001 at the Royal College of Physicians and Surgeons in Glasgow,
Scotland. Topics will include the identification and investigation of the outbreaks, the
epidemiological, microbiological, pathological, and toxicological findings, outbreak
management, and public health implications. Tye meeting is being convened by the Greater
Glasgow Health Board, in collaboration with the Scottish Centre for Infection and
Environmental Health, the Public Health Laboratory Service (England and Wales), the
Eastern Regional Health Authority (Ireland), and the Centers for Disease Control and
Prevention (Atlanta). For further details of the meeting, click here.
References:
1.
Maagaard A Hermansen N, Heger B, Bruheimand M, Meidell NK, Hoel T. Serious systemic illness among
injecting drug users in Europe: new case in Oslo. Eurosurveillance Weekly 2000; 4: 000914.
(http://www.eurosurv.org/2000/000914.htm)
2. Andraghetti R, Twisselmann B. Severe systemic sepsis in injecting drug users – Scottish outbreak control
team sets up website. Eurosurveillance Weekly 2000; 4: 000824.
(http://www.eurosurv.org/2000/000824.htm)
3. Andraghetti R, Goldberg D, Smith A, O’Flanagan D, Lieftucht A, Gill N. Severe systemic sepsis associated
with soft tissue inflammation (previously reported as ‘serious unexplained illness’) in injecting drug users in
Scotland, Ireland, England, and Wales. Eurosurveillance Weekly 2000; 4: 000803.
(http://www.eurosurv.org/2000/000803.htm)
4. Centers for Disease Control and Prevention. Update: Clostridium novyi and unexplained illness among
injecting-drug users – Scotland, Ireland, and England, April-June 2000. Morb Mortal Wkly Rep MMWR
2000; 29: 543-5. (http://www.cdc.gov/mmwr//preview/mmwrhtml/mm4924a6.htm)
5. Jones J, Gill N, Djuretic T, Murray K, Barry J, O’Flanagan D. ‘Serious unexplained illness’ among injecting
drug users in Britain and Ireland. Eurosurveillance Weekly 2000; 4: 000622.
(http://www.eurosurv.org/2000/000622.htm)
6. Greater Glasgow Health Board, Scottish Centre for Infection and Environmental Health, Djuretic T.
Clostridium novyi is likely cause of ‘serious unexplained illness’ as cases continue to be reported.
Eurosurveillance Weekly 2000; 4: 000615. (http://www.eurosurv.org/2000/000615.htm)
7. Centers for Disease Control and Prevention. Unexplained illness and death among injecting-drug users –
Glasgow, Scotland; Dublin, Ireland; and England, April-June 2000. Morb Mortal Wkly Rep MMWR 2000;
29: 489-92. (http://www.cdc.gov/mmwr//preview/mmwrhtml/mm4922a2.htm)
8. Greater Glasgow Health Board, Scottish Centre for Infection and Environmental Health. Serious
unexplained illness among injecting drug users in Scotland and the Republic of Ireland – update.
Eurosurveillance Weekly 2000; 4: 000608. (http://www.eurosurv.org/2000/000608.htm)
9. Eastern Regional Health Authority and National Disease Surveillance Centre Dublin. Deaths from
unexplained illness in heroin users in Dublin. Eurosurveillance Weekly 2000; 4: 000601.
(http://www.eurosurv.org/2000/000601.htm)
10. Ahmed S, Gruer L, Goldberg D. Serious unexplained illness among injecting drug users in Scotland:
update. Eurosurveillance Weekly 2000; 4: 000601. (http://www.eurosurv.org/2000/000601.htm)
11. Greater Glasgow Health Board and the Scottish Centre for Infection and Environmental Health.
Unexplained illness among drug injectors in Glasgow. Eurosurveillance Weekly 2000; 4: 000518.
(http://www.eurosurv.org/2000/000518.htm)
12. Høiby EA, Caugant DA, Ringertz SH, Jensenius M, Fossum K, Hoel T, et al. Systemic anthrax in an
injecting drug user: Oslo, Norway April 2000. Eurosurveillance Weekly 2000; 4: 000504.
(http://www.eurosurv.org/2000/000511.htm)
Reported by Johanna Reilly ([email protected]), Scottish Centre for
Infection and Environmental Health, Glasgow, Scotland.
Dip into The Lancet Infectious Diseases
A preview issue of a new journal, The Lancet Infectious Diseases, has appeared on the web
(1). The first full issue of what will be a monthly journal (print and online) is due to arrive in
August 2001, and browsers are welcome to try the preview free of charge.
The journal’s role appears to be as a vehicle for news and reviews, and as a forum for
debate, rather than a place in which to publish original reports. A wide range of topics is
covered in the preview issue - infection risks associated with earthquakes, hepatitis C
therapy, defences against biological warfare with smallpox, dengue, malaria, treatment of
sepsis and hospital acquired infections, and tickborne erhlichioses.
Dip in, but be warned when printing out. The page is set up to give a wide left margin and
miss out the right hand edge of the text, as I discovered 28 pages later.
Reference:
1. http://infection.thelancet.com/ accessed 22 May 2001.
Reported by Stuart Handysides ([email protected]), Eurosurveillance editorial
office.