During week 51 2008 (week ending December 21st), the general practitioner consultation rate for influenza-like illness (ILI) in Ireland increased to 61.6 per 100,000 population from a rate of 38.1 per 100,000 during week 50 (week ending December 14th). This rate continues to exceed the Irish baseline threshold of 17.8/100,000 (to assess influenza activity during the 2008/2009 influenza season in Ireland) above which the use of antiviral drugs is triggered. The rate of increase was most pronounced in the 0-4 years and the 5-14 years age categories. Genetic characterisation of the two influenza A (H3) viruses identified this season confirms them to be A/Brisbane/10/2007 which is included as a component in the 2008/2009 influenza vaccine. The flu report for week 51 is available here.
Due to the levels of influenza activity seen last week in Ireland, antiviral drugs for the prevention and/or treatment of influenza in at-risk patients continues to be recommended in line with the National Institute of Clinical Excellence (NICE) UK guidelines.
In line with the National Institute of Clinical Excellence (NICE) UK guidelines, the use of antiviral drugs for the treatment or prevention of influenza in at-risk patients is now recommended.
A summary of the NICE guidelines for the use of antiviral drugs for the treatment or prevention of influenza in at-risk patients is available here.
The complete NICE guidance are outlined below: Recommendations on the use of antiviral neuraminidase inhibitors for the treatment of influenza when influenza is known to be circulating in the community. http://www.nice.org.uk/Guidance/TA58.
Influenza Vaccine As influenza-like illness rates are increasing and influenza A is circulating, it is also important that persons in at-risk groups for influenza are vaccinated as these groups are at higher risk of developing complications from influenza.
Risk groups for influenza vaccine are outlined below as per the Immunisation Guidelines for Ireland 2008 (Chapter 7). They are as follows:
Those older than 6 months of age who are at increased risk of influenza-related complications including the following groups:
Persons aged 50 years or older as recommended by WHO*
Those with chronic illness requiring regular medical follow-up (e.g. chronic respiratory disease, including cystic fibrosis, moderate or severe asthma, chronic heart disease, bronchopulmonary dysplasia, diabetes mellitus, haemoglobinopathies, chronic renal failure, etc.)
Immunosuppression due to disease or treatment, including asplenia or splenic dysfunction
Children on long-term aspirin therapy (because of the risk of Reyes Syndrome)
Children with any condition (e.g. cognitive dysfunction, spinal cord injury, seizure disorder, or other neuromuscular disorder) that can compromise respiratory function
Residents of nursing homes, old people’s homes, and other long-stay facilities where rapid spread is likely to follow introduction of infection
Those likely to transmit influenza to a person at high risk for influenza complications (including household contacts and out-of-home caregivers)
Healthcare workers, both for their own protection - as these are a group likely to come in contact with influenza during outbreaks - and for the protection of their patients
Poultry workers, veterinary inspectors, agricultural workers, park rangers and those with likely contact with water fowl (as this puts them at risk of co-infection with avian influenza)
Pregnant women in the risk groups 2 and 3 listed above should be vaccinated before the influenzas season, regardless of the stage of pregnancy. Studies indicate that pregnancy may increase the risk of complications from influenza because of the alterations in heart rate, lung capacity and immunological function. It is estimated that immunisation could prevent 1-2 hospitalisations per 1,000 pregnant women. Because influenza vaccine is not a live vaccine it is considered safe in pregnancy.
*Currently HSE are implementing this in those aged 65 years and over
Botulism outbreak among injection drug users in Dublin
The Health Protection Surveillance Centre has been notified of six cases of botulism occurring in injection drug users in the Dublin region since the end of November. Additionally, one death associated with disease has been reported in an injection drug user (10th December 2008).
The incident is being managed by an outbreak control team from the Department of Public Health (East) and alerts have been issued to drug services and relevant clinical staff in emergency departments and other locations.
HPSC urges all clinicians and other health professionals to be on the lookout for botulism in injecting drug users. Injection drug users who may unknowingly be exposed to drugs that may be contaminated with the bug that causes botulism are urged to seek immediate medical attention if they develop any of the signs or symptoms of the disease.
Disease may develop between 4-14 days after use of contaminated drug. Symptoms typically begin with a dry mouth, blurred or double vision, drooping eyelids, difficulty swallowing, difficulty speaking and may progress to breathing problems, weakness of arms and legs and more severe paralysis. Any injection drug user who experiences these symptoms should seek medical attention immediately. Most people with botulism will recover with treatment, but it can take months. Even in countries with treatment the disease is fatal in 5-10% of cases.
Botulism outbreaks have previously been reported among injection drug users, most recently in 2002 when 3 cases were reported. Using contaminated heroin is a risk factor for botulism, particularly among drug users who inject the drug either into the muscle or under the skin (skin popping).
Cases increasing in Zimbabwe's cholera outbreak
Since August 2008, an extensive outbreak of cholera has been affecting much of Zimbabwe, adding to the already extensive burden of starvation being faced by much of the population. As of 8 December, more than 15,000 suspected cases including 774 deaths (giving an overall case fatality rate of 4.9%) have been reported from 9 of 10 provinces in Zimbabwe. Around 60% of cases reported are in Harare, the capital. The fatality rates appear to be much higher in the more rural areas (as high as 50% in some reports). In addition cases are being reported in neighbouring countries; in South Africa (468 cases, with 9 deaths) and Mozambique (310 cases with 9 deaths).
Travellers to Zimbabwe should boil all water for consumption (including water for brushing teeth) or use bottled water produced by reputable companies. Ice cubes should be avoided. It is important to bear in mind that vegetables and salads may have been washed in contaminated water and should be avoided unless you are sure the water used to rinse them has been boiled or bottled. It is important to observe good personal hygiene and wash hands following use of the toilet and before eating or feeding small children.
Health professionals urged to lookout for botulism after four suspected cases in drug users
HPSC and the HSE East Public Health Department have been informed of four presumptive cases of wound botulism – all affecting injecting drug users - which are under investigation in the HSE Eastern Region.
Wound botulism is a rare condition and further test results are awaited to confirm these cases. Wound botulism is caused by a toxin that is commonly found as spores in soil. The illness can be caused if a wound is contaminated by soil or gravel. In recent years this type of botulism has been most commonly reported among chronic drug users. It occurs mainly in skin abscesses from injecting heroin but can also be caused by snorting cocaine.
Symptoms usually develop about 12-36 hours after exposure to the toxin and typically begin with blurred vision, difficulty swallowing, difficulty speaking and occasionally breathing problems. Diarrhoea and vomiting can also occur and the disease can progress to paralysis. Anyone who experiences these symptoms should seek medical attention immediately. Most people with botulism will recover with treatment, but it can take months. The disease is fatal in 5-10% of cases.
Botulism has previously been reported in drug users but few cases are seen in Ireland. The last cases of botulism in drug users occurred in 2002 when three injecting drug users developed botulism.
World AIDS Day, December 1st 2008
1 December 2008 marks the 20th anniversary of World AIDS Day. The theme of World AIDS day 2008 is “Lead – Empower – Deliver”, building on last year’s theme of “Take the Lead”. The World AIDS campaign for 2005-2010 is “Stop AIDS. Keep the Promise”. Further information on the World AIDS campaign and World AIDS Day 2008 can be found at http://www.worldaidscampaign.info/.
According to the latest global figures published by UNAIDS and the WHO in their 2008 report on the Global AIDS Epidemic, the number of new HIV infections has declined from 3 million in 2001 to 2.7 million in 2007. However, although the number of new infections has fallen in several countries, the AIDS epidemic is not over in any part of the world and rates of new HIV infections are rising in many countries including China, Indonesia, the Russian Federation and Ukraine. It is estimated that there are 33 million people living with HIV worldwide with nearly 7,500 new infections each day. Further information on the global HIV and AIDS pandemic can be found on the UNAIDS website www.unaids.org.
Since the beginning of 2008 there has been an increase in mumps cases notified to the HPSC, with nearly a thousand cases reported by mid-November. Most cases are teenagers and young adults (15-24 year age group) with smaller numbers occurring among younger and older individuals.
Many outbreaks are reported in colleges, universities as well as in the general community.
Why is this increase occurring? From the data available to HPSC it appears that the majority of mumps cases are either unvaccinated or only partially vaccinated (only received one dose of MMR). Full vaccination requires two doses of MMR.
Why are we not seeing as many cases in the very young and older individuals? The lower incidence of disease in younger children is most likely related to better immunity among this group because these children are more likely to have received two doses of MMR in recent years. Older individuals are more likely to have immunity as a result of infection when they were children.
How effective is the vaccine? Outbreak based studies have demonstrated that the two doses of the MMR vaccine will protect between 80%-95% of individuals against mumps. During outbreak periods some cases are expected among vaccinated individuals because not all individuals will have protective immunity. Without vaccination more cases would occur.
What can be done to prevent mumps? The best way to prevent mumps for individuals who are not immune is by getting the MMR vaccine.
In the childhood immunization schedule MMR is already routinely given to children after 12 months of age and at 4-5 years of age.
Children who are older than 5 years of age and have not already been vaccinated through the school programme or by their GP and young adults (particularly those < 25 years of age) who have not received 2 doses of MMR should be vaccinated by contacting their GP.
Individuals who don’t know how many doses of MMR they have received Many individuals do not know what vaccines they had in childhood - in which case it is recommended that young adults and teenagers who have missed out on the school programme should receive at least one dose of the MMR vaccine to protect against the disease.
Where can people get the MMR vaccine? GPs are provided with the MMR vaccine from the National Immunisation Office. Payments for vaccine administration (but not the vaccine) may apply for some individuals.
The National Virus Reference Laboratory (NVRL) has identified the first case of influenza A virus this winter. The case was detected by a network of 54 sentinel general practices who report weekly on the number of patients with influenza-like illness.
The network was established by the Health Protection Surveillance Centre, in partnership with the Irish College of General Practitioners and the NVRL in 2000.
Commenting on the cases, HPSC Specialist in Public Health Medicine, Dr Joan O Donnell said that the first two confirmed cases of influenza this season have been detected even though overall influenza activity is low. In total, 150 laboratory confirmed cases of influenza were detected through the sentinel network during the 2007/2008 season, peaking in January 2008.
“As we enter the influenza season it is recommended that people in high-risk groups get vaccinated against influenza. These include:
The over 65s
People including children with severe illness such as chronic heart disease, chronic lung disease and diabetes
Those with lower immunity due to disease or treatment including those who have had their spleens removed
Children or teenagers on long-term aspirin therapy
Residents of nursing homes, old people’s homes and other long stay facilities
Health care workers
Poultry workers, veterinary inspectors, agricultural workers, park rangers and those with likely contact with water fowl (as influenza puts them at risk of co-infection with avian influenza)
“The symptoms of influenza infection usually develop over a matter of a few hours and include a high temperature, sore muscles, dry cough, headache and sore throat. This is different from the common cold, which tends to come on more gradually and usually includes a runny nose and a normal temperature. Anyone in the high risk categories who develops influenza symptoms should contact their GP.”
The weekly influenza surveillance reports are available to view here.
2008/2009 Influenza Season - FAQs from ECDC
Frequently asked questions from ECDC on the start of the Influenza Immunisation and Surveillance Season Week 40 (October) 2008 are available here.
The Influenza Season 2008/2009 commenced last week (Week 40 29/9/08). The first Influenza Surveillance Report of the season will be published by HPSC on Thursday 9th October 2008 and available to view here.
For more information from HPSC on seasonal influenza click here.
Salmonella Outbreak Ireland, the UK - update 01/10/08
The HPSC, the National Salmonella Reference Laboratory and the Food Safety Authority of Ireland (FSAI) are currently working with national HSE public health partners and Public Health agencies in the UK and Europe to investigate an outbreak of Salmonella Agona (S. Agona). This outbreak was recently identified in Ireland and the UK, and now also in Austria, Finland, France and Sweden. Eleven cases have been reported in Ireland, an increase on previous years when three, five and ten cases of S. Agona were notified in 2007, 2006 and 2005, respectively.
To date, 163 individuals have been notified as S. Agona cases, England (96 cases), Scotland (34 cases), Ireland (11 cases), Wales (11 cases), Northern Ireland (2 cases), Finland (1 case), France (3 cases), Austria (1 case), Luxembourg (2 cases) and Sweden (2 cases). Testing is underway to identify whether other individuals, also infected with salmonella species have the outbreak strain.
Information gathered by the outbreak control team has shown that contaminated products produced by Dawn Farm Foods, The Maudlins, Naas, Co. Kildare, have been associated with this outbreak. These include beef and bacon products which have been withdrawn from sale.
Further information is available on the FSAI website www.fsai.ie. For FSAI press releases click here.
People infected with Salmonella develop diarrhoea, fever, and abdominal cramps 12 to 72 hours after infection. The illness usually lasts 4 to 7 days, and most people recover without treatment. However, diarrhoea can occasionally be severe enough to warrant hospital admission. The elderly, infants, and those with impaired immune systems are more likely to have a severe illness. Consumers who believe any food they have eaten has made them ill should seek medical advice.
Further information on Salmonellosis can be found here.
Increase in Mumps Cases
The Health Protection Surveillance Centre (HPSC) has noted an increase in the number of mumps cases reported in 2008 compared to the previous year. To date in 2008, 459 mumps cases have been reported to HPSC, 22 of whom were admitted to hospital. Almost 60% of reported cases are in the 10 to 24 year age group. This follows 142 cases in 2007, 427 in 2006 and 1079 cases in 2005 which was due to a nationwide outbreak that year. Several mumps outbreaks have been notified in third level colleges and in schools, both primary and second-level this year.
Since 2004, teenagers and young adults have been most affected by mumps. Most individuals affected by mumps either never received or received just one dose of MMR (measles, mumps and rubella) vaccine. MMR protects against measles, mumps and rubella and two doses are needed to provide protection against infection. The vaccine is free although an administration fee may apply for non-medical card holders. The vaccine is available from GPs or student health services in third level colleges.
Mumps is a contagious acute viral illness which causes fever, headache and painful swollen glands. Complications are usually mild but it can cause meningitis, deafness and inflammation of the testicles, ovaries or pancreas. It is important to be aware that the best way to avoid it is to get vaccinated. It is also advised that anyone who has mumps should stay off work/college/school/crèche etc for nine days after the onset of swollen glands.
On 10 July 2008, the authorities in The Netherlands reported one confirmed case of Marburg fever. The case involves a woman who had recently returned from a holiday in Uganda. The travel included a visit to two caves in the Maramagambo forest. It is thought that she contracted the disease from contact with fruit bats.
It is important that people intending to travel to Uganda should be aware there may be a risk related to visiting caves in the Maramagambo forest.
The Swiss Federal Office of Public Health (FOPH) wishes to advise visitors to Switzerland about the on-going measles outbreak in Switzerland and the risk of acquiring tick-borne encephalitis in certain areas of Switzerland or Austria.
Football fans warned about measles vaccination following major disease outbreaks in Euro 2008 host countries
The Health Protection Surveillance Centre has warned football fans planning to travel to this summer’s Euro 2008 tournament to make sure that they have been vaccinated against measles, following major outbreaks of the disease in Austria and Switzerland, who are jointly hosting the competition.
While Ireland did not qualify for the tournament some fans may still travel and should be aware that measles is an extremely contagious and potentially fatal disease. These European outbreaks are a reminder of the importance of vaccination, especially for children, as it is the only safe and effective way to prevent measles from spreading. High levels of MMR vaccination are needed to protect against infection and to protect very young children - under 12 months of age - who are too young to be vaccinated.
While measles usually occur in children under four years old, people of any age if not already protected through natural infection or vaccination, can catch the disease. Severe disease and complications are most likely in young children under five years and adults over 20 years. It is important to realise that almost half of the deaths associated with measles occur in previously healthy children and young adults. The European outbreaks are a timely reminder to get vaccinated. MMR uptake for Irish children at 24 months of age in Ireland currently stands at 88% - which although the highest level ever recorded here - is still short of the 95% needed to prevent the virus from circulating and causing outbreaks. MMR is usually given in childhood – the first dose at 12 -15 months and the second at 4 - 5 years of age. Both the MMR vaccine and the administration fee is free for all children. Most adults, particularly those born before 1978, are likely to have already had measles infection. However, any individual in this age group who has never had measles infection or the measles vaccine should speak with their GP about getting it prior to travel. For adults administration fees may apply.
Clostridium difficile associated disease (CDAD) becomes a notifiable disease under the Acute Infectious Gastroenteritis Disease (AIG) category, from May 4th 2008
The Department of Health and Children has recently communicated to the HSE that Clostridium difficile (toxin producing) should be notifiable under the category of “Acute Infectious Gastroenteritis (AIG)”.
Notification of CDAD under the disease category of acute infectious gastroenteritis (AIG) is an interim measure until the specific disease and its related organism, Clostridium difficile (toxin producing), is specified on the Infectious Diseases Regulations schedule of notifiable diseases.
Beginning on the week commencing 4th May 2008, all medical practitioners or clinical directors of diagnostic laboratories are asked to notify all cases of Clostridium difficile – associated disease (CDAD) as per amended AIG case definition, to the relevant Department of Public Health. All new events of CDAD will be entered onto the national Computerised Infectious Disease Reporting (CIDR) system and weekly reports will be produced by HPSC and made available on the HPSC website
For more information on C. difficile and the amended Acute infectious gastroenteritis definition please click here.
Brazil reports significant upsurge in cases of Dengue
Brazil is reporting a significant upsurge in cases of Dengue. This mosquito borne disease is endemic in Brazil and outbreaks are frequently reported. Dengue produces a flu-like illness that can be unpleasant but mild. Occasionally, the disease can progress to Dengue Haemorrhagic Fever, a severe and often fatal form of the disease.
Up until the end of March 2008, Brazilian health authorities have reported more than 4000 cases of dengue hemorrhagic fever, with 34 deaths. Brazil is seeing many thousand cases more of uncomplicated Dengue Fever this year as compared with last year.
The Brazilian states most affected include Amazonas, Rondonia, Sergipe, Bahia, Rio Grande do Norte, Para, and Rio de Janeiro.
There is no vaccine available to protect against dengue. Travellers can reduce their risk of infection due to Dengue (and to other mosquito borne disease such as Yellow Fever and Malaria) by practising mosquito bite avoidance measures. Further information on Dengue Fever can be found here and ways to reduce the likelihood of being bitten by mosquitoes can be found here.
ECDC warns of upsurge of measles in Europe: unvaccinated people are at risk
In 2007, several European countries experienced high numbers of measles cases, notably Switzerland, and to a lesser extent the United Kingdom (UK) and Romania (more than one case per 100,000 population per year). Full data for measles cases in Europe for 2007 can be found on the website of EUVAC.Net, a European Union (EU) -funded Surveillance Community Network for Vaccine Preventable Infectious Diseases .
So far in 2008, over 1,300 measles cases have been reported in Europe. These cases have been in Switzerland, the UK, France, Denmark, Germany, Austria, Spain and Norway (unpublished EU data). The European Union alert system for communicable diseases guarantees that information on these outbreaks is shared between the Member States, the European Commission, the ECDC and the World Health Organization. On April 2, the Centers for Disease Control and Prevention in the United States (US) issued a health advisory regarding cases in several US states, some of which were linked to ongoing outbreaks in Europe and Israel . Since then, more US states and Canada have reported additional cases [3,4,5,6,].
In Europe, very few countries have reached the target of 95% measles vaccination coverage which is necessary to prevent outbreaks and eliminate the disease. Different factors contribute to low vaccination coverage, e.g. some people refuse to be vaccinated, and other groups may be hard to reach such as nomadic populations or specific religious communities . This results in a significant proportion of the European population remaining at risk for acquiring measles. Exposure to the virus may come from travellers who have visited outbreak-affected or endemic areas, as has been reported in the US.
ECDC would like to raise awareness of the ongoing measles outbreaks in several European countries and wants to use this as an opportunity to reiterate the importance of measles vaccination, which is the best available measure for preventing infection. Full protection is obtained by two consecutive doses of measles-containing vaccine. Further details on vaccination schedules can be obtained from national authorities.
In the light of the World Health Organization’s goal to eliminate measles in the European Region by the year 2010, the current outbreaks are worrying. Improving measles vaccination coverage is essential to containing and preventing further such outbreaks, and for reaching the goal of elimination .
3. Health Department advises New York city residents to make sure they have had measles shots before traveling abroad. New York City Department of Health and Mental Hygiene, New York, United States. 8 April 2008. Press release. Available from: http://www.nyc.gov/html/doh/html/pr2008/pr024-08.shtml
Brazil is currently experiencing an epidemic of dengue fever, with 49 deaths in the state of Rio de Janeiro this year, according to local health officials. Around 32,000 cases of dengue have been reported in the state this year, most of them in the capital city Rio de Janeiro. Recent media articles have stated that the capital registered 1,100 cases of dengue fever between March 17 and March 18 and that 80 cases of dengue are being reported every hour.
Brazil as a whole reported almost 560,000 cases of dengue in 2007, and 158 deaths . On 19 March, Brazil's Ministry of Health announced that it had established a dedicated crisis office to tackle the epidemic . Paraguay and other countries in Latin America have also been experiencing large outbreaks of dengue fever in recent months. The majority of cases in the region occur between January and May, corresponding to the rainy season in most of the affected countries.
Dengue fever is a viral disease endemic in the Americas, Asia, the Pacific, the Caribbean and Africa. Humans are infected with dengue virus through bites of Aedes mosquitoes. There are four closely related but serologically distinct dengue virus serotypes, all of which have the potential to cause either classic dengue fever or the more severe form of the disease, dengue haemorrhagic fever. The main clinical symptoms of classic dengue are fever for two to seven days, severe headaches with pain behind the orbits of the eyes, severe muscle and joint pain, nausea and vomiting. Although dengue fever does not naturally occur in the continental European Union, it is frequently reported by travellers.
There is currently no vaccine to prevent dengue or dengue haemorrhagic fever. Travellers to endemic countries instead need to rely on the following preventive measures to minimize the exposure to mosquito bites:
Use anti-mosquito devices (insecticide-treated bed nets, coils, smudge pots, spray, repellents) and wear long-sleeved and long-legged clothes, especially during the hours of highest mosquito activity (two to three hours after dawn and during the early evening morning and late afternoon). Mosquito repellent based on a 30% DEET concentration is recommended.
Before using repellents, pregnant women and children under the age of 12 years should consult a physician or pharmacist.
For infants younger than three months old, repellents are not recommended; instead, insecticide-treated bed nets should be used.
For more information on preventing dengue and ECDC's work on this disease, please see the following links:
World TB Day is held on March 24th each year and provides an opportunity to raise awareness about the international health threat presented by tuberculosis (TB). It is a day to recognise the collaborative efforts of all countries involved in fighting TB. TB can be cured, controlled, and with diligent efforts and sufficient resources, eventually eliminated.
The slogan for World TB Day 2008 is “I am stopping TB”. This year's World TB Day is about celebrating the lives and stories of people affected by TB: women, men and children who have taken TB treatment; nurses; doctors; researchers; community workers--anyone who has contributed towards the global fight against TB.
TB - The Facts TB remains a leading cause of death worldwide with up to 9 million cases and 1.6 million deaths reported per year. It is a disease closely related to poverty and more than 80% of the infected cases live in developing countries.
In 2005, (the latest validated figures) there were 450 cases of TB reported in Ireland, a notification rate of 10.6 cases per 100,000 population. In 2006, there were 458 cases provisionally reported to HPSC, a notification rate of 10.8/100,000. The rate in the indigenous population was 8.3 per 100,000 in 2005 while the rate in foreign-born persons was 24.8 per 100,000. There has been a considerable decline in TB cases since the early 1950s when 7,000 cases of TB were notified annually.
Measles outbreaks in Europe and United States - information for travellers
HPSC has been informed about a number of reported measles outbreaks occurring in Europe and the United States. These reports are summarised in the following sections. To date, HPSC is unaware of any Irish cases linked to these outbreaks. However, measles cases continue to be reported in Ireland. During the first 10 weeks of 2008, 14 measles cases were reported nationally, but only one was laboratory confirmed.
These outbreaks may place unimmunised Irish travellers to these destinations at risk of this highly infectious and potentially very serious disease. Two doses of MMR vaccine are recommended for all children and young adults to prevent infection with measles.
France Between January 21st and March 17th 2008, 16 measles cases were reported in the city of Reims, the Marne district (department), Champagne region, North-eastern France.
The first case occurred in a non-vaccinated young woman on January 21st 2008. She was hospitalised for pneumonia. Subsequently, her two young children and two other young adult household contacts were also diagnosed with measles, three of whom were also hospitalised. During her admission to hospital transmission of the measles virus occurred in the hospital to three hospital staff, a medical student and three hospitalised children (aged 11 months to 7 years). An additional four measles cases have been reported in Reims, and appear to be related to another strain.
Switzerland This nationwide outbreak has been ongoing since November 2006. Measles outbreaks are reported particularly in the cantons of Lucerne, Basel-Land, Zurich, Bern, Aargau and Geneva. In recent years, Switzerland has had a particularly high incidence of measles compared to other European countries. The current outbreak has mainly affected unvaccinated children of school age, but also unvaccinated young adults. Transmission occurred primarily in families and schools. As many Irish people may be travelling to Switzerland for the European football championship (EURO 2008) in June, MMR vaccination is recommended for all children and young adults who have not already received two doses.
Germany In February, German Health Authorities published a preliminary report in Eurosurveillance on 16 measles cases occurring in the region of Baden-Württemberg, south-west Germany. Some cases in this outbreak relate to German citizens with residence in Switzerland or to Swiss citizens who commute to Germany.
Denmark Danish Authorities have published data in the February edition of Eurosurveillance on an outbreak of five measles cases in Copenhagen. The index case was a 23-year-old unvaccinated man who developed a rash on 12 January 2008, nine days after his return to Denmark after travelling to Nepal and India. The following four cases were a 24-year-old woman, a 10-month-old girl, a 26-year-old woman and a 39-year-old man with onset of rash on 1 February. The second case was the girlfriend of the index case. Two cases are believed to have been infected from the index case while at the waiting room of two different general practitioners' practices and another one in the hospital to which the index case was admitted.
USA Twelve measles cases have been reported in San Diego, California linked to a measles case in a seven year old unvaccinated boy who returned from Switzerland with his family in mid-January 2008. Subsequent spread occurred among his two non-immunised siblings, school contacts, friends and children attending the same paediatrician's office. For further information on the USA outbreak please see the CDC report published in the MMWR on 29th February 2008.
Reminder about need for MMR vaccination for travellers and Irish residents:
Travel between Ireland and the aforementioned European countries, as well as more distant countries where measles is endemic, is common.
MMR vaccination is routinely recommended for all children at 12-15 months of age and a second dose is administered at 4-5 years of age. Older children and young adults who have not received at least two doses of MMR are advised to contact their GP for this vaccine. The vaccine is free.
All individuals travelling abroad should review their immunisation records and obtain MMR vaccination if required. Vaccination is particularly important for children and young adults who may be travelling as part of school groups, for business or on pleasure.
To prevent transmission in health care settings all health care workers and health care students should also be appropriately vaccinated.
Resistance to oseltamivir (Tamiflu) found in some European influenza virus samples
Preliminary results from the National Virus Reference Laboratory (NVRL) on antiviral drug susceptibility among seasonal influenza viruses circulating in Ireland has revealed that some of the A (H1N1) viruses in circulation this winter are resistant to the antiviral drug, oseltamivir (also know by the brand name Tamiflu). The NVRL conducted nucleotide sequencing on specimens taken by sentinel GPs between December 2007 and January 2008. As of February 20th 2008, three of 29 specimens (10.3%) tested by the NVRL have shown resistance to oseltamivir. The NVRL is currently arranging for further Irish samples to be tested. To date, oseltamivir resistant viruses have been detected in 15 European countries (including Ireland), the USA, Canada, Australia and Hong Kong. In Europe, the highest proportion of resistant viruses to date has been in Norway where 63 (66%) of the 95 samples tested positive for resistance to oseltamivir. The second highest proportion was noted in France with 80 (39%) of 207 specimens showing oseltamivir resistance. The latest European data is available from the European Centre for Disease Prevention and Control (ECDC).
Experts from ECDC, the European Commission, the European Influenza Surveillance Scheme (EISS) and the World Health Organization (WHO) are currently assessing the significance of this information. An interim risk assessment has been published by ECDC.
The current influenza vaccine provides good protection against A/H1N1 viruses. Current national guidance on use of antivirals for treatment and prophylaxis of influenza remain in place though they are being kept under review. For information on seasonal influenza and how to protect yourself against it click here.
Resistance to oseltamivir (Tamiflu) found in some European influenza virus samples
Preliminary results from a survey of antiviral drug susceptibility among seasonal influenza viruses circulating in Europe has revealed that some of the A(H1N1) viruses in circulation this winter are resistant to the antiviral drug, oseltamivir (also known by the brand name Tamiflu). So far, 437 influenza A(H1N1) viruses isolated during November 2007 to January 2008 from eighteen European countries have been tested. Of these 59 (13.5%) have shown evidence of resistance to oseltamivir. The highest level of resistance has been seen in Norway, where 26 of 37 samples (70%) have been resistant. In the UK, 8 of 162 samples (4.9%) have been resistant. The National Virus Reference Laboratory is currently arranging for Irish samples to be tested. This information is published in Eurosurveillance.
Experts from the European Centre for Disease Prevention and Control (ECDC), the European Commission, and WHO are currently assessing the significance of this information. An interim risk assessment, prepared by ECDC, and based on the limited data currently available, is available here. Frequently Asked Questions, prepared by WHO/ECDC are available here.
The current influenza vaccine provides good protection against A/H1N1 viruses. Current national guidance on use of antivirals for treatment and prophylaxis of influenza remain in place though they are being kept under review. For information on seasonal influenza and how to protect yourself against it click here.
Increase in Influenza-like illness
Influenza Season 2007/2008 During week 1 2008 (week ending January 6th), the general practitioner consultation rate for influenza-like illness (ILI) in Ireland increased to 52.4 per 100,000 population from a rate of 16.3 per 100,000 for week 52, 2007. This rate exceeds the threshold at which the UK National Institute of Clinical Excellence (NICE) guidelines (2003) for the use of antiviral drugs is triggered. ILI rates increased in all age groups and are highest in the 15 to 64 year age group. Much of the increase is from cases of influenza A in the 15 to 64 year age group. A small number of influenza B cases have also been reported.
In line with the NICE guidelines, the use of antiviral drugs for the prevention or treatment of influenza in at-risk groups is now recommended.
A summary of the NICE guidance is given below for ease of reference:
Recommendations on the use of antiviral neuraminidase inhibitors for the treatment of influenza when influenza is known to be circulating in the community
Algorithm for the use of antiviral drugs for the prevention (prophylaxis) of influenza
Note: The NICE algorithm on prescribing oseltamivir (Tamiflu) for prophylaxis refers to using oseltamivir (Tamiflu) in persons aged 13 years and older. In January 2006, oseltamivir was licensed for prophylactic use in children aged one year and over. NICE are reviewing their current guidelines at present. In the meantime until NICE completes its review, it would be appropriate to use oseltamivir (Tamiflu) for prophylaxis in persons aged 1 year and over according to the other conditions laid out in the above NICE algorithm for prophylaxis of influenza. Prescribers should also note a concomitant change to the licensed duration of post-exposure prophylaxis in children and adults which is now ten (10) days (as opposed to the previous seven (7) days).
Influenza Vaccine As influenza-like illness rates are increasing and influenza A and B are circulating, it is also important that persons in at-risk groups for influenza are vaccinated as these groups are at higher risk of developing complications from influenza.
Risk groups for influenza vaccine are outlined below as per the Immunisation Guidelines for Ireland 2002 (Chapter 7)
All persons aged 65 years or older
Persons with chronic illness requiring regular medical follow-up such as chronic heart disease, chronic lung disease, chronic renal disease, diabetes mellitus etc.
Persons who are immunosuppressed due to disease or treatment, including asplenia or splenic dysfunction
Children and teenagers on long-term aspirin therapy
Residents of nursing homes, old people's homes and other long stay facilities where rapid spread is likely to follow introduction of infection
Health care workers and carers of those in at risk groups.
HPSC advises employers to prepare for vomiting bug
The Health Protection Surveillance Centre today (Tuesday) issued advice for employers on how to deal with norovirus (aka winter vomiting bug), following an increase in the incidence of the illness.
HPSC Specialist in Public Health Medicine, Dr Paul McKeown said that because norovirus is highly contagious it can be very disruptive to organisations and can easily infect staff, customers and clients.
"It will never be possible to prevent this illness completely, but a few simple measures can greatly minimise its disruptive effects to business. Employers can prepare for the possibility of sickness in the workplace by having simple cleaning equipment available and staff assigned to clean and decontaminate soiled areas. Anyone who has norovirus should stay off work until their vomiting and diarrhoea has stopped and for 48 hours afterwards so that they do not infect others on their return.
It is one of the commonest forms of gastroenteritis - infecting as many as 5% of the population each year - and the main symptoms include vomiting and diarrhoea. However patients can develop headaches, muscle aches, fever, and abdominal pain. The onset is sudden and the illness is generally mild, although it can be more severe in older people. It rarely lasts more than a couple of days and most people make a full and rapid recovery," he said.