HPS Weekly Report

27 January 2015Volume 49 No. 2015/04ISSN 1753-4224 (Online)

CONTENTS

CURRENT NOTES

• Increasingnotificationsofmumps 39

•EbolainWestAfrica:12months on 39

•RCOG guideline on chickenpox in pregnancy 40

•RCOG/BASHH guideline on genital herpes in pregnancy 41

•EFSAStudy:fishconsumption-benefitsversusrisk 41

•EFSAre-evaluationofbisphenol A exposures 42

•Notificationtable 43

SURVEILLANCE REPORT

Travelhealth:HPSreportonlaboratory-confirmedtravel-relatedinfectionsreportedinScotland during 2014 44

CURRENT NOTESIncreasing notifications of mumps

49/0401HPSiscurrentlyrestatingtheadvicetoanyoneagedbetween20and35toensurethattheyarefullyvaccinatedagainstthemumpsvirus.Thisfollowsarecentthree-foldriseinnotificationsinthefirstthreeweeksof2015.Mostofthoseaffectedareyoungadults in Glasgow, Lanarkshire and Edinburgh with a particular outbreakoffamiliarpatterninstudentsreturningtostudiesatuniversity.

Themumpsvirusisspreadthroughrespiratorytransmissionfrominfectedindividuals.Theincubationperiodrangesfrom12-25days,andisusuallyabout18days.Amumpscaseisinfectiousfromaboutsix-sevendaysbeforeonsetofparotitisuntilninedaysafter,althoughcaseswhichshownoclinicalsymptomscanalsobecommunicable.

Clinicalfeaturesincludefever,headache,swellingofoneorbothcheeksorsidesofthejaw(parotitis)andswollenglands.Thefeverusuallylastsforonetosixdaysandtheparotitisforupto10days,ormore.Mumpscanhaveseriouscomplications,includingaseptic meningitis (4-6% cases), encephalitis (1 in 1000 cases), inflammationofthetestes(orchitis),pancreatitis,oophoritisandpermanentdeafness.Neurologicalinvolvementoccursin10-20%ofcasesandmayprecedeorfollowparotitis,andcanalsooccurinitsabsence.Orchitisisthemostcommoncomplicationofmumpsinadultmales(fouroutoftencases).Fulminantencephalitisisrare,butapotentiallyfatalcomplicationofmumps.

Ebola in West Africa: 12 months on

49/0402OneyearafterthefirstEbolacasesstartedtosurfaceinGuinea,theWorldHealthOrganizationhaspublishedaseriesof14papersthattakeanin-depthlookatWestAfrica’sfirstepidemicofEbolavirusdisease.Thepapersexplorereasonswhythediseaseevadeddetectionforseveralmonthsandthefactors,manyspecifictoWestAfrica,thatfuelleditssubsequentspread.

Themostextensivepaperstraceeventsineachofthethreemostseverelyaffectedcountries-Guinea,LiberiaandSierraLeone.These countries shared many common challenges, shaped by geography,culture,andpoverty,buteachalsofaced,addressedandsometimessolvedsomeuniqueproblems.

Keyeventsaresetoutchronologically,startingwiththechildwhoisbelievedtobetheindexcaseofthisepidemicthroughtotheDirector-General’scommitmenttosteadfastlysupportaffectedcountries until they reach zero cases.

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ThereportalsolooksbackatWHO’sresponseoverthepast12months,includingthe9Augustdeclarationofaninternationalhealthemergency.Itdocumentsthemanychallengesfacedbycountriesandtheinternationalcommunityindealingwiththelargest,longest,mostsevere,andmost complex Ebola outbreak in history.

Otherpapersprovideinsightinto:

•howthefast-trackdevelopmentofEbolavaccines,treatmentsandrapiddiagnostictestsisprogressing,withnocompromiseofsafetyandefficacystandards;

•howSenegal,NigeriaandlikelyMalimanagedtocontainimportedcasesandbringtheirownoutbreaksundercontrol;

•thestateofworldwidevigilanceandpreparedness,especiallyincountriestargetedbyWHOasbeingatgreatestriskofanimportedcase.

Thereportalsolooksahead,speculating(onthebasisoftheyear’sexperience)astowhatcriticalstrategiesandinterventionswouldgivecountriesandtheirpartnersthebestchanceofbringingsuchoutbreaksundercontrol.[Source:WHOMediaNote,15January2015.http://www.who.int/mediacentre/news/notes/2015/ebola-one-year-on/en/]

In a statement issued on 25 January, the WHO Director General has also noted that, while cases wereclearlydeclininginallthreecountries,continuedinternationaleffortwouldbeneededtoreachthecollectivegoalof‘zerocases’.[Source:DGSpeech,25January2015.http://www.who.int/dg/speeches/2015/executive-board-ebola/en/]

RCOG guideline on chickenpox in pregnancy

49/0403 Updated guidelines on managing chickenpox in pregnancy were published by the Royal CollegeofObstetriciansandGynaecologists(RCOG)on21January.

Chickenpox,orprimaryvaricella-zostervirus(VZV),isacommonchildhooddiseasethatusuallycausesamildinfection.Manywomenhaveantibodiestoprotectthemselvesagainstthevirusaftercontractingthevirusasachild,however,itisestimatedthatchickenpoxcomplicatesthreeinevery1000pregnancies.

TheRoyalCollege’srevised‘Green-topguideline’,nowinitsfourtheditionandavailableathttps://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg13/,coverspreventionofchickenpoxinpregnancy,managingwomenwhodevelopthevirusinpregnancy,treatmentoptions,modeofdelivery,riskstothebaby,adviceonbreastfeedingandrecommendationsforfutureresearch.

Theguidelinesstatethatwhenwomenbookforantenatalcaretheyshouldbeaskedaboutpreviouschickenpox/shinglesinfection.Womenwhohavenothadchickenpoxshouldbeadvisedtoavoidcontactwithchickenpoxandshinglesduringpregnancyandtoinformhealthcareworkersofapotentialexposurewithoutdelay.

Moreover,pregnantwomenwhodeveloptherashofchickenpoxshouldimmediatelycontacttheirdoctor.Theguidelinesalsostatethatwomenwhodevelopchickenpoxinpregnancyshouldbereferredtoafetalmedicinespecialistandthataneonatologistshouldbeinformedofthebirth.

Thetimingandmodeofdeliveryofthepregnantwomanwithchickenpoxmustbeindividualisedandwomenwithchickenpoxshouldbreastfeediftheywishtoandarewellenoughtodoso.[Source:RCOGNewsRelease,21January2015.https://www.rcog.org.uk/en/news/rcog-release-revised-guideline-on-chickenpox-in-pregnancy-published/]

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TheRCOGguidelinescomplementsthefollowinghealthprotectionresourcesforvaricellazoster(chickenpox):

•Green Book Chapter (Varicella) https://www.gov.uk/government/publications/varicella-the-green-book-chapter-34;

•PHEGuidanceonViralRashinPregnancyhttps://www.gov.uk/government/publications/viral-rash-in-pregnancy;

•PHEVZIGGuidancehttps://www.gov.uk/government/publications/immunoglobulin-when-to-use.

RCOG/BASHH guideline on genital herpes in pregnancy

49/0404ManagingthecareofwomenwithgenitalherpesinpregnancywasexploredinrecentguidelinesandpatientinformationpublishedjointlybytheRoyalCollegeofObstetriciansandGynaecologists(RCOG)andtheBritishAssociationforSexualHealthandHIV(BASHH).Theconsensusguideline(availableathttps://www.rcog.org.uk/en/guidelines-research-services/guidelines/genital-herpes/)replacespreviousseparateguidelinesandcoverstheinpatientandoutpatientmanagementofgenitalherpesintheantenatal,intrapartumandpostnatalperiods.Thenewpatientinformationisbasedontheguidelineandprovidesinformationforwomenandtheirfamilies.

Genitalherpesisacommoninfectioncausedbytheherpessimplexvirus(HSV).TherearetwotypesofHSV,type1andtype2.Bothtypescancauseinfectioninthegenitalandanalarea.Approximately50%ofneonatalherpesisduetotype1and50%duetotype2.

Neonatalherpesoccurswhenababycatchestheherpesvirusatbirth.Itcanbeserious,butisveryrareintheUK(1to2outofevery100,000newbornbabies).Thebabywillbecaredforinaneonatalunitwithaspecialistteamofdoctors.

Theriskoftransmissionisgreatest,however,whenawomanacquiresanewinfection(primarygenitalherpes)inthethirdtrimesterandparticularlywithinsixweeksofdelivery,asthebabyisunlikelytohaveprotectiveantibodies.

Theguidelinescovermanagementofwomenwithherpesinthefirstorsecondtrimesterandmodeofdeliveryforwomenwhohaveafirstepisodeinthethirdtrimester.Forwomenwithrecurrentgenitalherpeswheretheriskofneonatalherpesisverylow,theguidelinesstatethatvaginaldeliveryshouldbeanticipatedifthereisnootherreasontohaveacaesareansection.

Thenewinformationalsoprovidesadviceontreatmentforgenitalherpessuchasantiviraltabletswhicharesafetotakeinpregnancyandwhilebreastfeeding.TohelppreventpostnataltransmissionofHSV,adviceshouldbegivenaroundpractisingcarefulhandhygiene.[Source:RCOG News Release, 17 October 2014. https://www.rcog.org.uk/en/news/joint-rcogbashh-release-managing-genital-herpes-in-pregnancy--new-information-published/]

EFSA Study: fish consumption - benefits versus risk

49/0405Limitingconsumptionoffishspecieswithahighmethylmercurycontentisthemosteffectivewaytoachievethehealthbenefitsoffishwhilstminimisingtherisksposedbyexcessiveexposuretomethylmercury.ThisisthemainconclusionofastatementpublishedbytheEuropeanFoodSafetyAuthority(EFSA)ontherisksandbenefitsofseafood.EFSAisrecommendingthatindividualmemberstatesconsidertheirnationalpatternsoffishconsumptionandassesstheriskofdifferentpopulationgroupsexceedingsafelevelsofmethylmercurywhileobtainingthehealthbenefitsoffish.Thisparticularlyappliestocountrieswherefish/seafoodspecieswithahighmercurycontent-suchasswordfish,pike,tunaandhake-areconsumedregularly.

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Becauseofdifficultiesingeneralisingacrossthecontinent-therearelargevariationsintheproportionofpopulationsconsumingfish,inthefish/seafoodspeciesconsumedandintheaverageamountoffishconsumedbydifferentagegroupsacrossEurope-EFSAhascreatedscenariostogivesnapshotsofthesituationindifferentcountries.

These show that in some countries certain population groups - notably toddlers and children aged threetoten-reachedthesafetythresholdortolerableweeklyintake(TWI)formethylmercurybeforetheyreachedintakelevelsthatbroughtnutritionalbenefits.EFSAthereforeconcludesthat:

•fortoddlers,childrenandwomenofchildbearingage,thebenefitsofeatingfishshouldbemetbyincreasingtheconsumptionofspecieslowinmethylmercury;

•toprotectthefetusagainsttheadverseneurodevelopmentaleffectsofmethylmercury,womenofchildbearingageshouldnotexceedtheTWI;

•asthebrainisdevelopingalsoafterbirth,toddlersandchildrenregularlyexposedtomethylmercuryabovetheTWIshouldalsobeconsideredatriskfromtheneurotoxiceffectsofmethylmercury.

ThestatementbyEFSA’sScientificCommittee(accessibleathttp://www.efsa.europa.eu/en/efsajournal/pub/3982.htm)addressesthebenefitsoffish/seafoodconsumption,usingn-3long-chainpolyunsaturatedfattyacids(LCPUFA)asanexampleofabeneficialsubstance,comparedtotherisksofmethylmercuryinfish/seafood,inrelationtothenumberoffishservingsperweek.ItisbasedontwoearlierEFSAscientificopinionswhichlookedrespectivelyattherisksfrommercuryandmethylmercuryinfood,andthehealthbenefitsoffish/seafood.ThefirstopinionestablishedaTWIformethylmercuryof1.3mgperkgofbodyweight;thesecondrecommendedweeklyintakesoffishofbetweenonetotwoservingsandthreetofourservingsinordertorealisehealthbenefitssuchasimprovedneurodevelopmentinchildrenandreducedriskofcoronaryheartdiseaseinadultsrespectively.

Scenarioswerecreatedfordifferentpopulationgroupssuchastoddlers,adolescentsandadults.Thesewerebasedonthetypeoffish/seafoodspeciesandservingsizestypicallyconsumedbythesegroupsinvariousMemberStates,andtheresultingexposuretomethylmercuryandintakeofLCPUFA.Itwasthenestimatedhowmanyservingsoffish/seafoodperweekagivenpopulationgroupwouldneedtoreachtheTWIformethylmercuryandthedietaryreferencevalue(DRV)forLCPUFA.[Source:EFSAPressRelease,22January2015.http://www.efsa.europa.eu/en/press/news/150122.htm]

TheUKFoodStandardsAgency(FSA)hasrespondedbyreiteratingitsadviceonthisissueforUKconsumers,andisremindingpeopleoftheimportanceoffollowingtherecommendationsinthelightofEFSA’sreview.Forfurtherdetails,seeFSAnewsreleasehttp://www.food.gov.uk/news-updates/news/2015/13461/eating-fish-efsa.

EFSA re-evaluation of bisphenol A exposures

49/0406TheEuropeanFoodSafetyAuthority(EFSA)haspublishedamajorre-evaluationofbisphenolA(BPA)exposureandtoxicity.ThisassessmentconcludesthatBPAposesnohealthrisktoconsumersofanyagegroup(includingunbornchildren,infantsandadolescents)atcurrentexposurelevels.Exposurefromdietorfromacombinationofsources(diet,dust,cosmeticsandthermalpaper)isconsiderablyunderthesafelevel(the‘tolerabledailyintake’orTDI).

AlthoughnewdataandrefinedmethodologieshaveledEFSA’sexpertstoconsiderablyreducethesafelevelofBPAfrom50microgramsperkilogramofbodyweightperday(µg/kgofbw/day)tofourµg/kgofbw/day,thehighestestimatesfordietaryexposureandforexposurefromacombinationofsources(called‘aggregatedexposure’inEFSA’sopinion)arethreetofivetimeslower than the new TDI.

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UncertaintiessurroundingpotentialhealtheffectsofBPAonthemammarygland,reproductive,metabolic,neurobehaviouralandimmunesystemshavebeenquantifiedandfactoredintothecalculationoftheTDI.Inaddition,theTDIistemporarypendingtheoutcomeofalong-termstudyin rats, aimed at reducing these uncertainties.

BPAisachemicalcompoundusedinthemanufactureoffoodcontactmaterialssuchasre-usableplastictablewareandcancoatings(mainlyprotectivelinings).AnotherwidespreaduseofBPAisinthermalpapercommonlyusedintill/cashregisterreceipts.ResiduesofBPAcanmigrateintofoodandbeveragesandbeingestedbytheconsumer;BPAfromothersourcesincludingthermalpaper,cosmeticsanddustcanbeabsorbedthroughtheskinandbyinhalation.EFSA’sre-evaluationwaspromptedbythepublicationinrecentyearsofaveryhighnumberofnewresearchstudiesonthesubject.[Source:EFSANewsRelease,21January2015.http://www.efsa.europa.eu/en/press/news/150121.htm]

Notification table

49/0407ReaderswillnotethatthisissueoftheWeeklyReportdoesnotcontainthecustomaryNotificationTablesection.Owingtoachangeinthenotificationreportingprocedure,thepublicationscheduleofthesetablesiscurrentlyunderreview.Wehopetoresolvethisissueassoon as possible.

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Surveillance Report

Travel health: HPS report on laboratory-confirmed travel-related infections reported in Scotland during 2014

Preparedby:JamesMunro,ChrisRedman,FionaGenasi&SusanBrownlie

Introduction

Theriskofinfectionininternationaltravellersvariesaccordingtodestinationandmodeoftravel,amongotherfactors.1,2 Thecomplexinteractionofpathogenicity,immunity,behaviourandtheenvironmentmaycombinetoexposethetravellertoinfectionsnotencounteredathome.However,travel-relatedinfectionsarenotlimitedtotheexotic:travellersmayencounterinfectionsalsofoundathome,wheretheirriskofexposureisdifferent.

TherecentHPSreportontravel-relatedinfectioninpatientspresentingtotheBrownleeCentreinGlasgowshowedfebrileillnessandacutediarrhoeawerethemostcommonlyreportedconditions.3ApreviousstudyobservedthatScottishtravellerstodevelopingcountriesweremostfrequentlyaffectedbyfoodandwaterbornegastrointestinalinfectionsandbyrespiratoryinfections.4Studiesofothergroupsoftravellershaveshownskindisorderstobecommonlyreported.5,6

Somefebrileillnessesintravellers,whilepresentingadistressingexperiencefortheindividual,arelikelytobeself-limiting.Othershavethecapacitytocauseseriousillnessordeathandsomeareverylikelytodoso.7,8Further,infectionsacquiredduringtravelmayhavethecapacityfortransmissionintransitorwhenthetravellerarriveshomeoratanotherdestination.Effectivesurveillanceoftravel-relatedinfectioninformsprovisionofevidence-basedhealthadvicetothetraveller9andalsocontributestoprotectionofthedomesticpopulationfromimportedpathogens.InadditiontodiseaseseeninthosereturningtoScotlandfromtravelabroad,infectionsarealsoseeninforeigntravellersarrivinghere,asexemplifiedbyaproportionofimportedmalariacasesdiagnosed in Scotland.10

ConcernsabouttheprospectofimportedinfectionhavebeensignificantinScotlandthroughout2014.InJulyandAugust,thestagingoftheCommonwealthGamesinGlasgownecessitatedanenhancedsurveillanceeffortbyHPSinconjunctionwithNHSboards,theEuropeanCentreforDiseasePreventionandControlandPublicHealthEngland.Fromtheearlypartof2014therewasgrowinginternationaluneaseabouttheintensityandscaleoftheEbolavirusdisease(EVD)outbreakinWestAfrica,whichledtoincreasedactivityaimedatprotectingthepublicfromEVDintheeventofitsimportationintoScotland11aswellasactivityaimedatsupportingtheresponseinWestAfrica.

Travel abroad 2000 - 2013

Travel from the UKEstimatesoftravelabroadprovidedbytheUnitedKingdomOfficeforNationalStatisticsrevealedthat,afteralong-sustainedperiodofincreaseininternationaltravelfromtheUK,therewasafallin2008from69.0millionto58.6millionjourneys(Figure1).12Traveldeclinedto55.6millionjourneysin2010,13 but this has risen by 4% to 58.5 million in 2013.14TraveltoNorthAmericafromtheUKhasfollowedadownwardtrendbetween2000and2013,whileforAsiathetrendhasbeenupwardssince2009.TherehasbeenadecreaseintraveltoAfricasince2008whiletraveltoCentral&SouthAmerica&theCaribbeanhasbeengenerallyconstant.

Ofthe58.5millionforeignvisitsbyUKresidentsin2013,themajority(78%)weretoEurope,withanother6%,5%,4%and2%ofjourneystoNorthAmerica,Asia,Africa,andCentral&SouthAmerica&Caribbean,respectively.TraveltoAustraliaandNewZealandaccountedfor1%offoreignvisits.Forthesameperiod,holidaytravel,accountingfor64%offoreignvisits,fellbylessthan1%,asdidbusinesstravel.Travelinvolvingvisitstofamilyandfriends(VFRtravel)increasedby2%.

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FIGURE1:TravellersfromUK2000-2013(Source:OfficeforNationalStatistics,TravelTrends2013)

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Travel from Scotland In2013,therewereapproximately3.6millionjourneysabroadfromScotland,asinthepreviousyear,representing6%oftotaljourneysfromtheUK.Europe(78%)wasthemostvisiteddestinationfollowedbyNorthAmerica(7%),Asia(4%),Africa(3%),Central&SouthAmerica&theCaribbean(2%)andAustraliaandNewZealand(1%).

FIGURE2:TravellersfromScotland2000-2013(Source:OfficeforNationalStatistics,TravelTrends 2013)

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Surveillance of travel-related infections

MethodResultsofpositivelaboratorytestsforawidevarietyofpathogensarereceivedatHealthProtectionScotlandbyelectronictransferthroughECOSS.15ClinicaldiagnosesareonlyreceivedbyECOSSiftheyhavebeenrecordedwiththelaboratoryresult.Priorto2012,inconsultationwithstakeholders,theHPSTravel&InternationalHealthTeamreviewedandrevisedthetravel-associatedorganismsforwhichdataweretobecollected.CriteriaforepisodedefinitionwerealsoreviewedforeachorganismandappliedtotheECOSSdata.Thedatafor2014forselectedorganismswerecollated,episodecriteriacheckedandappliedandduplicatesremoved.

Itisassumedthatinfectionssuchasschistosomiasisandvector-bornevirusesarealwaystravel-relatedwhentheyareidentifiedinScotlandandarethereforeclassifiedasimported.InfectionsthatcanalsobetransmittedintheUKareonlyclassifiedasimportedwhentheappropriateinformationisrecordedintheECOSSreport.

Escherichia coliO157andmalariafiguresfor2014willbereportedlaterthisyear.

ResultsThenumberofreportsforthevariousorganismswasbroadlysimilartothatpublishedin2013.Allreportsaresubjecttoreviewandrevisionasfurtherinformationbecomesavailable.

Gastrointestinal protozoa In2014,therewere167episodesofGiardiain2014,36(22%)ofwhichwereimported.Thistotal included 121 (72%) Giardia lamblia, 19 (11%) G. duodenalis, 8 (5%) G. intestinalis and 19 (11%) Giardiasp.In2013therewerealso167episodes,althoughindifferentproportionsbyspeciescomparedto2014,ofwhich43(26%)werereportedasimported.In2014,431reportedepisodesofCryptosporidiumincluded31(7%)whichwereimported.Ofthese,354(82%)wereunspeciated, 46 (11%) were Cryptosporidium parvum, 29 (7%) were C. hominis and 2 (<1) were C. meleagridis.Thetotalfor2013wasalso431indifferentproportionsbyspeciescomparedto2014andofwhich24(6%)wereimported.In2014,11episodesofEntamoeba histolytica were reportedin2014,allofwhichwereimported.In2013,therewerethreeepisodesofE. histolytica, again all imported.

Enteric fever In2014,17episodesofentericfeverwerereportedtoHPSin2014comparedto2013whentherewere 14 episodes. The 2014 total comprised 10 (59%) SalmonellaParatyphiA,andseven(41%)S.Typhi.AlloftheS.ParatyphiAwerereportedasimported,aswerethree(43%)episodesofS. Typhi. In 2013 there were 10 S.Typhi,fourS.ParatyphiAandoneS.ParatyphiB,allofwhichwere imported.

RickettsiaIn2014,thereweresixepisodesofRickettsia,allofwhichwereimported,comparedtofivein2013, all imported.

Shigella In 2014, 90 ShigellaepisodeswerereportedtoHPSin2014,comparedto85episodesin2013.Thespeciesmostfrequentlyreportedin2014wasShigella sonnei (47, 52%). There were 34 (38%)episodesofS. flexneri, 4 (4%) S.boydi and 1 (<1%) S. dysenteriae. Four episodes (4%) ofShigellawereunspeciated.In2014,24%(22)ofShigella episodes were imported in 2014 compared to 34% (29) in 2013.

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Vibrio FiveVibrioepisodeswerereportedin2014,thesametotalasin2013.Ofthese,four(80%)wereV. choleraeofwhichthreeweretypedasnon-01/0139andonewasuntyped.Therewasone(20%)episodeofV. parahaemolyticus. All Vibrio episodes in 2014 were imported.

Hepatitis A and Hepatitis E Thirty-twoepisodesofhepatitisAand157ofhepatitisEweresubmittedin2014,ofwhich9%(3)and3%(5)respectivelywereimported.In2013therewere22episodesofhepatitisAand95ofhepatitisE,ofwhich1(5%)and3(3%)respectivelywereimported.

Vector-borne virusesAllvector-bornevirusesreportedinScotlandwereimported.Therewere28episodesofdenguevirusin2014,compared32in2013.Thenumberofreportsofchikungunyavirusrosetofivein2014,withtwohavingbeenreportedin2013.TherewerethreeepisodesofWestNilevirusin2014,thefirsttimethisvirushasbeenidentifiedinScotland.

Schistosomiasis In2014,203episodesofSchistosomainfectionwererecorded.Allbutoneofthesewereunspeciated,havingbeendetectedbyserologicaltesting.AsingleSchistosoma mansoni was speciated.In2013,therewere159episodesofSchistosomainfection,ofwhichtwowerespeciated - one S. haematobium and one S. mansoni.

Viral haemorrhagic feverTherewasoneepisodeofEbolavirusin2014,importedfromWestAfrica.

Discussion

Thisreportonlyconsidersthoseinfectionswhereaspecimenwastestedorexamined.Takeninisolationfromotherrecordingsystems,ECOSSdatacannotbereliedontoaccuratelyestimatelevelsofdiseaseinthetravellingpopulation.

HealthProtectionScotlandcarriedoutextensiveglobalanddomesticsurveillanceinrelationtotheCommonwealthGamesthroughoutthesummerof2014.InformationonoutbreaksfromacrosstheCommonwealthwascollatedandrisk-assessedbyHPSbeforeandduringtheGames.Therewasnoevidenceofchangesinimportationofinfectionduetotheevent.

Organismscausingtraveller’sdiarrhoea(TD)arefrequentlyreportedhere,aselsewhere.4,5,16 Escherichia coli, Salmonella, Shigella, Giardia and Entamoeba histolytica are all well-recognised causesoftraveller’sdiarrhoeawiththelattertwoorganismsmoreoftenseeninlong-termtravellers.17TDisoftenself-limiting,althoughsomediarrhoeagenicorganismswithglobaldistribution such as Vibrio cholerae, E. coli O157 and E. histolyticacanproducelife-threateningdisease.Gastrointestinalinfectiousdiseaseisoftendifficulttoprevent,giventhecausativeorganisms’widespreadenvironmentalandgeographicdistribution.Varyingproportionsofgastrointestinalinfectionswerereportedasbeingimportedin2014,butnotallrequestsfortestingareaccompaniedbypatientinformationincludingtravelhistory.

Gastrointestinalinfectionsareacquiredathomeaswellasabroad,butsomesuchasVibrio and entericfeverarestronglyassociatedwithtravel.Giardia and Cryptosporidium are commonly reported in Scotland and elsewhere in the UK, but only a small proportion are reported as being relatedtointernationaltravel,althoughschoolholidayactivitiesintheUKareoftenlistedamongthebiologicallyplausibleroutesofinfectionwithCryptosporidium.HPShasnoindicationofhowmanyshort-livedgastrointestinalinfectionsareacquiredabroadbutresolvebeforearrivalinScotland.

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Forsomepathogense.g.flaviviruses,18,19,20apositiveresultmayarisefromvaccinationorcross-reaction.Clinicalhistoryisoftenomittedfromlaboratoryreportsandtravelhistoryisalsofrequentlyabsent.Itistemptingtoassumethatpositiveserologyisindicativeofillnessorthatatestmusthavebeenprecipitatedbyspecificclinicalpresentation,butlaboratoryreportsalonedonotidentifyillnessandcanonlybeinterpretedfullyinthecontextofclinicalhistory.Occasionally,individualswilltestpositiveformorethanonepathogen.Inallcircumstances,surveillancecanbenefitfromeffectivecommunicationbetweenepidemiologistsandphysiciansusingclinicalreporting systems such as GeoSentinel.21

Theestablishmentofvector-borneimportedhumandiseaseisofcurrentinterestandconcernin Europe22 although in the United Kingdom ecological constraints limit the establishment and spreadofvectors.23,24,25Denguevirusis,again,themostfrequently-reportedvector-bornevirusinScotland.ImportedcasesofdenguefeverintravellersreturningtotheEUmaybetheoriginofsporadicdomesticoutbreaksinareaswherethemosquitovector(Aedes sp) is present.26 Cases ofautochthonousdenguehavebeenreportedinProvencein2010,27 and 2013.28 Chikungunya virushasbeenofsignificancetoEuropeantravellersin2014.AmajoroutbreakhasoccurredintheCaribbeanandtheAmericas,with170,000casesintheFrenchislandsoftheCaribbeantotheendoftheyear.29From1Mayto30November2014,1492casescompatiblewithdengueorchikungunyawerereportedinmetropolitanFrance.Ofthoseconfirmed,therewere443importedand11authochthonouschikungunya,163importedandfourautochthonousdengueandsiximportedco-infections.30WhiletherehavebeenfivereportsofChikungunyavirusinScotlandin2014,limitedtravelhistorymeansthatmostofthesereportscannotbelinkedtorecognisedoutbreak areas.

WestNileviruswasreportedinScotlandforthefirsttimein2014,withtworeportsfromtravellerswhohadbeenincountriesoutsideEuropewherethediseaseisendemic.However,WestNilevirusiswellestablishedinsouthern,centralandeasternEuropeandoccursannuallyinsomeareasofEuropethataredenselypopulatedandpopularwithtourists,notablythePoValleyofnorthernItaly.BirdsarethenaturalhostsofWNVand,whileWestNilefevercanbeofseriousclinicalsignificance,infectedhumansdonotposeapublichealthriskasviraemiaisshortlived31 anddoesnotrisetoalevelnecessaryfortransmissionviathemosquitovector.32

Clinicaldifferentiationofthemostcommonvector-bornevirusesisoftenchallenging,giventhesharedpictureoffever,nausea,jointpainandrashandthefrequentlyoverlappinggeographicrangeofinfectionsandvectors.Inseverecases,dengueandyellowfevermeetthecriteriaforviralhaemorrhagicfever(VHF).Consequently,itisessentialthattheycanbedistinguishedfromotherVHFssuchasEbolavirusdisease,whicharenotvector-borneandwhichcarryadangerousriskofspread.Indeed,theimportanceofeffectivesurveillanceforEVDandotherviralhaemorrhagicfevershasbecomeevenmoreacuteduringtheproductionofthisreport,withthefirstcaseofimportedEVDintheUnitedKingdominaScottishnursearrivinghomefromSierraLeone.33

TravellerscontinuetobeatriskofexposureSchistosomainendemicareas.Visitstosub-SaharanAfrica,especiallyMalawi,byyoungpeoplefromScotlandforschooltripsorvoluntaryactivitiesarenowcommonplace,andmayincreasetheriskofschistosomiasis.34 Appropriate health guidanceshouldbefollowedbyallschoolstaffplanningtravelabroad35andthusfaronlyaverysmallproportionofschistosomiasisdiagnosedinScotlandhasbeenrelatedtoschoolactivities.NearlyallcasesofschistosomiasisinScottishtravellersarediagnosedonserologicalscreeningastheinfectionremainsasymptomaticformonthsoryearsinthemajorityofthoseinfected.Wormburdensareusuallylowintravellerswithinfrequentexposureandeggsrarelyseeninstoolsorurine.Diagnosisofinfectionbymicroscopyisunlikely,hencetheinfrequentspeciationofinfectionindentifiedinScotland.SerologicaltestssuchasthoseavailableattheScottishParasiteDiagnosticandReferenceLaboratory(SPDRL)constitutethebasisofdiagnosis.36 In 2014, Schistosoma

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haematobiumwasidentifiedinFrenchandGermanholidaymakersinCorsica,wheretheparasitewaspreviouslyunrecorded.37Thisunusualoccurrenceisareminderthatunexpectedinfectionsmayoccurintravellersreturningfromdestinationsnotcommonlyassociatedwithhealthrisks.

Conclusion

Up-to-date,expertadviceontravelhealthandcountry-by-countrydiseaserisksisavailabletohealthcareprofessionalsonTRAVAX(http://www.travax.nhs.uk).Travellersarestronglyadvisedtoconsultthefitfortravelwebsite(http://www.fitfortravel.nhs.uk)inadvanceoftheirtravelforinformationonhowtostayhealthyabroad.Thewebsiteincludescountry-specificadviceonrecommendedvaccinesandantimalarialchemoprophylaxis,anddetailsonsafefoodandwater,accidentavoidance,sunexposureandinsectbites.TRAVAXrecommendsthattravellersconsultaGP,practicenurseortravelhealthclinicatleastsixweeksbeforetravel.38

Foodandwaterhygieneremainthemosteffectivemethodsforreducingtheriskofdiarrhoea.Someotherfoodandwaterbornediseasesi.e.hepatitisA,typhoidandpoliomyelitisarealsopreventablethroughvaccination.Asinpreviousyears,organismsassociatedwithtraveller’sdiarrhoeaweremostfrequentlyreported.Vector-borneinfectionswerelessfrequentlyreportedbutcontinuetohighlighttheneedforbiteavoidanceandvaccinationwherepossibleandappropriate.

Manytravel-relatedinfectionswillmanifesteitherduringorverysoonaftertravel,butsomemaypresentmonthsoryearslater,dependingonincubationperiod.Anytravellerbecomingunwell,evenmonthsafterarrivalinScotland,shouldseekmedicaladviceandreporttheirtravelhistorytotheirhealthcareprovider.ItisrecommendedthatanyonewhomayhavebeenexposedtoSchistosoma cercariaeduringtravelistestedontheirreturn,evenifasymptomatic.39HPSwouldencourageallcliniciansrequestinglaboratorytestingtoroutinelytakeatravelhistory,includingtravelseveralmonthspreviously,andtoprovidethisinformationonthelaboratoryrequestform,withdetailsofcountryofexposure.ThiswouldallowHPStoreportmoreaccuratelyontheoccurrenceoftravel-relatedinfectionsinScotland.

Respiratoryinfectionisoutsidethescopeofthisreportbutisamatterofcontinuingconcernanduncertainty,giventhepotentialforglobaloccurrenceofhighlypathogenicavianinfluenzaviruses40andthepersistenceofMiddleEastrespiratorysyndromecoronavirus(MERS-CoV)intheArabianPeninsula.41MediainterestinMERS-CoVhasdeclinedinrecentmonthsbutmeritsongoingvigilance,giventhesubstantialnumbersofpilgrimstravellingtotheArabianpeninsulaforpilgrimage,businessandleisure.HPSwillcontinuetoprovideinformationtotravellersviahealthprofessionalsandthefitfortravelwebsite.

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TABLE1:Travel-relatedpathogensreportedtoHPSin20142014 % Change

since 20132013

Organism Total*N

imported*%

imported* Total*N

imported*%

imported*ShigellaShigella boydii 4 2 50% 100% 2 1 50%Shigella dysenteriae 1 0 0% NA 0 NA NAShigella flexneri 34 7 21% 70% 20 4 20%Shigella sonnei 47 13 28% -24% 62 24 39%Shigella sp. 4 0 0% 300% 1 0 0%Total Shigella 90 22 24% 6% 85 29 34%Gastrointestinal protozoaCryptosporidium felis 0 NA NA -100% 1 0 0%Cryptosporidium hominis 29 3 10% -50% 58 3 5%Cryptosporidium meleagridis 2 0 0% NA 0 NA NACryptosporidium parvum 46 0 0% -53% 98 0 0%Cryptosporidium ubiquitum 0 NA NA -100% 1 0 0%Cryptosporidium sp. 354 28 8% 30% 273 21 8%Total Cryptosporidium 431 31 7% 0% 431 24 6%Entamoeba histolytica 11 11 100% 267% 3 3 100%Giardia duodenalis 19 3 16% 19% 16 4 25%Giardia intestinalis 8 2 25% -11% 9 3 33%Giardia lamblia 121 31 26% -7% 130 34 26%Giardia sp. 19 0 0% 58% 12 2 17%Total Giardia 167 36 22% 0% 167 43 26%Enteric fever (typhoid and paratyphoid)Salmonella paratyphi A 10 10 100% 150% 4 2 50%Salmonella paratyphi B 0 NA NA -100% 1 1 100%Salmonella typhi 7 3 43% -30% 10 10 100%Totalentericfever 17 13 76% 13% 15 13 87%Viral hepatitisHepatitis A 32 3 9% 45% 22 1 5%Hepatitis E 157 5 3% 65% 95 3 3%VibrioVibrio cholerae O1/0139 0 0 NA NA 0 NA NAVibrio cholerae non-01/0139 3 3 100% NA 0 NA NAVibrio cholerae untyped 1 1 100% NA 1 1 100%Vibrio parahaemolyticus 1 1 100% -75% 4 1 25%Total Vibrio 5 5 100% 0% 5 2 40%Vector-borne virusesChikungunyavirus 6 6 100% 200% 2 2 100%Denguevirus 28 28 100% -13% 32 32 100%Sandflyfevervirus 0 NA NA NA 0 NA NATick-borneencephalitisvirus 0 NA NA NA 0 NA NAWestNilevirus 3 3 100% NA 0 NA NAViral haemorrhagic feverCrimean Congo haemorrhagic fevervirus 0 NA NA NA 0 NA NA

Ebolavirus 1 1 100% NA 0 NA NARickettsiaRickettsia sp. 6 6 100% 20% 5 5 100%Schistosoma*S. haematobium 0 NA NA -100% 1 1 100%S. mansoni 1 1 100% 0% 1 1 100%Schistosoma sp. 202 202 100% 29% 157 157 100%Total Schistosoma 203 203 100% 28% 159 159 100%Vector-borne protozoaLeishmania sp. 0 NA NA -100% 2 2 100%Trypanosoma cruzi 0 NA NA NA 0 NA NATotal organisms 2070 683 1885 588

*LaboratorycodingofschistosomiasisreportinginScotlandhaschangedin2014,whichmayhaveinfluencedtheincreaseinnumberspublishedhere.

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ThelastTravelhealthSurveillanceReportwasinIssue14/46 ThenextTravelhealthSurveillanceReportwillbeinIssue15/15

NHS BOARD ABBREVIATIONSAA Ayrshire&Arran BR Borders DG Dumfries&Galloway GGC GreaterGlasgow&ClydeFF Fife FV ForthValley GR Grampian HG HighlandLO Lothian LN Lanarkshire OR Orkney SH Shetland TY Tayside WI WesternIsles

Correspondence to: The Editor, HPS Weekly Report, HealthProtectionScotland,MeridianCourt, 5 Cadogan Street, Glasgow, G2 6QE, ScotlandT 0141-300 1100 F 0141-300 1172 E NSS.HPSWReditor@nhs.net W http://www.ewr.hps.scot.nhs.uk/PrintedintheUK.HPSisadivisionoftheNHSNationalServicesScotland. RegisteredasanewspaperatthePostOffice.©HealthProtectionScotland2015