On 16 July 2019, Health Protection Scotland (HPS) published an annual report concerning general outbreaks of bacterial and protozoal infectious intestinal disease reported during 2018.

On 10 July 2019, Health Protection Scotland (HPS) released information leaflets on Vancomycin-resistant enterococci (VRE) for the use of healthcare workers and patients.

VRE are enterococci that are resistant to the vancomycin antibiotic and are often resistant to other types of antibiotics. While VRE does not cause more serious infections than other enterococci, it is more difficult to treat. They are most commonly spread through direct contact with the patient through contamination by healthcare workers or indirectly from the patient’s care environment, for example, frequently touched surfaces such as lockers or bed tables.

A total of 1,683 cases of imported malaria were reported in the UK in 2018, according to recently published annual data, 6.1% lower than reported in 2017.

A total of six UK deaths were associated with malaria importations in 2018, a number that has been steady since 2015. All were due to Plasmodium falciparum malaria acquired in Western Africa (three deaths), Middle Africa (one death), and an unspecified region of Africa (one death). Travel region has not been provided for the final death.

Cases were reported in England (1,597), Scotland (52), Wales (23) and Northern Ireland (11). Most cases in 2018 were caused by Plasmodium falciparum, which is consistent with previous years.

Of the cases that travelled abroad from the UK, and where the reason for travel was documented, 85% were visiting friends and relatives. This group of travellers appear not to be receiving, understanding or acting on health messages emphasising the importance of appropriate chemoprophylaxis. The UK Government has provided malaria prevention advice for travellers.

Further advice relating to malaria can be found on the TRAVAX (for health professionals) and fitfortravel (for the general public) websites.

Source: Public Health England (PHE), 8 July 2019

The World Health Organization (WHO) have updated their 2019 yellow fever vaccination requirements and recommendations. The requirements and recommendations are updated annually, following consultation between the WHO and state parties, who are asked to confirm or update their requirements for international travellers on a yearly basis.

The country pages on the TRAVAX and fitfortravel have been updated to reflect the 2019 changes. The changes include: 

• the removal of a country requirement for an international certificate of vaccination or prophylaxis (ICVP) 
• the addition of a country requirement for an ICVP, where a requirement did not previously exist 
• changes relating to transit through a yellow fever endemic country 
• changes to the minimum age at which an ICVP is required

Further advice relating to yellow fever can be found on the TRAVAX (for health professionals) and fitfortravel (for the general public) websites.

Sources: TRAVAX and fitfortravel (both 10 July 2019)

Measles is a highly contagious viral disease, which, despite the availability of a safe and effective vaccine, remains an important cause of death among young children globally. Measles is spread by airborne or droplet transmission, and is considered one of the most highly communicable infectious diseases.

Measles is found throughout the world and is still common in many developing countries, particularly in parts of Africa and Asia. In recent years there have been several outbreaks of measles in other countries out-with Africa and Asia including Japan, Taiwan, Philippines, New Zealand, Thailand, Syria, USA and many European countries.

The recent outbreak of measles across many European countries serves as a reminder of measles risk in individuals who are not vaccinated or not fully vaccinated. Countries affected include Austria, Bulgaria, Czech Republic, France, Finland, Germany, Greece, Hungary, Ireland, Italy, Poland, Portugal, Romania, and the United Kingdom. In addition, neighbouring countries Albania, Belarus, Georgia, Russia, Serbia, Turkey and Ukraine have also been affected. During the summer, the likelihood of individuals coming into contact with measles is potentially higher due to people coming together in holiday destinations.

Measles is spread by coughing, sneezing, close personal contact or direct contact with infected nasal or throat secretions. The virus remains active and contagious in the air or on infected surfaces for up to two hours. It can be transmitted by an infected person from four days prior to the onset of the rash, to four days after the rash erupts. Symptoms of measles include erythematous maculopapular rash with fever and cough, coryza or conjunctivitis. Measles infection can be severe, with complications including blindness, encephalitis, severe diarrhoea and related dehydration, and severe respiratory infections such as pneumonia. Measles can be fatal.

Young children and adults aged 15 and over who were not given the measles, mumps and rubella (MMR) vaccine when they were young are at highest risk of measles and its complications. Any non-immune person, (one who has not been vaccinated with two doses of measles-containing vaccine), can become infected. The measles vaccine has been in use since the 1960s and is safe, effective and inexpensive, and has been included in the UK national schedule since 1968. The World Health Organization (WHO) recommends immunisation for all susceptible children and adults for whom measles vaccination is not contraindicated.

Advice for healthcare professionals to prevent the international spread of measles

The travel consultation provides healthcare practitioners with a valuable opportunity to ensure travellers are protected against the measles virus by: 

• Checking their vaccination status is up-to-date ensuring that they have received two doses of a measles containing vaccine in the absence of a history of prior measles infection. 
• Receiving at least one dose of measles vaccine at least 15 days prior to travel if they are uncertain of their measles vaccination status. 
• Measles vaccine can be co-administered with other vaccines recommended for travellers. Where yellow fever vaccine and MMR are both required, ideally they should not be given on the same day but given at least four weeks apart. Where protection is required rapidly, then the vaccines may be given at any interval. 
• Children who are travelling to measles endemic areas or to an area where there is a current outbreak, and have received one dose of MMR at the routine age, should have the second dose brought forward to at least one month after the first. If the child is under 18 months of age and the second dose is given within three months of the first dose, then the routine pre-school dose, a third dose, should be given in order to ensure full protection. 
• Measles vaccines are not recommended for pregnant women.

In the UK, MMR is usually given to infants at around 12 months of age, with a second dose given before school, to ensure best protection. In some cases, MMR can be offered to babies from six months of age, for example for travel to countries where measles is common, or to an area where there is a current outbreak. As the response to MMR in infants is sub-optimal where the vaccine has been given before one year of age, immunisation with two further doses of MMR should be given at the recommended ages.

Advice for travellers

All travellers should seek advice from their healthcare provider in advance of travel and be aware of the risk of exposure to measles virus as well as transmission and symptoms of the disease. 

Individuals travelling to countries where measles is common or where outbreaks are occurring are at risk of catching the disease if not fully protected. Two doses of MMR in a lifetime are needed for a person to be considered fully protected. Susceptible travellers may also risk exposing others to this highly infectious, serious illness either while travelling, or on return to the UK. 

Transmission of infection may occur between passengers who are seated in the same area of an aircraft, usually as a result of a cough or sneeze or by touch. This is no different from being close to someone in any other form of transport such as a bus or train.

An airline has the right to refuse travel to any passenger who is unwell and they suspect may be contagious. In order to minimise the risk of passing infections in an aircraft, passengers who are actively unwell, especially if they have a fever, should delay travel until they have recovered. Where an individual has travelled on an airline whilst infectious with measles, contact tracing of passengers will be carried out by public health authorities. 

Susceptible travellers who have returned from a country or area where measles is common should be alert for symptoms for three weeks after their last day of travel, usually developing symptoms about 10 days after they are exposed. However, it can take as few as seven and as many as 18 days for symptoms to develop. Measles symptoms include: 

• fever 
• cough, runny nose, and sore red eyes 
• general tiredness and feeling unwell 
• a spotty, non-itchy rash that starts on your head and neck and spreads to the rest of your body

Travellers who experience any of these symptoms, should not attend public places, such as work, school, healthcare services, shopping centres, nor use public transport. They should seek medical attention and, importantly, call ahead to the medical practice or emergency department to advise them of the symptoms, so that measures can be taken to limit their exposure to other people when they arrive.

Further advice relating to measles can be found on the TRAVAX (for health professionals) and fitfortravel (for the general public) websites.

Sources: TRAVAX and fitfortravel (both 11 July 2019)

On 12 July 2019 the European Centre for Disease Prevention and Control (ECDC) published the Syphilis Annual Epidemiological Report for 2017.

In 2017, 33,189 confirmed syphilis cases were reported in 28 EU/EEA member states. Reported syphilis rates were nine times higher in men than in women and peaked among 25 to 34 year-old men. Two-thirds of syphilis cases, with information on transmission category, were reported in men who have sex with men (MSM). The trend in syphilis rates has been on the rise since 2011, particularly among men, mainly due to an increase in the number of cases among MSM. The slight increase of syphilis rates among women, seen already in 2016, continued in 2017.

Also on 12 July 2019, the ECDC published a technical report on syphilis and congenital syphilis in Europe, including a review of epidemiological trends from 2007 to 2018 and options for response. 

Since 2010, syphilis notification rates in the EU/EAA have been on the increase, and have accelerated predominantly among men having sex with men (MSM), with similar trends observed in high income countries outside the EU/EAA. The overall trend remains relatively stable, but outbreaks or clusters of syphilis cases have been reported among heterosexual populations in the EU/EEA. In several high income countries, including the USA, increases in congenital syphilis has occurred in connection with increased syphilis notifications among women.

Source: ECDC, 12 July 2019

Estimates from the University of Warwick suggest that the human papillomavirus (HPV) vaccine programme could prevent over 64,000 cervical cancers and nearly 50,000 non-cervical cancers by 2058. 

From September 2019, boys in their eighth school year will be offered the HPV vaccine for the first time. Girls have been offered the HPV vaccine from the NHS since 2008, amounting to 10 million doses of HPV vaccine given to young women, covering over 80% of women aged 15 to 24.

A Scottish study showed that the vaccine has reduced pre-cancerous cervical disease in women by up to 71%, while diagnoses of genital warts in 15 to 17 year-old girls and boys have declined by 90% and 70%, respectively.

The HPV vaccine helps to protect against all cancers linked to the HPV virus including cervical, penile, anal and genital cancers and some cancers of the head and neck. Cervical cancer is currently the most common cancer in women under 35, killing around 850 women each year. HPV is thought to be responsible for over 99% of cervical cancers, as well as 90% of anal cancer, about 70% of vaginal and vulvar cancers and more than 60% of penile cancers.

Source: UK Government, 9 July 2019

Eurosurveillance has produced a review of antimicrobial use reduction goals in human medicine, in countries which are members of the Transatlantic Taskforce on Antimicrobial Resistance (TATFAR).

On 31 March 2017, the European Centre for Disease Prevention and Control (ECDC) sent a questionnaire to national focal points for antimicrobial consumption and the national focal points for antimicrobial resistance (AMR) in 28 EU countries, Iceland and Norway. The same questionnaire was sent to the TATFAR implementers in Canada and the USA. Of the 30 countries who replied, nine countries indicated that they had established targets to reduce antimicrobial use in humans, while 21 countries replied that no target had been established. However, 17 of these 21 countries indicated that work is underway to establish targets in the context of developing a national action plan against AMR. 

Source: Eurosurveillance, 11 July 2019

The first List of Essential Diagnostics was published in 2018, concentrating on HIV, malaria, tuberculosis, and hepatitis. The 2019 list has been expanded to include more non-communicable and communicable diseases.

The World Health Organization (WHO) List of Essential Diagnostics for infectious diseases focuses on additional infectious diseases prevalent in low- and middle-income countries such as cholera, and neglected diseases like leishmaniasis, schistosomiasis, dengue and zika. In addition, a new section for influenza testing was added for community health settings where no laboratories are available.

The update includes a new section specific to tests intended for screening of blood donations, in response to a WHO-wide strategy to make blood transfusions safer.

Source: WHO, 9 July 2019

On 11 July 2019, the Department for Environment, Food & Rural Affairs (DEFRA) released the Air Quality Expert Group’s report on non-exhaust emissions (NEE) from road traffic. This refers to particles released into the air from brake wear, tyre wear, road surface wear and re-suspension of road dust during on-road vehicle usage. There is no legislation in place to limit or reduce NEE particles.

Data from the UK National Atmospheric Emissions Inventory indicate that particles from brake wear, tyre wear and road surface wear currently constitute 60% and 73% (by mass), respectively, of primary PM2.5 and PM10 emissions from road transport, and will become more dominant in the future. Currently they contribute 7.4% and 8.5% of all UK primary PM2.5 and PM10 emissions. The national inventory indicates that half of NEE occurs on urban roads, owing to the greater braking per km than on non-urban roads and making this of especial importance in urban environments.

The most effective mitigation strategies for NEE are to reduce the overall volume of traffic, lower the speed where traffic is free-flowing, for example on trunk roads and motorways, and promote driving behaviour that reduces braking and higher-speed cornering.

The Scottish Government’s ‘Clearer Air for Scotland’ document offers definitions on the various types of particulate matter [PM] mentioned above.

Source: DEFRA, 11 July 2019