Health Protection Scotland (HPS) have published their annual report of imported malaria in Scotland, which shows 52 cases for 2018. This number is unsurprising and similar to that seen in recent years. 

Enhanced surveillance shows that most malaria in Scotland is imported from Africa and is caused by the more dangerous Plasmodium falciparum.

HPS continues to provide advice on malaria prevention in travellers and emphasizes the importance of seeking specialist advice before travel.

Health Protection Scotland (HPS) published an update to the ‘Integrated guidance on health clearance of healthcare workers and the management of healthcare workers infected with bloodborne viruses (hepatitis B, hepatitis C and HIV)’ on 30 July 2019. This guidance, from the UK Advisory Panel for Healthcare Workers Infected with Bloodborne Viruses (UKAP), brings together past and new guidance on the management of bloodborne viruses (BBVs) in healthcare workers (HCWs). The key elements of the new guidance are as follows:

HCWs living with HBV

The guidance on restrictions of HCWs living with hepatitis B (HBV) to perform exposure-prone procedures (EPPs) is being updated. Previous guidance published in October 2017 restricted the practice of HCWs living with HBV if they were e-Antigen (HBeAg) positive and/or they had a pre-treatment viral load of >20,000 IU/mL (105 gEq/ml). These restrictions are now being removed provided HCWs meet the criteria for clearance and comply with monitoring by an occupational health service, as described in the updated guidance published by the UKAP. This change is due to the lower risk of virus transmission with new effective treatments which are now available for HBV. In addition, those HCWs living with HBV who wish to perform EPPs need to be registered on a confidential national register, the UK Advisory Panel for Healthcare Workers Infected with Blood-borne Viruses – Occupational Health Monitoring Register for BBV Infected HCWs (UKAP-OHR). The UKAP-OHR will be managed by Public Health England (PHE), which provides information about how to register HCWs onto the UKAP-OHR.

Changes to recommendations regarding patient notification/lookback exercises

Previous guidance recommended a series of investigations following the diagnosis of a BBV, i.e. HIV, HBV and hepatitis C (HCV), in a HCW who had undertaken EPPs, which included:

• Lookback initiatives to identify procedures undertaken by the HCW. 
• The cross-matching of resultant records with databases holding records of people diagnosed with BBVs to determine if any procedures had led to a subsequent diagnosis of a BBV. 
• Where appropriate, patient notification exercises involving the provision of information and the offer of a BBV.

A review by UKAP found that, in instances where an HCW was identified as BBV infected but there was no initial evidence of HCW to patient transmission, patient notification exercises failed to identify any such transmissions. It was furthermore found that such investigations are resource-intensive and patient notification often causes anxiety among those contacted. 

As a result of this review, the criteria for undertaking a detailed public health investigation and patient notification have been revised and these will now only be undertaken in circumstances where it is known, or suspected, that a patient has acquired infection from a HCW or where there is concern about the practice of the HCW which could have led to increased risk of exposure.

The changes described above are important in ensuring that the management of HCWs living with BBVs is proportionate, reflects the changing treatment options now available and current understanding of the long-term aspects of living with these infections, while ensuring that patient safety is not compromised.

It is hoped that the removal of restrictions on EPP practice, and the recommendation that patient notification/lookback exercises are only undertaken in exceptional circumstances, will reassure HCWs and give them the confidence to seek advice and testing for BBVs if they are concerned about exposures either in the workplace or in other settings.

The UKAP encourages the identification and treatment of BBVs as this has considerable benefits for HCWs. Treatments for HBV, if required, and HIV are generally safe, easy to take and highly effective in suppressing the viruses. For HCV, a short course of treatment is safe, easy to take and, for almost everyone, curative.

The European Centre for Disease Prevention and Control (ECDC) published their 2017 surveillance report for malaria, on 25 July 2019. The report, based on data for 2017 retrieved from the European Surveillance System (TESSy), records 8,401 cases reported in the EU/EEA, of which 8,393 (99.9%) were confirmed. Among 8,023 cases with known importation status, 99.8% were travel-related with 21 confirmed cases reported as acquired in the EU, seven each by Greece and Italy, three by the UK, two by France and one each by Germany and Spain.

Data showed a seasonal trend across all countries, with cases increasing during and immediately after the summer holiday months of July to September. The overall rate of confirmed malaria cases was higher among men than women, with 1.7 cases and 0.8 cases per 100,000 of the population respectively and a male-to-female ratio of 1.9:1.

Source: ECDC, 25 July 2019

The World Health Organization (WHO) has recommended the use of the HIV drug dolutegravir (DTG) as the preferred first- and second-line treatment for all populations, including pregnant women and those of childbearing age. The recommendation, made on 22 July 2019, is based on new data from two large clinical trials comparing the efficacy and safety of DTG and efavirenz (EFV) in Africa that have now expanded the evidence base.

DTG is a drug that is more effective, easier to take, and has fewer side effects than alternative drugs which are currently used. DTG also has a high genetic barrier to developing drug resistance, which is important given the rising trend of resistance to EFV and nevirapine-based regimens.

Source: WHO, 22 July 2019

A systematic review on Hepatitis B (HBV) and C (HCV) prevalence and incidence in key population groups with multiple risk factors in the EU/EEA, was published by Eurosurveillance on 25 July 2019. The review compiled evidence on HBV/HCV infection prevalence and incidence in people living with HIV (PLHIV) and people in prison in EU/EEA countries. This was compared with estimates from the general population in order to assess the extent of risk and prevalence that these groups have of HBV and HCV infection.

The review reports that estimates of HBV infection prevalence were higher for PLHIV than those reported for the general population in every country for which data were available. The highest estimates were from Romania and Greece, which are among EU/EEA countries with the highest HBV infection prevalence among the general population.

Source: Eurosurveillance, 25 July 2019

Public Health England (PHE) have published a vaccination update for July 2019, with the latest developments in vaccines, vaccination policies and procedures for immunisation practitioners. The update provides information on the following topics: 

• vaccinations recommended for 2019 summer holiday travellers 
• measles, mumps, rubella (MMR) boosters for the new school year 
• viral rash management in pregnancy 
• an occupational health pertussis vaccination for healthcare workers 
• flu vaccine information and availability for the 2019 to 2020 season 
• vaccine wastage reporting 
• information from the EU Falsified Medicines Directive (FMD) 
• vaccine supply for non-routine programmes

Source: PHE, 25 July 2019

The National Health Service (NHS) (Scotland) has provided advice to the general public for coping with higher than average summer temperatures  in Scotland. This includes keeping cool when it is hot outside by:

• drinking plenty of cool fluids and avoiding alcohol and caffeine which can cause dehydration 
• eating cold foods with high water content such as salads and fruit 
• taking cool showers, baths or body washes 
• sprinkling water over skin or clothing, or keeping a damp cloth on the back of your neck 
• closing curtains on rooms to keep indoor spaces cooler or finding a cool spot outside 
• avoiding extreme physical exertion

Other advice includes: 

• looking out for others, especially older people, young children and babies and those with underlying health conditions 
• ensuring that infants, young children or animals are never left in a parked car 
• closing curtains on rooms to keep indoor spaces cooler or finding a cool spot outside 
• wearing light, loose fitting cotton clothes 
• making sure you take water with you if you are travelling

Additional advice is to either stay out of the sun or keep covered to reduce ultraviolet (UV) radiation damage from the sun that can cause skin cancer. This can be achieved by: 

• getting into the shade, especially when the sun is at its hottest (11am - 3pm) 
• wearing a long-sleeved shirt, and a hat with a brim or flap that protects the ears and neck 
• wearing sunglasses to protect your eyes from damage 
• using sunscreen of at least SPF (sun protection factor) 15 on any part of the body you can’t cover up and apply it as directed on the label 
• re-applying sunscreen regularly, and always after being in water

Similar heat health advice was issued by Public Health England (PHE) on 24 July 2019.

Source: NHS Inform, July 2019

The Medicines and Healthcare products Regulatory Agency (MHRA) reported the sentencing in London of a man involved in the illegal supply and sale of potentially dangerous unauthorised and prescription-only medicines and Class C drugs.

The sentencing followed an in-depth investigation by enforcement officers from the MHRA into a network suspected to be involved in the illegal importation and supply of medicines such as Tadalafil, Sibutramine, and Sildenafil.

Supplying medicines from sources outside the regulated supply chain represents a significant public health risk as they may contain dangerous ingredients that can have negative health consequences for the people who use them.

Source: MHRA, 25 July 2019