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Communicable Diseases

Introduction

Communicable diseases are those that are transmittable from one person, or animal, to another. The disease may spread directly, via another species (vector) or via the environment. The spread of disease in the community is determined by environmental and social conditions that favour the infectious agent, and the relative immunity of the population.  

Healthcare associated infections (HCAI) are those infections which are acquired as a result of healthcare, often among people being cared for in hospital. HCAI are a public health problem because infections can spread quickly among hospitalised patients who are already experiencing other health problems and may have worse outcomes than similar infections in previously healthy people. Mandatory surveillance for certain types of HCAI is undertaken by Public Health England (PHE).

Public Health England provides local health protection services and leads the public health response to all communicable disease outbreaks and emergencies that need specialist expertise. They give local government, especially the Director of Public Health, access to specialised advice and support, which help to support the improvement of the health and wellbeing of their local population. The prevention and control of healthcare associated infections is led by infection prevention and control teams within NHS organisations, supported where appropriate by PHE.

What do we know?

Tuberculosis (TB)

Tuberculosis is a bacterial infection spread through inhaling tiny droplets from the coughs or sneezes of an infected person. Nationally, the rate of Tuberculosis (TB) infections has continued to increase in recent years. The incidence of TB in England is higher than most other Western European countries, and more than four times as high as in the USA. The majority of TB in England occurs in a small number of high incidence areas, two of which are in Berkshire. TB disproportionately affects more deprived populations and the majority of cases occur in people who were born outside the UK, often as a result of activation of previously asymptomatic (dormant/inactive) infection in new entrants. In Berkshire, TB services are of high quality with good treatment completion rates; however, referral of new entrants for screening needs to be improved. The Collaborative Tuberculosis Strategy for England was launched in 2015 and aims to achieve a year on year reduction in TB incidence and associated health inequalities and eventually to eliminate TB as a public health problem.

Gastrointestinal Infections

Gastrointestinal infections are those affecting the digestive system and often cause vomiting and or diarrhoea. Symptoms can vary in duration and severity depending on the pathogen (bug causing the infection). 

  • Campylobacter continues to be the most common cause of reported gastroenteritis nationally and locally, followed by Salmonella. (Figure 2) Many people do not seek care for mild gastrointestinal symptoms and so numbers of confirmed cases are likely to underestimate the true level of infections. 
  • Historically hepatitis E was considered a travel-associated infection, and the disease may have been under diagnosed locally and nationally. Numbers of hepatitis E cases have increased since 2010 in Berkshire, in line with the national picture.

Blood-borne Viruses (BBVs)

Blood-borne viruses (BBVs) are viruses that some people carry in their blood and can be spread from one person to another.

  • Hepatitis B - Berkshire has the highest rate of hepatitis B notifications out of the three counties in Thames Valley. Nationally, around 4% of cases notified are at the acute stage of infection when the case is most infectious. 56% of acute cases had associated exposure information, with the most common reported risk attributed being heterosexual exposure. 62 out of 457 national acute or probable acute cases of hepatitis B were reported in the south east in 2015. This gives a rate of 0.69 per 100,000, a decrease from 0.71 in 2014. This is in line with the national picture, which decreased from 0.91 to 0.87. (Acute hepatitis B (England): annual report for 2015)
  • Hepatitis C Virus (HCV) - Hepatitis C is a major public health problem with estimates of large numbers of undiagnosed infections. The majority of these are in current or former injecting drug users, where up to 50% are estimated to be infected with Hepatitis C. New direct acting antiviral drugs offer a fast and effective cure to the majority who receive them; with reduced complications compared to previous treatments. 40% more people are initiating HCV treatment in 2015, when compared to 2014. Deaths from HCV have reduced in 2015, ending the upward trend of the last 10 years. (Hepatitis C in the UK: 2016 report)

Group A Streptococcal Disease

Nationally, notifications of Group A Streptococcal disease increased during the 2015-2016 season and continue to be monitored by Public Health England. The number of invasive infections caused by the same bacterium also showed increased incidence in 2015-2016, no novel strains or unusual increases in specific strains have been identified. Levels of scarlet fever and invasive Group A Streptococcal infections in Thames Valley and across Berkshire reflected the national picture. (Group A streptococcal infections: fourth update on activity during the 2015 to 2016 season)

Healthcare Associated Infections

Public Health England collects data on blood stream infections caused by Methicillin-resistant Staphylococcus aureus (MRSA) and Methicillin-susceptible Staphylococcus aureus (MSSA), E. coli and infections caused by Clostridium difficile. In Berkshire, rates of C. difficile have decreased in the last five years across all Hospital Trusts.

Antimicrobial resistance: is covered in the antimicrobial resistance section.

Vaccine Preventable Diseases: are covered in the Immunisation section.

Sexually Transmitted Diseases including HIV: are covered in the Sexual Health section.

Facts, Figures and Trends

Mortality

Mortality from infectious and parasitic diseases shows the total number of deaths in a population from those diseases during a given time period. As the number of deaths in an area will be heavily influenced by the age and gender of the population, these factors are controlled by standardisation and presented as a rate per 100,000. This allows a more direct comparison between areas that have different population structures. Figure 1 shows that in Reading, the mortality from infectious and parasitic diseases was comparable with regional and national averages between 1995 and 2010. This rose above the England and South East rates in 2011 and then decreased between 2012 and 2014 but remaining above the England and South East rates. There were 78 deaths from communicable disease in Reading in 2014.

Figure 1: Mortality from infectious and parasitic disease in Reading, 1995 to 2014

image1

Source: Health and Social Care Information Centre - NHS Indicator Portal

Incidence of communicable disease

Figure 2 shows the number of communicable diseases in Reading by type of infection and pathogen (bug causing the infection) between 2012 and 2016. Figure 3 shows the rates of these infections over the same period. Following the introduction of a new electronic reporting system, SGSS, in 2015, we are receiving more reports from laboratories outside our area and this may impact these figures.

Figure 2: Number of communicable diseases cases by type in Reading, 2012-2016

Communicable diseases

2012

2013

2014

2015

2016

Hepatitis B (acute & chronic)

38

32

26

26

19**

Hepatitis C

36

38

22

22

13**

Legionella

<5

<5

<5

<5

0

Group A Streptococcal disease

Scarlet fever (notified cases)

27

52

88

61

51

Invasive Group A Strep

<5

6

6

11

5

Vaccine Preventable Diseases

Measles

0

<5

0

0

0

Mumps

0

8

5

<5

<5

Rubella

8 in Berkshire

0

<5 in Berkshire

0

0

Pertussis (notified)

34

15

9

12

12

Pertussis (confirmed)

18

6

<5

7

10

Meningococcal Disease

<5

<5

<5

<5

<5

Gastrointestinal Diseases

Campylobacter

139

127

104

106

87

Cryptosporidiosis

13

10

5

11

12

E. coli O157

0

0

<5

<5

0

Giardia lamblia

13

22

28

24

14

Hepatitis A

0

<5

<5

0

<5

Hepatitis E

<5

<5

<5

<5

<5

Salmonella typhi

<5

<5

<5

<5

<5

Salmonella paratyphi

<5

0

0

0

<5

Non typhoidal Salmonella

21

18

21

11

25

Shigella

12

7

6

7

<5

Source: Thames Valley Public Health England Team

Figure 3: Rates of communicable diseases by 100,000 population type in Reading, 2012-2016

Communicable diseases

2012

2013

2014

2015

2016

Hepatitis B (acute & chronic)

24.2

20.1

16.2

16.1

11.7**

Hepatitis C

22.9

23.9

13.7

13.6

8.0**

Legionella

*

*

*

*

0.0

Group A Streptococcal disease

Scarlet fever (notified cases)

17.2

32.7

54.7

37.7

31.5

Invasive Group A Strep

*

3.8

3.7

6.8

3.1

Vaccine Preventable Diseases

Measles

0.0

*

0.0

0.0

0.0

Mumps

0.0

5.0

3.1

*

*

Rubella

<5 in Berkshire

0.0

<5 in Berkshire

0.0

0.0

Pertussis (notified)

21.6

9.4

5.6

7.4

7.4

Pertussis (confirmed)

11.5

3.8

*

4.3

6.2

Meningococcal Disease

*

*

*

*

*

Gastrointestinal Diseases

Campylobacter

88.5

79.8

64.7

65.5

53.8

Cryptosporidiosis

8.3

6.3

3.1

6.8

7.4

E. coli O157

0.0

0.0

*

*

0.0

Giardia lamblia

8.3

13.8

17.4

14.8

8.7

Hepatitis A

0.0

*

*

0.0

*

Hepatitis E

*

*

*

*

*

Salmonella typhi

*

*

*

*

*

Salmonella paratyphi

*

0.0

0.0

0.0

*

Non typhoidal Salmonella

13.4

11.3

13.1

6.8

15.5

Shigella

7.6

4.4

3.7

4.3

*

* shows rates that have been suppressed due to small numbers

** These numbers may be revised due to late reporting for chronic hepatitis B and C

Source: Thames Valley Public Health England Team

There have been no significant changes from 2015 to 2016.

Incidence of HCAI

Figures 4 and 5 show the numbers and rates of Trust-apportioned HCAI for the two hospital trusts attended by most residents from Berkshire. Rates of infection in one Trust should not be compared to that of another Trust, as data has not been standardised for demographics or case mix. Instead, this can be used to examine trends in the same Trust over time. 

Frimley Park NHS Foundation Trust and Heatherwood & Wexham Park NHS Trust merged to form Frimley Health NHS Foundation Trust in November 2014. Data prior to November 2014 for these two Trusts have been combined and displayed under Frimley Health NHS Foundation Trust in Figures 4 to 6. 

Figure 4: Number of Trust-apportioned Healthcare Associated Infections by NHS Trust financial years 2011/12 to 2015/16

NHS Trust

Healthcare Associated Infections

2011/12

2012/13

2013/14

2014/15

2015/16

Royal Berkshire Foundation Trust

Meticilin resistant Staphylococcus aureus (MRSA) blood stream infections*

0

1

1 (0)

0 (2)

2

Meticilin sensitive Staphylococcus aureus (MRSA) blood stream infections

12

9

15

17

24

Clostridium difficle

108

29

40

29

32

Frimley Healthcare

Meticilin resistant Staphylococcus aureus (MRSA) blood stream infections*

3

1

6 (5)

3 (2)

2

Meticilin sensitive Staphylococcus aureus (MRSA) blood stream infections

25

25

38

31

34

Clostridium difficle

73

42

46

33

41

*MRSA recording changed from Trust apportioned cases in April 2013 to Post Infection Review (PIR) assigned cases. Numbers prior to Q1 2013 should not be directly compared to numbers from Q2 2013. Numbers of PIR Trust-assigned MRSA infections are shown in brackets.

Source: Public Health England (2014); Healthcare associated infections (HCAI): guidance, data and analysis.

Figure 5: Rates of Trust-apportioned Healthcare Associated Infections per 100,000 patient bed-days, by NHS Trust financial years 2011/12 to 2015/16

NHS Trust

Healthcare Associated Infections

2011/12

2012/13

2013/14

2014/15

2015/16

Royal Berkshire Foundation Trust

Meticilin resistant Staphylococcus aureus (MRSA) blood stream infections

0.0

0.5

0.5 (0.0)

0 (1.0)

1.0

Meticilin sensitive Staphylococcus aureus (MRSA) blood stream infections

5.7

4.2

6.8

8.2

11.5

Clostridium difficle

51.2

13.5

18.1

14.1

15.4

Frimley Healthcare

Meticilin resistant Staphylococcus aureus (MRSA) blood stream infections

0.8

0.3

1.5 (1.2)

0.7 (0.5)

0.5

Meticilin sensitive Staphylococcus aureus (MRSA) blood stream infections

6.8

6.6

9.3

7.3

7.7

Clostridium difficle

20.0

11.1

11.3

7.7

9.2

Nationally

Methicillin resistant Staphylococcus aureus (MRSA) blood stream infections

1.4

1.2

1.1

0.8

0.9

Methicillin susceptible Staphylococcus aureus (MSSA) blood stream infections

5.7

4.2

6.8

8.3

8.4

Clostridium difficile

22.3

17.4

14.7

15

14.9

*MRSA recording changed from Trust apportioned cases in April 2013 to Post Infection Review (PIR) assigned cases. Numbers prior to Q1 2013 should not be directly compared to numbers from Q2 2013. Numbers of PIR Trust-assigned MRSA infections are shown in brackets.

Source: Public Health England (2014); Healthcare associated infections (HCAI): guidance, data and analysis.

Nationally there were over 38,000 E.coli blood stream infections reported by NHS Trusts in 2015/16, an 18% increase from 2012/13. (https://www.gov.uk/government/statistics/escherichia-coli-e-coli-bacteraemia-annual-data). The majority of these are associated with urinary tract infections. The UK government has set a target to reduce E.coli blood stream infections by 50% by 2020. 

Figure 6 shows numbers and rates of all reported E. coli bloodstream infections. This refers to all E.coli-positive blood cultures reported by the Trust whose laboratory processes the specimen. It is important to note that this does not necessarily imply that the infection was acquired there.

Figure 6: All reported E.coli bloodstream infections by NHS Trust, financial years 2012/13 to 2015/16

NHS Trust

Healthcare Associated Infections

2012/13

2013/14

2014/15

2015/16

Royal Berkshire Foundation Trust

Number of E. coli bloodstream infections

231

245

255

255

Rate of E. coli bloodstream infections per 100,000 patient bed-days

107.4

110.7

123.6

122.7

Frimley Healthcare

Number of E. coli bloodstream infections

382

376

451

531

Rate of E. coli bloodstream infections per 100,000 patient bed-days

101.3

92.0

104.4

119.8

National

Rate of E. coli bloodstream infections per 100,000 patient bed-days

93.8

99.9

102.8

110.1

Source: Public Health England (2014); Healthcare associated infections (HCAI): guidance, data and analysis

Blood-Bourne Viruses (BBVs)

There were 19 cases of Hepatitis B in Reading in 2016 compared to 26 in 2015. There were 13 confirmed cases of Hepatitis C in Reading residents in 2016 compared to 22 in 2015. Public Health England modelling predicts that as of 2013 there were around 665 people living with hepatitis C in Reading, of whom 178 remain diagnosed and untreated (http://www.hcvaction.org.uk/resource/public-health-england-phe-commissioning-template-estimated-hcv-prevalence-and-numbers).

Group A Streptococcal Infection

In Reading, 51 cases of scarlet fever were notified in 2015 compared to 88 in 2014.  Numbers of invasive group A streptococcal infections remained very low at <5, this has been 6 or less for the last 5 years.

Gastrointestinal infections

Infections caused by Campylobacter species were the most common form of gastrointestinal infection in Reading. There were 87 confirmed cases in 2016, the lowest number in the last five years.

National & Local Strategies (Current best practices)

There are number of national and local strategies to control and prevent various communicable diseases. Key ones include:

What is this telling us?

  • Overall the number of people either "at risk" or suffering from communicable diseases in Reading is low.
  • There are however opportunities to reduce the burden of communicable diseases through population based behaviour change interventions,  increased uptake of childhood vaccination and improvements to BBV testing and treatment pathways.

What are the key inequalities, unmet needs/ service gaps?

  • Certain groups are more vulnerable to infections, settings such as childcare and residential and day care setting for older people have an increased risk of infections spreading from person to person. There is a need to ensure information and advice directed at the general public aims to prevent and reduce the spread of infections and for this to be prioritised to groups at increased risk as above.
  • There is a wide variation in BBV screening and Hepatitis B vaccination uptake among high-risk groups.
  • Over the last few years there has been a lack of clarity regarding referral pathways for Hepatitis B and C. Screening and treatment pathways from primary care, GUM and drug and alcohol services into secondary care have now been developed, however there is a need to monitor success and to raise awareness of the pathways among health professionals and others working with those at most risk of infection.
  • Refugees and migrants are at increased risk of blood borne infections and TB and may be less likely to register with a GP and to access immunisation.

Recommendations for consideration by other key organisations: 

  • Improve BBV screening and Hepatitis B vaccination service among high-risk groups, including follow up of all babies born to Hepatitis B positive mothers.
  • Consider development of peer support, education, and awareness raising and stigma reduction programmes for BBVs and HIV among high risk groups.
  • Agencies to work with under-served populations to increase access to immunisation.
  • Agencies to work with PHE to prevent and control communicable diseases including health-care associated infections.
  • Consider undertaking assessment of the health needs of migrant and other under-served populations in order to inform development of holistic interventions to improve access to healthcare and reduce burden of communicable and non-communicable disease in this group and the wider community.
  • Consider public awareness campaigns linked to hand hygiene and food safety to coincide with seasonal peaks e.g. norovirus in winter months, barbeque season in summer months.
  • Education and childcare settings to teach all children and young people, in an appropriate way for their age and ability, about the importance of washing and drying hands to prevent infections and stop them from spreading.
     

See also

Excess Winter deaths (for flu immunisation)

Sexual Health

Liver disease (for Hepatitis)

Tuberculosis

Antimicrobial resistance

 

  

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