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Not All Outbreaks Are GI Buy one get three free!

Get a flavour for other outbreaks!

Listeria Outbreak April – August 2019

Helen Doyle Emergency Planning Officer

Overview

• Listeriosis is a rare infection caused

by bacteria called listeria.

• It can be caught from eating food

containing this bacteria and is most frequently found in:

• Unpasteurised milk.
• Dairy products made from

unpasteurised milk.

• Soft cheese like camembert and brie
• Chilled ready to eat foods - prepacked

sandwiches, pate and deli meats.

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Clinical Presentations

• In older adults and immunocompromising conditions, the most common

clinical presentations are invasive infections, such as sepsis, meningitis, and meningoencephalitis.

• People can also experience focal infections, including septic arthritis,
• steomyelitis.
• Listeriosis during pregnancy is typically a relatively “flu-like” illness. Infection

during pregnancy can result in miscarriage, stillbirth, preterm labour, and sepsis or meningitis in the neonate.

• Some neonates with listeriosis develop a severe disorder involving the

internal organs and skin.

• Listeria can cause fever and diarrhoea similar to other foodborne germs, but

this type of Listeria infection is rarely diagnosed.

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Symptoms of Listeriosis

• A high temperature of 38 or above
• Aches and pains
• Chills
• Feeling sick or vomiting
• Diarrhoea
• The incubation period can last from 24

hours to 70 days.

• Listeriosis is can cause serious problems

for those who are pregnant, elderly or have a weak immune system.

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Outbreak Overview

• 26th April 2019 – 1 case of listeriosis (case 1) (deceased) was notified to PHE

North West.

• 4th May 2019 – 1 case of listeriosis (case 2) was notified to PHE North West by the

same hospital.

• 6th May 2019 – PHE were notified that case 2 was deceased.
• 21st May 2019 – Hospital chaired an incident management team (IMT) meeting and

following this handed over management of the outbreak to PHE.

• 23rd May 2019 – A further case of listeriosis (case 3) with the same whole genome

sequence as cases 1 and 2 was notified to PHE by a different hospital.

• Saturday 25th May 2019 – a standard incident was declared by PHE:

➢ During the weekend Consultant for PHE NW was incident director ➢ Representatives of various PHE national teams and external stakeholders joined the IMT ➢ The Department of Health and Social Care was notified

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Outbreak Overview Continued

• During the course of the late May bank holiday weekend, the incident acquired national

significance.

• The common exposure between cases was prepacked sandwiches and the investigation
• f the source focussed on the production of prepacked sandwiches.
• Affected product lines had been affected to some 43 NHS trusts and 1 independent

provider.

• A number of hospital trusts were now affected across the UK. Trusts were contacted and

advised to undertake a precautionary withdrawal of specific sandwich lines.

• The sandwich producer, meat supplier and distributor all voluntarily ceased production at

this stage.

• 31st May 2019 an enhanced incident was declared.
• On 3rd June 2019 a proactive press release was made which named the NHS Trusts

that were potentially affected .

• Further 6 cases were identified via Whole Genome Sequencing across the country.
• The incident was not de-escalated to standard until 18th July 2019.
• On 2nd August 2019 the incident was de-escalated further to routine.

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In The News

A selection of headlines following the proactive press release

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Key Points

1. Following the notification of the first case to PHE, the situation rapidly escalated to an

• utbreak.

2. It is important to be thorough in the investigation of cases to ensure that all patients affected are identified at the earliest opportunity due to lengthy incubation periods which can make identification of a possible source problematic. 3. Although the incident was lengthy, there were only 4 local Incident Management Team (IMT) meetings led by PHE in the North West, however there were an additional 22 National IMTs attended by PHE. 4. Due to the length of the outbreak, management became very resource intensive for all agencies involved. 5. The response (nature and scale) is not always determined by the number of cases but the:

• Nature of the infection
• Individuals affected (those at high risk)
• Settings involved e.g. hospitals
• Individual outcomes
• Community anxiety and media interest
• Potential for wider dissemination and spread

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Recommendations

• NHS Trusts should maintain a minimum 4 star food hygiene rating.
• Regular in house food hygiene inspections should take place to ensure that

standards of food safety and hygiene are maintained.

• Controls should be put in place to control hazards in chilled, pre-packed

foods including:

• Ensuring that fridges are working properly and are set to 5°or below
• Ensuring that food items are used by their sell by date
• Eating ready to eat foods within 4 hours of being taken out of the fridge

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Invasive Group A Streptococcal Disease (iGAS)

Jo McCullagh Specialist Registrar in Public Health

Overview

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• GAS transmission and symptoms
• National trend
• Background to local outbreak
• Investigations and findings
• Control Measures
• Recommendations

Group A Streptococcus Infection

• Carriage in throat, on skin and groin areas.
• Direct and indirect transmission.
• Most GAS infections are mild.
• iGAS symptoms: high fever, severe muscle/joint

aches, redness at wound sites.

• iGAS can cause severe conditions, leading to limb

amputation or death.

• More than 120 GAS emm types.
• iGAS incidence:

‾

3.33 per 100,000 in UK

‾

3.5 per 100,000 in North West

• Risk factors:
• Older age (65+)
• Chicken pox/ HIV infection
• Diabetes, heart disease, cancer
• Use of steroids/intravenous drugs
• Household contact

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National Trend

• Increase in GAS in people in prison, those who

use drugs, are homeless or live in hostels.

• 1,026 GAS infections, January 2018-August 2019.
• 651 invasive, resulting in 392 hospitalisations & 10

deaths.

• 71.4% had IDU history & 68.9% current drug

users.

• 34.6% homeless or in hostel.
• GAS emm types:
• 66.0 (27%)
• 108.1 (27%)
• 94.0 (8%)
• 83.1/83.13 (6%)

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Background

• 1st iGAS case in notified on 11 July 2019: PWID in a homeless hostel.
• 2nd iGAS case notified on 5 August 2019: PWID at the same address.

Time, Place, Person:

• 2 cases within 30 days
• Both lived together in the hostel at the same time
• Close friendship and shared injecting drug equipment
• Outbreak declared and an Outbreak Control Team (OCT) convened.

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Epidemiological Investigation

Case Definition ‘Residents who live at the hostel (including staff) with invasive GAS infection or non-invasive GAS infection e.g. sore throat, skin and soft tissue GAS infection of any emm type from July 2019.’ Case Finding

• 31/34 hostel residents and all staff

assessed for GAS symptoms.

• 11 residents had symptoms of

superficial GAS (sore throat, wound/skin infection).

• All staff asymptomatic.

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Microbiological Investigation

• 4/11 residents swabbed

confirmed positive for GAS.

• Molecular typing:
• 2 cases emm type 83.13
• 2 contacts emm type

83.13

• 1 contact 66.0
• 1 sample lost

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Environmental Investigation

• Unregistered 35-bed hostel,

unregulated by Local Authority.

• Overall condition and

cleanliness was poor.

• Several issues increasing risk
• f disease transmission:
• Broken toilets & showers
• Damp
• Mice and pigeons
• Bed bug infestations
• Discarded, used drug

equipment

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Control Measures

• Stakeholder notification: GPs, A&E,

Walk-in Centres, hostels, substance misuse services.

• Antibiotics for close contacts:
• CCG and primary care

misunderstanding of role

• Delayed prescribing & potential

disease transmission

• 2017 NHSE/CCG agreement
• Infection control advice, resources

& training for hostels.

• Development of onsite clinic and

weekly sessions:

• BBV testing
• STI screening
• Immunisation
• Harm reduction advice

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Recommendation 1

Delivery of bacterial infections training and resources to homeless hostels and substance misuse services.

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Recommendation 2

Reiteration of 2017 NHSE agreement to CCG’s and LMC’s to confirm their responsibility to support the provision of NHS resources during outbreak management.

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Recommendation 3

Consider increasing access to harm reduction services for residents of unregistered hostels:

• BBV testing
• Condoms/STI screening
• Immunisation: Hepatitis A & B,

tetanus, flu

• Wound care management
• Naloxone training & supply
• Needle exchange

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Norovirus in Schools – 2019 Update

Dr Sam Ghebrehewet

Norovirus

• Highly contagious.
• Transmission: Person-to-person by

faecal/vomit-oral routes, contaminated food, water and surfaces.

• Incubation: 12-48 hours.
• Cases infective for several days

before, during and after symptoms.

• Symptoms: Nausea, vomiting,

abdominal pain, diarrhoea.

• Symptoms more serious for young,

elderly or those with chronic health.

• Infectivity greatly reduces 48-hours

after symptoms have stopped.

• For every one case of norovirus

reported 1,500 more cases occur in the community.

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School Outbreaks

• 23 school outbreaks notified to HPT 11-29

November 2019.

• 19 Primary Schools, 4 High Schools.
• Variation in notification by area:
• 3 Cheshire East
• 2 Cheshire West & Chester
• 9 Liverpool
• 3 Sefton
• 5 St Helens
• 1 Warrington

Action

• PHE letter for schools.
• PHE/NHSE Communications.
• Advice to school:
• 48-hour exclusion after symptoms

stopped.

• Good hygiene.
• Enhanced cleaning using appropriate

products.

• CIPCT daily monitoring of cases.

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Thank You Any Questions?

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