Volume 2 Number 17 Published on: 25
April 2008
Current News
Malaria imported into the United Kingdom in 2007: Implications for
those advising travellers
France declares loss of rabies free status: implications for British
travellers
Mandatory MRSA bacteraemia and C. difficile infection data
published
Infection Reports
Immunisation
Laboratory reports of Haemophilus influenzae by age group and
serotype, England and Wales: January to March 2008 (2007)
Laboratory reports of hepatitis A and C infection in England and
Wales: October to December 2007
Quarterly report from the sentinel surveillance study of hepatitis
testing in England: data for October to December 2007 (quarter 4)
Health Protection Report Vol 2 No.17 25 April 2008
News
Volume 2 Number 17 Published on: 25
April 2008
Malaria imported into the United Kingdom in 2007: Implications for
those advising travellers
France declares loss of rabies free status: implications for British
travellers
Mandatory MRSA bacteraemia and C. difficile infection data
published
Malaria imported into the United Kingdom in 2007: implications for those
advising travellers
Latest data on malaria imported into the United Kingdom (UK), based on figures for 2007
reported to the Health Protection Agency (HPA) Malaria Reference Laboratory, indicate that a
significant cause of infections is UK travellers' failure to take prophylaxis. There was,
nevertheless, a small fall in reported cases in 2007 compared with the previous year.
A full, more-detailed analysis of the data will be provided in the biennial travel report, to be
published later in the year. (Details of methods of data collection for malaria are presented in
the HPA 2002 baseline report [1]).
Figure 1. Imported malaria cases (with P. falciparum cases) in the UK: 1987- 2007
There were 1548 cases of malaria reported in 2007, a slight decline on the 1758 cases of
malaria reported by this stage in 2006. (It is possible that a few cases have still to be reported).
Health Protection Report Vol 2 No.17 25 April 2008
This may be random variation, but there is evidence of a recent decline in malaria transmission
in some malaria-endemic countries visited by travellers, especially in East Africa, which could
have an impact on UK imported cases [2]. Over 70% of malaria cases are caused by (the
potentially fatal)
Plasmodium falciparum and the high proportion of falciparum malaria has been
sustained over many years, reflecting the fact most malaria imported to the UK is acquired in
Africa. The overall trend towards an increase in malaria numbers over the last 20 years is likely
to be due mainly to a steady increase in travel to malaria-endemic countries over this period
rather than increased risk per travel episode. The breakdown of malaria cases reported by
region of travel and parasite species is shown in table 1.
Table 1. Cases of malaria by species of parasite and primary region of travel, United
Kingdom: 2007
Geographic
Area
P.falciparum. P.vivax P.malariae P.ovale Pf/Pv Pf/Pm Pf/Po Pm/Pv Total
North Africa
-
-
-
-
-
-
-
-
0
Central Africa
23
-
2
2
-
-
-
-
27
East Africa
92
8
10
11
-
1
-
1
123
Southern
Africa
31
1
1
1
-
-
-
-
34
West Africa
719
2
11
67
1
3
5
-
808
Africa -
unspec.
12
1
-
1
-
-
-
14
Middle East
1
-
-
-
-
-
-
-
1
Asia
22
168
-
1
2
-
-
-
193
Asia -
unspecified
-
1
-
-
-
-
-
-
1
Far East/SE
Asia
1
3
-
-
-
-
-
-
4
Far East -
unspec.
-
1
-
-
-
-
-
-
1
Central/S.
America
2
11
-
1
-
-
-
-
14
Oceania
1
14
-
-
-
-
-
-
15
Not given
235
46
6
24
1
1
-
-
313
Total
1139
256
30
108
4
5
5
1
1548
Five deaths from malaria in 2007 have been reported to date, one from India, the rest from
Africa. Vivax malaria deaths are rare, and are often associated with co-morbidity. There is a
small variation in the number of deaths from malaria in the UK every year but the number for
2007 is broadly similar to the annual average since 2000.
Among patients with malaria where the history of prophylaxis was obtained, 704/844 (83%) had
not taken prophylaxis, and a high proportion of the remainder took prophylaxis not
recommended for their travel destination by the HPA Advisory Committee on Malaria Prevention
in UK Travellers (ACMP) [3]. This high proportion is similar to recent years. It is clear that some
groups are at particular risk of acquiring malaria and are not being reached by health messages
about the importance of antimalarial prophylaxis. The burden of falciparum malaria falls heavily
on those of African and south Asian ethnicity [4]. Of those who had malaria diagnosed in the
UK, where ethnicity was known, 144 were reported as white British, compared with 1001 who
were reported as African or of African descent and 190 reported as south Asian or of south
Health Protection Report Vol 2 No.17 25 April 2008
Asian decent. The overall trend has been for the proportion of malaria both in those of south
Asian descent and travelling to south Asia to decrease, whilst the proportion in those of African
descent to increase over time.
Among those who were travellers from the UK (rather than normally resident in an endemic
area) where reason for travel was known, 549/770 (72%) were visiting friends and relatives
(table 2). The ratio of malaria in UK residents visiting friends and relatives compared with
malaria cases acquired in holiday travellers was 5.1:1. As with all routinely collected data, exact
figures should be treated with caution. It seems likely that those travelling to visit friends and
relatives are either not seeking or able to access medical advice on malaria prevention before
they travel, or they are not being given good advice, or are not adhering to it as they do not
perceive the risk to be as great to them as to the holidaying public; probably all these contribute.
Targeting these groups, and their healthcare providers, should be considered a priority for
health promotion and education.
Table 2. Cases of malaria by stated reason for travel, UK: 2007
Population group
P.f.
P.v.
P.m.
P.o.
Pf/Pv
Pf/Pm Pf/Po
Pm/Pv
Total
New entrant
40
25
2
10
-
-
-
1
78
Visiting family in country of
origin
455
51
10
29
-
1
3
-
549
UK citizen living abroad
14
4
-
1
1
-
-
-
20
Civilian sea/air crew
2
-
-
-
-
-
-
-
2
British armed services
-
4
-
1
-
-
-
-
5
Business/professional
travel
35
8
2
5
-
-
-
-
50
Foreign student studying in
UK
24
6
1
3
-
-
1
-
35
Holiday travel
58
41
2
7
-
-
-
-
108
Foreign visitor ill while in
UK
56
27
4
7
1
1
-
-
96
Children visiting parents
living abroad
-
-
-
1
-
-
-
-
1
Not stated
455
90
9
44
2
3
1
-
604
Malaria, an almost completely preventable disease but one which can be fatal, remains a
significant issue UK travellers. Failure to take prophylaxis is associated with most cases of
malaria in UK residents travelling to malarial areas. There is continuing evidence that those of
African or Asian ethnicity going to visit friends and relatives are at increased risk and those
providing advice should engage with these travellers wherever possible. Recently updated
guidelines [5] should assist clinicians in helping travellers to make rational decisions about
protection against malaria.
References
1. Health Protection Agency (HPA).
Illness in England, Wales, and Northern Ireland associated
with foreign travel – a baseline report to 2002. London: HPA; 2004. Available at:
http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1203496904956?p=1158
945066450.
2. Bhattarai A, Ali AS, Kachur SP et al. Impact of artemisinin-based combination therapy and
insecticide-treated nets on malaria burden in Zanzibar.
PLoS Med. 2007 Nov 6;4(11):e309.
3. See http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1195733830209.
Health Protection Report Vol 2 No.17 25 April 2008
4. Health Protection Agency. Migrant Health:
Infectious diseases in non-UK born populations in
England , Wales and Northern Ireland. A baseline report 2006. London: Health Protection
Agency Centre for Infections. 2006.
5. Chiodini P, Hill D, Lalloo D, Lea G, Walker E, Whitty C and Bannister B.
Guidelines for
malaria prevention in travellers from the United Kingdom. London, Health Protection Agency,
January 2007. Available at
http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1195733823080?p=1191
942128258.
France declares loss of rabies free status: implications for British
travellers
Following the recent rabies incident in France [1] involving an illegally imported dog, with
transmission to two indigenous dogs, the French Ministry of Agriculture has declared that
France has lost its rabies-free status.
French officials have confirmed that there is a low but increased risk of rabies in three
previously identified areas of France (Gers, Grandpuits and Calvados) [2]. Elsewhere the risk of
rabies is considered to be extremely small, but cannot be completely ruled out.
Implications for British travellers to France
All travellers to France are reminded of the need to avoid contact with animals where possible.
Implications for travellers to the affected regions
•
For travellers to Gers (Auch city and surroundings), Seine-et-Marne (environs of Grandpuits)
and Calvados (Lisieux city and Thury Harcourt village and their surroundings)
There is a low but increased risk of exposure to rabies from animal exposures (bites, scratches
and licks around the eyes, mouth or on open wounds) in these areas. Those individuals
exposed as above should seek prompt medical assessment to determine whether post-
exposure prophylaxis (PEP) is required, either from the local rabies clinic in France [3] or, in the
case of British travellers, from their GP on their return to the UK .
•
For travellers to other parts of France
The risk of rabies is considered to be extremely low however exposed travellers are advised to
seek advice from the local rabies clinic as above, or, in the case of British travellers, if not
possible from their GP on return to the UK .
References
1. HPA. Canine rabies in France,
Health Protection Report [serial online] 2008; 2 (10, 7): news.
http://www.hpa.org.uk/hpr/archives/2008/news1008.htm
2 . French Ministry of Agriculture guidance for vets following the recent canine cases (in
French), 19 March 2008 [accessed 24 April 2008],
http://agriculture.gouv.fr/sections/publications/bulletin-officiel/2008/bo-n-12-du-21-03-08/note-d-
information-
dgal6060/downloadFile/FichierAttache_1_f0/DGALO20088008Z.pdf?nocache=1206087673.53
3. Addresses of French rabies clinics are available at:
http://cmip.pasteur.fr/cmed/voy/Car2007.pdf
Health Protection Report Vol 2 No.17 25 April 2008
Mandatory MRSA bacteraemia and C. difficile infection data published
The latest healthcare-associated infections quarterly report, for the final quarter of 2007, was
published by the HPA on 24 April, suggesting a plateauing of case reports following steady falls
achieved in the previous quarters of 2007 [1].
The new data comprises quarterly reports for both MRSA bacteraemia and
Clostridium difficile
infection collected through the mandatory surveillance systems [2].
MRSA bacteraemia
There were 1,080 episodes of MRSA bacteraemia in July-September 2007 and 1,087 in
October-December. This represents a levelling out against the significant decreases in numbers
seen in recent quarters. The tables and commentary also indicate special circumstances, for
instance cases which had been ‘double counted' by different Trusts.
Clostridium difficile
This week also saw the publication of the October-December 2007 figures for
C. difficile
infection. Over this period there were 9,872 episodes of
C. difficile infection in patients aged 65
years and over and 2,211 episodes of infection in patients aged 2-64 years. This is only the
third quarter in which
C. difficile infections in the latter age group have been published. The
number of infections in the 65 years and over age group represents an 8% decrease on the
previous quarter and 23% decrease on the same period in 2006.
Trusts are required to report all
C. difficile positive diarrhoeal specimens processed by their
laboratories, including samples taken in the community (e.g. at GP surgeries, nursing homes
and PCT hospitals). Data representing specimens taken in the reporting Trust and other
settings are presented separately. This indicates the patient's location when the specimen was
taken and does not necessarily reflect where the infection was acquired.
Recent changes to the Department of Health's surveillance requirements will have impacted on
the accuracy of the published data for
C. difficile infections as the data for this scheduled
publication had to be extracted before Trusts had fully completed reviewing their data. Changes
were identified in the Chief Medical Officer letter dated January 2008 [3] and include changes to
the episode definition; Trusts were also encouraged to add NHS number and admission date to
any incomplete records. Trusts were given until by 10 March 2008 to review all their data from
April 2007 in the light of these changes, but data had to be extracted for this publication before
10 March. Consequently not all reviews would have been completed. The effects of this review
on the data will be more accurately reflected in the next quarterly publication in July.
References
1. Latest figures show MRSA bloodstream infections plateau, HPA press release, 24 April 2008,
http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1209023435298?p=1204
186170287
2. These data are available, together with commentaries and historical annual data for both
organisms, and six-monthly data for MRSA bacteraemia at
http://www.hpa.org.uk/infections/topics_az/hai/Mandatory_Results.htm
3. http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Professionalletters
/Chiefmedicalofficerletters/DH_082107
Health Protection Report Vol 2 No.17 25 April 2008
Infection reports
Volume 2 Number 17 Published on: 25
April 2008
Immunisation
Laboratory reports of Haemophilus influenzae by age group and serotype,
England and Wales: January to March 2008 (2007)
Laboratory reports of hepatitis A and C infection in England and Wales: October
to December 2007
Quarterly report from the sentinel surveillance study of hepatitis testing in
England: data for October to December 2007 (quarter 4)
Laboratory reports of Haemophilus influenzae by age group and serotype,
England and Wales: January to March 2008 (2007)
Age
Type
<1y
1-4y
5-14y
15+
nk
Total
b 4
(
5)
1 (6)
2 (1)
19 (16)
0 (0)
26 (28)
nc
15 (7)
4 (3)
1 (1)
68 (81)
3 (0)
91 (93)
a,e,f
3 (3)
1 (0)
3 (1)
11 (9)
0 (0)
18 (13)
not typed
2 (3)
2 (2)
2 (1)
102 (61)
1 (1)
109 (67)
Total
24 (18)
8 (11)
8 (4)
200 (167)
4 (1)
244 (201)
Laboratory reports of hepatitis A and C infection in England and Wales:
October to December 2007
Laboratory reports of hepatitis A infection in England and Wales
During the fourth quarter of 2007, 58 cases of hepatitis A were reported to the HPA Centre for
Infections, lower than in any previous quarter of the year. In the fourth quarter, 62% of cases
were men aged between 15 and 44 (table 1), females accounting for 43% of cases in this age
group. Of those aged 45 years or more, 17% of cases were males and 43% females. Males and
females under 15 accounted for 21% and 14%, respectively, of cases. The decline in the
Health Protection Report Vol 2 No.17 25 April 2008
number of hepatitis A cases reflects an overall decline in the number of reports in all age groups
(figure 1).
Table 1. Laboratory reports of hepatitis A infection in England and Wales: October to
December 2007
Age group
Male
Female
Unknown
Total
<1 year
–
–
–
–
1-4 years
1
1
–
2
5-9 years
4
3
–
7
10-14 years
1
0
–
1
15-24 years
6
5
–
11
25-34 years
9
4
–
13
35-44 years
3
3
–
6
45-54 years
1
2
–
3
55-64 years
1
5
–
6
≥65 years
3
5
1
9
Unknown
–
–
–
–
Total
29
28
1
58
Figure 1. Laboratory reports of hepatitis A infection in England and Wales by age group
and sex: 2002 to December 2007
Laboratory reports of hepatitis C infection in England and Wales
A total of 2,058 cases of hepatitis C infection were reported to the in the fourth quarter (table 2).
The majority of reports were among those aged 25-44 years, as in previous quarters. Sixty four
per cent (1318/2058) of cases were in this age group. The ratio of males to females was 2.3:1.
Table 3. Laboratory reports of hepatitis C infection in England and Wales:
October to December 2007
Health Protection Report Vol 2 No.17 25 April 2008
Age group
Male
Female
Unknown
Total
1-4 years
4
2
–
6
5-9 years
2
–
1
3
10-14 years
3
–
–
3
15-24 years
69
62
5
136
25-34 years
424
182
24
630
35-44 years
497
172
19
688
45-54 years
259
104
14
377
55-64 years
92
43
3
138
≥65 years
38
32
1
71
Unknown
3
1
2
6
Total
1391
598
69
2058
Corrigendum: Laboratory reports of hepatitis C infection, July –September, 2007
Hepatitis C figures for the third quarter of 2007 – first reported in the Health Protection Report
Volume 2, Number 4, 25 January 2008 - have been amended (see below). A substantial
number of laboratory reports had loaded incorrectly into the national surveillance database. This
has since been addressed. It should also be noted that totals for hepatitis C and many other
infections are prone to late and incomplete reporting and are therefore subject to revision.
Laboratory reports of hepatitis C infection, July –September 2007 (revised)
A total of 2,161 cases of hepatitis C infection were reported to the HPA Centre for Infections in
the third quarter of 2007 (table 3) compared to 2188 and 2305 laboratory cases reported in the
first and second quarters of 2007, respectively. In the third quarter, 61% (1317/2161) of cases
occurred in 25-44 year olds compared to 63% and 62% in the first and second quarter of 2007,
respectively. The ratio of males to females was 2.3:1.
Table 3. Laboratory reports of hepatitis C infection in England and Wales:
July to September 2007 (revised)
Age group
Male
Female
Unknown
Total
1-4 years
1
2
–
3
5-9 years
–
2
–
2
10-14 years
71
68
2
141
15-24 years
411
219
11
641
25-34 years
501
166
9
676
35-44 years
318
101
5
424
45-54 years
117
41
3
161
55-64 years
1
1
–
2
≥65 years
49
37
2
88
Unknown
5
2
16
23
Total
1474
639
48
2161
Health Protection Report Vol 2 No.17 25 April 2008
Quarterly report from the sentinel surveillance study of hepatitis testing in
England: data for October to December 2007 (quarter 4)
The sentinel surveillance study of hepatitis testing, which began in 2002, aims to supplement
routine surveillance of hepatitis A, B and C infections in England by providing information on
trends in testing, individual risk exposures and clinical symptoms.
The study collects information on hepatitis A, B and C testing carried out in participating centres
regardless of test result and therefore can also be used to estimate prevalence in those
individuals tested.
This report includes, for the first time:
Data on hepatitis A-specific IgM testing
Data on hepatitis B surface antigen (HBsAg) testing are included for the first time this
quarter: these are shown in sections 2a (antenatal testing) and 2b (non-antenatal
testing).
In addition, the following changes to the content and presentation of this report should be noted:
Region is now based on the Strategic Health Authority (SHA) of the test request
location, in contrast to previous reports, in which region was assigned based on the
location of the sentinel centre;
In contrast to previous reports, individuals less than one year of age at first test are
excluded from all data on anti-HCV testing. Please note, however, that such individuals
are included in data on HBsAg testing.
Work is underway on the classification of individuals with evolving hepatitis B infections: these
data will be presented in future reports.
Health Protection Report Vol 2 No.17 25 April 2008
Hepatitis A IgM testing
The sentinel surveillance study also collects data on testing for hepatitis A-specific IgM antibody
(anti-HAV IgM), a marker of acute hepatitis A infection. Table 1 shows the number of individuals
tested, and testing positive, for anti-HAV IgM in sentinel laboratories between October and
December 2007.
Table 1. Number of individuals tested, and testing positive, for anti-HAV IgM in
participating centres, October – December 2007.
Number
Number
Region (number of centres)
tested
positive
East Midlands (1)
956
1
East of England (1)
403
–
London (5)
876
8
North East* (1)
3
–
North West (5)
1,050
1
South Central (1)
235
–
South East Coast (1)
331
–
South West (1)
759
7
Wales *
13
–
West Midlands (1)
364
–
Yorkshire & the Humber (2)
726
2
Total, all regions (19)
5,716
19
*Although there are no sentinel centres outside England , limited first-line testing from general practices in Wales
is carried out by sentinel centres in the North West and is therefore included here.
Excludes reference and confirmatory testing. Individuals aged less than one year are included. Some duplication
of individual patients may occur due to limitations of the information supplied. All data are provisional.
Health Protection Report Vol 2 No.17 25 April 2008
Table 2 shows the age and sex of individuals tested, and testing positive, for anti-HAV IgM in
sentinel laboratories between October and December 2007. Similar numbers of male and
female anti-HAV IgM-positive individuals were identified: reports from routine surveillance
suggest a male to female ratio of cases of hepatitis A infection of 1.3:1 [1]. Unfortunately no
information was available on potential risk exposures in these individuals.
Table 2. Number of individuals tested, and testing positive, for anti-HAV IgM in
participating centres, October – December 2007.
Female
Male
Unknown
Total
Number
Number
Number
Number
Age
Number
Number
Number
Number
positive
positive
positive
positive
group
tested
tested
tested
tested
(%)
(%)
(%)
(%)
Under 1
74
0 (0.0)
year
29
0 (0.0)
43
0 (0.0)
2
0 (0.0)
1-14 years
64
0 (0.0)
80
4 (5.0)
1
0 (0.0)
145
4 (2.8)
15-24
601
3 (0.5)
years
322
3 (0.9)
262
0 (0.0)
17
0 (0.0)
25-34
948
4 (0.4)
years
373
2 (0.5)
542
2 (0.4)
33
0 (0.0)
35-44
1,074
2 (0.2)
years
399
1 (0.3)
650
1 (0.2)
25
0 (0.0)
45-54
999
1 (0.1)
years
437
1 (0.2)
540
0 (0.0)
22
0 (0.0)
55-64
878
2 (0.2)
years
414
1 (0.2)
448
1 (0.2)
16
0 (0.0)
≥65 years
470
2 (0.4)
493
0 (0.0)
17
0 (0.0)
980
2 (0.2)
Unknown
4
0 (0.0)
11
1 (9.1)
2
0 (0.0)
17
1 (5.9)
Total, all
age
2,483
10 (0.4)
3,026
9 (0.3)
133
0 (0.0)
5,642
19 (0.3)
groups
Excludes reference and confirmatory testing. Individuals aged less than one year are included. Some duplication
of individual patients may occur due to limitations of the information supplied. All data are provisional.
Health Protection Report Vol 2 No.17 25 April 2008
Hepatitis B surface antigen (HBsAg) testing
All pregnant women in the UK are offered hepatitis B screening as part of their antenatal care.
Data from the test request location and freetext clinical details field accompanying the test
request were reviewed to distinguish individuals tested for HBsAg as part of routine antenatal
screening (section 2a) from those tested in other settings and for other reasons (section 2b). It
is possible that individuals undergoing antenatal screening may not be identified as such and
may therefore be included in Section 2b as non-antenatal testing.
a) Antenatal HBsAg testing
During the last quarter of 2007, a total of 17,252 individuals were identified as undergoing
antenatal testing for HBsAg in 19 participating sentinel centres (table 3). Of these, 0.6% (n=104)
were positive. This is the first time these individuals had been reported to the sentinel
surveillance scheme.
Variation in levels of testing by region will reflect local antenatal testing arrangements in each
area; for example, in some areas the majority of antenatal screening is carried out by National
Blood Service laboratories which do not participate in sentinel surveillance.
Individuals identified as undergoing antenatal testing comprised 29.8% of all individuals tested
for HBsAg in participating laboratories during the last quarter of 2007.
Table 3. Number of individuals tested, and testing positive, for HBsAg through antenatal
screening in participating laboratories, October – December 2007.
Region
Number
Number
(number of centres)
tested
positive (%)
East Midlands (1)
13
0 (0.0)
East of England (1)
840
1 (0.1)
London (5)
3,409
39 (1.1)
North East* (1)
1
0 (0.0)
North West (5)
4,328
22 (0.5)
South Central (1)
914
1 (0.1)
South East Coast (1)
1,527
5 (0.3)
South West (1)
3,042
14 (0.5)
West Midlands (1)
69
1 (1.4)
Yorkshire & the Humber (2)
3,109
21 (0.7)
Total, all regions (19)
17,252
104 (0.6)
*As noted above, changes in sample referral patterns in this region mean that a large proportion of hepatitis
testing is now carried out by local hospitals rather than the sentinel laboratory, which may account for the low
level of testing seen here.
Excludes reference and confirmatory testing. Some duplication of individual patients may occur due to limitations
of the information supplied. All data are provisional.
Health Protection Report Vol 2 No.17 25 April 2008
b) Non-antenatal HBsAg testing
This includes all individuals tested for HBsAg at participating centres who are not identified from
the test request location or the clinical details accompanying the test request as undergoing
antenatal screening.
During the last quarter of 2007, a total of 40,612 individuals were tested for HBsAg in 19
participating sentinel centres, excluding antenatal testing (table 4). Of these, 2.2% (n=889) were
positive. This is the first time these individuals had been reported to the sentinel surveillance
scheme.
The proportion of individuals testing positive was highest in London: this may reflect more
targeted testing of risk groups and/or genuinely higher prevalence in people being tested in this
region.
Table 4. Number of individuals tested, and testing positive, for HBsAg in participating
centres (excluding antenatal testing), October - December 2007.
Region
Number
Number
(number of centres)
tested
positive (%)
East Midlands (1)
3,753
45 (1.2)
East of England (1)
2,338
22 (0.9)
London (5)
11,909
397 (3.3)
North East (1)
455
1 (0.2)
North West (5)
7,625
187 (2.5)
South Central (1)
1,300
15 (1.2)
South East Coast (1)
2,739
28 (1.0)
South West (1)
4,233
67 (1.6)
Wales*
17
0 (0.0)
West Midlands (1)
1,809
24 (1.3)
Yorkshire & the Humber (2)
4,434
103 (2.3)
Total, all regions (19)
40,612 889
(2.2)
*Although there are no sentinel centres outside England, limited first-line testing from general practices in Wales
is carried out by sentinel centres in the North West and is therefore included here.
Excludes reference and confirmatory testing. Individuals aged less than one year are included. Some duplication
of individual patients may occur due to limitations of the information supplied. All data are provisional.
Excluding individuals identified from the test request location or clinical details as undergoing
antenatal testing, slightly more women than men were tested for HBsAg during the final quarter
of 2007 (table 5). This may represent antenatal testing that cannot be identified as such from
the information provided, or may reflect genuinely higher levels of testing among women.
The proportion testing positive for HBsAg was higher among men than women (2.7% against
1.6%). The relatively high prevalence of HBsAg among tested individuals of unknown sex may
reflect testing of individuals in settings such as prisons, drug services and GUM clinics where
few demographic details on patients (such as sex) were available and where service users may
be at high risk of hepatitis B infection.
Health Protection Report Vol 2 No.17 25 April 2008
Table 5. Age and sex of individuals tested for HBsAg in participating centres (excluding
antenatal testing), October – December 2007
Female
Male
Unknown
Total
Number
Number
Number
Number
Age
Number
Number
Number
Number
positive
positive
positive
positive
group
tested
tested
tested
tested
(%)
(%)
(%)
(%)
Under 1
year
61
1 (1.6)
80
1 (1.2)
7
0 (0.0)
148
2 (1.4)
1-14 years
276
7 (2.5)
294
5 (1.7)
9
0 (0.0)
579 12 (2.1)
15-24
years
5,586
56 (1.0)
3,394
68 (2.0)
173
2 (1.2)
9,153 126 (1.4)
25-34
years
6,260 126 (2.0)
4,525 151 (3.3)
262
13 (5.0)
1,1047 290 (2.6)
35-44
years
3,601
65 (1.8)
4,134 136 (3.3)
212
15 (7.1)
7,947 216 (2.7)
45-54
years
1,886
42 (2.2)
2,444
80 (3.3)
108
3 (2.8)
4,438 125 (2.8)
55-64
years
1,390
25 (1.8)
1,744
37 (2.1)
47
1 (2.1)
3,181 63 (2.0)
≥65 years
1,798
15 (0.8)
2,072
36 (1.7)
46
0 (0.0)
3,916 51 (1.3)
Unknown
59
1 (1.7)
56
1 (1.8)
88
2 (2.3)
203
4 (2.0)
Total, all
age
groups
20,917
338 (1.6)
18,743
515 (2.7)
952
36 (3.8)
40,612
889 (2.2)
Table excludes reference and confirmatory testing data. Individuals aged less than one year are included. Some
duplication of individual patients may occur due to limitations of the information supplied. All data are provisional.
To provide an indication of trends in testing, data from the 19 sentinel centres from which full
data were available were compared for the final quarters of 2006 and 2007. In the period
October to December 2007, 889 of 40,612 (2.2%) people tested positive for HBsAg (excluding
antenatal testing), compared to 977of 40,731 (2.4%) for the same period in 2006.
Figure 1 shows the five-weekly moving average for number of people tested for HBsAg and
percentage positive over the last year (excluding antenatal testing; January 2007 to December
2007) for the 19 centres from which full data were available.
Health Protection Report Vol 2 No.17 25 April 2008
Figure 1. Five-weekly moving average of number of people tested, and percentage
positive, for HBsAg between January 2007 and December 2007 (excluding antenatal
testing).
Hepatitis C testing
During the last quarter of 2007, a total of 32,761 individuals were tested at least once for
hepatitis C-specific antibodies (anti-HCV) in 19 participating sentinel centres (Table 6). This is
the first time these individuals had been reported to the sentinel surveillance scheme.
Overall, 4.3% of individuals tested for anti-HCV were positive, though this varied by region
(table 6). The high proportion of positives observed among individuals tested in the North East
is likely to be due to changes in sample referral patterns: many hospitals in this area have
started carrying out their own hepatitis testing rather than sending samples to the sentinel
laboratory. The services to which the sentinel laboratory continues to provide testing include
those accessed by individuals at high risk of hepatitis C infection, which may explain the high
percentage positive seen here. For example, 59 of the 264 individuals tested at the laboratory
during this quarter were tested in prison health services, 21 of whom were positive.
It is important to note that no laboratory methods are currently available to distinguish between
acute, chronic or resolved hepatitis C virus infections. Positive anti-HCV results do not therefore
necessarily represent incident infections and the data presented here should be interpreted with
care.
Health Protection Report Vol 2 No.17 25 April 2008
Table 6. Number of individuals tested, and testing positive, for anti-HCV in participating
centres, October – December 2007
Region (number of centres)
Number tested
Number positive (%)
East Midlands (1)
3,274
76 (2.3)
East of England (1)
1,258
53 (4.2)
London (5)
8,435
341 (4.0)
North East (1)
264
25 (9.5)
North West (5)
7,287
385 (5.3)
South Central (1)
888
38 (4.3)
South East Coast (1)
2,771
40 (1.4)
South West (1)
3,633
244 (6.7)
Wales*
15
0 (0.0)
West Midlands (1)
1,360
51 (3.8)
Yorkshire and Humberside (2)
3,576
151 (4.2)
Total, all regions (19)
32,761
1,404 (4.3)
* Although all sentinel centres are in England , a small amount of first-line testing from general practices in Wales
is carried out by laboratories in the North West and West Midlands.
Table excludes reference and confirmatory testing data. Excludes individuals aged less than one year, in whom
positive tests may reflect the presence of passively-acquired maternal antibody rather than true infection. Some
duplication of individual patients may occur due to limitations of the information supplied. All data are provisional.
Of the 1,404 individuals testing positive for anti-HCV during the last quarter of 2007, 649
(46.2%) were also tested for HCV RNA by PCR, of whom 431 were PCR-positive (66.4%).
Sex was reported for the majority of people tested. As in previous quarters, similar numbers of
males and females were tested (table 7); the ratio of males to females tested was 1.0:1. The
ratio of males to females testing positive was 2.1:1. The majority (64.9%) of people tested were
aged 15-44 years. Excluding individuals for whom age is unknown, the percentage of
individuals overall testing positive was highest among people aged 35-54 years. However, this
varied slightly by sex, with the highest prevalence in women observed among those aged
between 25-44 years but in men among those aged between 35-55 years.
Table 7. Age and sex of individuals tested for anti-HCV in participating centres, October –
December 2007*
Female
Male
Unknown
Total
Number
Number
Number
Number
Number
Number
Number
Number
Age
tested
positive (%) tested positive (%) tested positive (%)
tested
positive (%)
group
1-14
223
2 (0.9)
237
3(1.3)
5
0 (0.0)
465
5 (1.1)
15-24
3,602
40 (1.1)
2,506
40 (1.6)
119
0 (0.0)
6,227
80 (1.3)
25-34
3,822
153 (4.0)
3,972
227 (5.7)
250
5 (2.0)
8,044
385 (4.8)
35-44
2,887
119 (4.1)
3,879
346 (8.9)
215
11 (5.1)
6,981
476 (6.8)
45-54
1,825
70 (3.8)
2,163
196 (9.1)
108
5 (4.6)
4,096
271 (6.6)
55-64
1,422
42 (3.0)
1,562
86 (5.5)
49
3 (6.1)
3,033
131 (4.3)
≥65
1,763
19 (1.1)
1,942
28 (1.4)
52
0 (0.0)
3,757
47 (1.3)
Unknown
34
1 (2.9)
47
4 (8.5)
77
4 (5.2)
158
9 (5.7)
Total, all
15,578
446 (2.9)
16,308
930 (5.7)
875
28 (3.2)
32,761
1,404 (4.3)
ages
Health Protection Report Vol 2 No.17 25 April 2008
Excludes reference and confirmatory testing data. Individuals aged less than one year are excluded since
positive tests in this age group may reflect the presence of passively-acquired maternal antibody rather than true
infection. Some duplication of individual patients may occur due to limitations of the information supplied. All data
are provisional.
To provide an indication of trends in testing, data from the 19 sentinel centres from which full
data were available were compared for the final quarters of 2006 and 2007. In the period
October to December 2007, 1,404 of 32,761 (4.3%) people tested were positive for anti-HCV,
compared to 1,622 of 29,766 (5.4%) for the same period in 2006. This suggests increased
testing of people at lower risk of infection.
It should be noted that these data relate to different sentinel centres to those for whom trends
data were presented in the last quarterly report and therefore comparisons should not be made
between reports. However, figure 2 shows the five-weekly moving average for number of people
tested for anti-HCV and percentage positive over the last year (January 2007 to December
2007) for the 19 centres from which full data were available.
Apart from troughs during the Christmas and New Year holiday period, levels of anti-HCV
testing appear to remain fairly steady over the course of the year. Interestingly, the three peaks
in testing in the second half of the year correspond to simultaneous troughs in the percentage
positive, perhaps suggesting increased testing of people at low risk of infection.
Figure 2. Five-weekly moving average of number of people tested, and percentage
positive, for anti-HCV between January 2007 and December 2007. (Note difference in
scales to Figure 1.)
References
1 Health Protection Agency.
Health Protection Report [serial online] 2006;
1 (33): Immunisation.
Available at: http://www.hpa.org.uk/hpr/archives/2007/hpr3407.pdf
Health Protection Report Vol 2 No.17 25 April 2008
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