21 June 2022
Volume: 56 Issue: 24
- Eighteen cases of monkeypox reported in Scotland
- CCHF in Iraq
- Update on dengue in Brazil
- Chikungunya in Brazil
- Polio in Eritrea
- ECDC and WHO publishes report on monkeypox during the summer season
- ECDC publishes report examining responses to hepatitis B and C epidemics
- WHO publishes guideline on visceral leishmaniasis and HIV coinfection
- World Hepatitis Summit 2022 statement
- WHO publishes framework to control skin NTDs
- Report on the contribution of urban planning and management to resilience and health protection
- New measures to slash carbon emissions from housing stock
- Data tool measuring the effects human medicines have on Scotland’s environment launched
- Suspected drug deaths in Scotland, January to March 2022
HPS Weekly Report
21 Jun 2022
Volume 56 No. 24
Eighteen cases of monkeypox reported in Scotland
As of 19 June 2022, Public Health Scotland (PHS) confirmed there have been 18 laboratory-confirmed cases of monkeypox reported since 23 May 2022 in Scotland. On 17 June 2022, the UK Health Security Agency (UKHSA) reported 550 confirmed cases in England, six in Wales and two in Northern Ireland.
PHS and UKHSA are advising people to be alert to any new rashes or lesions, which appear like spots, ulcers or blisters, on any part of their body. Although this advice applies to everyone, the majority of cases identified to date have been among men who are gay, bisexual and men who have sex with men (MSM), so people in these groups, are advised to be aware of the symptoms, particularly if they have recently had a new sexual partner. Anyone with unusual rashes or lesions is advised to contact NHS 24 (Scotland), NHS 111 (England or Wales) or a sexual health service, contacting clinics ahead of visiting and avoiding close contact with others until seen by a clinician.
Monkeypox is a viral infection usually associated with travel to West Africa and has only rarely been reported out with this region. Monkeypox can be transmitted through close contact with a person who already has the infection, including direct contact during sex, and can also be passed on by contact with clothing or linens used by a person who has the disease. Initial symptoms of monkeypox include fever, headache, muscle aches, backache, swollen lymph nodes, chills and exhaustion. A rash can develop, often beginning on the face, then spreading to other parts of the body, including the genitals. The rash changes and goes through different stages before finally forming a scab, which later falls off.
PHS and the UKHSA are working closely with the NHS and other stakeholders, in order to urgently investigate where and how recent confirmed monkeypox cases were acquired, including how they may be linked to each other. Clinicians should be alert to individuals presenting with rashes without a clear alternative diagnosis and should contact local specialist services for advice, if monkeypox infection is suspected. S
Sources: PHS, 20 June 2022 and UKHSA, 17 June 2022
CCHF in Iraq
On 1 June 2022, the World Health Organization (WHO) issued a report on the continued transmission of Crimean-Congo haemorrhagic fever (CCHF) in Iraq, with 212 cases, including 27 deaths, being reported across the country from 1 January up to 22 May 2022.
CCHF is a potentially fatal tick-borne viral haemorrhagic fever (VHF), found in over 30 countries in Africa, Asia, the Middle East and Eastern and Southern Europe. There is no vaccine available for use in the UK.
Advice for travellers
CCHF is spread by ticks infected from an animal reservoir such as cattle, sheep and goats, and can also be transmitted by having contact with the blood or body fluids of an infected animal or person.
While CCHF is extremely rare in travellers, there is an increased risk to those visiting an endemic region who may:
- have an increased likelihood of tick bites during activities such as hiking, camping in rural areas or visiting farms
- be involved in animal slaughter, for example during religious or cultural events
- be travelling for veterinary or medical work reasons
Travellers with an increased risk of infection should be aware of the disease and prevent transmission by:
- practicing tick bite avoidance when partaking in outdoor activities
- following appropriate infection control procedures if working in a healthcare setting
- wearing gloves and other protective clothing while handling animals or their tissues, notably during slaughtering, butchering and culling procedures
Further information on CCHF can be found on the TRAVAX (for health professionals) and fitfortravel (for the general public) websites.
Sources: TRAVAX, 15 June 2022 and fitfortravel, 15 June 2022
Update on dengue in Brazil
The Brazilian Ministry of Health has reported the continuing spread of dengue fever in all five regions of the country. Between 1 January and 31 May 2022, 1,104,742 cases of dengue, including 504 deaths, were reported, which represents an increase of 198% in cases compared to the same period in 2021.
Dengue is an infection found in tropical and sub-tropical climates worldwide. Dengue is spread by Aedes mosquito bites and can cause a severe flu-like illness. There is no vaccine against dengue fever licensed in the UK, with treatment being supportive only.
Advice for travellers
- All travellers to endemic regions are potentially at risk of dengue fever and should be aware of this infection. Aedes mosquitoes are particularly persistent and aggressive, and bite between dawn and dusk. Prevention relies on avoiding mosquito bites at all times.
- Travellers developing a fever during or on return from travel are advised to seek medical attention as soon as possible.
Information and advice for travellers on dengue fever is available on the TRAVAX (for health professionals) and fitfortravel (for the general public) websites.
Sources: TRAVAX, 15 June 2022 and fitfortravel, 15 June 2022
Chikungunya in Brazil
The Brazilian Ministry of Health has reported continuing transmission of chikungunya in all five regions of the country, with 108,730 cases, including 19 deaths, recorded from 1 January to 21 May 2022, with a further 40 deaths under investigation. This number represents a 35% increase in cases, compared to the same period in 2021.
Advice for travellers
Chikungunya is a viral infection spread by mosquito bites which can cause acute fever and severe joint pain. All travellers to endemic regions are potentially at risk of chikungunya and should:
- be aware of chikungunya and understand that no vaccine is available to fight this disease
- avoid mosquito bites as Aedes mosquitoes are particularly persistent and aggressive, and bite between dawn and dusk
- seek medical attention as soon as possible if they develop a fever during, or on return, from travel and mention their travel history
Information and advice for travellers on chikungunya is available on the TRAVAX (for health professionals) and fitfortravel (for the general public) websites.
Sources: TRAVAX, 15 June 2022 and fitfortravel, 15 June 2022
Polio in Eritrea
On 8 June 2022, the Global Polio Eradication Initiative (GPEI) reported one new case of polio in Eritrea, with the Eritrean Government declaring a national public health emergency.
Advice for travellers
- Poliomyelitis is spread mainly through person-to-person contact via the faecal-oral route, and travellers should be offered a booster dose of poliomyelitis vaccine if it has been more than ten years since their last dose.
More information can be found on the TRAVAX Eritrea and poliomyelitis webpages (for health professionals) and on the fitfortravel Eritrea and poliomyelitis webpages (for the general public).
Sources: TRAVAX, 10 June 2022 and fitfortravel, 10 June 2022
ECDC and WHO publishes report on monkeypox during the summer season
On 14 June 2022, the European Centre for Disease Prevention and Control (ECDC) and the World Health Organization (WHO) published a joint technical report, providing guidance for health authorities and event organisers for the upcoming summer.
The guidance suggests that communication around events should focus on prevention messaging and good public health practices. Organisers of events should adapt and share key messages on their websites, social media accounts and event applications, in order to raise awareness of potential risks, along with the promotion of good hygiene practices, and ensure facilities are cleaned regularly.
Separately, the ECDC has also published a report offering guidance to gay and bisexual men, and other men who have sex with men, in collaboration with community organisations. Although this information addresses the group that has been most affected by the current outbreak to date, anyone who may be exposed to monkeypox infection can make use of this report.
Source: ECDC, 14 June 2022
ECDC publishes report examining responses to hepatitis B and C epidemics
On 15 June 2022, the European Centre for Disease Prevention and Control (ECDC) published a report, monitoring the progress of EU and EEA countries in 2020 towards meeting hepatitis elimination targets.
In major findings from the report:
- Nineteen EU and EEA countries have an action plan or strategy for viral hepatitis prevention and control, of which 11 countries reported national funding for implementation.
- Twenty-two countries reported that there was testing guidance for hepatitis B or hepatitis C, however, many countries’ guidance did not include one or more of the key populations at risk for hepatitis infections.
- Three countries reported that not all test costs were reimbursed, with nine countries reporting that testing was available in community-based drug service settings and 18 countries reported the existence of policies that require hepatitis tests be performed by healthcare workers, indicating another policy area that could be revised to allow for improved accessibility of testing.
- Overall, 20 countries provided data for at least one of the four key stages of the hepatitis B continuum of care, while 23 countries provided data for at least one of the four key stages for the hepatitis C continuum of care.
- The number of countries which were able to report data related to the continuum of care for both hepatitis B and C has fallen since 2018 and significant gaps in data completeness and robustness remain. Data was collected on WHO-defined indicators as well as newly proposed continuum of care indicators.
The estimated number of people living with chronic hepatitis B virus infection by country varied from 183 to 3,312 per 100,000 population. However, these estimates were derived from a range of methods of varying quality and were often based on studies from before 2016. For hepatitis B, it was not possible to assess progress towards the 2020 WHO European Region action plan targets for most of the targets due to lack of data. For the 2020 diagnosis target, four of eight countries reporting relevant data had met the 50% target and in terms of viral suppression, two countries had met the target of 90% of those on treatment being virally suppressed.
The estimated number of people living with current chronic hepatitis C virus infection by country ranged from 24 to 2,411 per 100,000 population. These estimates were also sourced from a range of methods and most estimates were from 2018 or earlier. For hepatitis C, data availability along the continuum of care was generally greater compared to hepatitis B, but it is still difficult to assess region-wide progress. Four of seven countries reporting relevant data achieved the 50% diagnosed target, with the best progress being seen in the HCV sustained virologic response target, with ten of the eleven countries reporting data exceeding the 90% target for those achieving SVR of those treated with antiviral medications.
The COVID-19 pandemic had wide-reaching impacts on hepatitis services in the EU and EEA and has negatively impacted on some hepatitis B and C prevention and testing services. Most countries reported negative impacts of the pandemic on clinic visits for routine care, testing for hepatitis B virus and hepatitis C virus, or the provision of community-based services. Additionally, almost half of the countries reported that there was reduced laboratory capacity for hepatitis B and C testing, however, some routine hepatitis B prevention services, such as routine antenatal screening, were not largely affected by the pandemic. Six countries reported that routine infant and childhood hepatitis B vaccination was negatively affected.
The COVID-19 pandemic did not appear to have a large impact on hepatitis B and C treatment and governmental funding for hepatitis programmes, though the pandemic did prompt some countries to implement newer strategies, such as virtual appointments and alternative modes of medication delivery.
Source: ECDC, 15 June 2022
WHO publishes guideline on visceral leishmaniasis and HIV coinfection
On 8 June 2022, the World Health Organization (WHO) published a new treatment guideline for visceral leishmaniasis in patients who are coinfected with the human immunodeficiency virus (HIV), with the guideline targeting visceral leishmaniasis in East Africa and South-East Asia.
Visceral leishmaniasis, or kala azar, is caused by different Leishmania species in distinct geographical areas. In East Africa (Ethiopia, South Sudan and Sudan) and South-East Asia (Bangladesh, India and Nepal), it is caused by L. donovani and has an anthroponotic cycle with a human reservoir.
The new recommendations are based on the results of studies conducted in India by Médecins Sans Frontières (MSF) and partners, and in Ethiopia by the Drugs for Neglected Diseases initiative and partners. The expectation is that there will be increased access to treatment and improved treatment outcomes, which will benefit national control programmes for neglected tropical diseases, HIV, tuberculosis and vector-borne diseases. Up to 5-7% of visceral leishmaniasis patients in India are detected with HIV infection, the highest level in South Asia, while a significant proportion also suffer from tuberculosis (TB).
The new guideline updates the 2010 recommendations, which were based on limited evidence extrapolated mainly from experience in countries around the Mediterranean Basin, where zoonotic L. infantum is the main causative species. The recommended treatment consisted of daily injections of liposomal amphotericin B (AmBisome) over a period of up to 38 days. However, evidence from the studies in Ethiopia and India shows that the new regimen combining liposomal amphotericin B with oral miltefosine performs better, as results in India found that relapse-free survival was recorded at 96%, against 88% for the standard treatment.
In Ethiopia, visceral leishmaniasis-HIV coinfection has increased by 20 to 30% since the early 1980s, with the highest coinfection rate in the world, and although the rate has declined, coinfection nevertheless remains a major public health challenge. The new combined regimen showed an increased efficacy of 88%, compared with the current standard treatment of 55%.
Leishmania and HIV coinfections have challenged the control and elimination of visceral leishmaniasis, as HIV-infected people are particularly vulnerable to the disease. Leishmania and HIV reinforce each other, posing significant clinical and public health problems, with both conditions suppressing the immune system, resulting in more severe morbidity, with limited therapeutic options and higher rates of relapse, exposure to medicines with increased toxicity and higher mortality rates.
First reported in the mid-1980s in southern Europe, the coinfection is now documented in around 45 countries, with high rates being reported in Brazil, Ethiopia and the Bihar state in India. Coinfected patients are vulnerable not only to other comorbid conditions, such as tuberculosis and cryptococcal meningitis, but also to stigmatization and human rights issues.
Leishmaniasis is caused by a protozoa parasite from over 20 Leishmania species, with over 90 sandfly species known to transmit Leishmania parasites. There are three main forms of the disease:
- Visceral leishmaniasis, which can be fatal if untreated, and is characterized by irregular bouts of fever, weight loss, enlargement of the spleen and liver, and anaemia.
- Cutaneous leishmaniasis which is the most common form of leishmaniases, causing skin lesions, mainly ulcers, on exposed parts of the body, leaving life-long scars and serious disability or stigma.
- Mucocutaneous leishmaniasis, which leads to partial or total destruction of mucous membranes of the nose, mouth and throat.
Source: WHO, 8 June 2022
World Hepatitis Summit 2022 statement
At the 2022 World Health Assembly, countries have recommitted to eliminate viral hepatitis by 2030.
Since the initial commitment in 2016, the Sustainable Development Goals 2020 target of reducing the prevalence of hepatitis B in children under five years of age to under 1% has been met globally and in most World Health Organization (WHO) regions, while the number of people receiving treatment for hepatitis C has increased tenfold, to more than 10 million people.
However, globally more than 350 million people are still living with hepatitis, with gains made being uneven across the world, as those most impacted are often least likely to benefit, and most countries have failed to meet the Global Health Sector Strategies (GHSS) 2020 targets. Few babies have access to the hepatitis B birth dose vaccine in many low- and middle-income countries, with less than 10% in Africa receiving a timely vaccine. Additionally, infection and prevention control in healthcare settings needs further improvements and harm reduction remains insufficiently scaled up and accessible. Stigma and discrimination also continue to be a barrier to testing and care. Only 10% and 21% of people know that they live with chronic hepatitis B or hepatitis C respectively, with fewer receiving treatment, and liver cancer related to hepatitis is on an exponential rise, especially in low- and middle-income countries. Furthermore, acute hepatitis A and E continue to impact people’s health all over the world.
The participants of the third World Hepatitis Summit believe that the new GHSS on HIV, viral hepatitis and sexually transmitted infections 2022 to 2030, provides an opportunity to refocus global efforts, accelerate the response and recommit to the elimination of viral hepatitis by 2030.
To make the elimination of hepatitis a reality within evolving health systems, countries, global partners and other stakeholders are urged to act towards achieving the 2025 and 2030 targets, by developing and implementing national hepatitis strategies which address the five strategic directions of the GHSS and put people living with viral hepatitis at the heart of the response.
The World Hepatitis Summit participants also:
- ask that multisectoral action, which recognises civil society as an integral partner, is taken to operationalise hepatitis programmes which promote integration, decentralisation and task shifting to improve access
- call on governments, global health agencies and donors to honour commitments already made and further commit to prioritise and fund comprehensive hepatitis programmes so that everyone has access to affordable prevention, testing, treatment and care
- call on the 350 million people living with viral hepatitis and their communities to unite, amplify their voices and take their place in the hepatitis response
Source: WHO, 10 June 2022
WHO publishes framework to control skin NTDs
On 8 June 2022, at a World Health Organization (WHO) hosted seminar, the WHO launched a strategic framework for skin-related neglected tropical diseases (skin NTDs), which identifies opportunities to integrate approaches for control and management, including common learning platforms, capacity-building for case detection and delivery of treatment. The framework is a companion to the WHO roadmap for neglected tropical diseases 2021 to 2030.
Skin NTDs afflict hundreds of millions of people, and cause immense discomfort, suffering, stigmatization and mental distress and affect the quality of life of mostly marginalized populations in remote rural areas.
At least 10 of the 20 NTDs prioritized by the WHO present with changes on the skin before other changes occur in the internal organs or physical disabilities develop. An integrated approach provides opportunities and solutions for addressing skin NTDs in the field, using measures ranging from education, awareness-raising and seeking medical care at the onset of symptoms, to building capacity by developing appropriate diagnostics and tools.
The WHO note that the general population of member states need to be shown greater awareness of skin diseases and their seriousness, and building the community health workforce to detect and report skin problems to health workers is vital, using the system previously used to protect against dracunculiasis, leprosy, yaws and other diseases.
Capacity building is reportedly critical to implementing integrated approaches. Online tools for front-line health workers include a training guide and a multilingual mobile app. The WHO say accurate, reliable tools are also essential to guide diagnosis and integrated management, given the co-endemicity and common differential diagnosis for many skin NTDs.
The WHO has been working to identify target product profiles to achieve the road map targets, which include case detection at the point of care for Buruli ulcer, dermal leishmaniasis and mycetoma. For mycetoma, the only effective approach is early case detection and management, involving long periods of antifungal treatment combined with surgery. An integrated approach provides opportunities to share available resources, improve case detection, reduce treatment costs and improve programme efficiency. A promising new medicine for eumycetoma, called fosravuconazole, is in clinical trials and may potentially shorten the duration of treatment.
Source: WHO, 13 June 2022
Report on the contribution of urban planning and management to resilience and health protection
On 14 June 2022, World Health Organization Europe (WHO/Europe), in collaboration with UN-Habitat, published four reports examining how health and environment can be protected by building urban resilience. The reports have reviewed evidence, practice and monitoring frameworks on urban resilience, in order to help local authorities and decision-makers reflect on the environment and health dimensions of local preparedness and resilience, and to promote the application of urban planning approaches to establish safe, healthy and sustainable cities.
Disasters and emergencies have a direct impact on population health, causing injuries and diseases, as well as mental and psychosocial outcomes. Extreme events also significantly affect the functionality of critical infrastructure, such as health care facilities, water and energy supply and transport. Over the last two decades, natural disasters, such as flooding and storm events, have claimed more than 300,000 lives globally, and affected cities across all countries of the WHO European Region, with disasters caused an estimated economic loss of US$271 billion across the region.
Various global frameworks have been established to address sustainable development, urban environments and resilience, and awareness of the local benefits associated with implementation of these global agendas is growing. Urban planning, risk governance and resilience have become increasingly important pathways for cities in preparation for disasters and to reduce or prevent associated public health impacts at a local level.
Cities need to understand what features and processes make them vulnerable to crises, and to environmental and technological emergencies, and their associated health impacts, while also recognising the most effective counteractions, in order to become better prepared and more resilient.
Overall, the strategic key messages of the project highlight the need for urban planners and decision-makers to:
- use relevant data and tools to enhance risk-informed decision-making and address inequality
- strengthen community involvement and engagement in urban interventions
- break down silos, establish common goals and enable a whole-of-government approach to emergency management and preparedness
- establish and implement land-use, building and infrastructure planning and regulations, with a preventive approach to protect health
- promote compactness, land-use mix and connectivity throughout the city to reduce distances and dependencies
- apply green and blue spaces and nature-based solutions strategically and synergistically in urban environments to build resilience and protect health
The reports of the project provide information and lessons learned on how to build forward better and apply environmental and infrastructural planning as an important pathway towards building urban resilience.
Source: WHO/Europe, 13 June 2022
New measures to slash carbon emissions from housing stock
On 15 June 2022, the Scottish Government published new regulations aimed at cutting emissions from all new-build homes by almost one-third. The regulations will also apply to newly built non-domestic buildings and form part of plans to reduce emissions across Scotland’s building stock by more than two-thirds by 2030.
Key elements contained in the new regulations include:
- improved performance targets aimed at reducing emissions from new homes by an aggregate of 32% and new non-domestic buildings by an aggregate of 20%
- the introduction of a new energy target for new buildings to set and report on performance of decarbonisation as new buildings are decarbonised
- a focus on reducing energy demand, including improved fabric insulation in new homes to reduce heating needs
- changes to make connection to low-carbon heating solutions, such as heat networks, easier
The new standards, which will apply from December 2022, also support plans for all new buildings to have zero emissions heating systems from 2024.
Data tool measuring the effects human medicines have on Scotland’s environment launched
The first open access interactive tool in the UK to combine national environmental and prescribing data, which aims to help researchers better understand the effects medicines have on Scotland’s environment, was launched on 13 June 2022 by the Scottish Environment Protection Agency (SEPA), on behalf of the One Health Breakthrough Partnership (OHBP).
The OHBP is a collaboration between SEPA, NHS Highland, Scottish Water and the University of the Highlands and Islands (UHI) and brings together key regional and national stakeholders across the water, environment, and healthcare sectors, who are committed to addressing the issue of pharmaceutical pollution and is designed to stimulate innovation towards helping achieve optimal health for people, animals and the environment.
The data tool leads on from a Centre of Expertise for Waters (CREW) project for the OHBP, which published its findings earlier this year. The project combined and assessed published and unpublished academic data, with monitoring data from Scottish Water and SEPA. These environmental data have been used to develop the data visualisation tool, alongside primary care prescribing data from Public Health Scotland (PHS).
The main route for human medicines to enter the water environment is via toilets. Some of this is due to the way our bodies metabolise medicines, with between 30% and 100% of the active ingredient in an oral dose ending up flushed away after people go to the toilet. Some is more easily avoidable, as a 2021 survey showed around one-in-10 people throw old and unused medicines down the sink or toilet, instead of returning them to a pharmacy for safe disposal. In both situations, medicines can end up in sewage at wastewater treatment works, where treatment has not been designed to remove such pollutants and are then discharged to the water environment.
Pollution of the water environment by medicines can negatively affect aquatic life by impacting their growth, behaviour, reproduction and survival. In most cases, the concentrations of medicines in the water environment are much lower than the therapeutic dose, which makes it difficult to determine what impact they may be having. Medicines in the environment may also be contributing to an increase in bacteria, viruses, fungi and parasites that no longer respond to medicines, known as antimicrobial resistance (AMR) and to the spread of antibiotic resistance in people. Making the data contained within the visualisation tool easily accessible means they can be used to inform research and improve wider understanding of these issues.
The tool will be used by the OHBP, research partners and others to explore and develop appropriate and sustainable solutions in reducing the discharge of pharmaceuticals to the environment and will also guide monitoring efforts, as the group continues to improve understanding of the environmental occurrence and impact of these pollutants.
Future interventions will target medicines which pose the highest environmental risk, giving prescribers and patients more information on the environmental effects of medicines. A key part of reducing the quantity of pharmaceuticals that enter sewerage systems is through educating people about the possible environmental effects of what they stock in their medicine cabinet and encouraging them to return unused medicines to pharmacies for proper disposal.
Changes to pharmaceutical prescribing practices, infection control strategies and future regulatory standards are other potential avenues for reducing the unintended release of medicines to the environment.
Source: SEPA, 13 June 2022
Suspected drug deaths in Scotland, January to March 2022
On 14 June 2022, the Scottish Government published its first quarterly statistics on the number of suspected drug deaths during the first quarter of 2022. The report focusses on management information from Police Scotland on suspected drug deaths, to provide as timely an indication of current trends in drug deaths in Scotland as is possible.
The report contains the following findings:
- There were 285 suspected drug deaths recorded between January and March 2022, similar to the numbers recorded for each of the previous two calendar quarters, October to December 2021 (288 deaths) and July to September 2021 (285 deaths).
- There were 108 fewer suspected drug deaths than the 393 deaths noted between January and March 2021.
- Males accounted for 70% of suspected drug deaths, a slight decrease on 72% noted between January and March 2021.
- There were 86 suspected drug deaths of females, a decrease from 110 deaths noted between January and March 2021.
- Two-thirds of suspected drug deaths were of people aged between 35 and 54 years old, comparable with previous quarters.
- There were 15 suspected drug deaths in the under-25 age group, a decrease from 20 deaths noted between January and March 2021.
- The police divisions with the greatest number of suspected drug deaths were Greater Glasgow (50), Edinburgh City (31) and Lanarkshire (29).
- There were 1,187 suspected drug deaths over the previous 12 months to March 2022, 299 fewer than the 12 months leading up to March 2021.
It should be noted that numbers of suspected drug deaths fluctuate from quarter to quarter and care should be taken not to interpret movements between individual calendar quarters as indicative of any long-term trend.