Over 30 new organisms have been discovered in the 30 years up to 20051 and with the threat of SARS and the direct effect of H1N1 the issue of emerging infections (EI) has been raised in the public imagination. A recent report highlighted the effect that recent episodes of EIs have had on the public health in Scotland including incidents involving anthrax, H1N1, rabies, Q fever, and extensively-drug resistant tuberculosis (XDRTB) among others.2 That report identified the main drivers for EIs as being:
- globalisation (population movement, trade)
- environmental change (climate, built environment),
- zoonotic transfer (husbandry, animal movement)
- antimicrobial resistance (in Scotland and imported) and
- new technologies (healthcare, biotechnological and other new industrial processes).
However EIs are not the only emerging public health threats that exist. Chemical, biological, radiological and nuclear (CBRN) threats are under continuous assessment, particularly as potentially terrorist resources, but also as by-products of manufacturing, processing and disposal industries, as well as from natural sources (e.g. volcanoes).
Not all agents or events identified by these means may subsequently affect the Scottish public health, however HPS has to be aware of these international events and to be able to carry out ongoing assessments of risk and carry out appropriate steps to mitigate any risk.
A number of methods have been developed to identify emerging threats at the global scale such as GPHIN, HealthMap, EpiSpider.3,4 These systems survey news and health sites to identity potential new foci of disease and seek to inform users quickly with varying degrees of specificity and sensitivity in identifying real incidents. In addition a range of agencies survey the literature in order to identify hazards for the purpose of risk assessment resulting in a number of publications with differing emphases covering international outbreaks, foodborne outbreaks, incidents affecting animal health (e.g. TRAVAX, NaTHNaC, National Expert Panel on New and Emerging Infections (NEPNEI), ECDC).a-d
Given the vast amount of information which is generated on a daily basis, HPS has recently begun developing a method to distil the important organisms and events while bearing in mind the rapid potential for change that exists. This method seeks to bring together data from the various reports but also to tap into networks of experts which liaise with the various teams in HPS as well as with the Scottish National Blood Transfusion (SNBTS) Service and the Scottish Salmonella Shigella and Clostridium difficile Reference Laboratory (SSSCDRL). The aim of this is to alert those involved in protecting the public health to key events and to help inform action and emergency preparedness as appropriate. An objective is to ensure that information assessed is not merely limited to EIs but takes an all-hazard approach including environmental hazards as well as hazards posed by manufacturing and processing industries.
Here we present the results of a pilot study which sought to obtain, collate and report on information gathered on new and emerging incidents and hazards from as wide a range of sources as possible for the one-month period 12 March to 11 April 2012.
An excel spreadsheet was sent to a named contact in each of the HPS teams and also to SNBTS and SSSCDRL with the request that they record any event which was reported to them between 12 March 2012 and 11 April 2012 and which met the criteria in Box 1 (Mandatory reporting) or which they believed to be of interest for public health professionals in Scotland in the context of emerging risks and hazards (Optional reporting). The data was collated by the Travel and International Health Team at HPS and summary tables and maps produced.
Box 1: Criteria for mandatory reporting
|Avian Flu (human)|
|Polio (wild type)|
|New Flu strains|
|New strain of any infection|
|New disease crossing species barrier|
|New presentation of a disease|
|New means of transmission of existing disease|
|New report of adverse event or failure associated with vaccine|
|New report of event with imported foods|
New report of event with manufacturing of vaccine
Reports were received from all HPS Teams as well as from SNBTS and SSSCDRL. These reports highlighted 24 incidents of which seven were due to one of the mandatory events (all human cases of influenza). The remaining incidents were related to infectious diseases (N=14), chemical contaminants (N=1), failure of testing kits (N=1), vaccine-related outcomes (N=1) and one to recovery from clinical rabies.
The majority (N=14) had potential interest for UK travellers abroad while two Schmallenberg virus in livestock and sodium nitrate mislabelling, had realistic potential to affect the international public health through the food chain. The report of a new case of malaria in the Bahamas has the potential to affect risk groups for donation of blood products.
- The majority of human cases of avian flu were single cases which were quickly identified in country and none reported were as a result of human-to-human transmission. There remains increasing cause for concern about bird flu in South East Asia after China in late December 2011 reported its first fatality in 18 months. The H5N1 strain has killed 353 people worldwide since 2003, according to WHO statistics (at 4 April).
- While nothing new was uncovered for the first time using this method it allowed the data across all groups and across parts of the wider health-protection community to be collated in one place for reporting.
- The pilot identified room for improved data collation including identifying what action has been taken as a result of any incident, and the need to identify further stakeholders, for example laboratories and the Food Standards Agency.
- However, the development and maintenance of this method of systematic collation and reporting on a routine basis should ensure that all teams and stakeholders note and report any event which they believe to be of interest as they occur.
- Furthermore the report produced, with accompanying Tables, Figures and Maps, will give HPS and its stakeholders a regular review of all incidents which have the potential to affect public health either through disease transmission, effects on food production or effects on other goods such as vaccines. The report produced will be improved as feedback is received.
- In addition to reporting on recent incidents and hazards, information will also be gathered and disseminated on future events, travel patterns, and guidance development in order to enable the development of timely preparedness plans and proactive public health messages.
- World Health Organization. Combating emerging infectious diseases in the South East Asia Region. SEA-CD-139. 2005.
- Roy K, Donaghy M, Creasey C. Health and Health Protection. Health Protection Stocktake. 2012.
- Friefeld, CC, Mandl KD, Reis BY et al. (2008). HealthMap: global infectious disease monitoring through automated classification and visualization of internet media reports. J American Medical Informatics Association. 2008;15(2):150-157.
- Keller, M, Freifeld, C, and Brownstein, J (2009). Automated Vocabulary discovery for geo-parsing online epidemic intelligence. BMC Bioinformatics. 2009;10:385-393.
- HPS. Travel associated acquisition of NDM-1 Klebsiella in Scotland. HPS Weekly Report. 2012;46(10):78. Available from: http://www.hps.scot.nhs.uk/ewr/redirect.aspx?id=50756.
- Golding N, Nunn MA, Medlock JM et al. (2012). West Nile virus vector Culex modestus established in southern England. Parasites & Vectors. 2012. 5:doi:10.1186/1756-3305-5-32.
- ProMED Mail. Avian Influenza, Human (24): Viet Nam (Binh Duong). Archive Number: 20120228.1055600. 28 February 2012. Available from: http://www.promedmail.org/direct.php?id=20120228.1055600.
- ProMED Mail. Avian Influenza, Human (38): Viet Nam (Dak Lak). Archive Number: 20120327.1082245. 27 March 2012. Available from: http://www.promedmail.org/direct.php?id=20120327.1082245.
- ProMED Mail. Avian Influenza, Human (41): Cambodia (Kampong Chhnang), Egypt (Demiatta, Giza). Archive Number: 20120403.1089377. 3 April 2012. Available from: http://www.promedmail.org/direct.php?id=20120403.1089377.
- ProMED Mail. Avian Influenza, Human (37): Egypt (Dakahlia). Archive Number: 20120320.1075689. 20 March 2012. Available from: http://www.promedmail.org/direct.php?id=20120320.1075689.
- ProMED Mail. Avian Influenza, Human (37): Indonesia (Nusa Tenggara Barat). Archive Number: 20120328.1083746. 28 March 2012. Available from: http://www.promedmail.org/direct.php?id=20120328.1083746.
- Health Protection Agency. HPA investigating problems with commercial syphilis test kit. HPA Press Release, 13 March 2012. Available from: http://www.hpa.org.uk/NewsCentre/NationalPressReleases/2012PressReleases/.
- ProMED Mail. Undiagnosed cerebral disease - Uganda (04): nodding disease. Archive Number: 20120317.1073307. 17 March 2012. Available from: http://www.promedmail.org/direct.php?id=20120317.1073307.
- Wadman M. African outbreak stumps experts. Nature. 2011;475:148-149.
- Federal Ministry of Health. Weekly updates on epidemics in Nigeria. 4 April 2012. Available from: http://www.fmh.gov.ng/index.php/component/content/article/930.
- EuroTravNet. blaNDM-1 carbapenemase resistant Pseudomonas aeruginosa after a stay in Serbia. 2012. [Personal Communication]
- ECDC. Schmallenberg virus, measles and influenza in focus. Communicable Disease Threats Report. 2012. Available from: http://ecdc.europa.eu/en/publications/Publications/Forms/ECDC_DispForm.aspx?ID=840.
- Wiedeman J, Glaser C, Messenger S et al. (2012). Recovery of a patient from clinical rabies – California 2011. MMWR. 2012;61(04):61-65. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6104a1.htm.
- ProMED Mail. Poliomyelitis - Worldwide (04): India, vaccine derived poliovirus type 2, request for information. Archive Number: 20120319.1074212. 19 March 2012. Available from: http://www.promedmail.org/direct.php?id=20120319.1074212.
- ECDC. Outbreak of measles in the Ukraine and potential for spread in the EU, 2012. Rapid Risk Assessment, 13 March 2012. Available from: http://ecdc.europa.eu/en/publications/Publications/Forms/ECDC_DispForm.aspx?ID=838.
- Janta D, Stanescu A, Lupulescu E et al. Ongoing rubella outbreak among adolescents in Salaj, Romania. Euro Surveill. 2012;17(7):pii=20089. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20089.
- Coia J. Shiga-toxin producing E. coli 026 (STEC 026) in USA. 2012. [Personal Communication].
- Coia J. Shiga-toxin producing E. coli 026 (STEC 026) in Ireland. 2012. [Personal Communication].
- Food Standards Agency. Warning over Mistral Laboratory Chemicals. FSA News Release, 29 March 2012. Available from: http://www.food.gov.uk/news/newsarchive/2012/mar/mistral.
- Borg ML, Modi A, Tostmann A, Gobin M, Cartwright J, Quigley C, Crook P, Boxall N, Paul J, Cheasty T, Gill N, Hughes G, Simms I, Oliver I. Ongoing outbreak of Shigella flexneri serotype 3a in men who have sex with men in England and Wales, data from 2009–2011. Euro Surveill. 2012;17(13):pii=20137. Available from: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20137.
- OIE. Immediate notification report: Ref OIE: 11710, Report Date: 26/03/2012. Available from: https://web.oie.int/wahis/reports/en_imm_0000011710_20120326_182555.pdf.
- CDC. Malaria case acquired in the Bahamas (Great Exuma). Malaria alert, 30 March 2012. Available from: http://www.cdc.gov/malaria/new_info/2012/malariabahamas.html.
Other resources cited:
a Travax: Outbreak index and daily/weekly updates. http://www.travax.nhs.uk/.
b NaTHNac: Outbreak index and weekly updates: http://www.nathnac.org/.
c. NEPNEI biannual updates: http://www.dh.gov.uk/ab/NEPNEI/index.htm.
d. ECDC weekly updates: http://ecdc.europa.eu/en/Pages/home.aspx.