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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. 3
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, osteomyelitis. • 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. 4
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. 5
Outbreak Overview • 26 th April 2019 – 1 case of listeriosis (case 1) (deceased) was notified to PHE North West. • 4 th May 2019 – 1 case of listeriosis (case 2) was notified to PHE North West by the same hospital. • 6 th May 2019 – PHE were notified that case 2 was deceased. • 21 st May 2019 – Hospital chaired an incident management team (IMT) meeting and following this handed over management of the outbreak to PHE. • 23 rd 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 25 th 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 4
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 of 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. • 31 st May 2019 an enhanced incident was declared. • On 3 rd 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 18 th July 2019. • On 2 nd August 2019 the incident was de-escalated further to routine. 7
In The News A selection of headlines following the proactive press release 8
Key Points 1. Following the notification of the first case to PHE, the situation rapidly escalated to an outbreak. 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 9
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 10
Invasive Group A Streptococcal Disease (iGAS) Jo McCullagh Specialist Registrar in Public Health
Overview • GAS transmission and symptoms • National trend • Background to local outbreak • Investigations and findings • Control Measures • Recommendations 12
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 13
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%) 14
Background 1 st iGAS case in notified on 11 July 2019 : PWID in a homeless hostel. • 2 nd 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. 15
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. 16
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 1 7
Environmental Investigation • Unregistered 35-bed hostel, unregulated by Local Authority. • Overall condition and cleanliness was poor. • Several issues increasing risk of disease transmission: - Broken toilets & showers - Damp - Mice and pigeons - Bed bug infestations - Discarded, used drug equipment 1 8
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 19
Recommendation 1 Delivery of bacterial infections training and resources to homeless hostels and substance misuse services. 20
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. 21
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 22
Norovirus in Schools – 2019 Update Dr Sam Ghebrehewet
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