Zoonoses Network Newsletter Produced on behalf of the UK Public Health Network for Zoonoses Number 14, Spring 2013 Please send any contributions and comments to Zoonoses@hpa.org.uk
In this issue: Page 1
Tick awareness Page 2
Cowpox Ornithosis Hantavirus Pulmonary leptospirosis Page 3
HAIRS risk assessment Orf outbreak, Turkey Sarcosystosis, Malaysia Cutaneous toxoplasmosis, Germany Page 4
Australian bat lyssavirus Pathogen from fish Rabies in Greece Alveolar echinococcosis, Europe HPA becomes part of Public Health England Conferences/CPD/ training opportunities
Ticks in the United Kingdom – raising awareness Ticks are blood feeding arachnids which become more active as spring temperatures increase. In the UK we have 20 endemic species, and 2 which are regularly imported but not established. The majority of these are specialist feeders found at particular locations, whereas others are widespread. One species, Ixodes ricinus, the sheep or deer tick, will feed on a wide range of different hosts, including mammals, birds and reptiles. Its wide distribution, high abundance and ability to transmit bacterial, viral and protozoal pathogens in Europe makes it an important species to both human and veterinary health. Ixodes ricinus is most commonly found in woodland, rough grassland, and heathland, but also increasingly in urban parks and gardens.
Tick surveillance and research in the UK
behind the knees, around the waist and in the underarm and groin areas. Young children are more commonly bitten around the neck, behind the ears, along the hairline and on the scalp. Remember to also check your pets and their bedding.
Since 2005, the HPA has been running the Tick Other prevention strategies include: Recording Scheme (TRS) with the aim of prowalking on clearly defined paths avoiding moting surveillance, monitoring national distridense vegetation and tall grass butions, determining the diversity of species wearing light-coloured clothing so it’s easier present and facilitating the detection of imported to spot any ticks and brush them off or unusual species. Using ticks collected by the general public, veterinarians, wildlife charities, health care professionals and amateur entomologists, we have updated our knowledge of tick distributions and identified imported exotic species. To date we have over 1400 records of 16 species of tick, representing over 6000 individual ticks. We have also recorded at least 150 new locations for Ixodes ricinus. The HPA Medical Entomology & Zoonoses Ecology group use data collected through the TRS and results from targeted field research to enhance our understanding of tick ecology. This allows us to better understand the role of ticks in transmission of infections to humans, and to translate this into health protection.
using repellents such as DEET If you find you have been bitten by a tick, it is important to remove it promptly, as this can minimise the risk of pathogen transmission. The only correct way to remove ticks is to use finetipped tweezers, or a tick removal tool. Grasp the tick as close to the skin as possible. Pull upwards slowly and firmly, as any bits left in the skin can cause a local infection Once removed, apply antiseptic to the bite area and be vigilant for signs/symptoms of infection. Contact your GP if you begin to feel unwell and remember to tell them that you were bitten by a tick.
Tick bite prevention and removal Ticks can transmit a variety of pathogens including the bacteria that cause Lyme disease, symptoms of which can include a circular rash, fatigue, and muscle and joint pain. More serious disease can develop without treatment, so prevention, prompt tick removal and early detection are crucial. Whilst spending time in tick habitats, it is important to regularly check your clothing and body, and remove any ticks promptly. On return home, carefully check your entire body, particularly in difficult to see areas such as skin folds,
[Text and images supplied by the Medical Entomology & Zoonoses Ecology team, HPA Porton tick@hpa.org.uk
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reservoir is wild rodents, from which it occasionally spreads to domestic cats Two siblings recently presented to der- (or rodents) thus giving rise to human matologists with vesicular lesions on cases. their hands and face. This was thought Despite its name it is now rare in cattle, to be hand, foot and mouth disease although two possible cases were re(due to enterovirus), however the parported from Norfolk with similar lesions ents noted similar lesions on the face of in cattle. In these cases, serology sugtheir cat around the same time. gested human cowpox but testing of The HPA Imported Fever Service was cattle was not fully undertaken and seconsulted, and vesicular fluid from both rology may have been affected by past cases was tested for a range of possi- smallpox vaccination. ble viruses. Tests included a panorthopox PCR. All but the latter were Ornithosis in poultry negative, strongly suggesting a diagnoworkers: role of personal sis of cowpox.
Cowpox in two children
protective equipment (PPE)
[Image: David Corby, Wikipedia]
Cowpox is caused by an orthopox virus and was the virus responsible for immunity to smallpox in milk-maids noted by Jenner. It is a zoonosis but the main
Hantavirus and pet rats Although serosurveys have in the past suggested that hantaviruses might be present in the UK and there have been sporadic cases of disease, the viruses responsible have until recently remained largely uncharacterised. The first evidence of hantavirus in UK wild rats came last year when Seoul hantavirus (SEOV) was identified in wild rats on the farm of a diagnosed case in the Humber region.1 SEOV has now also been identified in pet rats. Following positive serology for hantaviruses in a patient in Wales hospitalised with haemorrhagic fever with renal syndrome, SEOV was detected in samples from two pet rats in the patient’s household. Sequencing and phylogenetic analysis of viral RNA confirmed the virus to be a SEOV that is similar, but not identical, to previously reported UK strains from wild and laboratory rats.1 Screening of a number of rats in England which had had contact with the patient’s rats revealed that these were also SEOV positive. Serological testing of three other human contacts of the English and Welsh pet rats, found one
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An investigation into an outbreak of ornithosis (psittacosis) in poultry processing plant workers was recently published1. The outbreak occurred over several months in 2008 and resulted in 10 cases of this unusual but recognised occupational zoonosis. Workers are exposed to the infection, caused by Chlamydophila psittaci, through contact with dust (from faeces) on feathers of live or dead birds, and through contact with the viscera of infected birds during processing. It can cause an atypical pneumonia, more severe in pregnant women and immuno who had a history of an undiagnosed viral infection with renal impairment requiring hospitalisation - this person was strongly seropositive, potentially indicative of a past hantavirus infection. Of the other two, one was seronegative and one had a low level of antibody but no clinical disease.2 Further studies are planned to gather evidence on the prevalence of hantaviruses in the pet rodent population in England and Wales to assist in the provision of public health guidance. Advice on reducing the risk of infection from pet rodents3 has been produced by the HPA, Animal Health and Veterinary Laboratories Agency and Public Health Wales, with a public-friendly leaflet also available.4
-suppressed patients, but can also cause a milder influenza-like illness with fever and cough. A case-control study among workers found that the killing, hanging on and auto-evisceration areas within the plant were the highest risk for infection. Also, direct contact with blood and viscera from workers touching their faces or splattering from carcasses, was associated with infection. There was evidence that using FFP3 masks and eye protection reduced the risks associated with these exposures. This was supported by circumstantial evidence - further cases occurred after the initial outbreak in workers not using personal protective equipment, and since this has been made mandatory no further cases have occurred. Ornithosis is a rare but potentially serious illness that can give rise to outbreaks in this setting. Where cases are seen in poultry workers, introduction and enforcement of PPE usage can help prevent cases in workers. 1. Risk exposures for human ornithosis in a poultry processing plant modified by use of personal protective equipment: an analytical outbreak study. Williams et al. Epi & Infect December 2012
[Both features supplied by Chris Williams, East of England]
specific febrile illness including rigors and myalgia, which had started 3 days after her return from a trip to Malaysia. This trip had been described as visiting family and friends and no specific exposures were identified. Two days after admission the patient developed haemoptysis and became very unwell requiring transfer to the Intensive Care Unit. Advice was sought from the HPA Imported Fever Service and samples were sent for a range of possible pathogens based on the geographical area of travel. This included testing for influenza H5N1 and novel Coronavirus, both of which were negative. PCR testing of blood, urine and bronchoalveolar lavage samples identified Leptospira species, and a diagnosis of leptospirosis-associated severe pulmonary haemorrhagic syndrome was made.
1. Jameson et al., EuroSurv, Jan 2013 2. Jameson et al., EuroSurv Mar 2013 3. Guidance on reducing the risk of infecThe clinical course of leptospirosis is tion from pet rodents 4. Leaflet: reducing the risk of human recognised to be highly variable and severe illness occurs in 5-15% of infection from pet rodents
Pulmonary leptospirosis A 29 year old female was admitted under the care of the infectious diseases department of a local hospital in February 2013. She presented with a non-
cases. The case fatality rate for pulmonary haemorrhagic syndrome is over 50%. [Simon Padfield, Yorkshire & Humber]
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ning activities or from laboratory reports. Depending on the perceived urgency, results of these activities may be either disseminated immediately Interesting topics discussed at the within the group or are discussed as a Human Animal Infections and Risk Sur- standing agenda item at the monthly veillance (HAIRS) group are periodimeeting. cally included in this newsletter. Here Risk Assessment we describe in more detail the procIf a risk assessment is deemed necesesses it uses for risk assessment. sary, a formal assessment is carried HAIRS was established in early 2004 out by the group, and if appropriate, in as a cross-government multi-agency consultation with recognised experts. group that acts as a forum to identify The risk assessment procedure is choand discuss infections with potential for sen depending on the issue under coninterspecies transfer, particularly sideration; either a zoonotic potential zoonotic infections. There has been a assessment or an emerging Infection steady evolution and development of assessment. A recent development of the risk assessment processes used by these processes is to include all the group. sources of information employed as well as an assessment of the quality of Hazard Identification Potential hazards are identified by evidence used. This is in order to regroup members through horizon scan- duce the inherent subjective nature of
The HAIRS risk assessment process.
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qualitative risk assessments, particularly in instances for which limited information is available as is often the case for novel infections. Categorising the evidence in this manner allows for a degree of confidence in the estimation of risk to be recorded. Review and revision To ensure the relevance and accuracy of risk assessments produced by the HAIRS group, all assessments are informally reviewed at least annually. Examples Risk assessments completed recently include West Nile, Usutu and Ljungan viruses, and the zoonotic potential of Schmallenberg virus. Further details about HAIRS, the process and references available here
Incidents outside the UK Outbreak of orf on a burns unit Human orf infections usually arise following occupational contact with affected animals, and have also been associated with Islamic festival practices. Outbreaks are uncommon.
from a water tank, a pair of scissors, and an ointment box in the wound dressing room. All these were positive on PCR. All surfaces were subsequently cleansed with hypochlorite solution. Spillage of virus-containing droplets during wound care could have accounted for the extensive dissemination, however, transmission via the hands of care givers might also have taken place.
cysts of the parasite from an infected animal . Depending on the species of parasite this may be a fox, racoon, dog, coyote or wolf, or from pigs and cattle.
Epidemiological investigations are ongoing while the source of infection, parasite species, life cycle , and animal host remain to be identified. It has been suggested that as cats and macaques are numerous in Tioman Island and neighbouring places, these may also The outbreak terminated after the unit be candidates as infected predator aniwas closed to new admissions. Health- mals. care workers were educated on prob- Esposito et al. Eurosurveillance 2012 able routes of transmission, with emphasis on patient to patient cross contamination and on appropriate use of Cutaneous Toxoplasmosis personal protective equipment. A 60-year-old German patient undergoing therapy for aplastic anaemia preMidilli et al. Eurosurveillance 2013 sented with vesicular varicella-like skin [Image: educationalresource.info] lesions on the face, arms, legs, back Following the festival of El Eid Adha, an Sarcosystosis, Malaysia and abdomen. Tests for herpes virus outbreak of orf infections occurred in a Since 2011, at least 100 patients with were negative. Histology on a skin burns unit in Turkey. The index case an acute Sarcocystis-like illness associ- biopsy led to a tentative diagnosis of had extensive lesions on burned areas, ated with travel to Tioman Island, Matoxoplasmosis which was confirmed by but none on his intact skin. In the three laysia, have been reported. This is the immunohistochemistry and PCR. Retweeks following his admission to the largest reported cluster of patients with rospective analysis of serum samples unit, a further 12 confirmed cases of suspected acute muscular sarcocysto- revealed that the patient had had a disseminated orf occurred. sis. With little known about this disease systemic infection with Toxoplasma in humans, clinician awareness is likely gondii three weeks prior to the appearUsually benign, orf can be significant in to be low and cases may yet be unrec- ance of the skin lesions. burns patients due to the compromise ognised. Cutaneous toxoplasmosis, although of large areas of skin integrity. Contamination of the ward environment can Sarcocystosis is common amongst wild rare, can present in a variety of ways and may mimic other infections. Veand domestic animals, occurring in occur readily from their lesions, and sicular lesions associated with virus particles can survive on surfaces tropical and sub-tropical countries intoxoplasmosis have not been reported cluding South East Asia. Humans befor years. come infected by eating food contami- previously. Environmental samples were collected Zimmerman et al, J Clin Micro 2013 nated with faeces containing sporo-
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Australian bat lyssavirus
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1. Australian Society for Infectious Diseases press release 2. Hanna et al. Med J Aust. 2000
Human infection with a fish pathogen Infection in humans due to fish pathogens is relatively uncommon but can occur in those exposed to wild or farmed species. A case report describes a gallbladder infection due to [Image: Australian black flying foxes, Lactococcus garvieae in a fisherman Welbergen, Wikipedia] who consumed raw rainbow trout and A death due to infection with Australian other raw seafood. The organism which was clindamycin resistant, was bat lyssavirus (ABLV) has occurred in Queensland, Australia. The case was a isolated from gallbladder tissues, and its identity confirmed biochemically and child believed to have been bitten or via sequencing. The patient recovered scratched by an unknown species of bat three weeks before presentation of after surgery and antibiotic treatment. symptoms1. A small number of cases have been ABLV was first identified in 1996 and has been found in four kinds of flying foxes/fruit bats and one species of insect-eating bat. However, evidence of previous infection has been found in a number of other bat species, and it is therefore assumed that any bat in Australia potentially carries the virus. ABLV is the only lyssavirus known to be present in Australia. The two previous human cases of ABLV were reported in 1996 and 1998. These infections were acquired from different species of bat; a flying fox and a yellow-bellied sheathtail bat.2
previously reported, mostly associated with invasive disease and bacteraemia. The route of acquisition is likely to be percutaneous or ingestion. Kim at al. J Clin Micro 2013
Rabies in Greece, update Since October 2012, a total of 17 confirmed rabid animals, mostly foxes, have been found in areas of northern Greece. On 1st March 2013, a rabid farm cat was reported from Trikala in the region of Thessaly, some distance to the south of those regions previously reporting rabid animals. Report to OIE
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As a result of the spread of infected wildlife within northern Greece, the HPA reviewed its risk assessment for potential exposures in Greece. HPA
Alveolar echinococcosis, Europe Echinococcus multilocularis causes a potentially fatal human infection, and its incidence in wildlife across Europe has been increasing in recent years. Two recent reports describe substantial increases in human infections in 2011, in Austria1 and Poland2. Such increases may be due in part to past underreporting, fox population expansion, or the use of more sensitive diagnostic methods, but are nonetheless cause for concern. 1. Schneider et al 2013 2. Nahorski et al 2013 The UK is currently free of E. multilocularis and obtained a derogation for the use of tapeworm controls in the pet passport scheme in order to maintain this status. Defra PETS
[Image: Peter Trimming, Wikipedia]
Burden of orphan zoonotic disease in the UK. Halsby K et al. Zoonoses Public Health 2013. http://onlinelibrary.wiley.com/doi/10.1111/zph.12040/abstract Clinical Manifestations of Human Brucellosis: A Systematic Review and Meta-Analysis. A systematic review, commissioned by WHO. http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0001929
Public Health England st
On 1 April 2013, the Health Protection Agency will become part of Public Health England, an executive agency of the Department of Health.
We welcome suggestions on topics for inclusion in future issues of the Newsletter For further information on this newsletter, or to subscribe, please contact: Mandy Walsh Gastrointestinal, Emerging and Zoonotic Infections Dept Health Protection Services, HPA Colindale 61 Colindale Avenue London NW9 5EQ Phone: 020 8327 7483 E-mail: Zoonoses@hpa.org.uk or zoonoses@PHE.gov.uk
CPD/ training opportunities: 5 Nations Health Protection Conference: May 2013 http://5nations.org.uk/ MedVetNet 2013, June 2013 Details here Zoonosis and vector-borne diseases in Europe: challenges in clinical and biological diagnosis. June 2013. Details here North West Zoonoses Group Annual Zoonoses Conference: July 2nd 2013. http://www.northwestzoonoses.info/details.aspx?pageid=214&resid=5202 International Conference of the Association of Institutes for Tropical Veterinary Medicine, Johannesburg, South Africa, August 2013 http://www.aitvm2013.org/ ESCAIDE Conference: November 2013 http://ecdc.europa.eu/en/escaide/Pages/ESCAIDE.aspx