What is Health Protection

1. What is Health Protection Lorraine Lighton Consultant in Communicable Disease Control Greater Manchester HPU

2. Aims and objectives Surveillance Investigation Control and management of communicable diseases Environmental hazards Teach by example

3. Outbreak of VTEC

4. What is VTEC? Vero cytotoxin-producing E coli (aka STEC) Most important VTEC strain in UK is E coli O157 Illness varies from bloody diarrhoea to HUS/TTP Estimated 15% under 5yrs and 8% 5-9yrs develop HUS Case fatality rate highest in elderly Incubation 3 � 8 days (usually 3-4) 1034 cases in E&W in 2009 NW has second highest rate in England (after Y&H)

5. VTEC risk factors Exposure to livestock faeces Consumption of foods exposed to livestock faeces: Undercooked meat eg burgers Raw milk Herbs and vegetables Water Person to person transmission

6. Surveillance Laboratory reports Health Protection Regulations 2010 Notifications of infectious disease Health Protection Regulations 2010 Informal reporting, especially of outbreaks

7. VTEC Public Health Management Isolates to reference laboratory Enhanced surveillance questionnaire Identification of possible sources (eg open farms) and reporting to relevant HPU/LA Ascertain whether symptomatic contacts Exclusion of high risk cases and high risk contacts until microbiological clearance Exclusion of others until symptom free Call OCT if suspect an outbreak

8. E coli O157 outbreak Stockport Case 1. Reported confirmed E coli O157 9th June 2010 Visited by EHO and questionnaire completed 9 yr old child onset 4th June 2010 Several risk factors in week before onset: ate at carvery 29/5 horse riding on a farm (did not go to petting area) ate cheese and bean toastie without washing hands fishing 29/5 barbecue

9. Case 1. cont 9 month old sibling symptomatic onset 9th June 2010 2 other children who attended BBQ reported as symptomatic EHO arranged testing of Case 1�s family and friends who attended the BBQ

10. Next cases Mother and child reported +ve Saturday 12th June 2010 Both illness onset 9th June Attended BBQ 29th May Visited farm in Anglesey 29th May to 5th June with 7 others Attended christening party 6th June Close family friends of case 1, who also attended the christening

11. Sunday 13th June Total of 7 presumptive positive cases and 2 awaiting results All attended christening Outbreak control team convened

12. 14th June 2010 By 14th June, 14 confirmed or presumptive cases Multiple risk factors, including BBQ and visiting farm on Anglesey Only risk factor in common was attendance at christening party. Agreed by OCT that christening party was likely to have been place of exposure for all except primary case. Case defined as confirmed E coli O157, onset since 1st June and who attended christening. All isolates to be sent to reference lab

13. Case 1 Onset 4th June Attended christening 6th June Had bloody diarrhoea X 2 while at christening Mother had supervised use of toilet

14. The christening party Joint party for two christenings Approx 200 guests at party Held at a church hall Bouncy castle Bar Food prepared by hosts or bought from supermarket (list of foods available) Attendance list (of sorts) available

15. Environmental investigations Conditions at church hall generally good Cleaned immediately after party and was found to be clean by EHOs Cleaners report no evidence of gross faecal contamination in toilet areas No separate nappy changing area in toilets

16. Environmental investigations No food left from party Frozen burger from BBQ on 29th May submitted to FWE lab Farm in Stockport reported as satisfactory NPHS Wales inspected farm in Anglesey. Reported as satisfactory

17. Microbiological investigations All isolates from local laboratories submitted to reference laboratory Around 20% isolates from local labs not confirmed All confirmed isolates characterised as E coli O157 pt 8. All had same VTRN and PFGE types Environmental swabbing from church hall negative Frozen burger from BBQ negative

18. Immediate control measures Letter to all GPs in Stockport Hygiene advice given to cases Symptomatic cases excluded from work/school/nursery Cases in high risk groups excluded pending microbiological clearance Screening of contacts�.

19. June 17th EHO interviewed child with confirmed E coli O157 onset 11th June Had not attended christening Attended same childminder as two children who had been at the christening All children and childminder�s family screened One child who attended christening positive (asymptomatic)

20. Case definition redefined E coli O157 confirmed by reference laboratory Onset symptoms since 1st June (if symptomatic) Attended christening or Attended childminder or Contact of someone who attended christening or childminder

21. Cases during June 2010 24 cases identified meeting case definition of whom 7 asymptomatic All isolates characterised as E coli O157 pt 8. All had same VTRN and PFGE types. One other case who lived near outbreak cases but no known risk factors. No cases required hospital admission.