Infectious Disease Surveillance and Monitoring System for Animal and Human
Health: Summary of notable incidents of public health significance
December 2014 to March 2015
Outbreaks and incidents
Ebola virus disease (EVD), West Africa (PHE Weekly Ebola Epidemiology Update)
New confirmed cases per week
Epidemiological overview: By 4 January 2015, the overall total number of clinically
compatible EVD cases was 20,747 with 8235 deaths. Three months later (5 April), this
total had risen to 25,550 with 10,587 deaths. However, these cumulative figures hide the
considerable reduction in weekly incidence in the three most affected countries, as
indicated in the figure below.
Countries with widespread and intense transmission: Incidence in Guinea has
continually fluctuated whilst in Liberia and Sierra Leone the reductions have been more
consistent. Of particular note, has been the geographical contraction of active
transmission areas, such that disease is now largely confined to the capital cities and
surrounding areas (map – updated weekly). Liberia has demonstrated the most significant
control, with only a single case reported (in Conakry) since the third week of February.
Weekly totals for Guinea and Sierra Leone have plateaued in recent weeks, indicating
remaining barriers to overall control.
600
Guinea
Liberia
Sierra Leone
500
400
300
200
100
0
Epidemiological week ending
Cases outside of Africa: No EVD cases have been diagnosed outside Africa in 2015.
UK risk assessment: To date a single case of EVD has been imported into the UK, in a
returning healthcare worker. The risk of further importations was assessed as low.
Further information can be found in PHE’s weekly Ebola virus disease
epidemiological updates
December 2014 – March 2015
Astroviruses, human (case reports)
Astroviruses are generally regarded as causes of mild and usually self-limiting
gastrointestinal disease in humans. In 2010 a novel astrovirus was reported for the first
time as a cause of fatal encephalitis in an immunocompromised child. Two new papers
(Brown et al and Naccache et al) describe patients with a similar novel astrovirus infection
to this 2010 case. Both infections occurred post-transplantation, both patients died and the
reports provide more evidence of an apparent aetiological role for these viruses in
immunocompromised patients.
Avian influenza - international update (Incident – update)
Avian influenza A(H5N1) – Since 2003, a total of 826 confirmed human cases of avian
influenza A(H5N1) have been reported worldwide. Egypt has reported an upsurge in
human cases of influenza A(H5N1) since November 2014 with monthly totals higher than
those ever reported by any other country. So far this year, 119 confirmed cases have been
reported to WHO, more than three times 2014’s total. The increase in human cases in
Egypt may be attributed to several factors including: increased circulation of influenza
A(H5N1) viruses in poultry; lower public health awareness of risks in middle and upper
Egypt; seasonal factors such as closer proximity to poultry because of cold weather; and
possibly longer survival of the viruses in the environment (WHO). In addition, the
predominant strain of virus currently circulating belongs to a clade that may be associated
with increased human and poultry infections (Arafa et al). The risk of infection for UK
residents who are travelling to Egypt, or other affected areas remains very low, but
travellers to Egypt should avoid direct contact with poultry and birds or uncooked or
untreated poultry products.
Avian influenza A(H7N9) – Human infections associated with influenza A(H7N9) continue
to be reported from China (WHO) however, case numbers have decreased in recent
months. Further sporadic human cases are expected in affected and possibly
neighbouring areas. The risk of influenza A(H7N9) infection to UK residents who are
travelling to mainland China is very low.
Avian influenza A(H5N2) - Since December 2014, the United States Department of
Agriculture has confirmed several cases of highly pathogenic avian influenza A(H5N2)
along the North American Pacific, Central, and Mississippi migratory bird paths. The
disease has been found in wild birds, as well as in 84 backyard and commercial poultry
flocks with more than 11 million birds affected (as of 27 April). CDC considers the risk to
people from these influenza A(H5N2) infections to be low as no human cases have been
reported to date however, some serological evidence of human exposure to A(H5N2) has
been found in China (Wu et al).
Botulism, PWID (Incident - new)
A large number of botulism cases in persons who inject drugs have been reported in
Norway and Scotland in the last couple of months. The first cases in Norway were
reported in December 2014, and 10 cases have been recorded to date. In Scotland, 37
clinically compatible cases from six NHS Boards had been reported to the end of March
2015, of which 13 were confirmed and 22 probable. The causes of death in three fatalities
are under investigation. All cases reported intravenous, muscle/skin popping or snorting
heroin linked to Glasgow prior to symptom onset. Isolate sequencing may provide further
insight into the epidemiology of these outbreaks. To date, there have been no linked cases
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Summary of notable incidents of public health significance
in England. A single similar, and possibly linked, case was reported in Berlin. ECDC
published a risk assessment in February.
Chikungunya virus, Americas outbreak
As of 24 April, nearly 1.4 million cases of suspected and confirmed chikungunya cases
have been reported in the Americas since December 2013 [map], and further distribution
of this virus is likely (Weaver & Lecuit). In the UK, chikungunya is a travel-associated
infection. A 12-fold increase in imported cases was reported in 2014 in England, Wales
and Northern Ireland compared to 2013. The vast majority (76%) of these had a recent
history of travel to the Caribbean, especially Jamaica (PHE).
Cutaneous and renal glomerular vasculopathy (CRGV), UK (Incident – update)
CRGV remains a canine disease of unknown aetiology. To date, more than 50
pathologically confirmed canine cases of CRGV have been reported in the UK. A case
study has recently been published describing clinicopathological findings and outcomes in
30 confirmed CRGV cases identified between November 2012 and March 2014 that
presented with acute kidney injury (AKI) and skin lesions. Proportionately more cases
continue to be reported from the South of England, but the geographical distribution of
confirmed cases has expanded. CRGV is a serious specific condition in dogs but,
following a survey completed by Public Health England, there do not appear to be any
definitive links between the disorder in dogs and illness in their owners.
Enterovirus D68, North America and Europe (Incident – update)
In 2014, an outbreak of enterovirus D68 began in the United States associated with
severe respiratory symptoms predominantly in children, although other ages have been
affected. This outbreak coincided with an apparent increase in incidence of reported cases
of acute flaccid myelitis (AFM) and as of 14 April, 118 AFM cases in children have been
reported. A recent study (Greninger et al) has strengthened the association between
enterovirus D68 and the AFM outbreak by detecting enterovirus D68 and no further
organisms by metagenomics in AFM patients. In 2014/2015, reports of AFM cases
associated with enterovirus D68 infection in Norway and France have been published.
Lassa Fever, Benin (Incident – new)
An outbreak of Lassa fever was detected during heightened vigilance for Ebola in Benin.
Lassa fever had not previously been confirmed in Benin. A total of 16 cases with nine
deaths were confirmed, including cases which resulted from transmission in healthcare
settings. The outbreak was rapidly contained once the disease was recognised.
Reliefweb report, WHO summary
Livestock-associated (LA) MRSA, UK and overview (Research)
In December 2014, the third detection of ST398 LA-MRSA in livestock animals in the UK
was made in two piglets from the East of England (Hall et al). Comparison to isolates from
the two prior isolations determined that multiple incursions of ST398 LA-MRSA from
different sources have occurred.
Other information:
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First report of identification of ST9 LA-MRSA in retail meat in England (Dhup et al)
What is the origin of LA-MRSA CC398 isolates from humans without livestock
contact: an epidemiological and genetic analysis (Lekkerkerk et al)
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LA-MRSA: The United States Experience (Smith)
MERS-CoV, worldwide update (Incident - update)
According to the latest update on 29 April, 1110 laboratory-confirmed cases of MERS-CoV
including at least 422 related deaths worldwide have been reported to WHO, an increase
of 172 cases since mid-December. To date, all cases have been associated with the
Middle East (either directly or indirectly). The latest case diagnosed in Europe was in
Germany in March in a German citizen with recent travel to the United Arab Emirates. The
risk of sustained human-to-human transmission of MERS-CoV in Europe remains very
low. A recent seroprevalence study (Müller et al) in the Kingdom of Saudi Arabia has
determined that MERS-CoV antibodies were significantly higher in camel-exposed
individuals than in the general population. However, conflicting results have been reported
in a previous serosurvey (Hemida et al) and further work is required to determine whether
dromedary camels are a source of MERS-CoV infection for humans.
Mycobacterium chimaera, nosocomial, Europe (Incident – new)
In Switzerland, an investigation into an outbreak of M. chimaera infections associated with
open heart surgery has identified a total of six cases in persons who underwent surgery at
the Zurich Heart Centre between 2008 and 2012. Microbiological and molecular analysis
found identical M. chimaera strains in human isolates and in environmental samples
(water circuits of heater-cooler units connected to the cardiopulmonary bypass and from
air samples collected when the units were in use) (Sax et al). Investigations are ongoing in
Europe to determine whether this is a wider issue.
Polio virus, worldwide update (Incident - update)
Statement on the 4th IHR Emergency Committee meeting regarding the international
spread of wild poliovirus: Transmission continues in Pakistan with international spread of
wild poliovirus into neighbouring Afghanistan. There has been no other documented
international spread of wild poliovirus since March 2014, however the committee
considered that the possibility of international spread remains a global threat worsened by
the expansion of conflict-affected areas, particularly in the Middle East and Central Africa.
It concluded that the spread of polio still constitutes a Public Health Emergency of
International Concern and that extension of the Temporary Recommendations for a further
3 months was warranted.
Latest data: 22 cases have been diagnosed this year to the end of March, 21 in Pakistan
and 1 in Afghanistan. The onset for the most recent case was 17 March.
Circulation of wild poliovirus type 1 in Israel and implications for surveillance
Paper, Shulman et al: “Genetic analysis and characterization of wild Poliovirus Type 1
during sustained transmission in a population with >95% vaccine coverage, Israel 2013”
Editorial Commentary: “Emerging problems impeding the elimination of the last
Polioviruses: Silent circulation of wild strains in a well-immunized population”
Rocky Mountain Spotted Fever (RMSF), USA (Research)
Two recent papers describe the varied presentation and epidemiology of RMSF in
Arizona, which is significantly different from that seen in other areas of the USA.
A review (Traeger et al) of all cases of RMSF over the first ten years since it emerged,
notes the differing clinical presentation (cases were younger and reported fever and rash
less frequently than elsewhere in the US) and importance of the brown dog tick in
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Summary of notable incidents of public health significance
transmission in this area. Regan et al describe the risk factors for a fatal outcome from
RMSF in the same state. The case fatality in the Arizona series was higher (16/219, 7%)
than that in the rest of the US (<1%). RMSF can be a rapidly progressive disease:
comparing fatal cases with survivors, delayed recognition of the possibility of RMSF and
thus delay in initiating appropriate treatment, were both associated with a fatal outcome.
Scrapie prions, zoonotic potential (Research)
Despite many years of research, epidemiological and laboratory studies have failed to
identify any clear associations between scrapie in small ruminants and TSE occurrence in
humans, such as those identified between BSE and vCJD. A recent animal study using
mice genetically engineered to overexpress the human prion protein has demonstrated the
zoonotic potential of scrapie prions (Cassard et al). Serial transmission of different scrapie
isolates in these mice led to the propagation of prions that were phenotypically identical to
those that cause the rare disease sporadic CJD in humans. Further research is required to
determine the public health implications of this study.
Severe fever with thrombocytopenia syndrome virus (SFTS) (Research)
The geographical range of human cases of the recently emerged tickborne Bunyavirus
SFTS continues to expand. Since 2007 a limited number of cases have been officially
reported in China, South Korea and Japan. While human-to-human transmission of SFTS
virus has previously been reported (eg, in China), the first nosocomial cluster of SFTS has
recently been described in Korea. Four healthcare workers who were involved in
cardiopulmonary resuscitation of a patient with fatal SFTS subsequently developed fever
and were diagnosed with SFTS via seroconversion. Exposure to respiratory secretions,
blood, or gowns soiled by body fluids was significantly associated with this incident of
nosocomial transmission.
Typhoid fever, Uganda (Incident - new)
A large outbreak of typhoid fever is ongoing in Uganda. Beginning in Kampala City in
January 2015, by 25 March more than 4000 suspected cases had been reported, and by
mid-April this number had risen to >12,000 (CDC). Cases were first reported in downtown
Kampala, but have since spread through the city and into neighbouring Wakiso and
Mukono districts (map). Many water sources were found to be heavily contaminated with
Escherichia coli and faecal matter, and contaminated drinking water and juices have been
identified as the main sources of infection.
Vector-borne disease (Research)
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
Quantifying the risk of Introduction of West Nile virus into Great Britain by migrating
passerine birds
Effect of climate change on vector-borne disease risk in the UK
Male Mosquitoes as Vehicles for Insecticide: a novel approach that combines elements
of routine strategies by releasing artificially reared, male mosquitoes that are
contaminated with an insecticide
Novel agents and rare pathogens and disorders

Anaplasma capra: after its detection in the blood of goats in China, human infection
was noted in 28/477 Chinese individuals reporting tick bite and non-specific febrile
symptoms. Other tick associated infections were not detected in these patients. All
infections were successfully treated with doxycycline, though five patients required
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Summary of notable incidents of public health significance
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hospitalisation for severe disease
novel bornavirus: a report in February 2015 documented three fatal episodes of
meningoencephalitis in breeders of variegated squirrels which were linked to a novel
bornavirus. The first incident was in 2011, and two in 2013. Bornaviruses are
recognised to be animal pathogens but have not previously been unequivocally linked
with human disease. ECDC have published a risk assessment. A serological test has
been made available for persons in contact with variegated squirrels in Germany. No
further positive animals nor evidence of additional human cases has yet been found
Bourbon virus: a novel Thogotovirus associated with a fatal febrile illness in Kansas,
USA and possibly linked to tick bites. There was a high level viraemia and the illness
progressed to acute bone marrow suppression, lactic acidosis, and multi-organ failure
novel orthopoxvirus infection, Georgia: two men with occupational exposure to cows
developed cutaneous lesions due to a novel poxvirus. The viruses were very divergent
from other Eurasian isolates, suggesting a remote common ancestry with variola,
monkeypox, vaccinia, and cowpox viruses. A previous case in 2010 was
retrospectively diagnosed
Lagenidium giganteum: a fungus used for biological control of mosquitoes, has
recently been found to be pathogenic for some mammals and humans
Truncatella angustata: this fungal plant pathogen was found to cause a human
cutaneous infection which likely followed accidental inoculation from rotten wood. The
patient was immunocompetent and eventual resolution was achieved following
antifungal therapy
Also of interest
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in March, five wild living Eurasian beavers living on the River Otter in Devon were
trapped and tested for Echinococcus multilocularis, Francisella tularensis and
Mycobacterium bovis, all of which negative. Subsequently, the beavers were rereleased as Natural England has granted Devon Wildlife Trust a five year licence to
monitor the beavers on the River Otter
hepatitis E virus has been reported for the first time in a pet rabbit in Italy suggesting a
potential novel zoonotic transmission route
the Advisory Committee on the Microbiological Safety of Food has published its
extensive review of viruses in the food chain, considering specifically norovirus,
hepatitis A and hepatitis E
a new antibacterial agent (teixobactin) which inhibits cell wall synthesis has been
described. It is of microbial origin, and has activity against a range of Gram positive
bacteria. Teixobactin is the first member of a new class of lipid II binding antibiotics,
and is proposed as a promising therapeutic candidate
a review of toxigenic diphtheria infections in England between 2007 and 2013 (20
cases) found that of the 12 Corynebacterium ulcerans cases, 11 cases had contact
with companion animals (dogs, cats, or rabbits), three of whom also had contact with
farm and/or wild animals
a collaborative strategy to tackle Mycobacterium tuberculosis in England has been
published to address the lack of sustained reduction in overall rates of disease in
recent years
a comparative genomics study of human and swine isolates of Streptococcus suis has
shown that there are no consistent genomic differences between pig and human
clinical isolates. Also due to the lack of geographical clustering and high rates of
recombination, an increase in virulence anywhere in the world could have a global
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impact in a short time period.
further evidence for the potential of sexual transmission of Zika virus has been found
following the detection of virus in the semen of a case in Tahiti
Scottish government has agreed to a review of the trade and importations of exotic
animals for the pet trade
since the cessation of smallpox vaccination, orthopoxvirus (OPV) infections have
increased worldwide, and the immunologic status of the population against OPV is a
major risk factor for its re-emergence. A new paper reports on an atypically severe
outbreak of zoonotic vaccinia virus infections in rural Brazil which had resulted in
hospitalisation of 12 (of 24) cases, all of whom were unvaccinated
in December 2014, a case of glanders was detected in a horse in northern Germany
during pre-export screening. The horse was German-born and had no history of travel
to an endemic country (OIE). Despite thorough investigation including testing of equine
contacts, the source of infection for the animal could not be determined (OIE)
unexpected Burkholderia pseudomallei infections in monkeys in a primate research
facility were eventually traced to nosocomial infection. Microbiological analyses
showed that the strain in the monkeys was identical to that used concomitantly in a
research laboratory on the same site. Tulane report CDC statement
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Summary of notable incidents of public health significance