Research and analysis

HPR volume 12 issue 33: news (14 September)

Updated 21 December 2018

National Poisons Information Service annual report

UK healthcare professionals made more than 696,000 visits (or ‘user sessions’) to the NPIS’s online TOXBASE database in the period 2017 to 2018, and they directed nearly 2000 telephone enquiries to its consultant toxicologists, following – in particular – cases of exposure to drugs of misuse, to prescription pharmaceuticals, or to chemicals (including chemicals in household products), according to the latest NPIS annual report [1].

Hospital departments are principal users of the service – 160,000 poisoning-related hospital presentations occur in the UK each year. Other users are NHS telephone advice services – such as NHS 111 and NHS 24 – and individual professionals in the field, such as ambulance service personnel.

A high proportion of all enquiries relate to patients presenting to hospitals following suspected self-inflicted poisonings or the effects of substance misuse; also following accidental ingestions of potentially toxic substances, errors in dosing of medicines, or environmental or occupational exposures. In 2017 to 2018, the products or agents that were most frequently enquired about were pharmaceuticals or household products, as well as drugs of misuse.

Within the pharmaceutical category itself, medications to treat pain and inflammation generated the most activity. For example, there were 167,822 product accesses to paracetamol-containing preparations, and the service received 6,310 paracetamol-related telephone enquiries over the period 2017 to 2018.

The NPIS is uniquely placed to collate poisoning surveillance data and identify national trends, and these are presented in the annual report. Particular topics selected for review in the 2017 to 2018 report are: drugs of misuse; pesticides; carbon monoxide; dinitrophenol; snake bites; oral anticoagulants; and poisoning-related deaths.

NPIS has long encouraged the use of online enquiries as a ‘first point of call’ for information, while its telephone service is intended for more complex cases. To this end, a TOXBASE app offering both NHS and non-NHS subscribers access to TOXBASE [2] – on- and offline, at the point of care, via a mobile device – was introduced in 2012 to 2013 (and upgraded in 2015). There are currently 12,015 TOXBASE app subscribers who accessed 122,033 app pages during the period 2017 to 2018, representing a 50.8% increase from 2016 to 2017.

The annual report notes that “… analysis of the annual number of TOXBASE sessions, TOXBASE app accesses, telephone enquiries and consultant referrals”, between 2000 and the period 2017 to 2018, “demonstrates the [positive] impact of online access to TOXBASE in maintaining telephone enquiry numbers at a level that can be managed within constrained resources”.

Integrated within NPIS is the UK Teratology Information Service [3] whose functions include the provision of guidance on the best use of medicines for women who are pregnant, and the follow-up of pregnancy outcome after cases of maternal poisoning (to inform risk assessment and management of future cases).

Like NPIS, UKTIS provides both online and telephone services. The NPIS report records that in 2017 to 2018 there were more than 2 million accesses to the 187 pages of patient-focused information that is available on the UKTIS’s BUMPS website [4] – which has helped reduce pressure on the UKTIS national telephone service intended for enquiries relating to exposures requiring a case-specific risk assessment.

References

1. NPIS website (10 September 2018). National Poisons Information Service: Report 2017/18.
2. TOXBASE website.
3. UK Teratology Information Service website.
4. Best Use of Medicines in Pregnancy: BUMPS website.

Imported cases of monkeypox diagnosed in England

In the past week, 2 imported cases of monkeypox were diagnosed in England. This is the first time monkeypox has been diagnosed in England and the first outside Africa since the outbreak associated with imported African rodents in the United States in 2003. Both cases had recently stayed in Nigeria where they are believed to have contracted the infection. There is no UK epidemiological link between the 2 cases [1].

Information on monkeypox

Monkeypox is a rare viral zoonosis (transmitted from animals to humans). Infection in humans is usually a mild self-limiting illness and most people recover within several weeks. However, severe illness can occur in some individuals, particularly those with underlying conditions such as severe immunosuppression. The case fatality rate is less than 10%.

Monkeypox does not spread easily between people. It may occur when a person comes into close contact with an animal (rodents are believed to be the primary animal reservoir for transmission to humans), and more rarely an individual, or materials contaminated with the virus.

Monkeypox epidemiology

The first human case of monkeypox was recorded in 1970 in the Democratic Republic of Congo, and since then has been reported in other central and western African countries [2]. In 2018 in Africa, monkeypox cases have been reported from Cameroon, the Central African Republic, the Democratic Republic of Congo, Liberia as well as Nigeria.

In the period 2017 to 2018, approximately 40 years since Nigeria had its last confirmed case, the country experienced the largest documented outbreak of the infection. A total of 262 suspected cases across 26 states were reported, of which 113 were confirmed [3].

Information on the UK imported cases

The first case is a resident of Nigeria, where they are believed to have contracted the infection before traveling to the UK. They had been staying at a naval base in Cornwall, before being moved to the High Consequence Infectious Disease (HCID) unit at the Royal Free Hospital in London.

The second case is a UK resident who spent several weeks in Nigeria on holiday. They are believed to have contracted the infection there, and had various high-risk exposures. This patient presented to Blackpool Victoria Hospital and is now receiving specialist care in the HCID unit at the Royal Liverpool University Hospital.

As a precautionary measure, PHE is contacting those within England who have been identified as possible contacts of these 2 cases to carry out a risk assessment of their contact with the patient and provide them with appropriate advice, information and follow-up. PHE is also working with the Nigerian Centre for Disease Control to assist with their identification of contacts of these 2 cases in Nigeria.

UK risk assessment

Individuals who had potential contact with these 2 cases while they were infectious are being contacted. Person-to-person transmission of monkeypox is very uncommon, and these cases present a negligible risk to the wider public.

Although monkeypox is very rare in travellers, healthcare providers in the UK are reminded to consider monkeypox infection in those presenting with compatible symptoms having traveled to areas where the virus is known or presumed to occur [2].

Specialist guidance from Public Health England should be followed. As with all cases involving a pyrexia of unknown origin in a returning traveller, discussion with the local microbiology, virology or infectious disease consultant is recommended. They can then discuss with the Imported Fever Service if required.

References

1. Cases of monkeypox confirmed in England. PHE press release, 11 September 2018.
2. WHO website. African countries reporting human monkeypox cases, 1970-2017.
3. Nigeria Centre for Disease Control (12 September 2018). Monkeypox cases in the United Kingdom.

Additional information

• PHE guidance on epidemiology, symptoms, diagnosis and management of monkeypox virus infections
• PHE monkeypox: guidance for primary care
• PHE monkeypox: guidance for environmental cleaning and decontamination
• World Health Organization (WHO) monkeypox factsheet

EVD outbreak in eastern DRC: an update

The outbreak of Ebola virus disease declared on 1 August in the eastern Democratic Republic of the Congo continues. To date, 106 confirmed cases and 31 probable cases have been reported across 8 health zones in 2 provinces, North Kivu and Ituri (table 1). In the past month, there have been 55 new confirmed cases reported and an additional 2 health zones (Kalunguta and Masereka) affected. Cases continue to be reported in health care workers with 19 individuals affected to date.

In recent weeks there has been a noted decrease and then stabilisation in case incidence [2], but these trends need to be interpreted with caution. Suspected cases continue to be identified and investigated promptly, where community engagement permits. Further flare-ups of transmission are possible, especially as community resistance in some health zones is preventing complete contact tracing, vaccination of identified contacts and removal of suspected cases to Ebola treatment centres.

The risk to the UK public is currently very low to negligible. The situation is being monitored closely and the risk assessment is reviewed regularly.

Table 1. Case table for EVD outbreak in North Kivu and Ituri provinces, as of 12 September 2018. Data provided by DRC MoH [1].

Health zone	Confirmed	Probable	Fatalities
Masereka – North Kivu	1	0	1
Kalunguta – North Kivu	1	0	0
Béni – North Kivu	21	4	19
Butembo – North Kivu	4	2	3
Oicha – North Kivu	2	1	1
Mabalako – North Kivu	68	21	64
Musienene – North Kivu	0	1	1
Mandima – Ituri	9	2	3
TOTAL	106	31	92

Further information sources

• PHE Ebola collection Ebola virus disease: clinical management and guidance
• NaTHNaC Travel Health Pro website
• WHO Ebola virus disease
• Foreign and Commonwealth Office (FCO) DRC advice

References

1. DRC Ministry of Health (16 August 2018).
2. WHO AFRO Situation Report No. 2 (14 August 2018).

Infection reports in this issue of HPR

This issue includes reports on:

• Non-fatal overdose among people who inject drugs in England: 2018 report
• Routine GI infections (England and Wales, July/August)