Surge of lower respiratory tract group A streptococcal infections in England in winter 2022: epidemiology and clinical profile.

BACKGROUND: Following low incidence of invasive group A streptococcal (iGAS) infections during the COVID-19 pandemic, marked increases were noted in many countries during 2022, particularly in children. In November 2022, severe presentations of lower respiratory tract infections (LRTIs), including empyema, were notified by clinicians across the UK. UKHSA investigated this rise with the aim of informing clinical management and public health response. METHODS: We undertook a case-series analysis using multiple routine data sources, exempted from ethics approval or patient consent. We identified iGAS cases in England in children younger than 15 years with an LRTI reported between Oct 1 and Dec 21, 2022, using UKHSA laboratory surveillance data (GAS detected in LRT specimens) and notifications by clinicians and Health Protection Teams (HPTs). Symptoms, diagnoses, health-care interactions, and outcome (death or recovery) data were obtained from HPT case management notes, the National Child Mortality Database, and the NHS Digital Emergency Care Dataset. FINDINGS: We identified 147 cases of LRTI iGAS in children across England (77 [52%] male, 70 [48%] female; median age 4 years [IQR 2-6]). Predominant ethnicities were White (74 [65%] of 113 with known ethnicity) and Asian (18 [16%] of 113). Most reported symptoms were fever (90 [75%] of 120 children with ≥1 symptom) and cough (60 [50%] of 120), and 71 (48%) of all 147 children had a diagnosed respiratory viral coinfection (most commonly hMPV and RSV). 127 (86%) of children attended an emergency department, 31% (n=36/114 with onset date) at least twice within 21 days after symptom onset. 37 (25%) of 147 children died, with a median time from symptom onset to death of 4 days (IQR 3-7). Of 32 children with sample dates, 16 (84%) were tested for GAS on or after the day they died. Over half of deaths (21 [57%] of 37 deaths) occurred in the community after rapid deterioration, of whom 18 had previous contact with health-care services documented. INTERPRETATION: The UK saw an unusual rise in iGAS LRTIs in children in late 2022. One in four cases died, over half in the community. Non-specific symptoms, viral symptoms, or positive virology might have lowered suspicion of bacterial infection. Although the use of multiple available data sources expedited the analysis, varying data completeness limited interpretation. Our study highlights the need for earlier detection and identification of effective measures to prevent death. FUNDING: None.

Local Salmonella Enteritidis restaurant outbreak investigation in England provides further evidence for eggs as source in widespread international cluster, March to April 2023.

We report a 5-single nucleotide polymorphism cluster of Salmonella Enteriditis in England, part of a global cluster of S. Enteritidis ST11. Forty-seven confirmed cases have been investigated of whom 25 were linked to a restaurant. In addition, there were 18 probable cases with restaurant exposure. Epidemiological investigations suggested eggs or chicken as the most likely cause of the outbreak but were unable to distinguish between those two food vehicles. Ongoing food chain investigations indicated links to imported eggs from Poland.

The Unexpected Holiday Souvenir: The Public Health Risk to UK Travellers from Ticks Acquired Overseas.

Overseas travel to regions where ticks are found can increase travellers' exposure to ticks and pathogens that may be unfamiliar to medical professionals in their home countries. Previous studies have detailed non-native tick species removed from recently returned travellers, occasionally leading to travel-associated human cases of exotic tick-borne disease. There are 20 species of tick endemic to the UK, yet UK travellers can be exposed to many other non-native species whilst overseas. Here, we report ticks received by Public Health England's Tick Surveillance Scheme from humans with recent travel history between January 2006 and December 2018. Altogether, 16 tick species were received from people who had recently travelled overseas. Confirmed imports (acquired outside of the UK) were received from people who recently travelled to 22 countries. Possible imports (acquired abroad or within the UK) were received from people who had recently travelled to eight European countries. Species-specific literature reviews highlighted nine of the sixteen tick species are known to vector at least one tick-borne pathogen to humans in the country of acquisition, suggesting travellers exposed to ticks may be at risk of being bitten by a species that is a known vector, with implications for novel tick-borne disease transmission to travellers.

Study of general practitioner consultations for tick bites at high, medium and low incidence areas for Lyme borreliosis in England and Wales.

Lyme borreliosis (LB) is a tick-borne disease caused by Borrelia burgdorferi sensu lato complex. In Europe, it is predominately transmitted by the sheep tick, Ixodes ricinus. Compared with other European countries, the United Kingdom (UK) is considered to have a low incidence of LB, although this varies regionally. To determine whether an association exists between tick bite consultations and LB incidence in the UK, retrospective questionnaires were sent to general practitioners (GPs) in high (Wiltshire), medium (Cumbria) and low (Wales) incidence areas. During 2011, the greatest incidence of consultations for tick bites was reported by GPs in Cumbria (204 consultations per 100,000 inhabitants), followed by Wiltshire (160 per 100,000 population) and Wales (54 per 100,000 population). In Wiltshire and Cumbria, GPs predominantly provided advice on tick removal, whilst Welsh GPs mostly advised patients on tick bite prevention. Focusing on Cumbria during 2011-2013, 72.5% of GPs removed ticks from patients (incidence of 101 consultations per 100,000 population), and more GPs diagnosed LB based on clinical features than laboratory-confirmed diagnoses. To date, this is the first study to investigate the incidence of tick bite consultations and LB in England and Wales.

Seasonality and anatomical location of human tick bites in the United Kingdom.

Tick bites on humans can occur in a variety of habitats and may result in the transmission of tick-borne pathogens, such as the causative agent of Lyme borreliosis (LB), Borrelia burgdorferi sensu lato. As the risk of transmission of this pathogen to the host increases with the duration of tick feeding, the recognition and removal of ticks as soon as possible following attachment is important for reducing the risk of infection. Performing a thorough body examination for ticks following potential exposure is recommended by tick awareness campaigns. Knowledge of where on the body feeding ticks are frequently found, and at which times of year peak tick exposure occurs, provides important information for public health messaging and may aid those bitten by ticks to engage more effectively with tick-checking behaviour. This paper summarizes human tick bites in the United Kingdom (UK) during 2013-2018 reported to Public Health England's passive Tick Surveillance Scheme and further examines the anatomical location and seasonality of bites from the most commonly encountered tick and LB vector Ixodes ricinus. A total of 1,328 tick records from humans were received of which 93% were I. ricinus. Humans were most commonly bitten by I. ricinus nymphs (70% bites). Tick bites were recorded on all parts of the body, but there were significant differences in their anatomical location on adults and children. Most tick bites on adults occurred on the legs (50%), whereas on children tick bites were mostly on the head and neck (43%). Bites from I. ricinus were recorded throughout the year but were most numerous during May to August. This study adds to the body of research on the seasonality and anatomical location of human tick bites in temperate Europe and highlights the importance of data collected through passive surveillance in addition to research and epidemiological studies.

The public health importance of scabies in community domiciliary care settings: an exploratory cross-sectional survey of Health Protection Teams in England.

Scabies is a contagious skin infection commonly occurring in institutions such as care homes. However, a large proportion of vulnerable people in England receive domiciliary care in the community and their experience of scabies has not been described. We undertook a pragmatic cross-sectional survey of Health Protection Teams (HPTs) in England to determine the burden of scabies related to domiciliary care. Fifteen cases or outbreaks were notified to HPTs between January 2013 and December 2017. Although a relatively uncommon event for individual HPTs, they were complex to manage and required the co-ordination of multiple stakeholders. Diagnosis was often delayed and required several clinical consultations. A lack of guidance led to difficulties establishing stakeholder roles and responsibilities and sources of funding for treatment. The stigmatisation of scabies sometimes affected the quality of care provided to patients, such as use of excessive personal protective equipment. Our study demonstrates that scabies is an issue of public health importance for domiciliary care service providers and users, and research is required to better understand the impacts of the disease and to develop evidence-based guidance. More generally, there is a need for simpler treatment regimens and methods of diagnosing scabies.

Surveillance of British ticks: An overview of species records, host associations, and new records of Ixodes ricinus distribution.

Public Health England's passive Tick Surveillance Scheme (TSS) records the distribution, seasonality and host associations of ticks submitted from across the United Kingdom (UK), and helps to inform the UK government on emerging tick-borne disease risks. Here we summarise data collected through surveillance during 2010-2016, and compare with previous TSS data from 2005 to 2009, particularly in relation to the primary Lyme borreliosis vector Ixodes ricinus. 4173 records were submitted, constituting >14,000 ticks; 97% were endemic tick records (13,833 ticks of 11 species), with an additional 97 records of imported ticks (438 ticks of 17 species). Tick submissions were mainly from veterinary professionals (n = 1954; 46.8%) and members of the public and amateur entomologists (n = 1600; 38.3%), as well as from academic institutions (n = 249; 6.0%), wildlife groups (n = 239; 5.7%) and health professionals (n = 131; 3.1%). The most commonly reported hosts of endemic ticks were dogs (n = 1593; 39.1% of all records), humans (n = 835; 20.5%) and cats (n = 569; 14%). New host associations were recorded for a number of tick species. Ixodes ricinus was the most frequently recorded endemic tick species (n = 2413; 59.2% of all records), followed by I. hexagonus (n = 1355; 33.2%), I. canisuga (n = 132; 3.2%) and I. frontalis (n = 56; 1.4%), with other species each making up <1% total records. 81% of I. ricinus recorded from humans were nymphs, whereas 93.4% of I. ricinus from companion animals were adults. Recent TSS records of I. ricinus in the UK add a considerable amount of new presence data for this species, particularly in the southern regions of England, and confirm that this species is widespread across the UK. The scheme remains a valuable method of collecting continuous national distribution data on ticks from a variety of host species.

Potential risk posed by the importation of ticks into the UK on animals: records from the Tick Surveillance Scheme.

In order to monitor important tick vectors in the UK, Public Health England's Tick Surveillance Scheme (TSS) receives specimens from across the country for identification. In recent years, an increasing number of these specimens have been removed from animals with a recent history of travel outside the UK. This paper presents all data collated by the TSS on ticks entering the country on recently travelled or imported animals since surveillance commenced in 2005. Ten different tick species representing six different genera were identified, entering the UK from 15 different countries. Key themes appear to be emerging from the last 10 years of data, including canine travel from Cyprus and Spain being associated with Rhipicephalus sanguineus importation, and canine travel from France being associated with the importation of multiple tick species and canine illness. In addition, more unusual importation routes have been uncovered, such as the importation of Hyalomma lusitanicum on a dog. Some companion animal owners may not be fully aware of the risks associated with ticks, and may not seek advice from a veterinarian before travel or importing a pet. Promoting awareness of ticks and tickborne disease risk during and after travel or animal importation is needed and veterinarians play an importation role in disseminating this information to their clients.

Ticks and Borrelia in urban and peri-urban green space habitats in a city in southern England.

Ticks are becoming increasingly recognised as important vectors of pathogens in urban and peri-urban areas, including green space used for recreational activities. In the UK, the risk posed by ticks in such areas is largely unknown. In order to begin to assess the risk of ticks in urban/peri-urban areas in southern England, questing ticks were collected from five different habitat types (grassland, hedge, park, woodland and woodland edge) in a city during the spring, summer and autumn of 2013/2014 and screened for Borrelia burgdorferi sensu lato. In addition, seasonal differences in B. burgdorferi s.l. prevalence were also investigated at a single site during 2015. Ixodes ricinus presence and activity were significantly higher in woodland edge habitat and during spring surveys. DNA of Borrelia burgdorferi s.l. was detected in 18.1% of nymphs collected across the 25 sites during 2013 and 2014 and two nymphs also tested positive for the newly emerging tick-borne pathogen B. miyamotoi. Borrelia burgdorferi s.l. prevalence at a single site surveyed in 2015 were found to be significantly higher during spring and summer than in autumn, with B. garinii and B. valaisiana most commonly detected. These data indicate that a range of habitats within an urban area in southern England support ticks and that urban Borrelia transmission cycles may exist in some of the urban green spaces included in this study. Sites surveyed were frequently used by humans for recreational activities, providing opportunity for exposure to Borrelia infected ticks in an urban/peri-urban space that might not be typically associated with tick-borne disease transmission.

Importation of exotic ticks into the United Kingdom via the international trade in reptiles.

Due to the increased trade in exotic reptiles, many of which are infested with ticks of various genera, there is an increased risk of exotic ticks and pathogens being introduced and potentially becoming established in new geographical areas. Despite the number and variety of tick species collected from reptiles, their role in the maintenance of pathogens and transmission to humans has not been fully investigated for all species. The potential public health risks to the United Kingdom have been examined through a preliminary study involving the collection and identification of exotic tick species imported via the reptile trade. Reptiles imported into Heathrow Airport, London (July 2003-October 2004) were carefully examined for ectoparasites. Five species of tick were collected: Aponomma exornatum, Ap. latum, Amblyomma rotundatum, Am. dissimile and Am. nuttalli. This is the first report of Am. dissimile identified from an interception at Heathrow airport. The potential for establishment of exotic ticks in the UK and the public health risks are discussed.