Milton Keynes Health Protection Annual Report 2013-14
Final Report
Authors
Dr Kakoli Choudhury, Consultant, Public Health, Milton Keynes Council
Cath Fenton, Screening and Immunisation lead, Hertfordshire & South Midlands Area Team Screening & Immunisation Team
Hilary Angwin, Screening and Immunisation lead, Hertfordshire & South Midlands Public Health England Centre
Chris Londy, Environmental Health Officer, Milton Keynes Council
1 Contents
1. Summary 3
2. Introduction 3
3. Infectious diseases 4 3.1. Hepatitis B and C 4 3.2. Tuberculosis 5
4. Healthcare associated infections 7 4.1. Clostridium difficile infection 7 4.2. MRSA septicaemia 9
5. Screening 10 5.1. Antenatal and newborn screening 10 5.2. Cancer screening 11
6. Immunisation 12
7. Environmental health 13
2 1. Summary
1.1. Successes
Year 1 and 2 DTaP immunisation uptakes are above national target. Breast screening uptake is above national average. Treatment completion rate for pulmonary TB (TB of the lungs) in the first two quarters of 2013/14 was 85.1%.
1.2. Areas for concern
All people from high risk groups may not be getting tested for hepatitis B and C.
There is no formal BCG policy to vaccinate eligible children who miss being vaccinated at birth.
The current TB service is under-resourced with one consultant and one specialist nurse, with no provision for holiday cover and limited capacity to administer Directly Observed Therapy (DOT).
In 2013/14, there were 34 cases of Clostridium difficile infection in Milton Keynes Hospital and 64 cases among residents of Milton Keynes CCG. Both breached their respective targets.
In 2013/14, there were 3 cases of MRSA septicaemia cases in Milton Keynes Hospital and 6 cases among Milton Keynes CCG residents.
Bowel screening uptake up to the end of December 2013 was 54% against a target of 60%.
Cervical screening uptake for 25-64 year olds up to the end of quarter 3 in 2013/14 was 77.8% against a target of 80%.
Flu vaccination uptake was below the target in all eligible categories.
Among childhood immunisation, uptakes of pre-school DTP booster and second dose of MMR vaccines were of particular concern. They were each 89.9%.
2. Introduction
This is the first Milton Keynes Health Protection report after the transition of Public Health into local authorities. It provides information about current situation in Milton Keynes, issues and future priorities on hepatitis B and C, tuberculosis, healthcare associated infections, and routine immunisation and screening programmes.
3 3. Infectious diseases
The level of risk of contracting a particular infectious disease depends on a number of factors, including: i) Vulnerability of the individual: whether they have previously been exposed or vaccinated (a variable level of protection); whether they have a reduced immune function due to age (the very young and older people) or pre-existing disease or medication (more likely to experience complications);
ii) Severity of the infectious disease and the dose required to cause infection;
iii) How efficiently the infection transfers to an individual - through contaminated food or water (e.g. food poisoning), inhalation (e.g. pulmonary TB, influenza), injection or sexual contact (e.g. hepatitis B and C and HIV) More information on infectious diseases in Milton Keynes is available on the JSNA webpage: http://www.milton-keynes.gov.uk/social-care-and-health/health-and-wellbeing- board/strategic-needs-assessment/jsna/infectious-diseases
3.1. Hepatitis B and C
Hepatitis B and C are preventable and treatable, blood-borne viral infection of the liver. If untreated, they can cause long term damage of the liver and can lead to development of liver cancer. They spread from person to person through infected blood and other body fluid. Their main modes of transmission are through sharing contaminated injecting materials during drug use, from an infected mother to her unborn child, unprotected sex with an infected person, infected blood and blood products, through contaminated instruments used for body piercing or tattooing, and injury with contaminated needle sticks or other sharps.
Table 1 shows the number of notifications of new cases of hepatitis B and C in Milton Keynes between 2008 and 2012.
Table 1 Number of notifications of new hepatitis B and hepatitis C cases among Milton Keynes residents 2008 – 2012
Year Number of new hepatitis B Number of new hepatitis notifications among Milton C notifications among Keynes residents Milton Keynes residents 2008 76 49 2009 35 40 2010 44 47 2011 50 20 2012 35 10 Source: South Midlands and Hertfordshire Public Health England Centre
4 Table 2 shows the number of new cases of hepatitis B in Milton Keynes between 2008 and 2012 by age groups. Majority of cases of hepatitis B in Milton Keynes was seen between the ages of 21 and 40 years.
Table 2 Number of notifications of new hepatitis B cases among Milton Keynes residents by age groups 2008 - 2012
Year Age groups Total ≤ 20 years 21 - 40 years 41 – 60 years > 60 years 2008 6 52 16 2 76 2009 2 25 7 1 35 2010 1 32 9 2 44 2011 2 37 11 0 50 2012 0 24 10 1 35 Source: South Midlands and Hertfordshire Public Health England Centre
Table 3 shows the number of new cases of hepatitis C in Milton Keynes between 2008 and 2012 by age groups. Majority of cases of hepatitis C in Milton Keynes occurred between the ages of 21 and 60 years.
Table 3 Number of notifications of new hepatitis C cases among Milton Keynes residents by age groups 2008 - 2012
Year Age groups Total ≤ 20 years 21 - 40 years 41 – 60 years > 60 years 2008 1 25 18 5 49 2009 1 25 13 1 40 2010 0 19 24 4 47 2011 0 9 9 2 20 2012 0 6 4 0 10 Source: South Midlands and Hertfordshire Public Health England Centre
There has been a sharp drop in the number of new hepatitis B and C in Milton Keynes. There is a concern that all high risk groups are not being tested.
Future priorities Raise awareness of hepatitis B and C testing in high risk groups Ensure that testing and treatment pathways are adequate Set up a blood-borne virus network in Milton Keynes involving all key stakeholders to discuss key issues
3.2. Tuberculosis
Tuberculosis (TB) is a vaccine preventable infectious disease, caused by bacteria belonging to the Mycobacterium tuberculosis complex. TB usually causes disease in the lungs (pulmonary), but can also affect other parts of the body (extra-pulmonary).
Table 4 shows the number of new cases of TB and its rate, and figure 1 shows the trend of TB in Milton Keynes between 2006 and 2012. There was a year-on-year decrease in TB rates in Milton Keynes between 2006 and 2010, but the rate has risen in 2011 and 2012. These may not be statistically significant because of small numbers (a formal significance test has not been performed) but the recent trend shows an increase in the rate.
5 Table 4: Number of new cases of TB and its rate in Milton Keynes between 2006 and 2012
Year No. of cases TB rate per 100,000 2006 43 19.1 2007 43 18.8 2008 38 16.4 2009 34 14.6 2010 29 12.3 2011 36 14.9 2012 44 17.6 Source: South Midlands and Hertfordshire Public Health England Centre
Fig: 1 TB rate trend in Milton Keynes between 2006 and 2012
Source: South Midlands and Hertfordshire Public Health England Centre
Figure 2 shows the ethnicity distribution of the new cases of pulmonary TB diagnosed among Milton Keynes residents in 2012.
6 Figure 2 Ethnicity distribution of the new cases of pulmonary TB diagnosed among Milton Keynes residents in 2012
Source: South Midlands and Hertfordshire Public Health England Centre
41% of cases occurred in the Black African community and they together with the Indian and Pakistani communities had 77% of the new cases in 2012.
85.1% of patients with pulmonary TB had completed treatment in the first two quarters of 2013/14.
BCG vaccination:
The eligible babies born in Milton Keynes NHS Foundation Trust are vaccinated at birth by the midwives. However, there is no formal policy to vaccinate eligible children who have missed out on getting the vaccine at birth. Some of the eligible children are vaccinated by school nurses in year 9. The remaining children are vaccinated on an ad hoc basis by the paediatric team in the hospital.
There is no provision within Milton Keynes to provide BCG vaccination to adults. This is however a very rare requirement.
Current specialist TB service provision:
This is provided within Milton Keynes Hospital and is currently staffed by a consultant and a specialist nurse. There is no provision for annual leave or other leave cover. There is limited resource to provide Directly Observed Therapy (DOT). It will stretch the service further when new entrant screening for TB is introduced.
Future priorities: To raise professional and public awareness of TB To ensure that there are adequate provision for screening, treatment and BCG vaccination
4. Healthcare associated infections (HCAIs)
Healthcare associated infections (HCAIs) are infections that are acquired as a result of healthcare interventions. High standards of infection control practice minimise the risk of occurrence.
7 With treatment most patients recover from a HCAI without any problems. However, these infections can extend a patient's stay in hospital, and in severe cases can cause prolonged illness, disability or even death.
Clostridium difficile infections (CDI) and MRSA (methicillin resistant staphylococcus aureus) septicaemia (presence of bugs in the blood stream with signs of infection) are the most important HCAIs.
4.1. Clostridium difficile infections (CDI)
4.1.1. CDI objectives for 2014/15
Table 1 shows the CDI objectives for 2014/15.
Table 1 CDI objectives for 2014/15
Organisation CDI objectives 2014/15 Milton Keynes Hospital 19 Bedford hospital 18 Milton Keynes CCG 63
4.1.2. Acute trusts
Table 2 shows the number of CDI reported in Milton Keynes Hospital and Bedford Hospital in 2014/15.
Table 2 Number of CDI reported in Milton Keynes Hospital and Bedford Hospital 2014/15
Trust Apr’ May’ Jun’ Jul’ Aug’ Sep’ Oct’ Nov’ Dec’ Jan’ Feb’ Mar’ Total 14 14 14 14 14 14 14 14 14 15 15 15 Milton 3 5 Keynes Hospital Bedford 0 1 Hospital Source: Public Health England
Table 3 shows the number of CDI reported in Milton Keynes Hospital and Bedford Hospital in 2013/14. Milton Keynes Hospital had 34 cases against a maximum target of 13 cases for that year.
8 Table 3 Number of CDI reported in Milton Keynes Hospital and Bedford Hospital 2013/14
Trust Apr’ May’ Jun’ Jul’ Aug’ Sep’ Oct’ Nov’ Dec’ Jan’ Feb’ Mar’ Total 13 13 13 13 13 13 13 13 13 14 14 14 Milton 0 2 0 2 1 2 4 3 10 3 3 4 34 Keynes Hospital Bedford 0 0 0 7 0 2 0 1 0 1 0 0 11 Hospital Source: Public Health England
4.1.3. Milton Keynes CCG
Table 4 shows the number of CDI reported among Milton Keynes CCG residents in 2014/15.
Table 4 Number of CDI reported among Milton Keynes CCG residents 2014/15
CCG Apr’ May’ Jun’ Jul’ Aug’ Sep’ Oct’ Nov’ Dec’ Jan’ Feb’ Mar’ Total 14 14 14 14 14 14 14 14 14 15 15 15 Milton 7 11 Keynes CCG
Source: Public Health England
Table 5 shows the number of CDI reported among Milton Keynes CCG residents in 2013/14. They had 64 cases against a target of 44.
Table 5 Number of CDI reported among Milton Keynes CCG residents 2013/14
CCG Apr’ May Jun Jul’ Aug Sep’ Oct’ Nov’ Dec’ Jan’ Feb’ Mar’ Total 13 ’13 ’ 13 ’ 13 13 13 13 14 14 14 13 13 Milton 2 4 1 9 5 7 10 6 9 7 4 9 64 Keynes CCG
Source: Public Health England
4.2. MRSA septicaemia
There has been zero tolerance for MRSA septicaemia since April 2013. All cases are investigated through post-infection report to identify potential learning points.
4.2.1. Acute trusts
Table 6 shows the number of MRSA septicaemia reported in Milton Keynes Hospital and Bedford Hospital in 2014/15.
9 Table 6 Number of MRSA septicaemia reported in Milton Keynes Hospital and Bedford Hospital 2014/15
Trust Apr’ May’ Jun Jul’ Au Sep’ Oct’ Nov’ Dec’ Jan’ Feb’ Mar’ Total 14 14 ’14 14 g’1 14 14 14 14 15 15 15 4 Milton 0 0 Keynes Hospital Bedford 0 0 Hospital
Source: Public Health England
Table 7 shows the number of MRSA septicaemia reported in Milton Keynes Hospital and Bedford Hospital in 2013/14.
Table 7 Number of MRSA septicaemia reported in Milton Keynes Hospital and Bedford Hospital 2013/14
Trust Apr’ May’ Jun Jul’ Au Sep’ Oct’ Nov’ Dec’ Jan’ Feb’ Mar’ Total 13 13 ’13 13 g’1 13 13 13 13 14 14 14 3 Milton 0 0 0 1 0 0 0 0 1 0 0 1 3 Keynes Hospital Bedford 0 0 0 0 0 0 0 0 0 0 0 0 0 Hospital
Source: Public Health England
4.2.2. Milton Keynes CCG
Table 8 shows the number of MRSA septicaemia reported among Milton Keynes CCG residents in 2014/15.
Table 8 Number of MRSA septicaemia reported among Milton Keynes CCG residents 2014/15
CCG Apr’ May’ Jun’ Jul’ Aug Sep’ Oct’ Nov’ Dec’ Jan’ Feb’ Mar’ Total 14 14 144 14 ’14 14 14 14 14 15 15 15 Milton 0 0 Keynes CCG Source: Public Health England
Table 9 shows the number of MRSA septicaemia reported among Milton Keynes CCG residents in 2013/14.
Table 9 Number of MRSA reported among Milton Keynes CCG residents 2013/14
CCG Apr’ May’ Jun’ Jul’ Aug Sep’ Oct’ Nov’ Dec’ Jan’ Feb’ Mar’ Total 13 13 13 13 ’13 13 13 13 13 14 14 14 Milton 0 1 1 1 0 0 0 0 1 0 0 2 6 Keynes CCG
10 Source: Public Health England
Future priorities
To ensure that community infection control measures are adequate To ensure that care home infection prevention and control and immunisation of residents are adequate
5. Screening
5.1. Antenatal and new-born screening
Current situation
The Key Performance Indicators (KPIs) for antenatal and new-born screening for Milton Keynes Hospital show the programme is on the whole under-performing but improving for some indicators. Some of the indicators relate to very small numbers and hence performance can fluctuate quarter to quarter. In addition some of the indicators are dependent upon performance by other healthcare organisations e.g. newborn screening laboratories, Child Health.
A meeting was held in March 2014 with the Trust’s Head of Midwifery and lead consultant obstetrician, the Area Team and QA to discuss concerns about timely reporting and workforce capacity issues for the ante natal screening team. Up to now the screening meetings in the Trust have been internal meetings. It has now been agreed that the Area Team will take over responsibility of chairing this meeting where the KPIs will be monitored.
Milton Keynes Hospital Trust is currently unable to report on two indicators because it does not have a robust IT system to capture the eligible population. This issue is on the Trust risk register. Provision of a new IT system is currently out to tender but it was agreed that the Trust will develop an interim solution with QA support.
Future priorities
For the Area Team to take on chairing of the screening meeting and to convert it into a functioning Programme Management Board to ensure more robust monitoring of KPIs
For the Trust to develop an interim IT solution so that cohort data can be identified for KPIs
For the Area team/QA to support the Trust in the rollout of a new-born Infant Physical Examination IT system so that performance against this indicator can be measured.
11 12 5.2. Cancer screening
Table 9 shows the cancer screening coverage in Milton Keynes in the first three quarters of 2013-14. Breast cancer screening coverage (data available only up to August 2013) was higher than the national coverage. Cervical screening coverage was below the achievable target of 80%. Bowel cancer uptake in 2013 (calendar year) was below national target.
Table 9 Cancer screening coverage in Milton Keynes Q1-Q3 2013-14
Cancer screening Milton Keynes performance Standards Breast cancer, 3yr 78.7% - August 2013 Not set – national coverage, 53 – 70yrs comparison – 76.1% Cervical cancer screening Q1 – 78.0% Achievable target 80% coverage, 25 – 64yrs Q2 – 77.8% (2013/14) Q3 – 77.6% Cervical Cancer Screening Q1 - 71.6% Achievable target 80% coverage for ages 25- Q2 – 71.6% 49yrs, 3.3 – 5.5 years Q3 – 71.0% (2013/14) Cervical Cancer Screening Q1 – 77.1% Achievable target 80% coverage for 50 – 64yrs, 3.3 Q2 – 77.2% – 5.5 yrs (2013/14) Q3 – 77.1% Bowel cancer uptake 2013 54.01% 60% calendar year Source: NHS South Midlands and Hertfordshire Area Team
Cervical screening coverage is below target. Nationally and locally there is a small but measurable decline in uptake of the first screening invitation amongst women aged 25 years.
Performance is below target for bowel cancer screening. The Buckinghamshire and Milton Keynes Programme performance reflects the different deprivation across the areas of the programme’s geography; Milton Keynes has lower uptake than other parts of the programme area. There has been a national drop in uptake as the programme develops and recalls previous participants.
Future priorities of the NHS England South Midlands and Hertfordshire Area Team: To continue the regular Programme Management Boards that monitor performance of the screening programmes and expand membership where appropriate; for example, encourage engagement with CCG colleagues To work with local authority public health and CCG colleagues to promote the importance of screening & address health inequalities To produce quarterly reports to Director of Public Health and Health Protection Committee highlighting performance of the programmes To highlight performance variations amongst local practice populations. To support the roll-out of Bowel Scope Screening from March 2015.
13 6. Immunisation
Table 10 shows the coverage of routine childhood immunisation in Milton Keynes up to the third quarter of 2013-14. Year 1DTaP and Year 2 DTaP immunisation uptakes were above the target. But the uptakes of other immunisations were below the target. Particularly of concern are those offered to children before they start school (DTP, or the pre-school booster and the 2nd dose of MMR).
Table 10 Childhood routine immunisation in Milton Keynes up to third quarter 2013-14
Vaccine Milton Keynes percentage coverage Target 2013/14 (3rd quarter) Year 1 DTaP/IPV 95.5% 95% Year 2 DTaP 96% 95% Year 2 Hib/Men C 93.3% 95% Year 2 PCV 93.2% 95% Year 2 MMR 94% 95% Year 5 DTP booster 89.9% 95% Year 5 MMR (2nd dose) 89.9% 95% HPV Vaccine Uptake (% 85.1% 90% received all 3 doses since 1/9/2012 - Academic Year) Source: Source: NHS South Midlands and Hertfordshire Area Team
Table 11 shows the uptake of flu vaccination in Milton Keynes in 2013-14. Flu vaccination uptake for those above 65 years of age, those below 65 years of age and in a clinical risk groups and for pregnant women did not meet the national target. This was the first year that healthy 2 and 3 year olds were vaccinated.
Table 11 Flu vaccination uptake in Milton Keynes in 2013-14
Age Milton Keynes percentage Target coverage 2013/14 (up to Jan’14) 65 years and over 71.9% 75% Under 65 years at risk 50.1% 75% group All pregnant women 37% 75% Healthy 2 year olds 41.9% No target Healthy 3 year olds 33.7 No target Source: NHS South Midlands and Hertfordshire Area Team
Future priorities
To identify a target list of practices that the immunisation coordinator will work with to improve uptake; to visit all practices within 14/15 To expand the number of pharmacists offering flu vaccination to the younger “at risk” populations; from a baseline of 4 in 13/14 To produce quarterly reports to the DPH and HPC on immunisation uptake and work to improve uptake To undertake an analysis of immunisation in underserved groups (such as LAC and unregistered children) and identify methods of improving uptake in these groups
14 To work with colleagues in the CCG and Council Public Health team to raise awareness of vaccination and improve access; for example, vaccination within maternity units, promotion via residents newsletters
7. Environmental Health 2013 to 2014
2013 to 2014 was the first full year of operation of the new Regulatory Unit. This saw the merger of the majority of regulatory functions into one unit. The Regulatory Unit enforces a very wide range of legislation and during the year has undertaken much work to maintain the public’s health, the safety of the population and visitors to MK and to safeguard the environment. The principal areas of work undertaken by the Regulatory Unit included:- Environmental Health, Trading Standards, Envirocrime, Animal Health & Welfare, Building Control, Sustainability, Planning Enforcement, Antisocial Behaviour, Emergency Planning. Corner, Bereavement and Births, Deaths & Marriages.
During the year there have been several notable issues that have challenged the unit.
7.1. Unauthorised Encampments
The year saw a dramatic rise in the number of sites occupied. This included parkland, playing fields, highway verges, development sites and private land on industrial estates. The impact of the occupation of the sites varied between none to significant depending on the behaviour of the occupiers. The reasons for this dramatic rise are not fully understood but included the impact of the dry summer (which allowed sites to be occupied which previously were too wet for towing vehicles) and changes to public land ownership which may have led to a loss of corporate knowledge on the need to defend sites.
Because of the rising incidence of problems particularly with fly tipping and damage the Council held a summit with partners including the police and landowners to review how the problem could best be dealt with whilst respecting the human rights and welfare needs of the campers. This resulted in enhanced partnership working and greater intelligence sharing.
Each new site is visited and risk assessed. The occupants are interviewed about their intentions and enquiries made about any welfare requirements. Intelligence is sought from surrounding authorities and the police about the occupants and the site dealt with accordingly.
7.2. Public Health Funerals
Each year we get referred to us details of persons who have died where no arrangements are being made for a funeral or disposal of the body. This past year has seen a considerable increase in the numbers referred. In each case officers visit the home of the deceased and make enquiries to attempt to find friends or family. Sometimes we are successful but increasingly we find no one or, even where next of kin are found, there are reasons why they do not wish to take on the arrangements. This includes financial difficulties but also family break up etc. Advice is provided on arranging funerals and minimising the cost where this is an issue. Where no one can be found to organise the funeral the officers from the Regulatory Unit arrange one. We try to do this, where known, in accordance with the wishes of
15 the deceased including any religious requirements and with the involvement of friends etc. To minimise the impact on public funds officers seek to recover from any estate the cost of the funeral.
7.3. Tattooing
There has been a noticeable increase in the popularity of tattooing and other forms of body adornment. Milton Keynes seems to have become a location for tattoo conventions with at least two held every year. This sees numbers of body artists from across the country and abroad setting up in a venue, exhibiting their skills and tattooing the public. We take the potential public health risks from such events seriously and spend time working with the organisers, gathering information on the exhibitors and inspecting their arrangements.
7.4. Gambling
Whilst the opening of the Casino in the Xscape building has increased access to gambling there has also been a noticeable increase in the number of bookmakers each of which is allowed up to 4 fixed odds betting terminals.
Milton Keynes has 38 gambling licences, of these: 7 are Adult Gaming Centres 28 are Betting shops 1 is a track betting (in stadium) 1 is a Bingo 1 is a large casino large
These are mostly concentrated in the following areas: 10 gambling premises are in Bletchley 10 gambling premises are in CMK 4 gambling premises are in Wolverton
Of the ten in Bletchley, 5 betting shops and two Adult Gaming Centres are located on Queensway.
The current legislation has quite specific licensing objectives and it will/ has proved very difficult to evidence betting shops undermining them.
Casino money has been used to fund approx. 25 underage test purchases in Milton Keynes. These were part intelligence based. About 30% failure rate, though this includes children being permitted in the store as an offence.
7.5. Events
The past year has been a fallow one for very large events but has, nevertheless seen regular meetings of the Milton Keynes Safety Advisory Group to advise events’ organisers on public safety and on minimising the impact of their event on the community. Of particular note have been the Milton Keynes Festival of running and the MK Marathon which have become regular features on the events calendar. During the year the arena at stadium MK hosted its first major event – The English National Badminton Tournament. Also the upper tier at stadium MK was completed
16 increasing the capacity to 32000. Later this year the stadium hosts the Women’s FA cup final.
2014 will see 5 significant concerts at the National Bowl including Kings of Leon and Pearl Jam. MK is also due to host the Cyclocross World Championships in October 2014 in Campbell Park. Planning is also underway to prepare for MK being a host city for the Rugby World Cup in 2015.
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