South Midlands and Hertfordshire Public Health England Centre

Health Protection News September 2013

Contents Welcome to our

Rash decision 2 new Centre Director, Dr Jenifer Smith Rotavirus vaccine 3 Dr Jenifer Smith has now taken up her post as Centre Director for South Midlands and Hertfordshire and is busy getting to Rubella 3 know everyone, both those within PHE and those working in the wider public health system.

Head lice 4 Her previous consultant posts in public health have covered many aspects of public health practice, but she has not Infection Control previously had a working base in this part of the world. Most Top Tip 5 recently a Director of Public Health on the isle of Wight, this feels a long way from the sea, but she is enjoying exploring the cycle paths and is very glad to still be able to cycle to work Read the label 5 at least some days.

The immediate priority is to establish South Midlands and Keep water healthy 6 Hertfordshire as a real entity, incorporating the service teams shared with other PHE Centres, such as the Knowledge and Herts unregistered Information Team (“KIT”) shared with Anglia and Essex. tattooist project 8 Alongside this, work is underway establishing firm links with the Directors of Public Health and their local authority based Staff News 9 teams.

Duncan Selbie has been very active getting out and about and Kevin Fenton is now following suit. We are very pleased to say Care Home newsletter 9 that he is visiting South Midlands and Hertfordshire on October 11th.

Contact information: South Midlands and Hertfordshire PHE Centre Beacon House Tel: 0300 303 8537 Dunhams Lane Fax: 0300 303 8541 Letchworth Garden City Hertfordshire Email: [email protected] or [email protected] SG6 1BE

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minimising the “risk” of transmission of a highly infectious disease to other patients in Rash decision! the waiting room. The parents can be asked when making the appointment to make themselves known to the receptionist immediately on arrival at the surgery. If there is a separate waiting area in the building the case can be directed to that area.

2. Secondly, what should the procedure be if a parent just turns up at the surgery with the child without an appointment? Whenever possible, signs should be placed in GP surgery waiting areas advising parents with children who have any rash-type illness to report to reception immediately. If there is There are several viral and bacterial infections a separate waiting area the parents should be that commonly present with a generalised rash. requested to wait there. If the parent offers In the UK these include chicken pox, measles, the information to the receptionist as to why scarlet fever and parvovirus to name but a few. they have attended the surgery, the However, parents and indeed the adult patient receptionist can try to extract more themselves will not know whether the rash is information such as if the child has had a contagious or not; we would not expect them to fever or not. If the description of the rash and know. If a patient either young or old comes other symptoms sound suspiciously like a into the surgery with a new rash it may be contagious rash then the parent should be eczema, not contagious at all. However, it directed to a separate waiting area. could be measles, therefore, making the patient highly infectious as the period of Of course the same rules apply if the patient is communicability lasts until 4 days after the rash an adult. has appeared. Knowing whether the case is contagious, how contagious and how long for Yes it is very true that the GP Surgery’s requires medical intervention. receptionist job is a busy one and they prefer not to be having to police which patient sits So the dilemmas are: where whilst waiting to be seen by the GP. However, taking the example of measles it has a 1. Firstly, if an appointment is made for a reproduction rate of 15 - 17 secondary cases in patient with a rash-type illness, when a susceptible population for every one index should the patient be seen and where case. The transmission rate for chickenpox is should the patient wait? 96% of susceptible people exposed to an index Ensure receptionist know that, if the case will develop the disease. symptoms are a fever and rash, these are potentially infectious cases. If the receptionist Remember to that if a rash-type illness can extract enough information from the suspected to be an infectious disease is referred parent during the phone call requesting the to an A&E or hospital, the GP should be appointment and the symptoms sound at all informing the hospital staff so that the case can suspicious of a contagious rash, then the be appropriately isolated on arrival. appointment should be made for a time at the end of the surgery. Hence, this will assist in

Reference: Communicable Disease Control and Health Protection Handbook. Third edition. Hawker J, Begg N, Blair I et al. Wiley- Blackwell Publication, 2012.

3 Rotavirus vaccine The rotavirus immunisation programme started on • Infants who have not received their first dose the 1st July in the UK and will prevent a significant by week 15 of age (i.e.14 weeks and 6 days) number of young infants from developing this should not be offered Rotarix®. infection. A published study, estimated that vaccinating a birth cohort of infants in England and • There are two rotavirus vaccines authorised Wales may prevent around 90,000 infections, about for use by the European Medicines Agency, 10,000 hospitalisations and around two deaths due Rotarix® (manufactured by GSK) and to rotavirus in that cohort over the first five years of RotaTeq® (manufactured by Sanofi Pasteur life. It may also provide some additional protection MSD). Both are highly effective at preventing to the wider population through herd immunity. rotavirus infection in infants. However, the vaccines are not known to be inter-changeable The two dose oral course of rotavirus vaccine is and a course of vaccine started with one offered to infants alongside other routine product should be completed with the same immunisations when they are two and three months vaccine to achieve full protection. Neither of age. vaccine contains thiomersal nor any adjuvant.

The following are some answers to questions we • Oral live vaccines can be administered at the have received at the centre in the weeks following same time as parenteral vaccines or at any the start of the programme: interval before or after each other.

• If the infant spits out or regurgitates most of • Children can go swimming after receiving the vaccine, a single replacement dose may Rotarix. be given at the same vaccination visit. There are no restrictions on an infant’s consumption of food or drink before or after vaccination.

These include: polymerase chain reaction (PCR) and in 2012 and to date • eye problems, such Rubella in 2013, there have been no as cataracts Rubella (also known as german cases or rubella infection measles) is a viral infection that • deafness confirmed by oral fluid testing used to be common in children. • heart abnormalities in the South Midlands and Rubella is usually a mild Hertfordshire PHE Centre. infection and the symptoms • brain damage include: Rubella is unlikely in people Since the introduction of the who have been fully immunized • a distinctive red-pink skin rash measles, mumps and rubella (MMR) vaccine, CRS is now and other causes of rash illness • swollen glands very rare in the UK. (such as parvovirus B19, measles, scarlet fever) are • cold-like symptoms such as a more likely. sore head and runny nose So far this year, there have been 23 reported cases of rubella to The only time that rubella the South Midlands and A diagnosis of rubella in a child becomes a serious concern is if Hertfordshire PHE Centre who attends nursery or school a pregnant woman catches the (1 January to the 30 June 2013) can cause anxiety among infection during the first 16 which is more than the whole of pregnant staff and contacts. weeks of her pregnancy. The last year. It would be helpful if a full rubella virus can disrupt the immunization history and details development of the baby and All reported cases are offered of the school or nursery are cause a wide range of health oral fluid testing to confirm the provided for all rubella problems known as congenital diagnosis of rubella by IgM notifications so that a prompt risk rubella syndrome (CRS). antibody tests and/or assessment can be carried out.

4 Head lice infestation Head lice infestation is the condition caused by the parasitic insect Pediculus capitis, which lives on, and among, the hair of the scalp and neck of humans.

Live lice can be found anywhere on the scalp; the eggs are most commonly found behind the ears and at the back of the neck. The severity of infestation varies but a typical infestation might have about 30 lice per head.

If left untreated, infestation with head lice may persist for long periods.

To confirm a person has head lice: • Detection combing (systematic combing of wet or dry hair with a detection comb) • Active head lice infestation should only be made if a live head louse is found. An itching scalp is not sufficient to diagnose active infestation. • Nits alone (eggs) do not indicate active infestation. • A person should only be treated if a live head louse is found. • Only affected household members need simultaneous treatment.

Depending on the preference of the individual or parent and in conjunction with previous treatment history, head lice can be treated with: • Hedrin® (Dimeticone 4% lotion) • Full Marks Solution® (Isopropyl myristate and cyclomethicone solution) • Lyclear SprayAway® (.Coconut, anise, and ylang ylang spray) • Malathion 0.5% aqueous liquid.

All treatments consists of - 2 applications 1 week apart.

Treatment has the best chance of success if it is performed correctly and if all affected household members are treated on the same day, this way they are less likely to re infect each other.

Individuals should be advised to check that the treatment was successful by combing hair on day 2 or day 3 after completing a course of treatment, and again after an interval of 7 days (day 9 or day 10 after completing a course of treatment).

If treatment is unsuccessful: The same treatment should be repeated, or a different treatment tried. All affected household contacts need to be treated simultaneously again.

Children who are being treated for head lice can still attend school.

5 Infection Control Top Tip Are you aware of the 48 hour rule?

All cases of gastroenteritis should be regarded as potentially infectious and to prevent person to spread you should stay away from work, school or other institutional setting at least until 48 hours after vomiting and/or diarrhoea has stopped. This is particularly important in health care where people have direct contact with susceptible patients in whom a gastrointestinal infection could have potentially serious consequences. Read the Label

The Food Standards Agency guidance document ‘ E.coli 0157 Control of Cross- Contamination’ states that food business operators must ensure cleaning and disinfection procedures ensure the removal of E.coli 0157 and other pathogens from surfaces and equipment involved in food preparation.

Various cleaning and disinfection products are available and choosing the right disinfect. As with disinfectants, For further information: ones can be baffling. manufacturer’s instructions must be followed for correct dilution • E. coli 0157 Control of Cross- As a general guide, detergents and contact times to ensure the Contamination, Guidance for are products for general sanitiser is effective. food business operators and cleaning. They do not have enforcement authorities by disinfectant properties and are There are two officially the Food Standards Agency not capable of destroying recognised laboratory standards can be found at: harmful bacteria such as E.coli. for assessing the effectiveness http://food.gov.uk/multimedia/ Disinfectants are products that of disinfectants and sanitizers. pdfs/ecoli-control-cross- are capable of destroying These are BS EN 1276:1997 contam.pdf harmful bacteria when applied and BS EN 13697:2001. A to visibly clean surfaces at a product conforming to this • The latest edition of dilution and contact time standard is capable of reducing questions and answers on specified by the manufacturer. the levels of a range of bacteria the guidance (July 2012) can including E.coli. Food business be found at: Sanitisers are products that operators should ensure they http://food.gov.uk/multimedia/ combine both disinfectant and are using the appropriate pdfs/enforcement/ detergent properties and must product by checking the product crosscontaminationqanda.pdf be used in two stages. Firstly, label, confirming with their in general cleaning to provide a suppliers or directly with the clean surface and secondly, to product manufacturer.

6 Keep water healthy!

Before it gets to your tap, your drinking water is cleaned, disinfected and tested. Anglian Water spends millions of pounds and carry out hundreds of thousands of tests every year to make sure the water reaching customers’ taps is of the very highest standard.

Yet, poor plumbing, worn out washers and even cheap kettles are just some of the easily-fixed problems which prompt thousands of calls to Anglian Water each year about water issues that have been caused inside the home or at work.

Now, Anglian Water has launched a brand new campaign called ‘Keep Water Healthy’. The aim is to raise awareness of things in the home and at work that can lead to odd tastes, smells and even bacteria getting into the water people use for drinking, cooking and washing.

“People don’t have to put up with unusual tastes in water and we want to equip customers with the know-how to get rid of them,” said Anglian Water’s Water Quality Manager, Robin Price.

The most common problems include:

• Water tastes ‘medicinal’ or like TCP meat and other foods at the sink can allow bacteria to grow in the tap head. Regularly Often, this is caused by cheap, plastic disinfecting them with a bleach solution will kettles. Try boiling water in a pan to see if keep bugs at bay. Watch the video on how the taste disappears. to keep taps clean (see link below) http://www.anglianwater.co.uk/household/ Try changing tap washers or putting in a water-quality/videos.aspx quick-to-fit, non-return valve on washing machines and dishwashers. Anglian Water • Cloudy water sends out non-return valves free of charge to customers and businesses who think they This is generally caused by air bubbles need one. Call 0845. and is completely harmless. It can happen when hot and cold pipes are too close • Bacteria on taps together, so insulate the pipes. Make sure internal stop taps are fully open - partially Hand hygiene is at the forefront of every open stop taps can let air into the water health professionals mind, but what about and make it look cloudy. tap hygiene? Washing hands, equipment,

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There can be more serious problems too: register they can call Anglian Water to check. Robin Price added: “The quality of our • Spills of fuels, oils and solvents customers’ tap water is vitally important, so if anyone has concerns or questions, at any These can seep through plastic water pipes time, they should contact us. and contaminate your drinking water, which can be extremely harmful to health. “It may be an easy fix caused by some of the common problems we hope the Keep Water Take care when using fuels and chemicals Healthy campaign will address, but customers and clean up any spillages quickly. Watch the should contact us so we can investigate and video here (click on the link below) give specific advice.” http://www.anglianwater.co.uk/household/ water-quality/videos.aspx More information and videos on the Keep Anglian Water’s fact sheet is also available on Water Healthy campaign, are available at http://www.anglianwater.co.uk/_assets/ www.anglianwater.co.uk/keepwaterhealthy media/10899_ANW_WQ_16_Fuel_Contamin ation_(7)_SS.pdf Website visitors can tour an interactive house to understand where water quality problems • Older properties with lead pipes may arise.

Lead pipework can be harmful, especially for pregnant women or young children. If the property was built before the 1970s it’s possible it has lead pipes.

- Call Anglian Water on 0845 070 3445 for a free lead test if you think you have lead pipes.

- Only cook or drink with water from the kitchen cold water tap and run the tap for a few minutes before use until you feel the water temperature drop.

• Poor plumbing

Poor plumbing is often the culprit for poor water quality. Some serious examples include where a rain water harvesting system was connected to the home’s drinking water supply. In another, solar panels were wrongly installed causing drinking water to run through the panels before coming out of the tap. So, it’s important to use an approved plumber for any major plumbing work or complex jobs.

Anglian Water maintains a list of approved plumbers on its website, and if customers are unsure whether their plumber is on the

8 Hertfordshire Unregistered Tattooist Project - Think before you ink!

There has been a rise in popularity of tattoos and skin piercing. While there is no formal training body for these practitioners, local by-laws state they must be registered by the Local Authority. This generates an inspection of premises to check hygiene and disease prevention procedures by Environmental Health Officers.

While there are a number of registered tattooists, some authorities have received information about unregistered Before and after (from left to right) activity taking place in the community. Local Authorities compliance with the Skin- In addition to this, awareness have received allegations Piercing by-laws, and best days in town centres will also including; people tattooing from practice in the industry. It will take place and information will be their home and skin piercing offer an amnesty for practitioners displayed and distributed stating taking place in a pub. One of the who are not registered to come the risks of going to an allegations said a home tattooist forward and comply with the law unregistered practitioner. This will was advertising on Facebook, by becoming registered. also give the public chance to while another suggested that ask questions regarding this clients were obtaining tattoos To achieve these aims several of issue and give opportunity to while under the legal age the Hertfordshire Local encourage reporting of bad restriction of 18 . Authorities plan to issue a news practice. release to local media to promote Over the summer months the the campaign. An article will be A leaflet campaign will also take project aims to raise the published in the Local Authority place; this will include where to awareness amongst the public of town-wide magazines raising go for confidential advice if the risks of blood borne viruses awareness and request for help worried about the after effects of and infections which can be to combat rogue operators. a bad tattoo/piercing. These will passed on by bad skin piercing not only be widely distributed on and tattoo practice. As well as If anyone has concerns about a the awareness days, but it is verifying that all tattoo tattooist in the area or want a list hoped that they will also be practitioners in established of locally registered tattooists displayed in other public places premises are registered and are covering the Hertfordshire area: giving opportunity to reach an displaying their certificates, the email: extended audience, such as GP. project will also promote [email protected]

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Centre Director Jenifer Smith Staff news

Welcome Consultant Lead in Health Protection We welcome 3 new members of staff that have joined our Dr Mike Lilley team over the last couple of months:

CsCDC Dr Deepti Kumar, CsCDC Dr Lorna Milne Lorna Willcox, Health Protection Practitioner Dr Smita Kapadia Tracey Walsh, Health Protection Practitioner Dr Marianne Vinson Dr Deepti Kumar Farewell In July, Dr Peter Sheridan retired after many years Senior Health service. Protection Nurses Kate Morrow Kay Lack Care Home Newsletter Lesley Morley “During the Autumn months South Midlands and Health Protection Nurses Hertfordshire Public Health England Centre, (SMH PHEC) Judy Gilman Caroline Foley will be launching a Newsletter specifically produced for and Nigel Fletcher aimed at Care Homes. The purpose of this Newsletter is to Alison Wesson provide Care Homes with information that will assist in Audrey Pepperman keeping Care Home staff and Service Users up-to-date Alison Richards and fully informed of public health and infection control Health Protection issues. The items to be included in the Newsletter will Practitioners feature topics such as vaccination and immunisation Lorna Wilcox information, links to useful websites, tips on how to Tracey Walsh maintain compliance with Outcome 8, information about Trainees on placement common ailments which can affect the Service Users of all Helena Jopling ages and much more. The first issue will be a bumper

issue to explain the Public Health England Mission and the Unit Manager Stephen Murphy role of the team here at SMH PHE.”

Unit Administrator Julie Nicholson And finally …... Data Analyst Caroline Black If you have any contributions or have any interesting Admin Team news you would like to share for any of our future Ellie Faulkner newsletters, please could you send any suggestions Rebecca Tomlin to Nigel Fletcher [email protected] and Hannah Wilson Ellie Faulkner [email protected] Diane Crane Hayley Chapman Any feedback from this newsletter would be gratefully received to enable us to improve on future issues. Also, please let us know if you would like to be added to or removed from our mailing list.