Key Health Data for the West Midlands 2002
CHAPTER TWELVE: COMMUNICABLE DISEASE
List of Tables
List of Figures
Main Body
1: The Geography of the West Midlands
2: Life Expectancy and Inequalities
3: Drinking Water Quality
4: Chemical incidents in the West Midlands
5: Landfill Sites
6: IPPC
7: Fires in the West Midlands
8: Road Traffic Accidents
9: Drownings
10: Access to a healthy diet
11: National Health Service Priority Areas
12: Communicable Disease
13: Older People
12.1 Introduction
In the Chief Medical Officer's recent Infectious Disease Strategy, "Getting Ahead of the Curve", four areas were recommended for intensified action to reassert control over serious infectious disease problems; health care associated infection, antimicrobial resistance, tuberculosis, blood-borne and sexually transmitted viruses. In this section we present data on trends in these infections.
12.2. Health care associated infection and antimicrobial resistance
The Department of Health's mandatory healthcare associated bacteraemia scheme started in April 2001 with the collection of data on MRSA (methicillin resistant Staphylococcus aureus) bacteraemias. All acute NHS Trusts are required to submit quarterly data to their CDSC regional units for onward transmission to the centre. The "headline" rate is considered to be the number of MRSA bacteraemias per 1,000 bed days, from which hospital "league tables" have been derived. Critics of the scheme have pointed out that the measured rates are based on small numbers thus far, and that they are very dependent on a hospital's case mix, with immunosuppressed patients and those with intravenous lines being more liable to acquire MRSA bacteraemia. The case mix objection has been very partially met by dividing hospitals into three classes - general acute, single specialty, and specialist. One hundred and eighty seven English Trusts participated in the first year of the scheme. The national report of the first year's activity (http://www.phls.co.uk/publications/cdr/PDFfiles/2002/MRSA2502.pdf) states that there were 45 specialist Trusts with MRSA bacteraemia rates ranging from 0.08 to 0.66 per 1000 bed-days. MRSA bacteraemia rates in general acute Trusts (124 Trusts in total) ranged from 0.02 to 0.39 per 1000 occupied bed-days. The 18 single specialty Trusts had rates ranging from 0 to 0.23 per 1000 bed-days.
Figure 12.1 shows results for the English regions. Higher figures are generally observed in London and the south of the country. Figure 12.2 shows the MRSA bacteraemia rates for the West Midlands hospitals.
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The University Hospital Birmingham NHS Trust had a higher rate than any other hospital in England. This Trust is unusual by virtue of the highly specialist nature of much of its work, notably transplant work. Much effort is currently being devoted to control of infection measures within the Trust in order to minimise the MRSA problem.
12.3. Tuberculosis
Tuberculosis is statutorily notifiable. With the help of the Consultants for Communicable Disease Control and Chest Physicians, an enhanced surveillance scheme for tuberculosis was introduced in England and Wales on 1 January 1999. It replaced the five yearly national tuberculosis surveys with a continuous monitoring system, designed to enable more rapid detection of changes in the epidemiology of tuberculosis.
Tuberculosis notifications have fallen steadily throughout the 20th century, reaching their lowest point in England and Wales in 1987. Since that time, although there have been annual fluctuations, there has been a gradual rise in notifications.
Data for the West Midlands shows a slightly different pattern. A low point was also reached in 1987, but then rates in the region increased to a peak in 1992 before falling again (Figure 12.3). Although rates in the West Midlands increased between 1998 and 2000, they did not reach levels recorded in 1989-93.
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Figure 12.3. Tuberculosis notification rates in the West Midlands and England and Wales 1986 - 2001 |
Over 50% of tuberculosis cases in the West Midlands occur in people of South Asian origin, a rate 25-30 times higher than in those of white ethnicity. The majority of these cases occur in the long settled communities. Rates are even higher in those of Black African ethnicity, where more recent arrivals are a major contributor. Cases in white people continue to occur: these will include many cases of reactivation of old infection, particularly in older white people (see Table 12.1).
Most cases of tuberculosis occurred in the 15 to 34 year-old age group. This group also showed the highest rates of disease in females. For males, rates were highest in those aged over 75 (Figure 12.4).
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As of April 2002 District Health Authorities were abolished, and their functions taken over by the new Primary Care Trusts (PCTs). In response to this maps to show tuberculosis rates per 100,000 population by PCT have been produced. Rates are highest in Heart of Birmingham PCT, Oldbury and Smethwick PCT and Wednesbury and West Bromwich PCT. The lowest rates were seen in Herefordshire PCT (Figure 12.5).
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Figure 12.5. Tuberculosis rates around the West Midlands during 2001 by Primary Care Trust |
12.4. HIV / AIDS
HIV infection is not notifiable, however an enhanced surveillance scheme has been set up in the West Midlands funded by the West Midlands Regional Public Health Levy to act as a specialist information resource for all those involved in HIV prevention or care in the West Midlands.
Incidence of newly diagnosed cases of HIV infection remained fairly constant from 1990 to 1998 at about 100 cases per annum. Since then there has been an increase in the number of newly diagnosed cases each year, a statistically significant trend. One hundred and ninety five new cases of HIV infection were reported in 2001, 2.3 times higher than in 1996 (Figure 12.6). This is the highest yearly total ever to be seen in the West Midlands and is due to an increase in cases acquired heterosexually. Although the new diagnoses of HIV infection have increased, new diagnoses of AIDS and deaths have fallen both nationally and regionally due to the effectiveness of new combination antiretroviral therapies.
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Figure 12.6. Reports of diagnosed HIV and AIDS and deaths from AIDS, West Midlands 1990 to 2001 |
Overall 66% of cases are in white people but rates are around 100 times higher in those of Black African ethnicity (Figure 12.7) and this inequality is increasing (Figure 12.8). Cases in Black Africans are mainly heterosexually acquired abroad. Although the settled African population is small, the need for prevention programmes in students and refugees from sub-Saharan Africa should be reviewed urgently. There is, as yet, little evidence of substantial spread to UK residents of the HIV epidemic from the Indian subcontinent however, the need for preventative action among West Midlands residents with links to the subcontinent remains strong.
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Figure 12.7. Ethnic group of all reported cases of HIV in the West Midlands |
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The diagnosis and proportion of heterosexually acquired cases continues to increase (Figure 12.9). Figures for 2001 show the highest yearly total so far. Since cases acquired heterosexually usually present later than in other risk groups, the true proportion of new infections contracted heterosexually may be even higher.
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Figure 12.9. Incidence of HIV by year amongst MSM and heterosexuals in the West Midlands |
Figure 12.9. Incidence of HIV by year amongst MSM and heterosexuals in the West Midlands The number of new diagnoses in men who have sex with men (MSM) fell slightly in 2001, although the trend over the last 13 years is fairly static (Figure 12.9). However the proportion of total HIV infections occurring in this group has been falling for the last five years and now accounts for nearly a third of all new cases in 2001. There is no evidence of an increasing problem in young MSM, but two-thirds of recent cases in MSM continue to be in those aged 25 - 44 years at diagnosis (Figure 12.10). The ongoing high number of such cases suggests that districts need to review the effectiveness of prevention services aimed at men in this age group, as MSM continues to be the largest risk group for HIV contracted within the UK.
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12.5. Measles, Mumps and Rubella
The suggestion that there could be a link between the children's immunisation programme for measles, mumps and rubella (MMR) and autism has had considerable coverage in the news and media throughout the last few years. This has led to a fall in the uptake rate of the vaccine.
In the West Midlands MMR coverage fell from 92% in 1997 to 89.2% in 1999. Coverage then increased slightly between January and June 2000 before falling to 85.9% at the end of 2001. When compared to the UK as a whole, the percentage coverage in the West Midlands is about 2% higher (figure 12.11).
It is extremely important that we continue to work to try and achieve the 95% target for the population in order to be confident of preventing a resurgence of measles, mumps and rubella.
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© Department of Public Health and Epidemiology, University
of Birmingham