8.1. Introduction

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 Health Protection Agency regional surveillance 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: immunosuppressed patients and those with intravenous lines are 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 for the second year’s data states that all 177 acute NHS Trusts from nine English regions participated. The MRSA bacteraemia rate within Trusts ranged from 0 to 0.49/1000 bed-days. Single speciality Trusts had the lowest rates overall (0.10/1000 bed-days) and specialist Trusts the highest (0.23/1000 bed-days). General acute Trusts had intermediate rates (0.15/1000 bed-days).

Figure 8.1 shows results for the English regions. Higher figures were generally observed in London. Figure 8.2 shows the MRSA bacteraemia rates for the West Midlands hospitals. One trust in the West Midlands 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.

	Table 8.1. West Midlands acute Trusts MRSA bacteraemia rates (April 2001 to March 2003)
	Figure 8.1. MRSA bacteraemia rate* by English regions (April 2001 – March 2003)
	Figure 8.2. MRSA bacteraemia rate* by acute NHS Trust (West Midlands Region; April 2001 – March 2003)
	Figure 8.3. MRSA bacteraemia rate* in English specialist trusts (April 2001 – March 2003)
	Figure 8.4. MRSA bacteraemia rate* in English single speciality trusts (April 2001 – March 2003)
	Figure 8.5. MRSA bacteraemia rate* in English general acute trusts (April 2001 – March 2003)

8.2. Tuberculosis

Tuberculosis is a statutorily notifiable disease. Since 1999 an enhanced surveillance scheme for tuberculosis has been in place which replaced the five yearly national tuberculosis surveys. This continuous monitoring system has allowed 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 show a slightly different pattern, with rates that were also low in 1987 but following a peak in 1993 reached their lowest point ever in 1997. Since then figures have gradually risen, and although they appeared to level off between 1999 and 2001, figures for 2002 have shown a large increase with a rate similar to that seen in 1992.

Figure 8.6. Tuberculosis Notification Rates in the West Midlands and England and Wales 1986 – 2001

Patients of Indian sub-continent origin (Indian, Pakistani and Bangladeshi) accounted for over 50% of the total number of cases, followed by 24% in the white population. However, the highest rates of tuberculosis were seen in the Black African community. This population has seen a continuing trend of large yearly increases in the rates of disease, with the 2002 rate more than double that of 2001.

Figure 8.7. Tuberculosis Rates Per 100 000 Population by Ethnic Group in the West Midlands 1998 – 2002

The majority of tuberculosis cases occurred in the 15 to 34 year old age group. This was largely due to disease in the non-white population. The white population saw more disease occurring in the 55 to 74 year-old age group. This peak in the ageing white population probably reflects an increased proportion of cases due to activation of previously acquired tuberculosis infection, whilst the higher number in younger non-whites is likely to be the result of more recently acquired infection in these communities.

Figure 8.8. Age and Sex Distribution of Patients with Tuberculosis and Rates of Disease in the West Midlands, 2002

Enhanced tuberculosis surveillance now also includes treatment outcome monitoring. A form is completed for all reported cases of tuberculosis 12 months after diagnosis, and provides information on the success of treatment or otherwise.

Outcome surveillance forms were received for 89.5% of the tuberculosis cases reported to the Enhanced Tuberculosis Surveillance Scheme. Of these, 70% successfully completed a full course of anti-tuberculosis treatment within the 12 months after starting treatment.

Figure 8.9. Follow-up of the Outcome of Patients in the West Midlands 12 months after starting Tuberculosis Treatment

As of April 2002 District Health Authorities were abolished, and their functions were taken over by the new Primary Care Trusts (PCTs). In response to this a map to show tuberculosis rates per 100,000 population by PCT has been produced. Rates were highest in Heart of Birmingham PCT, Oldbury and Smethwick PCT, Wolverhampton PCT and Wednesbury and West Bromwich PCT. The lowest rates were seen in Cannock Chase PCT.

Figure 8.10. Tuberculosis Rates in the West Midlands During 2002 by Primary Care Trust

8.3. HIV / AIDS

The West Midlands HIV Surveillance Project is an enhanced surveillance system set up to act as a specialist information resource for all those involved in HIV prevention or care around the Region.

Incidence of newly diagnosed cases of HIV remained fairly constant from 1990 to 1998 at around 100 cases per annum. Since then there have been increases each year in the number of new diagnoses. There were 413 new cases of HIV infection reported in 2002, compared with 242 cases for 2001, an increase of 70%. This is the highest yearly total ever seen in the West Midlands, and is largely due to an increase in cases acquired through heterosexual intercourse.

Figure 8.11. Reports of diagnosed HIV, AIDS and deaths in the West Midlands, 1990 – 2002

HIV disproportionately affects some ethnic minorities. The proportion of all reported cases of HIV in the West Midlands for people of black ethnic origin (African, Caribbean and black other) is 29%. However, this group only makes up around 2% of the West Midlands total population. This inequality is increasing.

	Figure 8.12. Ethnic group of all reported HIV cases in the West Midlands
	Figure 8.13. Heterosexually acquired, newly diagnosed HIV cases in the West Midlands – changes in ethnic numbers over 3 different time periods

The number of new diagnoses in men who have sex with men (MSM) has increased over the last two years, with a 35% increase in 2002 compared with 2001.

Figure 8.14. Homosexually and heterosexually acquired HIV infections in the West Midlands by year of first positive test

Two thirds of recently acquired infections were in the 25-44 year old age group. Although the proportion of infections in this group has been falling for the last five years, MSM continue to be the largest risk group for HIV contracted within the UK. This, combined with the recent rise in new diagnoses, suggests that PCTs should review the effectiveness of prevention in this group.

Figure 8.15. Newly diagnosed HIV cases in the West Midlands in men who have sex with men: changes in age (at diagnosis) distribution over 3 different time periods

The diagnosis and proportion of heterosexually acquired cases continues to increase dramatically (Figure 8.13). Figures for 2002 show the highest yearly total so far, with a 78% rise in diagnoses compared with 2001. Because cases acquired heterosexually usually present later than in other risk groups, the true proportion of new infections contracted heterosexually may be even higher. Of those heterosexually acquired infections where further risk factors are known, around 70% are thought to have been infected abroad, the majority in Africa.

Fifteen cases of vertical (mother to child) transmission of infection were reported in 2002, the highest annual figure so far. The risk of transmission from mother to child can be reduced to less than 5% if the maternal infection is known to obstetric services, therefore pregnant mothers should be encouraged to take part in the national antenatal screening programme.

Sexually transmitted infections

There is also an enhanced surveillance system for sexually transmitted infections (STIs) – the West Midlands STI Surveillance Project. Eighteen of the twenty-one clinics in the Region participate in the scheme. Data are collected for a set of diagnoses selected for their public health importance and the frequency with which they are reported.

STIs declined in the 1980s and early 1990s. However since 1995 there has been a substantial increase in the number of diagnoses. This is illustrated by the most commonly diagnosed bacterial STI, chlamydia. Other STI’s including gonorrhoea and syphilis have undergone similar increases.

	Figure 8.16. Uncomplicated chlamydia diagnoses by year, 1996 – 2002
	Figure 8.17. Uncomplicated gonorrhoea diagnoses by year, 1996 – 2002
	Figure 8.18. Primary and secondary infectious syphilis diagnoses by year, 1996 – 2002

As with HIV, there are marked ethnic inequalities in the burden of STIs, with much higher infection rates amongst those of black ethnic origin.

Figure 8.19. Rates of all selected diagnoses by ethnic group at West Midlands GUM clinics 2001-2002

Between 2001 and 2002 rates have increased in all ethnic groups except Indian and black other.

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