Drinking water in England is very high quality. The Drinking Water Inspectorate is the regulator for drinking water quality, which is regulated through the Water Supply (Water Quality) Regulations 2016. These include strict standards for microbiology to protect public health from pathogens, together with a general requirement for water to be wholesome. The safety of drinking water is confirmed through regular sampling programmes, and any breaches are investigated and enforcement action taken when necessary. Water companies adopt a water safety planning approach, in line with WHO advice. Risks are identified, reported to the Inspectorate, and mitigated before they lead to any deterioration in quality or impact on consumers

Drinking water is treated in England and disinfected to protect consumers. Disinfection is highly effective against viruses and bacteria, including E. coli and staphylococcus aureus, and is not affected by anti-microbial resistance, because it relies on a different inactivation process, either using chlorine or UV disinfection.

Government regularly meets with representatives from the British pork industry and EU counterparts to discuss a wide range of topics which can include MRSA.

Officials from the Veterinary Medicines Directorate, who are responsible for antibiotic resistance policy, have met twice this year with the British pork industry to specifically discuss the topic of Livestock Associated MRSA. The last meeting was on 11 October 2016.

In April 2013 Public Health England took over the surveillance of methicillin-resistant staphylococcus aureus (MRSA) bacteraemia, formerly undertaken by the Health Protection Agency. We do not hold the data for 2000 and 2005.

Cases are published according to both trust apportionment and trust assignment. For the purpose of answering this question trust apportionment or assignment can be considered as “hospital borne” cases.

The assignment process was added to the MRSA surveillance in 2013 superseding the previously used apportionment method. The assignment process utilises individual case review and therefore allows for a much more considered categorisation of a case and associated learning to prevent similar cases occurring in the future, than was previously possible. The assignment process was only introduced in 2013 as MRSA numbers were previously considered to be too high to make this resource demanding method viable.

The total number of trust apportioned and trust assigned cases are displayed in Tables 1 and 2 respectively.

Table 1: Trust apportioned counts of MRSA bacteraemia in 2008, 2010 and 2015.

Table 2: Trust assigned counts of MRSA bacteraemia in 2015.

Notes:

1. Cases are published on a financial year basis.
2. Trust apportioned data are not available for the years 2000 and 2005.
3. Trust assigned are not available for the years 2000, 2005 and 2010.
4. Cases are deemed to be Trust apportioned if the following criteria are met:-

- The location where the specimen was taken is given as ‘acute trust’ or is not known;

- The patient was either an ‘In-patient’, ‘Day-patient’, in ‘Emergency assessment’ or is not known.

- Patient’s specimen date is on, or after, the third day of the admission (or admission date is null), where the day of admission is day 1.

5. Cases are deemed to be trust assigned on the basis of Post Infection Review (PIR) assignment and relevant cases are assigned to acute trusts.
6. The trust assignment method supersedes the apportionment one post 2013 and utilises case review by the teams caring for the patient.

A UK-wide baseline survey to look for the presence of livestock associated meticillin resistant Staphylococcus aureus (LA-MRSA) in UK pigs was performed in 2008 in line with European Food Safety Authority (EFSA) protocols. At that point, none of the farms tested were found to be positive for MRSA. Since then, the organism has been detected in livestock in the UK. Current advice from the Food Standards Agency (FSA) and Public Health England (PHE) is that LA-MRSA poses a low risk to human health.

The people that are most likely to become colonised by LA-MRSA are those who work with livestock. Defra is therefore undertaking a study with Public Health England (PHE) to investigate the occurrence of LA-MRSA in veterinarians and livestock workers. The results of this study will be used to inform the need for future surveillance.

Livestock associated meticillin resistant Staphylococcus aureus (LA-MRSA) is not a notifiable organism. There is no mandatory requirement to test imports of live breeding pigs or pig meat for the presence of LA-MRSA.

The National Pig Association recommends in its Import Protocol that imported pigs be screened for the presence of MRSA. Such testing is done on a voluntary and private basis.

Any controls or testing introduced for an organism must be proportionate to the risk posed by it. Current advice from the Food Standards Agency (FSA) and Public Health England (PHE) is that LA-MRSA poses a low risk to human health.

The Accelerated Access Review team is a joint unit between the Department of Health and the Department for Business, Innovation and Skills. The Accelerated Access Review is intended to reform the landscape for the assessment, adoption and reimbursement of innovative drugs, devices and other treatments across all therapeutic areas.

As hand hygiene is known to be an important part of a robust approach to infection prevention and control the Department’s guidance to the National Health Service on infection prevention and control was strengthened last year. However, a national assessment for 2015 is not available as information on hand hygiene compliance is not collected centrally. Auditing of hand hygiene is a local responsibility.

The number of Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia reported by and attributed to Sherwood Forest Hospitals NHS Foundation Trust, Nottingham University Hospitals NHS Trust in the past seven financial years (FYs) is provided in the table below. Total MRSA reports and acute trust attribution is also provided for England.

MRSA bacteraemia reported by and attributed to Sherwood Forest Hospitals NHS Foundation Trust, Nottingham University Hospitals NHS Trust (FY 2008/09 to FY 2014/15)

Source:

- Annual results from the mandatory MRSA reporting scheme (FY 2007/08 to 2014/15).

- Accompanying data for annual epidemiological commentary: MRSA, MSSA and E. coli bacteraemia and C. difficile infection data, up to and including financial year 2014 to 2015

This data is not case-mix adjusted (i.e. they do not take into account the different population types served by each hospital) and so are not directly comparable. It is important to note that MRSA bacteraemia cases are reported by the acute trust whose laboratory processes the specimen and this may not always reflect where the bacteraemia was acquired.

Public Health England is working, with partner organisations, to address antimicrobial resistance through the implementation of the UK Five Year Antimicrobial Resistance Strategy[1].

[1] https://www.gov.uk/government/publications/uk-5-year-antimicrobial resistance-strategy-2013-to-2018

Public Health England (PHE) is unable to provide the number of recorded Methicillin Resistant Staphylococcus Aureus (MRSA) infections by borough/district.

PHE is able to provide this information by clinical commissioning groups (CCGs) and acute trusts.

Table 1 details counts/rates of total MRSA bacteraemia reported by Havering, Barking and Redbridge University hospitals trust and Table 2 lists counts/rates of MRSA bacteraemia attributed to Havering CCG over the last three financial years.

It is important to note that MRSA bacteraemia cases are reported by the acute trust whose laboratory processes the specimen and that this may not always reflect where the bacteraemia was acquired. Counts/rates for total MRSA bacteraemia reported in other CCGs and acute trusts in England is attached and can be found on the gov.uk website:

https://www.gov.uk/government/statistics/mrsa-bacteraemia-annual-data

PHE is working, with partner organisations, to address antimicrobial resistance through the implementation of the ‘UK Five Year Antimicrobial Resistance Strategy’¹.

Table 1: Financial year counts and rates of total MRSA bacteraemia reported by Havering, Barking & Redbridge University hospitals (FY 2012/13 to FY 2014/15)

Source: PHE July 2015 annual publication of surveillance data

Notes:

Bed days were calculated using KH03 data for the stated period. The average daily bed occupancy for the Trust quoted has been multiplied by the number of days in the time period. Rate per 100,000 bed days is calculated as follows:

Calculation of rate (per 100,000 bed days) = [Number of MRSA bacteraemia reports from the trust for the time period divided by Average daily bed occupancy multiplied by Number of days in the time period] multiplied by 100,000

NB: Included KH03 data are as of April 2015. KH03 data for January to March 2015 were not available at this time. Data for the same quarter last year (January to March 2014) has been used in FY 2014/15 bed day calculation.

Table 2: Financial year counts and rates of MRSA bacteraemia attributed to Havering CCG (FY 2012/13 to FY 2014/15)

Source: PHE July 2015 annual publication of surveillance data

Notes: CCG Populations are based upon Office for National Statistics (ONS) Mid-Year Population Estimates (2011 Census based). The relevant rate per 100,000 population was calculated as follows:

Calculation of rate (per 100,000 bed days) = [Number of MRSA bacteraemia reports from that CCG for the given time period divided by CCG level population estimate] multiplied by 100,000

NB: Included population data are as of April 2015. 2014 population estimates were not available at this time. 2013 population estimate data has been used as a proxy for the FY 2014/15 population.

Livestock-associated meticillin resistant Staphylococcus aureus (LA-MRSA) has been found worldwide and is not the same as the MRSA strains that normally cause healthcare-associated infections. If meat is stored, handled and prepared properly, the risk to people is very low and there are no known cases of people contracting LA-MRSA from eating meat.

The annual progress report and implementation plan for the UK five-year Antimicrobial Resistance Strategy includes the measures on animal health to be taken over the next four years to promote the responsible use of antibiotics. This is attached and available at:

https://www.gov.uk/government/publications/progress-report-on-the-uk-five-year-amr-strategy-2014

Regarding LA-MRSA specifically, there are a number of initiatives to reduce the risk, for example, Public Health England regularly reminds diagnostic laboratories of the need for continued vigilance and ensuring that MRSA isolates are submitted for further tests if there may be an association with farming. In addition, Defra and the Veterinary Medicines Directorate are leading a review of options for increased surveillance, which will be proportionate to the low public health risk. Defra is also considering additional guidance for farmers on how to reduce the risk of importing LA-MRSA into their farm. Furthermore Defra have previously worked with the National Pig Association and recommend that anyone importing breeding pigs and semen to Britain should have them screened for MRSA before importation.

The most common type of LA-MRSA in Europe belongs to clonal complex 398 (CC398). MRSA CC398 is less virulent and transmissible compared to other strains and is unlikely to pass from person to person and become endemic in the human population.

However studies from various countries in continental Europe have demonstrated that in limited circumstances it is possible for MRSA CC398 to be transmitted from animals to people. This tends to be constrained to those who have regular contact with livestock that are carrying the bacteria, in particular pigs.