Andrew J Winter

The re-emergence of syphilis in the United Kingdom: the new epidemic phases.

Objective: The objective of this study was to characterize the resurgence of infectious syphilis in the United Kingdom between 1997 and 2003. Study: The authors conducted a retrospective analysis of routine surveillance data from genitourinary medicine clinics and data collected through enhanced surveillance. Results: Between 1997 and 2002, diagnoses of primary, secondary, and early latent syphilis made at genitourinary medicine clinics increased by 213% in heterosexual males, 1412% in men who have sex with men (MSM), and 22% in females. These increases have been driven by a series of outbreaks, the largest of which were seen in Manchester (528) and London (1222) up to the end of October 2003. All the outbreaks have been geographically localized and the majority of cases occurred in MSM. A high percentage of concurrent HIV infection was reported, and oral sex was often reported as a route of transmission. Conclusions: Syphilis has re-emerged in response to behavior change, probably driven by changes in the HIV epidemic. The future course of the epidemic is difficult to predict and control remains elusive.

2013 UK national guideline for consultations requiring sexual history taking Clinical Effectiveness Group British Association for Sexual Health and HIV

This guideline is an update of a previous version published in 2006. In this new version, we have reflected changes in the way sexual health services are now provided by adding an expanded section on integrated STI/ contraception services and a new section on outreach services. We have also expanded the sections on electronic patient records and the use of technology in sexual history taking. The other sections have been updated to reflect new evidence and practice.

Ethnicity and STIs: more than black and white

Because of its close links to behaviour, the epidemiology of sexually transmitted infections (STIs) involves forays into social science research. One of the most vexing problems has been defining the relation between ethnicity and STI risk. Defining these associations, even when methodologically carefully performed, is problematic because of the historical context of discrimination in both the United States and Europe. However, not dealing with these issues in a forthright manner may have profound public health consequences. Population based cross sectional studies in the United States have demonstrated increased rates of gonorrhoea, chlamydia,1 and genital herpes2 in African-Americans. The herpes studies are particularly instructive because they were based on a national sample—and the differences persist when controlled for socioeconomic status and other demographic variables. The differences are also stable over time. In the United Kingdom, studies have shown that gonorrhoea rates in Leeds,3 Birmingham,4 and south London5 and chlamydia rates in Coventry6 and Birmingham4 were substantially higher in black residents, again after controlling for socioeconomic status, and in an environment (in contrast with the United States) where there is universal access to free health care. Commenting on the papers by Low et al 5 and Lacey et al ,3 Raj Bhopal7 cautioned us to be prudent in using ethnicity data because of the historical propensity to marginalise and discriminate against minorities, but reminded us not to shirk from our responsibilities in protecting …

How to diagnose and treat aerobic and desquamative inflammatory vaginitis.

Abnormal vaginal discharge is a common problem which can usually be managed syndromically in non-specialist services.1 Common pathological causes include bacterial vaginosis (BV), candidiasis and Trichomoniasis (TV). Some women fail to improve with syndromic treatment, or present with additional symptoms such as severe dyspareunia or purulent discharge. This article focuses on a practical approach to investigating and managing such a presentation in a specialist setting where near-patient microscopy is available. It needs to be read in conjunction with guidelines, such as the 2011 European (IUSTI/WHO) Guideline on Management of Vaginal Discharge.2 ### Overgrowth conditions of the vagina Normal vaginal health in adult women is maintained by acid-secreting lactobacilli. In overgrowth conditions such as BV these healthy lactobacilli are disrupted, although the underlying cause for this remains unclear. In all these conditions vaginal pH rises and there is usually an increased discharge. BV presents with a painless but unpleasant, odorous discharge. There is overgrowth of anaerobic organisms, such as Gardnerella vaginalis , Mobiluncus spp., BV-associated bacteria 1–3 and Atopobium spp. causing a rise in vaginal pH, discharge, and smell, but little inflammation. Once BV is established, biofilm formation may explain the high recurrence rate.3 Aerobic vaginitis (AV) presents with a more purulent discharge with significant inflammation and epithelial disruption. Patients may also report burning, stinging and dyspareunia. There is predominance of aerobic flora such as Escherichia coli , group B streptococci, Staphylococcus aureus and evidence of local cytokine-mediated inflammation.4 Desquamative inflammatory vaginitis (DIV), is a chronic condition of unknown aetiology with vaginal rash and purulent discharge. Patients present with profuse discharge, vestibulovaginal irritation, dyspareunia and vaginal inflammation or erythema. Many patients have long-standing symptoms for 12 months or …

A Scottish multi-centre service evaluation examining the prevalence and diagnosis of Trichomonas vaginalis in symptomatic women attending sexual health clinics:

Trichomoniasis caused by the protozoan parasite Trichomonas vaginalis (TV) is one of the most commonly occurring sexually transmitted infections of non-viral origin. This study examines the prevalence of TV infection amongst consenting symptomatic women attending three of the largest sexual health clinics in Scotland, United Kingdom. In addition, an evaluation of three testing methods to identify TV from vaginal fluid was performed involving the commercial Hologic APTIMA TV transcription-mediated amplification assay, a real-time PCR assay and microscopy. A total of 398 patients consented to participation and all were tested by the three methods. The prevalence of TV was 2.8% (n = 11), with both molecular assays correctly detecting an additional two cases of TV compared to microscopy. The prevalence of three other sexually transmitted pathogens, namely Chlamydia trachomatis, Neisseria gonorrhoeae and herpes simplex virus were 7.3% (n = 31), 0.3% (n = 1) and 1.5% (n = 6), respectively. The majority of TV cases (78%; n = 8) occurred in women greater than 29 years of age compared to most Chlamydia trachomatis cases, who were aged 30 or less (97%; n = 30).

A brief recent history of the epidemiology of congenital syphilis in the United Kingdom

Within a century, congenital syphilis has been reduced from a major cause of morbidity and mortality to a condition rarely seen in the UK. Here, newly-derived literature and information searches were used to create a contemporary overview of the epidemic, including its epidemiology. Although constrained by high-quality healthcare services and with an incidence below the World Health Organization elimination threshold, congenital syphilis still has the potential to cause major consequences for the health and life chances of affected infants. If the complex challenges presented by this preventable disease are to be resolved, intervention strategies need to be optimised, rigorously assessed and extended across Europe.

2017 European guideline for the screening, prevention and initial management of hepatitis B and C infections in sexual health settings:

This guideline updates the 2010 European guideline for the management of hepatitis B and C virus infections. It is primarily intended to provide advice on testing, prevention and initial management of viral hepatitis B and C for clinicians working in sexual health clinical settings in European countries. The guideline is in a new question and answer format based on clinical situations, from which population/intervention/comparison/outcome questions were formulated. Updates cover areas such as epidemiology, point-of-care tests for hepatitis B, hepatitis C risk and ‘chemsex’, and HIV pre-exposure prophylaxis and hepatitis B. We have also included a short paragraph on hepatitis E noting there is no evidence for sexual transmission. The guideline has been prepared in accordance with the Europe protocol for production available at http://www.iusti.org/regions/europe/pdf/2017/ProtocolForProduction2017.pdf

A combined multiplex PCR test for herpes simplex-1/2 and Treponema pallidum: a review of 5-year routine use

In 2010, we published an initial evaluation of a multiplex PCR for the detection of herpes simplex virus (HSV)-1, HSV-2 and Treponema pallidum in patients with genital ulcer disease.1 This study indicated that the assay would improve our ability to detect primary syphilis with little detrimental impact on overall service costs and turnaround time (TRT). We now present 5-year experience (14 March 2009 to …

An observational study of the impact of the 2014 XX Commonwealth Games on the sexual and reproductive health services in Glasgow, Scotland

Background: Large sporting events have raised concerns about the effect on the sexual and reproductive health (SRH) of visiting and resident populations to the host city and increased demand on SRH services. However, there is little evidence to support these concerns. The aim of this study is to investigate if the 2014 XX Commonwealth Games had an effect on the service demands of a Glasgow city-wide integrated SRH service. Methods: Electronic patient records, city-wide pharmacy data and case note review was used to assess aspects of SRH; this included overall attendance at integrated services, clinic and community emergency contraception prescriptions, victims of sexual assault, acute sexually transmissible infections (STIs), post exposure prophylaxis after sexual exposure (PEPSE) prescriptions, condom distribution and termination of pregnancy. Results: There was a significant decrease in core sexual health attendances, total acute STIs and emergency hormonal contraception prescriptions. There was no change in PEPSE prescriptions or the number of reported sexual assaults throughout the city. Conclusions: This study found no evidence that the 2014 XX Commonwealth Games placed any increased demand on the local SRH services, and showed no increase in STIs, emergency hormonal contraception prescriptions or sexual assaults. These findings will help service planning in host cities hosting future large sporting events.

A limp with an unusual cause.

A 41 year old Ghanaian man resident in the United Kingdom presented with a five hour history of pain and swelling of the right ankle, left wrist, and right middle finger. He felt generally unwell but had no other specific symptoms on systemic inquiry. He had just returned from a two week visit to Ghana. There was no medical history of note, he was taking no regular drugs, and he had no known drug allergies. The appropriate travel prophylaxis had been adhered to. He had had unprotected intercourse with a new female partner about 10 days ago. On examination, his temperature was 37.8°C. There was evidence of synovitis (joint swelling, redness, tenderness, and reduced range of movement) of the right ankle, left wrist, and the proximal interphalangeal joint of the middle finger of his right hand. Initial investigations confirmed that his neutrophil count, C reactive protein concentration, and erythrocyte sedimentation rate were raised. Radiographs of the affected joints showed soft tissue swelling but were otherwise normal. The pain did not ease with oral non-steroidal anti-inflammatory drugs and he was admitted to hospital. ### 1. What is the differential diagnosis? #### Answer The main differential diagnosis is between polyarticular septic arthritis and reactive arthritis. Other possibilities include seronegative inflammatory arthritis, connective tissue disorder, and polyarticular gout. #### Discussion Septic arthritis may be polyarticular, although this is less common than monoarticular septic presentations. Polyarticular septic arthritis is caused by the haematogenous spread of organisms to affected joints. Most cases are caused by Staphylococcus aureus or Streptococcus spp. Less common causes are Gram negative organisms such as Escherichia coli and Neisseria gonorrhoeae .1 2 Risk factors for septic arthritis include local factors such as pre-existing joint …