Clare E French

Estimation of the rate of pelvic inflammatory disease diagnoses: trends in England, 2000-2008.

Background: Pelvic inflammatory disease (PID) is difficult to define and diagnose; therefore, a standardized methodology for identifying and monitoring PID diagnoses is required. We estimated the rate of PID in general practice in England, and investigated variations by definition of PID, time, age, and geographical area. Methods: We analyzed the United Kingdom General Practice Research Database between 2000 and 2008. Definitions of “definite,” “probable,” and “possible” PID among female patients (aged 16 to 44 years) were determined according to medical codes that denoted diagnoses or symptoms indicative of PID. Diagnoses rates were calculated per 100,000 person-years (py). Trends were assessed using Poisson regression. Results: The rate of clinical PID diagnoses was 281/100,000 py (95% confidence interval [95% CI]: 277–286) for definite cases; 326/100,000 py (95% CI: 321–331) for definite and probable cases; and 1117/100,000 py (95% CI: 1107–1126) for definite, probable, and possible cases. During 2000 to 2008, the rate of definite/probable PID decreased by 10.4% per year (95% CI: 9.7–11.1; P < 0.001). Rates declined in all areas and among all age groups with greatest decline in women aged 16 to 19 years. Meanwhile, the rate of possible PID increased. Conclusions: The definition of PID used has a major effect on the rate and trends over time. There was heterogeneity in rates of definite/probable PID by age and region, but homogeneity with regard to a trend of declining rates. Ongoing monitoring of PID diagnoses, with standard case definitions, will contribute to the evaluation of chlamydia screening in England.

Epidemiology and treatment outcome of childhood tuberculosis in England and Wales: 1999–2006

Objective: To describe the recent trends in demographic, clinical and microbiological characteristics and outcome of treatment in paediatric cases of tuberculosis. Design: National surveillance study. Setting: England and Wales. Patients: All children under the age of 16 years reported with tuberculosis to the national enhanced surveillance system between 1999 and 2006 were included. Main outcome measures: Proportions, and rates of disease, by demographic characteristics, site of disease, diagnostic delay, culture confirmation, species, drug susceptibility and treatment outcome. Results: 3563 cases of tuberculosis in children were reported between 1999 and 2006. The incidence rate remained stable at around 4.3 per 100 000 (95% CI 4.1 to 4.4). Patients born outside the UK had a tuberculosis rate higher than children born in the UK (37 per 100 000 vs 2.5 per 100 000) and this rate increased over the period. Rates in the black African ethnic group were highest at 88 per 100 000. 60% of children had pulmonary disease, the commonest presentation, but only 948 (27%) had culture confirmed tuberculosis. The median time to diagnosis from onset of symptoms was 37 days (interquartile range 12–89). The proportions of cases with rifampicin, isoniazid and multi-drug resistant isolates were 2.4%, 9.3% and 2.3%, respectively. 88% of children completed treatment and less than 1% died. Conclusions: Overall rates of tuberculosis in children have remained stable, with the majority completing treatment. Rates are, however, highest in children not born in the UK, particularly among certain ethnic minority groups. Levels of drug resistance are also high.

Impact of Opioid Substitution Therapy on Antiretroviral Therapy Outcomes: a Systematic Review and Meta-Analysis

This meta-analysis provides strong evidence that opioid substitution therapy improves several key outcomes of the HIV care continuum among people who inject drugs, including recruitment onto antiretroviral therapy, retention in care, adherence, and viral suppression.

Who is being tested by the English National Chlamydia Screening Programme? A comparison with national probability survey data.

Objectives We compare data collected by Englands National Chlamydia Screening Programme (NCSP) with national probability survey data to examine demographic and behavioural differences that may be important in understanding who the NCSP is reaching and interpreting chlamydia positivity. Methods Data for 538 119 men and women aged 16–24 years who were screened in 2008 and data collected from 2180 interviewees in Britains second National Survey of Sexual Attitudes and Lifestyles 1999–2001 (Natsal-2), of whom 644 were tested for chlamydia, were compared using the χ2 statistic and logistic regression. Results Compared with Natsal-2, the NCSP tested more women (67% vs 49%). NCSP participants were more likely to be younger: 29% were 16–17 years versus 16% of men and 15% of women in Natsal-2; from ethnic minority groups: 17% of men and 14% of women versus 8% and 6%, respectively, in Natsal-2; not to have used condoms at last sex: 66% of men and 68% of women versus 48% and 63%, respectively, in Natsal-2: and more likely to report two or more partners in the last year: 62% of men and 47% of women versus 47% and 30%, respectively, in Natsal-2. In multivariate analyses, higher AOR of chlamydia positivity were found for those reporting non-use of condoms and for those reporting multiple partners in both the NCSP and Natsal-2. Conclusions The NCSP is testing young people at increased risk of chlamydia. The impact of this testing bias on the effectiveness of the programme should be evaluated.

Incidence, patterns, and predictors of repeat pregnancies among HIV-infected women in the United Kingdom and Ireland, 1990-2009.

Objective: To explore the pattern of repeat pregnancies among diagnosed HIV-infected women in the United Kingdom and Ireland, estimate the rate of these sequential pregnancies, and investigate the demographic and clinical characteristics of women experiencing them. Design: Diagnosed HIV-infected pregnant women are reported through an active confidential reporting scheme to the National Study of HIV in Pregnancy and Childhood. Methods: Pregnancies occurring during 1990–2009 were included. Multivariable analyses were conducted fitting Cox proportional hazards models. Results: There were 14,096 pregnancies in 10,568 women; 2737 (25.9%) had 2 or more pregnancies reported. The rate of repeat pregnancies was 6.7 (95% confidence interval: 6.5 to 7.0) per 100 woman-years. The proportion of pregnancies in women who already had at least 1 pregnancy reported increased from 20.3% (32 of 158) in 1997 to 38.6% (565 of 1465) in 2009 (P < 0.001). In multivariable analysis, the probability of repeat pregnancy significantly declined with increasing age at first pregnancy. Parity was also inversely associated with repeat pregnancy. Compared with women born in the United Kingdom or Ireland, those from Europe, Eastern Africa, and Southern Africa were less likely to have a repeat pregnancy, whereas women from Middle Africa and Western Africa were more likely to. Maternal health at first pregnancy was not associated with repeat pregnancy. Conclusions: The number of diagnosed HIV-infected women in the United Kingdom and Ireland experiencing repeat pregnancies is increasing. Variations in the probability of repeat pregnancies, according to demographic and clinical characteristics, are an important consideration when planning reproductive health services and HIV care for people living with HIV.

Risk of nosocomial respiratory syncytial virus infection and effectiveness of control measures to prevent transmission events: a systematic review

Respiratory syncytial virus (RSV) causes a significant public health burden, and outbreaks among vulnerable patients in hospital settings are of particular concern. We reviewed published and unpublished literature from hospital settings to assess: (i) nosocomial RSV transmission risk (attack rate) during outbreaks, (ii) effectiveness of infection control measures. We searched the following databases: MEDLINE, EMBASE, CINAHL, Cochrane Library, together with key websites, journals and grey literature, to end of 2012. Risk of bias was assessed using the Cochrane risk of bias tool or Newcastle–Ottawa scale. A narrative synthesis was conducted. Forty studies were included (19 addressing research question one, 21 addressing question two). RSV transmission risk varied by hospital setting; 6–56% (median: 28·5%) in neonatal/paediatric settings (n = 14), 6–12% (median: 7%) in adult haematology and transplant units (n = 3), and 30–32% in other adult settings (n = 2). For question two, most studies (n = 13) employed multi‐component interventions (e.g. cohort nursing, personal protective equipment (PPE), isolation), and these were largely reported to be effective in reducing nosocomial transmission. Four studies examined staff PPE; eye protection appeared more effective than gowns and masks. One study reported on RSV prophylaxis for patients (RSV‐Ig/palivizumab); there was no statistical evidence of effectiveness although the sample size was small. Overall, risk of bias for included studies tended to be high. We conclude that RSV transmission risk varies widely during hospital outbreaks. Although multi‐component control strategies appear broadly successful, further research is required to disaggregate the effectiveness of individual components including the potential role of palivizumab prophylaxis.

Effectiveness of needle/syringe programmes and opiate substitution therapy in preventing HCV transmission among people who inject drugs

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the impact of needle/syringe programmes with and without opiate substitution therapy (OST) on the incidence of HCV infection among people who inject drugs (PWID).To assess the effect of OST alone on the incidence of HCV infection among PWID. RESEARCH QUESTIONS How effective are needle/syringe programmes (NSP) with and without the use of OST for reducing HCV incidence among PWID?How effective is OST alone for reducing HCV incidence among PWID?How does the effect of NSP and OST vary according to duration of treatment (i.e. for NSPs weekly attendance versus monthly)?How does the effect of NSP vary according to the type of service (fixed site versus mobile; high coverage versus low coverage)?How does the effect of OST vary according to the dosage of OST, type of substitution used and adherence to treatment?

Needle syringe programmes and opioid substitution therapy for preventing HCV transmission among people who inject drugs: findings from a Cochrane Review and meta-analysis.

Abstract Aims To estimate the effects of needle and syringe programmes (NSP) and opioid substitution therapy (OST), alone or in combination, for preventing acquisition of hepatitis C virus (HCV) in people who inject drugs (PWID). Methods Systematic review and meta‐analysis. Bibliographic databases were searched for studies measuring concurrent exposure to current OST (within the last 6 months) and/or NSP and HCV incidence among PWID. High NSP coverage was defined as regular NSP attendance or ≥ 100% coverage (receiving sufficient or greater number of needles and syringes per reported injecting frequency). Studies were assessed using the Cochrane risk of bias in non‐randomized studies tool. Random‐effects models were used in meta‐analysis. Results We identified 28 studies (n = 6279) in North America (13), United Kingdom (five), Europe (four), Australia (five) and China (one). Studies were at moderate (two), serious (17) critical (seven) and non‐assessable risk of bias (two). Current OST is associated with 50% [risk ratio (RR) =0.50, 95% confidence interval (CI) = 0.40–0.63] reduction in HCV acquisition risk, consistent across region and with low heterogeneity (I 2 = 0, P = 0.889). Weaker evidence was found for high NSP coverage (RR = 0.79, 95% CI = 0.39–1.61) with high heterogeneity (I 2 = 77%, P = 0.002). After stratifying by region, high NSP coverage in Europe was associated with a 56% reduction in HCV acquisition risk (RR = 0.44, 95% CI = 0.24–0.80) with low heterogeneity (I 2 = 12.3%, P = 0.337), but not in North America (RR = 1.58, I 2 = 89.5%, P = < 0.001). Combined OST/NSP is associated with a 74% reduction in HCV acquisition risk (RR = 0.26, 95% CI = 0.07–0.89, I 2 = 80% P = 0.007). According to Grades of Recommendation Assessment, Development and Evaluation (GRADE) criteria, the evidence on OST and combined OST/NSP is low quality, while NSP is very low. Conclusions Opioid substitution therapy reduces risk of hepatitis C acquisition and is strengthened in combination with needle and syringe programmes (NSP). There is weaker evidence for the impact of needle syringe programmes alone, although stronger evidence that high coverage is associated with reduced risk in Europe.

Control of carbapenemase-producing Enterobacteriaceae outbreaks in acute settings: an evidence review

BACKGROUND In recent years, infections with carbapenemase-producing Enterobacteriaceae (CPE) have been increasing globally and present a major public health challenge. AIM To review the international literature: (i) to describe CPE outbreaks in acute hospital settings globally; and (ii) to identify the control measures used during these outbreaks and report on their effectiveness. METHODS A systematic search of MEDLINE and EMBASE databases, abstract lists for key conferences and reference lists of key reviews was undertaken, and information on unpublished outbreaks was sought for 2000-2015. Where relevant, risk of bias was assessed using the Newcastle-Ottawa scale. A narrative synthesis of the evidence was conducted. FINDINGS Ninety-eight outbreaks were eligible. These occurred worldwide, with 53 reports from Europe. The number of cases (CPE infection or colonization) involved in outbreaks varied widely, from two to 803. In the vast majority of outbreaks, multi-component infection control measures were used, commonly including: patient screening; contact precautions (e.g. gowns, gloves); handwashing interventions; staff education or monitoring; enhanced environmental cleaning/decontamination; cohorting of patients and/or staff; and patient isolation. Seven studies were identified as providing the best-available evidence on the effectiveness of control measures. These demonstrated that CPE outbreaks can be controlled successfully using a range of appropriate, commonly used, infection control measures. However, risk of bias was considered relatively high for these studies. CONCLUSION The findings indicate that CPE outbreaks can be controlled using combinations of existing measures. However, the quality of the evidence base is weak and further high-quality research is needed, particularly on the effectiveness of individual infection control measures.

Immunologic status and virologic outcomes in repeat pregnancies to HIV-positive women not on antiretroviral therapy at conception: a case for lifelong antiretroviral therapy?

During their second pregnancy with diagnosed HIV (n = 1177), two-fifths of women in the UK/Ireland not on antiretroviral therapy (ART) at conception had an immunological indication for treatment (CD4+ <350 cells/&mgr;l), of whom nearly half had CD4+ at least 350 cells/&mgr;l in their previous pregnancy. Those initiating ART during pregnancy had a 4.3-fold increased odds of detectable viral load at delivery compared with those conceiving on treatment, suggesting that continuation of ART after pregnancy may be beneficial for many women.