Julie Dodds

Longitudinal study of infectious intestinal disease in the UK (IID2 study): incidence in the community and presenting to general practice

Objectives To estimate, overall and by organism, the incidence of infectious intestinal disease (IID) in the community, presenting to general practice (GP) and reported to national surveillance. Design Prospective, community cohort study and prospective study of GP presentation conducted between April 2008 and August 2009. Setting Eighty-eight GPs across the UK recruited from the Medical Research Council General Practice Research Framework and the Primary Care Research Networks. Participants 6836 participants registered with the 88 participating practices in the community study; 991 patients with UK-acquired IID presenting to one of 37 practices taking part in the GP presentation study. Main outcome measures IID rates in the community, presenting to GP and reported to national surveillance, overall and by organism; annual IID cases and GP consultations by organism. Results The overall rate of IID in the community was 274 cases per 1000 person-years (95% CI 254 to 296); the rate of GP consultations was 17.7 per 1000 person-years (95% CI 14.4 to 21.8). There were 147 community cases and 10 GP consultations for every case reported to national surveillance. Norovirus was the most common organism, with incidence rates of 47 community cases per 1000 person-years and 2.1 GP consultations per 1000 person-years. Campylobacter was the most common bacterial pathogen, with a rate of 9.3 cases per 1000 person-years in the community, and 1.3 GP consultations per 1000 person-years. We estimate that there are up to 17 million sporadic, community cases of IID and 1 million GP consultations annually in the UK. Of these, norovirus accounts for 3 million cases and 130 000 GP consultations, and Campylobacter is responsible for 500 000 cases and 80 000 GP consultations. Conclusions IID poses a substantial community and healthcare burden in the UK. Control efforts must focus particularly on reducing the burden due to Campylobacter and enteric viruses.

Increase in high risk sexual behaviour among homosexual men, London 1996-8: cross sectional, questionnaire study

Editorial by Grulich The incidence of HIV infection among homosexual men in the United Kingdom is increasing despite efforts to reduce high risk sexual behaviour.1 The likelihood of engaging in high risk sexual behaviour may be increasing as new treatments reduce concern about infection.2 We report the results of a repeated survey of sexual behaviour among gay men in London. A survey was conducted in 1996, 1997, and 1998 using the same methodology each year.3 A sampling frame was compiled of all commercial gay venues (bars, clubs, and saunas) and genitourinary medicine clinics within inner London. A sample of venue types and locations was then selected. Between 59 and 72 venues were sampled each year. Whenever possible the same venues were selected each year; if venues had closed they were replaced in the sample by similar ones. Health promotion workers distributed questionnaires with 16 items that covered demographic information and sexual behaviour. All …

Increasing risk behaviour and high levels of undiagnosed HIV infection in a community sample of homosexual men

Objectives: To estimate changes in sexual behaviour over time. To examine the proportion of undiagnosed HIV infection in a community sample of homosexual men. To explore the relation between HIV status, diagnosis, and sexual behaviour. Methods: Five cross sectional surveys of men attending selected gay community venues in London between 1996 and 2000 (n = 8052). Men were recruited in 45 to 58 social venues (including bars, clubs, and saunas) across London. Participants self completed an anonymous behavioural questionnaire. In 2000, participants in community venues provided anonymous saliva samples for testing for anti-HIV antibody. Results: The proportion of men having unprotected anal intercourse (UAI) increased significantly each year from 30% in 1996 to 42% in 2000 (p<<0.001). In 2000, 132 of 1206 (10.9%) saliva samples were HIV antibody positive. Of the HIV saliva antibody positive samples, 43/132 (32.5%) were undiagnosed. Around half of both diagnosed and undiagnosed HIV saliva positive men reported UAI in the past year. Of the 83% of men who reported their current perceived HIV status, 4.1% reported an incorrect status. HIV antibody positivity was associated with increasing numbers of UAI partners, and having a sexually transmitted infection (STI) in the past year (OR 2.15). Conclusions: Homosexual men continue to report increasing levels of UAI. HIV prevalence is high in this group, with many infections remaining undiagnosed. The high level of risky behaviour in HIV positive men, regardless of whether they are diagnosed, is of public health concern, in an era when HIV prevalence, antiretroviral resistance, and STI incidence are increasing.

Changes in Causes of Acute Gastroenteritis in the United Kingdom Over 15 Years: Microbiologic Findings From 2 Prospective, Population-Based Studies of Infectious Intestinal Disease

BACKGROUND Large-scale, prospective studies of infectious intestinal disease (IID) in developed countries are uncommon. Two studies of IID incidence and etiology have been conducted in the United Kingdom: the Infectious Intestinal Disease Study in England (IID1) in 1993-1996 and the Second Study of Infectious Intestinal Disease in the Community (IID2) in 2008-2009. We examined changes in etiology and diagnostic yield of IID cases over 15 years. METHODS Fecal samples submitted by IID cases were examined for a range of bacterial, viral, and protozoal pathogens using traditional and molecular microbiological methods. We calculated the percentage of specimens positive for each organism based on traditional methods and on traditional and molecular methods combined. We compared the distributions of organisms in the 2 studies. RESULTS For pathogens investigated in both studies, 40% of fecal samples submitted by cases in IID2 were positive compared with 28% in IID1. Viruses were most frequent among community cases in IID2. Campylobacter was the most common bacterial pathogen among cases presenting to healthcare. Major differences between the 2 studies were increases in the detection of norovirus and sapovirus and a decline Salmonella. CONCLUSIONS Most fecal specimens were negative for the pathogens tested in both studies, so new strategies are needed to close the diagnostic gap. Among known pathogens, effective control of norovirus, rotavirus, and Campylobacter remain high priorities. The reduction in nontyphoidal salmonellosis demonstrates the success of Europe-wide control strategies, notably an industry-led Salmonella control program in poultry in the United Kingdom.

Sexual risk behaviour and knowledge of HIV status among community samples of gay men in the UK

Objectives:Undiagnosed infection presents a potential risk for the onward transmission of HIV and denies men early interventions for their health. Little is known about the differences between men who are, and are not, aware of their HIV status in the UK. Methods:Cross-sectional surveys of men in commercial gay venues in London, Brighton, Manchester, Glasgow, and Edinburgh (2003–2005). Anonymous, self-completion questionnaires, and oral fluid samples (tested for HIV antibodies) were obtained from 3672 men (61% response rate). Results:Of 3501 men with a confirmed positive or negative oral fluid result, 318 were HIV positive (9.1%). Of these, 131 (41.2%) were undiagnosed; 81.1% of men with undiagnosed HIV had previously tested (92.2% tested negative; the remainder did not know the result); 62.3% still thought that they were negative. Undiagnosed and diagnosed men reported greater sexual risk and sexually transmitted infections than HIV-negative men. Compared with HIV-negative men, the adjusted odds ratio of unprotected anal intercourse with two or more partners was higher among undiagnosed men (odds ratio 2.21, 95% confidence interval 1.17–4.20), but highest among diagnosed men (odds ratio 6.80, 95% confidence interval 4.39–10.52). Conclusion:A high proportion of the HIV-positive men were undiagnosed and not receiving benefits of clinical care, but sexual risk and sexually transmitted infections were highest among men who were aware of their HIV-positive status. Clinics should proactively offer testing to reduce undiagnosed HIV, target repeat testing at high-risk men who have previously tested negative, and initiate evidence-based behavioural interventions to reduce sexual risk among men living with diagnosed HIV as well as those testing negative.

Behavioural predictors of subsequent hepatitis C diagnosis in a UK clinic sample of HIV positive men who have sex with men

Objective: To explore the associations between self reported high risk sexual behaviours and subsequent diagnosis with hepatitis C virus (HCV) infection. Methods: The Sex, Health and Anti-Retrovirals Project (SHARP) was a cross sectional study of sexual behaviour in HIV positive, men who have sex with men (MSM) attending a London outpatient clinic. From July 1999 to August 2000 participants completed a computer assisted self interview questionnaire (CASI) on recent sexual behaviour, recreational drug use, and detailed reporting of the last two sexual episodes involving different partners. Results were combined with routine clinic data and subsequent testing for HCV up to 21 April 2005. A new HCV diagnosis was defined as anti-HCV antibody seroconversion or positive HCV RNA following a previous negative. Incident rate ratios (IRR) were calculated using Poisson regression in Stata (version 9). Men contributed time at risk from interview until either their diagnosis or their last negative test result. Results: Of the 422 men who completed questionnaires, 308 (73%) had sufficient clinical and HCV testing data available for analysis. Incident HCV infection was identified in 11 men. Unprotected anal intercourse, more than 30 sex partners in the past year, higher numbers of new anal sex partners, rimming (oro-anal sex), fisting, use of sex toys, and intranasal recreational drug use were associated with HCV. In multivariate analysis only fisting remained associated with HCV (adjusted IRR 6.27, p = 0.005). Conclusions: In this study of HIV positive MSM, fisting is strongly associated with HCV infection. Where individuals report high risk sexual behaviours, clinicians should offer appropriate testing for HCV infection.

A tale of three cities: persisting high HIV prevalence, risk behaviour and undiagnosed infection in community samples of men who have sex with men.

Objectives: To examine the geographical variations in HIV prevalence (diagnosed and undiagnosed), use of sexual health services, sexually transmitted infections and sexual behaviour in a community sample of men who have sex with men in three cities in England, specifically London, Brighton and Manchester. Methods: Cross-sectional surveys of men visiting gay community venues in three large cities in England. Men self-completed a questionnaire and provided an anonymous oral fluid sample for HIV antibody testing. Results: HIV prevalence ranged from 8.6% to 13.7% in the three cities. Over one-third of HIV infection remained undiagnosed in all sites despite 69% of HIV-positive men reporting attending a genitourinary medicine clinic in the last year. Similar and high levels of risk behaviour were reported in all three cities. 18% of HIV-negative men and 37% of HIV-positive men reported unprotected anal intercourse with more than one partner in the last year. 20% of negative men and 41% of positive men reported an STI in the last year. Conclusions: Across all cities, despite widespread availability of anti-retroviral treatment and national policy to promote HIV testing, many HIV infections remain undiagnosed. Data from this community sample demonstrate high levels of risk behaviour and STI incidence, especially among those who are HIV positive. Renewed efforts are needed to increase diagnosis and to reduce risk behaviour to stem the continuing transmission of HIV.

Accuracy of urinary human papillomavirus testing for presence of cervical HPV: systematic review and meta-analysis

Objective To determine the accuracy of testing for human papillomavirus (HPV) DNA in urine in detecting cervical HPV in sexually active women. Design Systematic review and meta-analysis. Data sources Searches of electronic databases from inception until December 2013, checks of reference lists, manual searches of recent issues of relevant journals, and contact with experts. Eligibility criteria Test accuracy studies in sexually active women that compared detection of urine HPV DNA with detection of cervical HPV DNA. Data extraction and synthesis Data relating to patient characteristics, study context, risk of bias, and test accuracy. 2×2 tables were constructed and synthesised by bivariate mixed effects meta-analysis. Results 16 articles reporting on 14 studies (1443 women) were eligible for meta-analysis. Most used commercial polymerase chain reaction methods on first void urine samples. Urine detection of any HPV had a pooled sensitivity of 87% (95% confidence interval 78% to 92%) and specificity of 94% (95% confidence interval 82% to 98%). Urine detection of high risk HPV had a pooled sensitivity of 77% (68% to 84%) and specificity of 88% (58% to 97%). Urine detection of HPV 16 and 18 had a pooled sensitivity of 73% (56% to 86%) and specificity of 98% (91% to 100%). Metaregression revealed an increase in sensitivity when urine samples were collected as first void compared with random or midstream (P=0.004). Limitations The major limitations of this review are the lack of a strictly uniform method for the detection of HPV in urine and the variation in accuracy between individual studies. Conclusions Testing urine for HPV seems to have good accuracy for the detection of cervical HPV, and testing first void urine samples is more accurate than random or midstream sampling. When cervical HPV detection is considered difficult in particular subgroups, urine testing should be regarded as an acceptable alternative.

There is such a thing as asking for trouble: taking rapid HIV testing to gay venues is fraught with challenges.

Objectives: To explore the feasibility and acceptability of offering rapid HIV testing to men who have sex with men in gay social venues. Methods: Qualitative study with in-depth interviews and focus group discussions. Interview transcripts were analysed for recurrent themes. 24 respondents participated in the study. Six gay venue owners, four gay service users and one service provider took part in in-depth interviews. Focus groups were conducted with eight members of a rapid HIV testing clinic staff and five positive gay men. Results: Respondents had strong concerns about confidentiality and privacy, and many felt that HIV testing was “too serious” an event to be undertaken in social venues. Many also voiced concerns about issues relating to post-test support and behaviour, and clinical standards. Venue owners also discussed the potential negative impact of HIV testing on social venues. Conclusion: There are currently substantial barriers to offering rapid HIV tests to men who have sex with men in social venues. Further work to enhance acceptability must consider ways of increasing the confidentiality and professionalism of testing services, designing appropriate pre-discussion and post-discussion protocols, evaluating different models of service delivery, and considering their cost-effectiveness in relation to existing services.

Effects of antenatal diet and physical activity on maternal and fetal outcomes: Individual patient data meta-analysis and health economic evaluation

BACKGROUND Diet- and physical activity-based interventions in pregnancy have the potential to alter maternal and child outcomes. OBJECTIVES To assess whether or not the effects of diet and lifestyle interventions vary in subgroups of women, based on maternal body mass index (BMI), age, parity, Caucasian ethnicity and underlying medical condition(s), by undertaking an individual patient data (IPD) meta-analysis. We also evaluated the association of gestational weight gain (GWG) with adverse pregnancy outcomes and assessed the cost-effectiveness of the interventions. DATA SOURCES MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects and Health Technology Assessment database were searched from October 2013 to March 2015 (to update a previous search). REVIEW METHODS Researchers from the International Weight Management in Pregnancy Collaborative Network shared the primary data. For each intervention type and outcome, we performed a two-step IPD random-effects meta-analysis, for all women (except underweight) combined and for each subgroup of interest, to obtain summary estimates of effects and 95% confidence intervals (CIs), and synthesised the differences in effects between subgroups. In the first stage, we fitted a linear regression adjusted for baseline (for continuous outcomes) or a logistic regression model (for binary outcomes) in each study separately; estimates were combined across studies using random-effects meta-analysis models. We quantified the relationship between weight gain and complications, and undertook a decision-analytic model-based economic evaluation to assess the cost-effectiveness of the interventions. RESULTS Diet and lifestyle interventions reduced GWG by an average of 0.70 kg (95% CI -0.92 to -0.48 kg; 33 studies, 9320 women). The effects on composite maternal outcome [summary odds ratio (OR) 0.90, 95% CI 0.79 to 1.03; 24 studies, 8852 women] and composite fetal/neonatal outcome (summary OR 0.94, 95% CI 0.83 to 1.08; 18 studies, 7981 women) were not significant. The effect did not vary with baseline BMI, age, ethnicity, parity or underlying medical conditions for GWG, and composite maternal and fetal outcomes. Lifestyle interventions reduce Caesarean sections (OR 0.91, 95% CI 0.83 to 0.99), but not other individual maternal outcomes such as gestational diabetes mellitus (OR 0.89, 95% CI 0.72 to 1.10), pre-eclampsia or pregnancy-induced hypertension (OR 0.95, 95% CI 0.78 to 1.16) and preterm birth (OR 0.94, 95% CI 0.78 to 1.13). There was no significant effect on fetal outcomes. The interventions were not cost-effective. GWG, including adherence to the Institute of Medicine-recommended targets, was not associated with a reduction in complications. Predictors of GWG were maternal age (summary estimate -0.10 kg, 95% CI -0.14 to -0.06 kg) and multiparity (summary estimate -0.73 kg, 95% CI -1.24 to -0.23 kg). LIMITATIONS The findings were limited by the lack of standardisation in the components of intervention, residual heterogeneity in effects across studies for most analyses and the unavailability of IPD in some studies. CONCLUSION Diet and lifestyle interventions in pregnancy are clinically effective in reducing GWG irrespective of risk factors, with no effects on composite maternal and fetal outcomes. FUTURE WORK The differential effects of lifestyle interventions on individual pregnancy outcomes need evaluation. STUDY REGISTRATION This study is registered as PROSPERO CRD42013003804. FUNDING The National Institute for Health Research Health Technology Assessment programme.