Katy Turner

Can needle and syringe programmes and opiate substitution therapy achieve substantial reductions in hepatitis C virus prevalence? Model projections for different epidemic settings

AIMS To investigate the impact of scaling-up opiate substitution therapy (OST) and high coverage needle and syringe programmes (100%NSP-obtaining more sterile syringes than you inject) on HCV prevalence among injecting drug users (IDUs). DESIGN Hepatitis C virus HCV transmission modelling using U.K. estimates for effect of OST and 100%NSP on individual risk of HCV infection. SETTING Range of chronic HCV prevalent (20/40/60%) settings with no OST/100%NSP, and U.K. setting with 50% coverage of both OST and 100%NSP. PARTICIPANTS Injecting drug users. MEASUREMENTS Decrease in HCV prevalence after 5-20 years due to scale-up of OST and 100%NSP to 20/40/60% coverage in no OST/100%NSP settings, or from 50% to 60/70/80% coverage in the U.K. setting. FINDINGS For 40% chronic HCV prevalence, scaling-up OST and 100%NSP from 0% to 20% coverage reduces HCV prevalence by 13% after 10 years. This increases to a 24/33% relative reduction at 40/60% coverage. Marginally less impact occurs in higher prevalence settings over 10 years, but this becomes more pronounced over time. In the United Kingdom, without current coverage levels of OST and 100%NSP the chronic HCV prevalence could be 65% instead of 40%. However, increasing OST and 100%NSP coverage further is unlikely to reduce chronic prevalence to less than 30% over 10 years unless coverage becomes ≥80%. CONCLUSIONS Scaling-up opiate substitution therapy and high coverage needle and syringe programmes can reduce hepatitis C prevalence among injecting drug users, but reductions can be modest and require long-term sustained intervention coverage. In high coverage settings, other interventions are needed to further decrease hepatitis C prevalence. In low coverage settings, sustained scale-up of both interventions is needed.

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.

Multiple Streptococcus pneumoniae Serotypes in Aural Discharge Samples from Children with Acute Otitis Media with Spontaneous Otorrhea

ABSTRACT Among 55 children with cultures positive for acute otitis media with spontaneous otorrhea, 28 (51%) had cultures positive for aural Streptococcus pneumoniae, and in 10 of these, two distinct strains were detected, in which 5 had pairs of strains that were both capsule-bearing serotypes. Such cases were more likely to have cultures positive for other otopathogens than those with only one pneumococcus present.

Cross-sectional study to evaluate Trichomonas vaginalis positivity in women tested for Neisseria gonorrhoeae and Chlamydia trachomatis, attending genitourinary medicine and primary care clinics in Bristol, South West England

Background Highly sensitive, commercial nucleic acid amplification tests (NAAT) for Trichomonas vaginalis have only recently been recommended for use in the UK. While testing for T. vaginalis is routine in symptomatic women attending genitourinary medicine (GUM) clinics, it is rare in asymptomatic women or those attending primary care. The aim of this study was to evaluate the positivity of T. vaginalis using a commercial NAAT, in symptomatic and asymptomatic women undergoing testing for chlamydia and gonorrhoea in GUM and primary care settings. Methods Samples from 9186 women undergoing chlamydia and gonorrhoea testing in South West England between May 2013 and Jan 2015 were also tested for T. vaginalis by NAAT alongside existing tests. Results T. vaginalis positivity using NAAT was as follows: in GUM 4.5% (24/530, symptomatic) and 1.7% (27/1584, asymptomatic); in primary care 2.7% (94/3499, symptomatic) and 1.2% (41/3573, asymptomatic). Multivariable regression found that in GUM older age, black ethnicity and deprivation were independent risk factors for T. vaginalis infection. Older age and deprivation were also risk factors in primary care. Testing women presenting with symptoms in GUM and primary care using TV NAATs is estimated to cost £260 per positive case diagnosed compared with £716 using current microbiological tests. Conclusions Aptima TV outperforms existing testing methods used to identify T. vaginalis infection in this population. An NAAT should be used when testing for T. vaginalis in women who present for testing with symptoms in primary care and GUM, based on test performance and cost.

Pelvic inflammatory disease risk following negative results from chlamydia nucleic acid amplification tests (NAATs) versus non-NAATs in Denmark: A retrospective cohort

Background Nucleic Acid Amplification Tests (NAATs) are the recommended test type for diagnosing Chlamydia trachomatis (chlamydia). However, less sensitive diagnostic methods—including direct immunofluorescence (IF) and enzyme-linked immunoassay (ELISA)—remain in use in lower resourced settings. We estimate the risk of pelvic inflammatory disease (PID) following undiagnosed infection in women tested with non-NAATs and estimate the health gain from using accurate diagnostic tests. Methods and findings We used Denmark’s national Chlamydia Study dataset to extract all chlamydia tests performed in women aged 15–34 years (1998–2001). Tests were categorised as non-NAAT (IF/ELISA) or NAAT and limited to each woman’s first test in the study period. We linked test data to hospital presentations for PID within 12 months from the Danish National Patient Register. The study included 272,105 women with a chlamydia test, just under half (44.78%, n = 121,857) were tested using NAATs. Overall, 6.38% (n = 17,353) tested positive for chlamydia and 0.64% (n = 1,732) were diagnosed with PID within 12 months. The risk of PID following a positive chlamydia test did not differ by test type (NAAT 0.81% [95% CI 0.61–1.00], non-NAAT 0.78% [0.59–0.96]). The risk of PID following a negative test was significantly lower in women tested with NAATs compared to non-NAATs (0.55% [0.51–0.59] compared to 0.69% [0.64–0.73]; adjusted odds ratio (AOR) 0.83 [0.75–0.93]). We estimate that 18% of chlamydia infections in women tested with a non-NAAT were undiagnosed and that the risk of progression from undiagnosed chlamydia infection to PID within 12 months was 9.52% (9.30–9.68). Using non-NAATs could lead to an excess 120 cases of PID per 100,000 women tested compared to using NAATs. The key limitations of this study are under ascertainment of PID cases, misclassification bias in chlamydia and PID exposure status, bias to the association between clinical presentation and test type and the presence of unmeasured confounders (including other sexually transmitted infection [STI] diagnoses and clinical indication for chlamydia test). Conclusion This retrospective observational study estimates the positive impact on women’s reproductive health from using accurate chlamydia diagnostic tests and provides further evidence for restricting the use of inferior tests. Women with a negative chlamydia test have a 17% higher adjusted risk of PID by 12 months if they are tested using a non-NAAT compared to a NAAT.

Web-Based Activity Within a Sexual Health Economy: Observational Study

Background Regular testing for sexually transmitted infections (STIs) is important to maintain sexual health. Self-sampling kits ordered online and delivered in the post may increase access, convenience, and cost-effectiveness. Sexual health economies may target limited resources more effectively by signposting users toward Web-based or face-to-face services according to clinical need. Objective The aim of this paper was to investigate the impact of two interventions on testing activity across a whole sexual health economy: (1) the introduction of open access Web-based STI testing services and (2) a clinic policy of triage and signpost online where users without symptoms who attended clinics for STI testing were supported to access the Web-based service instead. Methods Data on attendances at all specialist public sexual health providers in an inner-London area were collated into a single database. Each record included information on user demographics, service type accessed, and clinical activity provided, including test results. Clinical activity was categorized as a simple STI test (could be done in a clinic or online), a complex visit (requiring face-to-face consultation), or other. Results Introduction of Web-based services increased total testing activity across the whole sexual health economy by 18.47% (from 36,373 to 43,091 in the same 6-month period—2014-2015 and 2015-2016), suggesting unmet need for testing in the area. Triage and signposting shifted activity out of the clinic onto the Web-based service, with simple STI testing in the clinic decreasing from 16.90% (920/5443) to 12.25% (511/4172) of total activity, P<.001, and complex activity in the clinic increasing from 69.15% (3764/5443) to 74.86% (3123/4172) of total activity, P<.001. This intervention created a new population of online users with different demographic and clinical profiles from those who use Web-based services spontaneously. Some triage and signposted users (29.62%, 375/1266) did not complete the Web-based testing process, suggesting the potential for missed diagnoses. Conclusions This evaluation shows that users can effectively be transitioned from face-to-face to Web-based services and that this introduces a new population to Web-based service use and changes the focus of clinic-based activity. Further development is underway to optimize the triage and signposting process to support test completion.

Comparing the characteristics of users of an online service for STI self-sampling with clinic service users: a cross-sectional analysis

Objectives Online services for self-sampling at home could improve access to STI testing; however, little is known about those using this new modality of care. This study describes the characteristics of users of online services and compares them with users of clinic services. Methods We conducted a cross-sectional analysis of routinely collected data on STI testing activity from online and clinic sexual health services in Lambeth and Southwark between 1January 2016 and 31March 2016. Activity was included for chlamydia, gonorrhoea, HIV and syphilis testing for residents of the boroughs aged 16 years and older. Logistic regression models were used to explore potential associations between type of service use with age group, gender, ethnic group, sexual orientation, positivity and Index of Multiple Deprivation (IMD) quintiles. We used the same methods to explore potential associations between return of complete samples for testing with age group, gender, ethnic group, sexual orientation and IMD quintiles among online users. Results 6456 STI tests were carried out by residents in the boroughs. Of these, 3582 (55.5%) were performed using clinic services and 2874 (44.5%) using the online service. In multivariate analysis, online users were more likely than clinic users to be aged between 20 and 30 years, female, white British, homosexual or bisexual, test negative for chlamydia or gonorrhoea and live in less deprived areas. Of the individuals that ordered a kit from the online service, 72.5% returned sufficient samples. In multivariate analysis, returners were more likely than non-returners to be aged >20 years and white British. Conclusion Nearly half (44.5%) of all basic STI testing was done online, although the characteristics of users of clinic and online services differed and positivity rates for those using the online service for testing were lower. Clinics remain an important point of access for some groups.

Getting to the bottom of toxocariasis prevention.

In last months issue of the Public Health, Black et al. present evidence for a deepening disparity in childhood obesity between the most and least deprived children in the United Kingdom and called for research into why this might be. While the reasons are no doubt complex and multifactorial, available spaces for outdoor play in more deprived areas, and their attractiveness or otherwise, might be an important factor. Specifically, areas heavily contaminated with dog faeces can dissuade people, including children and other vulnerable individuals, from taking outdoor exercise.

Spatial Patterns of Primate Electrocutions in Diani, Kenya

Electrocution from power infrastructure threatens many primate species, yet knowledge of effective evidence-based mitigation strategies is limited. Mitigation planning requires an understanding of the spatial distribution of electrocutions to prioritize high-risk areas. In Diani, a coastal Kenyan town, electrocution is an important cause of death for five primate species. In this study we aim to describe the spatial patterns of electrocutions and electric shock incidents (collectively referred to as electrocutions hereafter) and identify electrocution hotspots to guide an effective primate conservation approach in Diani. Colobus Conservation, a not-for-profit organization, has recorded electrocutions and annual primate census data since 1998. We georeferenced 329 electrocution data points and analyzed them using QGIS. We identified and compared hotspots across species, seasons, and time using kernel density estimation and Getis-Ord-Gi*. We employed spatial regression models to test whether primate population density and power line density predicted the location of electrocution hotspots. Electrocutions occurred in hotspots that showed little variation in location between species and seasons. The limited variation in hotspot location over time likely occurred as a result of new building development in Diani and variability in primate detection rates by community members. Primate density and power line density were significant predictors of electrocution density for Angolan black-and-white colobus (Colobus angolensis palliatus) and Sykes monkeys (Cercopithecus mitis albogularis), but the relationship was weak, suggesting the presence of additional risk factors. This study provides a framework for systematic spatial prioritization of power lines that can be used to reduce primate electrocutions in Diani, and can be adopted in other areas of the world where primates are at risk from electrocution.

P3.25 Quantification of the risk of pelvic inflammatory disease following a chlamydia trachomatis test by diagnostic test type

Introduction Nucleic Acid Amplification Tests (NAATs) are the recommended test type for diagnosing Chlamydia trachomatis (chlamydia). However poorer performing methods remain in use. We compared the risk of pelvic inflammatory disease (PID) in women tested for chlamydia by diagnostic test type. Methods We used a sub-set of the Danish Chlamydia study that included all female residents of Denmark who were tested for chlamydia (1998–2001) when aged 15–34 years. Chlamydia tests performed on urinary or genital samples with a definitive positive or negative result were categorised as non-NAAT (ELISA; IF; “antigen”) or NAAT (PCR; SDA; TMA; LCR; DNA/RNA) and limited to each woman’s first test. Test records were linked to hospital presentations for PID within 12 months. Women with previous PID or PID diagnosed on the same date as the test were excluded. We used logistic regression to compare the risk of PID by test type adjusted for age, test year and test result. Results Of the 2 72 105 women in the study, 44.78% were tested using NAAT, 6.38% tested positive for chlamydia and 0.64% were diagnosed with PID within 12 months. Overall, the adjusted risk of PID within 12 months of a chlamydia test was higher following a positive test (AOR 1.40 (95%CI 1.18–1.67) and in older women (25–34 years 1.36 (1.23–1.49)) and lower in women tested using a NAAT (0.87 (0.78–0.96)) and in the more recent time interval (2000/2001 0.89 (0.80–0.99)). In women with a positive test, and presumably treated infection, the risk of PID did not differ by test type (1.25 (0.87–1.79)). In women with a negative test, the risk of PID was lower following a NAAT (0.84 (0.75–0.93)). Conclusion Women with a negative result from a non-NAAT chlamydia test have a 16% higher risk of PID by 12 months compared to women with a negative result from a NAAT. This is presumably due to the increased proportion of false negative tests with the less sensitive non-NAATs. This study quantifies the health impact of using poorer performing chlamydia diagnostic tests and provides further evidence for phasing them out.