Laurence Gruer

Outbreak of HIV infection in a Scottish prison

Abstract Objectives: To investigate the possible spread of HIV infection and its route of transmission among prison inmates. Design: In response to an outbreak of acute clinical hepatitis B and two seroconversions to HIV infection, counselling and testing for HIV were offered to all inmates over a two week period in July 1993. Information was sought about drug injecting, sexual behaviour, and previous HIV testing. Setting: HM Prison Glenochil in Scotland. Subjects: Adult male prisoners. Main outcome measures: Uptake of HIV counselling and testing; occurrence and mode of HIV transmission within the prison. Results: Of a total 378 inmates, 227 (60%) were counselled and 162 (43%) tested for HIV. Twelve (7%) of those tested were positive for antibody to HIV. One third (76) of those counselled had injected drugs at some time, of whom 33 (43%) had injected in Glenochil; all 12 seropositive men belonged to this latter group. Thirty two of these 33 had shared needles and syringes in the prison. A further two inmates who injected in the prison were diagnosed as positive for HIV two months previously. Evidence based on sequential results and time of entry into prison indicated that eight transmissions definitely occurred within prison in the first half of 1993. Conclusion: This is the first report of an outbreak of HIV infection occurring within a prison. Restricted access to injecting equipment resulted in random sharing and placed injectors at high risk of becoming infected with HIV. Measures to prevent further spread of infection among prison injectors are urgently required. Key messages Key messages In this outbreak, acute hepatitis B was the earliest indicator of the possible occurrence of HIV transmission All infected inmates had shared injecting equipment within the prison Random sharing of equipment may still occur in settings where access to sterile needles and syringes is restricted

Set points, settling points and some alternative models: Theoretical options to understand how genes and environments combine to regulate body adiposity

The close correspondence between energy intake and expenditure over prolonged time periods, coupled with an apparent protection of the level of body adiposity in the face of perturbations of energy balance, has led to the idea that body fatness is regulated via mechanisms that control intake and energy expenditure. Two models have dominated the discussion of how this regulation might take place. The set point model is rooted in physiology, genetics and molecular biology, and suggests that there is an active feedback mechanism linking adipose tissue (stored energy) to intake and expenditure via a set point, presumably encoded in the brain. This model is consistent with many of the biological aspects of energy balance, but struggles to explain the many significant environmental and social influences on obesity, food intake and physical activity. More importantly, the set point model does not effectively explain the ‘obesity epidemic’ – the large increase in body weight and adiposity of a large proportion of individuals in many countries since the 1980s. An alternative model, called the settling point model, is based on the idea that there is passive feedback between the size of the body stores and aspects of expenditure. This model accommodates many of the social and environmental characteristics of energy balance, but struggles to explain some of the biological and genetic aspects. The shortcomings of these two models reflect their failure to address the gene-by-environment interactions that dominate the regulation of body weight. We discuss two additional models – the general intake model and the dual intervention point model – that address this issue and might offer better ways to understand how body fatness is controlled.

Lethal outbreak of infection with Clostridium novyi type A and other spore-forming organisms in Scottish injecting drug users

This report describes the investigation and management of an unprecedented outbreak of severe illness among injecting drug users (IDUs) in Scotland during April to August 2000. IDUs with severe soft tissue inflammation were prospectively sought among acute hospitals and a mortuary in Scotland. Cases were categorised as definite or probable: probable cases had severe injection site inflammation or multi-system failure; definite cases had both. Information about clinical course, mortality, post-mortem findings and laboratory data was gathered by standardised case-note review and interview. Sixty cases were identified--23 definite and 37 probable. Most had familial or social links with each other and 50 were from Glasgow. Median age was 30 years; 31 were female. The majority, especially definite cases, injected heroin/citric acid extravascularly. Of definite cases, 20 died (87% case-fatality rate; 13 after intensive care), 15 had necrotising fasciitis, 22 had injection site oedema and 13 had pleural effusion. Median white cell count was 60 x 10(9)/L. Of 37 probable cases, three died (8% case-fatality rate). Overall, the most frequently isolated pathogen was Clostridium novyi type A (13 cases: 8 in definite cases). The findings are consistent with an infection resulting from injection into soft tissue of acidified heroin contaminated with spore-forming bacteria. Toxin production led to a severe local reaction and, in many, multi-system failure.

Effect of tobacco smoking on survival of men and women by social position: a 28 year cohort study

Objective To assess the impact of tobacco smoking on the survival of men and women in different social positions. Design A cohort observational study. Setting Renfrew and Paisley, two towns in west central Scotland. Participants 8353 women and 7049 men aged 45-64 years recruited in 1972-6 (almost 80% of the population in this age group). The cohort was divided into 24 groups by sex (male, female), smoking status (current, former, or never smokers), and social class (classes I + II, III non-manual, III manual, and IV + V) or deprivation category of place of residence. Main outcome measure Relative mortality (adjusted for age and other risk factors) in the different groups; Kaplan-Meier survival curves and survival rates at 28 years. Results Of those with complete data, 4387/7988 women and 4891/6967 men died over the 28 years. Compared with women in social classes I + II who had never smoked (the group with lowest mortality), the adjusted relative mortality of smoking groups ranged from 1.7 (95% confidence interval 1.3 to 2.3) to 4.2 (3.3 to 5.5). Former smokers’ mortalities were closer to those of never smokers than those of smokers. By social class (highest first), age adjusted survival rates after 28 years were 65%, 57%, 53%, and 56% for female never smokers; 41%, 42%, 33%, and 35% for female current smokers; 53%, 47%, 38%, and 36% for male never smokers; and 24%, 24%, 19%, and 18% for male current smokers. Analysis by deprivation category gave similar results. Conclusions Among both women and men, never smokers had much better survival rates than smokers in all social positions. Smoking itself was a greater source of health inequality than social position and nullified women’s survival advantage over men. This suggests the scope for reducing health inequalities related to social position in this and similar populations is limited unless many smokers in lower social positions stop smoking.

Young people's access to tobacco, alcohol, and other drugs

Young peoples use of tobacco, alcohol, and other drugs causes concern. Early use of psychoactive substances can be harmful to health in the short term—for example, through injuries sustained or inflicted while intoxicated—and can lead to lasting patterns of consumption that increase the risk of many chronic diseases and social problems.1 2 Recent concern in the United Kingdom has focused on issues such as continued high levels of smoking by young women, binge drinking and associated antisocial behaviour by young people in general, and higher levels of cannabis use in adolescents than in most European countries.w1 One potential approach to reducing the use of psychoactive substances in young people is to control their availability, but public policy in this area has tended to tackle tobacco, alcohol, or illicit drugs in isolation and is not necessarily based on evidence about what works.3 We review the research evidence on availability and answer two key questions. Firstly, how easy is it for young people in the UK to obtain tobacco, alcohol, and other drugs? Secondly, do measures to control availability affect young peoples patterns of use? We concentrate on measures affecting price, tax, importation, licensing, sales practices, illicit markets, and enforcement in all of these areas. We do not deal with production, prohibition, rationing, marketing, or controls on possession or use (see bmj.com for rationale). This article is based on evidence about availability synthesised from nine population surveys of people aged under 25 in various parts of the UK and on evidence synthesised from 30 reviews (including seven systematic reviews) of the effects of measures to control availability on patterns of use (specifically hazardous use by young people, where available) and health outcomes. Where review level evidence was insufficient, we included relevant primary research and data from official reports. A …

The combined effect of smoking tobacco and drinking alcohol on cause-specific mortality: a 30 year cohort study

BackgroundSmoking and consuming alcohol are both related to increased mortality risk. Their combined effects on cause-specific mortality were investigated in a prospective cohort study.MethodsParticipants were 5771 men aged 35-64, recruited during 1970-73 from various workplaces in Scotland. Data were obtained from a questionnaire and a screening examination. Causes of death were all cause, coronary heart disease (CHD), stroke, alcohol-related, respiratory and smoking-related cancer. Participants were divided into nine groups according to their smoking status (never, ex or current) and reported weekly drinking (none, 1-14 units and 15 or more). Cox proportional hazards models were used to obtain relative rates of mortality, adjusted for age and other risk factors.ResultsIn 30 years of follow-up, 3083 men (53.4%) died. Compared with never smokers who did not drink, men who both smoked and drank 15+ units/week had the highest all-cause mortality (relative rate = 2.71 (95% confidence interval 2.31-3.19)). Relative rates for CHD mortality were high for current smokers, with a possible protective effect of some alcohol consumption in never smokers. Stroke mortality increased with both smoking and alcohol consumption. Smoking affected respiratory mortality with little effect of alcohol. Adjusting for a wide range of confounders attenuated the relative rates but the effects of alcohol and smoking still remained. Premature mortality was particularly high in smokers who drank 15 or more units, with a quarter of the men not surviving to age 65. 30% of men with manual occupations both smoked and drank 15+ units/week compared with only 13% with non-manual ones.ConclusionsSmoking and drinking 15+ units/week was the riskiest behaviour for all causes of death.

Does smoking reduction in midlife reduce mortality risk? Results of 2 long-term prospective cohort studies of men and women in Scotland

A long-term cohort study of working men in Israel found that smokers who reduced their cigarette consumption had lower subsequent mortality rates than those who did not. We conducted comparable analyses in 2 populations of smokers in Scotland. The Collaborative Study included 1,524 men and women aged 40–65 years in a working population who were screened twice, in 1970–1973 and 1977. The Renfrew/Paisley Study included 3,730 men and women aged 45–64 years in a general population who were screened twice, in 1972–1976 and 1977–1979. Both groups were followed up through 2010. Subjects were categorized by smoking intensity at each screening as smoking 0, 1–10, 11–20, or ≥21 cigarettes per day. At the second screening, subjects were categorized as having increased, maintained, or reduced their smoking intensity or as having quit smoking between the first and second screenings. There was no evidence of lower mortality in all reducers compared with maintainers. Multivariate adjusted hazard ratios of mortality were 0.91 (95% confidence interval (CI): 0.75, 1.10) in the Collaborative Study and 1.08 (95% CI: 0.97, 1.20) in the Renfrew/Paisley Study. There was clear evidence of lower mortality among quitters in both the Collaborative Study (hazard ratio = 0.66, 95% CI: 0.56, 0.78) and the Renfrew/Paisley Study (hazard ratio = 0.75, 95% CI: 0.67, 0.84). In the Collaborative Study only, we observed lower mortality similar to that of quitters among heavy smokers (≥21 cigarettes/day) who reduced their smoking intensity. These inconclusive results support the view that reducing cigarette consumption should not be promoted as a means of reducing mortality, although it may have a valuable role as a step toward smoking cessation.

A lasting public health response to an outbreak of HIV infection in a Scottish prison

Summary: Between April and June 1993, 8 cases of acute clinical hepatitis B infection and 2 seroconversions to HIV infection were detected among drug injecting inmates of HM Prison Glenochil in Scotland. To prevent the further spread of infection, an initiative which involved counselling and voluntary attributable HIV testing was conducted over a 10-day period commencing at the end of June. A team of 18 counsellors and phlebotomists was brought together rapidly as part of a unique organizational exercise in the field of public health. Fourteen cases of HIV infection were identified of which 13 were almost certainly infected in Glenochil. Following the exercise, a range of harm reduction measures for injecting prisoners was introduced; these included the availability of hepatitis B vaccine, provision of bleach tablets which could be used to clean injecting equipment, a methadone detoxification programme, increased training for prison officers and improved access to drug and harm minimization counselling for inmates. By mid-1996 all these measures had been sustained and several could be found in many other prisons throughout Scotland. Follow-up investigations showed no evidence of epidemic spread of HIV during the 12 months after the initiative. While the frequency of injecting and needle/syringe sharing may have decreased over the last 3 years, these activities are still being reported and it is highly likely that transmissions of bloodborne infections, in paticular hepatitis C, continue to occur. The surveillance and prevention of infections associated with injecting drug use in the prison setting remain a high public health priority.

Alcohol, Drug Use and Sexual Behaviour of Young Adults on a Mediterranean Dance Holiday

Aim: To measure the extent of drug, sex and other health risks among a group of young people travelling from the UK on a foreign dance holiday. Methods: A cross-sectional sample of 160 young people on a dance holiday compared with a crossectional sample of 90 young people at home. All respondents completed a quantitative questionnaire relating to their risk behaviours in the previous seven days. Qualitative interviews were also conducted whilst on holiday. Settings: Balearic Islands, (Spain), and a dance club in Scotland, (UK). Results: A significantly greater number of those on holiday reported using alcohol (91 %) and ecstasy (77 %), compared with 69 % and 63 % respectively of those at home. Approximately half of those who had sex with new partners whilst on holiday, and at home, used condoms. of those on holiday, 45 % reported sickness and diarrhoea compared with 23 % at home; 49 % of hol-idaymakers reported sunburn. Conclusions: As with other studies, this group of holidaymak-ers experienced increased...

ABC of Obesity: Obesity—can we turn the tide?

The problem of rising prevalence in obesity may get much worse—rates could climb still further, bankrupting the health system and leading soon to reductions in life expectancy. So, can we offer effective management? And can we reverse the rising trend in the prevalence of obesity, and if so, when? Recent headlines highlighting the current and projected obesity levels in the United Kingdom—in 2010 a third of adults will be obese—reiterate the cry that “its time to do something about it.” As already shown in this series, the consequences of obesity affect all ages and nearly all organ systems. Obesity diminishes quality of life, and many problems begin well before reaching a body mass index of 30. Well over half the entire population of the UK have a BMI of >25, and they will experience greater morbidity and total mortality. Medical complications of obesity Trends in obesity in adults in England, 1980-2002 (graph adapted from Health Survey for England 2004 ). Projected levels suggest that by 2010 nearly a third of adult men and 28% of women in England will be obese ( Forecasting obesity to 2010 , www.dh.gov.uk/). The figures will be higher for older people Vicious cycle of weight gain. Food provides short term pleasure and is addictive Although the old attitude of “pull yourself together, eat less, and exercise more” is receding, it is still evident among less perceptive health professionals and is commonly voiced by the media. Most overweight or obese individuals would prefer to be normal weight, and many are doing as much as they can to keep their weight lower than it would otherwise be. It is increasingly apparent that most individuals are unable to make enough “proactive” changes to prevent excess weight gain but are simply “reactive” to their environment. Thus education alone will fail to …