Paul Crook

Intercontinental dissemination of azithromycin-resistant shigellosis through sexual transmission: a cross-sectional study

BACKGROUND Shigellosis is an acute, severe bacterial colitis that, in high-income countries, is typically associated with travel to high-risk regions (Africa, Asia, and Latin America). Since the 1970s, shigellosis has also been reported as a sexually transmitted infection in men who have sex with men (MSM), in whom transmission is an important component of shigellosis epidemiology in high-income nations. We aimed to use sophisticated subtyping and international sampling to determine factors driving shigellosis emergence in MSM linked to an outbreak in the UK. METHODS We did a large-scale, cross-sectional genomic epidemiological study of shigellosis cases collected from 29 countries between December, 1995, and June 8, 2014. Focusing on an ongoing epidemic in the UK, we collected and whole-genome sequenced clinical isolates of Shigella flexneri serotype 3a from high-risk and low-risk regions, including cases associated with travel and sex between men. We examined relationships between geographical, demographic, and clinical patient data with the isolate antimicrobial susceptibility, genetic data, and inferred evolutionary relationships. FINDINGS We obtained 331 clinical isolates of S flexneri serotype 3a, including 275 from low-risk regions (44 from individuals who travelled to high-risk regions), 52 from high-risk regions, and four outgroup samples (ie, closely related, but genetically distinct isolates used to determine the root of the phylogenetic tree). We identified a recently emerged lineage of S flexneri 3a that has spread intercontinentally in less than 20 years throughout regions traditionally at low risk for shigellosis via sexual transmission in MSM. The lineage had acquired multiple antimicrobial resistance determinants, and prevailing sublineages were strongly associated with resistance to the macrolide azithromycin. Eight (4%) of 206 isolates from the MSM-associated lineage were obtained from patients who had previously provided an isolate; these serial isolations indicated atypical infection patterns (eg, reinfection). INTERPRETATION We identified transmission-facilitating behaviours and atypical course(s) of infection as precipitating factors in shigellosis-affected MSM. The intercontinental spread of antimicrobial-resistant shigella through established transmission routes emphasises the need for new approaches to tackle the public health challenge of sexually transmitted infections in MSM. FUNDING Wellcome Trust (grant number 098051).

A multi-country Salmonella Enteritidis phage type 14b outbreak associated with eggs from a German producer: 'near real-time' application of whole genome sequencing and food chain investigations, United Kingdom, May to September 2014.

We report an outbreak of Salmonella Enteritidis phage type 14b (PT14b) in the United Kingdom (UK) between May and September 2014 where Public Health England launched an investigation to identify the source of infection and implement control measures. During the same period, outbreaks caused by a Salmonella Enteritidis strain with a specific multilocus variable-number tandem repeat analysis (MLVA) profile occurred in other European Union Member States. Isolates from a number of persons affected by the UK outbreak, who had initially been tested by MLVA also shared this particular profile. Cases were defined as any person infected with S. Enteritidis PT14b, resident in England or Wales and without history of travel outside of this geographical area during the incubation period, reported from 1 June 2014 onwards, with a MLVA profile of 2–11–9-7–4-3–2-8–9 or a single locus variant thereof. In total, 287 cases met the definition. Food traceback investigations in the UK and other affected European countries linked the outbreaks to chicken eggs from a German company. We undertook whole genome sequencing of isolates from UK and European cases, implicated UK premises, and German eggs: isolates were highly similar. Combined with food traceback information, this confirmed that the UK outbreak was also linked to a German producer.

Intensified shigellosis epidemic associated with sexual transmission in men who have sex with men--Shigella flexneri and S. sonnei in England, 2004 to end of February 2015.

Surveillance data suggest an intensification of the shigellosis epidemic associated with sexual transmissionin men who have sex with men (MSM) in England with separate introductions into the population. In 2014, sexual transmission between MSM might have accounted for 97%, 89%, and 43% of non-travel associated Shigella flexneri 3a and S. flexneri 2a, andS. sonnei diagnoses. Clinicians should sensitively ascertain sexual history for men with enteric infections to facilitate prompt diagnosis and appropriate management.

Outbreak of hepatitis A associated with men who have sex with men (MSM), England, July 2016 to January 2017

Between July 2016 and January 2017, 37 confirmed cases of hepatitis A with two unique IA genotype strains primarily among men who have sex with men, were reported across eight areas in England and Northern Ireland. Epidemiological and laboratory investigations indicate that these strains may have been imported several times from Spain, with secondary sexual transmission in the United Kingdom. Local and national public health services are collaborating to control this ongoing outbreak.

Use of whole-genome sequencing for the public health surveillance of Shigella sonnei in England and Wales, 2015.

Shigella spp., including Shigella dysenteriae, Shigella boydii, Shigella flexneri and Shigella sonnei, are the most common cause of bacterial dysentery (bloody diarrhoea) worldwide (Kotloff et al., 1999). Although all species of Shigella contribute to the high burden of diarrhoeal disease in lowincome regions, S. sonnei is the most commonly reported species in middleand high-income countries (Thompson et al., 2015). In England and Wales, foodborne outbreaks of S. sonnei are rare with transmission most commonly associated with person-to-person spread (McDonnell et al., 2013; Morgan et al., 2006; Simms et al., 2015). Historically, schools and nurseries were regarded as the epidemic centres of domestically acquired S. sonnei infection (Evans & Maguire, 1996). More recently, outbreaks of S. sonnei amongst men who have sex with men (MSM) have been described, and the increasing incidence of S. sonnei infection in this community is a challenging public health problem (Morgan et al., 2006; Simms et al., 2015).

Identification of verocytotoxin-producing Escherichia coli O117:H7 in men who have sex with men, England, November 2013 to August 2014.

Between November 2013 and August 2014, nine cases of verocytotoxin-producing Escherichia coli O117:H7 VT1 were confirmed in adult men. Further investigation using semi-structured interviews revealed that eight cases were United Kingdom (UK)-born men who have sex with men (MSM) who had sexually acquired infection in the UK. Most were HIV-positive with high numbers of sexual partners. This behavioural profile resembles that associated with the recent rapid increase in other sexually acquired infections in MSM.

ESBL-Producing and Macrolide-Resistant Shigella sonnei Infections among Men Who Have Sex with Men, England, 2015

In England in 2015, Shigella sonnei isolates from men who have sex with men produced extended-spectrum β-lactamases and exhibited macrolide resistance. Whole-genome sequencing showed a close relationship among the isolates, which harbored a plasmid that was previously identified in a shigellosis outbreak among this population but has acquired a mobile element.

Expanded HIV testing in high‐prevalence areas in England: results of a 2012 audit of sexual health commissioners

The aim of the study was to examine whether UK HIV testing guidelines which recommend the expansion of HIV testing in high HIV prevalence areas have been implemented in England.

Olympics and Paralympics 2012 mass gathering in London: time-series analysis shows no increase in attendances at sexual health clinics

Objective To determine whether the 2012 Olympic and Paralympic Games were associated with a change in the number of patients attending or diagnosed with a new sexually transmitted infection (STI) at sexual health clinics in London and Weymouth. Methods We undertook an interrupted time-series analysis of surveillance data from the Genitourinary Medicine Clinic Activity Dataset (GUMCAD) collected at 33 genitourinary medicine (GUM) clinics in London and Weymouth (where Games events were concentrated) between 2009 and 2012. Mixed-effects linear regression models of weekly attendance and diagnoses, incorporating temporal trends, bank holidays, categorical month and clinic closures, were used to test for the effect of the ‘Olympic–Paralympic’ period. We subdivided the 9-week ‘Olympic–Paralympic’ period (16 July 2012 to 17 September 2012) into five periods, including three Olympic weeks, two Paralympic weeks, pre-, post- and inter-Games weeks. We also compared characteristics of patients attending during the Olympic–Paralympic period and those attending during the same period in 2011. Results During the 3 weeks of the Olympics, there was a significant reduction in the number of new episode attendances (2020 fewer, 5.6% reduction (95% CI −8.2 to −2.9)) and the number of patients diagnosed with an STI (267 fewer, 4.8% reduction (95% CI −8.6 to −0.9)) compared to expected. There were no important differences in the profile of patients attending during the 2012 Olympic–Paralympic period and those attending during the same period in 2011. Conclusions We conclude that a ‘business-as-usual’ approach to managing local sexual health clinics during the 2012 Olympic and Paralympics would have been appropriate.

Safer chemsex: consideration of Shigella.

We would like to follow up the recent editorial entitled ‘Safer “chemsex”’ by Ma and Perera1 by including sexually transmissible enteric infections (STEI) among the pathogens whose transmission may be associated with chemsex. Shigella , which causes a range of gastrointestinal symptoms in humans,2 is the primary example here, although verocytotoxin-producing Escherichia coli has also been described.3 Until recently, Shigella …