The public health response to the re-emergence of syphilis in Wales, UK.

During the 1990s, cases of infectious syphilis were uncommon in Wales. In 2002, an outbreak occurred in a sexual network of men who have sex with men (MSM) attending a sauna. A multidisciplinary outbreak control team was convened to raise awareness of the outbreak among MSM and health professionals, assess the extent of outbreak, and initiate surveillance measures. It is likely that early intensive control efforts dampened the epidemic curve. However, since 2006 the number of cases has increased steadily to a peak of four cases per 100,000 population in 2008. The majority of cases continue to occur in MSM (81% in 2009) and in those attending genitourinary (GU) medicine clinics in south east Wales (76%). Traditional sexual networks such as saunas, bars/clubs and cruising grounds remain frequently reported, but Internet-based networks are assuming increasing importance. Public health interventions have been sustained, using traditional partner notification, health promotion initiatives, and more innovative Internet network tracing methods.

Audit of routine rectal swabs for gonorrhoea culture in women.

The British Association for Sexual Health and HIV Guidelines on the Diagnosis and Treatment of Gonorrhoea (GC) in Adults recommends rectal screening only in special circumstances. Our genitourinary medicine clinic undertakes rectal swabs for gonorrhoea culture in all women attending for sexually transmitted infection screening. We undertook this audit to determine the value of our practice.

Audit of a network of sexually transmitted infections centred in South Wales.

The aim of this article is to audit the distribution and frequency of sexually transmitted infections (STIs) within a sexual network centred in South Wales. After diagnosis of a new case of HIV in February 2007, partner notification, HIV and STI testing were undertaken. Those traced were given information regarding safe sex practices and informed they had been in contact with HIV. Genitourinary (GU) medicine case-notes of contacts identified in the network were reviewed from February 2007 to 1 July 2008. Frequency and distribution of new diagnoses of STIs made on original identification in the network in 2007 were compared with subsequent new diagnoses within the network. One hundred and eighteen men who have sex with men (MSMs) and five women were identified in the original network in 2007. By 1 July 2008, 65 new sexual contacts (all MSMs) were added to the network and there were 25 new STI diagnoses in 13 contacts. Seven contacts originally identified in the cluster in 2007 were diagnosed with 16 of the new STIs. In conclusion, the sexual network has evolved by increasing in size with multiple new STIs diagnosed. The highest risk of STIs occurred in relatively few individuals. Standard interventions in health promotion in the GU medicine setting were not universally successful in preventing high-risk behaviour.

Emergence of high-level azithromycin resistance in Neisseria gonorrhoeae in England and Wales.

OBJECTIVES: This study aimed to investigate the origin of high-level azithromycin resistance that emerged in isolates of Neisseria gonorrhoeae in England and Wales in 2007, and to establish methods for identifying high-level azithromycin resistance. METHODS: The Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) data from 2001-07 were examined for emerging trends in azithromycin susceptibility. Further to the identification of six high-level azithromycin-resistant isolates in GRASP 2007, an additional 102 isolates were selected on the basis of azithromycin susceptibility and geographic origin from the GRASP 2006 and 2007 collections. Susceptibility testing by Etest and disc diffusion was performed on all 108 isolates and 75 of these were typed by N. gonorrhoeae multiantigen sequence typing. RESULTS: A slight drift towards higher MICs of azithromycin was observed in the gonococcal population since 2001. Of greater concern was the first example of a shift to high-level resistance observed in six isolates in 2007. All six isolates were sequence type 649, which was not observed in any of the lower-level azithromycin-resistant isolates from 2007 or in any isolates tested from the same geographical locations. Contact tracing data for one patient suggested a link with Scotland. Disc diffusion testing of all 108 isolates showed that azithromycin, but not erythromycin, discs can differentiate between low-level and high-level resistance. CONCLUSIONS: High-level azithromycin resistance has emerged in England and Wales. Contact tracing and typing data suggest this may have originated from Scotland. Surveillance of azithromycin resistance will be key in controlling its further dissemination.

Investigation of an HIV transmission cluster centred in South Wales.

OBJECTIVE: To describe an HIV transmission cluster centred in South Wales by the analysis of partner notification outcomes and demographic characteristics of individuals identified in the sexual network. METHODS: After diagnosis of the index case, HIV testing and partner notification were undertaken by Cardiff Genitourinary Medicine Clinic in collaboration with the local Health Protection Team, National Public Health Service for Wales and Terrence Higgins Trust Cymru. Rapid test and standard venepuncture methods were used for HIV screening and the resulting clinical and behavioural data were analysed. RESULTS: Of the 123 individuals identified in the sexual network, all were men who had sex with men (MSM) except for seven men who self-identified as bisexual and five heterosexual women. Fifteen new cases of HIV were diagnosed; all were men. Partner notification outcomes are as follows: 104 provider referrals were made, 57 were successfully contacted with known outcomes, 14 were successfully contacted but with unknown outcomes and 33 were uncontactable. Fifteen patient referrals were made, 11 had known outcomes but four had unknown outcomes. Four patients self-referred. Eleven reported previous HIV diagnosis. The sexual network was distributed over South and West Wales extending into England, with high reported rates of unprotected anal intercourse, previous HIV tests and concurrent sexually transmitted infections. A one in four positive rate for those with a known HIV status outcome and a 68% provider referral success rate compares favourably with other studies. CONCLUSIONS: Partner notification revealed a relatively young, well-educated HIV network with high-risk behaviour and ongoing transmission despite previous knowledge and awareness of HIV. This analysis adds to the evidence supporting HIV partner notification in MSM.

Risk factors associated with pelvic inflammatory disease.

OBJECTIVE: To investigate factors associated with pelvic inflammatory disease (PID). METHODS: A case-control study was used to investigate demographic and behavioural factors, and causative agents associated with PID. RESULTS: A total of 381 participants were recruited: 140 patients, and 105 and 136 controls in tubal ligation and general practice groups, respectively. When compared with a PID-free tubal ligation control group, increased risk of PID was associated with: age <25 years; age at first sexual intercourse <20 years; non-white ethnicity; not having had children; a self-reported history of a sexually transmitted disease; and exposure to Chlamydia trachomatis. When compared with a general practice control group, increased risk was associated with: age <25 years; age at first sexual intercourse <15 years; lower socioeconomic status; being single; adverse pregnancy outcome; a self-reported history of a sexually transmitted disease; and exposure to C trachomatis. Of the cases, 64% were not associated with any of the infectious agents measured in this study (idiopathic). CONCLUSIONS: A high proportion of cases were idiopathic. PID control strategies, which currently focus on chlamydial screening, have to be reviewed so that they can prevent all cases of PID. Behavioural change is a key factor in the primary prevention of PID, and potential modifiable risk factors were associated with PID.

Outreach health adviser in a community clinic screening programme improves management of genital chlamydia infection.

OBJECTIVE: To assess the effectiveness of an outreach health adviser on treatment, partner notification and outcome for clients diagnosed with genital chlamydia (CT) infection at a community young people's clinic. METHODS: From August 1999 to March 2000, a genitourinary medicine (GUM) based health adviser helped to develop testing and undertook outreach management of clients aged under 26 years diagnosed with CT infection. In addition to facilitating referral to GUM, she gave antibiotic treatment based on a GUM derived patient group direction to those not wishing to travel to the GUM clinic. She also advised them on contact tracing and the need for a compliance check (CC). RESULTS: Chlamydia positive tests with ligase chain reaction (LCR), on first void urine, were obtained for 62 (12.9%) of 481 female clients, one (5%) of 20 male clients, and nine (53%) of 17 male contacts of female positive cases. All 72 testing positive received their result and were treated. Two urine samples positive for CT showed positive LCR tests for gonorrhoea. Proportions of named contacts seen (67%) and reattendances for compliance checks (60%) were similar to those for women seen in GUM services. CONCLUSIONS: Health adviser input with the ability to treat can be effective in reducing the growth of identified but untreated genital chlamydia infection consequent upon community based screening. Such a strategy appears comparable with, and can add to, GUM based treatment of infection. It helps to address the need for alternative management strategies in the light of the national sexual health strategy.

Comparison of urine, first and second endourethral swabs for PCR based detection of genital Chlamydia trachomatis infection in male patients.

OBJECTIVES: To compare endourethral swabs and urine as diagnostic specimens for the detection of genital Chlamydia trachomatis infection using the polymerase chain reaction (PCR), in male patients attending a genitourinary clinic and to assess whether the first endourethral swab used solely for diagnosing gonococcal infection could be used for C trachomatis detection as well. METHODS: Two endourethral swabs were taken from 80 male patients, in whom the likelihood of genital C trachomatis infection was high. The first swab was used for microscopy and culture for Neisseria gonorrhoeae, before being used for C trachomatis detection. First voided urine specimens were collected from 61 of these patients. All three specimens were processed for C trachomatis DNA detection using the Roche Cobas Amplicor PCR. A diagnosis of genital C trachomatis infection was made if any one of the specimens tested reproducibly positive. Samples from 13 patients showing discrepant PCR results between swabs and/or urine were retested by ligase chain reaction (LCR). RESULTS: Chlamydia trachomatis DNA was detected in 35 (43.8%) of the 80 patients. In 17 of the 35 patients (48.6%), all the genital specimens were positive. However, in 18 (51.4%) patients, one or more of the genital specimens had negative PCR results. Among the 18 patients with discrepant results, urine was found to be a more sensitive diagnostic specimen than the second urethral swab picking up 13 out of 16 positives (81.3%) as opposed to five out of 18 (27.8%). There was no significant difference between the two swabs. Retesting by LCR, of the samples from 13 of the 18 patients with discrepant PCR results confirmed them all as true positives, although as with PCR, not all specimens in the set were concordantly positive. LCR detected all the 13 positives in urine, while there was no difference in the detection rate between the first and the second urethral swabs. CONCLUSIONS: Urine appeared to be a better diagnostic specimen than the conventional second endourethral swab for C trachomatis detection by PCR in this cohort of male patients. There was no difference between the first swab, intended primarily for N gonorrhoeae testing and the second swab intended for C trachomatis detection. This raises questions over the need for the conventional second swab for detecting C trachomatis.

Continuing medical ignorance: modern myths in the management of genital warts.

Genital warts are the most common sexually transmitted disease (STD) in industrialized countries. Since they also often respond poorly to current treatments, they account for substantial morbidity. Human papillomavirus (HPV) typing methods have shown that HPV 6 and 11, the most common types found in genital warts, are not found in cancer of the cervix. These types, however, do cause minor degrees of cervical dysplasia which also results in morbidity both through fear and through over-treatment. The sexual nature of transmission of genital warts has been known from ancient times; there is also good evidence of vertical transmission and transmission through non-genital contact. Barrier contractive methods do not completely prevent transmission of genital warts and may give little worthwhile protection. These facts, together with the established persistence of HPV contribute to the associated psychological morbidity. There are a number of treatments for genital (and other) warts. This attests to the fact that no one of these is clearly superior to the others. Until better treatments are developed much of the management of this condition must consist of using such treatments that are available to maximize efficacy while trying to reduce unnecessary costs, inconvenience and potential injury and sustaining morale through what may be a long and demoralizing course.

Evaluation of atovaquone in the treatment of patients with uncomplicated Plasmodium falciparum malaria.

The activity of atovaquone in patients with oligosymptomatic Plasmodium falciparum malaria was assessed in an open, non-comparative clinical study. The patients showed a good clinical response, but there was a high rate of recrudescence. The activity of atovaquone in combination with another antimalarial agent should be investigated.

Human papillomaviruses, cervical cancer and the developing world.

Carcinoma of the uterine cervix is the commonest cancer of women in the majority of developing countries; in developed countries it is much less common, as well as being less frequent than some other cancers, such as those of breast, lung and colon. The discovery of human papillomavirus (HPV) as an aetiological agent of cervical cancer (and of other anogenital malignancies) has prompted a great deal of interest in the biology and oncogenicity of this virus, including large-scale epidemiological surveys comparing the prevalence of HPV and other possible causative agents between areas of high and low incidence of cervical carcinoma. These studies have thrown up tantalizing clues concerning the virus' pathogenesis and disease associations. Sexual practices, parity, diet, smoking, other diseases (including sexually transmissible diseases) and immunogenetic characteristics may all play a contributory role in the development of cervical carcinoma. These factors may be independent of each other and of association with HPV infection. Immunization to prevent papillomavirus infection and thus cervical cancer is an attractive prospect. Although the potential in using such an approach has been demonstrated in several animal models, there are several major theoretical problems to solve before HPV vaccination becomes a practicality. Intervention to prevent exposure to other aetiological factors and to improve screening may be a more practicable strategy for reducing the burden of cervical cancer.