External validation of GO-FAR 2 calculator for outcomes after in-hospital cardiac arrest with comparison to GO-FAR and trial of expanded applications.

Aim: Externally validate the GO-FAR 2 tool for predicting survival with good neurologic function after in-hospital cardiac arrest with comparison to the original GO-FAR tool. Additionally, we collected qualitative descriptors and performed exploratory analyses with various levels of neurologic function and discharge destination. Methods: Retrospective chart review of all patients who underwent in-hospital resuscitation after cardiac arrest during the calendar years 2016-2019 in our institution (n = 397). GO-FAR and GO-FAR 2 scores were calculated based on information available in the medical record at the time of hospital admission. Cerebral performance category (CPC) scores at the time of admission and discharge were assessed by chart review. Results: The GO-FAR 2 score accurately predicted outcomes in our study population with a c-statistic of 0.625. The original GO-FAR score also had accurate calibration with a stronger c-statistic of 0.726. The GO-FAR score had decreased predictive value for lesser levels of neurologic function (c-statistic 0.56 for alive at discharge) and discharge destination (0.69). Descriptors of functional status by CPC score were collected. Conclusion: Our findings support the validity of the GO-FAR and GO-FAR 2 tools as published, but the c-statistics suggest modest predictive discrimination. We include functional descriptors of CPC outcomes to aid clinicians in using these tools. We propose that information about expected outcomes could be valuable in shared decision-making conversations.

Factors associated with return of home oral fluid kits by suspected cases of measles, cohort study, London and South East of England, 2016-2018.

A testing rate for measles above 80% is required by the WHO European Region Measles Elimination strategy to verify elimination. To comply with this rate, we explored factors associated with the return of oral fluid kits (OFK) by suspected measles cases. We described the cases and conducted a mixed-effects analysis to assess the relationship between socio-demographic and public health management characteristics and the likelihood of returning an OFK to the reference laboratory. Of 3,929 cases who were sent a postal OFK, 2,513 (67%) returned the kit. Adjusting for confounding, registration with a general practitioner (GP) (aOR:1.48, 95%CI:1.23-1.76) and living in a less deprived area (aOR:1.35, 95%CI:1.04-1.74) were associated with an increased likelihood of returning the OFK. The odds of returning the OFK also increased if the HPT contacted the parents/guardians of all cases prior to sending the kit and confirmed their address (aOR:2.01, 95%CI:1.17-3.42). Cases notified by a hospital (aOR:1.94, 95%CI:1.31-2.87) or GP (aOR:1.52; 95%CI:1.06-2.16) also had higher odds of returning the OFK. HPTs may want to consider these factors when managing suspected cases of measles since this may help in increasing the testing rates to the WHO-recommended level.

Sustained detection of type 2 poliovirus in London sewage between February and July, 2022, by enhanced environmental surveillance.

BACKGROUND: The international spread of poliovirus exposes all countries to the risk of outbreaks and is designated a Public Health Emergency of International Concern by WHO. This risk can be exacerbated in countries using inactivated polio vaccine, which offers excellent protection against paralysis but is less effective than oral vaccine against poliovirus shedding, potentially allowing circulation without detection of paralytic cases for long periods of time. Our study investigated the molecular properties of type 2 poliovirus isolates found in sewage with an aim to detect virus transmission in the community. METHODS: We performed environmental surveillance in London, UK, testing sewage samples using WHO recommended methods that include concentration, virus isolation in cell culture, and molecular characterisation. We additionally implemented direct molecular detection and determined whole-genome sequences of every isolate using novel nanopore protocols. FINDINGS: 118 genetically linked poliovirus isolates related to the serotype 2 Sabin vaccine strain were detected in 21 of 52 sequential sewage samples collected in London between Feb 8 and July 4, 2022. Expansion of environmental surveillance sites in London helped localise transmission to several boroughs in north and east London. All isolates have lost two key attenuating mutations, are recombinants with a species C enterovirus, and an increasing proportion (20 of 118) meet the criterion for a vaccine-derived poliovirus, having six to ten nucleotide changes in the gene coding for VP1 capsid protein. INTERPRETATION: Environmental surveillance allowed early detection of poliovirus importation and circulation in London, permitting a rapid public health response, including enhanced surveillance and an inactivated polio vaccine campaign among children aged 1-9 years. Whole-genome sequences generated through nanopore sequencing established linkage of isolates and confirmed transmission of a unique recombinant poliovirus lineage that has now been detected in Israel and the USA. FUNDING: Medicines and Healthcare products Regulatory Agency, UK Health Security Agency, Bill & Melinda Gates Foundation, and National Institute for Health Research Medical Research Council.

Community transmission of monkeypox in the United Kingdom, April to May 2022.

Between 7 and 25 May, 86 monkeypox cases were confirmed in the United Kingdom (UK). Only one case is known to have travelled to a monkeypox virus (MPXV) endemic country. Seventy-nine cases with information were male and 66 reported being gay, bisexual, or other men who have sex with men. This is the first reported sustained MPXV transmission in the UK, with human-to-human transmission through close contacts, including in sexual networks. Improving case ascertainment and onward-transmission preventive measures are ongoing.

Infection and transmission of SARS-CoV-2 in London care homes reporting no cases or outbreaks of COVID-19: Prospective observational cohort study, England 2020.

BACKGROUND: Care homes have been disproportionately affected by the COVID-19 pandemic. We investigated the potential role of asymptomatic infection and silent transmission in London care homes that reported no cases of COVID-19 during the first wave of the pandemic. METHODS: Five care homes with no cases and two care homes reporting a single case of COVID-19 (non-outbreak homes) were investigated with nasal swabbing for SARS-CoV-2 RT-PCR and serology for SARS-CoV-2 antibodies five weeks later. Whole genome sequencing (WGS) was performed on RT-PCR positive samples. Serology results were compared with those of six care homes with recognised outbreaks. FINDINGS: Across seven non-outbreak homes, 718 (387 staff, 331 residents) individuals had a nasal swab and 651 (386 staff, 265 residents) had follow-up serology. Sixteen individuals (13 residents, 3 staff) in five care homes with no reported cases were RT-PCR positive (care home positivity rates, 0 to 7.6%) compared to 13 individuals (3.0 and 10.8% positivity) in two homes reporting a single case.Seropositivity across these seven homes varied between 10.7-56.5%, with four exceeding community seroprevalence in London (14.8%). Seropositivity rates for staff and residents correlated significantly (rs 0.84, [95% CI 0.51-0.95] p <0.001) across the 13 homes. WGS identified multiple introductions into some homes and silent transmission of a single lineage between staff and residents in one home. INTERPRETATION: We found high rates of asymptomatic infection and transmission even in care homes with no COVID-19 cases. The higher seropositivity rates compared to RT-PCR positivity highlights the true extent of the silent outbreak. FUNDING: PHE.

Mass testing after a single suspected or confirmed case of COVID-19 in London care homes, April-May 2020: implications for policy and practice.

INTRODUCTION: Previous investigations have identified high rates of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among residents and staff in care homes reporting an outbreak of coronavirus disease 2019 (COVID-19). We investigated care homes reporting a single suspected or confirmed case to assess whether early mass testing might reduce risk of transmission during the peak of the pandemic in London. METHODS: Between 18 and 27 April 2020, residents and staff in care homes reporting a single case of COVID-19 to Public Health England had a nasal swab to test for SARS-CoV-2 infection by reverse transcription polymerase chain reaction and subsequent whole-genome sequencing. Residents and staff in two care homes were re-tested 8 days later. RESULTS: Four care homes were investigated. SARS-CoV-2 positivity was 20% (65/333) overall, ranging between 3 and 59%. Among residents, positivity ranged between 3 and 76% compared with 3 and 40% in staff. Half of the SARS-CoV-2-positive residents (23/46, 50%) and 63% of staff (12/19) reported symptoms within 14 days before or after testing. Repeat testing 8 days later in two care homes with the highest infection rates identified only two new cases. Genomic analysis demonstrated a small number of introduction of the virus into care homes, and distinct clusters within three of the care homes. CONCLUSIONS: We found extensive but variable rates of SARS-CoV-2 infection among residents and staff in care homes reporting a single case of COVID-19. Although routine whole-home testing has now been adopted into practice, care homes must remain vigilant and should be encouraged to report a single suspected case, which should trigger appropriate outbreak control measures.

Attendance at London workplaces after symptom onset: a retrospective cohort study of staff members with confirmed COVID-19.

BACKGROUND: Coronavirus disease (COVID)-secure workplace guidance, including the prompt self-isolation of those with COVID-19 symptoms, is fundamental to disease control in workplaces. Despite guidance, a large number of workplace outbreaks have been observed. This study aimed to identify the proportion of symptomatic staff members attending workplaces after symptom onset or testing, and associated factors. METHODS: This study of symptomatic COVID-19 cases associated with London workplaces used London Coronavirus Response Centre (LCRC) records from routine telephone calls with cases and employers, from 17th July to 10th September. For each case, symptoms, date of onset, date of testing and the last attendance at work were extracted. Univariable logistic regression was performed to investigate whether age, gender or occupation was associated with workplace attendance after the onset of symptoms. RESULTS: Out of 130 symptomatic COVID-19 cases, 42 (32.3%) attended the workplace after their reported date of symptom onset, including 16 (12.3%) with recorded COVID-19 symptoms. Five staff members attended after COVID-19 testing. Males were 66% less likely to attend the workplace after the onset of COVID-19 symptoms compared to females (odds ratio 0.34, P = 0.05). Age and occupation were not predictive for workplace attendance after the onset of symptoms. CONCLUSION: A minority of symptomatic cases attended the workplace after the onset of COVID-19 symptoms, with a smaller proportion attending after testing. Males appeared less likely to attend the workplace after the onset of COVID-19 symptoms. This study highlights the need for ongoing COVID-19 secure workplace practices and prompt self-isolation after COVID-19 symptom onset or testing.

High prevalence of SARS-CoV-2 antibodies in care homes affected by COVID-19: Prospective cohort study, England.

BACKGROUND: We investigated six London care homes experiencing a COVID-19 outbreak and found high rates of SARS-CoV-2 infection among residents and staff. Here we report follow-up investigations including antibody testing in the same care homes five weeks later. METHODS: Residents and staff in the initial investigation had a repeat nasal swab for SARS-CoV-2 RT-PCR and a blood test for SARS CoV-2 antibodies using ELISA based on SARS-CoV-2 native viral antigens derived from infected cells and virus neutralisation. FINDINGS: Of the 518 residents and staff in the initial investigation, 186/241 (77.2%) surviving residents and 208/254 (81.9%) staff underwent serological testing. Almost all SARS-CoV-2 RT-PCR positive residents and staff were seropositive five weeks later, whether symptomatic (residents 35/35, 100%; staff, 22/22, 100%) or asymptomatic (residents 32/33, 97.0%; staff 21/22, 95.5%). Symptomatic but SARS-CoV-2 RT-PCR negative residents and staff also had high seropositivity rates (residents 23/27, 85.2%; staff 18/21, 85.7%), as did asymptomatic RT-PCR negative individuals (residents 61/91, 67.0%; staff 95/143, 66.4%). Neutralising antibody was detected in 118/132 (89.4%) seropositive individuals and was not associated with age or symptoms. Ten residents (10/79 re-tested, 12.7%) remained RT-PCR positive but with higher RT-PCR cycle threshold values; 7/10 had serological testing and all were seropositive. New infections were detected in three residents and one staff. INTERPRETATION: RT-PCR provides a point prevalence of SARS-CoV-2 infection but significantly underestimates total exposure in outbreak settings. In care homes experiencing large COVID-19 outbreaks, most residents and staff had neutralising SARS-CoV-2 antibodies, which was not associated with age or symptoms. FUNDING: PHE.

Investigation of SARS-CoV-2 outbreaks in six care homes in London, April 2020.

BACKGROUND: Care homes are experiencing large outbreaks of COVID-19 associated with high case-fatality rates. We conducted detailed investigations in six London care homes reporting suspected COVID-19 outbreaks during April 2020. METHODS: Residents and staff had nasal swabs for SARS CoV-2 testing using RT-PCR and were followed-up for 14 days. They were categorized as symptomatic, post-symptomatic or pre-symptomatic if they had symptoms at the time of testing, in the two weeks before or two weeks after testing, respectively, or asymptomatic throughout. Virus isolation and whole genome sequencing (WGS) was also performed. FINDINGS: Across the six care homes, 105/264 (39.8%) residents were SARS CoV-2 positive, including 28 (26.7%) symptomatic, 10 (9.5%) post-symptomatic, 21 (20.0%) pre-symptomatic and 46 (43.8%) who remained asymptomatic. Case-fatality at 14-day follow-up was highest among symptomatic SARS-CoV-2 positive residents (10/28, 35.7%) compared to asymptomatic (2/46, 4.3%), post-symptomatic (2/10, 20.0%) or pre-symptomatic (3/21,14.3%) residents. Among staff, 53/254 (20.9%) were SARS-CoV-2 positive and 26/53 (49.1%) remained asymptomatic. RT-PCR cycle-thresholds and live-virus recovery were similar between symptomatic/asymptomatic residents/staff. Higher RT-PCR cycle threshold values (lower virus load) samples were associated with exponentially decreasing ability to recover infectious virus (P<0.001). WGS identified multiple (up to 9) separate introductions of different SARS-CoV-2 strains into individual care homes. INTERPRETATION: A high prevalence of SARS-CoV-2 positivity was found in care homes residents and staff, half of whom were asymptomatic and potential reservoirs for on-going transmission. A third of symptomatic SARS-CoV-2 residents died within 14 days. Symptom-based screening alone is not sufficient for outbreak control. FUNDING: None.

Increased risk of SARS-CoV-2 infection in staff working across different care homes: enhanced CoVID-19 outbreak investigations in London care Homes.

BACKGROUND: Care homes have been disproportionately affected by the COVID-19 pandemic and continue to suffer large outbreaks even when community infection rates are declining, thus representing important pockets of transmission. We assessed occupational risk factors for SARS-CoV-2 infection among staff in six care homes experiencing a COVID-19 outbreak during the peak of the pandemic in London, England. METHODS: Care home staff were tested for SARS-COV-2 infection by RT-PCR and asked to report any symptoms, their contact with residents and if they worked in different care homes. Whole genome sequencing (WGS) was performed on RT-PCR positive samples. RESULTS: In total, 53 (21%) of 254 staff were SARS-CoV-2 positive but only 12/53 (23%) were symptomatic. Among staff working in a single care home, SARS-CoV-2 positivity was 15% (2/13), 16% (7/45) and 18% (30/169) in those reporting no, occasional and regular contact with residents. In contrast, staff working across different care homes (14/27, 52%) had a 3.0-fold (95% CI, 1.9-4.8; P<0.001) higher risk of SARS-CoV-2 positivity than staff working in single care homes (39/227, 17%). WGS identified SARS-CoV-2 clusters involving staff only, including some that included staff working across different care homes. CONCLUSIONS: SARS-CoV-2 positivity was significantly higher among staff working across different care homes than those who were working in the same care home. We found local clusters of SARS-CoV-2 infection between staff only, including those with minimal resident contact. Infection control should be extended for all contact, including those between staff, whilst on care home premises.

The novel Group A Streptococcus antigen SpnA combined with bead-based immunoassay technology improves streptococcal serology for the diagnosis of acute rheumatic fever.

OBJECTIVES: Streptococcal serology provides evidence of prior Group A Streptococcus (GAS) exposure, crucial to the diagnosis of acute rheumatic fever (ARF) and post-streptococcal glomerulonephritis. However, current tests, which measure anti-streptolysin-O and anti-DNaseB antibodies, are limited by false positives in GAS endemic settings, and incompatible methodology requiring the two tests to be run in parallel. The objective was to improve streptococcal serology by combining the novel GAS antigen, SpnA, with streptolysin-O and DNaseB in a contemporary, bead-based immunoassay. METHODS: Recombinant streptolysin-O, DNAseB and SpnA were conjugated to polystyrene beads with unique fluorescence positions so antibody binding to all three antigens could be detected simultaneously by cytometric bead array. Multiplex assays were run on sera collected in three groups: ARF; ethnically matched healthy children; and healthy adults. RESULTS: The ability of the antigens to detect a previous GAS exposure in ARF was assessed using the 80th centile of the healthy children group as cut-off (upper limit of normal). SpnA had the highest sensitivity at 88%, compared with 75% for streptolysin-O and 56% for DNaseB. CONCLUSIONS: SpnA has favorable immunokinetics for streptococcal serology, and can be combined with anti-streptolysin-O and anti-DNaseB in a multiplex format to improve efficiency and accuracy.

Evidence of High Mortality and Increasing Burden of Sepsis in a Regional Sample of the New Zealand Population.

BACKGROUND: Sepsis is a life-threatening complication of infection. The incidence of sepsis is thought to be on the increase, but estimates making use of administrative data in the United States may be affected by administrative bias. METHODS: We studied the population-based incidence of sepsis in the Waikato region of New Zealand from 2007 to 2012 using International Classification of Diseases, Tenth Revision, Australian Modification, which lacks a specific code for sepsis. RESULTS: Between 2007 and 2012, 1643 patients met coding criteria for sepsis in our hospitals. Sixty-three percent of patients were 65 or over, 17% of cases were admitted to an intensive care unit, and the in-hospital and 1-year mortality with sepsis was 19% and 38%, respectively. Age-standardized rate ratios (ASRRs) demonstrated that sepsis was associated with male sex (ASRR 1.4; 95% confidence interval [CI], 1.23-1.59), Maori ethnicity (ASRR 3.22 compared with non-Maori; 95% CI, 2.85-3.65), study year (ASRR 1.62 comparing 2012 with 2008; 95% CI, 1.18-2.24), and socioeconomic deprivation (ASRR 1.72 comparing the highest with the lowest quintile of socioeconomic deprivation; 95% CI, 1.5-1.97). Multiorgan failure was present in approximately 20% of cases in all age groups. Intensive care unit admission rate fell from 30% amongst 25- to 34-year-olds to less than 10% amongst those aged 75 and over. CONCLUSIONS: In a 9% sample of the New Zealand population, the incidence of sepsis increased by 62% over a 5-year period. Maori, elderly, and disadvantaged populations were most affected.

Serological Evidence of Immune Priming by Group A Streptococci in Patients with Acute Rheumatic Fever.

Acute rheumatic fever (ARF) is an autoimmune response to Group A Streptococcus (GAS) infection. Repeated GAS exposures are proposed to 'prime' the immune system for autoimmunity. This notion of immune-priming by multiple GAS infections was first postulated in the 1960s, but direct experimental evidence to support the hypothesis has been lacking. Here, we present novel methodology, based on antibody responses to GAS T-antigens, that enables previous GAS exposures to be mapped in patient sera. T-antigens are surface expressed, type specific antigens and GAS strains fall into 18 major clades or T-types. A panel of recombinant T-antigens was generated and immunoassays were performed in parallel with serum depletion experiments allowing type-specific T-antigen antibodies to be distinguished from cross-reactive antibodies. At least two distinct GAS exposures were detected in each of the ARF sera tested. Furthermore, no two sera had the same T-antigen reactivity profile suggesting that each patient was exposed to a unique series of GAS T-types prior to developing ARF. The methods have provided much-needed experimental evidence to substantiate the immune-priming hypothesis, and will facilitate further serological profiling studies that explore the multifaceted interactions between GAS and the host.

Retrospective epidemiology of acute rheumatic fever: a 10-year review in the Waikato District Health Board area of New Zealand.

BACKGROUND: Acute rheumatic fever (ARF) is a preventable disease which remains a prominent burden of health in New Zealand, with an annual incidence comparable to that of developing countries. AIM: The aim of this study was to describe the epidemiology of ARF and recurrent ARF cases in the Waikato District Health Board (DHB) area of New Zealand from 1 January 2002 to 31 December 2011. METHODS: A total of 106 cases of ARF and four cases of recurrent ARF were identified through the Public Health Database - EpiSurv and the Hospital coding system, ICD-10. RESULTS: The overall Waikato DHB annual incidence of ARF was 3.1 per 100,000 population with Maori children aged 5-14 years experiencing higher rates of 46.1 per 100,000 population. Eighty-five percent of the cases were of Maori ethnicity, and 10% Pacific. Almost three-quarters of all cases lived in areas of the three most deprived deciles as described by the New Zealand Deprivation Index 2006. DISCUSSION: The rates of ARF seen in the Waikato DHB are comparable to that seen previously locally and nationally. High risk groups have been identified as children aged 5-14 years, Maori and Pacific ethnicity, and those living in lower socioeconomic areas which could be targeted by the Rheumatic Fever Prevention Programme (RFPP) with the intention to reduce the incidence of ARF nationally to 0.4 cases per 100,000 population by 2017.

Structural conservation, variability, and immunogenicity of the T6 backbone pilin of serotype M6 Streptococcus pyogenes.

Group A streptococcus (GAS; Streptococcus pyogenes) is a Gram-positive human pathogen that causes a broad range of diseases ranging from acute pharyngitis to the poststreptococcal sequelae of acute rheumatic fever. GAS pili are highly diverse, long protein polymers that extend from the cell surface. They have multiple roles in infection and are promising candidates for vaccine development. This study describes the structure of the T6 backbone pilin (BP; Lancefield T-antigen) from the important M6 serotype. The structure reveals a modular arrangement of three tandem immunoglobulin-like domains, two with internal isopeptide bonds. The T6 pilin lysine, essential for polymerization, is located in a novel VAKS motif that is structurally homologous to the canonical YPKN pilin lysine in other three- and four-domain Gram-positive pilins. The T6 structure also highlights a conserved pilin core whose surface is decorated with highly variable loops and extensions. Comparison to other Gram-positive BPs shows that many of the largest variable extensions are found in conserved locations. Studies with sera from patients diagnosed with GAS-associated acute rheumatic fever showed that each of the three T6 domains, and the largest of the variable extensions (V8), are targeted by IgG during infection in vivo. Although the GAS BP show large variations in size and sequence, the modular nature of the pilus proteins revealed by the T6 structure may aid the future design of a pilus-based vaccine.

A retrospective review of notified human cryptosporidiosis cases in the Waikato region of New Zealand, 2004 to 2011.

AIM: To retrospectively review notified human cryptosporidiosis cases in the Waikato region of New Zealand between 2004 and 2011 and to identify risk factors for human cryptosporidiosis infection. METHOD: Waikato cryptosporidiosis notification data for the period 1 January 2004 to 31 December 2011 were analysed to identify any trends in the rates and distribution of key variables. A comparison was made between urban and rural dwelling cases. RESULTS: Annual Waikato cryptosporidiosis notification rates were consistently higher than national rates. Analysis showed a seasonal peak centred around September with most cases having direct or indirect contact with cattle. Comparisons between urban and rural cases showed similar probable causes of infection and higher rates of infection in rural cases. CONCLUSION: Those who have contact with animals continue to be at risk of infection from Cryptosporidium. The data suggests that children who live on rural properties and have contact with animal faeces, either directly or via a contaminated drinking water supply, are at the highest risk of infection.

A retrospective review of notified human leptospirosis cases in the Waikato region of New Zealand, 2004 to 2010.

AIM: To retrospectively review notified human leptospirosis cases in the Waikato region of New Zealand between 2004 and 2010 and to identify risk factors for human leptospirosis infection. METHOD: Waikato leptospirosis notification data for the period 1 January 2004 to 31 December 2010 were analysed to identify any trends in the rates and distribution of key variables. RESULTS: Annual Waikato leptospirosis notification rates were consistently higher than national rates. Infection was associated with males (93%) of working age (97%) who had exposure to animals through their occupation. Most cases were employed in dry stock farming, dairy farming or in the meat processing industry. CONCLUSION: Those who work with cattle continue to be at risk of infection from Leptospira. The data suggests that dry stock cattle farmers are at the highest risk. It is speculated that the immunisation of all cattle herds may further reduce the incidence of leptospirosis, although more accurate collection of work exposure data and further analysis is needed to determine this.

Transmission of Mycobacterium orygis (M. tuberculosis complex species) from a tuberculosis patient to a dairy cow in New Zealand.

Mycobacterium orygis, previously called the oryx bacillus, is a member of the Mycobacterium tuberculosis complex and has been reported only recently as a cause of human tuberculosis in patients of South Asian origin. We present the first case documenting the transmission of this organism from a human to a cow.

Does a clinical guideline change chlamydia testing? Report from the Waikato Chlamydia Project.

BACKGROUND AND CONTEXT: Waikato District Health Board was one of three districts chosen to implement a national chlamydia management guideline, with the aim of optimising testing and treatment. Previous New Zealand studies suggest any test increases associated with such an intervention may be short-lived. ASSESSMENT OF PROBLEM: District-wide chlamydia test volumes were compared for three periods, before (June-Nov 2008), during (June-Nov 2009) and after (June-Nov 2010) guideline implementation by age, gender and ethnicity. Crude estimates of population test uptake were calculated. Azithromycin pharmacy claim volumes were assessed as a measure of treatment. RESULTS: Chlamydia test uptake for women was already high, with 23% of 15- to 24-year-old women tested during the period from June to November 2008. Although tests from under-25-year-olds increased during implementation in 2009, the change was not significant and was not sustained in 2010, p=0.06. Similarly, there were no significant sustained changes by gender or ethnicity following implementation. STRATEGIES FOR IMPROVEMENT: This includes a continued emphasis on optimal chlamydia case finding and treatment by focusing on those at greater risk of infection. Efforts to improve partner notification should be instigated which may in turn better engage men around sexual health. LESSONS: Local data should be used to identify local issues. There is a need to determine whether <25 years is the optimal age threshold for targeted chlamydia testing in New Zealand and to ensure appropriate resources, training and support are in place for primary care nurses who play a pivotal role in sexual health care delivery.