The impact of COVID-19 public health measures on attendance and overdose at supervised injecting facilities in Australia.

OBJECTIVES: The COVID-19 pandemic disrupted service provision of harm reduction and drug treatment services for people who inject drugs in many countries. The two supervised injecting facilities (SIFs) in Sydney and Melbourne were differentially impacted by the pandemic, requiring local procedural changes in each service. We aimed to examine the impact of pandemic responses (including restrictions on movement, known as 'lockdowns') on service use and key parameters such as client reports of drug injected and recorded overdose rates. STUDY DESIGN: Time series analysis of weekly client visits and monthly overdoses occurring at each service. METHODS: Administrative client data from the two SIFs (Sydney data from 1 January 2018 to 30 April 2022; Melbourne data from 1 July 2018 to 30 April 2022) were examined using interrupted time series analyses with lockdown dates in each state entered as interruption terms. We analysed weekly SIF visits overall and by drug type, and monthly rates of opioid overdose at each service. RESULTS: Lockdowns resulted in decreased visits to both services. The number of weekly client visits decreased during the first national lockdown for both the Sydney (trend change = -57.9; 95% CI [-109.4, -6.4]) and Melbourne SIF (near sig trend change = -54.8 [-110.8, 1.05]). Trends in visit numbers increased after lockdowns were lifted in each city; however, visits in Sydney have not returned to the numbers recorded prior to the pandemic. Visits to the Melbourne SIF related to heroin use declined at each lockdown (trend 1 = -42.7 [-81.5, -3.9]; trend 2 = -56.1 [-94.6, -17.7]; trend 3 = -33.8 [-67.4, -0.2]); heroin visits to the Sydney SIF declined during the first lockdown and remained low (trend = -55.6 [-82.8, -28.3]). Methamphetamine visits to the Sydney SIF fluctuated, surpassing heroin visits at several timepoints. Rates of monthly opioid overdoses at both services declined immediately following the start of the first lockdown (Sydney = -16.6 [-26.1, -6.8]; Melbourne = -6.4 [-8.7, -4.1]), with increasing trends recorded at the end of the final lockdown in each jurisdiction (Sydney = 2.8 [0.6, 5.0]; Melbourne = 1.3 [0.72, 3.2]). CONCLUSIONS: Public health restrictions related to the COVID-19 pandemic were associated with reduced client visits to, and overdoses in, Australian SIFs. Variations were noted in the drugs injected, likely reflecting changes in local drug markets. Shifts to other drugs during these periods were evident: methamphetamine in Sydney; co-injection of heroin and diphenhydramine in Melbourne.

Does sexuality matter? A cross-sectional study of drug use, social injecting, and access to injection-specific care among men who inject drugs in Melbourne, Australia.

BACKGROUND: Gay, bisexual and other men who have sex with men (GBMSM) are overrepresented in cohorts of people who inject drugs. GBMSM's substance use is usually explored in the context of its contribution to sexual risk. We examined drug use practices, connectedness to other people who inject drugs, peer-to-peer injecting, and access to care among men who inject drugs in Melbourne, Australia. We aim to describe similarities and differences in these parameters for GBMSM and other men. METHODS: Data were drawn from a prospective cohort study of people who inject drugs conducted in Melbourne, Australia, since 2009. This cross-sectional study used data collected between 2016 and 2021. Descriptive statistics were used to assess differences between GBMSM and other men. RESULTS: Of 525 men who injected drugs over the study period, 48 (9%) identified as gay or bisexual, or reported sex with other men in the past 12 months. GBMSM and other men reported similar socio-demographics, drug practices (age of injecting initiation, most injected drug, peer-to-peer injecting, receptive syringe sharing) and access to injecting-specific care (drug treatment, source of needle-syringes). A significantly greater percentage of GBMSM reported past 12-month hepatitis C testing (69% vs. 52%, p = 0.028) and preferring methamphetamine (31% vs. 16%, p = 0.022). A higher percentage of GBMSM reported knowing > 50 other people who inject drugs (46% vs. 37%), but this difference was not statistically significant. Both groups primarily obtained injecting equipment from needle-syringe programs; a minority had accessed injecting-specific primary care. CONCLUSION: Men who injected drugs in this cohort and those who identified as GBMSM reported similar drug and health-seeking practices. The higher prevalence of methamphetamine injecting among GBMSM may warrant different harm reduction support for this group. Health promotion should utilise opportunities to connect men who inject drugs in Melbourne to injecting-specific primary health care.

Trust and service engagement among people who inject drugs after release from prison.

BACKGROUND: Compounding histories of injecting drug use and incarceration can marginalise people engaging with services, making it difficult for them to address their health and social welfare needs, particularly when they navigate community re-entry service supports. Drawing on Hall and colleagues' five components of trust, this paper seeks to understand how trust in service providers fosters (or inhibits) effective service engagement from the perspective of people who inject drugs during the prison post-release period. METHODS: Between September 2018 and May 2020, qualitative in-depth interviews were completed with 48 adults (33 men, 15 women) recruited from SuperMIX (a longitudinal cohort study of people with a history of injection drug use in Victoria, Australia). Data relating to service engagement were coded against the five components of trust: competence, fidelity, honesty, global trust, and confidence. RESULTS: Reflections of post-release service engagement frequently focused on interactions with community corrections (parole) officers. Depictions of trust were consistently portrayed within the context of negative experiences and deficits, whereby trusting provider relationships and interactions were rarely described. Most participants recounted a stark absence of fidelity (that is, "pursuing a [client's] best interests"), with some participants detailing circumstances in which their vulnerability was purposefully, almost strategically, exploited. These encounters nearly always had the consequence of impeding the participant's positive progression in the post-release integration period. CONCLUSION: There is an urgent need to prioritise the client in health and social service delivery in the post-release transition-to-community period and recognise the importance of trust in delivering effective services to people whose life histories make them highly vulnerable to marginalisation.

Workplace intervention programmes for decreasing alcohol use in military personnel: a systematic review.

INTRODUCTION: Harmful or risky-single occasion drinking (RSOD) alcohol use in the military is a significant problem. However, most studies of interventions have focused on veterans, representing a missed opportunity for intervention with active military personnel. Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework, the aim of this systematic review was to analyse and synthesise the evidence related to workplace-based interventions for reducing alcohol use in active-duty military personnel. METHODS: Four electronic databases and reference lists of relevant articles were searched from database inception until 20 January 2020. This review focused on experimental and quasi-experimental studies of active-duty military personnel. Data extraction and methodological quality assessment were independently performed by two reviewers using a standardised checklist. A third reviewer was used to arbitrate the disputed studies for final selection. RESULTS: The search yielded seven studies from an initial 1582 records identified. A range of interventions were used in these studies (four randomised controlled trials, two non-randomised trials and one before and after cohort study), including web-based approaches, telephone-delivered interventions and individual and group-based face-to-face interventions. Seven studies found decreased drinking, measured using a range of outcomes, following the intervention. However, this was not sustained in the longer term in any of the studies. CONCLUSIONS: The low methodological rigour of most studies limited the capacity to demonstrate the efficacy of the interventions studied. Given the importance of reducing harmful or RSOD use of alcohol in the military, future studies would benefit from improved methodological rigour including ensuring adequate study power, randomisation, selection of validated outcome measures, including measures other than consumption (eg, attitudinal measures), and longer-term follow-up. There is also a need to develop methods that ensure participant loss to follow-up is minimised.

Comparing short versions of the Alcohol Use Disorders Identification Test (AUDIT) in a military cohort.

BACKGROUND: The Alcohol Use Disorders Identification Test (AUDIT) is widely used for monitoring harmful alcohol consumption among high-risk populations. A number of short versions of AUDIT have been developed for use in time-constrained settings. In military populations, a range of AUDIT variations have been used, but the optimal combination of AUDIT items has not been determined. METHODS: A total of 952 participants (80% male), recruited as part of a wider study, completed the AUDIT-10. We systematically assessed all possible combinations of three or four AUDIT items and established AUDIT variations using the following statistics: Cronbach's alpha (internal consistency), variance explained (R2) and Pearson's correlation coefficient (concurrent validity). RESULTS: Median AUDIT-10 score was 7 for males and 6 for females, and 380 (40%) participants were classified as having a score indicative of harmful or hazardous alcohol use (≥8) according to WHO classifications.A novel four-item AUDIT variation (3, 4, 8 and 9) performed consistently higher than established variations across statistical measures; it explained 85% of variance in AUDIT-10, had a Pearson's correlation of 0.92 and Cronbach's alpha was 0.63. The FAST, an established shortened AUDIT variant, together with several other four-item novel variants of AUDIT-10 performed similarly. The AUDIT-C performed consistently low on all measures, but with a satisfactory level of internal consistency (75%). CONCLUSION: Shortened AUDIT variations may be suitable alternatives to the full AUDIT for screening hazardous alcohol consumption in military populations. Four-item AUDIT variations focused on short-term risky drinking and its consequences performed better than three item versions. TRIAL REGISTRATION NUMBER: ACTRN12614001332617.

Repeat participation in annual cross-sectional surveys of drug users and its implications for analysis.

OBJECTIVE: We sought to establish the extent of repeat participation in a large annual cross-sectional survey of people who inject drugs and assess its implications for analysis. RESULTS: We used "porn star names" (the name of each participant's first pet followed by the name of the first street in which they lived) to identify repeat participation in three Australian Illicit Drug Reporting System surveys. Over 2013-2015, 2468 porn star names (96.2%) appeared only once, 88 (3.4%) twice, and nine (0.4%) in all 3 years. We measured design effects, based on the between-cluster variability for selected estimates, of 1.01-1.07 for seven key variables. These values indicate that the complex sample is (e.g.) 7% less efficient in estimating prevalence of heroin use (ever) than a simple random sample, and 1% less efficient in estimating number of heroin overdoses (ever). Porn star names are a useful means of tracking research participants longitudinally while maintaining their anonymity. Repeat participation in the Australian Illicit Drug Reporting System is low (less than 5% per annum), meaning point-prevalence and effect estimation without correction for the lack of independence in observations is unlikely to seriously affect population inference.

Assessing individual-level needle and syringe coverage parameters and the measurement of coverage in Melbourne, Australia: methods and impacts.

Background: To assess the structure of individual-level needle and syringe coverage measurement formula, and to estimate the impact of coverage-related behaviours/parameters (instances of syringe acquisition, total syringes acquired, peer-to-peer syringe distribution, injecting frequency) on overall coverage. Methods: Data are drawn from the Melbourne (Australia) injecting drug user cohort study, 2010-16. Data from 518 participants were analysed. We used correlations to explore the relationships between coverage parameters; pooled multiple-linear regression to estimate the effect of each parameter on coverage over time; and exploratory factor analysis to assess the relevance of each parameter within the coverage formula. Results: A 1-unit increase in injecting frequency over time reduced coverage by 10.93 percentage points, almost twice as much as other coverage parameters. Factor analysis results indicated potential improvements to coverage formula structure. Conclusions: Our results suggest that reducing injecting frequency amongst people who inject drugs has the largest improvement in coverage levels, indicating harm reduction services should prioritize it. We also demonstrate that coverage measurement has been inconsistent to date. We sought to refine the method to assist in generating comparable research.

Injecting drug use in low and middle-income countries: Opportunities to improve care and prevent harm.

Inadequate response to injecting drug use (IDU) is a significant problem the world over. Low levels of funding, political inaction, poor levels of health service coverage, high prevalence and incidence of IDU-related blood-borne viruses (BBVs) and ongoing stigmatization/marginalization affect people who inject drugs (PWID) regardless of the income status of the country they reside in. These barriers and system failings are, however, exacerbated in low and middle-income countries (LMICs), meaning that the potential consequences of inaction are more pressing. In this narrative review, we describe the levels of IDU and IDU-specific BBV prevalence in LMICs; levels of harm reduction implementation; the consequences of late or insufficient response, the shortcomings of data collection and dissemination; and the barriers to effective LMIC harm reduction implementation. We also exemplify cases where IDU-related harms and BBV epidemics have been successfully curtailed in LMICs, showing that effective response, despite the barriers, is possible. In conclusion, we suggest four key priorities on the basis of the review: confirming the presence or absence of IDU in LMICs, improving the collection and dissemination of national IDU-specific data, increasing the level of harm reduction programme implementation in LMICs, and increasing both national and international advocacy for PWID and attendant public health interventions.

The effects of needle-sharing and opioid substitution therapy on incidence of hepatitis C virus infection and reinfection in people who inject drugs.

Although high hepatitis C virus (HCV) prevalence has been observed in people who inject drugs (PWID) for decades, research suggests incidence is falling. We examined whether PWIDs' use of opioid substitution therapy (OST) and their needle-and-syringe sharing behaviour explained HCV incidence. We assessed HCV incidence in 235 PWID in Melbourne, Australia, and performed discrete-time survival with needle-sharing and OST status as independent variables. HCV infection, reinfection and combined infection/reinfection incidences were 7·6 [95% confidence interval (CI) 4·8-11·9], 12·4 (95% CI 9·1-17·0) and 9·7 (95% CI 7·4-12·6) per 100 person-years, respectively. Needle-sharing was significantly associated with higher incidence of naive HCV infection [hazard ratio (HR) 4·9, 95% CI 1·3-17·7] but not reinfection (HR 1·85, 95% CI 0·79-4·32); however, a cross-model test suggested this difference was sample specific. Past month use of OST had non-significant protective effects against naive HCV infection and reinfection. Our data confirm previous evidence of greatly reduced HCV incidence in PWID, but not the significant protective effect of OST on HCV incidence detected in recent studies. Our findings reinforce the need for greater access to HCV testing and prevention services to accelerate the decline in incidence, and HCV treatment, management and support to limit reinfection.

The relationship between age and risky injecting behaviours among a sample of Australian people who inject drugs.

BACKGROUND: Limited evidence suggests that younger people who inject drugs (PWID) engage in high-risk injecting behaviours. This study aims to better understand the relationships between age and risky injecting behaviours. METHODS: Data were taken from 11 years of a repeat cross-sectional study of sentinel samples of regular PWID (The Australian Illicit Drug Reporting System, 2001-2011). Multivariable Poisson regression was used to explore the relationship between age and four outcomes of interest: last drug injection occurred in public, receptive needle sharing (past month), experiencing injecting-related problems (e.g. abscess, dirty hit; past month), and non-fatal heroin overdose (past six months). RESULTS: Data from 6795 first-time study participants were analysed (median age: 33 years, interquartile range [IQR]: 27-40; median duration of injecting: 13 years [IQR: 7-20]). After adjusting for factors including duration of injecting, each five year increase in age was associated with significant reductions in public injecting (adjusted incidence rate ratio [AIRR]: 0.90, 95% confidence interval [CI]: 0.88-0.92), needle sharing (AIRR: 0.84, 95% CI: 0.79-0.89) and injecting-related problems (AIRR: 0.96, 95% CI: 0.95-0.97). Among those who had injected heroin in the six months preceding interview, each five year increase in age was associated with an average 10% reduction in the risk of heroin overdose (AIRR: 0.90, 95% CI: 0.85-0.96). CONCLUSIONS: Older PWID report significantly lower levels of high-risk injecting practices than younger PWID. Although they make up a small proportion of the current PWID population, younger PWID remain an important group for prevention and harm reduction.

Mortality and life-years lost due to alcohol: a comparison of acute and chronic causes.

OBJECTIVES: (i) To estimate the numbers of deaths and person-years of life lost (PYLL) due to high-risk alcohol consumption in Australia during 1997, using current estimates of consumption. (ii) To compare the number of deaths and PYLL due to acute conditions associated with bouts of intoxication and chronic conditions associated with long-term misuse of alcohol. METHODS: All Australian deaths during 1997 related to conditions considered to be partially or wholly caused by high-risk alcohol consumption were extracted from the Australian Bureau of Statistics Mortality Datafile and adjusted by alcohol aetiologic fractions calculated for Australia in 1997. A life-table method was used to estimate the PYLL for deaths from alcohol-caused conditions. MAIN OUTCOME MEASURES: Numbers of all deaths and PYLL due to chronic and acute alcohol-related conditions. RESULTS: Of the 3290 estimated alcohol-caused deaths in 1997, chronic conditions (eg, alcoholic liver cirrhosis and alcohol dependence) accounted for 42%, acute conditions (eg, alcohol-related road injuries and assaults) for 28% and mixed (chronic and acute) for 30%. Of the 62914 estimated potential life years lost, acute conditions were responsible for 46%, chronic for 33% and mixed for 21%. The average number of years of life lost through deaths from acute conditions was more than twice that from chronic conditions, because the former mostly involved younger people. CONCLUSIONS: In view of the societal burdens imposed by premature deaths, more effective public health strategies are needed to reduce the harm associated with occasional high-risk drinking (as well as sustained high-risk drinking), especially among young people.

Adherence of Staphylococcus aureus to endothelial cells: influence of capsular polysaccharide, global regulator agr, and bacterial growth phase.

The adherence of Staphylococcus aureus to human endothelial cells (EC) is probably an important step in the pathogenesis of systemic staphylococcal infections. We examined the influence of type 5 capsular polysaccharide (CP5) production, the global regulator agr, and the bacterial growth phase on S. aureus adherence to EC. Whereas S. aureus Newman showed maximal adherence to EC in the logarithmic phase of growth, an isogenic agr mutant showed maximal adherence in the stationary growth phase. S. aureus adherence to EC and CP5 expression were negatively correlated: a mutation in the agr locus diminished CP5 production and led to increased adherence. Likewise, induction of CP5 expression by addition of NaCl to the growth medium resulted in reduced staphylococcal adherence to EC. S. aureus Newman cells that adhered to EC did not express CP5. A Newman cap5O mutant was acapsular and showed significantly greater adherence to EC than the parental strain did (P<0.005). Complementation of the cap5O mutation in trans restored CP5 expression and reduced EC adherence to a level similar to that of the parental strain. The enhanced adherence shown by the cap5O mutant was similar in magnitude to that of the agr mutant or the cap5O agr double mutant. Cells of the cap5O mutant and cap5O agr double mutant harvested from stationary-phase cultures adhered significantly better than did cells harvested in the exponential growth phase. These data are consistent with the postexponential and agr-independent expression by S. aureus of at least one putative EC adhesin, whose binding domain may be masked by CP5.

Agr-independent regulation of fibronectin-binding protein(s) by the regulatory locus sar in Staphylococcus aureus.

Fibronectin-binding proteins (FnBPs) are thought to be important for the attachment of Staphylococcus aureus during infection. The regulation of the genes fnbA and fnbB by the global regulatory loci sar and agr was examined using site-specific regulatory mutants of S. aureus strain Newman. The results from binding assays using both aqueous and solid-phase fibronectin as well as ligand blotting with biotinylated fibronectin showed that the expression of FnBPA is enhanced in the agr mutant but inhibited in the sar mutant and the sar-agr double mutant. The same regulatory pattern was observed in Northern blot analysis using fnbA-specific probes. The introduction of sar on a multicopy plasmid increased the already enhanced fnbA transcription of the agr mutant. FnBPB was not detectable by ligand blotting and the fnbB promoter activity in promoter fusion assays was not affected by either sar or agr. The sequence encompassing ORF3 located upstream of sarA was found to be essential for the activation of fnbA transcription. We hypothesize that this sequence may modulate SarA expression and/or activity on the post-transcriptional level. Gel shift assays demonstrated that SarA binds to the fnbA promoter fragments, probably as a dimer. DNase I footprinting assays with SarA revealed a protected area of 102 bp upstream of fnbA.

Associations between alcohol related hospital admissions and alcohol consumption in Victoria: influence of socio-demographic factors.

OBJECTIVE: To examine the cross-sectional ecologic associations between apparent per-capita alcohol consumption, alcohol-related hospital admission rates, and the distributions of socio-demographic factors for people residing in 76 Local Government Areas (LGAs) in Victoria, during the 1995-1996 fiscal year. METHOD: Visitor-adjusted per-capita alcohol consumption was obtained from wholesale sales data from the Liquor Licensing Commission Victoria. Alcohol-related hospital admission rates were extracted from the Victorian Inpatient Minimum Dataset, and adjusted by the appropriate aetiologic fractions. Summary socio-demographic measures were derived from the 1996 Census. Their associations were analysed using multiple linear regression. RESULTS: Per-capita alcohol consumption ranged from 4 to 14 litres absolute alcohol/year and alcohol-related hospital admission rates ranged from 5 to 25 per 10,000 residents/year (external-cause diagnoses) and 8-37 per 10,000 residents/year (disease diagnoses). Higher levels of per-capita consumption were associated with higher admission rates (r = 0.45 for external cause diagnoses, r = 0.66 for disease diagnoses, and r = 0.70 for all diagnoses), each per-capita increase of one litre/year corresponding to increased admission rates of 0.6, 1.5 and 2.1 per 10,000 person-years, respectively. Further adjustments by summary socio-demographic measures reduced, but did not modify, the associations between per-capita consumption and admission rates. CONCLUSIONS AND IMPLICATIONS: Summary measures of sales-based per-capita alcohol consumption and socio-demographic environments may provide useful indicators of alcohol-related morbidity in Victorian communities.

Visual function following trabeculectomy: effect on corneal topography and contrast sensitivity.

PURPOSE: This study was to determine the role of changes in refractive error, contrast sensitivity, and corneal topography in transient changes in visual function following trabeculectomy. METHODS: We performed a prospective study evaluating these factors in 13 consecutive patients undergoing a standardized trabeculectomy. Preoperatively, and at 1, 4, and 12 weeks postoperatively, we measured best-corrected visual acuity, refractive error, and contrast sensitivity and analyzed computerized video-keratographic studies including estimated corneal visual acuity. RESULTS: One week postoperatively, best-corrected visual acuity decreased at least one line in 8 of 13 patients, whereas no eyes had decreased contrast sensitivity. Mean central corneal astigmatism increased 1.4 diopters along the surgical meridian. By 12 weeks, visual acuity returned to preoperative levels in all patients and the corneal topographic changes returned to within 1 diopter of preoperative values in 12 of 13 patients. Postoperative changes in estimated corneal visual acuity were similar to those in best-corrected visual acuity with no statistically significant difference. CONCLUSIONS: Corneal topographic changes appear to contribute to visual acuity reduction following trabeculectomy. In most cases this is transient with return to preoperative topography within 12 weeks.

TRANSFAC, TRRD and COMPEL: towards a federated database system on transcriptional regulation.

Three databases that provide data on transcriptional regulation are described. TRANSFAC is a database on transcription factors and their DNA binding sites. TRRD (Transcription Regulatory Region Database) collects information about complete regulatory regions, their regulation properties and architecture. COMPEL comprises specific information on composite regulatory elements. Here, we describe the present status of these databases and the first steps towards their federation.