Evidence for re-infection and persistent carriage of Shigella species in adult males reporting domestically acquired infection in England.

OBJECTIVES: We analysed national surveillance typing data of Shigella isolated from adult males with domestically acquired infection (a cohort largely consisting of men who have sex with men (MSM)) to establish whether multiple isolates from the same individual over time represented persistent carriage or re-infection. METHODS: We carried out a retrospective cohort study of adult males diagnosed with Shigella from 2004 to 2018. Median time intervals between multiple isolations of Shigella flexneri and S. sonnei were compared. Analysis of whole genome sequencing data provided strain discrimination at the single nucleotide level and was used to quantify the genetic distance among isolates. Maximum likelihood phylogenies were constructed to determine whether persistent carriage (characterized by multiple isolations of the same strain) or re-infection (characterized by multiple isolations of different strains) was best supported by the phylogenetic analysis. A comparison analysis was carried out using data linked to adult females with domestically acquired shigellosis. RESULTS: The number of men reporting multiple isolations of Shigella species was 165/4733 (3.5%) compared with 31/2423 (1.3%) females (p < 0.001). For isolate pairs from men associated with persistent carriage, the isolation time interval range was 6-176 days (median 23.5; IQR 8-70) and single nucleotide polymorphism (SNP) distance range was 0-7 SNPs (median 0.5; IQR 0-2). For those associated with re-infection, the isolation time interval was 34-2636 days (median 732; IQR 191-1258) and the SNP distance was 10-1462 SNPs (median 120; IQR 29-377). DISCUSSION: Multiple Shigella isolations in individuals with domestically acquired infections was more frequently observed in adult males than in adult females. Following the acute phase of infection, carriage can persist for months, and infection can recur within months, even with strains belonging to the same species and the same serotype. A combination of multiple sexual partners, persistent carriage following the acute phase of infection and evidence of recurrent re-infection is likely to contribute to sustained transmission in this population.

Use of gender distribution in routine surveillance data to detect potential transmission of gastrointestinal infections among men who have sex with men in England.

Detecting gastrointestinal (GI) infection transmission among men who have sex with men (MSM) in England is complicated by a lack of routine sexual behavioural data. We investigated whether gender distributions might generate signals for increased transmission of GI pathogens among MSM. We examined the percentage male of laboratory-confirmed patient-episodes for patients with no known travel history for 10 GI infections of public health interest in England between 2003 and 2013, stratified by age and region. An adult male excess was observed for Shigella spp. (annual maximum 71% male); most pronounced for those aged 25-49 years and living in London, Brighton and Manchester. An adult male excess was observed every year for Entamoeba histolytica (range 59.8-76.1% male), Giardia (53.1-57.6%) and Campylobacter (52.1-53.5%) and for a minority of years for hepatitis A (max. 69.8%) and typhoidal salmonella (max. 65.7%). This approach generated a signal for excess male episodes for six GI pathogens, including a characterised outbreak of Shigella among MSM. Stratified analyses by geography and age group were consistent with MSM transmission for Shigella. Optimisation and routine application of this technique by public health authorities elsewhere might help identify potential GI infection outbreaks due to sexual transmission among MSM, for further investigation.

The incidence of congenital syphilis in the United Kingdom: February 2010 to January 2015.

OBJECTIVE: To estimate the incidence of congenital syphilis in the UK. DESIGN: Prospective study. SETTING AND POPULATION: United Kingdom. METHODS: Children born between February 2010 and January 2015 with a suspected diagnosis of congenital syphilis were reported through an active surveillance system. MAIN OUTCOME MEASURES: Number of congenital syphilis cases and incidence. RESULTS: For all years, reported incidence was below the WHO threshold for elimination (<0.5/1000 live births). Seventeen cases (12 male, five female) were identified. About 50% of infants (8/17) were born preterm (<37 weeks' gestation): median birthweight 2000 g (865-3170 g). Clinical presentation varied from asymptomatic to acute disease, including severe anaemia, hepatosplenomegaly, rhinitis, thrombocytopaenia, skeletal damage, and neurosyphilis. One infant was deaf and blind. Median maternal age was 20 years (17-31) at delivery. Where maternal stage of infection was recorded, 6/10 had primary, 3/10 secondary and 1/10 early latent syphilis. Most mothers were white (13/16). Country of birth was recorded for 12 mothers: UK (n = 6), Eastern Europe (n = 3), Middle East (n = 1), and South East Asia (n = 2). The social circumstances of mothers varied and included drug use and sex work. Some experienced difficulty accessing health care. CONCLUSION: The incidence of congenital syphilis is controlled and monitored by healthcare services and related surveillance systems, and is now below the WHO elimination threshold. However, reducing the public health impact of this preventable disease in the UK is highly dependent on the successful implementation of WHO elimination standards across Europe. TWEETABLE ABSTRACT: Congenital syphilis incidence in the UK is at a very low level and well below the WHO elimination threshold.

Pelvic inflammatory disease and salpingitis: incidence of primary and repeat episodes in England.

Pelvic inflammatory disease (PID) and more specifically salpingitis (visually confirmed inflammation) is the primary cause of tubal factor infertility and is an important risk factor for ectopic pregnancy. The risk of these outcomes increases following repeated episodes of PID. We developed a homogenous discrete-time Markov model for the distribution of PID history in the UK. We used a Bayesian framework to fully propagate parameter uncertainty into the model outputs. We estimated the model parameters from routine data, prospective studies, and other sources. We estimated that for women aged 35-44 years, 33·6% and 16·1% have experienced at least one episode of PID and salpingitis, respectively (diagnosed or not) and 10·7% have experienced one salpingitis and no further PID episodes, 3·7% one salpingitis and one further PID episode, and 1·7% one salpingitis and ⩾2 further PID episodes. Results are consistent with numerous external data sources, but not all. Studies of the proportion of PID that is diagnosed, and the proportion of PIDs that are salpingitis together with the severity distribution in different diagnostic settings and of overlap between routine data sources of PID would be valuable.

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.

Contribution of transmission in HIV-positive men who have sex with men to evolving epidemics of sexually transmitted infections in England: an analysis using multiple data sources, 2009-2013.

HIV seroadaptive behaviours may have contributed to greater sexually transmitted infection (STI) transmission in HIV-positive men who have sex with men(MSM) and to the global increase in STIs. Using multiple national surveillance data sources and population survey data, we estimated the risk of STIs in HIV-positive MSM and assessed whether transmission in HIV-positive MSM has contributed to recent STI epidemics in England. Since 2009, an increasing proportion of STIs has been diagnosed in HIV-positive MSM, and currently, the population rate of acute bacterial STIs is up to four times that of HIV-negative or undiagnosed MSM. Almost one in five of all diagnosed HIV-positive MSM in England had an acute STI diagnosed in 2013. From 2009 to 2013, the odds of being diagnosed with syphilis increased from 2.71 (95% confidence interval (CI) 2.41­3.05, p<0.001) to 4.05 (95%CI 3.70-4.45, p<0.001) in HIV-positive relative to HIV negative/undiagnosed MSM. Similar trends were seen for gonorrhoea and chlamydia. Bacterial STI re-infection rates were considerably higher in HIV-positive MSM over a five-year follow-up period, indicative of rapid transmission in more dense sexual networks.These findings strongly suggest that the sexual health of HIV-positive MSM in England is worsening, which merits augmented public health interventions and continued monitoring.

Sex, drugs and smart phone applications: findings from semistructured interviews with men who have sex with men diagnosed with Shigella flexneri 3a in England and Wales.

OBJECTIVES: To inform control strategies undertaken as part of an outbreak of Shigella flexneri 3a among men who have sex with men (MSM). METHODS: All men aged ≥18 years diagnosed with S flexneri 3a between October 2012 and May 2013 were invited to participate. Semistructured in-depth quantitative interviews were conducted to explore lifestyle and sexual behaviour factors. RESULTS: Of 53 men diagnosed, 42 were interviewed of whom 34 were sexually active MSM. High numbers of sexual partners were reported (median=22) within the previous year; most were casual encounters met through social media networking sites (21/34). 63% (20/32) were HIV-positive and actively sought positive partners for condomless sex. 62% (21/34) of men had used chemsex drugs (mephedrone, crystal methamphetamine and γ-butyrolactone/γ-hydroxybutrate), which facilitate sexually disinhibiting behaviour during sexual encounters. 38% (8/21) reported injecting chemsex drugs. Where reported almost half (12/23) had attended or hosted sex parties. All reported oral-anal contact and fisting was common (16/34). Many had had gonorrhoea (23/34) and chlamydia (17/34). HIV-positive serostatus was associated with both insertive anal intercourse with a casual partner and receptive fisting (adjusted OR=15.0, p=0.01; adjusted OR=18.3, p=0.03) as was the use of web applications that promote and facilitate unprotected sex (adjusted OR=19.8, p=0.02). CONCLUSIONS: HIV-positive MSM infected with S flexneri 3a used social media to meet sexual partners for unprotected sex mainly at sex parties. The potential for the transmission of S flexneri, HIV and other infections is clear. MSM need to be aware of the effect that chemsex drugs have on their health.

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.

Recent outbreaks of infectious syphilis, United Kingdom, January 2012 to April 2014.

Six outbreaks of infectious syphilis in the United Kingdom, ongoing since 2012, have been investigated among men who have sex with men (MSM) and heterosexual men and women aged under 25 years. Interventions included case finding and raising awareness among healthcare professionals and the public. Targeting at-risk populations was complicated as many sexual encounters involved anonymous partners. Outbreaks among MSM were influenced by the use of geospatial real-time networking applications that allow users to locate other MSM within close proximity.

Ongoing outbreak of Shigella flexneri serotype 3a in men who have sex with men in England and Wales, data from 2009-2011.

Diagnoses of Shigella flexneri in the United Kingdom (UK) are usually travel-related. However, since 2009, there has been an overall increase in UK-acquired cases. The Health Protection Agency has been investigating a national outbreak of S. flexneri detected in 2011 and which is still ongoing. Cases occurred mostly in men who have sex with men and were of serotype 3a. The investigation aimed at obtaining epidemiological data to inform targeted outbreak management and control.

An ongoing outbreak of heterosexually-acquired syphilis across Teesside, UK.

Prior to 2006, diagnoses of heterosexually acquired syphilis were rare in Teesside (an area in the north east of England, UK). Since 2006, there has been an increase in such cases, with 24 cases diagnosed in 2006 and 22 in 2007. There was a marked reduction in cases in 2008 with six cases reported, but a large increase in diagnoses in 2009 (34 cases). There have been 14 cases to date in 2010. Of concern is the increase noted in women and younger age groups. Geographical mapping of cases shows a wide dispersion across Teesside although some clusters were identified, mostly in areas of high deprivation. Little detailed information is available to help identify social and sexual networks widely and target intervention. A multiagency outbreak control team is addressing this problem, based on the principles of partner notification, increased awareness, increased screening and health promotion activities. A range of measures, including a detailed communications plan, have been implemented.

An outbreak of infectious syphilis among young heterosexuals in an English town.

We describe a recent outbreak of syphilis in young heterosexuals in the north west of England. A cluster of 12 cases of syphilis (7 primary and 5 early latent) was identified in Rochdale in heterosexuals aged 20 or under. Nine were women. Five were asymptomatic at presentation. This outbreak occurred in a group not usually associated with syphilis transmission in the north west. Not all the identified cases could be linked, and so potentially this outbreak is a sentinel of a larger problem.

Surveillance of sexually transmitted diseases in general practice: a description of trends in the Royal College of General Practitioners Weekly Returns Service between 1994 and 2001.

This paper describes the incidence of sexually transmitted infections (STIs) recorded in the Weekly Returns Service (WRS) between 1994 and 2001. There were approximately 76,500 new diagnoses of STIs (7500 males, 71,000 females) and associated syndromes. Candidiasis was the commonest condition reported in males and females followed by pelvic inflammatory disease. The ratio of males to females was 7.1 for non-specific urethritis, and 9.1 and 2.1 for Reiter's syndrome and pediculosis pubis, respectively. The incidence of anogenital warts and genital herpes changed little over time. New diagnoses of genital herpes were higher in females than in males (ratio 2.8:1), whereas the mean annual incidence of genital warts was similar in males and females. The WRS provides an insight into the burden of STI diagnoses, and diagnoses related to STIs that are managed in general practice, and as such has the potential to make a substantial contribution to STI surveillance in England.

Application of a noninvasive oral fluid test for detection of treponemal IgG in a predominantly HIV-infected population.

The performance of a time-resolved fluorescence immunoassay (TRFIA) for detection of treponemal IgG from oral fluid specimens has been assessed in a predominantly HIV-infected population. Serological investigation is the method of choice for confirming clinical suspicion of syphilis; however, in the primary stage of disease, direct detection of treponemes in lesion fluid or Treponema pallidum DNA is recommended because of the reduced sensitivity of serological tests. There may be occasions when blood for serological investigation is difficult to obtain due to individual patient preference or logistical necessity to improve participation in screening initiatives, particularly in outreach situations. Collection of oral fluid for detection of treponemal antibody may prove an attractive alternative and, with this in mind, an oral fluid assay for detection of treponemal IgG was developed. Time-resolved fluorescence was used to detect treponemal IgG extracted from commercially available oral fluid collection devices. Paired serum and saliva samples were obtained from 210 individuals, 101 of whom were diagnosed with syphilis on the grounds of medical examination confirmed by serological testing. Oral fluid specimens from 14 subjects were rejected because they contained insufficient control antibody or were inhibitory. The population tested was predominantly men who have sex with men, many of whom were HIV infected. The overall sensitivity and specificity of the oral fluid assay was 95.8 and 86.1%, respectively, based on the 5th percentile of the positive results, and 93.7 and 91.1%, respectively, based on a cutoff derived by mixture model analysis. For individuals with primary syphilis, the optimum sensitivity of the oral fluid assay was 87.5%, whereas in those with disease classified as secondary syphilis and early latent syphilis, the sensitivity of the oral fluid assay was 100 and 94.7%, respectively. The oral fluid assay is a useful alternative to serological testing in certain situations, and further development of this technology to enable detection of treponemal IgM should increase its sensitivity for detecting cases of primary syphilis.