Are there missed opportunities for vaccinating against hepatitis B among people who inject drugs in the UK?

Sustaining the impact of hepatitis B virus (HBV) vaccination on incidence and prevalence of HBV infection requires increasing and maintaining the uptake of vaccine among those at risk. In recent years, the level of vaccine uptake among people who inject drugs (PWID) in the UK has levelled-off. Data (2015-2016) from the national unlinked-anonymous monitoring survey of PWID, an annual survey that collects data from PWID across England, Wales and Northern Ireland, were used to examine HBV vaccine uptake. Data from participants who had injected drugs during the previous year were used to investigate sources of hepatitis B vaccine doses as well as factors associated with vaccine uptake. Among the 3175 anti-HBc-negative participants, 3138 (99%) reported their vaccination status; 23% (714) reported no vaccine uptake. Among those not vaccinated, 447 (63%) reported being sexually active and 116 (16%) reported sharing needles and syringes. Majority of those not vaccinated reported accessing services in the previous year that could have provided hepatitis B vaccine doses. These missed opportunities for vaccinating of PWID indicate a need for additional targeted interventions.

Healthcare seeking and hospital admissions by people who inject drugs in response to symptoms of injection site infections or injuries in three urban areas of England.

People who inject drugs (PWID) are vulnerable to infections and injuries at injection sites. The factors associated with reporting symptoms of these, seeking related advice, and hospital admission are examined. PWID were recruited in Birmingham, Bristol and Leeds using respondent-driven sampling (N = 855). During the preceding year, 48% reported having redness, swelling and tenderness (RST), 19% an abscess, and 10% an open wound at an injection site. Overall, 54% reported ⩾1 symptoms, with 45% of these seeking medical advice (main sources emergency departments and General Practitioners). Advice was often sought ⩾5 days after the symptom first appeared (44% of those seeking advice about an abscess, 45% about an open wound, and 35% for RST); the majority received antibiotics. Overall, 9·5% reported hospital admission during the preceding year. Ever being diagnosed with septicaemia and endocarditis were reported by 8·8% and 2·9%, respectively. Interventions are needed to reduce morbidity, healthcare burden and delays in accessing treatment.

Factors associated with recently acquired hepatitis C virus infection in people who inject drugs in England, Wales and Northern Ireland: new findings from an unlinked anonymous monitoring survey.

Monitoring infections and risk in people who inject drugs (PWID) is important for informing public health responses. In 2011, a novel hepatitis C antibody (anti-HCV) avidity-testing algorithm to identify samples compatible with recent primary infection was introduced into a national surveillance survey. PWID are recruited annually, through >60 needle-and-syringe programmes and prescribing services. Of the 980 individuals that could have been at risk of HCV infection, there were 20 (2%) samples that were compatible with recent primary infection. These were more common among: those imprisoned ⩾5 times [8/213; adjusted odds ratio (aOR) 8·7, 95% confidence interval (CI) 2·04-37·03]; women (8/230; aOR 3·8, 95% CI 1·41-10·38); and those ever-infected with hepatitis B (5/56; aOR 6·25, 95% CI 2·12-18·43). This study is the first to apply this algorithm and to examine the risk factors associated with recently acquired HCV infection in a national sample of PWID in the UK. These findings highlight underlying risks and suggest targeted interventions are needed.

Injection site infections and injuries in men who inject image- and performance-enhancing drugs: prevalence, risks factors, and healthcare seeking.

People who inject drugs are vulnerable to infections and injuries at injection sites, but these have rarely been studied in those injecting image- and performance-enhancing drugs (IPEDs). This study examined the factors associated with reported symptoms of injection site infections and injuries in IPED injectors. Of the 366 male IPED injectors surveyed, 42% reported ever having redness, swelling and tenderness (36% in the preceding year), and 6·8% had ever had an abscess or open wound at an injection site. Having these symptoms was associated with a range of factors related to drug use and healthcare utilization. One sixth (17%) of those reporting redness, tenderness and swelling had ever sought treatment, as had the majority (76%) of those reporting an abscess, sore or open wound. Most common sources of advice were emergency clinics and General Practitioners. Interventions are needed to support access to appropriate injecting equipment and provide targeted harm reduction advice.

Sharp truth: health care workers remain at risk of bloodborne infection.

BACKGROUND: In 2013, new regulations for the prevention of sharps injuries were introduced in the UK. All health care employers are required to provide the safest possible working environment by preventing or controlling the risk of sharps injuries. AIMS: To analyse data on significant occupational sharps injuries among health care workers in England, Wales and Northern Ireland before the introduction of the 2013 regulations and to assess bloodborne virus seroconversions among health care workers sustaining a blood or body fluid exposure. METHODS: Analysis of 10 years of information on percutaneous and mucocutaneous exposures to blood or other body fluids from source patients infected with a bloodborne virus, collected in England, Wales and Northern Ireland through routine surveillance of health care workers reported for the period 2002-11. RESULTS: A total of 2947 sharps injuries involving a source patient infected with a bloodborne virus were reported by health care workers. Significant sharps injuries were 67% higher in 2011 compared with 2002. Sharps injuries involving an HIV-, hepatitis B virus- or hepatitis C virus (HCV)-infected source patient increased by 107, 69 and 60%, respectively, between 2002 and 2011. During the study period, 14 health care workers acquired HCV following a sharps injury. CONCLUSIONS: Our data show that during a 10-year period prior to the introduction of new regulations in 2013, health care workers were at risk of occupationally acquired bloodborne virus infection. To prevent sharps injuries, health care service employers should adopt safety-engineered devices, institute safe systems of work and promote adherence to standard infection control procedures.

Two decades of successes and failures in controlling the transmission of HIV through injecting drug use in England and Wales, 1990 to 2011.

Responses to injecting drug use have changed focus over the last 20 years. Prevalence and incidence of human immunodeficiency virus (HIV) among people who inject drugs (PWID) in England and Wales were examined in relation to these changes. A voluntary unlinked-anonymous surveillance study obtained a biological sample and questionnaire data from PWID through annual surveys since 1990. Prevalence and incidence trends were estimated via generalised linear models, and compared with a policy time-line. Overall HIV prevalence among 38,539 participations was 1.15%. Prevalence was highest among those who started injecting before 1985; throughout the 1990s, prevalence fell in this group and was stable among those who started injecting later. Prevalence was higher in 2005 than 2000 (odds ratio: 3.56 (95% confidence interval (CI) 1.40­9.03) in London, 3.40 (95% CI 2.31­5.02) elsewhere). Estimated HIV incidence peaked twice, around 1983 and 2005. HIV was an important focus of policy concerning PWID from 1984 until 1998. This focus shifted at a time when drug use and risk were changing. The increased incidence in 2005 cannot be ascribed to the policy changes, but these appeared to be temporally aligned. Policy related to PWID should be continually reviewed to ensure rapid responses to increased risk.

Hepatitis C infection among recent initiates to injecting in England 2000-2008: Is a national hepatitis C action plan making a difference?

Around 80% of hepatitis C virus (HCV) infections in England are among injecting drug users (IDUs). The HCV Action Plan launched in 2004 includes targets to reduce HCV prevalence in recent initiates (those starting injecting in the preceding 3 years), and to increase HCV voluntary confidential testing (VCT). The Action Plan's impact is examined using surveillance data from recent initiates participating in an annual survey of IDUs in contact with specialist services across England, 2000-2008. Participants provided an oral fluid sample (tested for anti-HCV) and completed a short questionnaire (including HCV VCT and result of last test). Overall, anti-HCV prevalence among the recent initiates was 18% (619/3463); in 2004, it was 20% (59/291), other than being lower in 2000 [11%, 73/672, adjusted odds ratio (AOR) = 0.63 95%CI 0.42-0.93] there was no change over time. Prevalence increased with age; was higher among those ever imprisoned, using a needle exchange, and having a HCV VCT; and varied by region. Overall, 42% (1460) had ever had a HCV VCT; in 2004 uptake was 45% (130/291) having increased from 26% (175/672, AOR = 0.57 95%CI 0.42-0.77) in 2000, and it rose to 62% (197/320, AOR = 2.12 95%CI 1.50-2.99) in 2008. The proportion of anti-HCV-positive IDUs aware of their infection was higher in 2006-2008 than in earlier years. The HCV Action Plan has probably helped increase recent initiates' uptake of HCV VCT and the proportion of those diagnosed with HCV infection. However, its impact on HCV transmission is unclear. There is a need to reinvigorate, and improve coverage of, interventions to prevent HCV transmission.

Occupational transmission of hepatitis C in healthcare workers and factors associated with seroconversion: UK surveillance data.

The study aims were to describe a case series of occupationally acquired hepatitis C (HCV) infections in UK healthcare workers and examine factors associated with transmission using exposure data reported to the Health Protection Agency between July 1997 and December 2007. Fifteen reported cases of documented HCV seroconversion occurred after percutaneous exposure, the majority from hollow-bore needles used in the source patient's vein or artery and contaminated with blood or blood-stained fluid. The seroconversion rate was 2.2% (14/626). In multivariable analysis of healthcare workers with percutaneous exposure to blood or blood-stained fluid, we demonstrate that blood sampling procedures (odds ratio [OR], 5.75; 95% CI, 1.33-24.91; P = 0.01) and depth of injury (OR for deep vs superficial injury, 21.99; 95% CI, 2.02-239.61; P = 0.02) are independently associated with a greater risk of HCV seroconversion. This is the first UK study of occupationally acquired HCV in healthcare workers. It has reinforced our knowledge of risk factors for HCV transmission. Most of these exposures and transmissions were preventable. Healthcare employers should provide regular education on the risks of occupational exposure and prevention through standard infection control procedures. They should ensure the availability of effective prevention measures and facilitate prompt reporting and adequate follow-up of exposures.

Tuberculosis and HIV co-infection in healthcare workers in England and Wales, 1999-2005.

This study used linked national tuberculosis (TB) and HIV surveillance data to investigate recent trends and factors associated with HIV co-infection (TB-HIV) in healthcare workers (HCWs) with TB in England and Wales. Methods applied were the χ2 trend test and logistic regression. Overall 14% (231/1627) of HCWs with TB were co-infected with HIV, increasing from 8% in 1999 to 14% in 2005 (P<0·001). Most (78%) HCWs were non-UK born and 74% of these developed TB ⩾2 years post-entry. Being born in Sub-Saharan Africa was an independent predictor for TB-HIV, especially for female HCWs (odds ratio 66·5, 95% confidence interval 16·3-271·1), who also had a lower median CD4 count than other co-infected women (106/mm3, interquartile range 40-200, P<0·01). Voluntary HIV testing of new HCWs should be encouraged as an opportunity for early diagnosis. Post-entry, a high index of clinical suspicion for TB in those most at risk remains important.

Spatial mapping of hepatitis C prevalence in recent injecting drug users in contact with services.

In developed countries the majority of hepatitis C virus (HCV) infections occur in injecting drug users (IDUs) with prevalence in IDUs often high, but with wide geographical differences within countries. Estimates of local prevalence are needed for planning services for IDUs, but it is not practical to conduct HCV seroprevalence surveys in all areas. In this study survey data from IDUs attending specialist services were collected in 52/149 sites in England between 2006 and 2008. Spatially correlated random-effects models were used to estimate HCV prevalence for all sites, using auxiliary data to aid prediction. Estimates ranged from 14% to 82%, with larger cities, London and the North West having the highest HCV prevalence. The methods used generated robust estimates for each area, with a well-identified spatial pattern that improved predictions. Such models may be of use in other areas of study where surveillance data are sparse.

Measuring the incidence, prevalence and genetic relatedness of hepatitis C infections among a community recruited sample of injecting drug users, using dried blood spots.

Monitoring hepatitis C virus (HCV) infection among injecting drug users (IDUs) in the community is complicated by difficulties in obtaining biological specimens and biases in recruitment and follow-up. This study examined the utility of dried blood spot (DBS) specimens from IDUs recruited using respondent-driven sampling (RDS). Active IDUs underwent a computer-assisted interview and provided a DBS sample, tested for HCV antibody (anti-HCV) and HCV-RNA. HCV incidence was estimated from the proportion of anti-HCV-negative subjects found HCV-RNA-positive and estimates of the duration of this state. Results were adjusted according to RDS derived sample weights. HCV-RNA testing was performed on 288 DBS samples; 173 were anti-HCV-positive (54% weighted), of which 70 (42%, 95%CI 34-50% weighted) were RNA-negative indicating cleared infection. Among the 115 anti-HCV-negatives, 14 were RNA-positive suggesting an incidence of 38-47 per 100pyrs. Incident infections were younger than anti-HCV-negative and prevalent infections: 25 vs. 29 and 34, respectively. Incidence was highest among individuals with poor needle exchange coverage. One hundred and fourteen were genotyped (60 1a, 46 3a): a cluster of 14 had homology of >98.5% including 10 incident infections. Public health surveillance of HCV among IDUs could be enhanced through the collection of DBS samples with appropriate recruitment approaches. DBS allow differentiation between individuals with cleared infections, ongoing infection and those recently infected. They also enable virus characterization at genotype and nucleotide level. This would allow surveillance to inform development of harm reduction interventions, and the international evidence base for these.

The extent of injection site infection in injecting drug users: findings from a national surveillance study.

Injection site infections in injecting drug users (IDUs) are associated with serious morbidity and healthcare costs. Factors associated with symptoms of these were examined through annual (2006-2008) unlinked-anonymous survey of IDUs in England, Wales and Northern Ireland. Overall 36% (1863/5209) self-reported having a symptom with no trend over time (35% 2006, 37% 2007, 34% 2008). Symptoms were less common in the North East of England; increased with years injecting; and were higher in women, those recently homeless, those recently using a needle exchange, and those injecting both opiates and stimulants. Of those injecting during the previous 4 weeks (n=3733) symptoms were associated with: injecting daily; injecting >or=10 times a day; injecting into hands, groin, or legs; sharing filters; and reusing water to flush syringes. Symptoms of injection site infections are common in IDUs. Better-targeted preventive interventions are needed, and continued surveillance should assist with assessing the impact of new initiatives.

A comparison between the force of infection estimates for blood-borne viruses in injecting drug user populations across the European Union: a modelling study.

A number of studies have been conducted in injecting drug user (IDU) populations in Europe, in which the prevalence of human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) was measured together with demographic and epidemiological information such as age and the age at first injection. A measure of the risk of becoming infected is the force of infection (FOI), defined as the per capita rate at which susceptible individuals acquire infection. The objective of this study was to estimate the FOI and its heterogeneity for HBV, HCV and HIV (where available) for IDU populations in a number of countries in Europe. Data were obtained from five countries: Belgium, the United Kingdom, Spain and Italy, and the Czech Republic, which provided two data sets. The model describes the prevalence of infection as a function of the FOI that may vary over time or duration of IDU. In addition to this, if two or more infections were being considered then a parameter describing the potential heterogeneity of the FOI within the IDU population was also estimated. The results here add to the growing evidence that new initiates to injecting are at an increased risk of blood-borne viral infection compared with more experienced IDUs. In addition, there is evidence of individual heterogeneity of FOI estimates within the overall IDU populations. This suggests that different proportions of individuals in each population are at increased risk of infection compared with the rest of the population. Future interventions should identify and target these individuals. Moreover, changes over time in individual heterogeneity estimates of IDU populations may provide an indicator for measuring intervention impacts.

Increase in diagnosed newly acquired hepatitis C in HIV-positive men who have sex with men across London and Brighton, 2002-2006: is this an outbreak?

OBJECTIVES: To determine the incidence of diagnosed newly acquired hepatitis C virus (HCV) in HIV-positive men who have sex with men (MSM) across London and Brighton in order to inform public health interventions. METHODS: Cases were defined as MSM attending London and Brighton HIV/genitourinary medicine clinics from January 2002 to June 2006, with HCV PCR RNA or antibody positive, and a negative HCV test in the previous three years. The yearly number of cases and HCV screening policy in MSM were examined. A negative binomial regression model was used to estimate HCV incidence density rate ratio and 95% CI. RESULTS: 20 out of 38 clinics provided information, covering 84% of the HIV-positive MSM workload in London and 100% in Brighton. The estimated overall incidence was 9.05 per 1000 HIV-positive MSM patient-years. It increased from 6.86 per 1000 in 2002 to 11.58 per 1000 during January-June 2006. Incidence at clinics ranged from 0 to 15.4 (median 6.52) per 1000 HIV-positive MSM patient-years. There was some evidence of difference in the incidence and trend (p = 0.02) in each clinic. The average annual rise in incidence of HCV was 20% (95% CI 4% to 39%, p = 0.001). There was little evidence of such transmission among MSM with negative or unknown HIV status. CONCLUSIONS: HCV incidence clearly increased among HIV-positive MSM in London and Brighton during January 2002 to June 2006. Prospective enhanced surveillance of HCV in MSM, including HIV status and behavioural risk factors, is recommended to help inform control measures and better determine the frequency of transmission in all MSM.

Hepatitis B virus, hepatitis C virus and other blood-borne infections in healthcare workers: guidelines for prevention and management in industrialised countries.

The Viral Hepatitis Prevention Board (VHPB) convened a meeting of international experts from the public and private sectors in order to review and evaluate the epidemiology of blood-borne infections in healthcare workers, to evaluate the transmission of hepatitis B and C viruses as an occupational risk, to discuss primary and secondary prevention measures and to review recommendations for infected healthcare workers and (para)medical students. This VHPB meeting outlined a number of recommendations for the prevention and control of viral hepatitis in the following domains: application of standard precautions, panels for counselling infected healthcare workers and patients, hepatitis B vaccination, restrictions on the practice of exposure-prone procedures by infected healthcare workers, ethical and legal issues, assessment of risk and costs, priority setting by individual countries and the role of the VHPB. Participants also identified a number of terms that need harmonization or standardisation in order to facilitate communication between experts.

No longer 'written off' - times have changed for the BBV-infected dental professional.

There is a recognised potential risk of transmission of blood-borne viruses (BBVs) from infected healthcare workers to patients during exposure prone procedures (EPPs). The restrictions placed on performance of EPPs by infected clinicians in the UK have had a particularly significant impact on dentists because of the exposure-prone nature of most dental procedures and the difficulties in identifying alternative career pathways in the profession that do not involve EPPs. More recently, the significant positive impact of antiviral drugs on viral load, together with a re-categorisation of EPPs in dentistry have resulted in evolution of the guidance with a consequent significant improvement to the career prospects of dentists infected with BBVs. This paper provides an update for practitioners on the progress that has been made and outlines the current position with respect to practice restrictions.

Low levels of hepatitis C diagnosis and testing uptake among people who inject image and performance enhancing drugs in England and Wales, 2012-15.

INTRODUCTION: People injecting image and performance enhancing drugs (IPEDs) have traditionally not been perceived as being at high risk of hepatitis C virus (HCV) infection. However, recent studies indicate the HCV antibody (anti-HCV) prevalence in this group is 10-times that in the general population. HCV testing uptake and undiagnosed infections are examined using data from a voluntary unlinked-anonymous survey. METHOD: People injecting IPEDs across England and Wales completed a short bio-behavioural survey (2012-15). Anti-HCV status and self-reports of HCV testing were used in the analysis. RESULTS: The participants median age was 31 years, 98% were men, 14% had also injected psychoactive drugs and the anti-HCV prevalence was 4.8% (N=564). Among those who had never injected psychoactive drugs the anti-HCV prevalence was 1.4%; among those who had recently injected psychoactive drugs (preceding 12 months) prevalence was 39% and among those who had done this previously 14% (p<0.001). Overall, 37% had been tested for HCV: among those who had recently injected psychoactive drugs 78% had been tested, as had 56% of those who had injected psychoactive drugs previously; 33% of those never injecting psychoactive drugs were tested (p<0.001). Overall, 44% of those with anti-HCV were aware of this; however, only 14% of those who had never injected psychoactive drugs were aware. CONCLUSIONS: One-in-twenty people who inject IPEDs have anti-HCV. HCV infections among those who had never injected psychoactive drugs were mostly undiagnosed, though this group had a lower prevalence. Targeted HCV testing interventions are also needed for those injecting IPEDs.

Not in the vein: 'missed hits', subcutaneous and intramuscular injections and associated harms among people who inject psychoactive drugs in Bristol, United Kingdom.

BACKGROUND: The extent of intentional or accidental subcutaneous and intramuscular injections and the factors associated with these have rarely been studied among people who inject drugs, yet these may play an important role in the acquisition bacterial infections. This study describes the extent of these, and in particular the factors and harms associated with accidental subcutaneous and intramuscular injections (i.e. 'missed hits'). METHODS: People who inject drugs were recruited using respondent driven sampling. Weighted data was examined using bivariate analyses and logistic regression. RESULTS: The participants mean age was 33 years (31% aged under 30-years), 28% were women, and the mean time since first injection was 12 years (N=329). During the preceding three months, 97% had injected heroin, 71% crack-cocaine, and 16% amphetamines; 36% injected daily. Overall, 99% (325) reported that they aimed to inject intravenously; only three aimed to inject subcutaneously and one intramuscularly. Of those that aimed to inject intravenously, 56% (181) reported ever missing a vein (for 51 this occurred more than four times month on average). Factors associated with 'missed hits' suggested that these were the consequence of poor vascular access, injection technique and/or hygiene. 'Missed hits' were twice as common among those reporting sores/open wounds, abscesses, or redness, swelling and tenderness at injection sites. CONCLUSION: Intentional subcutaneous and intramuscular injections are rare in this sample. 'Missed hits' are common and appear to be associated with poor injection practice. Interventions are required to reduce risk through improving injecting practice and hygiene.

Wound botulism in injectors of drugs: upsurge in cases in England during 2004.

Wound infections due to Clostridium botulinum were not recognised in the UK and Republic of Ireland before 2000. C. botulinum produces a potent neurotoxin which can cause paralysis and death. In 2000 and 2001, ten cases were clinically recognised, with a further 23 in 2002, 15 in 2003 and 40 cases in 2004. All cases occurred in heroin injectors. Seventy cases occurred in England; the remainder occurred in Scotland (12 cases), Wales (2 cases) and the Republic of Ireland (4 cases). Overall, 40 (45%) of the 88 cases were laboratory confirmed by the detection of botulinum neurotoxin in serum, or by the isolation of C. botulinum from wounds. Of the 40 cases in 2004, 36 occurred in England, and of the 12 that were laboratory confirmed, 10 were due to type A. There was some geographical clustering of the cases during 2004, with most cases occurring in London and in the Yorkshire and Humberside region of northeast England.

Wound botulism in injectors of drugs: upsurge in cases in England during 2004.

Wound infections due to Clostridium botulinum were not recognised in the UK and Republic of Ireland before 2000. C. botulinum produces a potent neurotoxin which can cause paralysis and death. In 2000 and 2001, ten cases were clinically recognised, with a further 23 in 2002, 15 in 2003 and 40 cases in 2004. All cases occurred in heroin injectors. Seventy cases occurred in England; the remainder occurred in Scotland (12 cases), Wales (2 cases) and the Republic of Ireland (4 cases). Overall, 40 (45%) of the 88 cases were laboratory confirmed by the detection of botulinum neurotoxin in serum, or by the isolation of C. botulinum from wounds. Of the 40 cases in 2004, 36 occurred in England, and of the 12 that were laboratory confirmed, 10 were due to type A. There was some geographical clustering of the cases during 2004, with most cases occurring in London and in the Yorkshire and Humberside region of northeast England.