Research and analysis

HPR volume 12 issue 2: news (12 January)

Updated 21 December 2018

CMO letter on HCW vaccination

Influenza activity in England, Wales, Scotland and Northern Ireland increased across all surveillance indicators during the first week of 2018, with notable increases in GP consultation rates, and in the number of respiratory outbreaks and influenza-confirmed hospitalisations, according to the PHE’s latest Weekly National Influenza Report [1,2].

In week 1 of 2018, GP consultation rates increased 78% compared with the last week of 2017; there were 233 new acute respiratory outbreaks reported (compared with 141 in the previous week); and the rate of influenza-confirmed hospitalisations (based on sentinel surveillance across 22 NHS Trusts in England) was 7.38 per 100,000 population, compared with 4.89 per 100,000 in the previous week. A slideset of charts and tables, illustrating these data trends, is published alongside the weekly report, on the PHE Weekly National Flu Reports webpage [3]

The Chief Medical Officer issued a letter to all NHS staff reiterating that a high level of vaccination uptake in frontline healthcare workers was critical to ensuring the well-being of vulnerable patients. The overall vaccination rate of frontline HCWs this season reached 59.3% as at 30 November 2017 but there was significant variation in rates between trusts, the CMO letter pointed out [4].

References

1. PHE (11 January). National flu report: 11 January 2018 (data up to week 1, ending 7 January 2018).
2. “UK flu levels continue to increase according to PHE statistics” PHE website news story, 11 January.
3. PHE (11 January). National flu report surveillance [slideset].
4. PHE (11 January). “Chief medical officer advises NHS staff to make sure they are vaccinated against flu” Department of Health and Social Care website news story, 11 January.

PHE research review 2016/17

Public Health England has published its Annual Review of Research, which highlights a number of significant public health research projects that led to important publications in peer-reviewed journals in 2016/17 [1].

PHE has a wide and robust research portfolio, including programmes delivered through NIHR Health Protection Research Units [2] in collaboration with academic partners. Snapshots of significant research projects during 2016/17 are presented in the research review, including the following:

• attributing human mortality to anthropogenic climate change [3]
• an evidence-based approach to protecting public health during prolonged fires [4]
• early analysis of the effectiveness of the rotavirus gastroenteritis vaccine [5]
• tuberculosis screening in migrants [6]
• the UK meningitis B immunisation programme [7]
• a pilot study on testing for blood-borne viruses [8]
• protecting the eyes of radiation workers [9]
• preventing infections following hip replacement surgery [10]
• supporting measures to address antimicrobial resistance, including: improving the detection of pathogens [11]; understanding the spread of pathogens [12]; improving the quality of antibiotic prescribing [13]; and generally supporting a diverse range of studies to facilitate decision-making by companies developing new antibiotics.

References

1. Mitchell D, Heaviside C, Vardoulakis S, Huntingford C, Massato G, Guillod BP, et al (2016). Attributing human mortality during extreme heat waves to anthropogenic climate change. Environmental Research Letters 11(7).
2. PHE website. PHE Research 2016 to 2017: Annual Review.
3. National Institute for Health Research website. Health Protection Research Units.
4. Stewart-Evans J, Kibble A, Mitchem L. (2016). An evidence-based approach to protect public health during prolonged fires. Int. J. of Emergency Management 12(1).
5. Atchison CJ, Stowe J, Andrews N, Collins S, Allen DJ, Nawaz S, et al (2016). Rapid declines in age group-specific rotavirus infection and acute gastroenteritis among vaccinated and unvaccinated individuals within one year of rotavirus vaccine introduction in England and Wales. J. Infect Dis. 213(2) 243-9.
6. Aldridge RW, Zenner D, White PJ, et al (2016). Prevalence of and risk factors for active tuberculosis in migrants screened before entry to the UK: a population-based cross-sectional study. Lancet Infect Dis. 16(8), 962-970.
7. Parikh SR, Andrews NJ, Beebeejaun K, Campbell H, Ribeiro S, Ward C, et al (2016). Effectiveness and impact of a reduced infant schedule of 4CMenB vaccine against group B meningococcal disease in England: a national observational cohort study. The Lancet 388(10061): 2775-2782.
8. Orkin C, Flanagan S, Wallis E, Ireland G, Dhairyawan R, Fox J, et al (2016). Incorporating HIV/hepatitis B virus/hepatitis C virus combined testing into routine blood tests in nine UK Emergency Departments: the “Going Viral” campaign. HIV Med. 17(3): 222-30.
9. Barnard SG, Ainsbury EA, Quinan EA and Boufller AD (2016). Radiation protection of the eye lens in medical workers — basis and impact of the ICRP recommendations. Br J Radiolog 89: 20151034.
10. Graves N, Wloch C, Wilson J, Barnett A, Sutton A, Cooper N, et al (2016). A cost-effectiveness modelling study of strategies to reduce risk of infection following primary hip replacement based on a systematic review.
11. Pankhurst LJ, del Ojo Elias C, Votintseva AA, et al (2016). Rapid, comprehensive, and affordable mycobacterial diagnosis with whole-genome sequencing: a prospective study. Lancet Respir Med 4(1): 49-58.
12. De Silva D, Peters J, Cole K, Cole MJ, Cresswell F, Dean G, et al (2016). Whole-genome sequencing to determine transmission of Neisseria gonorrhoeae: an observational study.Lancet Infectious Diseases 16(11) 1295-1303.
13. Ashiru-Oredope D, Budd EL, Bhattacharya A, Din N, McNulty CAM, Micallef C, et al (2016). Implementation of antimicrobial stewardship interventions recommended by national toolkits in primary and secondary healthcare sectors in England: TARGET and Start Smart Then Focus. J Antimicrobial Chemotherapy 71(5).

NaTHNaC annual report

The latest annual report from the National Travel Health Network and Centre (NaTHNaC) describes the activities of the public service during financial year 2016/17 [1].

NaTHNaC’s principal functions are the provision of guidance for UK travellers and health professionals who advise UK residents travelling abroad about important disease outbreaks affecting particular destination countries, liaison with travel industry stakeholders, and administering the network of more than 3,300 Yellow Fever Vaccination Centres (YFVC) operating across EWNI. NaTHNaC oversees the registration, training, standards, and audit of YFVCs in EWNI in compliance with the International Health Regulations.

Ensuring the provision of a reliable and high quality service for the traveller who visits a YFVC is an important aspect of NaTHNaC’s work and is considered key to helping to improve the overall care of UK travellers. The programme has been in place for over 10 years and is recognised internationally as an effective model for the provision of yellow fever vaccination services.

A total of 519 outbreak notices (or updates to existing notices) on health events abroad of importance for UK travellers were registered on the NaTHNaC website during 2016/17.

NaTHNaC’s TravelHealthPro website includes 236 Country Information Pages, of which the most frequently accessed, in the six months to the end of March 2017, were pages from Thailand, India, Vietnam, Mexico, South Africa and Sri Lanka. The range of thematic Factsheets on the website was expanded, of which the most popular were on VHF, diabetes, immunosuppression and medical tourism. Overall, the NaTHNaC website received more than 4.5 million unique page views during 2016/17.

Reference

1. NaTHNaC website.

HIV in London report

An estimated 38,700 are living with HIV in London and 1,967 London residents were newly diagnosed with HIV in 2016. However, combination prevention activities are proving effective in reducing transmission. There was a 30% fall in the number of new infections in gay, bisexual and other men who have sex with men (MSM) resident in London between 2015 and 2016: from 1,804 to 1,266 [1]. And the ambitious “90-90-90” UNAIDS treatment targets were met in London in 2016 (ie: 90% of people living with HIV were diagnosed, of these 97% were receiving anti-viral treatment and of these 97% were virally suppressed). (London is the third city, after Amsterdam and Melbourne, to satisfy all three UNAIDS criteria).

These are among the conclusions of the Annual Epidemiological Spotlight on HIV in London [2], published on the day that London joined the Fast Track Cities initiative to reduce new HIV infections and put a stop to HIV-related stigma. The Mayor of London signed the Paris Declaration on Fast Track Cities along with borough leaders, and representatives of PHE and NHS England [3].

Other key messages from the report are that:

• the new diagnosis rate for London residents aged 15 years or older (28 per 100,000) was nearly three times higher than the rate for England in 2016 (10 per 100,000)
• it is of particular concern that 34% of people with HIV are diagnosed late in London (defined by a CD4 count of fewer than 350 cells/mm3 at diagnosis).

References

1. Fall in new HIV diagnoses among MSM at selected London sexual health clinics. HPR 11(22), 23 June 2017.
2. PHE (January 2018). Annual epidemiological spotlight on HIV in London: 2016 data.
3. “London joins global Fast Track Cities initiative to reduce new HIV infections and eliminate stigma”. Mayor of London press release, 10 January 2018

Funding for immediate ART on HIV diagnosis

Effective anti-retroviral treatment (ART) for HIV has been available in the UK since 1996 and has drastically altered the HIV epidemic. About half of all AIDS diagnoses and deaths (in people with HIV) ever reported in the UK occurred before 1996; after that year, AIDS and deaths declined rapidly and have both remained consistently below 500 per year [1]. In recent years increasing evidence has indicated that early ART is clinically beneficial [2] and reduces the risk of onward transmission to extremely low levels [3,4]. This is to the extent that people living with HIV infection can have sex without condoms provided undetectable levels of virus are reached (colloquially referred to as “undetectable=untransmissible”). “Treatment as Prevention” has thus become an increasingly important part of the public health response to HIV globally [5]. As the evidence for Treatment as Prevention emerged, British HIV Association guidelines have progressively reduced the threshold at which patients may begin ART, from reaching a CD4 count <350 cells in 2008 [6] to maintaining the <350 cells threshold but recommending clinicians discuss the option of starting ART above 350 cells in order to prevent onward transmission to sexual partners in 2012. In 2015, guidelines were further updated to recommend ART is offered to all people living with HIV for the prevention of onward transmission. However, until recently, the position on the funding of ART for immediate ART among patients newly diagnosed with HIV remained unclear.

On 18 December 2017, NHS England announced that funding will be provided, from 1 April 2018, for immediate ART for all patients newly diagnosed with HIV in England [8]. This followed a consultation on a clinical commissioning policy for immediate ART for treatment of HIV-1 in adults and adolescents [9] comprising a clinical and stakeholder engagement in addition to an evidence review and an impact assessment report. The consultation concluded that there was a net clinical benefit for immediate ART with limited risk of adverse events [10]. The costs associated with this policy are the bringing forward of treatment costs for patients that would eventually be incurred two-five years after diagnosis. The impact assessment estimated that for every nine patients treated, one onward infection would be prevented, reducing treatment cost by £2.9 million in year one [11]. Furthermore, a 10-year impact assessment concluded that the policy would carry an overall cost of £49.2 million, with 46% of this cost relating to years one to three and 79% of the cost up to year five.

In 2016, 96% of the 91,987 people living with a diagnosed HIV infection in the UK received ART, compared to 94% in 2015 and 74% in 2007. In the same year 5,164 people were newly diagnosed with HIV, of whom 42% (2,170) had a CD4 count <350 cells and already eligible for immediate treatment. Consequently, approximately an additional 3,000 patients newly diagnosed will be eligible for funding from April 2018.

In reality, a high proportion of patients newly diagnosed with HIV start ART rapidly. In 2016, 76% (3,214/4,255) of people newly diagnosed with HIV started ART within 90 days of diagnosis: 85% (1,361/1,594) among those newly diagnosed with a CD4 count <350 cells, and 74% (1,647/2,229) among those diagnosed with a CD4 ≥350 cells) [1]. Consequently, in practice, the immediate ART policy is likely to result in an additional 750 patients starting treatment annually. However, the high rate of prompt treatment nationally masks substantial variation at an individual clinic level where the percentage of people starting treatment within 90 days of diagnosis ranges from 14% to 100% [1].

The commitment to funding immediate ART by NHS England is welcome. It is anticipated that swift and full implementation will reduce variation by HIV service and ensure all people diagnosed with HIV are rapidly treated across England. If this policy is combined with continued sustained efforts to increase HIV testing, including frequent testing of people at greatest risk of HIV, the decline in HIV incidence in gay and bisexual men may continue and make an impact on incidence in other populations [1]. Public Health England has a central role in monitoring the effect of the immediate ART policy both in further reducing the time from HIV diagnosis to ART and on its wider impact on the national HIV epidemic.

References

1. PHE (November 2017). Towards elimination of HIV transmission, AIDS and HIV-related deaths in the UK – 2017 report.
2. Lundgren JD, Babiker, AG, Gordin F, Emery S, Grund B, Sharma S, et al (2015). The INSIGHT START Study Group: initiation of antiretroviral therapy in early asymptomatic HIV Infection. N Eng J Med 373: 795-807.
3. Cohen MS, Chen YQ, McCauley M et al (2011). Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 365: 493–505.
4. Rodger AJ, Cambiano V, Bruun T, Vernazza P, Collins S, van Lunzen J et al (2016). Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner Is using suppressive antiretroviral therapy. JAMA 316(2): 171–181.
5. http://www.who.int/hiv/pub/arv/arv-2016/en/.
6. Gazzard BG (on behalf of the BHIVA Treatment Guidelines Writing Group) (2008). BHIVA guidelines for the treatment of HIV-1-infected adults with antiretroviral therapy 2008. HIV Med 9: 563–608.
7. British HIV Association (2015). BHIVA guidelines for the treatment of HIV-1‐positive adults with antiretroviral therapy.
8. https://www.england.nhs.uk/2017/12/nhs-england-announces-new-specialised-treatments-for-patients/.
9. https://www.engage.england.nhs.uk/consultation/commissioning-policy-antiretroviral-therapy/.
10. https://www.engage.england.nhs.uk/consultation/commissioning-policy-antiretroviral-therapy/user_uploads/antiretroviral-therapy-evidence-review.pdf.
11. https://www.engage.england.nhs.uk/consultation/commissioning-policy-antiretroviral-therapy/user_uploads/antiretroviral-therapy-integrated-impact-assessment.pdf.

Infection reports in this issue of HPR

The following infection reports are published in this issue of HPR. The links below are to the relevant webpage collections or publications.

• General outbreaks of foodborne illness in humans, England and Wales: weeks 48-52/2017.
• Salmonella infections (faecal specimens, England and Wales), reports to PHE: weeks 48-52/2017.
• Common GI infections (England and Wales), laboratory reports: weeks 48-52/2017.
• Less common pathogens: weeks 1/10/2017 to 31/12/2017.
• Suspected and laboratory-confirmed reported norovirus outbreaks in hospitals: outbreaks occurring in weeks 48-52, 20177.