Research and analysis

HPR volume 12 issue 42: news (23 November)

Updated 21 December 2018

Infections among people who inject drugs in the UK: annual report in summary

Shooting Up, the annual report on infections among people who inject drugs (PWID) in the United Kingdom, has been published by Public Health England [1]. The report was produced jointly by PHE, Health Protection Scotland, Public Health Wales, and Public Health Agency Northern Ireland.

PWID are vulnerable to a wide range of infections – including those caused by viruses such as HIV and hepatitis B and C, and bacteria such as Clostridium botulinum and Staphylococcus aureus – which can result in high levels of illness and death. The report examines the extent of infections and the associated risks among people who inject psychoactive drugs, such as heroin and cocaine.

Hepatitis C prevalence remains high and half of those infected are undiagnosed

Hepatitis C remains the most common blood-borne infection among PWID, and there are significant levels of transmission among this group in the UK. Two in every 5 PWID are living with hepatitis C. The increasing availability of the new direct-acting antiviral drugs provides an opportunity to reduce morbidity and mortality from hepatitis C, and to decrease the risk of onward transmission. Improving the offer and uptake of testing for hepatitis C is particularly important as approximately half (48%) of hepatitis C infections among PWID remain undiagnosed. Of those who were unaware of their infection, 22% reported that they had never been tested, and of those unaware but tested, 44% reported that their last test had been more than two years earlier.

HIV levels remain low, but risks continue

In the UK, around 1 in 100 PWID is living with HIV. Most have been diagnosed and will be accessing HIV care. However, HIV is often diagnosed at a late stage among PWID, and testing should be encouraged.

Hepatitis B remains rare, but vaccine uptake needs to be sustained, particularly in younger age groups

In the UK, around 1 in every 500 PWID is currently infected with hepatitis B. About three-quarters of PWID report taking up the vaccine against hepatitis B, but this level is no longer increasing, and is particularly low in younger age groups (64%) and among those who recently began injecting (57%).

Bacterial infections continue to be a problem

Bacterial infections in PWID are often related to poor general hygiene and unsterile injection practices. Bacterial infections can result in severe morbidity in PWID, with severity compounded by delays in seeking healthcare in response to the initial symptoms. In 2017, half (50%) of PWID report that they had a symptom of an injecting site infection during the preceding year; this is an increase from 28% during 2011-2013. Outbreaks of infections due to bacteria, particularly invasive Group A streptococci, are continuing to occur in this group.

Infographic illustrating the extent of hepatitis C, and bacterial infections, among those who injected psychoactive drugs in 2017.

Injecting risk behaviours have declined but remain a problem

The level of needle and syringe sharing among PWID has fallen across the UK but sharing remains a problem, with over 1 in 6 reporting sharing of needles and syringes in the past month during 2017.

Changing patterns of psychoactive drug injection remain a concern

Heroin remains the most commonly injected drug in the UK in 2017. Injection of crack has increased in recent years in England and Wales, with 51% of those who had injected in the preceding 4 weeks reporting crack injection in 2017 as compared to 35% in 2007. This increase was particularly marked in Wales, East of England, South East, South West and the East Midlands. In Scotland crack injection is much lower and none was reported in Northern Ireland.

There has also been an increase in the proportion of PWID reporting groin injection in the past month, with 2 in 5 reporting injecting in their groin in 2017.

Provision of effective interventions needs to be maintained and optimised

The findings presented in the report indicate a need to maintain and improve services that aim to reduce injecting-related harms and to support those who want to stop injecting. A range of services, including locally appropriate provision of needle and syringe programmes, opioid substitution treatment, and other drug treatment, should be provided [2,3]. Vaccinations and diagnostic tests for infections need to be routinely and regularly offered to people who inject or have previously injected drugs [3]. Care pathways and treatments should be optimised for those diagnosed with blood-borne viruses and bacterial infections.

References

1. PHE, Health Protection Scotland, Public Health Wales and Public Health Agency Northern Ireland (November 2018). “Shooting Up: infections among people who inject drugs in the UK, 2017”.

2. NICE (2014). Needle and syringe programmes: providing people who inject drugs with injecting equipment Public Health Guidance, PH52.

3. DH (2017). Drug Misuse and Dependence: UK guidelines on clinical management.

Prescribing for common infections: updated guidance published by NICE and PHE

PHE and NICE have published new Summary of Antimicrobial Prescribing Guidance: Managing Common Infections [1], bringing together – in the form of a single-document set of summary tables – guidance that takes account of:

• new guidance on the management of common infections jointly developed by NICE and PHE, and
• previous PHE antibiotic summary tables used by Clinical Commissioning Groups to develop their own localised guidance.

The consolidated guidance is aimed at primary and secondary care health practitioners managing common infections.

The new summary tables, hosted within the Antimicrobial Prescribing Guidelines section of the NICE website [2], cover 50 infections and are available in Word (as well as PDF) format, allowing CCGs to adapt them for their local requirements.

The NICE content is based on recently developed guidance for acute otitis media, sinusitis, acute sore throat, and urinary tract infections (lower, upper, recurrent and prostatitis). Each of the NICE/PHE infection summaries within the table are hyperlinked to relevant infographics and to full guidance on the NICE website.

For this new publication, the PHE content underwent a minor update, and there is a new section specific to Lyme disease. Each PHE infection summary links to the relevant rationale and references on the PHE website [3].

As further related items of infection guidance are jointly produced by NICE/PHE, they will replace the relevant PHE content within the summary tables.

References

1. NICE website. Summary of Antimicrobial Prescribing Guidance: Managing Common Infections.
2. NICE website. Antimicrobial Prescribing Guidelines.
3. PHE website (31 October 2018). Managing common infections: guidance for primary care.

EVD outbreak in eastern DRC: third update

The outbreak of Ebola virus disease declared on 1 August in eastern Democratic Republic of the Congo continues. To date, 346 confirmed cases and 47 probable cases have been reported across 14 health zones in 2 provinces, North Kivu and Ituri. In the past month, there have been 165 new confirmed cases recorded, with an additional 5 health zones (Katwa, Kyondo, Lubero, Mutwanga and Vuhovi) affected [1].

New and total confirmed cases by week. Data provided by DRC MoH [1].

In early October a significant increase in case incidence was reported, and this heightened rate has been maintained in recent weeks (see figure). Although contact tracing rates have improved since September/October, a high proportion of cases continue to be reported in individuals not regarded as contacts of confirmed cases. This would indicate uncontrolled and possible unknown chains of transmission within the affected communities. Increased effort is being placed on active case finding to stem these transmission chains, with a particular emphasis on formal and informal health facilities in Béni.

Response activities, particularly in Béni, are very sensitive to disruption. In the last month severe security incidents have continued to hamper response activities including contact tracing and vaccination [2]. It is anticipated that the outbreak could last at least another six months [3] but the World Health Organization is confident that it can be successfully contained in collaboration with the DRC Ministry of Health and other international partners [4].

The risk to the UK public remains very low to negligible. The situation is being monitored closely and the risk assessment is regularly reviewed.

Further information sources

• PHE website Ebola collection Ebola virus disease: clinical management and guidance
• NaTHNaC website for travel advice Travel Health Pro website
• WHO website EVD homepage Ebola virus disease
• Foreign and Commonwealth Office (FCO) DRC advice

References

1. DRC Ministry of Health (in French).
2. WHO AFRO Situation Report No. 16.
3. Reuters (13 November). Peter Salama (WHO) statement.
4. WHO (22 November). Disease Outbreak News.

Infection and vaccine coverage reports in this issue

This issue includes:

• Pertussis vaccination programme for pregnant women update: vaccine coverage (England): April to June 2018.
• Shingles immunisation programme 2017 to 2018: evaluation report.
• Laboratory-confirmed measles, mumps and rubella (England): July to Sept 2018.