Research and analysis

HPR volume 8 issue 42: news

Updated 23 December 2014

1. Latest Shooting Up report focuses on the changing nature of injecting drug use

The 12th annual report on infections among people who inject drugs (PWID) in the United Kingdom – Shooting Up – has been published by Public Health England [1].

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 botulism and group A streptococci – that can cause significant morbidity and mortality. The report examines the extent of infections and the associated risks among PWID under six headings:

1.1 Hepatitis C levels are still high

Among people who inject psychoactive drugs, such as heroin and mephedrone, around half have antibodies to hepatitis C (58% in Scotland, 50% in England, 47% in Wales, and 32% in Northern Ireland). As around a quarter of those infected with hepatitis C clear their infection, these data suggest that about two in five of those who inject psychoactive drugs are currently living with hepatitis C infection in the UK. Although the uptake of testing is high, about half of these hepatitis C infections remain undiagnosed, either because people have never had a test or have become infected since their last test. About one in 30 (3.6%) of those who inject image and performance enhancing drugs, such as anabolic steroids, are living with hepatitis C.

1.2 Hepatitis B is now rare and vaccine uptake has improved

Among people who inject psychoactive drugs the proportion ever infection with hepatitis B has declined (falling from 30% in 2003 to 16% in 2013 in England, Wales and Northern Ireland), probably reflecting the marked increase in the uptake of the hepatitis B vaccine. In 2013, only 0.57% of this group had a current hepatitis B infection. Vaccine uptake levels among people who inject psychoactive drugs have been stable in recent years (72% in England, Wales and Northern Ireland, 74% in Scotland in 2013), but could be increased further. Vaccine uptake is, however, much lower (40%) among people who inject image and performance enhancing drugs.

1.3 HIV levels remain low and the uptake of care is good

Around one in every 100 people who inject drugs is living with HIV. The level of HIV infection among those injecting image and performance enhancing drugs is similar to that among those injecting psychoactive drugs. Most people who inject psychoactive drugs report ever being tested for HIV (76% in England, Wales and Northern Ireland, and 78% in Scotland) and the majority of those with HIV are aware of their infection. Only 41% of those injecting image and performance enhancing drugs reported ever being tested for HIV. Overall, the uptake of HIV related care, including anti-retroviral therapy, is high among PWID.

1.4 Bacterial infections remain a major problem

Severe illnesses among people who inject drugs due to bacterial infections continue to place a significant burden on health services. Around a quarter (28%) of people who inject psychoactive drugs report a recent symptom of an injecting site bacterial infection. Among those who inject image and performance enhancing drugs, one in six (16%) report ever having a symptom of an injecting site bacterial infection.

1.5 Injecting risk behaviours have declined but remain a problem

Reported needle and syringe sharing among people injecting psychoactive drugs has halved over the last 10 years; in England, Wales and Northern Ireland this has fallen from 29% in 2003 to 16% in 2013. However, almost one in three (29%) of this group reported that they had injected drugs using a needle that they had attempted to clean. Sharing injecting equipment is less commonly reported among people injecting image and performance enhancing drugs; 13% of those surveyed in 2012-13 reported ever sharing a needle, syringe or vial of drugs

1.6 Changing patterns of psychoactive drug injection are a cause for concern

There has been a recent increase in the injection of amphetamines and amphetamine-type drugs, such as mephedrone – with more than one in two now reporting these as their main drug. The injection of these drugs has been associated with higher levels of infection risk. Although the injection of these drugs is much less common than the injection of opiates, crack-cocaine, or image and performance enhancing drugs, this increase is a concern.

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 should be provided including needle and syringe programmes, opioid substitution treatment, and other drug treatment, as well as easy access to diagnostic testing for hepatitis C and HIV (including access to care pathways for those living with these infections), to vaccinations including that for hepatitis B, and to information and advice on safer injecting practices, on preventing infections and on the safe disposal of used equipment. These services should be developed in line with published guidelines [2,3,4,5] to ensure that the interventions they provide have sufficient coverage to prevent infections.

1.7 References

1. Health Protection Agency, Health Protection Scotland, Public Health Wales and Public Health Agency Northern Ireland (November 2014). Shooting Up: infections among people who inject drugs in the UK, update November 2014.

2. Department of Health (2007). “Drug misuse and dependence – guidelines on clinical management: update 2007”.

3. NICE (July 2007). “Drug misuse: psychosocial interventions (Clinical Guideline CG51)”.

4. NICE (July 2007). “Drug misuse: opioid detoxification (Clinical Guideline CG52)”.

5. NICE (March 2014). “Needle and syringe programmes: providing people who inject drugs with injecting equipment”.

2. Updated guidance for healthcare professionals on the use of antivirals for the treatment and prophylaxis of influenza

Public Health England has published a summary for healthcare professionals of the current guidance and evidence on the use of antivirals for the treatment and prophylaxis of influenza [1,2]. This follows the publication of an updated Cochrane Review on the efficacy of NAIs for influenza in April 2014 [3].

The PHE guidance makes the following key recommendations:

• there is evidence that antivirals can reduce the risk of death in patients hospitalised with influenza

• in the light of this evidence it is important that doctors treating severely unwell patients continue to prescribe these drugs where appropriate

• PHE continues to support the early use of antivirals for patients with proven or suspected seasonal influenza who are in high risk groups or who are considerably unwell (even if not in a high risk group).

Influenza remains a significant cause of severe illness, hospital admissions and death, particularly over the winter season. The only class of drugs that are in regular use for the treatment of influenza are the antiviral drugs – neuraminidase inhibitors, NAIs – oseltamivir (‘Tamiflu’) and zanamivir (‘Relenza’).

The British Medical Journal (BMJ) and the Cochrane Collaboration have rightly campaigned to gain access to all clinical trial data for the antiviral drugs used against influenza. The 2014 Cochrane Review included previously unpublished data for healthy children and adults, and some who had chronic illness (asthma, diabetes, and hypertension). Overall the review adds to the evidence base for the treatment of influenza in some settings. However Cochrane Reviews consider evidence only from randomised control trials, which by their nature are usually carried out in an otherwise healthy population in the community setting. The findings of the review are not therefore necessarily applicable to the more severe end of the influenza spectrum.

Observational data is available in hospitalised patients but was not considered in the review, including evidence that antivirals can stop the deterioration of some types of influenza and reduce the risk of death in patients hospitalized with influenza. A recent meta-analysis of observational studies of patients hospitalised with influenza [4] showed that among adults, treatment with a NAI was associated with a 25% reduction in the likelihood of death compared with no antiviral treatment. Early treatment with NAIs within 48 hours of onset of symptoms halved the risk of death compared with no antiviral treatment. This supports the view that the benefit of NAI antiviral treatment is greatest when started within two days of onset of illness.

Although the findings of the 2014 Cochrane Review were not substantially different to the previous (2010 and 2012) reviews, and there is no evidence to support a change to the recommended use of NAIs, media reporting around the Cochrane Review 2014 publication suggested that antivirals are not effective for influenza. This may impact on the prescribing of these important drugs.

It is essential that physicians treating severely unwell patients in any setting are not deterred from prescribing what may be lifesaving drugs as a result of confusion over efficacy in this situation; this is especially true for patients hospitalised with proven or suspected influenza.

Due to the evidence that antivirals can be of benefit in patients with severe influenza, PHE continues to support the use of NAIs for patients with proven or suspected seasonal influenza who are in high risk groups (as per NICE guidance) or who are considerably unwell (even if not in a high risk group). PHE also continues to support stockpiling of antiviral drugs to ensure adequate national supply, as part of pandemic influenza preparedness.

The PHE position is consistent with that taken by the World Health Organisation (WHO) and other national public health organisations such as the USA’s Centers for Disease Control and Prevention (CDC).

2.1 References

1. “Antivirals in the fight against flu this winter”, PHE press release, 5 November 2014, https://www.gov.uk/government/news/antivirals-in-the-fight-against-flu-this-winter.
2. PHE (5 November 2014). “The use of antivirals for the treatment and prophylaxis of influenza: summary of guidance for healthcare professionals”. Available on the GOV.UK Guidance page “Influenza: treatment and prophylaxis using anti-viral agents”.
3. Cochraine Library (April 2014). “Neuraminidase inhibitors for preventing and treating influenza in healthy adults and children”.
4. Muthuri et al (2014). “Effectiveness of neuraminidase inhibitors in reducing mortality in patents admitted to hospital with influenza A H1N1pdm09 virus infection: a meta-analysis of individual participant data”, Lancet Respiratory Medicine 2(5), 396-404.