News Archives |
Volume 5 No 48; 2 December 2011
- Latest UK HIV data reinforce the need for “universal HIV testing” in high prevalence areas
- Consultation on HIV positive healthcare workers launched
- How to spoil a wedding – foodborne campylobacter outbreaks at catering premises and catered events
- Outbreak of UK acquired Shigella flexneri in men who have sex with men: an update
Latest UK HIV data reinforce the need for “universal HIV testing” in high prevalence areas
To mark World AIDS Day - 1 December - the Health Protection Agency released two related reports: HIV in the United Kingdom: 2011 report [1] and Sexually Transmitted Infections among men who have sex with men (MSM): 2011 report [2].
HIV in the UK
By the end of 2010, it is estimated that 91,500 (95% credibility interval* (CI): 85,400-99,000) people were living with HIV; by end-2012, it is expected that this number will reach over 100,000. In 2010, approximately one quarter (24%; CI: 19%-30%) were unaware of their HIV infection (figure 1).
Figure 1. Estimated number of adults living with HIV (both diagnosed and undiagnosed) in the United Kingdom: 2010 
In the UK, the estimated prevalence of HIV in 2010 was 1.5 per 1,000 (CI: 1.4 - 1.6) population of all ages (2.0 per 1,000 (CI: 1.8 - 2.2) men and 0.9 per 1,000 (CI: 0.9 - 1.0) women). Assuming that 3.4% of the adult male population in the UK are men who have sex with men (MSM), one in 20 MSM were living with HIV nationally (47 per 1,000 population), and one in 11 in London (83 per 1,000). HIV prevalence among black-Africans living in England and Wales was also high (31 per 1,000 among men and 64 per 1,000 women).
People living with diagnosed HIV infection in the UK can now expect a near-normal life expectancy, due to effective anti-retroviral therapy [3]. However, this is reliant on prompt HIV diagnosis. In 2010, half of adults were diagnosed late (CD4 count <350 cells/µl within three months of diagnosis). People diagnosed late carry a ten-fold increased risk of dying within a year of diagnosis, compared to those diagnosed promptly [4]. The high proportion of undiagnosed HIV infection and late HIV diagnoses emphasises the need to further improve HIV testing in the UK.
HIV testing
More than 2.1 million HIV tests were performed in England in 2010, and an estimated 3.7% of the English population were tested for HIV. Of the 1,469,500 new STI clinic visits among people not known to be HIV positive, one in five (22%) declined an HIV test when offered.
The HPA recommends that efforts to implement routine, universal HIV testing for general medical admissions and new registrants in general practice should be prioritised in areas with high HIV prevalence in accordance with national guidelines [5, 6,7]. In 2010, 54 English local authorities had a diagnosed prevalence above the 2 per 1,000 population threshold, of which 29 were in London (figure 2).
Figure 2. Prevalence of diagnosed HIV infection by local authority among population aged 15-59: UK, 2010 
Men who have sex with men
In 2010, an estimated 3,000 MSM were newly diagnosed with HIV, the highest number ever reported. MSM accounted for almost half of all HIV infections diagnosed in that year. One in four of all MSM and one in three of those aged 15-24, who were diagnosed in 2010, acquired their infection recently (figure 3). The findings indicate high rates of ongoing transmission among MSM.
Figure 3. Proportion of recent infections among men who have sex with men newly diagnosed with HIV: England and Northern Ireland, 2010 
Gonorrhoea and chlamydia are the most commonly diagnosed STIs among MSM (approximately 4,500 and 5,000, respectively). Syphilis disproportionately affects MSM, with the majority of all syphilis diagnoses in men made among MSM (82%) and about 35% are among HIV-diagnosed MSM [8]. Diagnoses of Lymphogranuloma venereum (LGV) more than doubled, from 190 in 2009 to 530 in 2010. The majority (84%) were known to have been diagnosed with HIV either prior to LGV diagnosis or at the time of LGV acquisition.
The HPA recommends that MSM test annually for HIV and STIs, and more often if they are having unprotected sex with new and casual partners.
Detailed tables on the UK HIV data for 2010, by geographic region and prevention groups, can be accessed on the HIV section of the HPA website at: http://www.hpa.org.uk/Topics/
InfectiousDiseases/InfectionsAZ/HIV/.
References
1. HIV in the United Kingdom: 2011 report, November 2011. HPA website: Home > Publications > Infectious diseases > HIV and sexually transmitted infections > HIV in the United Kingdom: 2011 report. See also: HPA press release, 29 November 2011: "HPA urges 'universal testing' for HIV as it is revealed more than 21,000 people are unaware they have the infection".
2. Sexually transmitted infections among men who have sex with men (MSM): 2011 report (November 2011). HPA website: Home > Publications > Infectious diseases >HIV and sexually transmitted infections > Sexually transmitted infections in men who have sex with men in the United Kingdom: 2011 report.
3. May M, Gompels M, Delpech V, Porter K, Post F, et al. Impact of late diagnosis and treatment on life expectancy in people with HIV-1: UK Collaborative HIV Cohort (UK CHIC) Study. BMJ. 2011 Oct 11; 343:d6016.
4. Brown AE, Kall M, Smith RD, Yin Z, Hunter A, Delpech V. Auditing national HIV guidelines and policies: the United Kingdom CD4 surveillance scheme. Open AIDS Journal 2011. In press.
5. National Institute for Health and Clinical Excellence. PH34: Increasing the uptake of HIV testing to reduce undiagnosed infection and prevent transmission among men who have sex with men (March 2011).
6. National Institute for Health and Clinical Excellence. PH33: Increasing the uptake of HIV testing to reduce undiagnosed infection and prevent transmission among black African communities living in England (March 2011).
7. British HIV Association, British Association for Sexual Health and HIV, and British Infection Society. UK National Guidelines for HIV Testing 2008 (2008). London, British HIV Association.
8. Jebbari H, Simms I, Conti S, Marongiu A, Hughes G, et al. Variations in the epidemiology of primary, secondary and early latent syphilis, England and Wales: 1999 to 2008. Sex Transm Infect 2011 87:191-8.
Consultation on HIV positive healthcare workers launched
A consultation into relaxing the restrictions placed on the work that can be undertaken by HIV positive healthcare workers has been launched by the Chief Medical Officer Dame Sally Davies, following a review of current arrangements by leading experts [1].
A tripartite working group of the Expert Advisory Group on AIDS, the UK Advisory Panel of Healthcare Workers Infected with Blood-borne Viruses and the Advisory Group on Hepatitis examined evidence of risk of HIV transmission from healthcare workers with HIV to patients.
The joint working group found that there have been no reported transmissions of HIV from healthcare workers even though there have been investigations involving 10,000 patients who were tested for HIV.
Few other countries have such tight restrictions as those in force in the UK whereby healthcare workers diagnosed with HIV are not allowed to perform "exposure-prone procedures", ie most surgical or dental procedures.
The joint working group concluded that the risk of HIV transmission from a healthcare worker who is undiagnosed and untreated is extremely low for the most invasive procedures such as open cardiac surgery; and is negligible for the least invasive procedures such as a local anaesthetic injection in dentistry.
The risk of HIV infection to any patient having the most invasive type of exposure-prone procedure - such as open cardiac surgery - has been estimated as about one in five million, a similar level of risk to being struck and killed by lightning. These risks can be reduced even further by effective antiretroviral drug therapy.
The consultation, which is open until 9 March 2012, invites views from the medical community as well as the public on whether current restrictions should be maintained and how the expert group's findings could be implemented effectively.
Reference
1. "Management of HIV-infected healthcare workers - a paper for consultation", 1 December 2011. DH website: http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_131532.
How to spoil a wedding – foodborne campylobacter outbreaks at catering premises and catered events
An increase in the number of general outbreaks of campylobacter infections associated with consumption of poultry liver pâté/parfait prepared and served at hotels and restaurants has been reported in recent years [1, 2, 3] and this increase has continued in 2011 (see figure). Similarly, laboratory confirmed cases of infection with campylobacter in England and Wales have also continued to increase [4]. Up to week 42 of 2011, the number of laboratory-confirmed campylobacter cases recorded in England and Wales was 3% greater than in the same period in 2010, and 15% up on the same period in 2009. Despite almost 63,000 laboratory confirmed cases reported during 2010, foodborne outbreaks of infections are rarely reported, usually representing around 0.1% of all cases.
Fourteen of the 18 general foodborne outbreaks of campylobacter infection reported to the HPA electronic Foodborne and non-Foodborne Gastrointestinal Outbreak Surveillance System (eFOSS) in 2011 - affecting 443 individuals, and including one hospitalisation - were associated with catering premises; the remainder included a community (1), school (1) and care homes (2).
Thirteen (93%) of the outbreaks at catering premises were linked to poultry liver parfait or pâté consumption (11 prepared from chicken livers and two from duck livers) and occurred in seven regions of England (East of England, East Midlands, North West, London, South East, South West and Yorkshire & Humberside) compared to five regions in 2010. Seven of the outbreaks were linked to catering at wedding receptions (at hotels, banqueting venues or public houses), six associated with catering at other functions (at hotels, clubs and restaurants).
UK control strategy
Campylobacter is the principal cause of bacterial gastroenteritis in the United Kingdom and control of campylobacter in poultry meat is a major public health strategy for the prevention of campylobacteriosis [5], an approach that has been shown to be effective in reducing foodborne disease in New Zealand [6]. Poultry livers carry a high risk of campylobacter contamination as the bacteria can be present throughout the liver, and may remain as a source of infection if insufficiently cooked [7]. Evidence gained from outbreaks during 2011 revealed that, as in 2009 and 2010, livers used to make the parfait or pâté were undercooked allowing the liver dish to remain pink in the centre. Poor practice regarding handling and cooking of liver and other offal presents an unacceptable level of risk to the consumer. Chefs and other caterers can reduce the risk of their customers becoming infected by ensuring that campylobacter is killed through proper cooking and avoiding contamination of ready-to-eat foods from raw poultry, liver and other offal.
The Food Standards Agency has issued updated advice to caterers on the safe handling and cooking of livers twice in 2010, ie livers should be thoroughly cooked before consumption (to a core temperature of 70°C for at least two minutes or equivalent using a meat thermometer to check the core temperature) [8, 9]. Despite this advice targeted to caterers campylobacter outbreaks associated with consumption of poultry liver pâté/parfait in 2011 have continued to occur.
For couples getting married it might be best to consider the chicken liver cooking options with the chef for the reception carefully!
General foodborne outbreaks of campylobacteriosis in England and Wales by year* 
References
1. Health Protection Agency. Food-borne outbreaks of campylobacter (associated with poultry liver dishes) in England. HPR 3(49): news.
2. Little CL, Gormley FJ, Rawal N, Richardson JF. A recipe for disaster: outbreaks of campylobacteriosis associated with poultry liver pâté in England and Wales. Epidemiol Infect 2010; 138: 1691-4.
3.Health Protection Agency. Food-borne outbreaks of Campylobacter associated with poultry liver pate/parfait - spotlight on caterers and food safety. HPR 4(48): news.
4. HPA press release, 1 December 2011.
5. Food Standards Agency. Food Standards Agency Consultation. Foodborne Disease Strategy 2010-15. London: FSA, 2010. Available at: http://www.food.gov.uk/multimedia/pdfs/fds2015.pdf.
6. Sears A, Baker MG, Wilson N, Marshall J, Muellner P, Campbell DM, et al. Marked campylobacteriosis decline after interventions aimed at poultry, new zealand. Emerg Infect Dis 2011 Jun;17(6):1007-15.
7. Whyte R, Hudson JA, Graham C. Campylobacter in chicken livers and their destruction by pan frying. Letters in Applied Microbiology 2006; 43: 591-5.
8. Food Standards Agency. Caterers warned on chicken livers. 28 July 2010. London: FSA, 2010. Available at: http://www.food.gov.uk/news/newsarchive/2010/jul/livers.
9. Food Standards Agency. FSA reminds caterers about safe preparation of chicken livers. 3 December 2010. London: FSA, 2010. Available at: http://www.food.gov.uk/news/newsarchive/2010/dec/chickenliver.
Outbreak of UK acquired Shigella flexneri in men who have sex with men: an update
The HPA is continuing to investigate an outbreak of UK-acquired Shigella flexneri affecting men who have sex with men (MSM).
An increase in UK-acquired cases of the infection was noted in London and Greater Manchester during the spring and summer of 2011, local investigations indicating that these were predominantly among MSM [1].
A national outbreak control team (OCT) was established in October and national enhanced surveillance was set up to collect additional information for all laboratory-confirmed cases with sample dates between 1 September and 31 December 2011.
As part of its investigation, the OCT also reviewed laboratory reports of Shigella flexneri from 2001 through to 2011 which indicated a sharp increase in cases with no or an unknown recent travel history since 2010.
Since 1 September, there have been 118 cases of the infection and, of these, 27 have been confirmed as non-travel related (see figure) and originate from London (8), the North West (5), the North East (4), Wales (3), Yorkshire and Humberside (3), the South East (3) and the East of England (1).
Epidemic curve of laboratory-confirmed cases identified from 1 September 2011 to 25 November 2011, by sample date and travel status (Source: Enhanced Surveillance)
The enhanced surveillance information from 1 September indicate that UK acquired cases were predominantly male (20/27) and of these 11 were identified as men who have sex with men (MSM), a further three men declined to provide information on sexual orientation and the remainder were identified as either not MSM or under 16 years old.
The confirmed UK-acquired cases were aged between three and 56 years old (mean 25 years, median 28 years). The cases identified as MSM were older, aged between 25 and 54 years old (mean 40 years, median 34 years).
Serotype of confirmed UK acquired cases with specimen dates since the 1st September, 2011
| Serotype | Total (MSM) |
|---|---|
1a |
1 (-) |
1b |
5 (4) |
2a |
2 (1) |
2b |
1 (-) |
3a |
10 (4) |
3b |
1 (UK) |
6 |
2 (1) |
1037 |
4 (-) |
Y |
1 (-) |
| Total | 27 (11) |
The serotype was available for all 27 UK-acquired cases and 10/27 of cases were infected with serotype 3a, see figure 2 for distribution of serotypes by sexual orientation.
The enhanced surveillance is expected to continue until the 31 December 2011. As a considerable proportion of cases of S. Flexneri occurred in MSM, an additional study to identify any potential risk factors and exposures in MSM will be conducted.
Reference
1. Outbreak of UK-acquired Shigella flexneri in men who have sex with men. HPR 5(40), 7 November: news, http://www.hpa.org.uk/hpr/archives/2011/news4011.htm#shgflx.