Sexually transmitted infections: epidemiological evidence of need Dr Kirsty Foster Consultant in Health Protection Public Health England Centre, North East

Surveillance of Sexually Transmitted Infections “ the continuing scrutiny of all aspects of the occurrence and spread of a disease through the systematic collection, collation and analysis of data and the prompt dissemination of the result information so that action can result”

Genito-urinary clinical activity dataset (GUMCAD) Numbers / rates of STIs, By LA of residence / gender / age group / sexual orientation / ethnicity Sexual health screens / testing Performance monitoring / Patient flows / activity by clinic Clinics attended by your resident population / people attending clinics in your area Collected quarterly (data available ~6-8 weeks later) Introducing system to collect data from other services (GUMCAD2)

Chlamydia testing activity dataset (CTAD) Single dataset for all chlamydia testing Can monitor the impact of chlamydia screening through numbers screened, numbers positive and diagnostic rates Public health outcome framework measure – combines numbers of people screened with positive diagnoses Overlapping with “old” NCSP system at the moment – will “go live” in 2013

HIV data Overall prevalence of HIV in local area New diagnoses of HIV Deaths from / with HIV Late diagnosis of HIV (indicator of poorer outcome) Number of people accessing care (Anonymised surveys used nationally to estimate the proportion of people with HIV who are undiagnosed)

How do we use the data?

Notes: 1. STIs included. Chlamydia, gonorrhoea, syphilis, genital herpes (first episode), genital warts (first episode), non specific urethritis, chancroid, LGV, donovanosis, molluscum, trichomoniasis, scabies, pubic lice. Includes data on chlamydia from community-based settings. 2. Rates calculated by patient LA of residence may be slightly underreported due to incomplete residence data reported by some clinics. The rate of acute STIs by Local Authority ranges from <190 to 2620 per 100,000 population. In 2011, rates of acute STI diagnoses were highest in residents of urban areas, particularly in London, reflecting to a large extent the distribution of core groups of the population who are at greatest risk of infection and areas of higher deprivation. Between 2010 and 2011, rates of diagnosis of acute STIs increased in 55% (178/326) of Local Authorities in England. The rate of acute STIs ranges from <190 per 100,000 in Dartford local authority (South East SHA) to 2,620 per 100,000 in Lambeth local authority (London SHA).

Epidemiology

Notes: STIs included. Chlamydia, gonorrhoea, syphilis, genital herpes (first episode), genital warts (first episode), non specific urethritis, chancroid, LGV, donovanosis, molluscum, trichomoniasis, scabies, pubic lice. Includes data on chlamydia from community-based settings. Young adults aged under 25 years experience the highest rates of STIs.

Notes: Like other acute STIs, young people share a disproportionate burden of gonorrhoea. Among women attending GUM clinics in 2011, 69% (4,095/5,972) of gonorrhoea diagnoses were in those less than 25 years of age. Rates of diagnoses peaked among women aged 19 and men aged 24.

Notes: Rates of syphilis are nine times higher among men.

STI diagnosis rates by ethnic group among females, England: 2011 Patterns of STI diagnosis rates are similar across ethnic groups, with rates of chlamydia being the highest for each ethnic group, followed by genital warts and rates of syphilis being the lowest. As in males, the rates of diagnoses of syphilis, gonorrhoea, genital herpes, genital warts and chlamydia were highest among females of ‘Black or Black British’ ethnicity (6.7/100,000, 132/100,000, 188/100,000 ,190/100,000 , 607/100,000 , respectively) and lowest among those of ‘Asian or Asian British’ ethnicity.

Notes: Excluding those born within the UK , men born within Europe (excl UK) make up the highest number of chlamydia, gonorrhoea and syphilis cases.

Notes: In England in 2011, for cases in men where sexual orientation was recorded, 75% (1,955/2,622) of syphilis diagnoses, 50% (7,487/14,992) of gonorrhoea diagnoses, 15% (7,483/51,352) of chlamydia diagnoses, 11% (1,301/11,931) of genital herpes and 8% (3,102/41,333) of genital warts were among MSM

Prevalence of diagnosed HIV infection by region of residence among population aged 15-59 years: United Kingdom, 2011 In areas of high prevalence of diagnosed HIV infection (>2 diagnosed infections per 1,000 population aged 15-59 years) UK national guidelines recommend expanding HIV testing among people admitted to hospital and new registrants to general practice. In 2011, 58 English local authorities had a diagnosed prevalence above 2 per 1,000, of which 30 were in London. Less than 1 1-2 London >2

Late diagnosis1 of HIV infection by exposure group: United Kingdom, 2011 Late diagnosis is the most important predictor of morbidity and mortality among those with HIV infection. In 2011, 47% (2,950) of HIV diagnoses were made at a late stage of infection (with a CD4 cell count <350 cells/mm3 within three months of diagnosis) including 26% (1,630) who were severely immunocompromised at diagnosis (CD4 cell count <200 cells/mm3). The proportion diagnosed late was lowest among MSM (35%; 1,050), while 56% of heterosexual women (941) and 64% of heterosexual men (840) were diagnosed late. Late diagnosis was highest among black African men (65%; 460/700) and black African women (61%; 650/1070), followed by black Caribbean women (46%; 30/60) and black Caribbean men (42%; 40/100), and white women (42%; 160/370) and white men (41%; 1,210/2960).

Two real-life examples Presentation title - edit in Header and Footer

Congenital syphilis The infection can be passed on from mother to baby Women are screened for syphilis as part of antenatal care, but if they have new “exposure” during pregnancy they can be infected and pass that infection on. These are preventable infections 4 cases of congenital syphilis in the North East in past 2 years Multi-professional working group to ensure that safe and robust procedures are in place at all steps of the pathway

Risk factors and case management - Regional audit of syphilis in women Assessment of case management Can we identify “at risk” pregnant women and offer increased screening? Presentation title - edit in Header and Footer

Gonorrhoea Infections and outbreaks are usually seen in MSM In summer 2011, the sexual health clinic in Northumberland noticed increase in heterosexual cases of gonorrhoea Young adults affected – locally defined area Numbers of cases continue to higher than previous years – been “rumbling on” for 18 months Multi-agency efforts to raise awareness, promote safe sex messages, ensure joined up work between services

Epidemic curves Northumberland Apr 11 – Dec 12 Newcastle Apr 11 – Jul 11 and Jan 12 – Dec 12 Summary of Gonorrhoea North of Tyne

Data analysis Comparisons of Northumberland and Newcastle resident cases   Northumberland Newcastle Female 57% 36% Heterosexual 94% 63% <20 50% 26% Most deprived 45% 43% Symptomatic 42% 51% Concurrent STI 41% 27% Re-infection 4% 5% Return for test of cure 46% 62% Summary of Gonorrhoea North of Tyne

Mapping the networks

Where should we be focussing our efforts? Partner notification Total Traceable Attended Positive Number 240 166 130 67 Percentage of total 100% 69% 54% 28% Percentage of previous category - 78% 53% total traceable attended Sheffield study highlights that the lack of engagement in risk data collection was in itself a risk factor for re-infection; could the same be said for providing accurate PN information – and could this be contributing to the ongoing transmission in the community? positive

Cases are increasing elsewhere: is the “outbreak” spreading or is this something new? Cases in other parts of the region Different patterns of infection Further review of epidemiology Molecular typing used to map cases Strain type G25 almost exclusively found in outbreak cases Other cases around region were different strain type Presentation title - edit in Header and Footer

Summary At risk groups / communities are well known to us Different approaches needed for different groups and infections How to say the simple safe sex message to different groups? Need to engage “new” commissioners and organisations and keep the “old” ones involved Presentation title - edit in Header and Footer