BACKGROUND:There has been an increasing trend in bacterial sexually transmitted infections (STIs) in England since the early 2000s. Since 2008, surveillance of STIs in England has been conducted using the Genitourinary Medicine Clinic Activity Dataset (hereafter referred to as 'GUMCAD'), a depersonalised dataset of all attendances at all publicly-commissioned sexual health services (SHS). The aim of is this article is to describe and evaluate the piloting and rollout of an enhanced specification of GUMCAD at SHS in England. METHODS:GUMCAD was enhanced in 2019 to allow SHS to report the gender identity (whether cisgender, transgender, gender diverse) of service users, and selected behavioural information collected during routine sexual history-taking such as the number of recent sex partners (last 3 months). RESULTS:Feasibility and acceptability of reporting these new data were confirmed in the pilot stage. 2023 was the first year over which most SHS (93%, 224/241) submitted enhanced GUMCAD data. Of all 4,610,410 consultations at SHS in 2023, gender identity (96% of consultations) and data on whether this varied from the sex registered at birth (88% of consultations) were well reported. Transgender women, transgender men, and gender-diverse individuals (identifying as non-binary or in any other way) respectively comprised 0.4%, 0.4%, and 0.5% of all consultations in 2023. There was less complete reporting of recent sex partners but, where reported, gay, bisexual and other men who have sex with men were more likely to report multiple recent sex partners. CONCLUSIONS:This enhancement provides novel insights into sexual health need relevant to targeting existing and novel preventative interventions for STIs such as 4CMenB vaccination for gonorrhoea and doxycycline post-exposure prophylaxis (doxyPEP) for syphilis in England. The reporting of these new STI surveillance data also raise new complexities in interpretation, and behavioural data completeness will require further support and development.

Objectives Determine the prevaccination healthcare impact of COVID-19 in patients with systemic lupus erythematosus (SLE) in England.Design Retrospective cohort study of adult patients with SLE from 1 May to 31 October 2020.Setting Clinical Practice Research Datalink (CPRD) Aurum and Hospital Episode Statistics (HES) databases from general practitioners across England combining primary care and other health-related data.Participants Overall, 6145 adults with confirmed SLE diagnosis ≥1 year prior to 1 May 2020 were included. Most patients were women (91.0%), white (67.1%), and diagnosed with SLE at age <50 (70.8%). Patients were excluded if they had a COVID-19 diagnosis before 1 May 2020.Primary and secondary outcome measures Demographics and clinical characteristics were compared. COVID-19 severity was determined by patient care required and procedure/diagnosis codes. COVID-19 cumulative incidence, hospitalisation rates, lengths of stay and mortality rates were determined and stratified by SLE and COVID-19 severity.Results Of 6145 patients, 3927 had mild, 1288 moderate and 930 severe SLE at baseline. The majority of patients with moderate to severe SLE were on oral corticosteroids and antimalarial treatments. Overall, 54/6145 (0.88%) patients with SLE acquired and were diagnosed with COVID-19, with 45 classified as mild, 6 moderate and 3 severe COVID-19. Cumulative incidence was higher in patients with severe SLE (1.4%) compared with patients classified as mild (0.8%) or moderate (0.8%). Ten COVID-19-specific hospital admissions occurred (n=6 moderate; n=4 severe). Regardless of COVID-19 status, hospital admission rates and length of stay increased with SLE severity. Of 54 patients with SLE diagnosed with COVID-19, 1 (1.9%) COVID-19-related death was recorded in a patient with both severe SLE and severe COVID-19.Conclusions SLE severity did not appear to impact COVID-19 outcomes in this study. The COVID-19 pandemic is evolving and follow-up studies are needed to understand the relationship between COVID-19 and SLE.

Background The World Health Organization End TB Strategy emphasises screening for early diagnosis of tuberculosis (TB) in high-risk groups, including migrants. We analysed key drivers of TB yield differences in four large migrant TB screening programmes to inform TB control planning and feasibility of a European approach. Methods We pooled individual TB screening episode data from Italy, the Netherlands, Sweden and the UK, and analysed predictors and interactions for TB case yield using multivariable logistic regression models. Results Between 2005 and 2018 in 2 302 260 screening episodes among 2 107 016 migrants to four countries, the programmes identified 1658 TB cases (yield 72.0 (95% CI 68.6–75.6) per 100 000). In logistic regression analysis, we found associations between TB screening yield and age (≥55 years: OR 2.91 (95% CI 2.24–3.78)), being an asylum seeker (OR 3.19 (95% CI 1.03–9.83)) or on a settlement visa (OR 1.78 (95% CI 1.57–2.01)), close TB contact (OR 12.25 (95% CI 11.73–12.79)) and higher TB incidence in the country of origin. We demonstrated interactions between migrant typology and age, as well as country of origin. For asylum seekers, the elevated TB risk remained similar above country of origin incidence thresholds of 100 per 100 000. Conclusions Key determinants of TB yield included close contact, increasing age, incidence in country of origin and specific migrant groups, including asylum seekers and refugees. For most migrants such as UK students and workers, TB yield significantly increased with levels of incidence in the country of origin. The high, country of origin-independent TB risk in asylum seekers above a 100 per 100 000 threshold could reflect higher transmission and re-activation risk of migration routes, with implications for selecting populations for TB screening. Tweetable abstract Factors associated with TB screening yield included increasing age, migrant typology, TB incidence in country of origin, TB case contact and period of screening. The TB yield among asylum seekers was higher than for other migrant categories. https://bit.ly/3VMLwFp

Background Evaluating interventions that might lead to a reduction in tuberculosis in high-income countries with a low incidence of the disease is key to accelerate progress towards its elimination. In such countries, migrants are known to contribute a large proportion of tuberculosis cases to the burden. We assessed the effectiveness of screening for active tuberculosis before entry to the UK and for latent tuberculosis infection (LTBI) post-entry for reduction of tuberculosis in new-entrant migrants to the UK. Additionally, we investigated the effect of access to primary care on tuberculosis incidence in this population. Methods We did a retrospective, population-based cohort study of migrants from 66 countries who were negative for active tuberculosis at pre-entry screening between Jan 1, 2011, and Dec 31, 2014, and eligible for LTBI screening. We used record linkage to track their first contact with primary care, uptake of LTBI screening, and development of active tuberculosis in England, Wales, and Northern Ireland. To assess the effectiveness of the pre-entry screening programme, we identified a control group of migrants who were not screened for active tuberculosis using the specific code for new entrants to the UK registering in primary care within the National Health Service patient registration data system. Our primary outcome was development of active tuberculosis notified to the National Enhanced Tuberculosis Surveillance System. Findings Our cohort comprised 224 234 migrants who were screened for active tuberculosis before entry to the UK and a control group of 118 738 migrants who were not. 103 990 (50%) migrants who were screened for active tuberculosis registered in primary care; all individuals in the control group were registered in primary care. 1828 tuberculosis cases were identified during the cohort time, of which 31 were prevalent. There were 26 incident active tuberculosis cases in migrants with no evidence of primary care registration, and 1771 cases in the entire cohort of migrants who registered in primary care (n=222728), giving an incidence rate of 174 (95% CI 166-182) per 100 000 person-years. 672 (1%) of 103 990 migrants who were screened for active tuberculosis went on to develop tuberculosis compared with 1099 (1%) of 118 738 not screened for active tuberculosis (incidence rate ratio [IRR] 1.49, 95% CI 1.33-1.67; p<0.0001). 2451 (1%) of the 222 728 migrants registered in primary care were screened for LTBI, of whom 421 (17%) tested positive and 1961 (80%) tested negative; none developed active tuberculosis within the observed time period. Migrants settling in the least deprived areas had a decreased risk of developing tuberculosis (IRR 0.74, 95% CI 0 . 62-0. 89; p=0.002), and time from UK arrival to primary care registration of 1 year or longer was associated with increased risk of active tuberculosis (2.96,2-.59-3.38; p<0-0001). Interpretation Pre-entry tuberculosis screening, early primary care registration, and LTBI screening are strongly and independently associated with a lower tuberculosis incidence in new-entrant migrants. Copyright (C) 2019 Elsevier Ltd. All rights reserved.

Background: Sexual health (SH) services increasingly need to prioritise those at greatest risk of sexually transmitted infections (STIs). We used SH surveillance data to develop algorithms to triage individuals attending SH services within two high-risk populations: men who have sex with men (MSM) and young people (YP). Methods: Separate multivariable logistic regression models for MSM and YP were developed using surveillance data on demographics, recent sexual history, prior STI diagnoses and drug/alcohol use from five clinics in 2015-2016 to identify factors associated with new STI diagnoses. The models were prospectively applied in one SH clinic in May 2017 as an external validation. Findings: 9530 YP and 1448MSMSH episodes informed model development. For YP, factors associatedwith new STI diagnosis (overall prevalence: 10.6%) were being of black or mixed white/black ethnicity; history of chlamydia diagnosis (previous year); and multiple partners/new partner (previous 3-months). The YPs model had reasonable performance (c-statistic: 0.703), but poor discrimination when externally validated (c-statistic: 0.539). For MSM, being of South Asian ethnicity; being born in Europe (excluding the UK); and condomless anal sex or drug use (both in previous 3-months) were associated with STI diagnosis (overall prevalence: 22.0%). The MSM model had a c-statistic of 0.676, reducing to 0.579 on validation. Interpretation: SH surveillance data, including limited behavioural data, enabled triage algorithms to be developed, but its implementation may be problematic due to poor external performance. This approach may be more suitable to self-triage, including online, ensuring patients are directed towards appropriate services. (C) 2018 Published by Elsevier Ltd.

Introduction Gastrointestinal infections (GII) can cause serious ill health and morbidity. Although primarily transmitted through faecal contamination of food or water, transmission through sexual activity is well described, especially among men who have sex with men (MSM). Methods We investigated the prevalence of GIIs among a convenience sample of MSM who were consecutively diagnosed with rectal Chlamydia trachomatis (CT) at 12 UK genitourinary medicine clinics during 10 weeks in 2012. Residual rectal swabs were coded, anonymised and tested for Shigella, Campylobacter, Salmonella, shiga toxin-producing Escherichia coli and enteroaggregative E. coli (EAEC) using a real-time PCR. Results were linked to respective coded and anonymised clinical and demographic data. Associations were investigated using Fisher's exact tests. Results Of 444 specimens tested, overall GII prevalence was 8.6% (95% CI 6.3% to 11.6%): 1.8% (0.9% to 3.6%) tested positive for Shigella, 1.8% (0.9% to 3.6%) for Campylobacter and 5.2% (3.5% to 7.7%) for EAEC. No specimens tested positive for Salmonella or other diarrhoeagenic E. coli pathotypes. Among those with any GII, 14/30 were asymptomatic (2/7 with Shigella, 3/6 with Campylobacter and 9/17 with EAEC). Shigella prevalence was higher in MSM who were HIV-positive (4.7% (2.1% to 10.2%) vs 0.5%(0.1% to 3.2%) in HIV-negative MSM; p=0.01). Conclusions In this small feasibility study, MSM with rectal CT appeared to be at appreciable risk of GII. Asymptomatic carriage may play a role in sexual transmission of GII.

The UK, like a number of other countries, has a refugee resettlement programme. External factors, such as higher prevalence of infectious diseases in the country of origin and circumstances of travel, are likely to increase the infectious disease risk of refugees, but published data is scarce. The International Organization for Migration carries out and collates data on standardised pre-entry health assessments (HA), including testing for infectious diseases, on all UK refugee applicants as part of the resettlement programme. From this data, we report the yield of selected infectious diseases (tuberculosis (TB), HIV, syphilis, hepatitis B and hepatitis C) and key risk factors with the aim of informing public health policy.

OBJECTIVES:Men who have sex with men (MSM) bear a disproportionate burden of STIs. While routine STI surveillance data suggest MSM regularly access specialist genitourinary medicine (GUM) clinics for their sexual healthcare, the extent to which MSM attend non-specialist sexual health services (SHSs) is unclear.METHODS:We used data from the GUM Clinic Activity Data Set (GUMCADv2), the national STI surveillance system, to compare the characteristics, service usage and STI outcomes of MSM accessing specialist and non-specialist (non-GUM) SHSs in England in 2014. Pearson's χ2, Student's t-test and logistic regression analysis were used.RESULTS:Where sexual orientation was recorded (92%), 11% (4552/41 597) of non-GUM attendances were among MSM compared with 28% (280 466/999 331) of GUM attendances (p<0.001). Compared with those attending GUM services, MSM attending non-GUM services were younger (mean age: 30.2 years vs 37.7 years; p<0.001) and were more likely to be of mixed ethnicity (4.9% vs 3.5%; p<0.001), to have had a full sexual health screen (chlamydia, gonorrhoea, syphilis and HIV tests) (48.0% vs 37.0%; p<0.001) and to be diagnosed with chlamydia (7.4% vs 4.1%; p<0.001) and gonorrhoea (8.5% vs 6.5%: p<0.001). MSM attending non-GUM services had slightly lower HIV test uptake (87.0% vs 95.0%; p=0.157) and were less likely to be diagnosed with HIV (0.5% vs 0.8%; p=0.019), compared with those attending GUM clinics.CONCLUSIONS:Non-specialist SHSs play an important role in the care of MSM and should ensure services meet their needs.

BackgroundIn high-income nations, men who have sex with men (MSM) are at increased risk of shigellosis. A sublineage of Shigella flexneri serotype 3a was recently shown to have spread worldwide in MSM, driven by mobilisable azithromycin resistance. Since then, the serotype 2a and the species S sonnei have become epidemic in the UK. We aimed to determine whether these subsequent outbreaks were also attributable to epidemic sublineages in MSM and mobilisable antimicrobial resistance.MethodsWe applied whole-genome sequencing to a random cross-section of S flexneri 2a (n=176) and S sonnei (n=188) isolates submitted to the UK national reference laboratory between 2004 and 2014 (10% and 2% of travel-associated and 20% and 10% of domestically acquired cases, respectively). Phylogenetic analysis and patient data (date of illness, age, sex, travel history) were combined to identify potential MSM-associated sublineages, and antimicrobial resistance determinants were compared among S sonnei, S flexneri 2a, and pandemic S flexneri 3a.FindingsShorter phylogenetic distances (more closely related isolates) were statistically associated with male–male patient pairs for both S sonnei and S flexneri 2a. For S flexneri 2a, this association manifested as a single low-diversity sublineage containing 47 of 176 isolates collected over the epidemic window (2012–2014) mainly (43 of the 47 isolates) from 16–60-year-old male patients without recent travel. This lineage was associated with azithromycin resistance (odds ratio 25·8, p<0·0001) carried by an antimicrobial resistance determinant identical to that found in the pandemic S flexneri 3a sublineage. For S sonnei there were multiple low-diversity sublineages with similar patient profiles, some of which were associated with this azithromycin resistance determinant.InterpretationThese results suggest that outbreaks of S flexneri 2a and S sonnei were associated with MSM. The mobilisation of azithromycin resistance between S flexneri 3a, S flexneri 2a, and S sonnei indicates that antimicrobial resistance has a role in driving these epidemic waves. The presence of a single resistance determinant associated with all three epidemics suggests that future antimicrobial resistance surveillance might be enhanced by focusing at the level of genetic determinants rather than pathogens.FundingWellcome Trust, Public Health England.

Recent evidence highlights an increase in ‘chemsex’, the use of recreational drugs during sex, in men who have sex with men (MSM) and an association with risky sexual behaviours and outbreaks of STIs.1 However, the extent of sexualised drug use in people attending sexual health clinics (SHCs) is unknown. STI surveillance in England is performed by Public Health England (PHE) using a disaggregated patient-level dataset of all diagnoses and services at SHCs.2 This is a minimum dataset with key demographic and clinical variables, but lacks behavioural data. To address this gap, PHE …

Background UK national guidelines will recommend that samples from all Chlamydia trachomatis (CT)-positive men who have sex with men (MSM) with proctitis and all asymptomatic CT-positive MSM with HIV should be tested for Lymphogranuloma venereum (LGV). Aim To investigate case characteristics and test outcomes of samples referred to the Sexually Transmitted Bacterial Reference Unit (STBRU) for LGV testing. Methods STBRU and GUMCADv2 data for 2014 in England were matched. Test numbers and outcomes for patients in different risk categories were compared to understand targeting of LGV testing. Results In 2014, 3,782 CT samples were tested for LGV, and 2,426 (64%) were matched to GUMCADv2. MSM accounted for 77% (1876/2426), heterosexual men 7% (178/2426) and women 11% (277/2426) of LGV tests (Table 1). Overall, LGV prevalence was 15% (366/2426), and was highest among HIV-positive MSM (33%; 230/692) and lowest in women (0.4%; 1/277). MSM accounted for 93% (342/366) of all positive samples, and 67% (230/342) of MSM with LGV were HIV-positive. In 2014, there were 3,434 CT diagnoses reported by GUM clinics in HIV-positive MSM, but we found only 692 HIV positive MSM had a CT sample tested for LGV, while 1,639 CT samples were from MSM without HIV, heterosexual men, or women, suggesting inadequate testing of CT samples from HIV-positive MSM. Conclusion Although miscoding in GUMCADv2 may partially explain some LGV testing in heterosexual men and women and HIV negative MSM, these data still suggest that LGV testing might be targeted more effectively to conserve resources and maximise identification of LGV.

Recent evidence highlights an increase in ‘chemsex’, the use of recreational drugs during sex, in men who have sex with men (MSM) and an association with risky sexual behaviours and outbreaks of STIs.1 However, the extent of sexualised drug use in people attending sexual health clinics (SHCs) is unknown.STI surveillance in England is performed by Public Health England (PHE) using a disaggregated patient-level dataset of all diagnoses and services at SHCs.2 This is a minimum dataset with key demographic and clinical variables, but lacks behavioural data. To address this gap, PHE …

Background National gonorrhoea treatment guidelines recommend ceftriaxone with azithromycin as first-line therapy, but doxycycline is recommended instead of azithromycin for patients with gonococcal pelvic inflammatory disease (PID). In 2013, 86.5% of patients in the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) were treated with the recommended therapy, but 3.9% were treated with doxycycline instead of azithromycin. Objectives The objective of this analysis was to determine whether ceftriaxone plus doxycycline were prescribed for appropriate indications. Methods Using GRASP 2013 data, patients prescribed the recommended therapy were compared with patients prescribed ceftriaxone and doxycycline, and associations were assessed using univariate and multivariate logistic regression. Results In 2013, of the 913 patients prescribed ceftriaxone and azithromycin, 45.9% were men who have sex with men (MSM), 20% were women and 34.1% were heterosexual men while, of the 45 patients prescribed ceftriaxone and doxycycline, 64.4% were MSM, 28.9% were women and 6.7% were heterosexual men (p = 0.001). Of those prescribed ceftriaxone and doxycycline, 22.2% were MSM with chlamydia co-infection and 17.7% were women with PID. On multivariate analysis, MSM co-infected with chlamydia (aOR 3.4, 95% CI, 2.5–4.6; p = 0.001) and women diagnosed with gonococcal PID (OR,144.8, 95% CI, 24.2–864.0; p < 0.001) were more likely to be prescribed ceftriaxone and doxycycline. Conclusion Less than a fifth of prescriptions for ceftriaxone with doxycycline were issued to treat gonococcal PID. Use of ceftriaxone with doxycycline may be preferred to treat MSM co-infected with chlamydia by some clinicians. However, as levels of tetracycline resistance in gonorrhoea are high, this may not provide the dual treatment coverage required.

Background Men who have sex with men (MSM) bear a disproportionate burden of sexually transmitted infections (STIs) including HIV. While routine STI surveillance data indicate MSM regularly access genitourinary medicine (GUM) services for their sexual health care, the extent to which MSM attend non-specialist Level 2 sexual health services is unclear. We investigated access of Level 2 services by MSM in England. Methods We used provisional data from the GUM Clinic Activity Dataset (GUMCADv2) to compare the characteristics, service usage and outcomes between MSM accessing GUM and Level 2 services who reported data in 2013. Results Of all male attendances where sexual orientation was recorded, 12.3% (6,957/57,048) of Level 2 attendances were among MSM compared to 26.3% (299,456/1,139,424) of GUM attendances (p < 0.001). MSM attending Level 2 compared to GUM services, were younger (mean age: 30.5 yrs vs 38.5 yrs; p < 0.001), and more likely to be of black ethnicity (6.8% vs 4.1%; p < 0.001) and reside in London (49.9% vs 46.0%; p < 0.001). MSM attending non-GUM services were more likely to have a full sexual health screen (41.4% vs 27.0%; p < 0.001), HIV test (8.9% vs 7.1%; p < 0.001), and be diagnosed with chlamydia (6.2% vs 3.0%; p < 0.001), gonorrhoea (5.6% vs 4.6%: p < 0.001) and first-episode genital warts (1.5% vs 1.0%: p < 0.001). There was no significant difference in the proportion newly diagnosed with HIV (0.57% vs 0.69%; p = 0.268) or first-episode genital herpes (0.47% vs 0.46%; p = 0.830). Conclusion Level 2 sexual health services play an important role in the sexual health care of MSM, especially those of younger age.