LGV in the UK national surveillance of a re-emerging disease

1. LGV in the UKnational surveillance of a re-emerging disease Helen Ward1,2, Iona Martin1, Ian Simms1, Neil Macdonald1, Sarah Alexander1, Kevin Fenton1,3, Cathy Ison1. • Health Protection Agency Centre for Infections, London, UK • Department of Infectious Disease Epidemiology, Imperial College London, UK • Centres for Disease Control, Atlanta, USA

2. Background • 2003: First case report of LGV in the Netherlands1 • 2004: Clusters reported from Netherlands, Belgium, Germany 2-3 • May 2004: ESSTI (European network for the Surveillance of STI) meeting collated reports of LGV • 2005: Further reports from France, Spain, Sweden, Germany, USA, Canada 4-7 • Sex transm inf 2003;79(6):453-5; • Clin Inf Dis 2004;39(7):996-1003 • MMWR 2004;53(42):985-8 • Sex transm inf 2005;81(1):91-2 5. Emerg Infect Dis 2005;1103.04 6. Eurosurv Weekly 2005;10(5) 7. CMAJ 2005;21;172(13):1674-6.

3. Characteristics of emerging LGV • Cases • Men who have sex with men • High level of co-infection with HIV • Proctitis • Clusters • Links between European countries • Parties, internet, sex on premises venues

4. Background in the UK • LGV rarely diagnosed in the UK pre-2004 • Sporadic imported cases of urogenital LGV • Reported together with chancroid and Donavonosis *Routine aggregate reporting of STI from genitourinary medicine clinics in the UK

5. Establishing a surveillance system • Diagnostic capacity • Enhanced surveillance based on case reports • Alert clinicians and microbiologists • Alert community groups

9. Internet information

10. Referral of specimens for confirmation of LGV “STBRL will accept • rectalspecimens from patients with proctitis or • urethral swabs from patients with inguinal lymphadenopathy • Urethral or rectal specimens from LGV contacts who have a confirmed positive CTresult (using NAAT, or EIA)”

11. Testing algorithm RT PCR for CT Confirm presence of CT neg pos Report issued RT PCR LGV specific Determine if LGV associated LGV pos Genotype retrospectively for L1, L2 or L3 Report issued

12. Reporting

13. UK LGV Surveillance form

14. UK LGV Surveillance form Available on www.hpa.org.uk/infections/topics_az/hiv_and_sti/LGV/lgv.htm

15. UK LGV Surveillance form

16. Oct 04 to Mar 061334 samples received 101 35 327 982 655 216

17. Map of 327 LGV cases

18. Map of 327 LGV cases

19. Map of 327 LGV cases

20. Total samples and LGV, Oct 2004 to Feb 2006

21. Epidemic curve for LGV by date of onset of symptoms, 2003 to end 2005 (n=277)

22. Case reports • 3 cases in heterosexual men • urethral syndrome • Contacts abroad • Excluded from rest of this analysis • 277 case reports in MSM • White 260 (95%) • British 194 (70%) • Age 21 to 65 (median 38) • 9 men with repeat infection

23. Presentation • Symptoms 228 (84%) • Contact referral 16 • Clinician referral 10 • Detected on routine screen 9 • Asymptomatic 8 • 4 LGV contacts • 4 during routine STI screen

24. Symptoms • Proctitis 262 (93%) • Plus genital symptoms 34 • Genital symptoms alone 12 (4%) • Duration of symptoms • 1 day to >18 months (median 12 days)

25. Presentation – anorectal (n=228)

26. Presentation - genital

27. Severity • 16 cases had been investigated by gastroenterologists • Hospital admission documented in five • Several reports of misdiagnosis including Crohn’s and ulcerative colitis1 1. See BMJ 2006;332(7533):99-100

28. Co-infection • HIV 214 (76%) • Including 9 newly diagnosed at time of LGV • 38% diagnosed within previous 2 years • 45% on ART • Hepatitis C 41 (19%) • Other STI 39%

29. Associations with HIV • No difference in demographics or sexual meeting places • Men with HIV • more likely to have PCR positive HCV, p=0.013 • More likely to report unprotected anal intercourse 77% vs 60%, p=0.031

30. Sexual behaviour • Partners in the past 3 months • 0 – 200, median 3 • Unprotected anal intercourse • 188 receptive • 139 insertive • Fisting reported by 32 • Sex toys reported by 15 But lots of missing data!

31. Sexual networks • 178 (79%) reported likely acquisition in UK • 48 (20%) reported partners overseas • Commonly Netherlands, Spain, and Europe • More contact in Netherlands for early (2004) than later (2005) cases: 7/40 (17.5%) vs 2/167 (1.2%) OR 17.5, 95%CI 4.48, 88.02

32. Meeting places • Data were available on meeting places for 113 men: • 80 (71%) reported sex on premises venues or at sex parties • 26 (23%) via the internet • A few men reported sex work and travel-related work

33. Summary • First national picture of LGV in MSM • Significant burden of infection • 327 cases in 17 months • Varied clinical presentation, often severe • Widespread across the UK, mostly local transmission • High level of co-infection

34. Underestimate of scale of infection • Limited diagnostic service • symptomatic MSM/ contacts • confirmed CT • Lack of awareness • Clinicians (outside of specialist clinics) • Patients

35. Evidence for: geographic clustering links to Netherlands in early cases Anecdotal evidence from clinicians common social venues with linked sexual networks all L2 Evidence against: No baseline data Increase could be artefact of surveillance Poor prevalence data Same serovar existed in MSM in the USA in the 1980s Is it an outbreak?

36. Has there been a shift in the epidemiology? • Introduced into favourable networks? • Sero-sorting and unsafe practices? • Opportunistic infection? • But likely to overestimate HIV link due to selection bias in diagnosis

37. Response • LGV incident group including • Public health • Microbiologists • Community groups • Clinicians • Communications/press officer

38. Awareness campaigns • Clinicians/ public health • Several articles in specialist and general journals • Talks at conferences • Liaison with specialist societies • Community • Outreach to venues • Ongoing press campaign • Banner adverts for websites

42. Information for gay men

43. Public health Maintain awareness clinicians community organisations Outreach, press coverage Case finding Ongoing exercise ? Recommend widespread screening Maintain active surveillance Clinical Alert to possible LGV STI clinics HIV clinics Gastroenterology Primary care Increase CT testing in MSM Symptomatic Contacts routine? Implications for practice

44. Recommendations • Extended testing for chlamydia in MSM • rectal samples for men with proctitis and others who may have been exposed • Presumptive treatment • (if unable to confirm LGV) • Use three weeks of therapy for rectal chlamydia and proctitis in MSM • Ensure test of cure • Active partner notification and follow-up • Local awareness campaigns

45. HPA Centre for Infections Sarika Desai Josephine Ruwende Alan Smith Maria Solomou Ucheoma Ugoji Terence Higgins Trust Will Nutland BASHH Sandy McMillan Pat Munday Society for Sexual Health Advisors Jamie Hardy National representatives Lesley Wallace (Scotland) Mary Cronin (Eire) Neil Irvine (Northern Ireland) Daniel Thomas (Wales) Local representatives Peter Trail (London) Helen Maguire (London) Patrick French (London) Stephen Gillespie (London) John White (London) Andy Winter (Glasgow) Gillian Dean (Brighton) Members of LGV Incident Group