Annual Sentinel Surveillance Research Articles

Significant increase in azithromycin “resistance” and susceptibility to ceftriaxone and cefixime in Neisseria gonorrhoeae isolates in 26 European countries, 2019

BackgroundThe European Gonococcal Antimicrobial Surveillance Programme (Euro-GASP) performs annual sentinel surveillance of Neisseria gonorrhoeae susceptibility to therapeutically relevant antimicrobials across the European Union/European Economic Area (EU/EEA). We present the Euro-GASP results from 2019 (26 countries), linked to patient epidemiological data, and compared with data from previous years.MethodsAgar dilution and minimum inhibitory concentration (MIC) gradient strip methodologies were used to determine the antimicrobial susceptibility (using EUCAST clinical breakpoints, where available) of 3239 N. gonorrhoeae isolates from 26 countries across the EU/EEA. Significance of differences compared with Euro-GASP results in previous years was analysed using Z-test and the Pearson's χ2 test was used to assess significance of odds ratios for associations between patient epidemiological data and antimicrobial resistance.ResultsEuropean N. gonorrhoeae isolates collected between 2016 and 2019 displayed shifting MIC distributions for; ceftriaxone, with highly susceptible isolates increasing over time and occasional resistant isolates each year; cefixime, with highly-susceptible isolates becoming increasingly common; azithromycin, with a shift away from lower MICs towards higher MICs above the EUCAST epidemiological cut-off (ECOFF); and ciprofloxacin which is displaying a similar shift in MICs as observed for azithromycin. In 2019, two isolates displayed ceftriaxone resistance, but both isolates had MICs below the azithromycin ECOFF. Cefixime resistance (0.8%) was associated with patient sex, with resistance higher in females compared with male heterosexuals and men-who-have-sex-with-men (MSM). The number of countries reporting isolates with azithromycin MICs above the ECOFF increased from 76.9% (20/26) in 2016 to 92.3% (24/26) in 2019. Isolates with azithromycin MICs above the ECOFF (9.0%) were associated with pharyngeal infection sites. Following multivariable analysis, ciprofloxacin resistance remained associated with isolates from MSM and heterosexual males compared with females, the absence of a concurrent chlamydial infection, pharyngeal infection sites and patients ≥ 25 years of age.ConclusionsResistance to ceftriaxone and cefixime remained uncommon in EU/EEA countries in 2019 with a significant decrease in cefixime resistance observed between 2016 and 2019. The significant increase in azithromycin “resistance” (azithromycin MICs above the ECOFF) threatens the effectiveness of the dual therapy (ceftriaxone + azithromycin), i.e., for ceftriaxone-resistant cases, currently recommended in many countries internationally and requires close monitoring.

Uptake of COVID-19 vaccination among people who inject drugs

BackgroundPeople who inject drugs (PWID) may be at elevated risk of adverse outcomes from SARS-CoV-2 infection; however, data on COVID-19 vaccine uptake among PWID are scarce. This study aimed to determine COVID-19 vaccine uptake among PWID, identify factors associated with sub-optimal uptake, and compare uptake to the general population.MethodsThe Australian Needle Syringe Program Survey is an annual sentinel surveillance project, comprising a self-completed questionnaire and provision of a dried blood sample for HIV and HCV testing. In 2021, respondents provided information on their COVID-19 vaccination status. Multivariate logistic regression models identified correlates of vaccine uptake.ResultsAmong 1166 respondents, 49% had been vaccinated and in most states and territories, vaccine uptake was significantly lower than among the general population. Independent predictors of vaccine uptake were longer duration of vaccine eligibility (AOR 3.42, 95% CI 2.65, 4.41); prior SARS-CoV-2 diagnostic testing (AOR 2.90, 95% CI 2.22, 3.79); injection of opioids (AOR 1.91, 95% CI 1.20, 3.05); and current opioid agonist therapy (AOR 1.70, 95% CI 1.23, 2.33). Women (AOR 0.70, 95% CI 0.54, 0.92) and those who reported daily or more frequent injection (AOR 0.75, 95% CI 0.57, 1.00) were significantly less likely to be vaccinated.ConclusionsIn most Australian states and territories, uptake of COVID-19 vaccine among PWID lagged uptake among the general population. Increased efforts are required to ensure PWID have equitable access to vaccination. Vaccination programmes within harm reduction services and via outreach, coupled with increased support for peers to act as vaccine champions, are likely to reduce barriers and improve COVID-19 vaccine uptake in this population.

Prevalence of HCV infection and related risk factors in drug users in Wenzhou, Zhejiang, 2011–2020

Objective To understand the prevalence of hepatitis C and related risk factors in drug users under sentinel surveillance in Wenzhou during 2011–2020 and provide evidence for the prevention and control of hepatitis C in this population. Methods A consecutive cross-sectional survey with standard questionnaire was conducted in about 400 drug users randomly selected in compulsory detoxification settings for the annual sentinel surveillance between April and July during 2011–2020, and basic demographic information and blood samples were collected from them. Multivariate logistic regression model was used to analyze the related risk factors of HIV infection. Results A total of 4052 drug users were included in the analysis, the prevalence rate of HCV infection was 41.91%. The average positive rate of HCV antibody was 54.10% during 2011–2013, and 36.65% during 2014–2020. However, the positive rate of HCV antibody increased from 30.00% in 2014 to 41.50% in 2020. Multivariate logistic regression analysis indicated HCV infection risk factors included age ≥30 years, living in Zhejiang, low education level, being traditional drug user or mixed drug user and injecting drug use. Among them, age ≥30 years, living in Zhejiang, being traditional drug user or mixed drug user and injecting drug use can explain the rise of HCV antibody positive rate from 2014 to 2020. Conclusion In the past 10 years, the prevalence of HCV infection in drug users in Wenzhou remained at a high level, showing a significant decline firstly and then a gradual rise. It is speculated that the early decrease of HCV infection level might be related to the improvement of the diagnosis and treatment of Hepatitis C, but the recent increase of HCV infection level is caused by the changes in the characteristics of drug users and the types or modes of drug use.

Stably high azithromycin resistance and decreasing ceftriaxone susceptibility in Neisseria gonorrhoeae in 25 European countries, 2016

BackgroundThe European Gonococcal Antimicrobial Surveillance Programme (Euro-GASP) performs annual sentinel surveillance of Neisseria gonorrhoeae susceptibility to therapeutically relevant antimicrobials across the European Union/European Economic Area (EU/EEA). We present the Euro-GASP results from 2016 (25 countries), linked to patient epidemiological data, and compared with data from previous years.MethodsAgar dilution and minimum inhibitory concentration (MIC) gradient strip methodologies were used to determine the antimicrobial susceptibility (using EUCAST breakpoints) of 2660 N. gonorrhoeae isolates from 25 countries across the EU/EEA. Significance of differences compared with Euro-GASP results in previous years was analysed using Z-tests.ResultsNo isolates with resistance to ceftriaxone (MIC > 0.125 mg/L) were detected in 2016 (one in 2015). However, the proportion of isolates with decreased susceptibility to ceftriaxone (MICs from 0.03 mg/L to 0.125 mg/L) increased significantly (p = 0.01) from 2015 to 2016. There were 14 (0.5%) isolates with ceftriaxone MICs 0.125 mg/L (on the resistance breakpoint), of which one isolate was resistant to azithromycin and four showed intermediate susceptibility to azithromycin. Cefixime resistance was detected in 2.1% of isolates in 2016 compared with 1.7% in 2015 (p = 0.26) and azithromycin resistance in 7.5% in 2016 compared with 7.1% in 2015 (p = 0.74). Seven (0.3%) isolates from five countries displayed high-level azithromycin resistance (MIC≥256 mg/L) in 2016 compared with five (0.2%) isolates in 2015. Resistance rate to ciprofloxacin was 46.5% compared with 49.4% in 2015 (p = 0.06). No isolates were resistant to spectinomycin and the MICs of gentamicin remained stable compared with previous years.ConclusionsOverall AMR rates in gonococci in EU/EEA remained stable from 2015 to 2016. However, the ceftriaxone MIC distribution shifted away from the most susceptible (≤0.016 mg/L) and the proportion of isolates with decreased susceptibility to ceftriaxone increased significantly. This development is of concern as current European gonorrhoea management guideline recommends ceftriaxone 500 mg plus azithromycin 2 g as first-line therapy. With azithromycin resistance at 7.5%, the increasing ceftriaxone MICs might soon threaten the effectiveness of this therapeutic regimen and requires close monitoring.

The Potential Reach of Opioid Substitution Settings to Deliver HCV Care to People Who Inject Drugs in Australia

BackgroundRecent efforts in Australia to engage people who inject drugs (PWID) in hepatitis C (HCV) care have focussed on opioid substitution treatment (OST) services as a delivery site. This approach potentially excludes non-opioid using PWID. This study aimed to determine differences between those currently receiving OST and those not among a sample of PWID. MethodsAdditional questions on HCV testing were included in the 2013 Illicit Drug Reporting System (IDRS), an annual sentinel surveillance system. The IDRS recruits PWID in all Australian capital cities from a range of sources, predominantly needle and syringe programs. All participants are reimbursed AUD$40 for a ~45minute interview-administered survey. ResultsCurrent OST was reported by 44% of the total sample, and two-thirds reported an opioid as their drug of choice. Those participants who reported current OST were significantly more likely than those not in OST to report heroin as their drug of choice (65% vs. 43%, p<0.0.001) and the drug injected most often (53% vs. 30%, p<0.001). Compared to those in OST, those not in OST were more likely to report methamphetamine as their drug of choice (29% vs. 14%, p<0.001) or drug injected most often (33% vs. 17%, p<0.001). Current OST clients were more likely to have been tested for HCV antibodies (anti-HCV) than those not in OST (96% vs. 93%, p<0.05) and to report an anti-HCV positive result (75% vs. 64%, p<0.001). Those receiving OST were no more likely than those not to undergo further HCV-related testing (e.g. RNA) (62% vs. 56%, p=0.136). Both groups reported further HCV-related testing was undertaken primarily at a community general practice. DiscussionDespite a large proportion of current PWID receiving OST, there remains a substantial minority who are neither seeking nor eligible for treatment. Efforts to improve access to HCV care for PWID in Australia therefore need to be expanded beyond OST, especially given the large proportion of participants who reported inadequate HCV testing.

Supervision and Quality Control Measures in Annual Sentinel Surveillance for HIV Infection in India

The National Institute of Health and Family Welfare (NIHFW) has been entrusted by the National AIDS Control Organisation (NACO) to undertake monitoring and supervision of annual Sentinel Surveillance (ASS) activity in India since 1998, to ensure that the data obtained are valid. Earlier Regional coordinating teams cooperated with NIHFW in this task. From 2006 onwards, NACO identified five regional institutes covering all the states and Union Territories and Central team members consisting of experts from various organisations for the monitoring and supervision of the ASS cycle to ensure quality control of both epidemiological data collection and HIV testing (NACO 2006a and b). We describe here the process of quality control and observations of the ASS rounds held from 2005 to 2007. The performance of a majority of sites was satisfactory. The testing laboratories usually adhered to standard operating procedures (SOPs). Lacunae observed during the supervisory visits have been enumerated along with the recommendations for the future surveillance rounds.

O1-S11.02 Determinants of time trends in HIV prevalence in the young antenatal population of Karnataka districts

BackgroundIn 2003, the Bill & Melinda Gates Foundation initiated a focused HIV prevention program (India AIDS Initiative: Avahan) among high-risk and bridge groups. We studied determinants of time trends in...

A population-based study of human immunodeficiency virus in south India reveals major differences from sentinel surveillance-based estimates

BackgroundThe human immunodeficiency virus (HIV) burden among adults in India is estimated officially by direct extrapolation of annual sentinel surveillance data from public-sector antenatal and sexually transmitted infection (STI) clinics and some high-risk groups. The validity of these extrapolations has not been systematically examined with a large sample population-based study.MethodsWe sampled 13838 people, 15–49 years old, from 66 rural and urban clusters using a stratified random method to represent adults in Guntur district in the south Indian state of Andhra Pradesh. We interviewed the sampled participants and obtained dried blood spots from them, and tested blood for HIV antibody, antigen and nucleic acid. We calculated the number of people with HIV in Guntur district based on these data, compared it with the estimate using the sentinel surveillance data and method, and analysed health services use data to understand the differences.ResultsIn total, 12617 people (91.2% of the sampled group) gave a blood sample. Adjusted HIV prevalence was 1.72% (95% confidence interval 1.35–2.09%); men 1.74% (1.27–2.21%), women 1.70% (1.36–2.04%); rural 1.64% (1.10–2.18%), urban 1.89% (1.39–2.39%). HIV prevalence was 2.58% and 1.20% in people in the lower and upper halves of a standard of living index (SLI). Of women who had become pregnant during the past 2 years, 21.1% had used antenatal care in large public-sector hospitals participating in sentinel surveillance. There was an over-representation of the lowest SLI quartile (44.7%) in this group, and 3.61% HIV prevalence versus 1.08% in the remaining pregnant women. HIV prevalence was higher in that group even when women were matched for the same SLI half (lower half 4.39%, upper 2.63%) than in the latter (lower 1.06%, upper 1.05%), due to referral of HIV-positive/suspected women by private practitioners to public hospitals. The sentinel surveillance method (HIV prevalence: antenatal clinic 3%, STI clinic 22.8%, female sex workers 12.8%) led to an estimate of 112635 (4.38%) people with HIV, 15–49 years old, in Guntur district, which was 2.5 times the 45942 (1.79%) estimate based on our population-based study.ConclusionThe official method in India leads to a gross overestimation of the HIV burden in this district due to addition of substantial extra HIV estimates from STI clinics, the common practice of referral of HIV-positive/suspected people to public hospitals, and a preferential use of public hospitals by people in lower socioeconomic strata. India may be overestimating its HIV burden with the currently used official estimation method.

Is the HIV burden in India being overestimated?

BackgroundThe HIV burden estimate for India has a very wide plausibility range. A recent population-based study in a south Indian district demonstrated that the official method used in India to estimate HIV burden in the population, which directly extrapolates annual sentinel surveillance data from large public sector antenatal and sexually transmitted infection (STI) clinics, led to a 2–3 times higher estimate than that based on population-based data.MethodsWe assessed the generalisability of the reasons found in the Guntur study for overestimation of HIV by the official sentinel surveillance based method: addition of substantial unnecessary HIV estimates from STI clinics, the common practice of referral of HIV positive/suspect patients by private practitioners to public hospitals, and a preferential use of public hospitals by lower socioeconomic strata. We derived conservative correction factors for the sentinel surveillance data and titrated these to the four major HIV states in India (Andhra Pradesh, Maharashtra, Karnataka and Tamil Nadu), and examined the impact on the overall HIV estimate for India.ResultsHIV data from STI clinics are not used elsewhere in the world as a component of HIV burden estimation in generalised epidemics, and the Guntur study verified that this was unnecessary. The referral of HIV positive/suspect patients from the private to the public sector is a widespread phenomenon in India, which is likely causing an upward distortion in HIV estimates from sentinel surveillance in other parts of India as well. Analysis of data from the nationwide Reproductive and Child Health Survey revealed that lower socioeconomic strata were over-represented among women seeking antenatal care at public hospitals in all major south Indian states, similar to the trend seen in the Guntur study. Application of conservative correction factors derived from the Guntur study reduced the 2005 official sentinel surveillance based HIV estimate of 3.7 million 15–49 years old persons in the four major states to 1.5–2.0 million, which would drop the official total estimate of 5.2 million 15–49 years old persons with HIV in India to 3–3.5 million.ConclusionPlausible and cautious extrapolation of the trends seen in a recent large and rigorous population-based study of HIV in a south Indian district suggests that India is likely grossly overestimating its HIV burden with the current official sentinel surveillance based method. This method needs revision.

Evidence for population level declines in adult HIV prevalence in Kenya

The HIV/AIDS epidemic in Kenya has been tracked through annual sentinel surveillance in antenatal clinics since 1990. The system started with 13 sites and now has over 35. Behaviours have...

Seroprevalence of Human Immunodeficiency Virus and Syphilis Infections among Patients Attending the STD, Gyn. and Obs., ANC Clinics of Northern India: Observations from Seven Rounds of Sentinel Surveillance (1998-2004)

The data of HIV sentinel surveillance, i.e., National Annual Sentinel Surveillance (NASS) carried out under the aegis of National AIDS Control Organisation (NACO) of seven rounds revealed that the prevalence of HIV infection is less among the attendees of STD, Obs.& Gyn., Antenatal ( ANC) clinics whereas that of Syphilis is high. This study was carried in order to assess the prevalence levels of infections with HIV and Syphilis as biological markers of risk among the patients attending the STD clinics, Obs. & Gyn.OPD, Antenatal (ANC) clinics of different District Hospitals of Uttar Pradesh. Unlinked anonymous coded sera samples received from 3978 patients during a period of 4 months, every year, over a period of 7 years, were screened for HIV and Syphilis infections. Of the 3978 coded sera samples, 42 (1.06%) were found to be positive for antibodies to HIV-1/2 and 322 (8.09%) were reactive to VDRL. The results revealed that patients attending these clinics, harbour HIV infection, which would otherwise remain undiagnosed in the absence of screening. While some of the variables, viz., sex, age-group and occupation were significant factors in the HIV-positivity, others like literacy status, locality, migration and even the presence of different STDs were not found to influence the HIV-positivity, significantly.