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After community transmission of monkeypox virus was identified in Europe, interviews of 45 case-patients from England indicated transmission in international sexual networks of gay and bisexual men since April 2022. Interventions targeting sex-on-premises venues, geospatial dating applications, and sexual health services are likely to be critical for outbreak control.

ObjectivesAlthough cardiovascular disease (CVD) is of growing importance in low- and middle-income countries (LMICs), there are conflicting views regarding CVD as a major public health problem for the urban poor, including those living in slums. We examine multivariable risk prediction in a slum population and assess the number of cardiovascular related deaths within 10 years of application of the tool.SettingWe use data from the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) population (residents of two slum communities) between May 2008 and April 2009.DesignThis is a secondary data analysis from a cross-sectional survey. We use the WHO/International Society of Hypertension (WHO/ISH) cardiovascular risk prediction tool to examine 10-year risk of major CVD events in a slum population. CVD deaths in the cohort, reported up until June 2018 and identified through verbal autopsy are also presented.Participants3063 men and women aged over 40 years with complete data for variables needed for the WHO/ISH risk prediction tool were eligible to take part.ResultsThe majority of study members (2895, 94.5%) were predicted to have ‘low’ risk (<10%) of a cardiovascular event over the next 10 years and just 51 (1.7%) to have ‘high’ CVD risk (≥20%). 91 CVD deaths were reported for the cohort up until June 2018. Of individuals classified as low risk, 74 (2.6%) were identified as having died of CVD. Nine (7.7%) individuals classified at 10% to 20% risk and eight (15.9%) classified at >20% were identified as dying of CVD.ConclusionsThis study shows that there is a low risk profile of CVD in this slum population in Nairobi, Kenya, in comparison to results from application of multivariable risk prediction tools in other LMIC populations. This has implications for health service planning in these contexts.

Background Shiga toxin-producing Escherichia coli (STEC) infections are a significant public health concern as they can cause serious illness and outbreaks. In England, STEC incidence is highest among children and guidance recommends that children under six diagnosed with STEC are excluded from childcare until two consecutive stool cultures are negative. We aimed to describe the barriers and facilitators to implementing exclusion and the impact of exclusion policies on young children and their families. Methods Individual level data was obtained from a wider study focusing on shedding duration among STEC cases aged < 6 years between March 2018 – March 2022. Data was extracted from England’s public health case management system. The case management system includes notes on telephone conversations, email correspondence and meeting minutes relating to the case. Collected data consisted of free text in three forms: (1) quotes from parents, either direct or indirect, (2) direct quotes from the case record by health protection practitioners or environmental health officers, and (3) summaries by the data collector after reviewing the entire case record. We analysed free text comments linked to 136 cases using thematic analysis with a framework approach. Results The median age of included cases was 3 years (IQR 1.5-5), with males accounting for 49%. Nine key themes were identified. Five themes focused on barriers to managing exclusion, including (i) financial losses, (ii) challenges with communication, engagement and collaboration, (iii) issues with sampling, processing, and results, (iv) adverse impact on children and their families and (v) conflicting exclusion advice. Four themes related to facilitators to exclusion, including (i) good communication with parents and childcare settings, (ii) support with childcare, (iii) improvements to sampling, testing, and reporting of results, and (iv) provision of supervised control measures. Conclusions Qualitative analysis of public health case records can provide evidence-based insights around complex health protection issues to inform public health guidelines. Our analysis highlights the importance of considering wider social and economic consequences of exclusion when developing policies and practices for the management of STEC in children.

IntroductionUnderstanding the effectiveness and durability of protection against SARS-CoV-2 infection conferred by previous infection and COVID-19 is essential to inform ongoing management of the pandemic. This study aims to determine whether prior SARS-CoV-2 infection or COVID-19 vaccination in healthcare workers protects against future infection.Methods and analysisThis is a prospective cohort study design in staff members working in hospitals in the UK. At enrolment, participants are allocated into cohorts, positive or naïve, dependent on their prior SARS-CoV-2 infection status, as measured by standardised SARS-CoV-2 antibody testing on all baseline serum samples and previous SARS-CoV-2 test results. Participants undergo monthly antibody testing and fortnightly viral RNA testing during follow-up and based on these results may move between cohorts. Any results from testing undertaken for other reasons (eg, symptoms, contact tracing) or prior to study entry will also be captured. Individuals complete enrolment and fortnightly questionnaires on exposures, symptoms and vaccination. Follow-up is 12 months from study entry, with an option to extend follow-up to 24 months.The primary outcome of interest is infection with SARS-CoV-2 after previous SARS-CoV-2 infection or COVID-19 vaccination during the study period. Secondary outcomes include incidence and prevalence (both RNA and antibody) of SARS-CoV-2, viral genomics, viral culture, symptom history and antibody/neutralising antibody titres.Ethics and disseminationThe study was approved by the Berkshire Research Ethics Committee, Health Research Authority (IRAS ID 284460, REC reference 20/SC/0230) on 22 May 2020; the vaccine amendment was approved on 12 January 2021. Participants gave informed consent before taking part in the study.Regular reports to national and international expert advisory groups and peer-reviewed publications ensure timely dissemination of findings to inform decision making.Trial registration numberISRCTN11041050.

Background In February 2022, the United Kingdom (UK) detected a cluster of monophasic Salmonella Typhimurium based on whole genome sequencing (WGS). Subsequently, several countries reported cases belonging to this cluster. Epidemiological, microbiological and traceability investigations pointed toward a chocolate food business operator (FBO) in Belgium. We describe the magnitude of the outbreak, investigations performed and control measures taken. Methods Cases were ascertained based on internationally agreed case definitions and interviewed about food consumption prior to disease onset. Analytical epidemiological studies were conducted by the UK and Ireland. The Belgian food safety authority (FSA) coordinated microbiological and traceability investigations. Results A total of 456 cases (61% female), belonging to two genetically different WGS clusters, in 14 countries of the European Union, the UK, Switzerland, Canada and the United States were linked to the outbreak, between December 2021 and June 2022. 87% of cases were younger than 10 years. Brand A chocolate eggs, marketed for children, were reported as consumed by 168 cases (80%) with information. Analytical studies in the UK and Ireland showed a significantly higher odds of disease associated with consumption of brand A chocolate products. Retrospective investigations by the FSA revealed that routine samples (raw materials, intermediate, semi-finished and finished products as well as environmental and rinse oil samples) taken by the FBO linked to the Brand A products between December 2021 and January 2022 had tested positive for salmonella. Nine isolates were submitted to EnteroBase and matched with human isolates from both WGS clusters. The authorization for production was temporarily withdrawn on 8 April 2022 and all products of brand A were recalled worldwide, followed by a decrease in cases. Conclusions A multi-country salmonellosis outbreak linked to chocolate occurred in the months before Easter 2022. International collaboration between stakeholders from epidemiological, microbiological and food safety entities with rapid sharing of WGS results from human and nonhuman isolates were key in containing the outbreak. Implementation of routine WGS on human and nonhuman isolates will strengthen public health responses to future outbreaks. The magnitude of the outbreak underlines the importance of timely and open communication of FBOs to FSAs in case of salmonella detection.

Background Estimates of chronic pain prevalence using coded primary care data are likely to be substantially lower than estimates derived from community surveys. Most primary care studies have estimated chronic pain prevalence using data searches confined to analgesic medication prescriptions. Increasingly, following recent NICE guideline recommendations, patients and doctors opt for non-drug treatment of chronic pain thus excluding these patients from prevalence estimates based on medication codes. We aimed to develop and test an algorithm combining medication codes with selected diagnostic codes to estimate chronic pain prevalence using coded primary care data. Methods Following a scoping review 4 criteria were developed to identify cohorts of people with chronic pain. These were (1) people with one of 12 (‘tier 1’) conditions that almost always results in the individual having chronic pain (2) people with one of 20 (‘tier 2’) conditions included when there are also 3 or more prescription-only analgesics issued in the last 12 months (3) chronic neuropathic pain, or (4) 4 or more prescription-only analgesics issued in the last 12 months. These were translated into 8 logic rules which included 1,932 SNOMED CT codes. Results The algorithm was run on primary care data from 41 GP Practices in Lambeth. The total population consisted of 386,238 GP registered adults ≥ 18 years as of the 31st March 2021. 64,135 (16.6%) were identified as people with chronic pain. This definition demonstrated notably high rates in Black ethnicity females, and higher rates in the most deprived, and older population. Conclusions Estimates of chronic pain prevalence using structured healthcare data have previously shown lower prevalence estimates for chronic pain than reported in community surveys. This has limited the ability of researchers and clinicians to fully understand and address the complex multifactorial nature of chronic pain. Our study demonstrates that it may be possible to establish more representative prevalence estimates using structured data than previously possible. Use of logic rules offers the potential to move systematic identification and population-based management of chronic pain into mainstream clinical practice at scale and support improved management of symptom burden for people experiencing chronic pain.

Shigellosis, traditionally a foodborne and waterborne infection, causes substantial morbidity globally. It is now a leading cause of sexually transmitted gastroenteritis among gay, bisexual, and other men who have sex with men (MSM). We describe an ongoing outbreak of extensively drug-resistant (XDR) Shigella sonnei in the UK. Routine laboratory surveillance (Second Generation Surveillance System, Gastrointestinal Data Warehouse) identified an exceedance of S sonnei clade 5 in England, first detected in September, 2021. Cases within this clade were subsequently reported from Scotland, Wales, and Northern Ireland. Confirmed cases in this outbreak were defined as individuals diagnosed with S sonnei clade 5 in the UK, with a specimen date between Sept 1, 2021, and Feb 9, 2022, who were genomically confirmed as part of a ten-single nucleotide polymorphism (SNP) linkage cluster. We used whole-genome sequencing with SNP typing to identify genomic clusters and antimicrobial-resistance determinants, analysing cases across the UK. We collected demographic, epidemiological, and clinical data from people infected with S sonnei clade 5 in England using questionnaires (standard and bespoke outbreak questionnaires). We used descriptive summary statistics to characterise cases. 72 cases (70 [97%] male, median age 34 years [IQR 27–39]) belonging to the ten-SNP single linkage cluster of S sonnei clade 5 were identified between Sept 4, 2021, and Feb 9, 2022. Isolates were predominantly XDR, with 66 (92%) of 72 harbouring blaCTX-M-27, a plasmid-mediated gene for production of extended-spectrum β-lactamases (ESBLs). Of 33 cases with clinical data, 19 (58%) received antibiotics and eight (24%) were hospitalised. 21 (78%) of 27 cases with completed bespoke outbreak questionnaires were HIV-negative MSM taking HIV pre-exposure prophylaxis (PrEP) who reported sexual contacts in the UK and Europe within the incubation period. We highlight the rapid dissemination of XDR ESBL-producing S sonnei in sexual networks of MSM. We recommend strengthening shigella testing where clinically indicated, antimicrobial-resistance surveillance, and integrated health promotion messaging among all MSM, including PrEP users, to reduce the burden of shigellosis. National Institute for Health Research Health Protection Research Unit in Gastrointestinal Infections at the University of Liverpool in partnership with the UK Health Security Agency.

•We present a seroprevalence survey of diphtheria in England in 2021 and compare results to 2009 estimates.•The study used residual sera from hospital laboratories and sera collected alongside routine blood tests in primary care.•There has been no overall change in proportions protected against diphtheria between 2009 and 2021.•There has been an increase in diphtheria immunity in teenagers and working age adults.•There is consistent waning immunity in older age groups. Diphtheria is rare in England because of an effective national immunisation schedule that includes 5 doses of a diphtheria-containing vaccine at 2, 3, 4 months, preschool and adolescent boosters. However, in recent years there has been a notable increase in cases due to Corynebacterium ulcerans among older adults and evidence of endemic transmission of C. diphtheriae (normally associated with travel to endemic countries). We aimed to update 2009 estimates of diphtheria immunity considering the evolving epidemiology. Residual sera collected from diagnostic laboratories and general practitioners in England in 2021 were randomly selected and tested for diphtheria antibody, to estimate proportions protected per age group. Diphtheria antibody levels were defined as susceptible (<0.01 IU/mL), basic protection (0.01–0.099 IU/mL) and full protection (≥0.1 IU/mL). Immunity estimates were standardised to the England population and compared to 2009. Based on 3,745 residual sera tested, 89% (95%CI: 87%–90%) of the 2021 England population had at least basic diphtheria protection (vs. 90% [88%–92%] in 2009) and 50% (48%–52%) full protection (vs. 41% [38%–44%]). Higher antibody levels were observed in those aged 1 and under, 10–11, 12–15, 25–34 and 35–44 years compared to 2009. The largest proportion susceptible were observed in those aged 70+, 26% (21%–31%) vs 12% (7%–18%) in 2009. Basic diphtheria protection is comparable between 2021 and 2009. The increase in immunity in working age adults is likely due to the school leaver booster introduced in 1994. The current vaccination schedule is maintaining sufficient population immunity. However, we recommend clinicians remain vigilant to severe diphtheria outcomes in older adults, because of their observed susceptibility.

Excluding children with Shiga toxin-producing Escherichia coli (STEC) from childcare until microbiologically clear of the pathogen, disrupts families, education, and earnings. Since PCR introduction, non-O157 STEC serotype detections in England have increased. We examined shedding duration by serotype and transmission risk, to guide exclusion advice. We investigated STEC cases aged <6 years, residing in England and attending childcare, with diarrhoea onset or sample date from 31 March 2018 to 30 March 2022. Duration of shedding was the interval between date of onset or date first positive specimen and earliest available negative specimen date. Transmission risk was estimated from proportions with secondary cases in settings attended by infectious cases. There were 367 cases (STEC O157 n = 243, 66.2%; STEC non-O157 n = 124, 33.8%). Median shedding duration was 32 days (IQR 20–44) with no significant difference between O157 and non-O157; 2% (n = 6) of cases shed for ≥100 days. Duration of shedding was reduced by 17% (95% CI 4–29) among cases reporting bloody diarrhoea. Sixteen settings underwent screening; four had secondary cases (close contacts’ secondary transmission rate = 13%). Shedding duration estimates were consistent with previous studies (median 31 days, IQR 17–41). Findings do not warrant guidance changes regarding exclusion and supervised return of prolonged shedders, despite serotype changes.

Aims/hypothesis We aimed to examine the effects of bariatric surgery on microvascular complications in patients with type 2 diabetes using objective measures. Methods Prospective case–control study of 70 obese surgical patients with type 2 diabetes undergoing gastric bypass surgery matched for age, sex and duration of diabetes to 25 medical patients treated using international guidelines. Microvascular complications were assessed before and 12–18 months after intervention using urine albumin creatinine ratio (ACR) measurements, two-field digital retinal images and peripheral nerve conduction studies (in the surgical group only). Results Urine ACR decreased significantly in the surgical group but increased in the medical group. There were no significant differences between the surgical and medical groups in the changes in retinopathy. There were no changes in the nerve conduction variables in the surgical group. Conclusions/interpretation In the short term, bariatric surgery may be superior to medical care in the treatment of diabetic nephropathy, but not retinopathy or neuropathy.