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Kirwan PD, Hall VJ, Foulkes S, Otter AD, Munro K, Sparkes D, Howells A, Platt N, Broad J, Crossman D, Norman C, Corrigan D, Jackson CH, Cole M, Brown CS, Atti A, Islam J, Presanis AM, Charlett A, De Angelis D, Hopkins S. Effect of second booster vaccinations and prior infection against SARS-CoV-2 in the UK SIREN healthcare worker cohort. Lancet Reg Health Eur 2024; 36:100809. [PMID: 38111727 PMCID: PMC10727938 DOI: 10.1016/j.lanepe.2023.100809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 11/20/2023] [Accepted: 11/20/2023] [Indexed: 12/20/2023]
Abstract
Background The protection of fourth dose mRNA vaccination against SARS-CoV-2 is relevant to current global policy decisions regarding ongoing booster roll-out. We aimed to estimate the effect of fourth dose vaccination, prior infection, and duration of PCR positivity in a highly-vaccinated and largely prior-COVID-19 infected cohort of UK healthcare workers. Methods Participants underwent fortnightly PCR and regular antibody testing for SARS-CoV-2 and completed symptoms questionnaires. A multi-state model was used to estimate vaccine effectiveness (VE) against infection from a fourth dose compared to a waned third dose, with protection from prior infection and duration of PCR positivity jointly estimated. Findings 1298 infections were detected among 9560 individuals under active follow-up between September 2022 and March 2023. Compared to a waned third dose, fourth dose VE was 13.1% (95% CI 0.9 to 23.8) overall; 24.0% (95% CI 8.5 to 36.8) in the first 2 months post-vaccination, reducing to 10.3% (95% CI -11.4 to 27.8) and 1.7% (95% CI -17.0 to 17.4) at 2-4 and 4-6 months, respectively. Relative to an infection >2 years ago and controlling for vaccination, 63.6% (95% CI 46.9 to 75.0) and 29.1% (95% CI 3.8 to 43.1) greater protection against infection was estimated for an infection within the past 0-6, and 6-12 months, respectively. A fourth dose was associated with greater protection against asymptomatic infection than symptomatic infection, whilst prior infection independently provided more protection against symptomatic infection, particularly if the infection had occurred within the previous 6 months. Duration of PCR positivity was significantly lower for asymptomatic compared to symptomatic infection. Interpretation Despite rapid waning of protection, vaccine boosters remain an important tool in responding to the dynamic COVID-19 landscape; boosting population immunity in advance of periods of anticipated pressure, such as surging infection rates or emerging variants of concern. Funding UK Health Security Agency, Medical Research Council, NIHR HPRU Oxford, Bristol, and others.
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Affiliation(s)
- Peter D. Kirwan
- MRC Biostatistics Unit, University of Cambridge, United Kingdom
| | | | | | | | | | | | | | | | | | - David Crossman
- School of Medicine, University of St Andrews, United Kingdom
| | | | | | | | | | | | - Ana Atti
- UK Health Security Agency, United Kingdom
| | | | | | | | - Daniela De Angelis
- MRC Biostatistics Unit, University of Cambridge, United Kingdom
- UK Health Security Agency, United Kingdom
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Dunn D, McCabe L, White E, Delpech V, Kirwan PD, Khawam J, Croxford S, Ward D, Brodnicki E, Rodger A, McCormack S. Electronic health records to capture primary outcome measures: two case studies in HIV prevention research. Trials 2023; 24:244. [PMID: 36997941 PMCID: PMC10063429 DOI: 10.1186/s13063-023-07264-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/20/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND There is increasing interest in the use of electronic health records (EHRs) to improve the efficiency and cost-effectiveness of clinical trials, including the capture of outcome measures. MAIN TEXT We describe our experience of using EHRs to capture the primary outcome measure - HIV infection or the diagnosis of HIV infection - in two randomised HIV prevention trials conducted in the UK. PROUD was a clinic-based trial evaluating pre-exposure prophylaxis (PrEP), and SELPHI was an internet-based trial evaluating HIV self-testing kits. The EHR was the national database of HIV diagnoses in the UK, curated by the UK Health Security Agency (UKHSA). In PROUD, linkage to the UKHSA database was performed at the end of the trial and identified five primary outcomes in addition to the 30 outcomes diagnosed by the participating clinics. Linkage also produced an additional 345 person-years follow-up, an increase of 27% over clinic-based follow-up. In SELPHI, new HIV diagnoses were primarily identified via UKHSA linkage, complemented by participant self-report through internet surveys. Rates of survey completion were low, and only 14 of the 33 new diagnoses recorded in the UKHSA database were also self-reported. Thus UKHSA linkage was essential for capturing HIV diagnoses and the successful conduct of the trial. CONCLUSIONS Our experience of using the UKHSA database of HIV diagnoses as a source of primary outcomes in two randomised trials in the field of HIV prevention was highly favourable and encourages the use of a similar approach in future trials in this disease area.
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Affiliation(s)
- David Dunn
- MRC Clinical Trials Unit at UCL, London, UK.
- Institute for Global Health, University College London, London, UK.
| | | | | | | | | | | | | | | | | | - Alison Rodger
- Institute for Global Health, University College London, London, UK
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Kirwan PD, Croxford S, Aghaizu A, Murphy G, Tosswill J, Brown AE, Delpech VC. Re-assessing the late HIV diagnosis surveillance definition in the era of increased and frequent testing. HIV Med 2022; 23:1127-1142. [PMID: 36069144 PMCID: PMC7613879 DOI: 10.1111/hiv.13394] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 08/10/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Late HIV diagnosis (CD4 <350 cells/mm3 ) is a key public health metric. In an era of more frequent testing, the likelihood of HIV diagnosis occurring during seroconversion, when CD4 counts may dip below 350, is greater. We applied a correction, considering markers of recent infection, and re-assessed 1-year mortality following late diagnosis. METHODS We used national epidemiological and laboratory surveillance data from all people diagnosed with HIV in England, Wales, and Northern Ireland (EW&NI). Those with a baseline CD4 <350 were reclassified as 'not late' if they had evidence of recent infection (recency test and/or negative test within 24 months). A correction factor (CF) was the number reclassified divided by the number with a CD4 <350. RESULTS Of the 32 227 people diagnosed with HIV in EW&NI between 2011 and 2019 with a baseline CD4 (81% of total), 46% had a CD4 <350 (uncorrected late diagnosis rate): 34% of gay and bisexual men (GBM), 65% of heterosexual men, and 56% of heterosexual women. Accounting for recency test and/or prior negative tests gave a 'corrected' late diagnosis rate of 39% and corresponding CF of 14%. The CF increased from 10% to 18% during 2011-2015, then plateaued, and was larger among GBM (25%) than heterosexual men and women (6% and 7%, respectively). One-year mortality among people diagnosed late was 329 per 10 000 after reclassification (an increase from 288/10 000). CONCLUSIONS The case-surveillance definition of late diagnosis increasingly overestimates late presentation, the extent of which differs by key populations. Adjustment of late diagnosis is recommended, particularly for frequent testers such as GBM.
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Affiliation(s)
- Peter D Kirwan
- Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge,United Kingdom Health Security Agency, London,Corresponding author Contact details: Peter Kirwan, United Kingdom Health Security Agency, London, NW9 5EQ Phone: +44 (0)7837 723563,
| | | | | | - Gary Murphy
- United Kingdom Health Security Agency, London
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Jackson CH, Tom BD, Kirwan PD, Mandal S, Seaman SR, Kunzmann K, Presanis AM, De Angelis D. A comparison of two frameworks for multi-state modelling, applied to outcomes after hospital admissions with COVID-19. Stat Methods Med Res 2022; 31:1656-1674. [PMID: 35837731 PMCID: PMC9294033 DOI: 10.1177/09622802221106720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We compare two multi-state modelling frameworks that can be used to represent dates of events following hospital admission for people infected during an epidemic. The methods are applied to data from people admitted to hospital with COVID-19, to estimate the probability of admission to intensive care unit, the probability of death in hospital for patients before and after intensive care unit admission, the lengths of stay in hospital, and how all these vary with age and gender. One modelling framework is based on defining transition-specific hazard functions for competing risks. A less commonly used framework defines partially-latent subpopulations who will experience each subsequent event, and uses a mixture model to estimate the probability that an individual will experience each event, and the distribution of the time to the event given that it occurs. We compare the advantages and disadvantages of these two frameworks, in the context of the COVID-19 example. The issues include the interpretation of the model parameters, the computational efficiency of estimating the quantities of interest, implementation in software and assessing goodness of fit. In the example, we find that some groups appear to be at very low risk of some events, in particular intensive care unit admission, and these are best represented by using 'cure-rate' models to define transition-specific hazards. We provide general-purpose software to implement all the models we describe in the flexsurv R package, which allows arbitrarily flexible distributions to be used to represent the cause-specific hazards or times to events.
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Affiliation(s)
| | - Brian Dm Tom
- 47959MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Peter D Kirwan
- 47959MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- Public Health England, London, UK
| | | | - Shaun R Seaman
- 47959MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Kevin Kunzmann
- 47959MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Anne M Presanis
- 47959MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Daniela De Angelis
- 47959MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- Public Health England, London, UK
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5
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Wallace S, Hall V, Charlett A, Kirwan PD, Cole M, Gillson N, Atti A, Timeyin J, Foulkes S, Taylor-Kerr A, Andrews N, Shrotri M, Rokadiya S, Oguti B, Vusirikala A, Islam J, Zambon M, Brooks TJG, Ramsay M, Brown CS, Chand M, Hopkins S. Impact of prior SARS-CoV-2 infection and COVID-19 vaccination on the subsequent incidence of COVID-19: a multicentre prospective cohort study among UK healthcare workers - the SIREN (Sarscov2 Immunity & REinfection EvaluatioN) study protocol. BMJ Open 2022; 12:e054336. [PMID: 35768083 PMCID: PMC9240450 DOI: 10.1136/bmjopen-2021-054336] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Understanding 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 ANALYSIS This 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 DISSEMINATION The 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 NUMBER ISRCTN11041050.
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Affiliation(s)
- Sarah Wallace
- National Infection Service, UK Health Security Agency, London, UK
| | - Victoria Hall
- National Infection Service, UK Health Security Agency, London, UK
| | - Andre Charlett
- Statistics, Modelling and Economics Unit, UK Health Security Agency, London, UK
| | - Peter D Kirwan
- National Infection Service, UK Health Security Agency, London, UK
- MRC Biostatistics Unit, Cambridge, UK
| | - Michele Cole
- National Infection Service, UK Health Security Agency, London, UK
| | - Natalie Gillson
- National Infection Service, UK Health Security Agency, London, UK
| | - Ana Atti
- National Infection Service, UK Health Security Agency, London, UK
| | - Jean Timeyin
- National Infection Service, UK Health Security Agency, London, UK
| | - Sarah Foulkes
- National Infection Service, UK Health Security Agency, London, UK
| | | | - Nick Andrews
- Statistics, Modelling and Economics Unit, UK Health Security Agency, London, UK
| | | | - Sakib Rokadiya
- National Infection Service, UK Health Security Agency, London, UK
| | - Blanche Oguti
- National Infection Service, UK Health Security Agency, London, UK
| | | | - Jasmin Islam
- National Infection Service, UK Health Security Agency, London, UK
| | - Maria Zambon
- National Infection Service, UK Health Security Agency, London, UK
| | - Tim J G Brooks
- National Infection Service, UK Health Security Agency, London, UK
| | - Mary Ramsay
- National Infection Service, UK Health Security Agency, London, UK
| | - Colin S Brown
- National Infection Service, UK Health Security Agency, London, UK
| | - Meera Chand
- National Infection Service, UK Health Security Agency, London, UK
| | - Susan Hopkins
- National Infection Service, UK Health Security Agency, London, UK
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Presanis AM, Harris RJ, Kirwan PD, Miltz A, Croxford S, Heinsbroek E, Jackson CH, Mohammed H, Brown AE, Delpech VC, Gill ON, Angelis DD. Trends in undiagnosed HIV prevalence in England and implications for eliminating HIV transmission by 2030: an evidence synthesis model. Lancet Public Health 2021; 6:e739-e751. [PMID: 34563281 PMCID: PMC8481938 DOI: 10.1016/s2468-2667(21)00142-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 06/03/2021] [Accepted: 06/07/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND A target to eliminate HIV transmission in England by 2030 was set in early 2019. This study aimed to estimate trends from 2013 to 2019 in HIV prevalence, particularly the number of people living with undiagnosed HIV, by exposure group, ethnicity, gender, age group, and region. These estimates are essential to monitor progress towards elimination. METHODS A Bayesian synthesis of evidence from multiple surveillance, demographic, and survey datasets relevant to HIV in England was used to estimate trends in the number of people living with HIV, the proportion of people unaware of their HIV infection, and the corresponding prevalence of undiagnosed HIV. All estimates were stratified by exposure group, ethnicity, gender, age group (15-34, 35-44, 45-59, or 60-74 years), region (London, or outside of London) and year (2013-19). FINDINGS The total number of people living with HIV aged 15-74 years in England increased from 83 500 (95% credible interval 80 200-89 600) in 2013 to 92 800 (91 000-95 600) in 2019. The proportion diagnosed steadily increased from 86% (80-90%) to 94% (91-95%) during the same time period, corresponding to a halving in the number of undiagnosed infections from 11 600 (8300-17 700) to 5900 (4400-8700) and in undiagnosed prevalence from 0·29 (0·21-0·44) to 0·14 (0·11-0·21) per 1000 population. Similar steep declines were estimated in all subgroups of gay, bisexual, and other men who have sex with men and in most subgroups of Black African heterosexuals. The pace of reduction was less pronounced for heterosexuals in other ethnic groups and people who inject drugs, particularly outside London; however, undiagnosed prevalence in these groups has remained very low. INTERPRETATION The UNAIDS target of diagnosing 90% of people living with HIV by 2020 was reached by 2016 in England, with the country on track to achieve the new target of 95% diagnosed by 2025. Reductions in transmission and undiagnosed prevalence have corresponded to large scale-up of testing in key populations and early diagnosis and treatment. Additional and intensified prevention measures are required to eliminate transmission of HIV among the communities that have experienced slower declines than other subgroups, despite having very low prevalences of HIV. FUNDING UK Medical Research Council and Public Health England.
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Affiliation(s)
- Anne M Presanis
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK.
| | | | - Peter D Kirwan
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK; Public Health England, London, UK
| | - Ada Miltz
- Public Health England, London, UK; Institute of Global Health, University College London, London, UK
| | | | | | - Christopher H Jackson
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | | | | | | | | | - Daniela De Angelis
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK; Public Health England, London, UK
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Pantazis N, Rosinska M, van Sighem A, Quinten C, Noori T, Burns F, Cortes Martins H, Kirwan PD, O'Donnell K, Paraskevis D, Sommen C, Zenner D, Pharris A. Discriminating Between Premigration and Postmigration HIV Acquisition Using Surveillance Data. J Acquir Immune Defic Syndr 2021; 88:117-124. [PMID: 34138772 DOI: 10.1097/qai.0000000000002745] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/02/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Migrant populations are overrepresented among persons diagnosed with HIV in the European Union and the European Economic Area. Understanding the timing of HIV acquisition (premigration or postmigration) is crucial for developing public health interventions and for producing reliable estimates of HIV incidence and the number of people living with undiagnosed HIV infection. We summarize a recently proposed method for determining the timing of HIV acquisition and apply it to both real and simulated data. METHODS The considered method combines estimates from a mixed model, applied to data from a large seroconverters' cohort, with biomarker measurements and individual characteristics to derive probabilities of premigration HIV acquisition within a Bayesian framework. The method is applied to a subset of data from the European Surveillance System (TESSy) and simulated data. FINDINGS Simulation study results showed good performance with the probabilities of correctly classifying a premigration case or a postmigration case being 87.4% and 80.4%, respectively. Applying the method to TESSy data, we estimated the proportions of migrants who acquired HIV in the destination country were 31.9%, 37.1%, 45.3%, and 45.2% for those originating from Africa, Europe, Asia, and other regions, respectively. CONCLUSIONS Although the considered method was initially developed for cases with multiple biomarkers' measurements, its performance, when applied to data where only one CD4 count per individual is available, remains satisfactory. Application of the method to TESSy data, estimated that a substantial proportion of HIV acquisition among migrants occurs in destination countries, having important implications for public health policy and programs.
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Affiliation(s)
- Nikos Pantazis
- Department of Hygiene, Epidemiology and Medical Statistics, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Magdalena Rosinska
- Department of Epidemiology of Infectious Diseases and Surveillance, National Institute of Public Health-National Institute of Hygiene, Warsaw, Poland
| | | | - Chantal Quinten
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - Teymur Noori
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - Fiona Burns
- Institute for Global Health, University College London, London, United Kingdom
| | | | - Peter D Kirwan
- Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, United Kingdom
- Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Division, Public Health England, London, United Kingdom
| | - Kate O'Donnell
- HSE-Health Protection Surveillance Centre, Dublin, Ireland
| | - Dimitrios Paraskevis
- Department of Hygiene, Epidemiology and Medical Statistics, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | | | - Dominik Zenner
- Centre for Global Public Health, Institute for Population Health Sciences, Queen Mary University London, London, United Kingdom
| | - Anastasia Pharris
- European Centre for Disease Prevention and Control, Stockholm, Sweden
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Kirwan PD, Amin-Chowdhury Z, Croxford SE, Sheppard C, Fry N, Delpech VC, Ladhani SN. Invasive Pneumococcal Disease in People With Human Immunodeficiency Virus in England, 1999-2017. Clin Infect Dis 2021; 73:91-100. [PMID: 32789498 DOI: 10.1093/cid/ciaa522] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 08/12/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The 7-valent and 13-valent pneumococcal conjugate vaccines (PCVs) were introduced into the UK childhood immunization program in 2006 and 2010, respectively, with high effectiveness and resulting in both direct and indirect protection. We describe the epidemiology of invasive pneumococcal disease (IPD) in adults with human immunodeficiency virus (HIV) in England following the introduction of both PCVs. METHODS Data on a national cohort of people with HIV were linked to confirmed IPD cases in adults aged ≥ 15 years during 1999-2017. Date of HIV infection was estimated using a CD4 slope decline algorithm. RESULTS Among 133 994 adults with HIV, 1453 developed IPD during 1999-2017, with 70% (1016/1453) developing IPD ≥ 3 months after their HIV diagnosis. IPD and HIV were codiagnosed within 90 days in 345 (24%) individuals. A missed opportunity for earlier HIV diagnosis was identified in 6% (89/1453), mostly in earlier years. IPD incidence in people with HIV increased from 147/100 000 in 1999 to 284/100 000 in 2007 before declining and stabilizing between 92 and 113/100 000 during 2014-2017. Mean annual IPD incidence was lower among those receiving antiretroviral therapy during 2014-17 (68 vs 720/100 000; incidence rate ratio [IRR] 9.3; 95% confidence interval [CI], 7.3-11.8; P < .001) and was markedly lower in those with a suppressed viral load (50 vs 523/100 000; IRR 10.4; 95% CI, 7.6-14.1; P < .001). The latter group still had 4.5-fold higher (95% CI, 3.8-5.3; P < .001) IPD incidence compared to the general population (11.2/100 000). CONCLUSIONS IPD incidence among people with HIV reduced after PCV13 introduction and has remained stable. Adults presenting with IPD should continue to be tested for HIV infection.
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Affiliation(s)
- Peter D Kirwan
- Human Immunodeficiency Virus Section, Public Health England, London, United Kingdom
| | - Zahin Amin-Chowdhury
- Immunisation and Countermeasures Division, Pubic Health England, London, United Kingdom
| | - Sara E Croxford
- Human Immunodeficiency Virus Section, Public Health England, London, United Kingdom
| | - Carmen Sheppard
- Respiratory and Vaccine Preventable Bacterial Reference Unit, Pubic Health England, London, United Kingdom
| | - Norman Fry
- Respiratory and Vaccine Preventable Bacterial Reference Unit, Pubic Health England, London, United Kingdom
| | - Valerie C Delpech
- Human Immunodeficiency Virus Section, Public Health England, London, United Kingdom
| | - Shamez N Ladhani
- Immunisation and Countermeasures Division, Pubic Health England, London, United Kingdom.,Paediatric Infectious Diseases Research Group, St George's University of London, London, United Kingdom
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Docherty AB, Mulholland RH, Lone NI, Cheyne CP, De Angelis D, Diaz-Ordaz K, Donegan C, Drake TM, Dunning J, Funk S, García-Fiñana M, Girvan M, Hardwick HE, Harrison J, Ho A, Hughes DM, Keogh RH, Kirwan PD, Leeming G, Nguyen Van-Tam JS, Pius R, Russell CD, Spencer RG, Tom BD, Turtle L, Openshaw PJ, Baillie JK, Harrison EM, Semple MG. Changes in in-hospital mortality in the first wave of COVID-19: a multicentre prospective observational cohort study using the WHO Clinical Characterisation Protocol UK. Lancet Respir Med 2021; 9:773-785. [PMID: 34000238 PMCID: PMC8121531 DOI: 10.1016/s2213-2600(21)00175-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/14/2021] [Accepted: 03/28/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Mortality rates in hospitalised patients with COVID-19 in the UK appeared to decline during the first wave of the pandemic. We aimed to quantify potential drivers of this change and identify groups of patients who remain at high risk of dying in hospital. METHODS In this multicentre prospective observational cohort study, the International Severe Acute Respiratory and Emerging Infections Consortium WHO Clinical Characterisation Protocol UK recruited a prospective cohort of patients with COVID-19 admitted to 247 acute hospitals in England, Scotland, and Wales during the first wave of the pandemic (between March 9 and Aug 2, 2020). We included all patients aged 18 years and older with clinical signs and symptoms of COVID-19 or confirmed COVID-19 (by RT-PCR test) from assumed community-acquired infection. We did a three-way decomposition mediation analysis using natural effects models to explore associations between week of admission and in-hospital mortality, adjusting for confounders (demographics, comorbidities, and severity of illness) and quantifying potential mediators (level of respiratory support and steroid treatment). The primary outcome was weekly in-hospital mortality at 28 days, defined as the proportion of patients who had died within 28 days of admission of all patients admitted in the observed week, and it was assessed in all patients with an outcome. This study is registered with the ISRCTN Registry, ISRCTN66726260. FINDINGS Between March 9, and Aug 2, 2020, we recruited 80 713 patients, of whom 63 972 were eligible and included in the study. Unadjusted weekly in-hospital mortality declined from 32·3% (95% CI 31·8-32·7) in March 9 to April 26, 2020, to 16·4% (15·0-17·8) in June 15 to Aug 2, 2020. Reductions in mortality were observed in all age groups, in all ethnic groups, for both sexes, and in patients with and without comorbidities. After adjustment, there was a 32% reduction in the risk of mortality per 7-week period (odds ratio [OR] 0·68 [95% CI 0·65-0·71]). The higher proportions of patients with severe disease and comorbidities earlier in the first wave (March and April) than in June and July accounted for 10·2% of this reduction. The use of respiratory support changed during the first wave, with gradually increased use of non-invasive ventilation over the first wave. Changes in respiratory support and use of steroids accounted for 22·2%, OR 0·95 (0·94-0·95) of the reduction in in-hospital mortality. INTERPRETATION The reduction in in-hospital mortality in patients with COVID-19 during the first wave in the UK was partly accounted for by changes in the case-mix and illness severity. A significant reduction in in-hospital mortality was associated with differences in respiratory support and critical care use, which could partly reflect accrual of clinical knowledge. The remaining improvement in in-hospital mortality is not explained by these factors, and could be associated with changes in community behaviour, inoculum dose, and hospital capacity strain. FUNDING National Institute for Health Research and the Medical Research Council.
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Affiliation(s)
| | | | - Nazir I Lone
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Christopher P Cheyne
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | | | | | - Cara Donegan
- Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Thomas M Drake
- Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK
| | - Jake Dunning
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Sebastian Funk
- London School of Hygiene & Tropical Medicine, London, UK
| | - Marta García-Fiñana
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Michelle Girvan
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Hayley E Hardwick
- Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Janet Harrison
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Antonia Ho
- MRC University of Glasgow Centre for Virus Research, Glasgow, UK
| | - David M Hughes
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Ruth H Keogh
- London School of Hygiene & Tropical Medicine, London, UK
| | - Peter D Kirwan
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Gary Leeming
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Jonathan S Nguyen Van-Tam
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Riinu Pius
- Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK
| | - Clark D Russell
- The Usher Institute, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Rebecca G Spencer
- Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Brian Dm Tom
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Lance Turtle
- Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Peter Jm Openshaw
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | | | - Ewen M Harrison
- Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK
| | - Malcolm G Semple
- Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK; Department of Respiratory Medicine, Alder Hey Children's Hospital, Liverpool, UK
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10
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Mulchandani R, Taylor-Philips S, Jones HE, Ades AE, Borrow R, Linley E, Kirwan PD, Stewart R, Moore P, Boyes J, Hormis A, Todd N, Colda A, Reckless I, Brooks T, Charlett A, Hickman M, Oliver I, Wyllie D. Association between self-reported signs and symptoms and SARS-CoV-2 antibody detection in UK key workers. J Infect 2021; 82:151-161. [PMID: 33775704 PMCID: PMC7997203 DOI: 10.1016/j.jinf.2021.03.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/16/2021] [Accepted: 03/19/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Screening for SARS-CoV-2 antibodies is under way in some key worker groups; how this adds to self-reported COVID-19 illness is unclear. In this study, we investigate the association between self-reported belief of COVID-19 illness and seropositivity. METHODS Cross-sectional study of three key worker streams comprising (A) Police and Fire & Rescue (2 sites) (B) healthcare workers (1 site) and (C) healthcare workers with previously positive PCR result (5 sites). We collected self-reported signs and symptoms of COVID-19 and compared this with serology results from two SARS-CoV-2 immunoassays (Roche Elecsys® and EUROIMMUN). RESULTS Between 01 and 26 June, we recruited 2847 individuals (Stream A: 1,247, Stream B: 1,546 and Stream C: 154). Amongst those without previous positive PCR tests, 687/2,579 (26%) reported belief they had COVID-19, having experienced compatible symptoms; however, only 208 (30.3%) of these were seropositive on both immunoassays. Both immunoassays had high sensitivities relative to previous PCR positivity (>93%); there was also limited decline in antibody titres up to 110 days post symptom onset. Symptomatic but seronegative individuals had differing symptom profiles and shorter illnesses than seropositive individuals. CONCLUSION Non-COVID-19 respiratory illness may have been mistaken for COVID-19 during the outbreak; laboratory testing is more specific than self-reported key worker beliefs in ascertaining past COVID-19 disease.
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Affiliation(s)
- Ranya Mulchandani
- UK Field Epidemiology Training Programme (FETP), Public Health England, London, United Kingdom; Field Service, Midlands, National Infection Service, Public Health England, Birmingham, United Kingdom
| | | | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom; NIHR Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, University of Bristol, Bristol, United Kingdom
| | - A E Ades
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom; NIHR Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, University of Bristol, Bristol, United Kingdom
| | - Ray Borrow
- Seroepidemiology Unit (SEU), Manchester Royal Infirmary, Public Health England, Manchester, United Kingdom
| | - Ezra Linley
- Seroepidemiology Unit (SEU), Manchester Royal Infirmary, Public Health England, Manchester, United Kingdom
| | - Peter D Kirwan
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Richard Stewart
- Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, United Kingdom
| | - Philippa Moore
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, United Kingdom
| | - John Boyes
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, United Kingdom
| | - Anil Hormis
- The Rotherham NHS Foundation Trust, Rotherham, United Kingdom
| | - Neil Todd
- York Teaching Hospital NHS Foundation Trust, York, United Kingdom
| | - Antoanela Colda
- Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, United Kingdom
| | - Ian Reckless
- Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, United Kingdom
| | - Tim Brooks
- Rare and Imported Pathogens Laboratory (RIPL), Porton Down, Public Health England, Salisbury, United Kingdom
| | - Andre Charlett
- Statistical Unit, Public Health England, London, United Kingdom
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom; NIHR Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, University of Bristol, Bristol, United Kingdom
| | - Isabel Oliver
- NIHR Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, University of Bristol, Bristol, United Kingdom; National Infection Service, Public Health England, Bristol, United Kingdom
| | - David Wyllie
- Field Service, East of England, National Infection Service, Public Health England, Cambridge, United Kingdom; NIHR Health Protection Research Unit (HPRU) in Genomics and Data Enabling, University of Warwick, Warwick, United Kingdom.
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11
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Hall VJ, Foulkes S, Charlett A, Atti A, Monk EJM, Simmons R, Wellington E, Cole MJ, Saei A, Oguti B, Munro K, Wallace S, Kirwan PD, Shrotri M, Vusirikala A, Rokadiya S, Kall M, Zambon M, Ramsay M, Brooks T, Brown CS, Chand MA, Hopkins S. SARS-CoV-2 infection rates of antibody-positive compared with antibody-negative health-care workers in England: a large, multicentre, prospective cohort study (SIREN). Lancet 2021; 397:1459-1469. [PMID: 33844963 DOI: 10.1101/2021.01.13.21249642] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/01/2021] [Accepted: 03/12/2021] [Indexed: 05/27/2023]
Abstract
BACKGROUND Increased understanding of whether individuals who have recovered from COVID-19 are protected from future SARS-CoV-2 infection is an urgent requirement. We aimed to investigate whether antibodies against SARS-CoV-2 were associated with a decreased risk of symptomatic and asymptomatic reinfection. METHODS A large, multicentre, prospective cohort study was done, with participants recruited from publicly funded hospitals in all regions of England. All health-care workers, support staff, and administrative staff working at hospitals who could remain engaged in follow-up for 12 months were eligible to join The SARS-CoV-2 Immunity and Reinfection Evaluation study. Participants were excluded if they had no PCR tests after enrolment, enrolled after Dec 31, 2020, or had insufficient PCR and antibody data for cohort assignment. Participants attended regular SARS-CoV-2 PCR and antibody testing (every 2-4 weeks) and completed questionnaires every 2 weeks on symptoms and exposures. At enrolment, participants were assigned to either the positive cohort (antibody positive, or previous positive PCR or antibody test) or negative cohort (antibody negative, no previous positive PCR or antibody test). The primary outcome was a reinfection in the positive cohort or a primary infection in the negative cohort, determined by PCR tests. Potential reinfections were clinically reviewed and classified according to case definitions (confirmed, probable, or possible) and symptom-status, depending on the hierarchy of evidence. Primary infections in the negative cohort were defined as a first positive PCR test and seroconversions were excluded when not associated with a positive PCR test. A proportional hazards frailty model using a Poisson distribution was used to estimate incidence rate ratios (IRR) to compare infection rates in the two cohorts. FINDINGS From June 18, 2020, to Dec 31, 2020, 30 625 participants were enrolled into the study. 51 participants withdrew from the study, 4913 were excluded, and 25 661 participants (with linked data on antibody and PCR testing) were included in the analysis. Data were extracted from all sources on Feb 5, 2021, and include data up to and including Jan 11, 2021. 155 infections were detected in the baseline positive cohort of 8278 participants, collectively contributing 2 047 113 person-days of follow-up. This compares with 1704 new PCR positive infections in the negative cohort of 17 383 participants, contributing 2 971 436 person-days of follow-up. The incidence density was 7·6 reinfections per 100 000 person-days in the positive cohort, compared with 57·3 primary infections per 100 000 person-days in the negative cohort, between June, 2020, and January, 2021. The adjusted IRR was 0·159 for all reinfections (95% CI 0·13-0·19) compared with PCR-confirmed primary infections. The median interval between primary infection and reinfection was more than 200 days. INTERPRETATION A previous history of SARS-CoV-2 infection was associated with an 84% lower risk of infection, with median protective effect observed 7 months following primary infection. This time period is the minimum probable effect because seroconversions were not included. This study shows that previous infection with SARS-CoV-2 induces effective immunity to future infections in most individuals. FUNDING Department of Health and Social Care of the UK Government, Public Health England, The National Institute for Health Research, with contributions from the Scottish, Welsh and Northern Irish governments.
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Affiliation(s)
- Victoria Jane Hall
- Public Health England Colindale, Colindale, London, UK; The National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at the University of Oxford, University of Oxford, Oxford, UK
| | - Sarah Foulkes
- Public Health England Colindale, Colindale, London, UK
| | - Andre Charlett
- Public Health England Colindale, Colindale, London, UK; The National Institute for Health Research Health Protection Research Unit in Behavioural Science and Evaluation at University of Bristol in partnership with Public Health England, Bristol, UK
| | - Ana Atti
- Public Health England Colindale, Colindale, London, UK
| | | | - Ruth Simmons
- Public Health England Colindale, Colindale, London, UK
| | | | | | - Ayoub Saei
- Public Health England Colindale, Colindale, London, UK
| | - Blanche Oguti
- Public Health England Colindale, Colindale, London, UK; Oxford Vaccine Group, University of Oxford, Oxford, UK
| | - Katie Munro
- Public Health England Colindale, Colindale, London, UK
| | - Sarah Wallace
- Public Health England Colindale, Colindale, London, UK
| | - Peter D Kirwan
- Public Health England Colindale, Colindale, London, UK; Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, UK
| | | | | | | | - Meaghan Kall
- Public Health England Colindale, Colindale, London, UK
| | - Maria Zambon
- Public Health England Colindale, Colindale, London, UK
| | - Mary Ramsay
- Public Health England Colindale, Colindale, London, UK; Oxford Vaccine Group, University of Oxford, Oxford, UK
| | - Tim Brooks
- Public Health England Colindale, Colindale, London, UK
| | - Colin S Brown
- Public Health England Colindale, Colindale, London, UK
| | - Meera A Chand
- Public Health England Colindale, Colindale, London, UK; Guys and St Thomas's Hospital NHS Trust, London, UK
| | - Susan Hopkins
- Public Health England Colindale, Colindale, London, UK; The National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at the University of Oxford, University of Oxford, Oxford, UK.
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12
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Hall VJ, Foulkes S, Charlett A, Atti A, Monk EJM, Simmons R, Wellington E, Cole MJ, Saei A, Oguti B, Munro K, Wallace S, Kirwan PD, Shrotri M, Vusirikala A, Rokadiya S, Kall M, Zambon M, Ramsay M, Brooks T, Brown CS, Chand MA, Hopkins S. SARS-CoV-2 infection rates of antibody-positive compared with antibody-negative health-care workers in England: a large, multicentre, prospective cohort study (SIREN). Lancet 2021; 397:1459-1469. [PMID: 33844963 PMCID: PMC8040523 DOI: 10.1016/s0140-6736(21)00675-9] [Citation(s) in RCA: 400] [Impact Index Per Article: 133.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/01/2021] [Accepted: 03/12/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Increased understanding of whether individuals who have recovered from COVID-19 are protected from future SARS-CoV-2 infection is an urgent requirement. We aimed to investigate whether antibodies against SARS-CoV-2 were associated with a decreased risk of symptomatic and asymptomatic reinfection. METHODS A large, multicentre, prospective cohort study was done, with participants recruited from publicly funded hospitals in all regions of England. All health-care workers, support staff, and administrative staff working at hospitals who could remain engaged in follow-up for 12 months were eligible to join The SARS-CoV-2 Immunity and Reinfection Evaluation study. Participants were excluded if they had no PCR tests after enrolment, enrolled after Dec 31, 2020, or had insufficient PCR and antibody data for cohort assignment. Participants attended regular SARS-CoV-2 PCR and antibody testing (every 2-4 weeks) and completed questionnaires every 2 weeks on symptoms and exposures. At enrolment, participants were assigned to either the positive cohort (antibody positive, or previous positive PCR or antibody test) or negative cohort (antibody negative, no previous positive PCR or antibody test). The primary outcome was a reinfection in the positive cohort or a primary infection in the negative cohort, determined by PCR tests. Potential reinfections were clinically reviewed and classified according to case definitions (confirmed, probable, or possible) and symptom-status, depending on the hierarchy of evidence. Primary infections in the negative cohort were defined as a first positive PCR test and seroconversions were excluded when not associated with a positive PCR test. A proportional hazards frailty model using a Poisson distribution was used to estimate incidence rate ratios (IRR) to compare infection rates in the two cohorts. FINDINGS From June 18, 2020, to Dec 31, 2020, 30 625 participants were enrolled into the study. 51 participants withdrew from the study, 4913 were excluded, and 25 661 participants (with linked data on antibody and PCR testing) were included in the analysis. Data were extracted from all sources on Feb 5, 2021, and include data up to and including Jan 11, 2021. 155 infections were detected in the baseline positive cohort of 8278 participants, collectively contributing 2 047 113 person-days of follow-up. This compares with 1704 new PCR positive infections in the negative cohort of 17 383 participants, contributing 2 971 436 person-days of follow-up. The incidence density was 7·6 reinfections per 100 000 person-days in the positive cohort, compared with 57·3 primary infections per 100 000 person-days in the negative cohort, between June, 2020, and January, 2021. The adjusted IRR was 0·159 for all reinfections (95% CI 0·13-0·19) compared with PCR-confirmed primary infections. The median interval between primary infection and reinfection was more than 200 days. INTERPRETATION A previous history of SARS-CoV-2 infection was associated with an 84% lower risk of infection, with median protective effect observed 7 months following primary infection. This time period is the minimum probable effect because seroconversions were not included. This study shows that previous infection with SARS-CoV-2 induces effective immunity to future infections in most individuals. FUNDING Department of Health and Social Care of the UK Government, Public Health England, The National Institute for Health Research, with contributions from the Scottish, Welsh and Northern Irish governments.
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Affiliation(s)
- Victoria Jane Hall
- Public Health England Colindale, Colindale, London, UK; The National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at the University of Oxford, University of Oxford, Oxford, UK
| | - Sarah Foulkes
- Public Health England Colindale, Colindale, London, UK
| | - Andre Charlett
- Public Health England Colindale, Colindale, London, UK; The National Institute for Health Research Health Protection Research Unit in Behavioural Science and Evaluation at University of Bristol in partnership with Public Health England, Bristol, UK
| | - Ana Atti
- Public Health England Colindale, Colindale, London, UK
| | | | - Ruth Simmons
- Public Health England Colindale, Colindale, London, UK
| | | | | | - Ayoub Saei
- Public Health England Colindale, Colindale, London, UK
| | - Blanche Oguti
- Public Health England Colindale, Colindale, London, UK; Oxford Vaccine Group, University of Oxford, Oxford, UK
| | - Katie Munro
- Public Health England Colindale, Colindale, London, UK
| | - Sarah Wallace
- Public Health England Colindale, Colindale, London, UK
| | - Peter D Kirwan
- Public Health England Colindale, Colindale, London, UK; Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, UK
| | | | | | | | - Meaghan Kall
- Public Health England Colindale, Colindale, London, UK
| | - Maria Zambon
- Public Health England Colindale, Colindale, London, UK
| | - Mary Ramsay
- Public Health England Colindale, Colindale, London, UK; Oxford Vaccine Group, University of Oxford, Oxford, UK
| | - Tim Brooks
- Public Health England Colindale, Colindale, London, UK
| | - Colin S Brown
- Public Health England Colindale, Colindale, London, UK
| | - Meera A Chand
- Public Health England Colindale, Colindale, London, UK; Guys and St Thomas's Hospital NHS Trust, London, UK
| | - Susan Hopkins
- Public Health England Colindale, Colindale, London, UK; The National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at the University of Oxford, University of Oxford, Oxford, UK.
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13
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Kirwan PD, Hibbert M, Kall M, Nambiar K, Ross M, Croxford S, Nash S, Webb L, Wolton A, Delpech VC. HIV prevalence and HIV clinical outcomes of transgender and gender-diverse people in England. HIV Med 2020; 22:131-139. [PMID: 33103840 DOI: 10.1111/hiv.12987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 08/07/2020] [Accepted: 09/23/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We provide the first estimate of HIV prevalence among trans and gender-diverse people living in England and compare outcomes of people living with HIV according to gender identity. METHODS We analysed a comprehensive national HIV cohort and a nationally representative self-reported survey of people accessing HIV care in England (Positive Voices). Gender identity was recorded using a two-step question co-designed with community members and civil society. Responses were validated by clinic follow-up and/or self-report. Population estimates were obtained from national government offices. RESULTS In 2017, HIV prevalence among trans and gender-diverse people was estimated at 0.46-4.78 per 1000, compared with 1.7 (95% credible interval: 1.6-1.7) in the general population. Of 94 885 people living with diagnosed HIV in England, 178 (0.19%) identified as trans or gender-diverse. Compared with cisgender people, trans and gender-diverse people were more likely to be London residents (57% vs. 43%), younger (median age 42 vs. 46 years), of white ethnicity (61% vs. 52%), under psychiatric care (11% vs. 4%), to report problems with self-care (37% vs. 13%), and to have been refused or delayed healthcare (23% vs. 11%). Antiretroviral uptake and viral suppression were high in both groups. CONCLUSIONS HIV prevalence among trans and gender-diverse people living in England is relatively low compared with international estimates. Furthermore, no inequalities were observed with regard to HIV care. Nevertheless, trans and gender-diverse people with HIV report poorer mental health and higher levels of discrimination compared with cisgender people.
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Affiliation(s)
- P D Kirwan
- Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Division, Public Health England, London, UK.,Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - M Hibbert
- Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Division, Public Health England, London, UK
| | - M Kall
- Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Division, Public Health England, London, UK
| | - K Nambiar
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | | | - S Croxford
- Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Division, Public Health England, London, UK
| | - S Nash
- Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Division, Public Health England, London, UK
| | - L Webb
- LGBT Foundation, Manchester, UK
| | - A Wolton
- Chelsea and Westminster Hospital NHS Trust, London, UK
| | - V C Delpech
- Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Division, Public Health England, London, UK
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14
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Rodger AJ, Dunn D, McCabe L, Weatherburn P, Lampe FC, Witzel TC, Burns F, Ward D, Pebody R, Trevelion R, Brady M, Kirwan PD, Khawam J, Delpech VC, Gabriel M, Collaco-Moraes Y, Phillips AN, McCormack S. Sexual risk and HIV testing disconnect in men who have sex with men (MSM) recruited to an online HIV self-testing trial. HIV Med 2020; 21:588-598. [PMID: 32776431 DOI: 10.1111/hiv.12919] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 04/21/2020] [Accepted: 06/18/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We report the frequency of previous HIV testing at baseline in men who have sex with men (MSM) who enrolled in an HIV self-testing (HIVST) randomized controlled trial [an HIV self-testing public health intervention (SELPHI)]. METHODS Criteria for enrolment were age ≥ 16 years, being a man (including trans men) who ever had anal intercourse (AI) with a man, not being known to be HIV positive and having consented to national HIV database linkage. Using online survey baseline data (2017-2018), we assessed associations with never having tested for HIV and not testing in the previous 6 months, among men who reported at least two recent condomless AI (CAI) partners. RESULTS A total of 10 111 men were randomized; the median age was 33 years [interquartile range (IQR) 26-44 years], 89% were white, 20% were born outside the UK, 0.8% were trans men, 47% were degree educated, and 8% and 4% had ever used and were currently using pre-exposure prophylaxis (PrEP), respectively. In the previous 3 months, 89% reported AI and 72% reported CAI with at least one male partner. Overall, 17%, 33%, 54%, and 72% had tested for HIV in the last 3 months, 6 months, 12 months and 2 years, respectively; 13% had tested more than 2 years ago and 15% had never tested. Among 3972 men reporting at least two recent CAI partners, only 22% had tested in the previous 3 months. Region of residence and education level were independently associated with recent HIV testing. Among current PrEP users, 15% had not tested in the previous 6 months. CONCLUSIONS Most men in SELPHI, particularly those reporting at least two CAI partners and current PrEP users, were not testing in line with current UK recommendations. The results of the trial will inform whether online promotion of HIVST addresses ongoing testing barriers.
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Affiliation(s)
- A J Rodger
- Institute for Global Health, University College London, London, UK
| | - D Dunn
- MRC Clinical Trials Unit at UCL, London, UK
| | - L McCabe
- MRC Clinical Trials Unit at UCL, London, UK
| | - P Weatherburn
- London School of Hygiene & Tropical Medicine, London, UK
| | - F C Lampe
- Institute for Global Health, University College London, London, UK
| | - T C Witzel
- London School of Hygiene & Tropical Medicine, London, UK
| | - F Burns
- Institute for Global Health, University College London, London, UK
| | - D Ward
- MRC Clinical Trials Unit at UCL, London, UK
| | | | | | - M Brady
- King's College Hospital NHS Foundation Trust, London, UK
| | - P D Kirwan
- National Infection Service, Public Health England, London, UK
| | - J Khawam
- National Infection Service, Public Health England, London, UK
| | - V C Delpech
- National Infection Service, Public Health England, London, UK
| | - M Gabriel
- MRC Clinical Trials Unit at UCL, London, UK
| | | | - A N Phillips
- Institute for Global Health, University College London, London, UK
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15
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Brown AE, Nash S, Connor N, Kirwan PD, Ogaz D, Croxford S, Angelis DD, Delpech VC. Towards elimination of HIV transmission, AIDS and HIV-related deaths in the UK. HIV Med 2018; 19:505-512. [PMID: 29923668 DOI: 10.1111/hiv.12617] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Our objective was to present recent trends in the UK HIV epidemic (2007-2016) and the public health response. METHODS HIV diagnoses and clinical markers were extracted from the HIV and AIDS Reporting System; HIV testing data in sexual health services (SHS) were taken from GUMCAD STI Surveillance System. HIV data were modelled to estimate the incidence in men who have sex with men (MSM) and post-migration HIV acquisition in heterosexuals. Office for National Statistics (ONS) data enabled mortality rates to be calculated. RESULTS New HIV diagnoses have declined in heterosexuals as a result of decreasing numbers of migrants from high HIV prevalence countries entering the UK. Among MSM, the number of HIV diagnoses fell from 3570 in 2015 to 2810 in 2016 (and from 1554 to 1096 in London). Preceding the decline in HIV diagnoses, modelled estimates indicate that transmission began to fall in 2012, from 2800 [credible interval (CrI) 2300-3200] to 1700 (CrI 900-2700) in 2016. The crude mortality rate among people promptly diagnosed with HIV infection was comparable to that in the general population (1.22 vs. 1.39 per 1000 aged 15-59 years, respectively). The number of MSM tested for HIV at SHS increased annually; 28% of MSM who were tested in 2016 had been tested in the preceding year. In 2016, 76% of people started antiretroviral therapy within 90 days of diagnosis (33% in 2007). CONCLUSIONS The dual successes of the HIV transmission decline in MSM and reduced mortality are attributable to frequent HIV testing and prompt treatment (combination prevention). Progress towards the elimination of HIV transmission, AIDS and HIV-related deaths could be achieved if combination prevention, including pre-exposure prophylaxis, is replicated for all populations.
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Affiliation(s)
- A E Brown
- HIV and STI Department, National Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, UK
| | - S Nash
- HIV and STI Department, National Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, UK
| | - N Connor
- HIV and STI Department, National Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, UK
| | - P D Kirwan
- HIV and STI Department, National Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, UK
| | - D Ogaz
- HIV and STI Department, National Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, UK
| | - S Croxford
- HIV and STI Department, National Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, UK
| | | | - V C Delpech
- HIV and STI Department, National Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, UK
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16
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Brown AE, Mohammed H, Ogaz D, Kirwan PD, Yung M, Nash SG, Furegato M, Hughes G, Connor N, Delpech VC, Gill ON. Fall in new HIV diagnoses among men who have sex with men (MSM) at selected London sexual health clinics since early 2015: testing or treatment or pre-exposure prophylaxis (PrEP)? ACTA ACUST UNITED AC 2017; 22:30553. [PMID: 28662762 PMCID: PMC5490453 DOI: 10.2807/1560-7917.es.2017.22.25.30553] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 06/20/2017] [Indexed: 11/27/2022]
Abstract
Since October 2015 up to September 2016, HIV diagnoses fell by 32% compared with October 2014–September 2015 among men who have sex with men (MSM) attending selected London sexual health clinics. This coincided with high HIV testing volumes and rapid initiation of treatment on diagnosis. The fall was most apparent in new HIV testers. Intensified testing of high-risk populations, combined with immediately received anti-retroviral therapy and a pre-exposure prophylaxis (PrEP) programme, may make elimination of HIV achievable.
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Affiliation(s)
- Alison E Brown
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom.,These authors contributed equally to this work and share first authorship
| | - Hamish Mohammed
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom.,These authors contributed equally to this work and share first authorship
| | - Dana Ogaz
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom
| | - Peter D Kirwan
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom
| | - Mandy Yung
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom
| | - Sophie G Nash
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom
| | - Martina Furegato
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom
| | - Gwenda Hughes
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom
| | - Nicky Connor
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom
| | - Valerie C Delpech
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom
| | - O Noel Gill
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom
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Abstract
Thirteen cases of various natures, selected from a collection shown and discussed at Ultrapath VI, are presented in quiz format for recognition or diagnosis.
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Affiliation(s)
- E J Wills
- Department of Anatomical Pathology, Royal Prince Alfred Hospital Camperdown, NSW, Australia
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18
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Isai H, Sheil AG, Bell R, Woodman K, Painter DM, Earl J, Kirwan PD, Liu WG. A comparison of UW solution with and without hydroxyethyl starch for liver preservation using the isolated porcine liver perfusion model. Transplant Proc 1990; 22:2152-3. [PMID: 1699330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- H Isai
- Department of Surgery, University of Sydney, New South Wales, Australia
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19
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Tuck RR, McLeod JG, Basten A, Ellis D, Kirwan PD. Total lipodystrophy--a report of a case with peripheral neuropathy and glomerulonephritis. Aust N Z J Med 1983; 13:65-9. [PMID: 6309131 DOI: 10.1111/j.1445-5994.1983.tb04553.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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