Hepatotoxicity of titanium dioxide nanoparticles

The food additive E171 (titanium dioxide, TiO2), is widely used in foods, pharmaceuticals and cosmetics. It is a fine white powder, with at least one third of its particles sized in the nanoparticulate (˂100 nm range, TiO2 NPs). The use of E171 is controversial as its relevant risk assessment has never been satisfactorily accomplished. In vitro and in vivo studies have shown dose-dependent toxicity in various organs including the liver. TiO2 NPs have been shown to induce inflammation, cell death and structural and functional changes within the liver. The toxicity of TiO2 NPs in experimental models varies between organs and according to their physiochemical characteristics and parameters such as dosage and route of administration. Among these factors, ingestion is the most significant exposure route, and the liver is a key target organ. The aim of this review is to highlight the reported adverse effects of orally administered TiO2 NPs on the liver and to discuss the controversial state of its toxicity.

Development of a non-infectious control for viral hemorrhagic fever PCR assays

Assay validation is an essential component of disease surveillance testing, but can be problematic in settings where access to positive control material is limited and a safety risk for handlers. Here we describe a single non-infectious synthetic control that can help develop and validate the PCR based detection of the viral causes of Crimean-Congo hemorrhagic fever, Ebola virus disease, Lassa fever, Marburg virus disease and Rift Valley fever. We designed non-infectious synthetic DNA oligonucleotide sequences incorporating primer binding sites suitable for five assays, and a T7 promotor site which was used to transcribe the sequence. Transcribed RNA was used as template in a dilution series, extracted and amplified with RT-PCR and RT-qPCR to demonstrate successful recovery and determine limits of detection in a range of laboratory settings. Our results show this approach is adaptable to any diagnostic assay requiring validation of nucleic acid extraction and/or amplification, particularly where sourcing reliable, safe material for positive controls is infeasible.

VEGF-A related SNPs: a cardiovascular context

Cardiovascular diseases (CVDs) are the leading cause of death worldwide. Currently, cardiovascular disease risk algorithms play a role in primary prevention. However, this is complicated by a lack of powerfully predictive biomarkers that could be observed in individuals before the onset of overt symptoms. A key potential biomarker for heart disease is the vascular endothelial growth factor (VEGF-A), a molecule that plays a pivotal role in blood vessel formation. This molecule has a complex biological role in the cardiovascular system due to the processes it influences, and its production is impacted by various CVD risk factors. Research in different populations has shown single nucleotide polymorphisms (SNPs) may affect circulating VEGF-A plasma levels, with some variants associated with the development of CVDs, as well as CVD risk factors. This minireview aims to give an overview of the VEGF family, and of the SNPs reported to influence VEGF-A levels, cardiovascular disease, and other risk factors used in CVD risk assessments.

Co-Selection of Bacterial Metal and Antibiotic Resistance in Soil Laboratory Microcosms

Accumulation of heavy metals (HMs) in agricultural soil following the application of superphosphate fertilisers seems to induce resistance of soil bacteria to HMs and appears to co-select for resistance to antibiotics (Ab). This study aimed to investigate the selection of co-resistance of soil bacteria to HMs and Ab in uncontaminated soil incubated for 6 weeks at 25 °C in laboratory microcosms spiked with ranges of concentrations of cadmium (Cd), zinc (Zn) and mercury (Hg). Co-selection of HM and Ab resistance was assessed using plate culture on media with a range of HM and Ab concentrations, and pollution-induced community tolerance (PICT) assays. Bacterial diversity was profiled via terminal restriction fragment length polymorphism (TRFLP) assay and 16S rDNA sequencing of genomic DNA isolated from selected microcosms. Based on sequence data, the microbial communities exposed to HMs were found to differ significantly compared to control microcosms with no added HM across a range of taxonomic levels.

Feasibility and acceptability of telehealth and contactless delivery of human papillomavirus (HPV) self-testing for cervical screening with Māori and Pacific women in a COVID-19 outbreak in Aotearoa New Zealand

AIM

To determine the feasibility and acceptability of a telehealth offer and contactless delivery of human papillomavirus (HPV) cervical screening self-test during the 2021 COVID-19 Level 4 lockdown in Auckland, New Zealand.

METHODS

A small proof-of-concept study was undertaken to test telehealth approaches in never-screened, due or overdue Māori and Pacific women enrolled in a local Primary Health Organisation (PHO). Study invitation, active follow-up, nurse-led discussions, result notification and a post-test questionnaire were all delivered through telehealth.

RESULTS

A sample of 197 eligible Māori and Pacific women were invited to take part, of which 86 women were successfully contacted. Sixty-six agreed to take part. Overall uptake was 61 samples returned (31.8%) and uptake of all contactable women was 70.9%. Six of the 61 HPV self-tests (9.8%) were positive, all for non 16/18 types, and were referred for cytology. Three had negative cytology results, and three with positive cytology results were referred for colposcopy.

CONCLUSION

The offer of HPV self-testing during COVID-19 lockdown was both feasible and highly acceptable for Māori and Pacific women. Importantly, HPV self-testing via telehealth and mail-out, alongside other options, offers a potential pro-equity approach for addressing the impact of deferred screens due to COVID-19 and other longstanding coverage issues.

Human papillomavirus self-testing among unscreened and under-screened Māori, Pasifika and Asian women in Aotearoa New Zealand: A preference survey among responders and interviews with clinical-trial nonresponders

INTRODUCTION

Māori, Pasifika and Asian women are less likely to attend cervical screening and Māori and Pasifika women are more likely to be diagnosed with later-stage cervical cancer than other women in Aotearoa New Zealand. This study-with under-screened women taking part in a randomized-controlled trial comparing self-testing and standard screening-explored the acceptability of a human papillomavirus (HPV) self-test kit and the preferred method for receiving it.

METHODS

Māori, Pasifika and Asian women (N= 376) completed a cross-sectional postal questionnaire. Twenty-six women who had not accepted the trial invitation were interviewed to understand their reasons for nonparticipation.

RESULTS

Most women found the self-test kit easy and convenient to use and reported that they did not find it painful, uncomfortable or embarrassing. This was reflected in the preference for a self-test over a future smear test on the same grounds. Most women preferred to receive the kit by mail and take the test themselves, rather than having it done by a doctor or nurse. There was a range of preferences relating to how to return the kit. Phone calls with nonresponders revealed that, although most had received the test kit, the reasons for not choosing to be involved included not wanting to, being too busy or forgetting.

CONCLUSION

HPV self-testing was acceptable for Māori, Pasifika and Asian women in Aotearoa New Zealand. HPV self-testing has considerable potential to reduce the inequities in the current screening programme and should be made available with appropriate delivery options as soon as possible.

PATIENT OR PUBLIC CONTRIBUTION

This study explored the acceptability of HPV self-testing and their preferences for engaging with it among Māori, Pasifika and Asian women. Thus, women from these underserved communities were the participants and focus of this study.

Acceptability of human papillomavirus (HPV) self-sampling among never- and under-screened Indigenous and other minority women: a randomised three-arm community trial in Aotearoa New Zealand

Background

Internationally, self-sampling for human papillomavirus (HPV) has been shown to increase participation in cervical-cancer screening. In Aotearoa New Zealand, there are long-standing ethnic inequalities in cervical-cancer screening, incidence, and mortality, particularly for indigenous Māori women, as well as Pacific and Asian women.

Methods

We invited never- and markedly under-screened (≥5 years overdue) 30-69-year-old Māori, Pacific, and Asian women to participate in an open-label, three-arm, community-based, randomised controlled trial, with a nested sub-study. We aimed to assess whether two specific invitation methods for self-sampling improved screening participation over usual care among the least medically served populations. Women were individually randomised 3:3:1 to: clinic-based self-sampling (CLINIC – invited to take a self-sample at their usual general practice); home-based self-sampling (HOME – mailed a kit and invited to take a self-sample at home); and usual care (USUAL – invited to attend a clinic for collection of a standard cytology sample). Neither participants nor research staff could be blinded to the intervention. In a subset of general practices, women who did not participate within three months of invitation were opportunistically invited to take a self-sample, either next time they attended a clinic or by mail.

Findings

We randomised 3,553 women: 1,574 to CLINIC, 1,467 to HOME, and 512 to USUAL. Participation was highest in HOME (14.6% among Māori, 8.8% among Pacific, and 18.5% among Asian) with CLINIC (7.0%, 5.3% and 6.9%, respectively) and USUAL (2.0%, 1.7% and 4.5%, respectively) being lower. In fully adjusted models, participation was statistically significantly more likely in HOME than USUAL: Māori OR=9.7, (95%CI 3.0-31.5); Pacific OR=6.0 (1.8-19.5); and Asian OR=5.1 (2.4-10.9). There were no adverse outcomes reported. After three months, 2,780 non-responding women were invited to participate in a non-randomised, opportunistic, follow-on substudy. After 6 months,192 (6.9%) additional women had taken a self-sample.

Interpretation

Using recruitment methods that mimic usual practice, we provide critical evidence that self-sampling increases screening among the groups of women (never and under-screened) who experience the most barriers in Aotearoa New Zealand, although the absolute level of participation through this population approach was modest. Follow-up for most women was routine but a small proportion required intensive support.

Trial registration

ANZCTR Identifier: ACTRN12618000367246 (date registered 12/3/2018) https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371741&isReview=true; UTN: U1111-1189-0531

Funding

Health Research Council of New Zealand (HRC 16/405)

Protocol

http://publichealth.massey.ac.nz/assets/Uploads/Study-protocol-V2.1Self-sampling-for-HPV-screening-a-community-trial.pdf

Human Papillomavirus (HPV) Self-Sampling among Never-and Under-Screened Indigenous Māori, Pacific and Asian Women in Aotearoa New Zealand: A Feasibility Study

In Aotearoa, New Zealand, the majority of cervical cancer cases occur in women who have never been screened or are under-screened. Wāhine Māori, Pacific and Asian women have the lowest rate of cervical screening. Self-sampling for human papillomavirus (HPV-SS) has been shown to increase participation in cervical cancer screening. A whole-of-system approach, driven by evidence in the most effective delivery of HPV-SS, is required to mitigate further widening of the avoidable gap in cervical screening access and outcomes between groups of women in Aotearoa. This single-arm feasibility and acceptability study of HPV self-sampling invited never- and under-screened (≥5 years overdue) 30–69-year-old women from general practices in Auckland, Aotearoa. Eligible women were identified by data matching between the National Cervical Programme (NCSP) Register and practice data. Focus groups were additionally held with eligible wāhine Māori, Asian and Pacific women to co-design new patient information materials. Questionnaires on HPV knowledge and post-test experience were offered to women. Our follow-up protocols included shared decision-making principles, and we committed to follow-up ≥90% of women who tested positive for HPV. Data matching identified 366 eligible never- and under-screened wāhine Māori, Pacific and Asian women in participating practices. We were only able to contact 114 women, and 17, during the discussion, were found to be ineligible. Identifying and contacting women overdue for a cervical screen was resource-intensive, with a high rate of un-contactability despite multiple attempts. We found the best uptake of self-sampling was at focus groups. Of the total 84 HPV-SS tests, there were five positive results (6%), including one participant with HPV18 who was found to have a cervical Adenocarcinoma at colposcopy. In our feasibility study, self-sampling was acceptable and effective at detecting HPV and preventing cervical cancer in under-screened urban wāhine Māori, Pacific and Asian women in Aotearoa. This is the first report of cervical Adenocarcinoma (Grade 1B) as a result of an HPV-18 positive self-sample in Aotearoa. We co-designed new patient information materials taking a health literacy and ethnicity-specific approach. This work provides policy-relevant information to the NCSP on the resources required to implement an effective HPV self-sampling programme to improve equity in national cervical cancer screening.

A survey of knowledge, attitudes and awareness of the human papillomavirus among healthcare professionals across the UK

BACKGROUND

Human papillomavirus (HPV) is a common sexually transmitted infection implicated in 5% of cancers worldwide including most cervical cancer cases. In the UK, the HPV vaccine has been offered routinely to girls aged 11-13 since 2008 while cervical screening is offered to women aged 25-64. HPV testing will soon replace cytology as the primary screening method. This research evaluates what healthcare professionals (HCPs) across the UK know about HPV.

METHODS

A total of 643 UK-based HCPs from primary and secondary care took part in an anonymous cross-sectional survey between March and April 2018. The survey measured general HPV knowledge; HPV triage and test of cure knowledge; HPV vaccine knowledge; attitudes to the HPV vaccine and self-perceived adequacy of knowledge.

RESULTS

Participants had a generally good understanding of HPV and the vaccination but there were gaps in detailed knowledge of the National Health Service HPV testing processes. There were some gaps in knowledge about the health sequelae of HPV for males. Years since HPV training was associated with triage and test of cure and vaccine knowledge scores. Furthermore, nurses and doctors in colposcopy clinics had much greater odds of having higher knowledge across all domains than other roles. In total, 76.2% of participants felt adequately informed about HPV and 35.6% made suggestions for improvements in training, many of which requested additional frequency and topics.

CONCLUSION

Our results suggest that additional training is needed to ensure HCPs are equipped to deal with the changing landscape of HPV screening and vaccination in the UK.

Comparison of two invitation-based methods for human papillomavirus (HPV) self-sampling with usual care among un- and under-screened Māori, Pacific and Asian women: study protocol for a randomised controlled community trial to examine the effect of self-sampling on participation in cervical-cancer screening

Background

Māori, Pacific and Asian women in New Zealand have lower cervical-cancer screening rates than European women, and there are persistent inequities in cervical cancer outcomes for Māori and Pacific women. Innovative ways to address access barriers are required. New Zealand is transitioning to screening with human papillomavirus (HPV) DNA testing, which could allow women themselves, rather than a clinician, to take the sample. Internationally, self-sampling has been found to increase screening participation rates. The aim of this open-label community-based randomised controlled trial is to investigate whether self-sampling increases screening participation among un- and under-screened Māori, Pacific and Asian women in New Zealand.

Methods/design

We aim to invite at least 3550 un- or under-screened (≥5 years overdue) Māori, Pacific and Asian women (1050, 1250, 1250 respectively), aged 30–69 years, for screening. The three study arms are: usual care in which women are invited to attend a clinic for a standard clinician-collected cytology test; clinic-based self-sampling in which women are invited to take a self-sample at their usual general practice; and mail-out self-sampling in which women are mailed a kit and invited to take a self-sample at home. Women will be randomised 3:3:1 to the clinic and mail-out self-sampling groups, and usual care. There is also a nested sub-study in which non-responding women in all allocation groups, when they subsequently present to the clinic for other reasons, are offered clinic or home-kit self-sampling. The primary outcome will be the proportion of women who participate (by taking a self-sample or cytology test).

Discussion

This trial is the first to evaluate the effectiveness of mailed self-sampling in New Zealand and will be one of the first internationally to evaluate the effectiveness of opportunistic in-clinic invitations for self-sampling. The trial will provide robust evidence on the impact on participation proportions from different invitation approaches for HPV self-sampling in New Zealand un- and under-screened Māori, Pacific and Asian women.

Trial registration

ANZCTR Identifier: ACTRN12618000367246 (date registered 12/3/2018) https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371741&isReview=true; UTN: U1111–1189-0531.

Acceptability of human papillomavirus self-sampling for cervical-cancer screening in under-screened Māori and Pasifika women: a pilot study

AIM

To assess whether self-sampling for cervical-cancer screening is acceptable to New Zealand women.

METHODS

Māori, Pacific and Asian un- or under-screened women aged 30-69 years were asked to: 1) examine three self-sampling devices; 2) complete a questionnaire on demographics and experiences with the devices; and 3) take a self-sample. Samples were tested 'off-label' using the cobas® 4800 human papillomavirus (HPV) test (Roche Diagnostics NZ).

RESULTS

Thirty-one Pacific, 12 Māori, nine Asian and four women of other ethnicities participated (mean age, 39.5 years). Before trying any devices, 78% indicated a preference to self-sample, compared to 22% who preferred a physician-collected sample (PCS). After trying a device (HerSwab™, 91%; Delphi Screener™, 14%; cobas Swab, 13%; 12.5% used >1 device), fewer women (66%) preferred to self-sample next time, fewer (16%) preferred a PCS, while 18% expressed no preference. One of 32 samples with valid results (35 were tested) was positive for HPV 'other' oncogenic types.

CONCLUSIONS

This was the first New Zealand study to invite women, including Māori women, to take a self-sample for cervical-cancer screening. The pilot study suggests that un- and under-screened women generally find self-sampling acceptable and all sample types are suitable for use with the cobas HPV test.

Knowledge, attitudes and awareness of the human papillomavirus among health professionals in New Zealand

Background

Human papillomavirus (HPV) is a common sexually transmitted infection that is implicated in 99.7% of cervical cancers and several other cancers that affect both men and women. Despite the role that HPV plays in an estimated 5% of all cancers and the evolving role of HPV vaccination and testing in protecting the public against these cancers, preliminary research in New Zealand health professionals suggest knowledge about HPV may not be sufficient.

Methods

A total of 230 practice nurses, smear takers and other clinical and laboratory staff who attended a range of training events completed a cross-sectional survey between April 2016 and July 2017. The survey explored four broad areas: demographics and level of experience, HPV knowledge (general HPV knowledge, HPV triage and test of cure (TOC) knowledge and HPV vaccine knowledge), attitudes towards the HPV vaccine and self-perceived adequacy of HPV knowledge.

Results

The mean score on the general HPV knowledge questions was 13.2 out of 15, with only 25.2% of respondents scoring 100%. In response to an additional question, 12.7% thought (or were unsure) that HPV causes HIV/AIDS. The mean score on the HPV Triage and TOC knowledge questions was 7.4 out of 10, with only 9.1% scoring 100%. The mean score on the HPV vaccine knowledge questions was 6.0 out of 7 and 44.3% scored 100%. Only 63.7% of respondents agreed or strongly agreed that they were adequately informed about HPV, although 73.3% agreed or strongly agreed that they could confidently answer HPV-related questions asked by patients. Multivariate analyses revealed that knowledge in each domain predicted confidence in responding to patient questions. Furthermore, the number of years since training predicted both HPV knowledge and Triage and TOC knowledge.

Discussion

Although overall level of knowledge was adequate, there were significant gaps in knowledge, particularly about the role of HPV testing in the New Zealand National Cervical Screening Programme. More education is required to ensure that misinformation and stigma do not inadvertently result from interactions between health professionals and the public.

Healthcare-seeking behaviour of people with sexually transmitted infection symptoms attending a Sexual Health Clinic in New Zealand

AIMS

Untreated sexually transmitted infections (STIs) can lead to serious health complications and may be transmitted to uninfected individuals. Therefore, the early detection and subsequent management of STIs is crucial to control efforts. Time to presentation for STI symptoms and risk of transmission in this period has not been assessed in New Zealand to date.

METHODS

All new clients presenting to an urban sexual health clinic (SHC) were invited to complete a questionnaire, which included demographic information, sexual health history, and details about the clinic visit.

RESULTS

Of 331 people approached, 243 (73.4%) agreed to complete the questionnaire. Four incomplete questionnaires were excluded, leaving 239 participants (47.3% female and 52.7% male, 43.8% under the age of 25). The most common reason for seeking healthcare was experiencing symptoms (39.4%) and 41.7% of people with symptoms waited more than seven days to seek healthcare. Around a third (30.6%) of people with symptoms had sex after they first thought they may need to seek healthcare. Infrequent condom use was reported more often by people who had sex with existing partners (84.6%) than by people who had sex with new partners (10.0%).

CONCLUSIONS

This is the first study to quantify healthcare-seeking behaviour for STI in New Zealand. Delayed healthcare-seeking (defined as waiting more than seven days) was common and almost a third of people reported engaging in sex while symptomatic. Enabling prompt healthcare-seeking is crucial to minimise transmission risk. Structural barriers such as the financial cost of STI tests must be removed and education around symptom recognition and healthcare system navigation should be provided.

Barriers to sexually transmitted infection testing in New Zealand: a qualitative study

OBJECTIVE

To investigate the barriers that prevent or delay people seeking a sexually transmitted infection (STI) test.

METHODS

Qualitative in-depth interviews were conducted with 24 university students, who are a group prone to behaviours putting them at risk of STIs, to understand the factors that had prevented or delayed them from going for an STI test in the past. Resulting data were thematically analysed employing a qualitative content analysis method, and a final set of themes identified.

RESULTS

There were three main types of barrier to STI testing. These were: personal (underestimating risk, perceiving STIs as not serious, fear of invasive procedure, self-consciousness in genital examination and being too busy); structural (financial cost of test and clinician attributes and attitude); and social (concern of being stigmatised). Conclusions and implications for public health: These data will help health providers and policy-makers provide services that minimise barriers and develop effective strategies for improving STI testing rates. The results of this study suggest a holistic approach to encouraging testing is required, which includes addressing personal beliefs, working with healthcare providers to minimise structural barriers and developing initiatives to change social views about STIs.

Using iron studies to predict HFE mutations in New Zealand: implications for laboratory testing

BACKGROUND

The diagnosis of hereditary haemochromatosis (HH) is not straightforward because symptoms are often absent or non-specific. Biochemical markers of iron-overloading may be affected by other conditions.

AIM

To measure the correlation between iron studies and HFE genotype to inform evidence-based recommendations for laboratory testing in New Zealand.

METHODS

Results from 2388 patients genotyped for C282Y, H63D and S65C in Wellington, New Zealand from 2007 to 2013 were compared with their biochemical phenotype as quantified by serum ferritin (SF), transferrin saturation (TS), serum iron (SI) and serum transferrin (ST). The predictive power of these markers was evaluated by receiver operator characteristic (ROC) curve analysis, and if a statistically significant association for a variable was seen, sensitivity, specificity and predictive values were calculated.

RESULTS

Test ordering patterns showed that 62% of HFE genotyping tests were ordered because of an elevated SF alone and only 11% of these had a C-reactive protein test to rule out an acute phase reaction. The association between SF and significant HFE genotypes SF was low. However, TS values ≥45% predicted HH mutations with the highest sensitivity and specificity. A SF of >1000 µg/L was found in one at-risk patient (C282Y homozygote) who had a TS <45%.

CONCLUSION

Our analysis highlights the need for clear guidelines for investigation of hyperferritinaemia and HH in New Zealand. Using our findings, we developed an evidence-based laboratory testing algorithm based on a TS ≥45%, a SF ≥1000 µg/L and/or a family history of HH which identified all C282Y homozygotes in this study.

Pre-vaccination type-specific HPV prevalence in confirmed cervical high grade lesions in the Māori and non-Māori populations in New Zealand

Background

New Zealand initiated HPV vaccination in 2008, and has attained 3-dose coverage of ~50 % in 12–13 year old girls. Due to the success of program initiatives in Māori girls, higher coverage rates of ~60 % have been achieved in this group. We have previously reported a benchmark overall pre-vaccination prevalence of oncogenic HPV infection in high grade cervical lesions in New Zealand. The current extended analysis provides separate pre-vaccination benchmark prevalence for Māori and non-Māori women.

Methods

The National Cervical Screening Programme Register (NCSP-R) was used to identify any woman aged 20–69 years of age with an index high grade cytology report from 2009–2011. Extended recruitment was performed until 2012 in clinics with a high proportion of Māori women. Ethnicity status was based on self-reported information by participating women through phone contact supplemented by recordings on the study questionnaire (the NCSP-R was not used to extract ethnicity status). A total of 730 women consented to participate and had a valid HPV test result; 418 of these had histologically-confirmed cervical intraepithelial neoplasia (CIN) 2/3 lesions (149 Māori, 269 non-Māori). The prevalence of any cervical oncogenic HPV infection, HPV16, and HPV18 was calculated in women with CIN2/3.

Results

In confirmed CIN2/3, the prevalence of any oncogenic HPV, HPV16 and HPV18 was 96 % (95 % CI:91–99 %), 54 % (95 % CI:46–63 %), 11 % (95 % CI:7–18 %) in Māori and 96 % (95 % CI:93–98 %), 54 % (95 % CI:48–60 %), 11 % (95 % CI:7–15 %) in non-Māori women, respectively. Age-specific patterns of infection for HPV16/18 in confirmed CIN2/3 differed between the two groups (P_interaction = 0.02), with a lower prevalence in younger vs. older Māori women (57 % in 20–29 years vs 75 % in 40–69 years) but a higher prevalence in younger vs. older non-Māori women (70 % in 20–29 years vs 49 % in 40–69 years); the difference in the age-specific patterns of infection for HPV16/18 was not significant either when considering confirmed CIN2 alone (p = 0.09) or CIN3 alone (p = 0.22).

Conclusions

The overall prevalence of vaccine-included types in CIN2/3 was similar in Māori and non-Māori women, implying that the long-term effects of vaccination will be similar in the two groups.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-1034-5) contains supplementary material, which is available to authorized users.

Lymphogranuloma venereum in men who have sex with men: evidence of local transmission in New Zealand

Lymphogranuloma venereum (LGV) is a sexually transmitted infection caused by Chlamydia trachomatis. Five laboratory confirmed cases of LGV were detected in MSM (men who have sex with men) in the upper North Island; four in Auckland between September and December 2013 and a fifth case was detected in Waikato in June 2014. The absence of a recent travel history for four cases supports the likelihood of local transmission of this uncommon infection.

Direct detection of markers associated with Neisseria gonorrhoeae antimicrobial resistance in New Zealand using residual DNA from the Cobas 4800 CT/NG NAAT assay

OBJECTIVES

To use nucleic acid amplification techniques (NAAT) for detection of markers associated with gonococcal antimicrobial resistance (AMR) in non-cultured clinical samples to enhance surveillance of Neisseria gonorrhoeae AMR in New Zealand.

METHODS

A total of 198 clinical samples from patients living in two cities, Wellington and Auckland and the more rural region of Gisborne, New Zealand, which were positive for N. gonorrhoeae by the Cobas 4800 were tested for three markers that predict reduced susceptibility or resistance to three antibiotics. Residual DNA extracts from the Cobas 4800 NG/CT test were tested for a single-nucleotide polymorphism in the gyrA gene at codon 91 associated with quinolone resistance; a sequence on the plasmid in penicillinase-producing N. gonorrhoeae (PPNG) which confers resistance to penicillin and the mosaic penA sequence associated with reduced susceptibility to extended-spectrum cephalosporins in N. gonorrhoeae.

RESULTS

A total of 186/198 (94%) of the samples provided a valid result on gyrA genotyping, confirming the utility of N. gonorrhoeae DNA extracted by the Roche Cobas 4800 CT/NG test for subsequent detection of AMR markers. The NAAT results for Wellington, Auckland and Gisborne, respectively, showed that 77%, 33% and 32% of samples had the marker associated with quinolone resistance, while 4%, 15% and 0% were positive for the PPNG plasmid marker, and 9%, 5% and 0% samples were positive for mosaic penA sequence.

CONCLUSIONS

The use of residual clinical DNA samples from the Cobas 4800 CT/NG test proved an efficient and effective method for performing AMR genotyping. These data also show for the first time the presence of gonococci with a mosaic penA sequence in New Zealand. Overall, the results further highlight the potential of molecular methods to aid N. gonorrhoeae AMR surveillance, particularly for regions where gonococcal culture is no longer performed.

Comparison of the cobas 4800 CT/NG test with culture for detecting Neisseria gonorrhoeae in genital and nongenital specimens in a low-prevalence population in New Zealand

To assess the clinical utility of replacing microbial culture for Neisseria gonorrhoeae with a nucleic acid amplification test (NAAT), we compared N. gonorrhoeae culture with the cobas 4800 CT/NG test for 18,247 urogenital and 666 nongenital samples. For urogenital specimens, the sensitivity, specificity, and positive and negative predictive values of the cobas N. gonorrhoeae PCR were 98.7%, 100%, 95.6%, and 100%, respectively, and for nongenital specimens, the values were 100%, 99.8%, 92.9%, and 100%, respectively. In our test population, 37% (10,185) of patients tested over the study period were screened for C. trachomatis by PCR but were not screened for gonorrhea by culture. Of these, 43 were N. gonorrhoeae positive by PCR and therefore went undiagnosed. The cobas 4800 CT/NG test diagnosed 33% (n = 30) more urogenital and 25% (n = 3) more rectal gonorrhea infections than culture and, based on the above performance indicators, does not require supplementary testing for urogenital or rectal specimens. The ability to test noninvasive specimens (such as urine and self-taken vulvovaginal swabs) for N. gonorrhoeae will enable more patients to be screened for infection, thus offering significant positive public health benefits.

Type-specific oncogenic human papillomavirus infection in high grade cervical disease in New Zealand

BACKGROUND

The national Human Papillomavirus (HPV) Immunisation Programme in New Zealand was introduced in 2008, and involves routine vaccination of girls 12-13 years with a catch-up for females aged up to 19 years. The aims of this study were to measure the pre-vaccination prevalence of oncogenic HPV infection in women aged 20-69 years who were participating in the New Zealand National Cervical Screening Programme (NZ-NCSP) and who were: (1) referred with high grade cytology with a subsequent histologically-confirmed high grade cervical intraepithelial neoplasia (CIN2/3) or adenocarcinoma in situ (AIS); or (2) were in the wider group of women who had a cytological prediction of high grade squamous disease or glandular abnormality (ASC-H/ HSIL+/AGC/AIS).

METHODS

Women aged 20-69 years appearing on the NZ-NCSP register between August 2009-February 2011 with a cytology record of ASC-H/HSIL+/AGC/AIS were invited to participate in the study. Liquid-based cytology specimens were tested for 37 HPV types using Linear Array genotyping. The prevalence of type-specific HPV infection was reported within women with histologically-confirmed CIN 2/3 and within the wider group with ASC-H/HSIL+/AGC/AIS cytology. Age-specific trends for the relative proportion of HPV 16/18 vs. other oncogenic types in CIN2/3 were assessed.

RESULTS

A total of 594 women with ASC-H/HSIL+/AGC/AIS cytology and a valid HPV test were recruited; of these 356 (60%) had confirmed CIN2/3 and 6 (1%) had confirmed AIS or glandular dysplasia. Positivity rates for any oncogenic HPV infection and for HPV16 and/or 18 within confirmed CIN2/3-AIS were 95% (95%CI: 92-97%) and 60% (54-65%) respectively; in all women with ASC-H/HSIL+/AGC/AIS cytology it was 87% (84-89%) and 53% (49-57%), respectively. The most common reported HPV types in women with CIN 2/3 were 16 (51%), 52 (19%), 31 (17%), 33 (13%) and 18 (12%). A trend for higher rates of HPV 16/18 infection compared to other oncogenic types was observed in younger women (p=0.0006).

CONCLUSIONS

The prevalence of HPV 16/18 in confirmed high grade disease in New Zealand is comparable to that observed in Australia and European countries. Test positivity rates for type 52 appear higher than in comparable studies in other developed countries. A greater proportion of high grade lesions in younger women appear to be associated with HPV 16/18 infection.

Poor uptake of self-sample collection kits for Chlamydia testing outside primary care

OBJECTIVES

New strategies are needed to reach at-risk populations for Chlamydia screening.

METHOD

Self-sample collection kits containing instructions and all items required for testing were developed and piloted in a three-month trial in primary care. Practice staff offered kits to young people receiving opportunistic Chlamydia screening to pass on to their 'social contacts.'

RESULTS

The 'pass it on' approach failed to reach adequate numbers of youth for testing: of 67 kits distributed, three specimens were sent to the laboratory (4.5%).

CONCLUSIONS

The method of kit distribution trialled here was not successful in reaching at-risk youth for testing outside the primary care setting.

IMPLICATIONS

Use of self-sample collection for chlamydia testing outside healthcare settings is likely to be important for increased access to testing. The importance of chlamydia testing needs to be widely promoted and methods for kit distribution to reach at-risk youth identified.

Increasing the uptake of opportunistic chlamydia screening: a pilot study in general practice

INTRODUCTION

Genitourinary Chlamydia trachomatis infection is common and associated with considerable personal and public health cost. Effective detection strategies are needed.

AIM

To assess feasibility of an opportunistic incentivised chlamydia screening programme in general practice over six months.

METHODS

This study was designed as a pilot for a randomised controlled trial in primary care. Three general practices were randomly allocated to intervention (two practices) and control groups. The intervention involved practice education, self-sample collection and practice incentives (funding and feedback) for a three-month 'active' intervention period. Feedback and education was discontinued during the second three-month period. Practice-specific nurse- or doctor-led strategies were developed for identifying, testing, treating and recalling male and female patients aged 16-24 years. The main outcome measure was the difference between the practices' chlamydia screening rates over the six months following introduction of the intervention, controlling for baseline rates from the previous year.

RESULTS

Chlamydia testing rates during the year prior to the intervention ranged from 2.9% to 7.0% of practice attendances by 16-24-year-olds. The intervention practices had higher rates of screening compared with the control practice (p<0.001) at three months, but both practices reverted to pre-intervention rates by six months. The nurse-led screening strategy was more effective (35% declining to 5.5% over six months) than the doctor-led strategy (15% declining to 1.6% over six months) (p=0.04).

DISCUSSION

Incentivised opportunistic chlamydia screening of 16-24-year-old patients attending their general practitioner with a programme involving practice education, feedback and self-sample collection can increase screening rates.

Increasing the uptake of opportunistic chlamydia screening: a pilot study in general practice

INTRODUCTION: Genitourinary Chlamydia trachomatis infection is common and associated with considerable personal and public health cost. Effective detection strategies are needed. Aim: To assess feasibility of an opportunistic incentivised chlamydia screening programme in general practice over six months. METHODS: This study was designed as a pilot for a randomised controlled trial in primary care. Three general practices were randomly allocated to intervention (two practices) and control groups. The intervention involved practice education, self-sample collection and practice incentives (funding and feedback) for a three-month ‘active’ intervention period. Feedback and education was discontinued during the second three-month period. Practice-specific nurse- or doctor-led strategies were developed for identifying, testing, treating and recalling male and female patients aged 16–24 years. The main outcome measure was the difference between the practices’ chlamydia screening rates over the six months following introduction of the intervention, controlling for baseline rates from the previous year. RESULTS: Chlamydia testing rates during the year prior to the intervention ranged from 2.9% to 7.0% of practice attendances by 16–24-year-olds. The intervention practices had higher rates of screening compared with the control practice (p<0.001) at three months, but both practices reverted to pre-intervention rates by six months. The nurse-led screening strategy was more effective (35% declining to 5.5% over six months) than the doctor-led strategy (15% declining to 1.6% over six months) (p=0.04). DISCUSSION: Incentivised opportunistic chlamydia screening of 16–24-year-old patients attending their general practitioner with a programme involving practice education, feedback and self-sample collection can increase screening rates. KEYWORDS: Primary health care; chlamydia; mass screening; randomized controlled trial

High prevalence of Mycoplasma genitalium in women presenting for termination of pregnancy

BACKGROUND

Sexually transmitted infections increase the risk of postoperative complications after termination of pregnancy. Mycoplasma genitalium is sexually transmitted and associated with adverse clinical outcomes in both males and females. The prevalence of M. genitalium is not yet known in New Zealand women or among women presenting for termination of pregnancy.

STUDY DESIGN

This study involved prospective data collection at a public hospital clinic for termination of pregnancy. Participants were 300 under 25-year-old women presenting for termination of pregnancy. The study aimed to describe the prevalence of M. genitalium in women presenting for termination of pregnancy using real-time polymerase chain reaction (PCR) testing. Women provided a vaginal swab that was sent to the laboratory for PCR detection of M. genitalium. Data collection included age, ethnicity, previous pregnancy history, gestational age, procedure type, results of STI tests performed on referral for a termination of pregnancy (C. trachomatis, N. gonorrhoeae, T. vaginalis and bacterial vaginosis) and use of antimicrobials in the past 3 weeks.

RESULTS

M. genitalium was detected in 26 women (8.7%). Rates of infection did not differ significantly by patient characteristics such as age, ethnicity or previous pregnancies. Infection with M. genitalium was not significantly associated with bacterial vaginosis or C. trachomatis infection.

CONCLUSIONS

To our knowledge, this is the first prospective study designed to determine the prevalence of M. genitalium in women presenting for termination of pregnancy. Given the high proportion of cases observed in this study, further research is needed to determine the clinical significance of M. genitalium in postoperative termination of pregnancy complications.

Case report: lymphogranuloma venereum in New Zealand

We report New Zealand’s first two cases of anorectal lymphogranuloma venereum (LGV). Although infection in these cases was probably acquired off-shore, the cases are reported to demonstrate the need to be vigilant to the possibility of LGV when men who have sex with men present with symptoms of proctitis. Investigation and management of LGV is discussed.

Self-obtained vaginal swabs for PCR chlamydia testing: A practical alternative

This study shows that given a choice, New Zealand women at high risk for sexually transmitted infections (STI) opt to provide a self-taken vaginal swab over a clinician-taken sample for STI testing. Self-obtained vaginal swabs have previously been shown to have equal sensitivity and specificity to endocervical swabs and greater sensitivity than urine for the detection of Chlamydia trachomatis by polymerase chain reaction (PCR). We suggest that self-obtained vaginal swabs should be a readily available option offered to women for chlamydia testing by PCR in New Zealand.

Chlamydia screening in Wellington Family Planning Association (FPA) clinics: a demonstration project

AIMS

To demonstrate that enhanced screening for Chlamydia over and above the usual opportunistic screening in family planning (FPA) clinics is feasible, practical, and acceptable.

METHODS

Over a 6-month period from November 2004 to May 2005, all under-25-year-olds attending three Wellington FPA clinics in New Zealand were offered Chlamydia urine testing. Staff interviews before and after the study were carried out to assess the impact of enhanced screening on clinic routines. Interviews were conducted with 50 clients to assess the acceptability to young persons. Additional questions were asked of 22 Chlamydia-positive clients to ascertain the acceptability of the procedures for follow up.

RESULTS

From a total of 4674 participants, a valid urine test was carried out on 2533 (54%). The most common reason for exclusion was having passed urine in the last hour. Positive tests were detected in 212 (8%). A positive result was more likely in those with a history of partner change or in Māori and Pacific ethnic groups; it was least likely in those who always used condoms. For the staff, time constraints were the most important barrier to screening. The procedures were acceptable to clients.

CONCLUSIONS

We demonstrated that improvements in Chlamydia screening are feasible, practical and acceptable to clients

Regulation of T-cadherin by hormones, glucocorticoid and EGF

The cell adhesion molecule T-cadherin is an unusual member of the cadherin superfamily that lacks a cytoplasmic domain, binding instead to the cell membrane via a glycophosphatidyl inositol anchor. T-cadherin is a receptor for hexameric Acrp30/adiponectin and binds low-density lipoproteins in endothelial cells. T-cadherin is expressed widely in the brain and cardiovascular system, but expression is absent or decreased in several cancers. Little is known about the mechanisms and factors that control T-cadherin expression. Therefore, to investigate regulation of T-cadherin expression, we analysed 3.9 kb of the 5'-flanking region of human T-cadherin for promoter activity and identified potential transcription factor binding sites. Western blotting and a quantitative real-time RT-PCR assay developed for T-cadherin showed that estradiol, progesterone, EGF, dexamethasone and factors in serum were involved in transcriptional and post-transcriptional regulation of T-cadherin in human osteosarcoma cells; the effects observed were opposite to those described for T-cadherin's ligand, adiponectin. The data suggest that T-cadherin is regulated in a complex manner indicative of a role in hormone and drug-induced changes in bone morphology and pathology.

Prevalence and risk factors for Chlamydia trachomatis infection in female New Zealand university students

AIMS

To measure the prevalence of urogenital Chlamydia trachomatis infection in a sample of sexually active female university students, to identify risk factors associated with infection, and to measure the uptake of screening.

METHODS

Female students aged 18-25 years, presenting to a university student health service from March to October 2003, were invited to participate. Information on demographic details and sexual behaviour was collected with a self-completed questionnaire. The students were tested for Chlamydia infection using the Roche Amplicor CT/NG PCR test of first void urine specimens.

RESULTS

Chlamydia prevalence was 2.7% (19/715). Infection was associated with previous sexually transmitted infection (STI), non-European ethnicity, and irregular use of condoms. Most participants were not using condoms regularly despite the risk of STI. Screening was technically straightforward and the participation rate was 59.9% (718/1199).

CONCLUSIONS

New Zealand needs to develop and implement an adequately resourced and evidence-based Chlamydia control strategy. This strategy should contain national guidelines on screening in a range of settings, including universities, as well as strategies for primary prevention of Chlamydia and other STI. Clinicians treating university-aged students should consider opportunistic Chlamydia screening for all of those who are sexually active. Further research, preferably in conjunction with intervention studies, is essential to assess the prevalence of Chlamydia in other populations.

Rates of Chlamydia trachomatis testing and chlamydial infection in pregnant women

AIMS

To determine the rate of Chlamydia trachomatis testing and chlamydial infection in pregnancy (by auditing a community medical laboratory database).

METHODS

Data for women registered with a maternity care provider between 1999 and 2002 were matched with a community medical laboratory database for patients who met one of three criteria: tested for C. trachomatis, or had a first or second antenatal blood screen at that laboratory. The rate of C. trachomatis testing and of chlamydial infection was then calculated in this sample.

RESULTS

The overall rate of C. trachomatis testing for 6614 matched deliveries was 37.5%, with 4.8% of those tests positive for chlamydial infection. The rate of testing differed significantly between age-bands (p<0.0001), and by ethnicity (p<0.0001). The rate of infection showed a significant effect of age (p<0.0001) and ethnicity (p<0.0001). Maori and Pacific women, and those under the age of 25 years, had the highest rates--both of testing and of C. trachomatis infection.

CONCLUSIONS

There is a high rate of maternal C. trachomatis in under 25-year-olds, and in Maori and Pacific women, together with incomplete testing for the infection in pregnancy. This highlights the need to instigate routine testing for C. trachomatis in pregnancy--to reduce the significant, yet preventable, morbidity associated with chlamydia in both the mother and the neonate.