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

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LGV in the UKnational surveillance of a
re-emerging disease

• Helen Ward1,2, Iona Martin1, Ian Simms1, Neil
  Macdonald1, Sarah Alexander1, Kevin Fenton1,3,
  Cathy Ison1.

• Health Protection Agency Centre for Infections,
  London, UK
• Department of Infectious Disease Epidemiology,
  Imperial College London, UK
• Centres for Disease Control, Atlanta, USA

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Background

• 2003 First case report of LGV in the
  Netherlands1
• 2004 Clusters reported from Netherlands,
  Belgium, Germany 2-3
• May 2004 ESSTI (European network for the
  Surveillance of STI) meeting collated reports of
  LGV
• 2005 Further reports from France, Spain, Sweden,
  Germany, USA, Canada 4-7

• Sex transm inf 200379(6)453-5
• Clin Inf Dis 200439(7)996-1003
• MMWR 200453(42)985-8
• Sex transm inf 200581(1)91-2

5. Emerg Infect Dis 20051103.04 6. Eurosurv
Weekly 200510(5) 7. CMAJ 200521172(13)1674-6.

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Characteristics of emerging LGV

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

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Background in the UK

• LGV rarely diagnosed in the UK pre-2004
• Sporadic imported cases of urogenital LGV
• Reported together with chancroid and Donavonosis

Routine aggregate reporting of STI from
genitourinary medicine clinics in the UK
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Establishing a surveillance system

• Diagnostic capacity
• Enhanced surveillance based on case reports
• Alert clinicians and microbiologists
• Alert community groups

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Internet information
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Referral of specimens for confirmation of LGV

• STBRL will accept
• rectal specimens from patients with proctitis or
• urethral swabs from patients with inguinal
  lymphadenopathy
• Urethral or rectal specimens from LGV contacts
• who have a confirmed positive CT result (using
  NAAT, or EIA)

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Testing algorithm
RT PCR for CT
Confirm presence of CT
neg
pos
Report issued
RT PCR LGV specific
Determine if LGV associated
LGV pos
Genotype retrospectively for L1, L2 or L3
Report issued
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Reporting
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UK LGV Surveillance form
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UK LGV Surveillance form
Available on www.hpa.org.uk/infections/topics_az/h
iv_and_sti/LGV/lgv.htm
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UK LGV Surveillance form
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Oct 04 to Mar 061334 samples received
101
35
327
982
655
216
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Map of 327 LGV cases
Country or region N ()
London 233 (71)
South East - Brighton 42 (13)
- Rest of region 5 (2)
North West 15 (5)
Scotland 11 (3)
South West 6 (2)
East of England 3 (1)
East Midlands 3 (1)
Wales 3 (1)
West Midlands 3 (1)
Yorks and Humberside 2 (1)
North East 1 (0)
Total 327
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Map of 327 LGV cases
Country or region N ()
London 233 (71)
South East - Brighton 42 (13)
- Rest of region 5 (2)
North West 15 (5)
Scotland 11 (3)
South West 6 (2)
East of England 3 (1)
East Midlands 3 (1)
Wales 3 (1)
West Midlands 3 (1)
Yorks and Humberside 2 (1)
North East 1 (0)
Total 327
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Map of 327 LGV cases
Country or region N ()
London 233 (71)
South East - Brighton 42 (13)
- Rest of region 5 (2)
North West 15 (5)
Scotland 11 (3)
South West 6 (2)
East of England 3 (1)
East Midlands 3 (1)
Wales 3 (1)
West Midlands 3 (1)
Yorks and Humberside 2 (1)
North East 1 (0)
Total 327
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Total samples and LGV, Oct 2004 to Feb 2006
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Epidemic curve for LGV by date of onset of
symptoms, 2003 to end 2005 (n277)
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Case reports

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

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Presentation

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

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Symptoms

• Proctitis 262 (93)
• Plus genital symptoms 34
• Genital symptoms alone 12 (4)
• Duration of symptoms
• 1 day to gt18 months (median 12 days)

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Presentation anorectal (n228)
N ()
Rectal discharge 179 (79)
Rectal pain 157 (69)
Rectal bleeding 133 (58)
Tenesmus 65 (29)
Constipation 56 (25)
3 or more local symptoms 116 (50.9)
Systemic symptoms 68 (30)
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Presentation - genital
Symptoms N12
Genital ulcer 5
Urethral discharge 2
Dysuria 1
Inguinal lymphadenopathy 6
Systemic symptoms 4
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Severity

• 16 cases had been investigated by
  gastroenterologists
• Hospital admission documented in five
• Several reports of misdiagnosis including Crohns
  and ulcerative colitis1
• 1. See BMJ 2006332(7533)99-100

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Co-infection

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

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Associations with HIV

• No difference in demographics or sexual meeting
  places
• Men with HIV
• more likely to have PCR positive HCV, p0.013
• More likely to report unprotected anal
  intercourse 77 vs 60, p0.031

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Sexual behaviour

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

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Sexual networks

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

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Meeting places

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

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Summary

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

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Underestimate of scale of infection

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

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Is it an outbreak?

• Evidence for
• geographic clustering
• links to Netherlands in early cases
• Anecdotal evidence from clinicians
• common social venues with linked sexual networks
• all L2

• Evidence against
• No baseline data
• Increase could be artefact of surveillance
• Poor prevalence data
• Same serovar existed in MSM in the USA in the
  1980s

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Has there been a shift in the epidemiology?

• Introduced into favourable networks?
• Sero-sorting and unsafe practices?
• Opportunistic infection?
• But likely to overestimate HIV link due to
  selection bias in diagnosis

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Response

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

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Awareness campaigns

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

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Information for gay men
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Implications for practice

• Public health
• Maintain awareness
• clinicians
• community organisations
• Outreach, press coverage
• Case finding
• Ongoing exercise
• ? Recommend widespread screening
• Maintain active surveillance

• Clinical
• Alert to possible LGV
• STI clinics
• HIV clinics
• Gastroenterology
• Primary care
• Increase CT testing in MSM
• Symptomatic
• Contacts
• routine?

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Recommendations

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

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Members of LGV Incident Group

• HPA Centre for Infections
• Sarika Desai
• Josephine Ruwende
• Alan Smith
• Maria Solomou
• Ucheoma Ugoji
• Terence Higgins Trust
• Will Nutland
• BASHH
• Sandy McMillan
• Pat Munday
• Society for Sexual Health Advisors
• Jamie Hardy

• National representatives
• Lesley Wallace (Scotland)
• Mary Cronin (Eire)
• Neil Irvine (Northern Ireland)
• Daniel Thomas (Wales)
• Local representatives
• Peter Trail (London)
• Helen Maguire (London)
• Patrick French (London)
• Stephen Gillespie (London)
• John White (London)
• Andy Winter (Glasgow)
• Gillian Dean (Brighton)