Limiting worker exposure to highly pathogenic avian influenza a (H5N1): a repeat survey at a rendering plant processing infected poultry carcasses in the UK.

BACKGROUND: Current occupational and public health guidance does not distinguish between rendering plant workers and cullers/poultry workers in terms of infection risk in their respective roles during highly pathogenic avian influenza poultry outbreaks. We describe an operational approach to human health risk assessment decision making at a large rendering plant processing poultry carcasses stemming from two separate highly pathogenic avian influenza A (H5N1) outbreaks in England during 2007. METHODS: During the first incident a uniform approach assigned equal exposure risk to all rendering workers in or near the production line. A task based exposure assessment approach was adopted during the second incident based on a hierarchy of occupational activities and potential for infection exposure. Workers assessed as being at risk of infection were offered personal protective equipment; pre-exposure antiviral prophylaxis; seasonal influenza immunisation; hygiene advice; and health monitoring. A repeat survey design was employed to compare the two risk assessment approaches, with allocation of antiviral prophylaxis as the main outcome variable. RESULTS: Task based exposure assessment during the second incident reduced the number of workers assessed at risk of infection from 72 to 55 (24% reduction) when compared to the first incident. No cases of influenza like illness were reported in workers during both incidents. CONCLUSIONS: Task based exposure assessment informs a proportionate public health response in rendering plant workers during highly pathogenic avian influenza H5N1 outbreaks, and reduces reliance on extensive antiviral prophylaxis.

Many vaginal microbicide trial participants acknowledged they had misreported sensitive sexual behavior in face-to-face interviews.

OBJECTIVE: We investigated whether participants in a phase II randomized clinical trial of a candidate vaginal microbicide ever intentionally misled interviewers. STUDY DESIGN AND SETTING: We used audio computer-assisted self-interviews (ACASI) to ask the South African women (n=132) participating in the trial about the accuracy of self-reported data collected during face-to-face interviews. The trial protocol recommended that women use their assigned gel (active microbicide or placebo) with condoms during each vaginal sex act. RESULTS: Nearly four-fifths of participants (n=104, 79%) reported that they had misinformed trial interviewers at least once. Motivations included politeness (n=45, 34% of ACASI participants) to avoid criticism or seek praise (n=32, 24%), and embarrassment (n=24, 18%). Participants acknowledged misreporting eligibility characteristics to enroll (11%) and, during follow-up, exaggerating their enthusiasm for the study gel (13%), applicator (13%), and the effect of the gel on sexual pleasure (13%). In general, women who were untruthful had actually used the gel with condoms less and used the gel alone more than they had reported during the trial. Women overwhelmingly found the computer survey easy. CONCLUSION: Researchers cannot assume that participants always tell the truth about sensitive behaviors in face-to-face interviews. ACASI was efficient and acceptable in this population.

Partner notification.

INTRODUCTION: Many people diagnosed with a sexually transmitted disease (STD) do not have symptoms, and may not inform their past or current sexual partners of their diagnosis or routinely use condoms. Several strategies have been used to notify and treat partners of people diagnosed with an STD, but only a limited number of RCTs of their effectiveness have been undertaken. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of partner notification strategies in people with different STDs? What are the effects of interventions to improve effectiveness of patient referral in people with STDs? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2008 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 17 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review, we present information relating to the effectiveness and safety of the following interventions: contract referral; counselling (both alone and in combination with educational interventions) of index patients; educational interventions for the index patient; information for the index patient or partner; outreach assistance; patient referral; patient referral via different types of healthcare professional; patient-delivered partner therapy; patient-delivered home-sampling kits; provider referral; and reminders (any format) for the index patient.

Agreement between self- and clinician-collected specimen results for detection and typing of high-risk human papillomavirus in specimens from women in Gugulethu, South Africa.

We assessed the agreement in detection of high-risk human papillomavirus (HPV), as well as specific HPV types, between self- and clinician-obtained specimens for 450 women over 18 years of age attending a community health center in Gugulethu, South Africa. Both self-collected swabs and tampons had high agreement with clinician-obtained brushes when the Roche Reverse Line Blot Assay (RLBA) was used (for swabs, 86% concordance, with a kappa statistic [kappa] of 0.71; for tampons, 89% concordance, with kappa of 0.75). Agreement was lower, although still fair, with the Digene Hybrid Capture 2 test (HC2), with kappa higher for swabs than for tampons (for swabs, 81% concordance, with kappa of 0.61; for tampons, 82% concordance, with kappa of 0.55). Low-risk HPV types were nearly two times more common in self-collected specimens than in clinician-collected specimens tested by RLBA. All 15 women diagnosed with high-grade lesions by cytology tested positive for high-risk HPV with clinician-collected specimens tested by RLBA and HC2, while 11 out of 15 tested positive with self-collected specimens by HC2 and 5 out of 6 tested positive by RLBA. Self-collected specimens can provide valid specimens for HPV testing using nucleic acid amplification tests, although a few cytological abnormalities may be missed.

Partner notification.

INTRODUCTION: Many people diagnosed with sexually transmitted disease do not have symptoms, and may not inform their past or current sexual partners of their diagnosis, or routinely use condoms. Several strategies have been used to notify and treat partners of people diagnosed with sexually transmitted diseases, but only a limited number of RCTs of their effectiveness have been undertaken. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of different partner notification strategies in people with different sexually transmitted diseases? What can be done to improve the effectiveness of patient referral? We searched: Medline, Embase, The Cochrane Library and other important databases up to April 2006 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found seven systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: contract referral, educational videos, information pamphlets, outreach assistance, patient referral, patient referral via different types of healthcare professionals, provider referral, telephone reminders, and contact cards.

Two methods of self-sampling compared to clinician sampling to detect reproductive tract infections in Gugulethu, South Africa.

OBJECTIVES: To assess the validity, feasibility, and acceptability of 2 methods of self-sampling compared to clinician sampling during a speculum examination. GOAL: To improve screening for reproductive tract infections (RTIs) in resource-poor settings. STUDY DESIGN: In a public clinic in Cape Town, 450 women underwent a speculum examination and were randomized to self-sample with either a tampon or vaginal swabs. All specimens were tested for the same pathogens using the same diagnostic tests. RESULTS: Self-sampling resulted in satisfactory validity for N gonorrhoeae, C trachomatis, bacterial vaginosis, and Candida species (tampons and swabs) and high-risk human papillomavirus (swabs only) when tested with molecular tests or microscopy, but not for T vaginalis by culture. Self-sampling was feasible and acceptable, but some women preferred speculum examinations, which allow the clinician to view the vagina and cervix. CONCLUSIONS: Although self-sampling should not replace speculum examinations in all circumstances, it should be explored further as an RTI screening strategy.

Phase III microbicide trial methodology: opinions of experienced expanded safety trial participants in South Africa.

In preparation for effectiveness trials of candidate vaginal microbicides, scientists are debating trial design and implementation challenges, including choice of control arm(s), product-sharing across arms, and visit schedules. This study involved a survey of South African women participating in an expanded safety trial of the candidate microbicide Carraguard gel. The first 100 consenting women who attended the study clinics in Ga-Rankuwa and Gugulethu (total N = 200) were interviewed; all women had been using a study gel for at least 6 months at the time of the interview. The study found that many participants thought that including a condoms-only arm would result in increased product-sharing, male partner resistance to trial participation and decreased enrollment; no clear patterns emerged regarding the potential effect on condom use and cohort retention. The majority of women preferred a monthly visit schedule, would be willing to use a product for 2 years, and thought that their product use would not decrease over time. Thus flexibility in trial design and implementation strategies is needed until evidence-based decisions can be made. When including a condoms-only arm, extra efforts should be made to explain the importance of all study arms to potential participants and to measure adherence and product-sharing.

From people to places: focusing AIDS prevention efforts where it matters most.

OBJECTIVES: To develop and implement a method to identify and characterize places where people meet new sexual partners and to assess HIV prevention program coverage in those places. METHODS: In three townships (populations 60 000-100 000 each) and one business district (population < 20 000) in South Africa, interviewers asked over 250 informants per area to identify public sites where people meet new sexual partners. All reported sites were visited and mapped. A knowledgeable person onsite was interviewed about the site and its patrons. Individuals socializing at sites were interviewed about their sexual behavior. RESULTS: More than 200 sites in each township and 64 sites in the central business district were identified and visited. The male to female ratio among site patrons was approximately 2:1. In each area, men and women socializing at sites reported high rates of new sexual partner acquisition and low condom use. Almost half of the 3085 men and 1564 women interviewed while socializing reported having a new sexual partner in the last 4 weeks. A third reported meeting a new partner at the site of the interview. Commercial sex was rare in the townships but available at 31% of central business district sites. Fewer than 15% of township and only 20% of business district sites had condoms. CONCLUSION: The PLACE method successfully identified sites where people with high rates of new sexual partnerships can be reached for prevention programs. Sexual networks in these areas are extensive, diffuse, and characterized by high rates of new partnership formation and concurrency with little acknowledged commercial sex.

Improving care for patients with sexually transmitted infections in South Africa.

AIM: To assess the quality of integrated sexually transmitted infection (STI) services in primary health care. METHOD: A two-page questionnaire, in collaboration with district health service supervisors, was developed to assess the quality of care and health services for STIs in individual clinics. RESULTS: The data suggest that the quality-assessment instrument used has the potential to promote the improvement of STI care delivery at district and clinic levels. CONCLUSION: The quality-assessment instrument proved easy to use, can be adapted to local requirements and is appropriate for use in developing countries. The authors maintain that using this instrument in various district clinics could help supervisors identify the main impediments to the delivery of high quality services, and give them a platform from which to set priorities in training, infrastructure, equipment and supplies.

A systematic review of strategies for partner notification for sexually transmitted diseases, including HIV/AIDS.

This review compares the effects of various sexually transmitted disease (STD) partner-notification strategies. Using review methods endorsed by the Cochrane Collaboration, it updates previous reviews, and addresses some of their methodological limitations. It includes 11 randomized controlled trials (RCTs) comparing two or more strategies, including 8014 participants. Only two trials were conducted in developing countries, and only two trials were conducted among HIV-positive patients. The review found moderately strong evidence that: (1) provider referral alone, or the choice between patient and provider referral, when compared with patient referral among patients with HIV or any STD, increases the rate of partners presenting for medical evaluation; (2) contract referral, when compared with patient referral among patients with gonorrhoea, results in more partners presenting for medical evaluation; (3) verbal, nurse-given health education together with patient-centred counselling by lay workers, when compared with standard care among patients with any STD, results in small increases in the rate of partners treated. The review concludes that there is a need for evaluations of interventions combining provider training and patient education, for evaluations conducted in developing countries, and for the measurement of potential harmful effects.