Chemsex - the 'ins and outs' of managing an outbreak: a local health protection team's response
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A local health protection team was notified in May 2014 of an STI outbreak among men who had sex with men involved in chemsex (sex under the influence of drugs) in London. The team coordinated the response, which included investigating transmission networks, heightened surveillance, targeted health promotion through dedicated clinics and outreach, and improving integration between sexual health and drug services. Challenges included obtaining accurate surveillance data while maintaining confidentiality and addressing ongoing risky behaviors like illicit drug use. Lessons showed a need for more tailored services and cross-sector collaboration to respond to changing behaviors.
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Chemsex - the 'ins and outs' of managing an outbreak: a local health protection team's response
- 1. Chemsex - The ‘ins and outs’ of managing an outbreak: A local Health Protection Team’s response Kemi Olufon, Health Protection Nurse Specialist Sofia Saeed, Health Protection Practitioner
- 2. Objectives Epidemiology of STIs • The National & London Picture • MSM & Sexual Health Incident Management • Outbreak Notification • Challenges • Lessons Learned 2 Chemsex - The ‘ins and outs’ of managing an outbreak: A local Health Protection Team’s response
- 3. Epidemiology of STIs Sofia Saeed – Health Protection Practitioner
- 4. National & London PHE sexual health teams 4 Chemsex - The ‘ins and outs’ of managing an outbreak: A local Health Protection Team’s response CIDSC CIDSC STI/HIV Head – Noel Gill NCSP – Kevin Dunbar SH Facilitators – Kate Folkard HIV – Valerie Delpech STI - Gwenda Hughes Indicators – Katy Sinka SRHAD – Cathy Lowndes HPV – Kate Soldan Health Promotion / HIV testing – Anthony Nardone London PHE Centre Jenifer Smith – SH lead Meroe Bleasdille – London SH facilitator Tania Misra – NECLHPT lead Mary Maimo – SWL HPT lead Rachel Heathcock- SELHPT lead Elsie Acheampong - NWLHPT lead Jayshree Dave – Micro lead Operations Rashmi Shukla – Chair of SH Board FES Paul Crook- FES SH lead Josh Forde – FES Victoria Information Officer PHE CKO Paul Brown –CKO SH lead Wendi Slater – SW KIT London London KIT PHE HWB Jane Anderson – PHE SH lead Owen Brigstock Barron – Programme Manager Alison Hadley/Kate Guthrie – Reproductive Health
- 5. 5 Chemsex - The ‘ins and outs’ of managing an outbreak: A local Health Protection Team’s response24 Public Health England: 2014 STI Slide Set Rates of new STI diagnoses by LAof residence: England, 2014 • Data from routine GUM service returns & chlamydia data from community services • Data type: residence data England London
- 6. 6 Chemsex - The ‘ins and outs’ of managing an outbreak: A local Health Protection Team’s response Source: Public Health England, GUMCAD and CTAD Map of new STI rates per 100,000 residents by upper tier local authority in London: 2014
- 7. MSM and sexual health • Compared to the rest of the United Kingdom (UK), London has a higher proportion of men who have sex with men (MSM) • Despite representing less than an estimated 2% of the London adult population (3.8% of the male population), MSM constituted 28% of all London residents diagnosed with a new sexually transmitted infection (STI) in sexual health clinics in 2014 • The number of MSM living with diagnosed HIV in London has increased by 68% over the past 10 years to 17,572 in 2014 • Over 63% of new diagnoses of HIV in London are among MSM • The numbers of new HIV diagnoses in London are increasing, with the 1,586 diagnosed in 2014 representing a 31% rise since 2005 • Evidence of a sustained increase in UK acquired Shigella flexneri in MSM in London. • LGV (lymphogranuloma venereum) diagnoses are made almost exclusively in MSM– previously rare form of Chlamydia 7 Chemsex - The ‘ins and outs’ of managing an outbreak: A local Health Protection Team’s response
- 8. 9 Chemsex - The ‘ins and outs’ of managing an outbreak: A local Health Protection Team’s response Number of STI diagnoses among MSM: England, 2005-2014 38 Public Health England: 2014 STI Slide Set • Data from routine GUM service returns; New HIV diagnoses sourced from HIV & AIDS New Diagnoses & Deaths Database • * First episode; ** Includes diagnoses of primary, secondary & early latent syphilis • Chlamydia data from 2012 onwards are not comparable to data from previous years (please see ‘Notes’ slide for more details) • Data type: service data 0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000 18,000 20,000 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Numberofdiagnoses Year Chlamydia Gonorrhoea HIV Syphilis***
- 9. Diagnoses of the five main STIs among men who have sex with men (MSM) in GUM clinics: London residents, 2010-2014 9 Chemsex - The ‘ins and outs’ of managing an outbreak: A local Health Protection Team’s response Source: Public Health England, GUMCAD . 732 2,049 2,588 10,871 2,545 6,460 516 732 1,018 1,395 0 2,000 4,000 6,000 8,000 10,000 12,000 2010 2011 2012 2013 2014 Numberofdiagnoses Syphilis Gonorrhoea Chlamydia Genital Herpes Genital Warts GUMCAD started in 2009. Reporting of sexual orientation is less likely to be complete for earlier years, so rises seen may be partly artefactual. Any increase in gonorrhoea diagnoses may be due to the increased use of highly sensitive nucleic acid amplification tests (NAATs) and additional screening of extra-genital sites in MSM. Any decrease in genital wart diagnoses may be due to a moderately protective effect of HPV-16/18 vaccination. Any increase in genital herpes diagnoses may be due to the use of more sensitive NAATs. Any increase or decrease may reflect changes in testing.
- 10. Incident Management Kemi Olufon – Health Protection Nurse Specialist
- 11. Chemsex “We lack robust and timely data on ‘Chemsex’, a term describing sex that occurs under the influence of drugs. However, there is evidence that Chemsex is associated with risky sexual behaviour and that MSM in London are more likely to use the common Chemsex drugs, such as crystal methamphetamine, GHB/GBL and mephedrone” HIV and STIs in men who have sex with men in London PHE Report September 2014 11 Chemsex - The ‘ins and outs’ of managing an outbreak: A local Health Protection Team’s response Why are drugs being used? Ability to boost self-confidence Remove insecurities Increased sexual desire though dependence on drugs to have sex is widely reported
- 12. 12 Chemsex - The ‘ins and outs’ of managing an outbreak: A local Health Protection Team’s response
- 13. Notification of outbreak May 2014 - Notified by Sexual Health Advisor from London Sexual Health Clinic of an STI outbreak - Initially informed of men living at or associated with same postal address. - Reports of drug use, adult film, fisting and sex parties - All newly infected with: HIV, Gonorrhoea, Syphilis, Chlamydia and Hep C, 13 Chemsex - The ‘ins and outs’ of managing an outbreak: A local Health Protection Team’s response
- 14. Management of local STI Outbreaks 14 Chemsex - The ‘ins and outs’ of managing an outbreak: A local Health Protection Team’s response
- 15. 15 Chemsex - The ‘ins and outs’ of managing an outbreak: A local Health Protection Team’s response Summary of key professional roles and responsibilities
- 16. What would you do? SCREAM FOR HELP!! • Have other London Health Protection Teams dealt with a chemsex outbreak? • Discuss with other HPTs are they seeing increased cases/reports/ their experience • Familiarise with available guidance: “Guidance for managing STI outbreaks and incidents, 2010” • Follow management for STI Outbreak • Arrange Incident meeting with relevant stakeholders • Liaise with Sexual Health Clinic regarding outreach work 16 Chemsex - The ‘ins and outs’ of managing an outbreak: A local Health Protection Team’s response
- 17. 17 Chemsex - The ‘ins and outs’ of managing an outbreak: A local Health Protection Team’s response Funky House!Organogram demonstrating the connections with premises – May 2014
- 18. Targeted Health Promotion • Set up dedicated Chemsex Clinics • Needle Exchange services available at GUM Clinics • Sexual health messages and media alerts using Smartphone Geospatial Networks • Heightened surveillance • Alerts across East London Sexual Health Clinics • GUM clinic visiting property, interviewing tenants 18 Chemsex - The ‘ins and outs’ of managing an outbreak: A local Health Protection Team’s response “Where sexual health networks are available, they may have a place in coordinating sexual health promotion activities, particularly when outbreaks affect more than one LA within the Network area.”
- 19. The Challenges 19 Chemsex - The ‘ins and outs’ of managing an outbreak: A local Health Protection Team’s response - local surveillance tools to detect local outbreaks - How to obtain surveillance data from client group Building Trust & maintaining confidentiality with client group - Illicit drug use (Class A) - How to prevent infection with ongoing risky behaviours
- 20. Lessons Learned - Services must now be tailored towards changes in client behaviour in order to remain relevant and useful - Greater integration between Sexual Health Clinics, Drugs and Alcohol services. - Needle exchange services to be embedded in Sexual Health Clinics across East London - Additional GUM Staff training on changing behaviours and best practice for one-to-one interventions 20 Chemsex - The ‘ins and outs’ of managing an outbreak: A local Health Protection Team’s response
- 21. References • Guidance for managing STI outbreaks and incidents, Health Protection Agency, 2010 • Recreational drug use among men who have sex with men – Public Health England’s response to an STI Outbreak, BMJ pending publication • Annual Epidemiological Spotlight on STIs in London: 2014 data. Field Epidemiology Services, South East and London • HIV and STIs in men who have sex with men in London September 2014, Field Epidemiology Services, South East and London • Sexually Transmitted Infections in England, 2014. HIV and Sexually Transmitted Infections Department, 2014. Centre for Infectious Disease Surveillance and Control 21 Chemsex - The ‘ins and outs’ of managing an outbreak: A local Health Protection Team’s response
- 22. Acknowledgements Dr Paul Crook and Josh Forde, Field Epidemiology Services Dr Marko Kerac, London School of Hygiene & Tropical Medicine Dr Simon Cathcart, NENCL Health Protection Team Chris Lovitt – Tower Hamlets Public Health Department Dr Andy Williams – Ambrose King Sexual Health Clinic, Barts and the London Late Heather Anderson - Ambrose King Sexual Health Clinic, Barts and the London 22 Chemsex - The ‘ins and outs’ of managing an outbreak: A local Health Protection Team’s response
Editor's Notes
- HPT ROLE Providing data Establish and ensure our links with GU clinics in our patch for joint case management e.g. shigella and acute hep B Management of outbreaks Attendance to local authority sexual health meetings
- PHE dominated, any slide with National Picture – demonstrate loads of people involved
- STI, PHE priority, national conference, context of slide acitivity in London, rep of hotspots in other areas. (includes Chlamydia) Inner london borough issues Haringey, Camden and Islington – as you come towards inner boroughs, higher rates of STIs; younger population with at risk groups > Inner boroughs tend to have higher rates that outer boroughs -Hackney = younger MSM concentration, most inner London boroughs have a younger MSM population
- failure to prevent the 1,088 UK acquired infections in MSM diagnosed in London in 2014 has cost the health service an estimated £348 million in future direct health care costs MSM – in particular gay & bisexual men ALSO BETTER AT GETTING TESTED; evidence of increase MSM – population is smaller so numbers according to the population is high; we haven't got denominator data so cannot get rates MSM are a minority of the population and MSM new STIs are increasing steadily – which is not seen in other groups Why MSM risk of STIs and HIV -Relatively high prevalence population Unprotected anal sex Stigma Social settings – drugs/alcohol Partner turnover Concurrent relationships Serosorting
- National picture instead of London, move up. burden of syphilis and gonorrhoea is particularly high among MSM. sustained transmission of these infections indicates high levels of risky sexual behaviour. Syphilis – associated with higher risk groups of MSM gonorrhoea = women more likely to be asymptomatic so likely to be undiagnosed; linked with high risk sexual behaviour e.g. MSM; dual testing can improve diagnosis but where prevalence is below 1%, can get false positives -chlamydia = widespread in heterosexual population; men are more likely to be asymptomatic so under-diagnosis in men Public Health England (PHE) has published an action plan for promoting the health and wellbeing of gay, bisexual and other MSM, using a whole system approach to promote health and wellbeing, including mental health.19 PHE has also recently produced a strategic action plan to improve sexual health and reversing the HIV epidemic, which includes MSM as a key population group. - On agenda for health and well being boards
- Is this really a new thing? Drug use and sex has been going on within the MSM community for a number of years but the term chemsex is now widely used to describe this behaviour. What is new is the choice of drugs now being used in relation to chemsex – crystal meth, GHB most MSM do not use drugs not all MSM who use drugs use them in a sexual setting not all MSM who use drugs in a sexual setting do so in a problematic way MSM who use drugs as part of chemsex are often in full-time employment, use drugs intermittently and often generally function well in life
- DEAN STREET GUM, raise awareness within MSM Community, The perfect Storm http://www.vice.com/en_uk/video/watch-the-trailer-for-our-new-film-chemsex-422 If there is internet access, prior to presentation copy link in browser and play at this slide, was unable to embed into presentation. If this doesn’t work tell people to google VICE chemsex to watch later.
- How do you think this was picked up? National surveullance programme, potential challenge, timely identification of localised increased in clusters. This could be triggered by local lab or GUM. Without continuity in clinical service could have been missed but will looked into. Routine surveillance channels? Etc Sexual Health advisor noticed the men coming into clinic and noting the same address and their residence. Wouldn’t have picked this up until much later
- As HPT responsiblle to lead outbreak & IC response Incidence response that involves MDT it’s not obvious but we have defined roles. However STIs, by the nature of their mode of transmission are distinct from other infections, and this needs to be taken into consideration when planning intervention and control strategies.
- Outbreak Control Team Chair The person taking responsibility for Outbreak Control Team chair would be decided at the group’s first meeting, but usually it would be either the DPH or CCDC. Direct and co-ordinate overall management of outbreak. Ensure each member of the control group understands his/her role. Be available throughout the episode for consultation and advice. Be responsible for liaison between senior staff and clinicians and ensure timely communication between members of the Outbreak Control Team and other parties. Outbreak Control Team has responsibility for declaring the incident over. Ensure that an incident report is written and that lessons learned are disseminated. CCDC / CHP (or Unit Sexual Health Lead depending on local arrangements) Outbreak identification through routine surveillance. Provide local epidemiological support. Highlight priority to the commissioning authority and advocate if necessary for additional resources to deal with outbreak. Maintain heightened surveillance of the infection to evaluate the effectiveness of interventions. Audit management of local outbreaks in conjunction with GUM/RE. Develop materials for training purposes from lessons learnt (outbreak). Provide guidance on the overlap between public health and GUM. PHE Colindale Provide guidance on whether the observed increase was an outbreak or could be explained in terms of other factors. Provide information resources to advise on incident management. Provide advice on local research studies that may be undertaken. Assist in development of investigative tools. Occasionally, provide personnel to assist with field investigation or analysis of results. Development of methods to evaluate control measures. Advice and specialist microbiological investigation. GUM Physicians, nurses & health advisors Early identification of increasing STIs and communication to CCDCs. Facilitate confirmation of outbreaks through focused studies. Appraise capacity of local GUM services to respond to STI outbreak. Identify and help implement locally appropriate and acceptable control measures in conjunction with the Outbreak Control Team. Consultant Microbiologist Identify outbreaks through routine surveillance. Provide expert advice to Outbreak Control Team on interpretation of microbiological data, investigative methods, collection of specimens and outbreak control methods. Provide expert advice on use of specialist diagnostic methods. Arrange prompt analysis and reporting of clinical samples. Arrange further testing at appropriate reference laboratories (see section 3.1.1). PHE Field Epidemiology Service Identify possible outbreaks through routine surveillance. Epidemiological expertise and support with the investigation and control of the outbreak. Keep PHE Centre Directors informed and seek their support as/when required. Assistance with auditing incidents. Support with the development of training exercises. Communications Manager Lead on discussions to ascertain the most appropriate form of media management of the incident, that is proactive or reactive. Draft all media messages in close contact with appropriate sexual health lead and ensure chair of the IMT signs these off. Liaise with relevant communications managers of key stakeholders involved in the incident. Liaise with National PHE Press office if you suspect national media interest into the incident to ensure key messages are shared for the out of hours press office service. Advise on all internal communications. Sexual Health Network Where sexual health networks are available, they may have a place in coordinating sexual health promotion activities, particularly when outbreaks affect more than one LA within the Network area. Service commissioner LAs are currently responsible for the provision of sexual health services for their population, either through commissioning or providing services directly. In the event of an outbreak of a STI, the DPH or LA Health Protection Lead will be involved in the OCT. Sexual health promotion team. This is likely to be based in the LA and who will play an important role in control / intervention work. LA Sexual Health Commissioning Lead will be responsible for ensuring the funding of any surge capacity / change to service delivery.
- We knew the guidance was being updated and asked for the draft! Use the old and new guidelines to ensure we cover all bases. Next day telecon set up to confirm aim, objectives, how to prevent ongoing spread Set up Incident Control Team Attendance: BLT AKC Consultant and Sexual Health Adviser who identified outbreak Residence was outside of area in which GUM clinic was based. DPHs in boroughs involved invited to Both WF DPH and Tower Hamlets DPH invited to first telecon FES representation HPT representation Sexual Health Lead for HPT
- London Res Address, time, reported to GUM. Organogram demonstrating connections with premises… shows the large numbers linked to this one address started off with 27 men and by June 40 men linked to the Household, showing the property was still posing a health risk. Sexual Health Adviser and Consultant unplanned visited to the property shortly after outbreak notified, interview those found at property, engage with local GUM services.
- Prevention & Control addressing drug use in association with STIs and risk-taking behaviour. Needles were made available in sexual health clinics to patients reporting injecting drug use and access to drugs and alcohol services was improved by providing dedicated after-hour clinics to service users. Analyse how many hits on apps and accessing info on sexual health services (Barts Health) Messages and Outreach workers at Gay Venues.
- (timeliness, reliance, descriptive rather than identifying exceedance) – user involvement in the development of appropriate messages. – link to video. comparison made to food outbreak interesting, whereas that has a more ‘traceable’ pathway and clinical endpoint, the social contexts of sexual behaviour do not provide the same endpoint. The outbreak also illustrated difficulties in using traditional epidemiological approaches, where contact tracing and questionnaire completion are essential, as the client group declined to engage in order to protect confidentiality. House of multiple occupancy, new entrants, access to services, no recourse to public funds/other services. Suspicion of registration within UK, STIs are often associated with social stigma, and consequently concerns over patient confidentiality may restrict access to data held by genitourinary medicine (GUM) clinics and other clinical settings.
- opportunity to advocate for greater integration of SH, drug and alcohol services – particularly with regard to NX services. staff training Health Advisers are receiving more formal specialised training specific to MSM and club drug use General training aimed at the wider MDT continues questions about drug use are being asked more uniformly soon be implementing a new method of recording drug use which will provide a means for data extraction that doesn’t currently exist. Outbreak Prevention Offering or starting treatment as prevention for HIV patients at risk of onward transmission Limitations on surveillance: we remain very limited in how we can identify networks. What could we have done better? Presented in structured way but outbreak like this is quite unconventional, select survey etc. info can not be easily obtained when youre actively trying to case find.