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Aim: Needle and syringe (NS) provision is a proven intervention for reducing harms associated with injecting drug use, such as infections, but impact is coverage-dependent. We characterised people who injected drugs (PWID) in England and Wales who had insufficient NS in the past month to meet their injecting requirements. Methods: This study utilised 2017–2019 data from the annual Unlinked Anonymous Monitoring (UAM) Survey of PWID recruited through specialist services. Logistic regression was used to identify factors associated with inadequate NS coverage. Findings: Of 2,442 PWID surveyed who had injected in the past month, 34% reported inadequate NS coverage (or as high as 51% if including unsuccessful injections). Younger PWID (adjusted odds ratio: 2.18, 95% confidence interval: 1.35–3.52), those who began injecting in the past three years (1.46, 1.09–2.00), and those who reported sharing injecting equipment (1.46, 1.22–1.75) had greater odds of having inadequate NS coverage. PWID currently prescribed Opioid Substitution Treatment (OST) had lower odds of inadequate NS coverage (0.60, 0.49–0.73). Conclusion: Given the poor reported coverage of NS provision in England and Wales, there is urgent need to address inequity in accessing sufficient NS and increase coverage among this vulnerable group to reduce injecting-related harms.

Hepatitis B virus (HBV) is a highly infectious blood-borne virus, which remains endemic in large geographic areas and represents a major global healthcare challenge. HBV transmission from healthcare workers, who perform exposure prone procedures (EPP), to patients is a recognised transmission risk, which varies widely globally. Although the risk is small in developed countries, it increases significantly in high-prevalent, low-resource countries, representing a major challenge to these healthcare systems and underlining the necessity for robust guidance to be in place. The HBV landscape has evolved as a result of global vaccination programs, implementation of standard precautions and the advent of new generation antiviral agents (3rd generation nucleos(t)ide analogues). In light of the progress in the field, the UK Advisory Panel for Healthcare Workers Infected with Blood Borne Viruses (UKAP) recently issued updated guidance, which essentially removes past barriers, restricting healthcare workers from performing EPPs solely on the basis of HBV DNA level, regardless of hepatitis B 'e' antigen and/or treatment status. Although the current recommendations remain conservative compared to those of other developed healthcare systems, UK practice is now in line with other high-income countries, while ensuring patient safety remains paramount, without unduly restricting HCWs from clinical practice. The current article presents the latest UKAP guidance, considers its implications for HCWs and compares it with the guidance from major international scientific societies and governing bodies.

People who inject drugs are at high risk of blood-borne infections. We describe the epidemiology of HIV among people who inject drugs in England, Wales, and Northern Ireland (EWamp;NI) since 1981.National HIV surveillance data were used to describe trends in diagnoses (1981-2019), prevalence (1990-2019), and behaviours (1990-2019) among people who inject drugs aged ≥15 years in EWamp;NI. HIV care and treatment uptake were assessed among those attending in 2019.Over the past four decades, the prevalence of HIV among people who inject drugs in EWamp;NI remained low (range: 0.64%-1.81%). Overall, 4978 people who inject drugs were diagnosed with HIV (3.2% of cases). Diagnoses peaked at 234 in 1987, decreasing to 78 in 2019; the majority were among white men born in the UK/Europe (90%), though the epidemic diversified over time. Late diagnosis (CD4lt;350 cells/µl) was common (2010-2019: 52% [429/832]). Of those who last attended for HIV care in 2019, 97% (1503/1550) were receiving HIV treatment and 90% (1375/1520) had a suppressed viral load (lt;200 copies/ml). HIV testing uptake has steadily increased among people who inject drugs (32% since 1990). However, in 2019, 18% (246/1404) of those currently injecting reported never testing. The proportion of people currently injecting reporting sharing needles/syringes decreased from 1999 to 2012, before increasing to 20% (288/1426) in 2019, with sharing of any injecting equipment at 37% (523/1429).The HIV epidemic among people who inject drugs in EWamp;NI has remained relatively contained compared with in other countries, most likely because of the prompt implementation of an effective national harm reduction programme. However, risk behaviours and varied access to preventive interventions among people who inject drugs indicate the potential for HIV outbreaks.

Background and aims:\ud Mortality and drug treatment data suggest that the median age of people who inject drugs is increasing. We aimed to describe changes in the characteristics of people injecting drugs in the United Kingdom (UK).\ud \ud Design:\ud Repeat cross-sectional surveys and modelling.\ud \ud Setting:\ud Low-threshold services in the United Kingdom such as needle and syringe programmes.\ud \ud Participants:\ud A total of 79 900 people who recently injected psychoactive drugs in the United Kingdom, recruited as part of the Unlinked Anonymous Monitoring Survey (England, Wales, Northern Ireland, 1990–2019) and Needle Exchange Surveillance Initiative (Scotland, 2008–2019).\ud \ud Measurements:\ud Age of people currently injecting, age at first injection, duration of injecting (each 1990–2019) and estimates of new people who started injecting (1980–2019).\ud \ud Findings:\ud In England, Wales and Northern Ireland between 1990 and 2019, the median age of people injecting increased from 27 (interquartile range [IQR], 24–31) to 40 (IQR, 34–46); median age at first injection increased from 22 (IQR, 19–25) to 33 (IQR, 28–39); and median years of injecting increased from 7 (IQR, 3–11) to 18 (IQR, 9–23). Values in Scotland and England were similar after 2008. The estimated number that started injecting annually in England increased from 5470 (95% prediction interval [PrI] 3120-6940) in 1980 to a peak of 10 270 (95% PrI, 8980-12 780) in 1998, and then decreased to 2420 (95% PrI, 1320-5580) in 2019. The number in Scotland followed a similar pattern, increasing from 1220 (95% PrI, 740–2430) in 1980 to a peak of 3080 (95% PrI, 2160–3350) in 1998, then decreased to a 270 (95% PrI, 130–600) in 2018. The timing of the peak differed between regions, with earlier peaks in London and the North West of England.\ud \ud Conclusions:\ud In the United Kingdom, large cohorts started injecting psychoactive drugs in the 1980s and 1990s and many still inject today. Relatively few people started in more recent years. This has led to changes in the population injecting drugs, including an older average age and longer injecting histories.

Hepatitis C virus (HCV) transmission in the UK is driven by injecting drug use. We explore HCV testing uptake amongst people who inject drugs (PWID) in England, Wales and Northern Ireland, and identify factors associated with i) ever having an HCV test amongst people who have ever injected drugs, and ii) recently having an HCV test (within the current or previous year) amongst people who currently inject drugs (reported injecting drugs within the last year).We analysed data from the 2019 'Unlinked Anonymous Monitoring Survey' of PWID, using logistic regression.Of 3,127 PWID, 2,065 reported injecting drugs within the last year. Most (86.7%) PWID had a lifetime history of HCV testing. In multivariable analysis, higher odds of ever testing were associated with: female sex (aOR=1.54; 95%CI 1.11-2.14), injecting duration ≥3 years (aOR=2.94; 95%CI 2.13-4.05), ever receiving used needles/syringes (aOR=1.74; 95%CI 1.29-2.36), ever being on opioid agonist treatment (aOR=2.91; 95%CI 2.01-4.21), ever being imprisoned (aOR=1.86; 95%CI 1.40-2.48) and ever being homeless (aOR=1.54; 95%CI 1.14-2.07). Amongst PWID who had injected drugs within the last year, 49.9% had recently undertaken an HCV test. After adjustment, factors associated with higher odds of undertaking a recent HCV test included: injecting crack in the last year (aOR=1.29; 95%CI 1.03-1.61), experiencing a non-fatal overdose in the last year (aOR=1.39; 95%CI 1.05-1.85), ever being on opioid agonist treatment (aOR=1.48; 95%CI 0.97-2.25), receiving HCV information in the last year (aOR=1.99; 95%CI 1.49-2.65) and using a healthcare service in the last year (aOR=1.80; 95%CI 1.21-2.67).Results suggest that PWID who have experienced homelessness and incarceration - amongst the most vulnerable and marginalised in the PWID population - are engaging with HCV testing, but overall there remain missed testing opportunities. Recent initiates to injecting have highest HCV infection risk but lower odds of testing, and peer-education may help target this group.

PurposeThere are significant health inequalities experienced by women in prison. They face distinct challenges and have particular and complex needs, specifically with regard to their physical and mental health. The purpose of this paper is to describe the approach taken to develop a set of health and wellbeing standards for the women’s prison estate in England, which can be applied elsewhere.Design/methodology/approachA structured literature review of standard healthcare databases and grey literature was used to inform development of suggested standards. A multidisciplinary expert panel provided consensus on the standards through an online survey and women with a history of contact with the criminal justice system were consulted through consensus groups.FindingsA total of 549 papers were included in the final review. From this, 127 standards were identified for inclusion in the Delphi process. Consensus was achieved on all standards; this, combined with the analysis of qualitative feedback provided by both the survey and the consensus groups, resulted in the development of 6 overarching principles and 122 standards, across ten topic areas.Originality/valueThese standards are the most extensive that are known to exist for health and wellbeing of women in prison and the first to be developed in England. The process used ensures the standards have high validity, acceptability and feasibility and can be used to support those developing similar methodologies. There are few papers which document the development of standards to improve health and to the authors knowledge, only one other paper has been published detailing the development of health standards in prison settings specifically.

We report a national hepatitis A virus (HAV) outbreak linked to the consumption of Medjool dates. Twenty-nine cases of three genetically related sequences have been identified. Epidemiological investigations identified a suspected product (adjusted odds ratio: 47.36; 95% confidence interval: 1.79–1,256.07; p = 0.021). Microbiological testing has confirmed the presence of HAV on dates recovered from two cases and the product has been recalled. Date consumption is currently likely to be increased in connection with Ramadan, with potential ongoing contamination risk.

BackgroundPeople who inject drugs are at increased health risk in a pandemic due to their greater susceptibility to severe disease and as a consequence of the restrictions put in place to halt the spread of infection. Harm reduction (HR) services, which aim to reduce the negative effects of drug use on health, are likely to be diminished in a pandemic. However, innovative HR interventions and messaging may also develop in response to such a crisis. It is vital to understand the most effective ways to deliver HR in pandemic situations so that guidance can be provided for current and future disruptions to service provision.MethodsA rapid evidence review was conducted with the aim of exploring what HR interventions and messaging are most effective during a pandemic-type situation. Ten health databases were systematically searched using terms relevant to the research aim. A search was also made of grey literature, including a targeted search of HR messaging from key national and service provider websites.ResultsIn the initial search, 121 pieces of evidence were identified which, after screening and de-duplication, resulted in 60 for inclusion. The included evidence consists mainly of non-peer reviewed, pre-publication or expert opinion pieces. The rapid findings suggest that HR services should be deemed essential during a pandemic, with staff supported to work safely and social distancing adaptations implemented. Services should be encouraged to operate more flexibly; for instance, in deciding the amounts of take-home supplies of injecting equipment and medications. The evidence on HR communication was very limited but key messages on infection control, uncertain drug supply and accessing services were identified.ConclusionsThis rapid evidence review identifies implications for national policy makers, commissioners and HR service providers. A person-centred rather than disease-centred approach to HR delivered by collaborating partners, as well as prioritizing tailored HR messaging, is recommended. Further research evaluating the delivery of HR services and messaging, particularly focusing on health inequalities, is urgently needed.

As a result of reading this chapter you will be able to: understand the language of ethics and the role ethics play in public; health practice; understand the principles of priority-setting for health and healthcare; systems within a constrained budget; appreciate how an ethical framework guides choices for population; health and health policy-making, including making choices to reduce health inequalities

Will the new Health Research Authority (HRA) framework go far enough? Dr Emily Phipps, Professor Sian Griffiths of The Chinese University of Hong Kong, and Dr Mark Sheehan of the Nuffield Department of Population Health, Oxford University, consider the challenges facing the new HRA framework in addressing research into public health interventions on both an individual and a population level.IntroductionIn 2013, the public health functions of the National Health Service (NHS) in England moved to local government as part of reforms under the Health and Social Care Act 2012.[1] In this setting, the public health team commissions and manages a broad portfolio of programmes that aim to positively influence the local population's health and wellbeing, reduce inequalities and promote a healthy lifestyle.[2] The very nature of this work requires public health interventions to span the functions of health and politics, bringing together expertise from clinical, nursing, social care and local government backgrounds.Developing a robust evidence base for the delivery of public health interventions is key to ensuring that public health teams can provide the most effective and efficient service possible. Research governance processes regulate the design, implementation and dissemination of studies into public health interventions and are a legal requirement of health research conducted in England. However, there is currently significant variation in the quality and accessibility of research governance processes in local authorities in England to support the study of public health interventions.[1] In a recent nationwide study by Rainey et al.,[3] 35% of research governance leads listed on a national local authority database were no longer in post, and 25% of respondents from local authority public health and social care teams reported not having or not being aware of research governance arrangements in their local authority.Where such processes are available, a lack of familiarity with the relatively recently introduced public health functions to local authority can make it difficult for research projects to be assessed in a robust and appropriate manner. Research governance leads unfamiliar with governance issues pertinent to the study of public health interventions may be reluctant to pass review and approval. This risk may mean that projects are altered at the point of design to 'fit' the model most familiar to the research governance lead, rather than being of a methodology best suited to the hypothesis in question, in order to increase the likelihood of approval.Ethical review processes are a fundamental part of research governance, protecting the safety, dignity, rights and wellbeing of study participants. Researchers wishing to study public health interventions in local authorities rely on there being robust and appropriate ethical review services available in that organisation. As the nature of this research is unlikely to involve conventional methodology or typically medical interventions, local NHS research governance teams will likely not feel appropriately equipped to provide approval. In addition, academic research ethics committees often will not review the ethics of applications for research that is being conducted without university involvement, and vary widely in their approval processes and remit.[4] National guidance on the provision of research governance services, such as ethical review processes within local authority settings in England, may be one way to ensure standardised and appropriate services are available.In January 2015, the Health Research Authority (HRA) took over the responsibilities of the National Research Ethics Service and National Social Care Research Ethics Committee, so that all research involving health and social care in England is now governed by the same authority. The HRA are currently developing a high-level framework to guide the revision of local research governance policy which should recognise the changes to health and social care functions introduced in 2012. …

End State refers to the condition of a nuclear licensed site (or part of the site) following all physical decommissioning and clean-up activities required to make the site (or part of the site) available for its next use. To reach the End State, a site must be compliant with the requirments for release of the site from environmental regulations. Site operators may apply to the environment agencies for agreement for a site to be released from radioactive substances regulation (RSR). The release of the site will only be granted when all disposals of radioactive waste have ended and the site is in a state that will ensure a satisfactory standard of protection for people and the environment. A guidance document, known as “the GRR”, on the release of nuclear sites from RSR was published in July 2018. A site specific assessement of the benefits and detriments of clean-up and radioactive waste disposal options must be carried out as a requirement of the GRR. This involves identification of potential disposal options, assesssment and comparison of options, with stakeholder engagement, and optimisation of the preferred option if any radioactive material is to be left on site. As part of the assessment of waste disposal options, the GRR requires that operators assess potential consequnces of inadvertent human intrusion into the site, and aqueous releases from features on the site after the End State has been reached. Calculations of potential impacts from human intrusion and aqueous release scenarios are carried out and compared against guidance levels specified in the GRR. These assessments should also show that the consequential effects on non-human species are acceptable. Results of these assessments allow consideration of the implications of leaving radioactivity associated with particular features and components of the site, and inform comparison of alternative End State options.

Purpose – Diagnosis of Huntington's disease (HD) is with genetic tests and predictive testing for HD has been available for almost two decades. In the age of advancing genetic techniques, the question arises as to how the predictive tests can affect a person, his or her family and relatives, life choices and future. The paper aims to discuss these issues. Design/methodology/approach – A case study is presented demonstrating the complex issues surrounding genetic testing in HD. Relevant literature was then reviewed to further explore ethical issues linked to predictive testing for HD and also looked into findings on resolving this complex issue. Findings – Predictive testing in HD gives rise to ethical issues in social, legal, economical and imperatively personal aspects of an individual and society. Education and dispersion of knowledge to general society, regarding the test, its impact and also the illness would be a starting point in an attempt to resolve these issues. Need for counselling and support for patients in this context is vital and hence the imperative need to ensure provisions for standardised training and supply of professionals in this setting. Universal and enforceable framework along the lines of International Huntington Association recommendation should be adopted nationally. Originality/value – This paper presents a case study with significant value in demonstrating the challenges faced by genetic testing in HD, and provides insight in to this issue significant for all clinicians.

We are writing in response to the letter published by McGill and colleagues ( VR , 15 September, 2018, vol 183, pp 327-328), with a request for a retraction of incorrect information reported, and to emphasise the public health importance of tuberculosis (TB) to both people and animals. McGill and colleagues state that ‘one member of staff … developed a latent infection with M bovis spoligotype …

Emily Phipps discusses the potential benefits of preconception health education to adolescents for future generations of mothers and children, and why she believes school nurses should get involved in its delivery.