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Introduction Understanding the effectiveness and durability of protection against SARS-CoV-2 infection conferred by previous infection and COVID-19 is essential to inform ongoing management of the pandemic. This study aims to determine whether prior SARS-CoV-2 infection or COVID-19 vaccination in healthcare workers protects against future infection. Methods and analysis This is a prospective cohort study design in staff members working in hospitals in the UK. At enrolment, participants are allocated into cohorts, positive or naïve, dependent on their prior SARS-CoV-2 infection status, as measured by standardised SARS-CoV-2 antibody testing on all baseline serum samples and previous SARS-CoV-2 test results. Participants undergo monthly antibody testing and fortnightly viral RNA testing during follow-up and based on these results may move between cohorts. Any results from testing undertaken for other reasons (eg, symptoms, contact tracing) or prior to study entry will also be captured. Individuals complete enrolment and fortnightly questionnaires on exposures, symptoms and vaccination. Follow-up is 12 months from study entry, with an option to extend follow-up to 24 months. The primary outcome of interest is infection with SARS-CoV-2 after previous SARS-CoV-2 infection or COVID-19 vaccination during the study period. Secondary outcomes include incidence and prevalence (both RNA and antibody) of SARS-CoV-2, viral genomics, viral culture, symptom history and antibody/neutralising antibody titres. Ethics and dissemination The study was approved by the Berkshire Research Ethics Committee, Health Research Authority (IRAS ID 284460, REC reference 20/SC/0230) on 22 May 2020; the vaccine amendment was approved on 12 January 2021. Participants gave informed consent before taking part in the study. Regular reports to national and international expert advisory groups and peer-reviewed publications ensure timely dissemination of findings to inform decision making. Trial registration number NCT11041050.

Objective To determine whether the 2012 Olympic and Paralympic Games were associated with a change in the number of patients attending or diagnosed with a new sexually transmitted infection (STI) at sexual health clinics in London and Weymouth. Methods We undertook an interrupted time-series analysis of surveillance data from the Genitourinary Medicine Clinic Activity Dataset (GUMCAD) collected at 33 genitourinary medicine (GUM) clinics in London and Weymouth (where Games events were concentrated) between 2009 and 2012. Mixed-effects linear regression models of weekly attendance and diagnoses, incorporating temporal trends, bank holidays, categorical month and clinic closures, were used to test for the effect of the ‘Olympic–Paralympic’ period. We subdivided the 9-week ‘Olympic–Paralympic’ period (16 July 2012 to 17 September 2012) into five periods, including three Olympic weeks, two Paralympic weeks, pre-, post- and inter-Games weeks. We also compared characteristics of patients attending during the Olympic–Paralympic period and those attending during the same period in 2011. Results During the 3 weeks of the Olympics, there was a significant reduction in the number of new episode attendances (2020 fewer, 5.6% reduction (95% CI −8.2 to −2.9)) and the number of patients diagnosed with an STI (267 fewer, 4.8% reduction (95% CI −8.6 to −0.9)) compared to expected. There were no important differences in the profile of patients attending during the 2012 Olympic–Paralympic period and those attending during the same period in 2011. Conclusions We conclude that a ‘business-as-usual’ approach to managing local sexual health clinics during the 2012 Olympic and Paralympics would have been appropriate.

Objective: To determine if a structured complex intervention increases opportunistic chlamydia screening testing of patients aged 15-24 years attending English general practitioner (GP) practices.\ud Methods: A prospective, Cluster Randomised Controlled Trial with a modified Zelen design involving 160 practices in South West England in 2010. The intervention was based on the Theory of Planned Behaviour (TPB). It comprised of practice-based education with up to two additional contacts to increase the importance of screening to GP staff and their confidence to offer tests through skill development (including videos). Practical resources (targets, posters, invitation cards, computer reminders, newsletters including feedback) aimed to actively influence social cognitions of staff, increasing their testing intention.\ud Results: Data from 76 intervention and 81 control practices were analysed. In intervention practices, chlamydia screening test rates were 2.43/100 15-24-yearolds registered preintervention, 4.34 during intervention and 3.46 postintervention; controls testing rates were 2.61/ 100 registered patients prior intervention, 3.0 during intervention and 2.82 postintervention. During the intervention period, testing in intervention practices was 1.76 times as great (CI 1.24 to 2.48) as controls; this persisted for 9 months postintervention (1.57 times as great, CI 1.27 to 2.30). Chlamydia infections detected increased in intervention practices from 2.1/1000 registered 15-24-year-olds prior intervention to 2.5 during the intervention compared with 2.0 and 2.3/1000 in controls (Estimated Rate Ratio intervention versus controls 1.4 (CI 1.01 to 1.93).\ud Conclusions: This complex intervention doubled chlamydia screening tests in fully engaged practices. The modified Zelen design gave realistic measures of practice full engagement (63) and efficacy of this educational intervention in general practice; it should be used more often.\ud Trial registration: The trial was registered on the UK Clinical Research Network Study Portfolio database. UKCRN number 9722.

Objectives: To undertake a systematic review to obtain estimates of genital Chlamydia trachomatis prevalence in various populations in the United Kingdom and Ireland; to determine which populations have the highest rates of infection; and to explore the most important determinants of infection. Methods: Electronic databases were searched using the keywords "chlamydia" and "England," "Wales," "UK," "Scotland," "Ireland," or "Britain." Additional unpublished data and references were solicited from experts. Studies were included in the analysis if C trachomatis prevalence was reported, and if they met inclusion criteria. Nine variables identified as potentially important descriptors of chlamydia prevalence were extracted from each study and analysed using various logistic regression models. Only studies reporting prevalence in female populations were included in the models, because there were few data from males. Results: 357 studies were identified using the search methods, 90 of which met inclusion criteria, and 19 of which contributed to the final model. The most influential variables on prevalence were age and setting of the population tested. In general practice surgeries, the under 20 year old age group had an estimated prevalence of 8.1% (95% CI 6.5 to 9.9), 20–24 year olds 5.2% (95% CI 4.3 to 6.3), 25–29 year olds 2.6% (95% CI 2.0 to 3.3), decreasing to 1.4% (95% CI 1.0 to 1.9) in those aged over 30 years. Overall, healthcare settings had higher prevalence estimates than population based studies. For example, among under 20 year olds, estimates were 17.3% (95% CI 13.6 to 21.8) in genitourinary medicine clinics, 12.6% (95% CI 6.4 to 23.2) in antenatal clinics, 12.3% (95% CI 9.8 to 15.3) in termination of pregnancy clinics, 10.7% (95% CI 8.3 to 13.8) in youth clinics, 10.0% (95% CI 8.7 to 11.5) in family planning clinics, and 8.1% (95% CI 6.5 to 9.9) in general practice, compared to 5.0% (95% CI 3.2 to 7.6) in population based studies. The type of test, specimen used, date, and location of test were not strongly associated with chlamydia prevalence. Conclusion: The chlamydia prevalence estimates by age and setting from the model may be used to inform chlamydia screening strategies. The systematic review revealed much heterogeneity in the studies identified, but with clear patterns of prevalence. It also indicated gaps in the knowledge about chlamydia prevalence in certain subgroups such as men and the general population.

Tuberculosis cases in children (aged under 15 years) in the National Surveys rose from 308 (rate: 3.3 per 100,000) in 1988 to 408 (4.2 per 100,000) in 1993 and then fell to 364 (3.6 per 100,000) in 1998. The rates in white children were 1.6, 2.0, and 1.1 per 100,000 respectively; in Indian subcontinent children, the rates were unchanged between 1988 and 1993 at around 33 per 100,000 but fell to 23 per 100,000 in 1998. In black African children, the rates were 15, 34, and 71 per 100,000 respectively. From 1988 to 1998, the proportion of cases resident in London more than doubled to 49% (rate: 11.9 per 100,000) and the proportion of cases in children born abroad increased from 13% to 27% in the country as a whole. Although the overall rate of tuberculosis in children in England and Wales has changed little between 1988 and 1998, the distribution of disease has changed in line with the change in adults. Services for the diagnosis and treatment of tuberculosis in children should be adapted to the changing pattern of disease in this group. Continuous enhanced tuberculosis surveillance will enable more detailed and timely scrutiny of trends in tuberculosis in the future.

Background—Helicobacter pylori is a gastroduodenal pathogen associated with ulceration, dyspepsia, and adenocarcinoma. Recent preliminary studies have suggested that H pylori may be protective for oesophageal adenocarcinoma. In addition, strains of H pylori identified by the presence of the cytotoxin associated gene A( cagA) are shown to have a significant inverse association with oesophageal adenocarcinoma. Given that cagA + H pylori may protect against oesophageal carcinoma, these strains may be protective for oesophagitis, a precursor of oesophageal carcinoma. Aims—The aim of this study was to investigate the association between cagA + H pylori and endoscopically proved oesophagitis. Patients—The study group included 1486 patients attending for routine upper gastrointestinal tract endoscopy. Methods—At endoscopy the oesophagus was assessed for evidence of reflux disease and graded according to standard protocols. Culture and histology of gastric biopsy specimens determined H pylori status. The prevalence of cagA was identified by an antibody specific ELISA (Viva Diagnostika, Germany). Results—H pylori was present in 663/1485 (45%) patients and in 120/312 (38%) patients with oesophagitis. Anti-CagA antibody was found in 499/640 (78%) H pylori positive patients. Similarly, anti-CagA antibody was found in 422/521 (81%) patients with a normal oesophagus and in 42/60 (70%) with mild, 24/35 (69%) with moderate, and 11/24 (46%) with severe oesophagitis. The risk of severe oesophagitis was significantly decreased for patients infected with cagA + H pylori after correction for confounding variables (odds ratio 0.57, 95% confidence interval 0.41‐0.80; p=0.001). Conclusions—These results suggest that infection by cagA + H pylori may be protective for oesophageal disease. (Gut 2001;49:341‐346)

OBJECTIVES: To describe the incidence of gonorrhoea diagnosed in genitourinary medicine (GUM) clinics in South Thames (West) between 1995 and 1996, and how it changed among population subgroups. SETTINGS AND SUBJECTS: Cases of uncomplicated and complicated gonorrhoea diagnosed at 13 GUM clinics in the former South Thames West (STW) Regional Health Authority that reported disaggregate data to the South Thames GUM Clinic Collaborative STD Surveillance Scheme. METHODS: Annual incidence rates (per 100,000) of gonorrhoea diagnoses by sex, age group, ethnic group, area of residence, and year were calculated. Poisson regression models were used to calculate risk ratios (RR) to describe the key differences in the variation of gonorrhoea cases by these variables. Relative differences in the incidence of diagnosed gonorrhoea between 1995 and 1996 were investigated by including an interaction between year and the other variables (age group, sex, ethnic group, region) and testing whether any were significant using a likelihood ratio test. RESULTS: Area of residence, sex, age group, and ethnic group were key predictors of the rates of diagnosed gonorrhoea. The risk ratio for gonorrhoea (after adjustment for the other variables) was: 13 times higher among blacks than the white population; twice as high in inner London compared with outer London; and three times lower in the "shire" region compared with outer London. The rate of diagnosed gonorrhoea was significantly higher in the black population in the shire region than the inner London white population. The rate of gonorrhoea diagnosed by GUM clinics from 1995 to 1996 almost doubled in the white population aged 15-44 years, from 16 cases per 100,000 to 30 cases per 100,000 (adjusted RR 2.0, 95% CI 1.6 to 2.4), whereas increased rates in the black and Asian/other ethnic groups were not statistically significant (adjusted RR 1.1, 95% CI 0.9 to 1.4; and 1.4, 95% CI 0.7 to 2.7 respectively). CONCLUSION: The observed increase in gonorrhoea between 1995 and 1996 occurred mostly among heterosexual white men and women. Overall, the rates of gonorrhoea among young people, especially in the black population and in inner London represent a significant public health problem that may merit further targeted interventions, the effectiveness of which could be monitored through further development of routine surveillance data.

Introduction We present the long-term outcome of Barrett’s oesophagus (BO) observed over 37 years at a District General Hospital. We comment on the risk of developing oesophageal adenocarcinoma (OAC), its outcome, and on the value of endoscopic surveillance. Methods The study includes all patients diagnosed with BO from 1.1.1977 to 31.12.2011 and followed-up until 31.12.2013 (37 years). Patients with prevalent OAC were excluded from analysis. Data were prospectively collected and updated at every visit and all deaths recorded. Patients were followed-up by surveillance endoscopy or if contraindicated by age or co-morbidity then by clinic visit or telephone survey, with urgent endoscopy reserved for recurrence of symptoms for all patients. To compare outcome we divided OAC patients according to their method of follow-up at the time OAC was diagnosed. To adjust for the confounding factor of age when creating survival estimates we applied a Cox proportional hazards regression which included gender, age, and age squared (for there is evidence that the relationship with age and survival is not linear). Results Total numbers: 1977–2011 n = 1381. BO numbers steadily increased but plateaued towards the end of the study. BO diagnosis was confirmed by histology in 88%. Outcome: In a total FU of 10366 patient-years (mean 7.5y range 0–36y), 54/1381 (3.9%) developed OAC (mean interval 9 years, SD 5.5, range 13 months–25.4 years). Thus 1 OAC developed per 192 patient-years of FU i.e. 0.52% per year. Mortality: Deaths from all causes were 417/1381 (30.2%). Surveillance and survival: Mortality was significantly lower in the 37 patients under endoscopic surveillance at the time OAC was diagnosed (51% vs 88% p = 0.0141) due in part to the older age and co-morbidity of the other 17 in whom serial endoscopy was contraindicated (mean age 67y vs 75y p = 0.002, respectively). However, after adjusting for age there was no significant difference in mortality between the two groups (p = 0.08). Importantly though, the estimated hazard rate ratio was lower in the surveillance group (0.64, 95% CI 0.30 to 1.48). Conclusion Reduction of risk: The risk of dying from OAC was reduced by about one-third in those under endoscopic surveillance at the time OAC was diagnosed. Identifying such a reduction of risk is a very useful indicator of the value of surveillance. Numbers and implications: This substantial long-term study was still not large enough to show a significant reduction in death once adjusted for confounding factors. Our results stress the need for individual centres to contribute to data warehouses such as national registries. We now have clear evidence that BO surveillance confers benefit. With today’s technology which offers a wider scope of both palliative and curative treatments, and a continued systematic and disciplined approach, we have reason to expect that endoscopic surveillance will give even better results in the future. Disclosure of Interest None Declared

Introduction Provision of sexual health services in primary care is necessary to reduce STIs, such as chlamydia. We piloted an educational training programme, based on the theory of planned behaviour, for general practice staff with the aim of increasing chlamydia and HIV testing, and provision of condoms and contraceptive information (3Cs and HIV). Methods The pilot was delivered with a step wedge design over three phases. Chlamydia testing and diagnosis rates pre and post-training were compared separately for men and women using a multivariable negative binomial regression model with general practice fitted as a random effect. Month of test and practice population size were adjusted for and an interaction between the intervention and area of implementation fitted. Results 460 general practices agreed to participate in the pilot. These conducted 2448 tests across the pre and post intervention period. Intention to treat analysis showed decreased median test and diagnoses per month post-intervention (2.68 vs 2.67; 0.14 vs 0.13 respectively). The multivariable regression analysis did not find a significant change in testing or diagnoses of men. There was a significant increase in testing (IRR 1.15 CI 1.01–1.31) of women but no change in diagnoses (IRR 0.98 CI 0.84–1.18). Interaction between the intervention and area of implementation was found in both testing rate models for women. Conclusion This large national pilot found that educational support sessions slightly increased chlamydia testing in women within general practices after they received the 3Cs and HIV training but not diagnoses. The area of implementation had an impact on the programme’s effect, so further exploration of the factors that contribute to this increase is required. Disclosure of interest statement Public Health England is funded by the UK Department of Health.

Introduction In England, 80% of HIV diagnoses are in sexually transmitted infection (STI) clinics. Since 2009, Public Health England offered testing for recent HIV infection. Aim To estimate HIV incidence among STI clinic attendees in 2012. Methods The AxSYM avidity assay, modified to determine antibody avidity, was conducted on aliquots of newly diagnosed persons and results linked to the national HIV database. An incident case was defined as avidity Results Of 212 STI clinics in England, 150(71%) submitted specimens for recent infection testing, comprising 3,930 persons newly diagnosed; 50% were MSM. The number of HIV tests/diagnosis was 210 for all clinic attendees, 38 for MSM, 403 for all heterosexuals and 46 for black African heterosexuals. HIV incidence was 0.15% (95% C.I. 0.13–0.18%) for all attendees, 1.22% (95% C.I. 1.07–1.42%) for MSM, 1.41% (95% C.I. 1.21%-1.66%) for MSM in London, 0.03% (95% C.I. 0.02–0.04%) for heterosexuals and 0.13% (0.05–0.22%) for black African heterosexuals. Discussion/conclusion Testing for recent HIV infection combined with routinely collected clinical data provides robust and timely national estimates of HIV incidence. HIV incidence among MSM and black African heterosexuals attending STI clinics was 40 and nine times higher respectively than among all heterosexuals, and exceeds the WHO-defined elimination threshold of 0.1%.

Background/introduction General practice (GP) offers a wide range of sexual health services, although provision varies across England. Educational support visits to GPs are effective in improving sexual health services. 3Cs and HIV is a national pilot that provided GP training for opportunistic offers of chlamydia testing, free condoms and information about contraceptive services to 15–24 year olds (i.e. 3Cs), plus HIV testing according to national guidelines. Aim(s)/objectives To describe local authority (LA) and GP engagement with the 3Cs and HIV pilot using process evaluation measures. Methods The training programme comprises two practice educational support visits, the first on 3Cs and the second on HIV testing. Data on LA and GP recruitment, retention and implementation of the training was collected throughout the programme. Results In total, 56 LAs invited 2,532 practices to the programme, 461 agreed to participate. Data was returned by 46 LAs accounting for 405 practices (88%). Half of participating practices received at least one visit (255/461, 55%). Nearly a third of practices received only the 3Cs visit (143/461, 31%) and 24% (111/461) received both the 3Cs and HIV visits. More general practitioners than nurses attended the training (826 vs. 752), especially for the HIV sessions (263 vs. 211). Discussion/conclusion Many practices reported an interest in receiving sexual health educational support visits, however a large proportion did not start or complete the full programme. This highlights the difficulties sustaining GP engagement over time, which may be due to competing priorities for protected learning time. Future programmes may need to be shorter.

Introduction Squamous oesophageal carcinoma is more prevalent in those with lower socio-economic status. Little is known about this for oesophageal adenocarcinoma (OAC). Anecdotally, OAC has been observed in higher socio-economic groups. Barrett’s oesophagus (BO) is the only known precursor of OAC. This study investigates the association between BO and social deprivation using the 2010 Index of Multiple Deprivation (IMD). Methods Patients : 1076 BO diagnosed in Rotherham, between April 1978 and August 2012. IMD: The Office for National Statistics (ONS) divides England into geographical areas each with a similar population size termed Lower Layer Super Output Areas (LSOA). The 2010 IMD comprising a combination of 38 separate indicators is assigned to each LSOA. Every residential postcode is assigned to a LSOA and thus an IMD. This was applied to the postcodes of Rotherham patients at time of BO diagnosis. IMD Quintiles were derived by dividing the distribution of all IMD scores in England into 5 equal categories. The 6257 residential postcodes for Rotherham and the 1076 BO patients were placed in the quintiles relevant to their IMD score. Analysis: Chi square goodness of fit tests were used to compare the observed (O) distribution of BO to the expected (E). Analysis was stratified into those diagnosed before 2001 and 2001 onwards, this being the median year of diagnosis. Results (See Table) 2/3rds of all Rotherham postcodes fell into the 2 most deprived quintiles. The O/E IMD distribution of the BO cohort diagnosed before 2001 was similar to that of the Rotherham population but highly significant differences emerged later (p = 0.0001): the two least deprived quintiles had 170 BO patients against 124 expected (37% increase). Conclusion No single factor is likely to explain the change observed in the last decade, however, the highly significant difference observed points to a strong association between lower deprivation and increasing risk of BO. To the best of our knowledge this is the first report showing a quantitative link between BO and socio-economic status, which may form a basis for the apparent socio-economic shift between squamous oesophageal cancer and OAC. Disclosure of Interest None Declared.

Objective To summarise the evidence for the role of antibiotics in preventing further cases of meningococcal disease through chemoprophylaxis given to the index patient, household contacts, and children in day care settings after a single case. Design Systematic review. Methods Studies were identified by searching Embase (1983-2003), Medline (1965-2003), and CAB Health (1973-2003) and by contacting the World Health Organization and the European meningococcal disease surveillance network and examining references of identified papers. The review included all studies with at least 10 cases in which outcomes were compared between treated and untreated groups. Main outcome measure Subsequent cases of meningococcal disease 1-30 days after onset of disease in the index patient. Results Four observational studies and one small trial met the inclusion criteria. Meta-analysis of studies on chemoprophylaxis given to household contacts showed a significant reduction in risk (risk ratio 0.11, 95% confidence interval 0.02 to 0.58). The number needed to treat to prevent a case was estimated as 218 (121 to 1135). Primary outcome data were not available in studies of chemoprophylaxis given to the index patient: when prophylaxis had not been given, rate of carriage after discharge from hospital was estimated as 3% (0 to 6), probably an underestimate of the true rate. No studies of chemoprophylaxis in day care settings were identified that met the inclusion criteria. Conclusion There have been no high quality experimental trials looking at control policies for meningococcal disease. The best available evidence is from retrospective studies. The risk of meningococcal disease in household contacts of a patient can be reduced by an estimated 89% if they take antibiotics known to eradicate meningococcal carriage. Chemoprophylaxis should be recommended for the index patient and all household contacts.

EDITOR,--N Bhatti and colleagues present an interesting analysis of changing rates of notification of tuberculosis based on national notifications and local data from Hackney.1 The findings are interpreted as suggesting that the national increase is largely due to socioeconomic factors that have affected the white population and established ethnic minority communities to a similar extent. The authors suggest that recent immigration has made only a small contribution to this increase. The study's findings do not justify these conclusions. As quoted in the paper, …