A review of the evidence for the effectiveness of primary prevention interventions for Hepatitis C among injecting drug users

BACKGROUND Hepatitis C (HCV) prevalence is most common amongst injecting drug users where up to 98% of the population can be infected despite a low prevalence of HIV. This review considers the evidence for the effectiveness of primary prevention interventions to reduce incidence or prevalence of hepatitis C. MEHODS Systematic review of the major electronic medical databases: Medline, EMBASE, PsycINFO, CINAHL and the Cochrane Library (Evidence Based Health). Either intervention or observational studies were included if they described an intervention targeting injecting drug using populations with the outcome to reduce either the prevalence or incidence of hepatitis C infection. RESULTS 18 papers were included in the final review from 1007 abstracts. Needle exchange programmes reduce the prevalence of HCV though prevalence remains high. Similarly the effectiveness of methadone maintenance treatment is only marginally effective at reducing HCV incidence. There is limited evidence evaluating either the effectiveness of behavioural interventions, bleach disinfectants, or drug consumption rooms. CONCLUSION Primary prevention interventions have led to a reduction in HIV incidence, have been less effective at reducing HCV incidence. Global prevalence of HCV remains disturbingly high in injecting drug users. A robust response to the global health problem of HCV will require provision of new interventions. Behavioural interventions; distribution of bleach disinfectant; other injecting paraphernalia alongside sterile needle distribution; and evaluation of drug consumption rooms merit further expansion internationally and research activity to contribute to the emerging evidence base. Whilst the prevalence of HCV remains high, nevertheless many current interventions aimed at primary HCV prevention have been shown to be cost-effective due to their significant positive impact upon prevalence of HIV

The Leeds Evaluation of Efficacy of Detoxification Study (LEEDS) prisons project pilot study: protocol for a randomised controlled trial comparing dihydrocodeine and buprenorphine for opiate detoxification

Background In the United Kingdom (UK), there is an extensive market for the class 'A' drug heroin. Many heroin users spend time in prison. People addicted to heroin often require prescribed medication when attempting to cease their drug use. The most commonly used detoxification agents in UK prisons are buprenorphine, dihydrocodeine and methadone. However, national guidelines do not state a detoxification drug of choice. Indeed, there is a paucity of research evaluating the most effective treatment for opiate detoxification in prisons. This study seeks to address the paucity by evaluating routinely used interventions amongst drug using prisoners within UK prisons. Methods/Design The Leeds Evaluation of Efficacy of Detoxification Study (LEEDS) Prisons Pilot Study will use randomised controlled trial methodology to compare the open use of buprenorphine and dihydrocodeine for opiate detoxification, given in the context of routine care, within HMP Leeds. Prisoners who are eligible and give informed consent will be entered into the trial. The primary outcome measure will be abstinence status at five days post detoxification, as determined by a urine test. Secondary outcomes during the detoxification and then at one, three and six months post detoxification will be recorded

Impact of a positive Hepatitis C Diagnosis on homeless Injecting Drug Users

Background: Increasing numbers of injecting drug users are presenting to primary care and a growing number of general practices are specifically providing care for homeless people. Injecting drug users are at the greatest risk of hepatitis C infection and homeless drug misusers, because of their drug-taking behaviour and patterns, have been identified as being at greater risk of harm of blood-borne diseases than the general population. However, little work has been conducted with injecting drug users or homeless people who have hepatitis C and little is known about how the virus may affect them. Aim: To explore the impact of a positive hepatitis C diagnosis on homeless injecting drug users. Design of study: This study employed qualitative research. In-depth interviews allowed the exploration of the impact of a potentially life-threatening diagnosis within the context of a person's expressed hierarchy of needs. Setting: A primary care centre for homeless people in the north of England. Method: In-depth interviews about the impact of a positive hepatitis C diagnosis on their lives were conducted with 17 homeless injecting drug users who had received a positive hepatitis C diagnosis. The interviews were audiotaped, transcribed, and analysed using the framework approach. Results: Receiving a positive diagnosis for hepatitis C resulted in feelings of shock, devastation, disbelief, anger, and questioning. A positive diagnosis had lasting social, emotional, psychological, behavioural, and physical effects on homeless injecting drug users, even years after the initial diagnosis. Most responders were diagnosed by a doctor in primary care or by hospital staff; however, not all had sought testing and a number were tested while inpatients and were unaware that blood had been taken for hepatitis C virus serology. Conclusions: The implications for clinical policy and primary care practice are discussed, including the issues of patient choice, confidentiality, and pre- and post-test discussions. Posttest discussions should be followed up with additional social, psychological, and medical support and counselling

Temporal and spatial prediction of radiocaesium transfer to food products

A recently developed semi-mechanistic temporal model to is used predict food product radiocaesium activity concentrations using soil characteristics available from spatial soil databases (exchangeable K, pH, % clay and % organic matter content). A raster database of soil characteristics, radiocaesium deposition, and crop production data has been developed for England and Wales and used to predict the spatial and temporal pattern of food product radiocaesium activity concentrations (Bq kg-1). By combining these predictions with spatial data for agricultural production, an area's output of radiocaesium can also be estimated, we term this flux (Bq y-1 unit area-1). Model predictions have been compared to observed data for radiocaesium contamination of cow milk in regions of England and Wales which received relatively high levels of fallout from the 1986 Chernobyl accident (Gwynedd and Cumbria). The model accounts for 56 and 80% of the observed variation in cow milk activity concentration for Gwynedd and Cumbria respectively. Illustrative spatial results are presented and suggest that in terms of food product contamination areas in the north and west of England and Wales are those most vulnerable to radiocaesium deposition. When vulnerability is assessed using flux the spatial pattern is more complex and depends upon food product

The identification of areas vulnerable to radiocaesium deposition in Hungary

Radiocaesium is an important and persistent environmental contaminant that can be deposited f o l l o w i n g nuclear accidents. It became apparent after the Chernobyl accident that some regions were vulnerable to radiocaesium deposition. Prior identification of vulnerable areas using spatial models that incorporate variation i n radiocaesium soil-to-plant transfer as a function of soil properties would allow post-accident management options to be prioritised and effectively implemented. In this paper, an assessment of the influence of different input soil property data sets for Hungary upon spatial model predictions of cow milk 1 3 7Cs activity concentrations and the identification of vulnerable areas is presented. Although predictions of cow m i l k 1 3 7Cs activity concentrations after Chernobyl made using the three input soil property data sets are all broadly similar and i n reasonable agreement w i t h national monitoring data, the identification of vulnerable areas is greatly influenced by the input soil property data set used. Our results suggest that using soil property databases derived f r om amalgamation of soil properties into broad soil categories w i l l lead to vulnerable areas not being identified. The findings presented i n this paper have important implications for the use of spatial models i n the prediction of radiocaesium transfer, identification o f vulnerable areas and management o f contaminated areas

Factors contributing to radiocaesium variability in upland sheep flocks in west Cumbria (United Kingdom)

Following the Chernobyl accident in 1986, restrictions were placed on the movement and slaughter of sheep within upland areas of the UK because radiocaesium activity concentrations in their meat exceeded 1000 Bq kg−1 fresh weight. Some farms remain under restriction in 2007. From 1991 to 1993 detailed studies were conducted on three sheep farms within the restricted area of west Cumbria to systematically assess the various parameters which may contribute to the observed variability in radiocaesium activity concentrations within sheep flocks. This paper reports the spatial variation in soil and vegetation activity concentrations across the grazed areas at these farms and determines the influence of grazing behaviour on variability in 137Cs activity concentrations between individual sheep within the flocks. Together with previously reported results, these new data are used to draw conclusions on the factors determining variability within the three flocks. However, the factors are too site specific to be able to generalise the findings to other farms within the restricted areas of the UK

Predicting the transfer of radiocaesium from organic soils to plants using soil characteristics

A model predicting plant uptake of radiocaesium based on soil characteristics is described. Three soil parameters required to determine radiocaesium bioavailability in soils are estimated in the model: the labile caesium distribution coefficient (kdl), K+ concentration in the soil solution [mK] and the soil solution→plant radiocaesium concentration factor (CF, Bq kg−1 plant/Bq dm−3). These were determined as functions of soil clay content, exchangeable K+ status, pH, NH+4 concentration and organic matter content. The effect of time on radiocaesium fixation was described using a previously published double exponential equation, modified for the effect of soil organic matter as a non-fixing adsorbent. The model was parameterised using radiocaesium uptake data from two pot trials conducted separately using ryegrass (Lolium perenne) on mineral soils and bent grass (Agrostis capillaris) on organic soils. This resulted in a significant fit to the observed transfer factor (TF, Bq kg−1 plant/Bq kg−1 whole soil) (P<0.001, n=58) and soil solution K+ concentration (mK, mol dm−3) (P<0.001, n=58). Without further parameterisation the model was tested against independent radiocaesium uptake data for barley (n=71) using a database of published and unpublished information covering contamination time periods of 1.2–10 years (transfer factors ranged from 0.001 to 0.1). The model accounted for 52% (n=71, P<0.001) of the observed variation in log transfer factor

Holistic countermeasures evaluation and the sustainable restoration and long-term management of contaminated rural, urban and industrial ecosystems

Both urban (including industrial) and rural environments may be contaminated for many years after a nuclear accident. To sustain acceptable living and working conditions, the capability to implement robust and effective restoration strategies is required. The criteria on which countermeasures are evaluated need to be extended from simply effectiveness and radiological protection criteria to a more integrated, holistic approach. Specifically, aspects such as whether measures can be practically applied, incur considerable direct or indirect (or side-effect) costs, have significant environmental effects, and are acceptable to society need to be incorporated. In addition, we should explore suitable approaches for successfully communicating with a wide range of stakeholders. Remediation following an accident cannot be based upon the evaluation of individual countermeasures in isolation; rather optimal strategies which combine a number of countermeasures need to be designed. A developing methodology to optimise restoration strategies is discussed using the results of an evaluation of a hypothetical accident. This initial evaluation is restricted to countermeasures that reduce ingestion doses and considers the effect of environmental restrictions, and dose distribution on the selection of remediation strategies. Communication strategies to be used within restoration are also discusse