1. What is meant by ‘quality’ in the phrase ‘quality of care’? Quality, broadly speaking, is a subjective measure of excellence and when applied to health care, ‘quality’ can be understood as systems and provisions of care said to be free from defects, deficiencies, and significant variations. Within the NHS, this encompasses the provision of high quality primary, secondary and community care in which the interests of patients are protected through a comprehensive set of nationally aligned policies. Lord Darzi defines quality of care as “clinically effective, personal and safe”. How is this achieved? Within the NHS, quality is achieved through robust regulation, inspection, standard setting, change management, community and patient advocacy, alongside continual assessment of clinical competency (Leatherman and Sunderland, 2003). Quality is about effectiveness of care, from the clinical procedure the patient receives to their quality of life after treatment. The Equity and excellence: Liberating the NHS white paper’s assertion is that ‘to achieve our ambition for world-class healthcare outcomes, the service must be focused on outcomes and quality standards that deliver them’.

Leatherman S, Sutherland K, (2003) The quest for quality in the NHS: a mid term evaluation of the ten year quality agenda. London: The Stationery Office,

2. In 2008, the Department of Health published the report High quality care for all: NHS Next Stage Review final report. 30 June 2008. (a) Please summarise the main approaches to improving quality proposed by the report (b) compare and contrast these approaches to those described in Gwyn Bevan’s editorial (quoted from above).

The Department of Health report approaches improving quality by:

High Quality Care for All proposes that all providers of NHS healthcare services should produce a Quality Account: an annual report to the public about the quality of services delivered. The Health Act 2009 places this requirement onto a statutory footing.

Stringent regulation from bodies with increased statutory powers. The Care Quality Commission will have new enforcement powers. NICE will be expanded to set and approve more independent quality standards.

New Quality Observatories will be established in every NHS region to inform local quality improvement efforts

Strategic health authorities will have a new legal duty to promote innovation. This will be twinned with a portal to share evidence-based, best practice among clinicians and other NHS staff.

Devolvement of power to ensure the involvement of clinicians in decision making at every level of the NHS.

The introduction of medical directors and quality boards feature at regional and national level

Increasing patient information and choice will be introduced in the first NHS Constitution. Patient information will include the “systematically measure and publish information about the quality of care from the frontline up”.

Individualisation will become the key to the way in which patients are handled with “a personalised care plan”. Noting that one size doesn’t fit all.

Incentivisation of care outcomes will include a new best practice tariff and the paper suggests this will make funding reflect quality of care.

Partnership will be embraced, utilising “local authorities, with the services offered personalised to meet the specific needs of their local populations”

Prevention not just treatment will be paramount with “focus on improving health as well as treating sickness”.

Bevan’s editorial evaluates the internal market systems that have been tested within the NHS according to the Audit Commission and the Health Care Commission’s paper ‘Is treatment working?’ Suggesting that despite the core intention of the internal market models to improve quality and efficiency of services for patients, as Black insists, there is little evidence to suggest that this has resulted from past models or alternatively the scrapping of the internal market when Labour came to power in 1997; i.e. formation of foundation trusts, increased commissioning autonomy, patient choice or the incentivisation of health outcomes (payment by results). The NHS internal market models aimed to keep healthcare costs low by forcing providers to compete for patients not compete on the basis of quality. A stark contrast in rhetoric is seen in the proposals that are raised in the report, where marketization is the key driver of systemic improvement in quality of care. The ‘High quality care for all: NHS Next Stage Review final report’ shows the need for a more market-orientated strategy: a patient choice-led approach to hospital funding, the removal of barriers preventing the use of private health providers to carry out NHS work, and the devolution of management and budgetary control from Whitehall to local communities. It appears reform is circular and the report bears a resemblances to pre-1991 measures where received funding was based on local populations.

While the Report is indicative of the need for a tripartite arrangement for achieving quality, with stakeholders as informants and agents for change, Bevan argues that the internal market model proposed, although attractive, relies on the assumptions that “purchasers can be effective commissioners and that failing providers will be removed from the market”. The centrepiece of the White Paper reforms and Operating Framework is the handing over of decisions on care, treatments and commissioning solely to GPs, ultimately creating a stable internal model where there will be a ‘quality equilibrium’. GPs will be burdened with the challenge of acting as a middleman between the patient and provider, ultimately as a gateway to funding and care. They with fundamentally be dismantling the current monopoly of care provision. Their decision making will be accountable to local communities and a board. This ‘new buyer’ position is thought to remove duplication of population care commissioning and streamline decision making to where the Government foresees a natural place to put this responsibility. Propper et al, (2003) noted that in 1991, the Conservatives “created a set of buyers, funded by central government, who were free to purchase health care for their populations from both public and private sector suppliers. Public sector suppliers were therefore not given direct funding, but were set to compete with each other, alongside a small private sector, for contracts from these public buyers.” The autonomy of Foundation Trusts as buyers, in Bevan’s opinion, has led to a free market of care with little standardisation, with the private sector benefitting from the poor levels of governance most.

Bevans’s editorial suggests this may have benefit to the population because so much healthcare cost is driven by decisions that GPs make and should not be guided by ministerial change. Unviable providers will be pushed out of the market by new entrants, creating a self-regulated, internal market. The White Paper suggests there is evidence that health systems work better where budgets and spending power are moved as close to patients as possible. Providers will be paid according to their performance. Furthermore, that a bottleneck on the road to driving the quality agenda is linked to ministerial involvement in the day-to-day running of the NHS. This “new public management” gives GPs greater autonomy, placed them at arm’s length from the government, interlinks purchasing and providing functions, and increases competition with quality in mind. GPs will be responsible for all aspects of performance; acting as bureaucratic gatekeepers for all care needs their patients, and potential scapegoats for ministerial politicking. As it stands, effectiveness of this system is being hindered by hierarchical bureaucracy and political micromanagement on both a local and national level, including politically driven reforms with each new government.

The report suggests the forced autonomy of GP Consortia, comparatively to Bevan whom notes the “earned autonomy” system, in which, the independent health care inspectorate awarded each NHS provider an annual “star rating” of zero to three stars. Providers that scored well on the star ratings gain small financial bonuses but win much greater operational freedom, and the ability to apply to become an independent not-for-profit “NHS foundation trust” status. Autonomy was the incentive as this gave managers more choice. At the other end of the spectrum, providers that score zero stars are placed on “special measures,” and if progress is not soon forthcoming, their management is replaced. Bevan suggests that measures of ‘Provider’ performance (cost, equity of access, outcomes, patient satisfaction etc.) have proved difficult to progress forward and that only patients acting as ‘consumers’ has left a marked change on the system. I think it is questionable whether in the short term, GP buying powers will drive quality in a market in which there are few providers.

The 2008 DH report takes note of such and relays the importance of an individualised service in which patient information to inform choice will breed quality. Patient choice and measures of satisfaction will simultaneously puts more pressure on providers to increase performance of measured care outcomes, which in turn become incentivised by cash rewards. They foresee GP consortia, evaluating Services considered to be sub-standard and withdrawing them from service if patient satisfaction and quality care outcomes are not met.

Propper, C., Burgess, S., and Gossage, D. (2003).Competition and quality: Evidence from the NHS

internal market 1991-1999. Unpublished paper, University of Bristol.

3. As one of the accompanying papers to the White Paper Liberating the NHS, the DH has recently published ‘Transparency in outcomes – a framework for the NHS.’http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_117583 Please summarise the main approaches to improving quality proposed by this consultation.

The NHS Operating Frame is an accountability framework which should, if followed, ensure that the NHS Commissioning Board works to deliver better healthcare outcomes. This will be through measures that are valid, reliable and sensitive to change, notably evidence-based outcome measures, not process targets. The outcomes and incentives emerging from the frameworks will be organised around 5 national outcome goals /domains that cover all treatment activity for which the NHS is responsible. Outcomes appear to be related to feasibility, cost of improvements and pre-existing data sets. ‘Quality of care’ as advocated by Lord Darzi in realised in three of the domains; patient experience, safety and effectiveness. The domains fail to include outcomes of access/equity, expediency in service or efficiency, which seems to underlie previous national reforms imposed by the Labour Government in 1997. The Operating Framework fails to identify purposeful ways of addressing deficiencies and poor outcome performance. Incentives and regulation are suggested but may not be drivers.

Each of these five areas will have:

outcome indicators

improvement areas according to evidence (collected data, patient surveying of experience, etc)

Quality standards, developed by NICE, will inform the commissioning of all NHS care and payment systems.

Measuring and reporting on outcomes will focus the attention of clinicians and managers on how well they are doing, where the gaps might be between actual performance and the high aspirations of those who use the NHS. I don’t believe all the outcomes are necessarily reliable measures of quality. In Domain 2, for example, there is a focus on functional outcomes and qualities of life for long term illness, which may lead to patients to receive care they do not want. A great deal of the outcomes will be developed through incrementalism, for example those related to compassion, dignity and respect as indicators of the quality of care. The measured outcomes should represent the overall quality of healthcare provided by the NHS, as well as being responsive to population need and demand. The outcomes should also be attributable directly to the actions of health care provided within the NHS, to enable accountability. Best practice should be identified and used as a basis for ensuring that the framework itself does not propagate practice that in itself leads, however indirectly, to inequalities.

Key to the five high level outcome/domains is the need for a whole system approach in aspiring for complete transparency, effectiveness and patients exercising appropriate choices, alongside a need to balance local priorities. Seven principles underpin the framework which are intended to improve the quality of health care, these are:

Balanced between need and demand

Accountability and transparency

Internationally comparability

Patient and clinician centred environments and service delivery.

Excellence and equality promotion

Adaptability and focus on outcomes that can be forged in partnership with other public services.

International comparability

The Health Secretary will be able to hold the new independent NHS Commissioning Board to account for securing improved health outcomes, and measuring the outcomes that are most important to patients and healthcare professionals. These will be backed up by authoritative, evidence-based quality standards that will ensure everyone understands how those outcomes can be achieved

Based on past experience, what do you think are the likelihoods of success of this latest initiative? Please ensure that you consider these in the context of the likely challenges for the NHS over the next few years. (Please cite references if referring to evidence of the impact of previous initiatives).

The attention of policymakers is always firmly fixed on the future and rarely on documented measures of progress to assess the impact of one set of reforms, before the next wave of organizational change. Political values dominate empirical evidence for reform. With such levels of political uncertainty, it is hard to evaluate if in five years’ time, a general election will lead to a change in leadership and new Health Minister. With this in mind, change often does not necessarily make best use of available resources, skills and knowledge. The direct influence of research evidence on decision making is often tempered by factors such as financial constraints, shifting timescales and decision makers’ own experiential knowledge (Elliott 1999). With devolvement of power to local government, there is need for a precise balance to be struck between strategies based on choice and competition on the one hand, and local “voice” and democratization on the other.

On its own, I don’t think the NHS reforms will create a patient-led system. It is the people, the leaders and staff of the NHS, who will make or break the change process. Central to this, is the way in which the White Paper reforms will radically change the way in with GPs work collaboratively with providers to better the health and social care of the population they serve. Reorganisation will ultimately mean GPs will have to create new organisations and learn new skills. This will take behavioural change that is likely to be unwelcomed, as there’s a shift towards increased paperwork and decreased patient time. GPs have shown considerable levels of apathy towards working reforms and changes in service delivery in the past, including contracted hours. For example, previously published opinion has indicated that the medical profession were predominantly opposed to the package of NHS reforms outlined in the Working for Patients and were especially opposed to the administration of hospitals by self-governing trusts (Lister, 1990). GP consortia will be exactly that, self-operating. As the Operating Framework enters its live consultation it will be important to gather evidence as to strength of feeling with which those opinions, either for or against various aspects of the NHS reforms are held.

Reform is costly, since managers and other NHS professionals invest a huge amount of time and effort with each re-organization. The NHS faces the need to make cost savings of £15-20 billion over the next four years. It is faced with the challenge to create better health outcomes with less resources. Moving to the new system, maintaining control of day-to-day services, and implementing these savings is going to require skilled management. This at time when the NHS is shedding much of its management workforce – and when managers have been under political attack.

Introduced in 2004 as part of the General Medical Services Contract, the QOF is a voluntary incentive scheme for GP practices in the UK, rewarding them for how well they care for patients. the higher the score, the higher the financial reward for the practice. The very suggestion that this was ‘voluntary’ implies that not everyone welcomed such change.

The introduction of a free market, in which providers can tender for supplying a service as opposed to an internal market, could serve to drive efficiency savings and quality of care. However, accountability and patient choice would require considerably management and information sharing across GP consortia.

Department of Health. Payment by Results. London: DoH, 2002.

5. One of the differences in the current UK coalition government’s approach to improving quality, compared to previous governments’, is in the use of targets.

Targets are defined by the DH (DH 2004) as: ‘Targets refer to a defined level of performance that is being aimed for, often with a numerical and time dimension. The purpose of a target is to incentivise improvement in the specific area covered by the target over a particular timeframe.’ List the possible benefits of using targets to improve health/health services and then list the potential disadvantages of using targets. Use examples (either from your experience or from what you’ve heard on the media) to illustrate your points. On balance, are you for or against publication?

The benefits of health/ health services targets include:

Supports priority setting

Promotes consistency

Improves commitment and fosters accountability

Guides allocation of resources

Milestones for incremental improvements

The disadvantages of health/ health services targets include:

Priorities may be misdirected and are often politically engineered

Not always evidence based

Hard to measure/quantify

Not always related to health care outcomes

Often cost related, not need related.

Clouded by bureaucracy

Often incentive driven – ie pay to treat.

One such health target in the Labour Government’s Health Policy, the ‘four-hour target’, imposed in Accident and Emergency Departments has received mixed reviews. It was just one of a range of centrally imposed standards, most of them designed to speed up treatment. With such a target, volume of patients being treated and the expediency of their treatment is implied to be of greater importance that the quality of care or health outcomes of patients. The Guardian, (2010) reports “In opposition Lansley had been critical of the way that targets “distorted” the behaviour of doctors, saying in the case of A&E that people should be treated in relation to the “severity of their injury” not an arbitrary time limit”.

6. The current government is strengthening the role of the regulator. Please summarise the role of the Care Quality Commission (CQC). What challenges do you think the CQC will face over the next few years?

In April 2009, as the result of passing of the Health and Social Care Act 2008 (2008 Act), the outcome-based regulator, Care Quality Commission (CQC) was officially established. Their primary role is to act as an independent regulator of the quality and capacity of health and adult social care. They are responsible for registering, reviewing and inspecting health, adult social care and mental health services to judge the clinical quality of healthcare. Regulation directly relates to the quality of care experienced by people, so called ‘end users’, who use the services and align to the Coalition’s vision of a “user-centred, integrated service with a strong focus on quality” (CDC, 2010). Indeed, when services fail to meet the health and safety legal requirements of their compulsory registration, action against them is taken through strict enforcement powers.

In the next few years, as we transition from one governance model to the next, exchanging power to a local level, improvements must be closely aligned to quality and substantial, evidence-based research. Research grants are being cut and it is likely public sector research, including health research, will suffer as result of such austerity. The CDC’s broad remit to oversee NHS organisations is not limited to particular service areas or functions, like that of many of the existing regulators. They may find themselves over extending and unable to fully engage with the public in a transparent and meaningful way.

As ‘quality of care’ is embedded to offer assurance and to deliver improvements over time, there is potential for major disruption to be caused by the scale of the change management discussed within the White Paper. The CQC’s model of regulation puts user involvement and community level accountability at the core of their actions. Though this is consistent with the changes implied within both the White Paper and Operational Framework, there is still considerable ambiguity surrounded where responsibility will lie across all regulated services, especially with the introduction of GP consortia. Until this is resolved and clarity found, ambiguity will only be escalated by poor engagement of stakeholders and insufficient information dissemination through the crucial transitional points.

As patterns of service provision change, consistently identifying providers and commissioners, and then allowing for local communities to hold them to account for the services they provide may prove difficult. Once established within a professional capacity, the CDC will need to be aware of the information on outcomes and how it should be presented in a format that is accessible and meaningful to influence patient choice.

Furthermore, in their role as an advocate of patients, as a consumer champion, the CDC will also be required to ensure that people who use services understand the care choices available to them and are involved in making decisions about their own care and support. The CDC (2010) note that “Patient and public involvement in health organisation will be strengthened by the creation of HealthWatch England – a new independent consumer champion within the Care Quality Commission”. As a so called ‘consumer’ champion, this suggests end user expectations may be heightened. Questions must be asked of how HealthWatch England shall be regulated.

Summary reflection –Modules 5 – 9

Working as a learning disability nurse, poses a career fraught with many interesting and often frustrating challenges. However, this is a population that cannot be ignored or slighted medically just because they present with special needs (DOH 2001). Emerson et al. (2001) state that 2.5 – 3% of the population in the UK are among the learning disabled, with 30% of these individuals presenting with categorically severe or profound learning disabilities. Emerson et al. (2001) also tell us that frequently multiple learning disabilities present in the same individual, including physical and/or sensory impairments, physical or sensory disability and/or behavioural difficulties.

The five modules presented an opportunity to explore various aspects of this specialty area and reflect on the experience on a module by module basis. The act of revisiting the individual reflection pieces to present the current summary essay allowed for not only intellectually experiencing what I wrote, but it also allowed me to re-experience each situation and gain a new appreciation for the patients I worked with, the teams I took part in, the pros and cons of each situation and what I have learned that will be immediately applicable to a real world work environment.

Importance of reflection

Driscoll

and Teh (2001) tell us that practitioners can gain a stronger understanding about various interventions and protocols used, as well as reviewing the situation specifics of each incident, through the process of reflection. In particular, Foster (1985) stressed the importance of using a journal for purposes of written reflection on nursing practices and procedures in order to help clarify issues and make them more real and visual. Gardiner and Lawley (1995) believe that self awareness, one of the outcomes of nursing reflection, can enable staff to recognise the skills they employ and add meaning to their interactions with peers, team members and clients/patients.

There were many positives and negatives I experienced on a module by module basis, but in summary, these will be presented thematically.

Achievements

Module Five offered the opportunity to gain insight into the lifestyle experienced by those with learning disabilities. Similarly, Module Seven provided much needed and interesting information on the role of special health needs observed in those with special needs. This enabled me to make a difference for a client with diabetes through the development of a health care action plan that included the client’s smoking cessation; something the social worker assigned to the case was no knowledgeable of.

It was quite exciting to improve my communication skills throughout the five modules. For example, I was able to improve my rapport with other colleagues and various multidisciplinary healthcare professionals as well as clients as I achieved Module Nine communication based learning objectives. Godsell and Scarbrough (2006) comment communication skills are essential for healthcare practitioners. I believe they are even more critical for those working with the learning disabled. Another example was the ability to communicate effectively myself and help others, such as residential home management, communicate with a specific autistic client experiencing difficulty in choosing daily activities based on his disability. I was able to include this client in the decisions made which is critical to empowering the client with a sense of self. Similarly, during Module Five, I worked with a cerebral palsy client who was screaming due to discomfort; that was her mode of communication, which at the time I failed to recognise, but upon reflection now know actions as well as words are important modes of communication for those with learning disabilities.

Shortcomings

In general, a major negative I encountered was feeling I was used as “the help” rather than as a student nurse during my placement. This limited my ability to contribute and to grow personally and professionally. This was particularly evident during Module Five. Similarly, during Module Eight I was faced with a situation creating a significant amount of stress with no stress management advice or training opportunities from which to learn how to effectively cope. Contrary to Davidson’s (2001) research, there were no in-house stress management training opportunities to take advantage of.

There was a sharp discrepancy in Module Nine when reviewing the Valuing People (2001) discourse in relation to people with learning disabilities (PWLD) between what was written in the document and what I experienced at work; whereas the document stresses the rights inherent for all people be extended to PWLD, it was my experience that daily patients and clients were denied access to services due to budgetary measures rather than expressing interest in people’s rights to quality healthcare and a quality standard of life. Gates (2003) tells us those with learning disabilities have rights and should be encouraged to attain respect and reach their potential.

Challenges/Learning opportunities

One of the main challenges I experienced in the module series, particularly with Module Five, was relating theory to practice. However, through additional research and self motivated learning I was able to bridge the gap.

I also experienced a number of personal and professional challenges that I believe helped me become a stronger person and future professional. For example, at the beginning of Module Six, my mentor informed me he would not be available to me. This was very frustrating and upsetting as I knew without the help of a mentor, it would be very difficult to achieve the specific learning objectives outlined. However, I was able to turn this situation into a positive by becoming an active contributor to my own educational process by learning, understanding and solving real life problems (Kaufman, Mann & Jennet 2000). Similarly, in Module Nine, I found several of the teaching styles challenging, but that helped to develop my research skills and allow me to make contributions in the group and EBL sessions. This also helped to develop my learning and presentation skills.

An additional challenge in Module Nine was situation I encountered when viewing a medication administration concern at work. While I informed my manager of the situation, the team had a negative reaction rather than positive which would have been consistent with concern over patient/client care. Thomas, Mason and Ford (2003) tell us it is difficult for workers to become whistleblowers, especially in situations related to patient/client care or maintaining standards of care. This was an even more difficult challenge for me as I was only a student with limited status in the work environment. This was similar to the situation I found myself in during Module Seven when the community care social worker appeared to be neglecting the client’s diabetes, which is inconsistent with the General Social Care Council (2002) code of practices. I felt I was caught in the middle being a student making suggestions and pointing out care inconsistencies. Through the increased communication skills I developed, I was able to participate with the social worker in the role Gates (2003) identified as a learning disability nurse educator and facilitate changes.

In conclusion, through the combined effects of achieving the modules’ learning objectives, reflection on the positive and negative events as well as challenges I encountered throughout modules 5 – 9 have enhanced my skill development of working with the learning disabled, improved my problem solving skills, allowed for improved communicative ability both on interdisciplinary teams as well as working with learning or developmentally challenged persons. The added use of written reflection as a tool will further my ability to transfer these skills into practice in my future placement and allow me to be effective in my nursing capacity on day one of my engagement.

References

Davidson, J. 2001.

Stress management: Minute 10 guide

. New York: Macmillan, USA.

Department of Health. 2001. Valuing People: A new strategy for learning disability for the 21st century. White Paper CM5086. Great Britain.

Driscoll, J & Teh, B. 2001. The potential of reflective practice to develop individual orthopaedic nurse practitioner and their practice.

Journal of Orthopedic Nursing

,

5

, 95 – 103.

Emerson, E, Hatton, C, Felce, D & Murphy, A. 2001.

Fundamental facts

. London

:

The Foundation of People with a Learning Disability.

Gates, B. 2004.

Learning disabilities: Towards inclusion (4


th


ed).

London: Churchill Livingstone.

General Social Care Council. 2002. Code of Practice for Social Care Workers and

Code of Practice for Employers of Social Care Workers. [Online]. Retrieved from:

http://www.gscc.org.uk/NR/rdonlyres/8E693C62-9B17-48E1-A806-3F6F280354FD/0/CodesofPractice.doc

[Accessed 20 September 2008].

Godsell, M & Scarbrough, K. 2006. Improving communication for people with learning disabilities.

Nursing Standards

,

20

(30), 58 – 68.

Kaufman, DM, Mann, KV & Jennet, P. 2000. Teaching and learning in medical education: How theory can inform practice. London: Association for the Study of Medical Education Monograph.

Gardiner, A & Lawley, K. 1995.

Health and social care: Longman advanced GNVQ test and assessment guide.

London: Longman Publishing Group.

Thomas, A, Mason, L & Ford, S. 2003.

Care management in practice for the registered manager award: Essential reading for all care managers (2


nd


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Oxford: Heinemann Educational Publishers

1.5T MRI to Investigate Potential Etiologies of Brain Swelling in Pediatric Cerebral Malaria

Abbreviations:

Red Blood Cell (RBC)

Parts per billion (ppb)

Cerebral malaria (CM)

Blood brain barrier (BBB)

Abstract

Objective:

Cerebral malaria (CM) remains a common cause of death in African children. The pathologic hallmark of pediatric CM is sequestration of parasitized red blood cells in the cerebral microvasculature. Recent Malawi-based research utilizing a 0.35T MRI has established that severe brain swelling is associated with fatal CM, but the etiology of brain swelling remains unclear. Autopsy and clinical studies suggest several potential etiologies, but technical limitations of 0.35T MRI precluded optimal investigations into swelling pathophysiology. A 1.5T MRI in Zambia allowed for further investigations including susceptibility weighted imaging (SWI). SWI is an ideal sequence for identifying regions of sequestration and microhemorrhages given the ferromagnetic properties of hemozoin and blood.

Methods:

Using 1.5T MRI, Zambian children with retinopathy-confirmed CM underwent imaging with SWI, T2, T1 pre- and post-gadolinium, DWI with ADC and T2/FLAIR sequences.

Results:

Sixteen children including two with moderate/severe edema were imaged. All survived. Gadolinium extravasation was not seen. Cerebral perfusion was intact with DWI abnormalities sparing the gray matter. SWI findings consistent with microhemorrhages and parasite sequestration co-occurred in white matter regions where DWI changes consistent with vascular congestion were seen. Findings consistent with posterior reversible encephalopathy syndrome as a cause of swelling were also present.

Interpretations:

High field MRI findings indicate that vascular congestion associated with parasite sequestration, local inflammation from microhemorrhages and autoregulatory dysfunction contribute to brain swelling in CM.

Keywords:

sequestration; venous congestion; hemozoin

Introduction:

Pediatric cerebral malaria (CM), defined as

P. falciparum

peripheral parasitemia and unarousable coma with no other coma etiology evident, primarily affects children in sub-Saharan Africa [

1

]. Although antimalarial agents provide rapid parasite clearance, mortality rates remain high (8-25%) [

2

,

3

]. The pathological hallmark of pediatric CM at autopsy is intravascular sequestration in which parasitized red blood cells (RBCs) adhere to the endothelium of cerebral microvessels.

Although malaria causes almost a million deaths per year, neuroimaging capacity is typically limited in malaria-endemic regions. Only one large MRI case series from Malawi using a 0.35T MRI has provided insights into the

in vivo

structural abnormalities associated with pediatric CM [

4

]and CM mortality [

5

]. Other studies and case reports using higher field MRIs have been performed on adults [

6

,

7

], but adult CM appears to represent a different disease syndrome [

8

]. In adult CM, coma onset largely occurs some days after illness onset in the setting of multisystem organ failure often including hepatic dysfunction, renal failure and gross electrolyte abnormalities. As such, the coma of adult CM is clinically dominated by the effects of a toxic, metabolic encephalopathy. In contrast, in pediatric CM coma onset occurs very early in the malaria illness, often as one of the first signs of the illness, with very limited hepatic or renal involvement and no evident systemic cause for coma. MRI insights gained from imaging pediatric CM to date have been limited to low field MRI technology.

The recent pediatric CM MRI study used 0.35T technology to establish that increased intracranial pressure due to increased brain volume is the cause of death in CM [

9

], but the low field MRI technology was unable to further evaluated the potential etiologies of brain swelling in pediatric CM, so the underlying cause(s) of cerebral edema in CM remains unclear. Further study delineating the underlying cause(s) of swelling is needed to develop appropriate interventions. Potential etiologies suggested by autopsy and clinical studies include any/all of the following: (a) blood brain barrier (BBB) breakdown with resultant vasogenic edema [

10

,

11

]; (b) impaired perfusion resulting in cell death with cytotoxic edema [

12

]; (c) vascular congestion due to occlusion at the post-capillary venules [

13

]; (d) hyperemia with auto-regulatory dysfunction due to endothelial injury and CM-associated seizures, anemia and hyperpyrexia [

14

,

15

], [

16

]; and (e) diffuse cerebral microhemorrhages (i.e. ring hemorrhages) [

11

].

Hemozoin is an iron-rich breakdown product of the parasite’s metabolism of hemoglobin [

5

]. Hemozoin is present primarily in mature, sequestered parasites. Thus, susceptibility weighted imaging (SWI) [

17

], which is extremely sensitive to the magnetic field inhomogeneity caused by ferromagnetic substances, is an ideal imaging sequence for identifying regions of parasite sequestration. SWI also offers the ability to identify small hemorrhages on the order of several µg of blood per gram of tissue [

18

],[

19

].

We hypothesized that imaging retinopathy-confirmed pediatric CM with a 1.5T MRI including DWI, SWI and gadolinium enhanced sequences would identify pathophysiological mechanisms underlying cerebral edema in pediatric CM and undertook an imaging study of CM in Zambia where 1.5T MRI is available specifically seeking evidence of blood brain barrier breakdown, impaired perfusion, parasite sequestration, autoregulatory dysfunction and microhemorrhages.

Material and Methods:

Subjects and Recruitment

During the malaria seasons (Jan-June) in 2012-2014, comatose children with retinopathy-confirmed [

20

] CM underwent brain MRI on the 1.5T MRI scanner (Siemens Magnetom Essenza using Syngo MR 200 4A version software, Germany) at the Cancer Diseases Hospital in Lusaka, Zambia within 24 hours of admission. Inclusion criteria were: (1) admission to the pediatric high care unit of the University Teaching Hospital, (2) a Blantyre Coma Score of ≤ 2 [

21

], (3)

P. falciparum

infection as determined by a Paracheck Rapid Diagnostic Test (RDT), (4) the presence of malarial retinopathy, and (5) no other evident etiology for coma. A thick peripheral blood smear to identify parasitemia was also obtained prior to recruitment, but was not immediately available and was not required for inclusion. All children received standard antimalarial treatment, anticonvulsants, antipyretics, antibiotics and blood transfusions, as clinically indicated and in accordance with national treatment guidelines. As per present treatment standards, no steroids were given. Children with comorbid meningitis as determined by cerebrospinal fluid analysis were excluded from enrollment. Written consent was obtained from the child’s parent or guardian. Children with impaired renal function (creatinine ≥2.0) did not receive gadolinium. This study was approved by the Institutional Review Boards at the University of Zambia, Michigan State University and the University of Rochester.

Imaging

Gadolinium (Magnevist) doses were determined by individual patient weight and administered intravenously (0.2 mL/kg, 0.1 mmol/kg) by hand injection. The scanning protocol is provided in an appendix. Apparent diffusion coefficient (ADC) calculations were provided by the standard Siemens software algorithms [

22

]. SWI phase images were collected unfiltered and post-processed with a 64×64 high pass filter then viewed using SPIN (signal processing in nMR) software. SWI was also collected with a shorter echo time (15ms) for some subjects to avoid potential aliasing [

17

].

Interpretation

Images were reviewed independently by two radiologists (MJP; neuroradiologist, and SDK; MRI fellowship trained radiologist) and data were managed using NeuroInterp, a web-based program that allows radiographic findings to be entered into a searchable and quantified database [

23

]. Reader discrepancies, determined in advance of the analysis, were reevaluated by the two radiologists to develop a consensus interpretation.

Increased brain volume, the imaging finding associated with fatal cerebral malaria, was rated on a scale from 1-8 with 3 being no edema, 1 and 2 indicating atrophy. An edema score of 4-5 indicated minimal-mild edema, with no loss of sulcal markings. Grade 6 (moderate edema) was defined as loss of some sulcal markings. An edema score of 7 represented moderate/severe edema with diffuse sulcal and cisternal effacement universally evident but without herniation present, and the severe edema score of 8 required sulcal and cisternal effacement with evidence of herniation.

MRI findings coded within the NeuroInterp database that could plausibly be associated with the five potential pathogenic mechanisms of brain swelling in CM were then reviewed. Specifically, (a) to evaluate diffuse BBB breakdown causing vasogenic edema, we looked for evidence of gadolinium enhancement [

24

], (b) to assess for impaired perfusion and subsequent cytotoxic edema we looked for gray matter diffusion weighted imaging (DWI) abnormalities [

25

], (c) evidence for vascular congestion or venous micro-occlusion was sought by looking for white matter DWI abnormalities [

26

], (d) autoregulatory dysfunction was evaluated by looking for focal regions of symmetric hemispheric edema of varying confluence in regions susceptible to autoregulatory vulnerabilities [

9

,

27

], and (e) SWI abnormalities were assessed clinically and quantitatively based upon effective voxel susceptibility with the anticipation that these would be located in the same anatomical regions as ring hemorrhages and sequestration have been identified in prior autopsy studies [

28

]. Given the small anticipated sample size (<20 subjects) and the lack of a normal control group, no statistical analyses or comparisons were planned.

Results:

Patient Characteristics and Data Acquisition

Twenty three children met study inclusion criteria during the enrollment period. Parents declined participation for 2 children and 5 children were deemed too ill to transfer for imaging or died before imaging could be performed, so 16 subjects were imaged–5 (31%) were male and the mean age was 6.4 years (range 1-15). Table 1 provides demographic data and admission clinical characteristics from the 16 subjects who were imaged.

Of the 5 consented children who were not imaged, 3 died. Among the 16 subjects imaged, the scans for one patient was non-diagnostic on the SWI sequence due to movement artifact. Renal function could not be ascertained on two children, so these subjects did not receive gadolinium. There were no fatalities among the imaged study subjects and none had clinical sequelae evident at discharge. Table 2 provides the frequencies of the 1.5T MRI findings identified and captured in NeuroInterp.

MRI Findings

Increased brain volume: None of the subjects had severe (grade 8) edema. Moderate/severe (grade 7) edema was present in 2/16 (13%); moderate (grade 6) edema in 4/16 (25%); minimal/mild (grade 4 & 5) edema in 7/16 (44%) and no edema in 3/16 (19%).

T2 signal changes: The total number of cases exhibiting white matter increased T2 signal was 12/16 (75%), and two distinct patterns were observed: primarily subcortical (10/12, or 83%) and primarily periventricular/peritrigoneal (2/12, 17%) (Figure 1). These generally occurred in isolation; only 2 cases had both findings.

Gadolinium enhancement: The expected normal physiological intravascular and circumventricular organ enhancement was evident in all subjects on the post-contrast images (Figure 2). A small region of subtle focal cortical enhancement was seen in one subject with positive SWI signal and no associated T2 abnormalities consistent with a capillary telangiectasia. There was no evidence of gadolinium extravasation in the other 13 patients who received contrast.

Cortical findings: Cortical swelling and increased T2 signal was seen in 10/16 (63%), but these signal abnormalities were relatively mild in extent, confluent, and without associated cortical DWI findings. Increased cortical T2 signal was generally diffuse, with only 2/16 (13%) having a posterior predominant pattern [

4

]. DWI showed restricted water diffusion in the subcortical white matter in 10/16 (63%) which was confirmed by accompanying ADC maps.

Basal Ganglia and Thalamus Abnormalities: The structures in the basal ganglia had different levels of involvement. T2/FLAIR signal abnormalities were present in the globus pallidus and putamen in 10/16 (63%), and the caudate in 9/16 (56%). While frequently involved simultaneously, there was generally a region of predominance (Figure 3). Regional differences were also illustrated in the DWI images. Fifty six percent of subjects had DWI abnormalities in the globus pallidus, 13% in the putamen and none in the caudate.

Pontine and Brainstem Signal Abnormalities: This was assessed at two levels, within the pons at the level of the middle cerebellar peduncle and within the brainstem at the level of the substantia nigra. Pontine involvement was seen in 9/16 (56%) and brainstem in 11/16 (69%). Abnormalities were usually diffuse, and consisted of generalized increase in T2 signal. However, focal areas of involvement were also seen.

Corpus callosum: Showed increased T2 signal and thickening in 10/16 (63%) with 6/10 having associated positive DWI findings as confirmed by ADC maps. The splenium was the primary site of involvement in 9/10 (90%) of cases.

SWI Findings: Decreased signal is defined as a positive SWI finding as it localizes to areas of magnetic field inhomogeneity caused by the presence of a ferromagnetic substance (Figure 4). SWI findings were noted along the regions of the venules of both the superficial and deep venous systems corresponding to areas of parasite sequestration and ring hemorrhages. SWI resolution did not allow distinction between gray and white matter involvement in the cerebellum. One SWI dataset was not interpretable due to severe motion artifact. In the remaining cases, 7/15 (47%) showed abnormal paramagnetic signal within the following regions of the parenchyma: corpus callosum (7/15, 47%), sub-cortical white matter (6/15, 40%), cerebellum (5/15, 33%), lenticulae striate (5/15, 33%), and periventricular white matter (2/15, 13%). In two subjects, both the internal capsule and optic radiation had abnormal paramagnetic signal.

The susceptibility of heavily infected red blood cells is ~1880 parts per billion (ppb) relative to water [

18

]. The effective voxel susceptibilities in the corpus callosum and junction of the cortical gray and white matter was 50 ppb relative to water in SWIM. As distributed within the voxel, this represents a 1/38th decrease in susceptibility. Given the voxel size of 0.5 x 0.5 x 2.0 mm3, this represents 1/78th µL. Assuming the capillary volume is ~5% (or 1/20th of the pixel) [

29

], this indicates that ~half of the capillaries are filled with hemozoin.

The combination of moderate to severe symmetrical cortical swelling (edema score of 6 or 7), with corresponding underlying subcortical white matter changes with associated DWI and ADC findings was evident in 4/16 (25%) of cases (Figure 5) with two of the four showing a predominantly posterior distribution.

Table 3 summarizes the MRI findings seen using 1.5T in 16 Zambian children with CM in the context of the proposed mechanisms for brain swelling in CM and the 1.5T MRI findings anticipated for each mechanism.

Discussion

:

MRI findings using a 0.35T MRI have shown that death from pediatric CM occurs due to increased brain volume [

9

] but low field MRI was unable to further delineate the etiology for the brain swelling. Interventions studies aimed at reducing or preventing cerebral edema in CM would ideally target the underlying mechanism of swelling. Existing clinical and autopsy data suggest at least five potential etiologies for brain swelling in CM. In this study, we describe what the MRI findings associated with each of these potential etiologies would be and then used 1.5T MRI in children with retinopathy-confirmed CM to identify the presence or absence of findings consistent with each of the five proposed etiologies. As such, the results of this study can be subdivided into evidence both for and against these specific potential origins of brain swelling in pediatric CM.

Decreased SWI signal was evident on the brain MRIs of children with CM and furthermore these changes were seen in regions where autopsy studies have shown microhemorrhages (Figure 6) as well as in the regions where sequestration is common. Since the SWI signal effectively identifies blood and hemozoin, both sequestration and ring hemorrhages were likely identified. Marked T2/DWI abnormalities were evident in the subcortical brain regions most sensitive to venous outflow obstruction. If perfusion is obstructed in regions with SWI signal changes, then blood flow to the tissue would decrease by ~50% which is consistent with what is seen in an animal model of malaria where blood flow was found to be reduced to 53% +/- 12% [

29

].

In the setting of the sequestration-associated SWI abnormalities and intact large venous drainage systems (i.e. no venous thrombosis), the T2/DWI findings are strongly suggestive of a venous obstruction phenomenon in the capillary bed system. Much of what is known about pediatric cerebral malaria has been learned from autopsy studies, so it is reassuring to see that the distribution of microhemorrhages and parasite sequestration found in prior autopsy studies are very similar in distribution to the microhemorrhages and parasite sequestration identified in living children who survived CM.

Vasogenic edema was demonstrated by increased T2 signal in the white matter. Cytotoxic edema has a similar appearance, but is accompanied by restricted water motion identified by increased DWI signal. Both were evident in this cohort, with cytotoxic being more common. This tended to be significant and diffuse. None of these children died and there were no clinical sequelae at discharge, suggesting that the process is reversible, and may represent early cytotoxic edema rather than tissue infarction.

MRI findings of symmetrical cortical swelling with underlying white matter changes were seen, consistent with posterior reversible encephalopathy syndrome (PRES) and suggestive of autoregulatory dysfunction. Pediatric CM is congruent with many other clinical conditions associated with PRES. Specifically, pediatric CM generally involves a rapid neurologic deterioration, usually in the setting of seizure, followed by relativity prompt full recovery in most patients. Radiographically, brain swelling with underlying vasogenic edema associated with positive DWI findings is the hallmark of both CM and PRES [

4

,

16

]. Autoregulatory dysfunction as a result of the primarily endothelial process associated with parasite sequestration in CM may result in vasoconstriction coupled with hypoperfusion causing vasogenic edema and associated brain swelling. This is the favored theory for the etiology of the radiographic findings seen in PRES [

27

].

We found no evidence of cortical cytotoxic edema and there was no radiographic evidence of gadolinium enhancement although gadolinium was clearly seen within the vessels and in circumventricular organs. Gadolinium, as a contrast agent, is chelated by a range of very small molecules (Magnevist 0.54kDa)[

30

]. These agents are all hydrophobic, so they do not cross the intact BBB. At autopsy in CM, areas of sequestration show fibrinogen (340kDa)[

24

] leakage and ring hemorrhages which require sufficient BBB breakdown to allow a deformable, non-parasitized blood cells (7 µM) to escape. The SWI imaging in this study identified ring hemorrhages so some BBB breakdown associated with their presence must have occurred, but if there was associated gadolinium extravasation, the quantity and concentration of gadolinium was insufficient to be visually evident on MRI. Gross BBB breakdown indicative of severe vasogenic edema was not evident in this small series of non-fatal pediatric CM.

This study is limited by the small sample size, less severe disease spectrum, and lack of a comparison group. In Zambia, children felt to be at risk of imminent death were not imaged since transport for imaging there requires ambulance transportation to an adjacent facility. The small number of subjects prevented meaningful quantitative analyses despite the use of NeuroInterp. Although no a prior analyses were planned, we did conducted a post-hoc comparison to determine if the edema score or the presence of SWI, DWI, or focal cortical abnormalities was associated with age, coma duration prior to admission or the seizures prior to admission. No associations were found (all p’s >0.05). The absence of subjects with severe brain swelling or fatal disease may have impacted our findings, as florid BBB breakdown might not occur to a significant degree in less severe CM. Normal MRIs on a similar aged comparison group were not available. In the Zambian setting, most imaging is obtained on advanced disease with normal images being uncommon. Acquisition of imaging in an age-comparable group of healthy children was not feasible given the risk of sedation, particularly in this environment. Finally, more quantitative MRI analyses would have allowed more optimal assessments, but the power injections equipment required to obtain perfusion studies and/or dynamic contrast enhanced studies, which could detect contrast influx too small to be visually evident, is prohibitively expensive and was not available in this resource limited setting.

Conclusions:

Pediatric CM brain MRI findings in non-fatal cases using 1.5T technology suggest that vascular congestion, autoregulatory dysfunction, and microhemorrhages likely contribute to brain swelling pathogenesis.

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World Health Organization defines health as “the science and art of preventing disease, prolonging life and promoting health through organised efforts of society” (WHO, n.d.). While health impact, can present positive or negative effects to an individual’s well-being or mental health. Sexual activity is known as an essential element of human health and well-being contributing to quality of adult partnerships and a requirement for natural creation and, so the continued existence of humanity. Yet it poses a lot of risks to health through transmission of sexually transmitted infections (STIs). Although syphilis, gonorrhoea and chancroid are generally considered as the main STIs, various other pathogens are also transmissible including Herpes Simplex Virus type 2 (HSV-2), Chlamydia trachomatis, Herpes Papilloma Virus (HPV), Hepatitis B Virus (HBV).

The purpose of this paper is to first discuss the public health impact of STIs, followed by the approaches to their control/prevention in the UK. Unfortunately the public health impact of STIs is negative as it causes or contributes to ill-health. In the UK and other parts of the world, STIs pose enormous challenges for the public health which may be individual well-being, mental health or the burden on health costs. Focus of this paper will be mainly on genital Chlamydia, gonorrhoea, syphilis, HIV/AIDS, and Human Papilloma Virus (HPV – [genital warts]) amongst other STIs due to the reported high rates of infection.

Sexually transmitted infections affect people of all ages with the greatest occurrence amongst those under the age of 25 years (Nicoll, 2001; Johnson, 2001; NCSP, 2009). In the UK, certain groups of populations are affected more than others thus creating sexual health (s.h.) inequalities. Primary and secondary syphilis occurs more often in the African community than it does in the White community. Gonorrhoea is reported more commonly among some ethnic minorities while Chlamydia infection rates are disproportionately high in the under 25s. Data on ethnic differences in behaviour and infection susceptibility are meagre and the observed differences are not accounted for. Poverty could be attributable to the high incidence rates in the ethnic minorities as STIs are more common in ethnic minorities than among the white majority which might also be a link between an increased risk and belonging to a minority population. In 2007, women aged 16-24 accounted for 65% of all Chlamydia diagnoses, genital warts were 55%, infections from gonorrhoea were 50% through the genitourinary medicine clinics (GUM) within the UK (HPA, 2008). Chlamydia rate of infectivity at national level for young people aged 15-24 is one in nine supporting the level of sexual activity in that group.

The conquest of the majority of communicable disease has been one of the main successes of modern medicine. The diseases have presented the highest causes of mortality and morbidity prior the twentieth century. Until the mid twentieth century in Britain, particularly for women, the pleasures of sex were tempered by the dangers of poor health and social outcomes. However, communicable diseases menace has mostly been contained due to the advancement of contemporary antibiotics and effective vaccines, and remarkably sex became safer.

Although sex became safer, STIs rates significantly increased in recent years in the UK predominantly from unsafe sex practices arising from various factors like sexual risk behaviours and poor infection control. They have become a major public health concern as highlighted in the National Strategy for Sexual Health and HIV (Department of Health, 2001). The 16-24 year age group comprising of only 12% of the population but with the largest diagnosis of STI cases of almost 50% of newly acquired infections. Control of STIs is complicated since many of them are asymptomatic. The economic impact caused by STIs is huge on health services with high costs mostly experienced in the management of infection complications. However, older women and men are also at risk especially those entering into new relationships after breaking up from a long-standing relationship. Hence there is ample requirement for protecting, supporting and restoring s.h. in people.

Public Health Impact of Sexually Transmitted infections in the UK

History

Syphilis and gonorrhoea records have been collected for more than 80 years. In England, Wales and Scotland, diagnosis of syphilis and gonorrhoea was recorded highest in 1946, which coincided with the coming back of the armed forces after World War II (Figure 1). A sharp drop was subsequently detected and was linked to the use of penicillin and the re-establishment of social stability.

Figure 1: Numbers of diagnoses of syphilis (primary, secondary and early latent) by sex, GUM clinics, England, Wales and Scotland*, 1931 – 2003.

*Corresponding Scotland and Ireland data are excluded as they are not complete from 1925 to 2003.

Source: KC60 statutory returns and ISD(D) 5 data.

During the sixties and seventies, there was a stable rise in STIs diagnosis owing to more relaxed mind-sets to sexual behaviour. There was an upsurge in cases of Syphilis in males, while in women the number of cases continued to be stable. This implied sex among men during that time turned out to be the main route of transmission (CDC, 1999). Yet an increase in diagnosis was recorded in both males and females for gonorrhoea, genital warts and genital herpes signifying that these infections were acquired during heterosexual sex. Probably the rise in a small number of the STIs could have resulted from enhanced diagnostic sensitivity or public awareness, adding to higher rates of infectivity.

However, in the early eighties, HIV and AIDS were first reported which supposedly had considerable effect on other serious STIs. A brisk drop of syphilis and gonorrhoea diagnosis was experienced in early to mid- eighties. This happened simultaneously with the widespread AIDS coverage of embracing of safer sex behaviours, and resulted in a subsequent decline in transmission of HIV amongst male homosexuals (Bosch, 1995).

Sexually Transmitted Infections Trends

Since 1998 to mid 2004, cases of Chlamydia infection rose by 108%, gonorrhoea by 87% and infectious syphilis by 486% (Ryan, 2004). Still the young people bear the greatest burden. In 2001, women under 20 years of age had reported cases of 42% from gonorrhoea and 36% of Chlamydia. As reported by the Department of Health (DH), diagnosis of new STIs and other STI diagnosed cases in the UK such as re-infections made in genitourinary medicine clinics (GUM) showed a gradual rise in 1999-2008. The introduction of the National Chlamydia Screening Programme (NCSP) in 2003 and other health screens in England, Wales and Northern Ireland and in 2005 in Scotland resulted in an increase of s.h. screens from 759,770 to 1,219,308. For the same period, there was an increase of HIV tests recorded from 520,278 to 951,148. In 2008, uncomplicated infections from Chlamydia, syphilis, genital warts, and genital herpes rose considerably from 1999. Yet for the same year, cases of new diagnosis of gonorrhoea and syphilis were reported to have dropped.

The National Survey of Sexual Attitudes and Lifestyles (NATSSAL) identified sexual behaviour as the risk of acquiring an STI in the young age groups. The factors included lower age at time of having sexual intercourse for the first time, partners frequently changed, increased likelihood of being involved with concurrent partnerships, irregular use of condoms and the increased chances of being involved with a partner who comes from a part the world other than UK that is regarded as high risk (Hughes, 2000; Johnson, 2001, Mueller, 2008; Skinner, 2010). However, the young people appear to be the central part of the risk of passing on the infection to other groups of the population. Thus prevention should be mostly targeted at this core group which would result in economic benefits.

Chlamydia

Chlamydia trachomatis is the most widespread bacterial pathogen transmitted through infected secretions and mucous membranes of urethra, cervix, rectum, conjunctivae and throat following unprotected sexual contact with an infected partner. In addition, an infected mother can infect her baby during vaginal delivery. It is the most commonly diagnosed STI in individuals less than 25 years in the UK (Fenton, et al, 2001; Creighton, et al, 2003). Most people infected with Chlamydia are asymptomatic until a diagnostic test is performed and in most cases they do not seek medical care. Thus, in those individuals affected by the disease, if efficient and effective health measures are not administered, the diases has the potential of causing a significant amount of health complications to women’s well-being including infertility and pelvic inflammatory disease (Golden, et al, 2000; Garnett, 2008). There is also greater risk in those with recurring infection and untreated infections to spread to other reproductive organs resulting in chronic pelvic pains (La Montagne, et al, 2007). The number of diagnosed episodes of Chlamydia infection has been rising over the past 10 years (Figure 1). Furthermore, the economic impact of Chlamydia infections on the health service is enormous with high cost in the management of female health complications arising from Chlamydia infection (Garside, 2001; Simms, 2006). Because of the impact of Chlamydia infection on the health of young people, it is important to identify and treat infected patients and their partners and as a result reduce the burden of the disease on the people and health systems.

Figure 1: Rates of genital Chlamydia infection by sex and age group (1995 – 2004).

Source: Health Protection Agency, London

In men Chlamydia infection causes epididymo-orchitis and urethritis. Also rectal pain, discharge and bleeding occur from proctitis which is from infection of the rectal mucosa. Additionally, individuals can develop dysuria after their treatment for gonorrhoea causing postgonococcal urethritis.

HIV/AIDS

In nearly three decades, ever since HIV was first identified, HIV infection has turned out to be a deadly disease and has caused a disturbing adversity to humans, in almost all areas of life. In the early eighties, when the first few cases of AIDS were reported, few might have realised its propensity to become a global public health problem. The UK is facing a s.h. crisis. Between 1999 and 2002, HIV prevalence rose by about 20% annually, and almost a third of HIV-positive individuals did not know their HIV status (Fenton, 2002). Furthermore, the increase in rates of HIV infections could be brought about by the rise in STI incidences in the public as already highlighted in this paper. In 2004, a minimum of 49,000 individuals had HIV in England.

The disturbing extent of its increase, infection, very long incubation phase, secondary susceptibility of spread and the absence of a vaccine to prevent it calls for attainment of comprehensive information about the disease. Currently, AIDS prevention mainly relies on health education and behavioural modifications based on AIDS awareness, predominantly in the high risk group of young people.

Gonorrhoea

Gonorrhoea infection is caused by an organism, Neisseria gonorrhoeae (N. gonorrhoeae) which is highly infectious and a bacterial sexually transmitted pathogen. In heterosexuals, its occurrence is associated with age (<25 years), black ethnicity, and socioeconomic deprivation. It is estimated that the disease may possibly be more common in men who have sex with men than in heterosexual men (McMillan, 2000; Bignell, 2006; HPA, 2008). At the endocervix and urethra in women, the disease is also asymptomatic, and usually (>90%) asymptomatic in the rectum and oropharynx in both women and men (Hook, 1999; Knox, 2002). In the GUM clinics and various health services, testing for N. gonorrhoeae is a core factor of screening for STIs. Although there is not much evidence to direct testing, every mucosal site correlated with the disease symptoms ought to be tested for infection (Barlow, 1978; Harry, 1997; CDC, 2002; Ghanem, 2004; Bergen, 2006). Screening measures are subjective to an individual’s sexual history and repeat screening may be encouraged (Miller, 2003). The number of new gonorrhoea infections in the United Kingdom dropped from 18,649 in 2007 to 16,629 in 2008, the lowest number recorded since 1999. Its treatment is simple through the administration of antibiotics orally or as an injection but recently some strains have resistant (Frenton, 2003).

Syphilis

Syphilis is caused by infection from Teponema pallidum subspecies pallidum, is a mucocutaneous STI with high infectivity in the early infectious stages. It may also be transmitted through the placenta in pregnant women from week nine of gestation onwards. Screening is recommended for all asymptomatic patients attending GUM clinic or those attending other health services are referred appropriately (Nicoll, 2002). Incidence of syphilis also showed a 4% fall, from 2,633 in 2007 to 2,524 in 2008, (HPA, 2008). Over the last year, there has been almost three times the number of heterosexual cases of syphilis in south London than were diagnosed in 2001 (25 in 2001, 72 in 2002 and over 40 cases in the first five months of this year) (Fenton, 2001; Poulton, 2001; HPA, 2008). Infection from syphilis is controllable and treated with penicillin as the best recommended or doxycycline as an oral substitute.

Human Papilloma Virus

The spread of genital HPV is normally spread during intimate, skin to skin or sexual contact. It is also asymptomatic and can be dormant for years. HPV high risk strains are 16, 18, 31, 33 and 45, which are likely to increase the probability of getting cervical cancer. These strains exist in nearly every woman with cancer of the cervix. Although HPV testing is still not regularly accessible, the National Health Service is considering it to be included in the screening programme of cancer of the cervix. Women who test positive for high risk types of HPV are more likely to need treatment for borderline or mildly abnormal cervical smears. Although in ninety percent of HPV cases, clearance of the virus occurs naturally within two years. Yet, continued use of condoms may possibly facilitate in lowering the risk of infection from genital HPV. Infection from HVP is now being prevented through administration of vaccines for types of HPV that causes cervical cancer (Wallin, 2002; Winer, 2006). In 2007, the UK DH licensed Cervarix as a vaccine against cervical neoplasia for use in 12-13 year old girls.

However, the genital warts strains 6 and 11 normally develop within weeks or months following sexual contact with an infected partner who might be asymptomatic. Sometimes if treatment is not administered, they might disappear, or remain unaltered and not cancerous. In 2007, genital warts were the most commonly diagnosed STI accounting for 49,250 cases showing an increase of 8% from that in 2006 (HPA, 2008).

Approaches to prevention and Control of sexually transmitted infections

The health of the people and the social and economic success of the UK are extremely connected. The related economic and social costs to public health are enormous and surpass UK’s future. Marmot’s (2010) six recommendations further support the prevention and control of STIs in UK’s population. In two of the six recommendations he states that, “enabling all children, young people and adults to maximise their capabilities and have control over their lives” and that of “strengthening the role and impact of ill-health excellent well-being over their lives”. It is vital that UK’s population is educated on s.h. issues so that they are able to make well informed sex decisions that contribute to their well-being and reducing the burden caused by STIs. Marmot’s report further emphasised other research work (Picket & Wilkinson, 2009) that “it is not only the poor who suffer from the effects of inequality, but the majority of the population”. High priority should therefore be given to the integration of STI control measures into primary health care. The worldwide interest in and resources committed to preventing AIDS provide a unique opportunity for health workers to make considerable progress in controlling the other STIs.

Control programmes for STIs will continue to be the most prominent in public health management and have been at an increase since the mid nineties with rates of unwanted pregnancies still being reported high. Strategies to prevent transmission of organisms spread by intimate human contact must remain flexible and adapt to the social, technical, clinical, financial and political realities. A strategy of primary prevention, based on sexual behavioural change combined with the provision of adequate clinical services, is vital for the control of STI. In response to the re-emergence of these diseases in the UK, it was decided by the Department of Health to open for the first time ever STI clinics (GUM) across the country to help reduce the burden of the STIs. These clinics are staffed with a multidisciplinary group of specialists that offer s.h. services to different age groups of the community.

Given the unequal burden of STIs for young people, it is imperative to ascertain effective prevention programmes. Although enhancing access to Chlamydia testing has been an important and urgent focus of the NCSP and has led to renewed efforts to increase access to Chlamydia testing (WHO, 2001; Santer 2000; Santer, 2003). While more people learn their Chlamydia infection status, factors related to Chlamydia awareness remain crucial to identify in order to design comprehensive Chlamydia management services that meet the needs of the population at risk of infection (Brabin, et al, 2009).

Responsibility for the National Chlamydia Screening Programme (NCSP) was taken over in 2005 by the Health Protection Agency from the Department of Health. Screening is conducted in various locations across the UK, the main ones being youth services, community contraceptive services, general practices, education premises (universities or colleges). This oversees all the screening plus s.h. awareness media campaigns. More partnership work is required to tackle the variances including that of offering screening in health clubs such as gyms and boxing clubs.

Presently prevention and control of STIs is aimed at minimising the period of infection (i.e. early diagnosis and treatment), reducing the number of susceptible persons and reducing infection transmission (modification of sexual behaviour plus frequent use of condoms). A study by Shiely, et al (2009) showed that in Ireland, age specific behavioural interventions could be effective by targeting increased use of condoms to decrease STI incidences. Also in order to boost condom use, a 5% reduction from 13.5% in taxation on condoms could be implemented at policy level. Other studies also revealed age as a risk factor for STI transmission and to that regard there should be enhanced sex education promotion to the target group to enhance behavioural changes ((Holmes, 2004; Manhart, et al, 2004; Fenton, et al, 2005). A further study also showed that diagnosis of a viral STI was not associated with multiple partners but however it was possible for females who had more than one sexual partner to be more likely to use protection since they will be more experienced and aware of STI infection (Fenton, et al, 2005).

Although there has been a rise in frequent use of condoms universally, in the UK the scale of their usage is still low. The enormous differences could be associated with economic and social causes of sexual behaviour which further affect intervention. While personal behaviour modification is fundamental to s.h. enhancement, attempts should be made to tackle those that relate to the social circumstances thus addressing factors that play a part to risky sexual behaviour (Wellings, 2006). More work is required to tackle the menace from STIs by the provision of comprehensive s.h. education, promotion of s.h. interventions, easy access to s.h. services, high quality individualised s.h. education to empower those at risk.

Accomplishing excellent s.h. for the population of the UK has always created its own distinctive challenges. Meagre s.h. is often disproportionately impacting on those who are already at risk and experiencing inequalities, for instance the young people, black and minority ethnic groups, those in lower socio-economic class, and gay men. Thus the need for comprehensive behavioural interventions that would tackle the social context for individual-level programmes, support and sustainability of behavioural change, and the structural factors that is contributory to risky sexual behaviour. STIs have been shown to be important cofactors in HIV transmission (Fleming, 1999). New approaches to STI control and prevention are needed to reduce the spread of infection and minimize associated suffering.

The National Institute for Health and Clinical Excellence (NICE) suggested the need for health professionals to identify individuals at higher risk of becoming infected with STIs, ascertained by one’s sexual history, and organize one to one talks to minimise the risk of infection. However, the s.h. guidance recommends a variety of circumstances for assessing risk of infections which include opportunities where a patient seeks contraception, abortion or pregnancy or when conducting cervical smear test, obtaining STI test, obtaining travel immunisation, and during regular care. Additionally for those who have been tested positive, should be assisted in having their partners tested and treated.