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Surveillance of injecting‐related injury and diseases in people who inject drugs attending a targeted primary health care facility in Sydney's Kings Cross

Surveillance of injecting‐related injury and diseases in people who inject drugs attending a... P eople who inject drugs (PWID) are a population group with a disproportionate burden of disease and limited access to health care compared to the general population. 1 While the burden of disease associated with blood‐borne viral infections (BBIs) such as HIV and hepatitis C virus (HCV) has been well documented in PWID, other health issues such as injecting‐related injuries and diseases (IRIDs) have received less attention. A series of conditions is grouped under IRIDs and there is variation in the definition and classification of these conditions in the literature. Most often, cutaneous conditions such as abscess and cellulitis are included among IRIDs together with sequelae such as septic arthritis, osteomyelitis, septicaemia and bacterial endocarditis. Other conditions associated with injecting drug use such as haematoma and injection site scarring (also known as ‘track marks’) are also sometimes classified as IRIDs 2 or included in a separate category of injecting‐related problems. 3,4 However, BBIs and drug overdose, although associated with injecting drug use, are not generally classified as IRIDs. Injecting practices such as repeated injection in the same area, not cleaning the injection site and use of non‐sterile injecting equipment; ubiquitous skin flora (e.g. streptococci, staphylococci); and the physical and chemical proprieties of the substances being injected can all contribute to skin damage and the development of cutaneous and vascular IRIDs. 5–9 Outbreaks produced by spore‐forming bacteria (e.g. Clostridium novyi, Bacillus anthracis ), invasive group A streptococci and the emergence of methycillin resistant staphylococcus (MRSA) infection have also been described in PWID. 5,6,10–13 Previous studies have identified a substantial burden of IRIDs among Australian PWID with self‐reported lifetime prevalence of abscesses between 16 and 27%, thrombosis 4–12%, septicaemia 2–9%, and endocarditis 1–4%. 2–4 International studies have reported even higher prevalence of IRIDs. Thirty‐two per cent of participants in a San Francisco study had abscesses when examined by a clinician 14 (likely related to the injection of black tar heroin) 15 and 69% of methadone treatment patients in Dublin reported ever having had an abscess. 16 The current study aimed to identify the range and prevalence (lifetime and recent) of IRIDs and associated risk factors among PWID attending a targeted primary health care service for the first time. Methods Our study was conducted at Kirketon Road Centre (KRC), a targeted primary health care service of the South Eastern Sydney Local Health District in Sydney's Kings Cross. KRC aims to prevent and treat HIV/AIDS and other transmissible infections in PWID, ‘at‐risk’ young people and sex workers. 17 The Centre is among the most integrated health services of its kind, 18 offering free, anonymous and confidential medical and nursing care, counselling, social welfare assistance, a needle and syringe program, outreach services and a methadone access program to a large cohort of people actively engaged in injecting drugs illicitly. KRC is thus well placed to offer medical assessment and treatment for IRIDs in this cohort. KRC also contributes to a broader public health mandate through active surveillance, developing, implementing and evaluating prevention and harm reduction interventions 17 and disseminating its findings to the broader public health field. We conducted a retrospective cross‐sectional study based on data collected between March 2010 and May 2012. All new KRC clients identified as having ever injected drugs who completed a clinician‐administered (by doctor or nurse) KRC intake survey during this period were included. The intake survey (in use in its current form since March 2010) incorporated a table to record lifetime and recent experience of IRIDs. A group of experienced KRC clinicians developed the table to ensure that a wide range of clinically relevant conditions were included. The range of IRIDs included cutaneous conditions (abscess, cellulitis, skin ulcer), ostheo‐articular and systemic infections (osteomyelitis, septic arthritis, septicaemia, endocarditis), vascular conditions (phlebitis, thrombosis, distal limb amputation) and other conditions (arrhythmia, other cardiac conditions, drug‐induced psychosis, convulsions and any other conditions). Plain language descriptions of IRIDs were used rather than medical terms (e.g. for cellulitis ‐ skin is red, hot, swollen and tender) to facilitate their reporting. The form also collected information about the drug involved, area of the body injected and hospital attendance at the last episode for each condition. Lifetime and recent (last year and last month) prevalence of IRIDs were calculated. Two IRIDs binary (yes/no) outcome variables were constructed: i) Cutaneous IRIDs: defined as at least one lifetime episode of a cutaneous IRIDs (i.e. abscess, cellulitis, or skin ulcer); and ii) Non‐cutaneous IRIDs: defined as at least one lifetime episode of non‐cutaneous IRIDs (ostheo‐articular and systemic infections, vascular or other conditions as described above). These variables were constructed to reflect the clinical relevance of conditions included based on differences in their severity and complexity of the clinical management required. Multiple logistic regression was used to assess factors associated with each of the two IRIDs outcome variables. A purposeful method was used for model building. 19 Variables with a p value <0.20 in the univariable analysis were considered for inclusion in the multiple logistic regression model. Variables significant at p ≤0.05 in the multivariable analysis were included in the final model. Potential confounders were tested by assessing changes >15% in regression coefficients in models with and without the potential confounders. Missing data categories were constructed for categorical variables and included in the logistic regression models. Data were analysed using Stata12 software (Stata Corporation, College Station, TX). Ethical approval for the project was obtained from the South Eastern Sydney Local Health District Human Research Ethics Committee. Results Our study included 702 PWID, with mean age of 36 years (range 15–70 years). The majority (67%) were male and 11% identified as Aboriginal and/or Torres Strait Islander (Table ). More than half (56%) did not complete secondary education and 44% reported living in unstable accommodation. About two‐thirds (68%) were currently unemployed. About two‐thirds of women (67%) and 16% of men reported ever working in the sex industry. Almost half (49%) reported a history of incarceration and 42% had a history of treatment and/or hospital admission for a psychiatric illness. Demographic characteristics and injecting‐related behaviours of the sample (N=702). Demographic characteristic n (%) Injecting‐related behaviours n(%) Gender Duration of injecting (years) Male 473 (67.4) <5 94 (13.4) Female 223 (31.7) 5–10 119 (17.0) Transgender 4 (0.6) >10 415 (59.1) Missing 2 (0.3) Missing 74 (10.5) Age (years) Receptive syringe sharing(ever) >25 81 (11.5) Yes 281 (40.0) 25–29 120 (17.1) No 249 (35.5) 30–34 128 (18.2) Missing 171 (24.5) 35 or more 373 (53.1) Frequency of injecting (last month) Aboriginal and/or Torres Strait Islander Less than daily 359 (51.1) Non‐Aboriginal 588 (83.8) Once a day or more 274 (39.0) Aboriginal 79 (11.2) Missing 69 (9.9) Missing 35 (5.0) Injected in custody (ever) Education Yes 54 (7.7) Not completed secondary 393 (56.0) No 165 (23.5) Secondary/tertiary (some or complete) 255 (36.3) Not applicable (i.e. never in custody) 297 (42.3) Missing 54 (7.7) Missing 186 (26.5) Accommodation (current) Injected other than in the arm (ever) Stable* 348 (49.6) Yes 273 (38.9) Unstable** 308 (43.8) No 379 (54.0) Missing 46 (6.6) Missing 50 (7.1) Incarceration (ever) Opioid overdose (ever) Yes 343 (48.9) Yes 297 (42.3) No 297 (42.3) No 234 (33.3) Missing 62 (8.8) Missing 171 (24.4) Worked in sex industry (ever) Injected in public places***(last injection) Yes 224 (31.9) Yes 125 (17.8) No 448 (63.8) No 218 (31.1) Missing 30 (4.3) Missing 359 (51.1) Current unemployment Injected alone(last injection) No 177 (25.2) Yes 177 (25.2) Yes 477 (68.0) No 407 (58.0) Missing 48 (6.8) Missing 118 (16.8) Treated or admitted for a psychiatric illness (ever) Washed hands(last month) Yes 295 (42.0) Always 186 (26.5) No 354 (50.4) Sometimes 149 (21.2) Missing 53 (7.6) Never 60 (8.5) Drug & alcohol treatment(ever) Not applicable (i.e. did not inject last month) 107 (15.2) Yes 443 (63.1) Missing 200 (28.5) No 228 (32.5) Missing 31(4.4) * Current accommodation reported as: home owner, private rental, Department of housing/Community housing, living with family) ** Current accommodation reported as: boarding house, hostel, shelter, refuge, staying with friends/couch surfing, squat, street *** Public places = street, park, beach, public toilet or squat More than half of the participants (59%) had injected drugs for ten or more years and 39% reported daily or more frequent injecting in the last month. Forty per cent reported lifetime receptive syringe sharing (ever) and 15% of those with a history of incarceration reported injecting while in custody. Thirty‐nine per cent reported ever injecting in places other than the arm (e.g. hand, leg, foot, groin or neck) and only a quarter (26%) always washed their hands prior to injecting. A total of 63% had a history of drug and alcohol treatment. Lifetime prevalence of cutaneous IRIDs was 23% and of non‐cutaneous IRIDs 21%. Thirty‐five per cent of participants reported at least one episode of either cutaneous or non‐cutaneous IRIDs while 8% reported both. Five per cent reported a cutaneous IRID episode in the past month. Cellulitis was the most frequently reported cutaneous condition (14%, n=100) (Table ). Two per cent had at least one episode of an osteo‐arthritic or systemic infection, with septicaemia most frequently reported (1.7%, n=12). One in ten (11%) had at least one episode of a vascular condition with phlebitis most frequently reported (9%, n=63). Nearly half of the patients with a history of abscess (42%) attended hospital at their most recent episode; and 23 and 27% attended hospital at their last skin ulcer and cellulitis episode, respectively. Heroin was most frequently reported as the drug injected at the time of the last episode of a cutaneous IRIDs (cellulitis 31%, abscess 30% and skin ulcer 23%). Prevalence of IRIDs (lifetime and most recent) among PWID attending Kirketon Road Centre (N=702). Last IRIDs episode IRIDs Lifetime prevalence of IRIDs n (%)* Last month** n (%)* Last year*** n (%)* >1 year ago n (%)* Cutaneous conditions Cellulitis Abscess Skin ulcer 100 (14.2) 81(11.5) 26 (3.7) 23 (3.3) 13 (1.8) 4 (0.6) 25 (3.6) 23 (3.3) 5 (0.7) 52 (7.4) 45 (6.4) 17 (2.4) Ostheo‐articular and systemic conditions Septicaemia Endocarditis Osteomyelitis Septic arthritis 12 (1.7) 10 (1.4) 3 (0.4) 2 (0.3) 0 1 (0.1) 1 (0.1) 1 (0.1) 2 (0.3) 1 (0.1) 1 (0.1) 1 (0.1) 10 (1.4) 8 (1.1) 1 (0.1) 0 Vascular conditions Phlebitis Thrombosis Limb amputation 63 (9) 13 (1.8) 3 (0.4) 19 (2.7) 1 (0.1) 1 (0.1) 13 (1.8) 2 (0.3) 1 (0.1) 31 (4.4) 10 (1.4) 1 (0.1) Other conditions Drug‐induced psychosis Convulsions/fits Arrhythmia / palpitations Any other condition Other cardiac conditions 71 (10.1) 17 (2.4) 14 (1.9) 11 (1.6) 4 (0.6) 1 (0.1) 1 (0.1) 4 (0.6) 1 (0.1) 2 (0.3) 9 (1.3) 3 (0.4) 0 2 (0.3) 0 61 (8.7) 13 (1.8) 10 (1.4) 8 (1.1) 2 (0.3) * Participants reported one or multiple IRIDs types therefore the percentages do not add to 100% ** Last month = last 30 days (31 or 28) *** Last year = last 12 months Female gender, lifetime receptive syringe sharing (RSS), injecting while in custody and ever injecting in places other than the arm were all independently associated with lifetime prevalence of cutaneous IRIDs (Table ). A history of injecting in places other than the arm, injecting for five or more years and lifetime RSS were independently associated with lifetime prevalence of non‐cutaneous IRIDs (Table ). Factors associated with lifetime IRIDs among PWID attending Kirketon Road Centre (N=702). Demographic and risk behaviour factors Cutaneous IRID Non‐cutaneous IRID Unadjusted OR (95%CI) p value Adjusted OR a (95% CI) p value Unadjusted OR (95%CI) p value Adjusted OR b (95% CI) p value Gender Male/Transgender* 1.00 1.00 Female 1.50 (1.04–2.16) 0.029 1.56(1.04–2.34) 0.031 1.19 (0.81–1.75) 0.370 – Age (years) Less than 25 1.00 1.00 25–29 1.52 (0.74–3.10) 0.245 0.76 (0.36–1.59) 0.475 – 30–34 1.52 (0.75–3.09) 0.237 1.08 (0.54–2.17) 0.815 – 35 or more 1.47 (0.79–2.75) 0.220 1.19 (0.65–2.18) 0.552 – Aboriginal and/or Torres Strait Islander Non‐Aboriginal 1.00 1.00 Aboriginal 1.16 (0.68–1.99) 0.566 1.21 (0.69–2.10) 0.500 – Education Not completed secondary 1.00 1.00 Secondary/tertiary (some or complete) 0.66 (0.45–0.97) 0.039 0.53 (0.35–0.79) 0.002 – Treated or admitted for a psychiatric illness (ever) No 1.00 Yes 1.20 (0.84–1.73) 0.300 Accommodation (current) Stable 1.00 1.00 Unstable** 0.97 (0.68–1.39) 0.896 1.42 (0.98–2.07) 0.063 – Incarceration (ever) No 1.00 1.00 Yes 1.93 (1.32–2.80) 0.001 1.66 (1.13–2.45) 0.010 – Worked in sex industry (ever) No 1.00 1.00 Yes 1.01(0.69–1.47) 0.949 1.2 (0.88–1.90) 0.182 – Current unemployment No 1.00 1.00 Yes 1.97(1.25–3.09) 0.003 2.07 (1.28–3.34) 0.003 – Duration of injecting (years) < 5 1.00 1.00 1.00 5–10 1.82 (0.88–3.77) 4.10 (1.61–10.43) 0.003 2.98 (1.14–7.81) 0.026 > 10 2.30 (1.23–4.30) 5.03 (2.13–11.84) 0.000 3.18 (1.31–7.69) 0.01 Receptive syringe sharing (ever) No 1.00 1.00 1.00 Yes 2.45 (1.63–3.67) 0.000 1.87 (1.21–2.91) 0.005 2.60 (1.69–3.98) 0.000 2.00 (1.27–3.13) 0.002 Frequency of injecting (last month) Less than daily 1.00 1.00 Once a day or more 1.88 (1.31–2.72) 0.001 1.58 (1.08–2.31) 0.017 – Injected in custody (ever) No 1.00 1.00 1.00 Yes 2.47 (1.32–4.64) 0.005 2.55 (1.30–5.00) 0.006 1.75 (0.91–3.34) 0.090 – Not applicable (i.e. never in custody) 0.51 (0.32–0.79) 0.003 0.62 (0.38–1.01) 0.058 0.57 (0.36–0.90) 0.016 – Injected other than in the arm (ever) No 1.00 1.00 1.00 1.00 Yes 3.92 (2.66–5.77) 0.000 3.62 (2.41–5.43) 0.000 3.44 (2.32–2.11) 0.000 2.92 (1.94–4.38) 0.000 Opioid overdose(ever) No 1.00 1.00 Yes 0.95 (0.65–1.40) 0.829 1.36 (0.91–2.04) 0.125 – Injected in public places*** (last injection) No 1.00 1.00 Yes 1.59 (0.98–2.60) 0.059 1.01 (0.61–1.67) 0.959 – Wash hands (last month) Always 1.00 1.00 Sometimes 1.44 (0.89–2.33) 0.131 1.38 (0.84–2.28) 0.196 – Never 1.20 (0.62–2.31) 0.579 0.93 (0.93–3.35) 0.080 – Injected alone (last injection) No 1.00 1.00 Yes 1.05 (0.70–1.57) 0.800 0.86 (0.56–1.33) 0.518 – Drug &alcohol treatment (ever) No 1.00 1.00 Yes 3.33 (2.11–5.25) 0.000 (1.92–4.95) 0.000 *Contains 4 transgender observations;**Unstable accommodation = boarding house, hostel, shelter, refuge, staying with friends/couch surfing, squat, street; ***Public places = street, park, beach, public toilet or squat; a: model further adjusted for unspecified/missing: RSS (24.5%); injecting in places other than arm (7.1%); injecting while in custody (26.5%) b: model further adjusted for unspecified/missing: RSS (24.5%), injecting in places other than arm (7.1%) Discussion In this study, lifetime prevalence of cutaneous IRIDs was 23% and of non‐cutaneous IRID was 21%, confirming that IRIDs are a substantial health issue among PWID. Conditions reported as IRIDs and their classification varies across previous Australian and international studies; thus, comparison for individual conditions rather than for overall IRIDs prevalence is warranted. In our study, lifetime prevalence of abscesses was 11%, which was midway between the prevalence of 16% reported in a community‐based Australian study in 2006 2 and 6% among clients attending the Sydney Medically Supervised Injecting Centre between 2001 and 2007, 3 which is also located in Sydney's Kings Cross. Five per cent of our respondents reported cutaneous IRIDs in the last month compared to 8% reporting infection/abscesses in the 2012 Illicit Drugs Reporting System survey, 20 Prevalence of thrombosis (1.8%) septicaemia (1.7%) and endocarditis (1.4%) in our sample was comparable with results from previous studies. 2,3 However, participants in the 2006 Australian NSP Survey (ANSPS) reported considerably higher lifetime prevalence of abscesses (27%), thrombosis (12%), septicaemia (9%) and endocarditis (4%). 4 The participants in our study were similar to ANSPS survey participants with regard to age, gender and duration and frequency of injecting. While the participants in the two studies may have differed in regards to other risk factors (not reported) it is likely that differences in data collection methods contributed to observed differences in prevalence (i.e. utilisation of a self‐administered questionnaire, which did not include specific descriptions of various IRIDs in the ANSPS vs. a clinician‐administered survey in our study). International studies have reported higher prevalences of cutaneous IRIDs than documented in the current study. Differences in injecting‐related practices and the type and formulation of drugs injected, as well as differences in the availability of clean injecting equipment, may explain the lower prevalence of IRIDs observed in the current study and in Australia more generally. Injecting practices such as skin‐popping (i.e. injecting subcutaneously or intramuscularly) and injecting in the groin and neck are less frequent among PWID in Australia compared to elsewhere in the world. 21,22 Heroin hydrochloride (or other salt forms) has historically been more available in Australia and, when injected, leads to less vein damage, compared with more granular forms of heroin such as free base or black tar. Lack of universal access to health care, as well as limited access to specific harm reduction advice and clean injecting equipment, and levels of homelessness – especially in cold climates – affecting the ability of PWID to maintain health and personal hygiene may also contribute to the higher prevalence of IRIDs observed in these studies. Consistent with previous research, 3,4 women in our study were more likely to report lifetime prevalence of cutaneous IRIDs. Gendered social roles associated with injecting drug use 23 and differences in health care seeking and reporting 24,25 have been suggested as possible explanations for this difference. Our study found an association between high‐risk injecting practices and lifetime prevalence of both cutaneous and non‐cutaneous IRIDs, highlighting the importance of risk reduction interventions to address this public health issue. Injecting in places other than the arm and RSS were independently associated with cutaneous IRIDs, as found by previous studies. 2,26,27 Injecting while in custody was associated with cutaneous IRIDs after controlling for injecting behaviours and demographic characteristics. Canadian studies have previously identified recent incarceration as a risk factor for reporting an abscess in the last six months and for accessing emergency department care for cutaneous injecting‐related infections (abscesses and cellulitis). 28,29 Previously reported associations between IRIDs and unstable accommodation, 2,3 sex work and injecting in public places 3 were not observed in our study. A significant proportion of clients in our study reported attending hospital at their last cutaneous IRIDs episode. Presentations to hospital EDs are often delayed, increasing the risk of complications. Abscesses and cellulitis, if left untreated, increase the risk of serious complications such as endocarditis, septicaemia and necrotising fasciitis. This can pose challenges in treatment and increase health care costs. 30–35 Most cutaneous IRIDs can be managed in primary care settings. Targeted low threshold care models 18 such as KRC can increase accessibility and acceptability and encourage early presentation, thus lowering the likelihood of complications and reducing the costs associated with tertiary care. Such settings are also ideally placed to implement harm reduction interventions. The novelty of our study consists in reporting on a wide range of IRIDs utilising data from a surveillance system integrated in a primary health care centre. In contrast, previous research measured IRIDs mostly among participants specifically recruited for research. There are several advantages in integrating surveillance into clinical practice. Data collected was used for individual clinical assessment, as well as for surveillance, thus contributing to a broader public health function. Clinicians with extensive experience in working with PWID participated in the design of the surveillance tool. This ensured that the tool was clinically relevant, and the data collected could meaningfully inform clinical service planning and the development of prevention programs. The involvement of clinicians in data collection ensured better description of IRIDs, thus facilitating their identification. Surveillance of IRIDs at KRC has been supplemented recently by incorporating a comprehensive list of IRIDs‐related codes within the clinical database. This allows clinicians to report IRIDs‐related presentations and clinical diagnoses as well as associated treatment and referral. This will allow for a more accurate description of the burden of IRIDs in this group and the monitoring of trends over time, and will inform service planning. Moreover, this setting is well placed for future inclusion of a microbiological component into the IRIDs surveillance system with potential to inform clinical management of cutaneous IRIDs and early detection of pathogens with outbreak potential. Most recently, IRIDs surveillance data informed the development of a KRC clinician‐led safer injecting intervention offered opportunistically to PWID at the time of venepuncture when collecting blood for serological testing. Our study has several limitations. The cross sectional study design means that we are unable to make causal inferences. We relied on self‐reported data which may be subject to recall bias. The data were collected during clients' first visit at KRC and addressed issues of a sensitive nature such as behaviours related to illegal activities. Trust between the client and clinician is developed over time and, as such, social desirability bias may have led to under‐reporting of injecting‐related behaviours and their sequelae. Furthermore self‐reports of IRIDs may be less accurate than data obtained from objective clinical examinations. However, some evidence suggests that PWID descriptions of injecting‐related problems are consistent with clinicians' findings. 33 On the other hand, most other studies involved either self‐administered or researcher‐administered surveys whereas clinicians (nurses and doctors), who were experienced in the assessment and diagnosis of IRIDs, obtained the information in this study. This also enabled clients' understanding of definitions of the range of IRIDs to be clarified by clinicians, potentially improving the reliability of this self‐reported information. There are limitations in associating recent behavioural factors (e.g. injecting frequency in the last month) with lifetime prevalence of IRIDs, as behaviours may change over time, and it is possible that some of the reported IRIDs may have preceded these behaviours. Despite the fact that the KRC accesses a diverse population of high‐risk injectors, our results may not be generalisable to the broader populations of PWID, including those who do not access health services. KRC is the only primary health care service targeting PWID with a medical capacity in the area and thus may be more likely to attract those with underlying medical issues. 17,36 Conclusions IRIDs are a substantial health issue for PWID and a key driver of preventable morbidity and mortality associated with injecting drug use. This warrants their ongoing surveillance, particularly in targeted primary care setting, where such data can directly inform the development of accessible, acceptable and effective prevention and early management interventions. These interventions could reduce the need for acute hospital admission and ongoing care. It would be hoped that this would also result in reductions in the economic costs associated with late hospital presentations. Acknowledgements We would like to acknowledge the contribution of Kirketon Road Centre clients and staff. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Surveillance of injecting‐related injury and diseases in people who inject drugs attending a targeted primary health care facility in Sydney's Kings Cross

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References (39)

Publisher
Wiley
Copyright
© 2015 Public Health Association of Australia
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/1753-6405.12363
pmid
25827187
Publisher site
See Article on Publisher Site

Abstract

P eople who inject drugs (PWID) are a population group with a disproportionate burden of disease and limited access to health care compared to the general population. 1 While the burden of disease associated with blood‐borne viral infections (BBIs) such as HIV and hepatitis C virus (HCV) has been well documented in PWID, other health issues such as injecting‐related injuries and diseases (IRIDs) have received less attention. A series of conditions is grouped under IRIDs and there is variation in the definition and classification of these conditions in the literature. Most often, cutaneous conditions such as abscess and cellulitis are included among IRIDs together with sequelae such as septic arthritis, osteomyelitis, septicaemia and bacterial endocarditis. Other conditions associated with injecting drug use such as haematoma and injection site scarring (also known as ‘track marks’) are also sometimes classified as IRIDs 2 or included in a separate category of injecting‐related problems. 3,4 However, BBIs and drug overdose, although associated with injecting drug use, are not generally classified as IRIDs. Injecting practices such as repeated injection in the same area, not cleaning the injection site and use of non‐sterile injecting equipment; ubiquitous skin flora (e.g. streptococci, staphylococci); and the physical and chemical proprieties of the substances being injected can all contribute to skin damage and the development of cutaneous and vascular IRIDs. 5–9 Outbreaks produced by spore‐forming bacteria (e.g. Clostridium novyi, Bacillus anthracis ), invasive group A streptococci and the emergence of methycillin resistant staphylococcus (MRSA) infection have also been described in PWID. 5,6,10–13 Previous studies have identified a substantial burden of IRIDs among Australian PWID with self‐reported lifetime prevalence of abscesses between 16 and 27%, thrombosis 4–12%, septicaemia 2–9%, and endocarditis 1–4%. 2–4 International studies have reported even higher prevalence of IRIDs. Thirty‐two per cent of participants in a San Francisco study had abscesses when examined by a clinician 14 (likely related to the injection of black tar heroin) 15 and 69% of methadone treatment patients in Dublin reported ever having had an abscess. 16 The current study aimed to identify the range and prevalence (lifetime and recent) of IRIDs and associated risk factors among PWID attending a targeted primary health care service for the first time. Methods Our study was conducted at Kirketon Road Centre (KRC), a targeted primary health care service of the South Eastern Sydney Local Health District in Sydney's Kings Cross. KRC aims to prevent and treat HIV/AIDS and other transmissible infections in PWID, ‘at‐risk’ young people and sex workers. 17 The Centre is among the most integrated health services of its kind, 18 offering free, anonymous and confidential medical and nursing care, counselling, social welfare assistance, a needle and syringe program, outreach services and a methadone access program to a large cohort of people actively engaged in injecting drugs illicitly. KRC is thus well placed to offer medical assessment and treatment for IRIDs in this cohort. KRC also contributes to a broader public health mandate through active surveillance, developing, implementing and evaluating prevention and harm reduction interventions 17 and disseminating its findings to the broader public health field. We conducted a retrospective cross‐sectional study based on data collected between March 2010 and May 2012. All new KRC clients identified as having ever injected drugs who completed a clinician‐administered (by doctor or nurse) KRC intake survey during this period were included. The intake survey (in use in its current form since March 2010) incorporated a table to record lifetime and recent experience of IRIDs. A group of experienced KRC clinicians developed the table to ensure that a wide range of clinically relevant conditions were included. The range of IRIDs included cutaneous conditions (abscess, cellulitis, skin ulcer), ostheo‐articular and systemic infections (osteomyelitis, septic arthritis, septicaemia, endocarditis), vascular conditions (phlebitis, thrombosis, distal limb amputation) and other conditions (arrhythmia, other cardiac conditions, drug‐induced psychosis, convulsions and any other conditions). Plain language descriptions of IRIDs were used rather than medical terms (e.g. for cellulitis ‐ skin is red, hot, swollen and tender) to facilitate their reporting. The form also collected information about the drug involved, area of the body injected and hospital attendance at the last episode for each condition. Lifetime and recent (last year and last month) prevalence of IRIDs were calculated. Two IRIDs binary (yes/no) outcome variables were constructed: i) Cutaneous IRIDs: defined as at least one lifetime episode of a cutaneous IRIDs (i.e. abscess, cellulitis, or skin ulcer); and ii) Non‐cutaneous IRIDs: defined as at least one lifetime episode of non‐cutaneous IRIDs (ostheo‐articular and systemic infections, vascular or other conditions as described above). These variables were constructed to reflect the clinical relevance of conditions included based on differences in their severity and complexity of the clinical management required. Multiple logistic regression was used to assess factors associated with each of the two IRIDs outcome variables. A purposeful method was used for model building. 19 Variables with a p value <0.20 in the univariable analysis were considered for inclusion in the multiple logistic regression model. Variables significant at p ≤0.05 in the multivariable analysis were included in the final model. Potential confounders were tested by assessing changes >15% in regression coefficients in models with and without the potential confounders. Missing data categories were constructed for categorical variables and included in the logistic regression models. Data were analysed using Stata12 software (Stata Corporation, College Station, TX). Ethical approval for the project was obtained from the South Eastern Sydney Local Health District Human Research Ethics Committee. Results Our study included 702 PWID, with mean age of 36 years (range 15–70 years). The majority (67%) were male and 11% identified as Aboriginal and/or Torres Strait Islander (Table ). More than half (56%) did not complete secondary education and 44% reported living in unstable accommodation. About two‐thirds (68%) were currently unemployed. About two‐thirds of women (67%) and 16% of men reported ever working in the sex industry. Almost half (49%) reported a history of incarceration and 42% had a history of treatment and/or hospital admission for a psychiatric illness. Demographic characteristics and injecting‐related behaviours of the sample (N=702). Demographic characteristic n (%) Injecting‐related behaviours n(%) Gender Duration of injecting (years) Male 473 (67.4) <5 94 (13.4) Female 223 (31.7) 5–10 119 (17.0) Transgender 4 (0.6) >10 415 (59.1) Missing 2 (0.3) Missing 74 (10.5) Age (years) Receptive syringe sharing(ever) >25 81 (11.5) Yes 281 (40.0) 25–29 120 (17.1) No 249 (35.5) 30–34 128 (18.2) Missing 171 (24.5) 35 or more 373 (53.1) Frequency of injecting (last month) Aboriginal and/or Torres Strait Islander Less than daily 359 (51.1) Non‐Aboriginal 588 (83.8) Once a day or more 274 (39.0) Aboriginal 79 (11.2) Missing 69 (9.9) Missing 35 (5.0) Injected in custody (ever) Education Yes 54 (7.7) Not completed secondary 393 (56.0) No 165 (23.5) Secondary/tertiary (some or complete) 255 (36.3) Not applicable (i.e. never in custody) 297 (42.3) Missing 54 (7.7) Missing 186 (26.5) Accommodation (current) Injected other than in the arm (ever) Stable* 348 (49.6) Yes 273 (38.9) Unstable** 308 (43.8) No 379 (54.0) Missing 46 (6.6) Missing 50 (7.1) Incarceration (ever) Opioid overdose (ever) Yes 343 (48.9) Yes 297 (42.3) No 297 (42.3) No 234 (33.3) Missing 62 (8.8) Missing 171 (24.4) Worked in sex industry (ever) Injected in public places***(last injection) Yes 224 (31.9) Yes 125 (17.8) No 448 (63.8) No 218 (31.1) Missing 30 (4.3) Missing 359 (51.1) Current unemployment Injected alone(last injection) No 177 (25.2) Yes 177 (25.2) Yes 477 (68.0) No 407 (58.0) Missing 48 (6.8) Missing 118 (16.8) Treated or admitted for a psychiatric illness (ever) Washed hands(last month) Yes 295 (42.0) Always 186 (26.5) No 354 (50.4) Sometimes 149 (21.2) Missing 53 (7.6) Never 60 (8.5) Drug & alcohol treatment(ever) Not applicable (i.e. did not inject last month) 107 (15.2) Yes 443 (63.1) Missing 200 (28.5) No 228 (32.5) Missing 31(4.4) * Current accommodation reported as: home owner, private rental, Department of housing/Community housing, living with family) ** Current accommodation reported as: boarding house, hostel, shelter, refuge, staying with friends/couch surfing, squat, street *** Public places = street, park, beach, public toilet or squat More than half of the participants (59%) had injected drugs for ten or more years and 39% reported daily or more frequent injecting in the last month. Forty per cent reported lifetime receptive syringe sharing (ever) and 15% of those with a history of incarceration reported injecting while in custody. Thirty‐nine per cent reported ever injecting in places other than the arm (e.g. hand, leg, foot, groin or neck) and only a quarter (26%) always washed their hands prior to injecting. A total of 63% had a history of drug and alcohol treatment. Lifetime prevalence of cutaneous IRIDs was 23% and of non‐cutaneous IRIDs 21%. Thirty‐five per cent of participants reported at least one episode of either cutaneous or non‐cutaneous IRIDs while 8% reported both. Five per cent reported a cutaneous IRID episode in the past month. Cellulitis was the most frequently reported cutaneous condition (14%, n=100) (Table ). Two per cent had at least one episode of an osteo‐arthritic or systemic infection, with septicaemia most frequently reported (1.7%, n=12). One in ten (11%) had at least one episode of a vascular condition with phlebitis most frequently reported (9%, n=63). Nearly half of the patients with a history of abscess (42%) attended hospital at their most recent episode; and 23 and 27% attended hospital at their last skin ulcer and cellulitis episode, respectively. Heroin was most frequently reported as the drug injected at the time of the last episode of a cutaneous IRIDs (cellulitis 31%, abscess 30% and skin ulcer 23%). Prevalence of IRIDs (lifetime and most recent) among PWID attending Kirketon Road Centre (N=702). Last IRIDs episode IRIDs Lifetime prevalence of IRIDs n (%)* Last month** n (%)* Last year*** n (%)* >1 year ago n (%)* Cutaneous conditions Cellulitis Abscess Skin ulcer 100 (14.2) 81(11.5) 26 (3.7) 23 (3.3) 13 (1.8) 4 (0.6) 25 (3.6) 23 (3.3) 5 (0.7) 52 (7.4) 45 (6.4) 17 (2.4) Ostheo‐articular and systemic conditions Septicaemia Endocarditis Osteomyelitis Septic arthritis 12 (1.7) 10 (1.4) 3 (0.4) 2 (0.3) 0 1 (0.1) 1 (0.1) 1 (0.1) 2 (0.3) 1 (0.1) 1 (0.1) 1 (0.1) 10 (1.4) 8 (1.1) 1 (0.1) 0 Vascular conditions Phlebitis Thrombosis Limb amputation 63 (9) 13 (1.8) 3 (0.4) 19 (2.7) 1 (0.1) 1 (0.1) 13 (1.8) 2 (0.3) 1 (0.1) 31 (4.4) 10 (1.4) 1 (0.1) Other conditions Drug‐induced psychosis Convulsions/fits Arrhythmia / palpitations Any other condition Other cardiac conditions 71 (10.1) 17 (2.4) 14 (1.9) 11 (1.6) 4 (0.6) 1 (0.1) 1 (0.1) 4 (0.6) 1 (0.1) 2 (0.3) 9 (1.3) 3 (0.4) 0 2 (0.3) 0 61 (8.7) 13 (1.8) 10 (1.4) 8 (1.1) 2 (0.3) * Participants reported one or multiple IRIDs types therefore the percentages do not add to 100% ** Last month = last 30 days (31 or 28) *** Last year = last 12 months Female gender, lifetime receptive syringe sharing (RSS), injecting while in custody and ever injecting in places other than the arm were all independently associated with lifetime prevalence of cutaneous IRIDs (Table ). A history of injecting in places other than the arm, injecting for five or more years and lifetime RSS were independently associated with lifetime prevalence of non‐cutaneous IRIDs (Table ). Factors associated with lifetime IRIDs among PWID attending Kirketon Road Centre (N=702). Demographic and risk behaviour factors Cutaneous IRID Non‐cutaneous IRID Unadjusted OR (95%CI) p value Adjusted OR a (95% CI) p value Unadjusted OR (95%CI) p value Adjusted OR b (95% CI) p value Gender Male/Transgender* 1.00 1.00 Female 1.50 (1.04–2.16) 0.029 1.56(1.04–2.34) 0.031 1.19 (0.81–1.75) 0.370 – Age (years) Less than 25 1.00 1.00 25–29 1.52 (0.74–3.10) 0.245 0.76 (0.36–1.59) 0.475 – 30–34 1.52 (0.75–3.09) 0.237 1.08 (0.54–2.17) 0.815 – 35 or more 1.47 (0.79–2.75) 0.220 1.19 (0.65–2.18) 0.552 – Aboriginal and/or Torres Strait Islander Non‐Aboriginal 1.00 1.00 Aboriginal 1.16 (0.68–1.99) 0.566 1.21 (0.69–2.10) 0.500 – Education Not completed secondary 1.00 1.00 Secondary/tertiary (some or complete) 0.66 (0.45–0.97) 0.039 0.53 (0.35–0.79) 0.002 – Treated or admitted for a psychiatric illness (ever) No 1.00 Yes 1.20 (0.84–1.73) 0.300 Accommodation (current) Stable 1.00 1.00 Unstable** 0.97 (0.68–1.39) 0.896 1.42 (0.98–2.07) 0.063 – Incarceration (ever) No 1.00 1.00 Yes 1.93 (1.32–2.80) 0.001 1.66 (1.13–2.45) 0.010 – Worked in sex industry (ever) No 1.00 1.00 Yes 1.01(0.69–1.47) 0.949 1.2 (0.88–1.90) 0.182 – Current unemployment No 1.00 1.00 Yes 1.97(1.25–3.09) 0.003 2.07 (1.28–3.34) 0.003 – Duration of injecting (years) < 5 1.00 1.00 1.00 5–10 1.82 (0.88–3.77) 4.10 (1.61–10.43) 0.003 2.98 (1.14–7.81) 0.026 > 10 2.30 (1.23–4.30) 5.03 (2.13–11.84) 0.000 3.18 (1.31–7.69) 0.01 Receptive syringe sharing (ever) No 1.00 1.00 1.00 Yes 2.45 (1.63–3.67) 0.000 1.87 (1.21–2.91) 0.005 2.60 (1.69–3.98) 0.000 2.00 (1.27–3.13) 0.002 Frequency of injecting (last month) Less than daily 1.00 1.00 Once a day or more 1.88 (1.31–2.72) 0.001 1.58 (1.08–2.31) 0.017 – Injected in custody (ever) No 1.00 1.00 1.00 Yes 2.47 (1.32–4.64) 0.005 2.55 (1.30–5.00) 0.006 1.75 (0.91–3.34) 0.090 – Not applicable (i.e. never in custody) 0.51 (0.32–0.79) 0.003 0.62 (0.38–1.01) 0.058 0.57 (0.36–0.90) 0.016 – Injected other than in the arm (ever) No 1.00 1.00 1.00 1.00 Yes 3.92 (2.66–5.77) 0.000 3.62 (2.41–5.43) 0.000 3.44 (2.32–2.11) 0.000 2.92 (1.94–4.38) 0.000 Opioid overdose(ever) No 1.00 1.00 Yes 0.95 (0.65–1.40) 0.829 1.36 (0.91–2.04) 0.125 – Injected in public places*** (last injection) No 1.00 1.00 Yes 1.59 (0.98–2.60) 0.059 1.01 (0.61–1.67) 0.959 – Wash hands (last month) Always 1.00 1.00 Sometimes 1.44 (0.89–2.33) 0.131 1.38 (0.84–2.28) 0.196 – Never 1.20 (0.62–2.31) 0.579 0.93 (0.93–3.35) 0.080 – Injected alone (last injection) No 1.00 1.00 Yes 1.05 (0.70–1.57) 0.800 0.86 (0.56–1.33) 0.518 – Drug &alcohol treatment (ever) No 1.00 1.00 Yes 3.33 (2.11–5.25) 0.000 (1.92–4.95) 0.000 *Contains 4 transgender observations;**Unstable accommodation = boarding house, hostel, shelter, refuge, staying with friends/couch surfing, squat, street; ***Public places = street, park, beach, public toilet or squat; a: model further adjusted for unspecified/missing: RSS (24.5%); injecting in places other than arm (7.1%); injecting while in custody (26.5%) b: model further adjusted for unspecified/missing: RSS (24.5%), injecting in places other than arm (7.1%) Discussion In this study, lifetime prevalence of cutaneous IRIDs was 23% and of non‐cutaneous IRID was 21%, confirming that IRIDs are a substantial health issue among PWID. Conditions reported as IRIDs and their classification varies across previous Australian and international studies; thus, comparison for individual conditions rather than for overall IRIDs prevalence is warranted. In our study, lifetime prevalence of abscesses was 11%, which was midway between the prevalence of 16% reported in a community‐based Australian study in 2006 2 and 6% among clients attending the Sydney Medically Supervised Injecting Centre between 2001 and 2007, 3 which is also located in Sydney's Kings Cross. Five per cent of our respondents reported cutaneous IRIDs in the last month compared to 8% reporting infection/abscesses in the 2012 Illicit Drugs Reporting System survey, 20 Prevalence of thrombosis (1.8%) septicaemia (1.7%) and endocarditis (1.4%) in our sample was comparable with results from previous studies. 2,3 However, participants in the 2006 Australian NSP Survey (ANSPS) reported considerably higher lifetime prevalence of abscesses (27%), thrombosis (12%), septicaemia (9%) and endocarditis (4%). 4 The participants in our study were similar to ANSPS survey participants with regard to age, gender and duration and frequency of injecting. While the participants in the two studies may have differed in regards to other risk factors (not reported) it is likely that differences in data collection methods contributed to observed differences in prevalence (i.e. utilisation of a self‐administered questionnaire, which did not include specific descriptions of various IRIDs in the ANSPS vs. a clinician‐administered survey in our study). International studies have reported higher prevalences of cutaneous IRIDs than documented in the current study. Differences in injecting‐related practices and the type and formulation of drugs injected, as well as differences in the availability of clean injecting equipment, may explain the lower prevalence of IRIDs observed in the current study and in Australia more generally. Injecting practices such as skin‐popping (i.e. injecting subcutaneously or intramuscularly) and injecting in the groin and neck are less frequent among PWID in Australia compared to elsewhere in the world. 21,22 Heroin hydrochloride (or other salt forms) has historically been more available in Australia and, when injected, leads to less vein damage, compared with more granular forms of heroin such as free base or black tar. Lack of universal access to health care, as well as limited access to specific harm reduction advice and clean injecting equipment, and levels of homelessness – especially in cold climates – affecting the ability of PWID to maintain health and personal hygiene may also contribute to the higher prevalence of IRIDs observed in these studies. Consistent with previous research, 3,4 women in our study were more likely to report lifetime prevalence of cutaneous IRIDs. Gendered social roles associated with injecting drug use 23 and differences in health care seeking and reporting 24,25 have been suggested as possible explanations for this difference. Our study found an association between high‐risk injecting practices and lifetime prevalence of both cutaneous and non‐cutaneous IRIDs, highlighting the importance of risk reduction interventions to address this public health issue. Injecting in places other than the arm and RSS were independently associated with cutaneous IRIDs, as found by previous studies. 2,26,27 Injecting while in custody was associated with cutaneous IRIDs after controlling for injecting behaviours and demographic characteristics. Canadian studies have previously identified recent incarceration as a risk factor for reporting an abscess in the last six months and for accessing emergency department care for cutaneous injecting‐related infections (abscesses and cellulitis). 28,29 Previously reported associations between IRIDs and unstable accommodation, 2,3 sex work and injecting in public places 3 were not observed in our study. A significant proportion of clients in our study reported attending hospital at their last cutaneous IRIDs episode. Presentations to hospital EDs are often delayed, increasing the risk of complications. Abscesses and cellulitis, if left untreated, increase the risk of serious complications such as endocarditis, septicaemia and necrotising fasciitis. This can pose challenges in treatment and increase health care costs. 30–35 Most cutaneous IRIDs can be managed in primary care settings. Targeted low threshold care models 18 such as KRC can increase accessibility and acceptability and encourage early presentation, thus lowering the likelihood of complications and reducing the costs associated with tertiary care. Such settings are also ideally placed to implement harm reduction interventions. The novelty of our study consists in reporting on a wide range of IRIDs utilising data from a surveillance system integrated in a primary health care centre. In contrast, previous research measured IRIDs mostly among participants specifically recruited for research. There are several advantages in integrating surveillance into clinical practice. Data collected was used for individual clinical assessment, as well as for surveillance, thus contributing to a broader public health function. Clinicians with extensive experience in working with PWID participated in the design of the surveillance tool. This ensured that the tool was clinically relevant, and the data collected could meaningfully inform clinical service planning and the development of prevention programs. The involvement of clinicians in data collection ensured better description of IRIDs, thus facilitating their identification. Surveillance of IRIDs at KRC has been supplemented recently by incorporating a comprehensive list of IRIDs‐related codes within the clinical database. This allows clinicians to report IRIDs‐related presentations and clinical diagnoses as well as associated treatment and referral. This will allow for a more accurate description of the burden of IRIDs in this group and the monitoring of trends over time, and will inform service planning. Moreover, this setting is well placed for future inclusion of a microbiological component into the IRIDs surveillance system with potential to inform clinical management of cutaneous IRIDs and early detection of pathogens with outbreak potential. Most recently, IRIDs surveillance data informed the development of a KRC clinician‐led safer injecting intervention offered opportunistically to PWID at the time of venepuncture when collecting blood for serological testing. Our study has several limitations. The cross sectional study design means that we are unable to make causal inferences. We relied on self‐reported data which may be subject to recall bias. The data were collected during clients' first visit at KRC and addressed issues of a sensitive nature such as behaviours related to illegal activities. Trust between the client and clinician is developed over time and, as such, social desirability bias may have led to under‐reporting of injecting‐related behaviours and their sequelae. Furthermore self‐reports of IRIDs may be less accurate than data obtained from objective clinical examinations. However, some evidence suggests that PWID descriptions of injecting‐related problems are consistent with clinicians' findings. 33 On the other hand, most other studies involved either self‐administered or researcher‐administered surveys whereas clinicians (nurses and doctors), who were experienced in the assessment and diagnosis of IRIDs, obtained the information in this study. This also enabled clients' understanding of definitions of the range of IRIDs to be clarified by clinicians, potentially improving the reliability of this self‐reported information. There are limitations in associating recent behavioural factors (e.g. injecting frequency in the last month) with lifetime prevalence of IRIDs, as behaviours may change over time, and it is possible that some of the reported IRIDs may have preceded these behaviours. Despite the fact that the KRC accesses a diverse population of high‐risk injectors, our results may not be generalisable to the broader populations of PWID, including those who do not access health services. KRC is the only primary health care service targeting PWID with a medical capacity in the area and thus may be more likely to attract those with underlying medical issues. 17,36 Conclusions IRIDs are a substantial health issue for PWID and a key driver of preventable morbidity and mortality associated with injecting drug use. This warrants their ongoing surveillance, particularly in targeted primary care setting, where such data can directly inform the development of accessible, acceptable and effective prevention and early management interventions. These interventions could reduce the need for acute hospital admission and ongoing care. It would be hoped that this would also result in reductions in the economic costs associated with late hospital presentations. Acknowledgements We would like to acknowledge the contribution of Kirketon Road Centre clients and staff.

Journal

Australian and New Zealand Journal of Public HealthWiley

Published: Apr 1, 2015

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