Uptake of COVID-19 vaccinations amongst 3,433,483 children and young people: meta-analysis of UK prospective cohorts

SARS-CoV-2 infection in children and young people (CYP) can lead to life-threatening COVID-19, transmission within households and schools, and the development of long COVID. Using linked health and administrative data, we investigated vaccine uptake among 3,433,483 CYP aged 5-17 years across all UK nations between 4th August 2021 and 31st May 2022. We constructed national cohorts and undertook multi-state modelling and meta-analysis to identify associations between demographic variables and vaccine uptake. We found that uptake of the first COVID-19 vaccine among CYP was low across all four nations compared to other age groups and diminished with subsequent doses. Age and vaccination status of adults living in the same household were identified as important risk factors associated with vaccine uptake in CYP. For example, 5-11 year-olds were less likely to receive their first vaccine compared to 16-17 year-olds (adjusted Hazard Ratio [aHR]: 0.10 (95%CI: 0.06-0.19)), and CYP in unvaccinated households were less likely to receive their first vaccine compared to CYP in partially vaccinated households (aHR: 0.19, 95%CI 0.13-0.29).

Undervaccination and severe COVID-19 outcomes: meta-analysis of national cohort studies in England, Northern Ireland, Scotland, and Wales

BACKGROUND

Undervaccination (receiving fewer than the recommended number of SARS-CoV-2 vaccine doses) could be associated with increased risk of severe COVID-19 outcomes-ie, COVID-19 hospitalisation or death-compared with full vaccination (receiving the recommended number of SARS-CoV-2 vaccine doses). We sought to determine the factors associated with undervaccination, and to investigate the risk of severe COVID-19 outcomes in people who were undervaccinated in each UK nation and across the UK.

METHODS

We used anonymised, harmonised electronic health record data with whole population coverage to carry out cohort studies in England, Northern Ireland, Scotland, and Wales. Participants were required to be at least 5 years of age to be included in the cohorts. We estimated adjusted odds ratios for undervaccination as of June 1, 2022. We also estimated adjusted hazard ratios (aHRs) for severe COVID-19 outcomes during the period June 1 to Sept 30, 2022, with undervaccination as a time-dependent exposure. We combined results from nation-specific analyses in a UK-wide fixed-effect meta-analysis. We estimated the reduction in severe COVID-19 outcomes associated with a counterfactual scenario in which everyone in the UK was fully vaccinated on June 1, 2022.

FINDINGS

The numbers of people undervaccinated on June 1, 2022 were 26 985 570 (45·8%) of 58 967 360 in England, 938 420 (49·8%) of 1 885 670 in Northern Ireland, 1 709 786 (34·2%) of 4 992 498 in Scotland, and 773 850 (32·8%) of 2 358 740 in Wales. People who were younger, from more deprived backgrounds, of non-White ethnicity, or had a lower number of comorbidities were less likely to be fully vaccinated. There was a total of 40 393 severe COVID-19 outcomes in the cohorts, with 14 156 of these in undervaccinated participants. We estimated the reduction in severe COVID-19 outcomes in the UK over 4 months of follow-up associated with a counterfactual scenario in which everyone was fully vaccinated on June 1, 2022 as 210 (95% CI 94-326) in the 5-15 years age group, 1544 (1399-1689) in those aged 16-74 years, and 5426 (5340-5512) in those aged 75 years or older. aHRs for severe COVID-19 outcomes in the meta-analysis for the age group of 75 years or older were 2·70 (2·61-2·78) for one dose fewer than recommended, 3·13 (2·93-3·34) for two fewer, 3·61 (3·13-4·17) for three fewer, and 3·08 (2·89-3·29) for four fewer.

INTERPRETATION

Rates of undervaccination against COVID-19 ranged from 32·8% to 49·8% across the four UK nations in summer, 2022. Undervaccination was associated with an elevated risk of severe COVID-19 outcomes.

FUNDING

UK Research and Innovation National Core Studies: Data and Connectivity.

Risk of severe COVID-19 outcomes after autumn 2022 COVID-19 booster vaccinations: a pooled analysis of national prospective cohort studies involving 7.4 million adults in England, Northern Ireland, Scotland and Wales

Background

UK COVID-19 vaccination policy has evolved to offering COVID-19 booster doses to individuals at increased risk of severe Illness from COVID-19. Building on our analyses of vaccine effectiveness of first, second and initial booster doses, we aimed to identify individuals at increased risk of severe outcomes (i.e., COVID-19 related hospitalisation or death) post the autumn 2022 booster dose.

Methods

We undertook a national population-based cohort analysis across all four UK nations through linked primary care, vaccination, hospitalisation and mortality data. We included individuals who received autumn 2022 booster doses of BNT162b2 (Comirnaty) or mRNA-1273 (Spikevax) during the period September 1, 2022 to December 31, 2022 to investigate the risk of severe COVID-19 outcomes. Cox proportional hazard models were used to estimate adjusted hazard ratios (aHR) and 95% confidence intervals (CIs) for the association between demographic and clinical factors and severe COVID-19 outcomes after the autumn booster dose. Analyses were adjusted for age, sex, body mass index (BMI), deprivation, urban/rural areas and comorbidities. Stratified analyses were conducted by vaccine type. We then conducted a fixed-effect meta-analysis to combine results across the four UK nations.

Findings

Between September 1, 2022 and December 31, 2022, 7,451,890 individuals ≥18 years received an autumn booster dose. 3500 had severe COVID-19 outcomes (2.9 events per 1000 person-years). Being male (male vs female, aHR 1.41 (1.32-1.51)), older adults (≥80 years vs 18-49 years; 10.43 (8.06-13.50)), underweight (BMI <18.5 vs BMI 25.0-29.9; 2.94 (2.51-3.44)), those with comorbidities (≥5 comorbidities vs none; 9.45 (8.15-10.96)) had a higher risk of COVID-19 hospitalisation or death after the autumn booster dose. Those with a larger household size (≥11 people within household vs 2 people; 1.56 (1.23-1.98)) and from more deprived areas (most deprived vs least deprived quintile; 1.35 (1.21-1.51)) had modestly higher risks. We also observed at least a two-fold increase in risk for those with various chronic neurological conditions, including Down's syndrome, immunodeficiency, chronic kidney disease, cancer, chronic respiratory disease, or cardiovascular disease.

Interpretation

Males, older individuals, underweight individuals, those with an increasing number of comorbidities, from a larger household or more deprived areas, and those with specific underlying health conditions remained at increased risk of COVID-19 hospitalisation and death after the autumn 2022 vaccine booster dose. There is now a need to focus on these risk groups for investigating immunogenicity and efficacy of further booster doses or therapeutics.

Funding

National Core Studies-Immunity, UK Research and Innovation (Medical Research Council and Economic and Social Research Council), Health Data Research UK, the Scottish Government, and the University of Edinburgh.

Surgical sensation during caesarean section: a qualitative analysis

BACKGROUND

Caesarean section (CS) is a major abdominal surgery performed usually on a young and healthy population under neuraxial anesthesia with little to no sedation. This creates a distinct surgical experience whereby patients are aware of the surgical process, physical sensations, and their environment. This study aimed to provide an in-depth descriptive assessment of subjective surgical experience during CS under regional anaesthesia. We expected the information gained would enhance our current understanding and better alleviate patient anxiety through informed counselling.

METHODS

This qualitative descriptive study was conducted at a Canadian academic centre. Twenty patients participated in semi-structured interviews within a week of CS, using an interview guide developed for this study. Patient medical records were reviewed to collect demographic and surgical information. Thematic analysis was conducted using an inductive approach to determine common themes.

RESULTS

Nine themes were identified. Five themes were identified in the category of surgical sensation and four themes were identified in the category of peri-operative education.

CONCLUSIONS

Patients commonly experienced pressure and movement sensations at varying intensity, and most did not experience pain. Environmental factors, including sounds and distraction by the newborn, affected perception of surgical sensation. Patients wish to receive pre-operative counselling regarding potential surgical sensations, as well as ongoing communication from their anaesthesiologist. These results can be used to guide informed discussions with patients and direct further investigation in this area.

Risk of COVID-19 death in adults who received booster COVID-19 vaccinations in England

The emergence of the COVID-19 vaccination has been critical in changing the course of the COVID-19 pandemic. To ensure protection remains high in vulnerable groups booster vaccinations in the UK have been targeted based on age and clinical vulnerabilities. We undertook a national retrospective cohort study using data from the 2021 Census linked to electronic health records. We fitted cause-specific Cox models to examine the association between health conditions and the risk of COVID-19 death and all-other-cause death for adults aged 50-100-years in England vaccinated with a booster in autumn 2022. Here we show, having learning disabilities or Down Syndrome (hazard ratio=5.07;95% confidence interval=3.69-6.98), pulmonary hypertension or fibrosis (2.88;2.43-3.40), motor neuron disease, multiple sclerosis, myasthenia or Huntington's disease (2.94, 1.82-4.74), cancer of blood and bone marrow (3.11;2.72-3.56), Parkinson's disease (2.74;2.34-3.20), lung or oral cancer (2.57;2.04 to 3.24), dementia (2.64;2.46 to 2.83) or liver cirrhosis (2.65;1.95 to 3.59) was associated with an increased risk of COVID-19 death. Individuals with cancer of the blood or bone marrow, chronic kidney disease, cystic fibrosis, pulmonary hypotension or fibrosis, or rheumatoid arthritis or systemic lupus erythematosus had a significantly higher risk of COVID-19 death relative to other causes of death compared with individuals who did not have diagnoses. Policy makers should continue to priorities vulnerable groups for subsequent COVID-19 booster doses to minimise the risk of COVID-19 death.

Investigating the impact of an online hydration intervention in care homes using the COM-B model: a mixed methods study

BACKGROUND

Antimicrobial resistance is a serious threat to public health. To reduce antimicrobial resistance, interventions to reduce gram-negative infections, specifically urinary tract infections, are vital. Early evidence suggests increased fluid intake is linked with a reduction in UTIs and subsequently has potential to reduce antibiotic usage. Care homes have a high prevalence of UTIs and provide an opportunity in a closed setting to deliver an intervention focused on increasing fluid intake, where it is supported and monitored by health care workers. The study aimed to evaluate the impact and feasibility of an online staff focused intervention over a 30 day period to increase the hydration of care home residents with a view to reducing the burden of AMR in this setting.

METHODS

The study was a pre and post intervention with a sequential explanatory mixed methods design. The intervention was delivered online in 3 care homes, containing 3 main components underpinned by the COM-B model including hydration training, 7 structured drinks rounds and a hydration champion to change behaviour of care home staff. A pre and post questionnaire assessed the impact of the intervention on staff and data was collected on fluid intake, drinks rounds delivered to residents, UTIs, antibiotic used to treat UTIs, falls and hospitalisation. Descriptive statistics summarised and assessed the impact of the study. Focus groups with care home staff provided qualitative data which was thematically analysed.

RESULTS

Staff increased in self-perceived knowledge across the six components of hydration care. 59% of residents had an increase in median fluid intake post intervention. During the time of the intervention, a 13% decrease in UTIs and antibiotic usage to treat UTIs across the 3 care homes was recorded, however falls and hospitalisations increased. Themes arising from focus groups included the role of information for action, accessibility of online training, online training content.

CONCLUSIONS

This study demonstrates that a brief, low cost, online multi-component intervention focused on care home staff can increase the fluid intake of residents. A reduction in UTIs and antibiotic consumption was observed overall. Empowering care home staff could be a way of reducing the burden of infection in this setting.

Active video games and weight management in overweight children and adolescents-systematic review and meta-analysis

BACKGROUND

The prevalence of childhood obesity has been increasing for several decades. Active video games (AVG) may be an effective intervention to help manage this rising health crisis. The aim of this review is to evaluate whether AVG are effective at reducing weight or improving body composition in overweight youths.

METHOD

Medline, Embase, SportDiscus, ASSIA, CINAHL Plus, CENTRAL, CDSR and PsychINFO databases were searched for studies assessing quantitative or qualitative impact of AVG in overweight adolescents published in English. Three authors screened the results using inclusion/exclusion criteria.

RESULTS

A total of 12 studies met the inclusion criteria; 11 reported a significant decrease in at least one weight outcome. Results from seven randomized controlled trials were pooled by meta-analysis, which compared with controls subjects in AVG groups demonstrated greater body mass index (BMI) Z-score reduction (mean difference: -0.09 (-0.12, -0.05) I2 = 34%, P < 0.0001). The mean weight reduction (-2.66 Kg (-5.67, +0.35) I2 = 0%, P = 0.08) and BMI (-2.29 (-4.81, +0.22) I2 = 49%, P = 0.07) were greater in AVG groups but results did not reach statistical significance.

CONCLUSIONS

BMI Z-score was significantly reduced in the AVG group and the majority of included studies reported significant results in at least one weight outcome, suggesting AVG can be used to reduce weight or improve body composition in overweight youths. Further studies investigating the long-term sustainability of this change in body composition are needed.

Using the COM-B framework to elucidate facilitators and barriers to COVID-19 vaccine uptake in pregnant women: a qualitative study

Since April 2021, COVID-19 vaccines have been recommended for pregnant women. Despite this, COVID-19 vaccine uptake in this group is low compared to the non-pregnant population of childbearing age. Our aim was to understand barriers and facilitators to COVID-19 vaccine uptake among pregnant women in Northern Ireland using the COM-B framework, and so to make recommendations for public health interventions. The COM-B proposes that human behaviour is influenced by the extent to which a person has the capability, opportunity, and motivation to enact that behaviour. Understanding the factors underpinning behaviour through this lens helps discern what needs to change to change behaviour, therefore supporting the development of targeted interventions.This study consisted of eight semi-structured interviews with new/expectant mothers who did not receive a COVID-19 vaccine dose while pregnant since April 2021, and a focus group with five participants who received at least one COVID-19 vaccine dose while pregnant. Interview and focus group data were analysed using semi-deductive reflexive thematic analysis framed by a subtle realist approach. The COM-B was used to categorise codes and subthemes were developed within each COM-B construct.Within Psychological Capability, subthemes captured the need for consistent and reliable COVID-19 vaccine information and access to balanced and jargon-free, risk-benefit information that is tailored to the pregnant individual. The behaviour/opinions of family, friends, and local healthcare providers had a powerful influence on COVID-19 vaccine decisions (Social Opportunity). Integrating the COVID-19 vaccine as part of routine antenatal pathways was believed to support access and sense of familiarity (Physical Opportunity). Participants valued health autonomy, however experienced internal conflict driven by concerns about long-term side effects for their baby (Reflective Motivation). Feelings of fear, lack of empathy from healthcare providers, and anticipated guilt commonly underpinned indecision as to whether to get the vaccine (Automatic Motivation).Our study highlighted that the choice to accept a vaccine during pregnancy generates internal conflict and worry. Several participants cited their concern was primarily around the safety for their baby. Healthcare professionals (HCPs) play a significant part when it comes to decision making about COVID-19 vaccines among pregnant women. HCPs and pregnant women should be involved in the development of interventions to improve the delivery and communication of information.

The impact of the COVID-19 pandemic on antibiotic consumption and prevalence of pathogens in primary and secondary healthcare settings in Northern Ireland

AIM

To evaluate the impact of the COVID-19 pandemic on the patterns of antimicrobial use and the incidence of pathogens in primary and secondary healthcare settings in Northern Ireland.

METHODS

Data were collected on antibiotic use and Gram-positive and Gram-negative pathogens from primary and secondary healthcare settings in Northern Ireland for the period before (January 2015-March 2020) and during (April 2020-December 2021) the pandemic. Time series intervention analysis methods were utilized.

RESULTS

In the hospital setting, the mean total hospital antibiotic consumption during the pandemic was 1864.5 defined daily doses (DDDs) per 1000 occupied-bed days (OBD), showing no significant change from pre-pandemic (P = .7365). During the pandemic, the use of second-generation cephalosporins, third-generation cephalosporins, co-amoxiclav and levofloxacin increased, there was a decrease in the percentage use of the hospital Access group (P = .0083) and an increase in the percentage use of Watch group (P = .0040), and the number of hospital Klebsiella oxytoca and methicillin-susceptible Staphylococcus aureus cases increased. In primary care, the mean total antibiotic consumption during the COVID-19 pandemic was 20.53 DDDs per 1000 inhabitants per day (DID), compared to 25.56 DID before the COVID-19 pandemic (P = .0071). During the pandemic, there was a decrease in the use of several antibiotic classes, an increase in the percentage use of the Reserve group (P = .0032) and an increase in the number of community-onset Pseudomonas aeruginosa cases.

CONCLUSION

This study provides details of both changes in antibiotic consumption and the prevalence of infections in hospitals and primary care before and during the COVID-19 pandemic that emphasize the importance of antimicrobial stewardship in pandemic situations.

How public health authorities can use pathogen genomics in health protection practice: a consensus-building Delphi study conducted in the United Kingdom

Pathogen sequencing guided understanding of SARS-CoV-2 evolution during the COVID-19 pandemic. Many health systems developed pathogen genomics services to monitor SARS-CoV-2. There are no agreed guidelines about how pathogen genomic information should be used in public health practice. We undertook a modified Delphi study in three rounds to develop expert consensus statements about how genomic information should be used. Our aim was to inform health protection policy, planning and practice. Participants were from organisations that produced or used pathogen genomics information in the United Kingdom. The first round posed questions derived from a rapid literature review. Responses informed statements for the subsequent rounds. Consensus was accepted when 70 % or more of the responses were strongly agree/agree, or 70 % were disagree/strongly disagree on the five-point Likert scale. Consensus was achieved in 26 (96 %) of 27 statements. We grouped the statements into six categories: monitoring the emergence of new variants; understanding the epidemiological context of genomic data; using genomic data in outbreak risk assessment and risk management; prioritising the use of limited sequencing capacity; sequencing service performance; and sequencing service capability. The expert consensus statements will help guide public health authorities and policymakers to integrate pathogen genomics in health protection practice.

Severe COVID-19 outcomes after full vaccination of primary schedule and initial boosters: pooled analysis of national prospective cohort studies of 30 million individuals in England, Northern Ireland, Scotland, and Wales

BACKGROUND

Current UK vaccination policy is to offer future COVID-19 booster doses to individuals at high risk of serious illness from COVID-19, but it is still uncertain which groups of the population could benefit most. In response to an urgent request from the UK Joint Committee on Vaccination and Immunisation, we aimed to identify risk factors for severe COVID-19 outcomes (ie, COVID-19-related hospitalisation or death) in individuals who had completed their primary COVID-19 vaccination schedule and had received the first booster vaccine.

METHODS

We constructed prospective cohorts across all four UK nations through linkages of primary care, RT-PCR testing, vaccination, hospitalisation, and mortality data on 30 million people. We included individuals who received primary vaccine doses of BNT162b2 (tozinameran; Pfizer-BioNTech) or ChAdOx1 nCoV-19 (Oxford-AstraZeneca) vaccines in our initial analyses. We then restricted analyses to those given a BNT162b2 or mRNA-1273 (elasomeran; Moderna) booster and had a severe COVID-19 outcome between Dec 20, 2021, and Feb 28, 2022 (when the omicron (B.1.1.529) variant was dominant). We fitted time-dependent Poisson regression models and calculated adjusted rate ratios (aRRs) and 95% CIs for the associations between risk factors and COVID-19-related hospitalisation or death. We adjusted for a range of potential covariates, including age, sex, comorbidities, and previous SARS-CoV-2 infection. Stratified analyses were conducted by vaccine type. We then did pooled analyses across UK nations using fixed-effect meta-analyses.

FINDINGS

Between Dec 8, 2020, and Feb 28, 2022, 16 208 600 individuals completed their primary vaccine schedule and 13 836 390 individuals received a booster dose. Between Dec 20, 2021, and Feb 28, 2022, 59 510 (0·4%) of the primary vaccine group and 26 100 (0·2%) of those who received their booster had severe COVID-19 outcomes. The risk of severe COVID-19 outcomes reduced after receiving the booster (rate change: 8·8 events per 1000 person-years to 7·6 events per 1000 person-years). Older adults (≥80 years vs 18-49 years; aRR 3·60 [95% CI 3·45-3·75]), those with comorbidities (≥5 comorbidities vs none; 9·51 [9·07-9·97]), being male (male vs female; 1·23 [1·20-1·26]), and those with certain underlying health conditions-in particular, individuals receiving immunosuppressants (yes vs no; 5·80 [5·53-6·09])-and those with chronic kidney disease (stage 5 vs no; 3·71 [2·90-4·74]) remained at high risk despite the initial booster. Individuals with a history of COVID-19 infection were at reduced risk (infected ≥9 months before booster dose vs no previous infection; aRR 0·41 [95% CI 0·29-0·58]).

INTERPRETATION

Older people, those with multimorbidity, and those with specific underlying health conditions remain at increased risk of COVID-19 hospitalisation and death after the initial vaccine booster and should, therefore, be prioritised for additional boosters, including novel optimised versions, and the increasing array of COVID-19 therapeutics.

FUNDING

National Core Studies-Immunity, UK Research and Innovation (Medical Research Council), Health Data Research UK, the Scottish Government, and the University of Edinburgh.

Examining the association between socio-demographic factors, catheter use and antibiotic prescribing in Northern Ireland primary care: a cross-sectional multilevel analysis

Inappropriate use of antibiotics is among the key drivers of antimicrobial resistance (AMR). Antibiotic use in Northern Ireland (NI) is the highest in the UK and approximately 80% is prescribed in primary care. Little information however exists about the patient and prescriber factors driving this. We described the trend in NI primary care total antibiotic prescribing 2010–2019 and conducted a cross-sectional study using a random sample of individuals registered with an NI GP on 1st January 2019. We used multilevel logistic regression to examine how sociodemographic factors and urinary catheter use was associated with the likelihood of being prescribed an antibiotic during 2019, adjusting for clustering at GP practice and GP federation levels. Finite mixture modelling (FMM) was conducted to determine the association between the aforementioned risk factors and quantity of antibiotic prescribed (defined daily doses). The association between age and antibiotic prescription differed by gender. Compared to males 41–50 years, adjusted odds of prescription were higher for males aged 0–10, 11–20 and 51 + years, and females of any age. Catheter use was strongly associated with antibiotic prescription (aOR = 6.82, 95% CI 2.50–18.64). Socioeconomic deprivation and urban/rural settlement were not associated in the multilevel logistic analysis. GP practices and federations accounted for 1.24% and 0.12% of the variation in antibiotic prescribing respectively. FMM showed associations between larger quantities of antibiotics and being older, male and having a catheter. This work described the profile of individuals most likely to receive an antibiotic prescription in NI primary care and identified GP practice as a source of variation; suggesting an opportunity for reduction from effective interventions targeted at both individuals and general practices.

Do interviewer attitudes to data linkage influence respondents' consent to linkage? Analysis of Understanding Society

BACKGROUND

Variable consent rates threaten the validity of linked datasets. One modifiable element is the interviewer-respondent relationship. We examine interviewer attitudes to consent to linkage and the effect on respondent consent.

METHODS

Subjects were 27 380 respondents from the Wave 1 Understanding Society (US) survey in Great Britain and 449 interviewers who completed the US Interviewer Survey. Two types of consent were considered: (i) whether the interviewer would hypothetically agree to having their data linked if he/she was an US respondent and (ii) whether the respondent consented to have their data linked. Factors influencing the interviewer's propensity to link data were examined using logistic regression. The association between interviewer consent and respondent consent to health record linkage was assessed using multi-level logistic regression models.

RESULTS

The interviewer's propensity to consent to data linkage was strongly positively associated with its perceived usefulness: those that found it somewhat useful were 57% less likely to consent [adjusted odds ratio (AOR) 0.43, 95% CI: 0.22-0.82] compared to those who thought it was very useful. Positive beliefs about data security and their ability to understand the data linkage information were also associated. Respondents were 17% less likely to consent when interviewed by an interviewer who would not consent to record linkage (AOR 0.83, 95% CI: 0.71-0.97).

CONCLUSIONS

The interviewer's propensity to consent was influenced by their beliefs about data linkage, which in turn influenced respondent consent. We recommend using interviewer training to emphasize the usefulness of data linkage and the measures around data security.

The epidemiology and management of candidemia in Northern Ireland during 2002-2011, including a 12-month enhanced case review

In Northern Ireland there are concerns about candidaemia, with rates higher than those reported in England and Wales. Our aim was to explore the epidemiology of candidaemia during a 10 year period and the clinical management upon suspicion of cases during a one year enhanced investigation in Northern Ireland.Candidaemia reports to the Public Health Agency were validated during 2002-2011 and used to examine incidence and antifungal sensitivity trends (during 2007-2011). A clinical proforma was used to collate information for all patients with candidaemia in 2011.The majority (96%) of isolates were captured through voluntary laboratory reporting. There was a year-on-year increase in candidaemia from 2002-2011, from 80 to 131 episodes (incidence rate ratio 1.09 95% CI 1.05-1.13). Rates were highest in males under 1 year and over 75 years. 83/98 (85%) of case notes were available from candidaemia patients during 2011. The most prevalent risk factors were patients on total parenteral nutrition (26 people, 31.3%), surgery in the two months prior to the candidaemia (25 people, 30.1%), significant steroid use in the previous 3 months (24 people, 28.9%) and active neoplastic disease (23 people, 27.7%),This study confirmed an increase in candidaemia rates over time, with the observed incidence in 2011 higher than England and Wales. We identified areas for improvement around the clinical management of candidaemia. We recommend raising the awareness of guidelines for fundoscopy, echocardiography and central venous catheter removal.

Individual risk factors and critical care unit effects on Invasive Candida Infection occurring in critical care units in the UK: A multilevel model

Geographical variation is observed in invasive candida infection (ICI) and differences between critical care units (CCUs) may contribute. To examine rates, risk factors and individual and unit-level variation of ICI in UK CCUs. Data from the Fungal Infection Risk Evaluation Study was used to examine individuals admitted to 96 CCUs in the UK; July 2009-March 2011. Cases were non-neutropenic individuals aged 18 years and over with ICI identified after admission. Mixed-effects Poisson regression models adjusted for the CCU. There were 225 cases of ICI, a rate of 6.84/10 000 bed days and a threefold variation between the lowest and highest UK regions. Independent risk factors included abdominal surgery (adjusted incidence rate ratio (AIRR) 2.03 95% CI 1.49, 2.76), parenteral nutrition (AIRR 1.89 95% CI 1.33, 2.70), fungal colonisation at two or more sites (AIRR 2.30 95% CI 1.34, 3.95) and indwelling devices. Approximately 4% of the variation in ICI rates could be attributed to the CCU. We identified independent risk factors for ICI and showed, for the first time, that the critical care unit effect was small. Despite this, future studies should consider the hierarchical structure of the data to ensure robust estimates.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Health status in Europe: comparison of 24 urban areas to the corresponding 10 countries (EURO-URHIS 2)

Background

: In Europe, over 70% of the population live in urban areas (UAs). Most international comparative health research is done using national level data, as reliable and comparable urban data are often unavailable or difficult to access. This study aims to investigate whether population health is different in UAs compared with their corresponding countries. : Routinely available health-related data were collected by the EURO-URHIS 2 project, for 10 European countries and for 24 UAs within those countries. National and UA level data for 11 health indicators were compared through the calculation of relative difference, and geographical patterns within Europe were investigated using the Mann Whitney U test. Linear regression modelling was used to adjust for population density, gross domestic product and urbanicity. : In general, the urban population in Eastern Europe is less healthy than the Western European urban population. However, people in Eastern Europe have significantly better broad health outcomes in UAs as compared with the corresponding country as a whole, whereas people in Western Europe have generally worse broader health outcomes in UAs. : For most European countries and UAs that were investigated, the national level health status data does not correspond with the health status at UA level. In order to identify health problems in UAs and to provide information for local health policy, health monitoring and international benchmarking should also be conducted at the local level.

Changing epidemiology of Pneumocystis pneumonia, Northern Ireland, UK and implications for prevention, 1 July 2011-31 July 2012

PURPOSE

There is a lack of consensus about which non-human immunodeficiency virus (HIV) patient groups would benefit from prophylaxis. Here, we analysed an enhanced Pneumocystis jirovecii database to describe the epidemiology of Pneumocystis pneumonia (PCP) and P. jirovecii colonizations in Northern Ireland (NI) with a view to identifying risk groups who may benefit from prophylaxis.

METHODOLOGY

We prospectively collected information on demographics, clinical severity and clinical features for all hospital inpatients in NI aged ≥18 years with P. jirovecii confirmed in any respiratory tract sample. We defined P. jirovecii colonization or PCP according to clinical symptoms and radiological findings. We compared P. jirovecii colonization to PCP using exact logistic regression and presented the odds ratios (OR), 95 % confidence intervals (CI) and likelihood ratio test P-values.Results/Key findings. Overall, 36/49 (73 %) of P. jirovecii detections were categorized as PCP. A total of 28/36 (78 %) were in non-HIV patients, of which 18 (64 %) had cancer. The odds of PCP compared to P. jirovecii colonization were eight times higher in those with current exposure to chemotherapy (OR 8.73; 95 % CI 0.84, ∞), 16 times higher for those diagnosed with HIV (OR 16.2; 95 % CI 1.71, ∞) and 12 times higher for those ever exposed to another immunosuppressive drug (OR 12.1; 95 % CI 1.94, ∞).

CONCLUSION

The greatest burden of PCP is now in the non-HIV group, particularly cancer patients. We recommend increasing clinician awareness of PCP risk and strengthening prevention guidelines in non-HIV patients, and promoting the consideration of prophylaxis on a case-by-case basis.

Serious pneumococcal disease outbreak in men exposed to metal fume - detection, response and future prevention through pneumococcal vaccination

Welders and those exposed to metal fume are known to be at increased risk of pneumococcal pneumonia and invasive pneumococcal disease. Current UK guidance recommends that vaccination against pneumococcus be considered in those at risk of frequent or continuous occupational exposure to metal fume, taking into account the exposure control measures in place. We report an outbreak of serious pneumococcal disease that occurred between April and June 2015 among a multinational workforce exposed to metal fumes while working on the refurbishment of an oil rig in a Belfast shipyard. Four confirmed and five probable cases were identified, which occurred despite the use of environmental control measures and the availability of respiratory protective equipment. To provide direct protection to those at risk of pneumococcal disease and to eradicate carriage of pneumococcus and interrupt transmission, pneumococcal polysaccharide vaccine (PPV23) and antibiotic prophylaxis were offered to 680 individuals identified as potentially exposed to metal fume. Low levels of prior pneumococcal vaccination were reported among this target group (<1%). Genomic sequencing indicated a common strain of serotype 4 pneumococcus in two of the confirmed cases and a distinct serotype 4 in one case. The fourth confirmed case was identified as likely serotype 3 using a serotype-specific immunoassay on a urine specimen. Both serotypes 3 and 4 are vaccine-preventable strains covered by the conjugate and polysaccharide pneumococcal vaccines currently available. We propose that consideration should be given to strengthening implementation around pneumococcal vaccination for those exposed to metal fume through their work, even when other control measures are in place, to reduce the risk of future cases and outbreaks of serious pneumococcal disease.

Outbreak of invasive pneumococcal disease at a Belfast shipyard in men exposed to welding fumes, Northern Ireland, April-May 2015: preliminary report

We report an outbreak of four confirmed cases of invasive pneumococcal disease (IPD) in individuals occupationally exposed to welding fumes, at a Belfast shipyard (Northern Ireland). All cases were hospitalised. A high-risk sub-group of 679 workers has been targeted for antibiotic prophylaxis and pneumococcal vaccination. Physicians and public health institutions outside Northern Ireland should be alert to individuals presenting with pneumonia or IPD and recent links to the shipyard, to facilitate early assessment and treatment.

Large panel-survey data demonstrated country-level and ethnic minority variation in consent for health record linkage

OBJECTIVES

To investigate individual, household, and country variation in consent to health record linkage.

STUDY DESIGN AND SETTING

Data from 50,994 individuals aged 16-74 years recruited to wave 1 of a large UK general purpose household survey (January 2009-December 2010) were analyzed using multilevel logistic regression models.

RESULTS

Overall, 70.7% of respondents consented to record linkage. Younger age, marriage, tenure, car ownership, and education were all significantly associated with consent, although there was little deviation from 70% in subgroups defined by these variables. There were small increases in consent rates in individuals with poor health when defined by self-reported long-term limiting illness [adjusted odds ratio (OR) = 1.11; 95% confidence intervals (CIs): 1.06, 1.16], less so when defined by General Health Questionnaire score (adjusted OR = 1.05; 95% CIs: 1.00, 1.10), but the range in absolute consent rates between categories was generally less than 10%. Larger differences were observed for those of nonwhite ethnicity who were 38% less likely to consent (adjusted OR = 0.62; 95% CIs: 0.59, 0.66). Consent was higher in Scotland than England (adjusted OR = 1.17; 95% CIs: 1.06, 1.29) but lower in Northern Ireland (adjusted OR = 0.56; 95% CIs: 0.50, 0.63).

CONCLUSION

The modest overall level of systematic bias in consent to record linkage provides reassurance for record linkage potential in general purpose household surveys. However, the low consent rates among nonwhite ethnic minority survey respondents will further compound their low survey participation rates. The reason for the country-level variation requires further study.

The relationship between BMI and the prescription of anti-obesity medication according to social factors: a population cross sectional study

Background

Obesity is a global public health problem. There are a range of treatments available with varying short and long term success rates. One option is the use of anti-obesity medication the prescription of which has increased dramatically in recent years. Despite this, little is known about the individual and GP practice factors that influence the prescription of anti-obesity medication.

Methods

Multi-level logistic regression analysis was used to investigate factors associated with the prescription of anti-obesity medication in Northern Ireland using a population primary care prescribing database (~1.5 million people aged 16+ years) during 2009/10.

Results

While 25.0% of people are obese, only 1.3% (2.1% of females, 0.6% of males) received anti-obesity medication. The relationship between medication rates and age differed by gender (P < 0.001) with prescriptions higher in younger females and older males. Prescribing of anti-obesity medication reflected obesity prevalence across urban/rural areas and deprivation. There was an unexplained two-fold difference, between the 25^th and 75^th percentile, in the GP practice prescription of anti-obesity medication.

Conclusions

There is evidence of relative under-prescribing in males compared to females despite a similar prevalence of obesity. While the prevalence (and presumably the health consequences) of obesity worsens with age, younger females are more likely to be prescribed anti-obesity medication. This suggests an element of patient demand. Educational material to improve the understanding of the role of anti-obesity medication, for patients and practitioners, is recommended. But further study is needed to understand the factors responsible for the variation in prescribing between GP practices.

Prescribing for weight loss in primary care: evidence from a population based study

BACKGROUND

Taking antiobesity medication can be a cost effective way to lose weight. Uptake is determined in part by a General Practitioner's decision to prescribe weight loss medication and, in part, by patient preference. It is probable that the latter may indicate a patient's readiness to lose weight.

METHODS

Analysis of cross-sectional data (from February 2003 to March 2011) from a population based prescribing database (∼1.75 million people) using an adjusted Poisson regression.

RESULTS

The number of antiobesity medications increased from 23.4 per 1000 population in 2004 to 30.7 per 1000 population in 2010 and was three times higher in female than in male subjects. Against this background, a marked seasonal variation in the number of antiobesity medications dispensed was evident (p<0.001), peaking in June/July with a trough in December/January (±8.0% peak to trough). The seasonal component was stronger in female subjects, ±11.2% peak to trough, compared with ±3.5% for male subjects.

CONCLUSIONS

Obese patients, particularly women, increase their uptake of weight loss medication in the months leading up to the summer holiday period. The period prior to the summer may represent a time that health professionals could promote increased participation of obese patients in weight loss programmes.

Morbidity and mortality associated with Clostridium difficile ribotype 078: a case-case study

The morbidity and mortality associated with Clostridium difficile ribotype 078 were examined by comparison with other known outbreak strains. A healthcare interaction within eight weeks of a positive specimen significantly increased the likelihood of ribotype 078 compared with ribotype 027. Individuals with ribotype 078 also tended to come from community sources, have a hospital stay post specimen similar to ribotype 027 and a lower 30-day mortality, but these differences were not statistically significant. This study generates several hypotheses and a methodological platform to explore this unique profile.

The development and performance of a rapid-access neurovascular (TIA) assessment clinic in a rural hospital setting

INTRODUCTION

Following the withdrawal of acute medical services from rural Angus, a rapid-access Neurovascular (TIA) Clinic was established at Stracathro Hospital in December 2003. Referral protocols were agreed with Angus Primary Care. We measured the performance of this clinic over its first two years against national standards outlined by Quality Improvement Scotland (2005).

METHODS

In a retrospective study between 1st December 2003 and 30th November 2005, patient demographics, waiting times, investigation results, diagnoses, and secondary prevention issues were analysed. Challenges presented by a rural setting were also examined,

RESULTS

By November 2005, from a total of 355 patients, 79% were seen within 7 days and 98% within 14 days of clinic referral. Pre-clinic bloods were increasingly done in general practice. All patients had CT head and carotid NIVA scans performed on the day of clinic attendance. A high positive diagnostic yield from CT scanning was obtained in the first year of the clinic, and a significant proportion of patients had new secondary drug prevention treatment recommended. Organisational and transport difficulties were addressed and overcome.

DISCUSSION

Developing a rapid-access neurovascular clinic in a rural setting is achievable, and waiting times approaching national standard targets are possible. A TIA clinic can identify rapidly those with cerebrovascular disease, allowing commencement of appropriate secondary prevention therapy.

Pre-training to improve workshop performance in supervisor skills: an exploratory study of Latino agricultural workers

Employees with limited education may be excluded from advanced training due to assumptions that they might not learn rapidly. However, preparatory training may be able to overcome missing experience in education. The purpose of this study was to test the hypothesis that computer-based training (CBT) in supervisor skills of Latino agricultural workers would improve subsequent performance in a workshop designed to teach supervisor skills. Ten men born and educated in Mexico participated in the study; all spoke Spanish, the language of the training. Five participants (mean 6.4 years of education) completed supervisor skills CBT, and five participants (mean 8.2 years of education) completed hazard communication (HazCom) CBT as a control condition. Following the CBT, all participants completed a two-day face-to-face workshop on supervisory skills conducted by an experienced behavior management consultant. Although the groups did not differ in their knowledge scores on a multiple-choice test before the face-to-face workshop, after the workshop the HazCom group had a mean test score of 51.2% (SD = 8.7) while the supervisor group had a higher mean test score of 65.2% (SD = 14.3). The difference was marginally significant by a t-test (p = 0.052), and the effect size was large (d = 1.16). The results suggest that computer-based training in supervisor skills can be effective in preparing participants with limited education to learn supervisor skills from a face-to-face workshop. This result suggests that limited educational attainment is not a barrier to learning the complex knowledge required to supervise employees, that pre-training may improve learning in a workshop format, and that training may be presented effectively in a computer-based format to employees with limited education.

An audit of the use of isolation facilities in a UK National Health Service trust

To aid the ongoing battle against hospital-acquired infection in the UK, all acute National Health Service (NHS) trusts should have audit data about how dedicated isolation beds within the trust are being used. In a previously published audit, we demonstrated that one-third of patients admitted to a dedicated isolation room in Tayside were not thought to be an infection risk by experienced healthcare staff. Since this audit, Tayside's isolation facilities have moved from a small peripheral 'fever' hospital to a large central teaching hospital site. At the time of this move, and using the above audit data, we designed and implemented a guideline for general practitioners and hospital doctors regarding the admission of patients to an isolation bed. The aim of this study was to compare the use of isolation beds before and after the move to the new facilities, which we anticipated would increase the demand for isolation. The results show that by all three criteria used, the utilization of isolation beds has deteriorated following the move, mainly due to the increased admission of general medical 'boarders' and low-risk infection patients. At a time when hospital-acquired infections are increasing, NHS trusts should ensure that dedicated isolation beds are used appropriately.

Series of laryngomalacia, tracheomalacia, and bronchomalacia disorders and their associations with other conditions in children

Laryngomalacia, bronchomalacia, and tracheomalacia are commonly seen in pediatric respiratory medicine, yet their patterns and associations with other conditions are not well-understood. We prospectively video-recorded bronchoscopic data and clinical information from referred patients over a 10-year period and defined aspects of interrelationships and associations. Two hundred and ninety-nine cases of malacia disorders (34%) were observed in 885 bronchoscopic procedures. Cough, wheeze, stridor, and radiological changes were the most common symptoms and signs. The lesions were most often found in males (2:1) and on the left side (1.6:1). Concomitant malacia lesions ranged from 24% for laryngotracheobronchomalacia to 47% for tracheobronchomalacia. The lesions were found in association with other disorders such as congenital heart disorders (13.7%), tracheo-esophageal fistula (9.6%), and various syndromes (8%). Even though the understanding of these disorders is in its infancy, pediatricians should maintain a level of awareness for malacia lesions and consider the possibility of multiple lesions being present, even when one symptom predominates or occurs alone.