Identifying and handling data bias within primary healthcare data using synthetic data generators

Advanced synthetic data generators can simulate data samples that closely resemble sensitive personal datasets while significantly reducing the risk of individual identification. The use of these advanced generators holds enormous potential in the medical field, as it allows for the simulation and sharing of sensitive patient data. This enables the development and rigorous validation of novel AI technologies for accurate diagnosis and efficient disease management. Despite the availability of massive ground truth datasets (such as UK-NHS databases that contain millions of patient records), the risk of biases being carried over to data generators still exists. These biases may arise from the under-representation of specific patient cohorts due to cultural sensitivities within certain communities or standardised data collection procedures. Machine learning models can exhibit bias in various forms, including the under-representation of certain groups in the data. This can lead to missing data and inaccurate correlations and distributions, which may also be reflected in synthetic data. Our paper aims to improve synthetic data generators by introducing probabilistic approaches to first detect difficult-to-predict data samples in ground truth data and then boost them when applying the generator. In addition, we explore strategies to generate synthetic data that can reduce bias and, at the same time, improve the performance of predictive models.

The cost of primary care consultations associated with long COVID in non-hospitalised adults: a retrospective cohort study using UK primary care data

BACKGROUND

The economic impact of managing long COVID in primary care is unknown. We estimated the costs of primary care consultations associated with long COVID and explored the relationship between risk factors and costs.

METHODS

Data were obtained on non-hospitalised adults from the Clinical Practice Research Datalink Aurum primary care database. We used propensity score matching with an incremental cost method to estimate additional primary care consultation costs associated with long COVID (12 weeks after COVID-19) at an individual and UK national level. We applied multivariable regression models to estimate the association between risk factors and consultations costs beyond 12 weeks from acute COVID-19.

RESULTS

Based on an analysis of 472,173 patients with COVID-19 and 472,173 unexposed individuals, the annual incremental cost of primary care consultations associated with long COVID was £2.44 per patient and £23,382,452 at the national level. Among patients with COVID-19, a long COVID diagnosis and reporting of longer-term symptoms were associated with a 43% and 44% increase in primary care consultation costs respectively, compared to patients without long COVID symptoms. Older age, female sex, obesity, being from a white ethnic group, comorbidities and prior consultation frequency were all associated with increased primary care consultation costs.

CONCLUSIONS

The costs of primary care consultations associated with long COVID in non-hospitalised adults are substantial. Costs are significantly higher among those diagnosed with long COVID, those with long COVID symptoms, older adults, females, and those with obesity and comorbidities.

Completeness, agreement, and representativeness of ethnicity recording in the United Kingdom's Clinical Practice Research Datalink (CPRD) and linked Hospital Episode Statistics (HES)

BACKGROUND

This descriptive study assessed the completeness, agreement, and representativeness of ethnicity recording in the United Kingdom (UK) Clinical Practice Research Datalink (CPRD) primary care databases alone and, for those patients registered with a GP in England, when linked to secondary care data from Hospital Episode Statistics (HES).

METHODS

Ethnicity records were assessed for all patients in the May 2021 builds of the CPRD GOLD and CPRD Aurum databases for all UK patients. In analyses of the UK, English data was from combined CPRD-HES, whereas data from Northern Ireland, Scotland, and Wales drew from CPRD only. The agreement of ethnicity records per patient was assessed within each dataset (CPRD GOLD, CPRD Aurum, and HES datasets) and between datasets at the highest level ethnicity categorisation ('Asian', 'black', 'mixed', 'white', 'other'). Representativeness was assessed by comparing the ethnic distributions at the highest-level categorisation of CPRD-HES to those from the Census 2011 across the UK's devolved administrations. Additionally, CPRD-HES was compared to the experimental ethnic distributions for England and Wales from the Office for National Statistics in 2019 (ONS2019) and the English ethnic distribution from May 2021 from NHS Digital's General Practice Extraction Service Data for Pandemic Planning and Research with HES data linkage (GDPPR-HES).

RESULTS

In CPRD-HES, 81.7% of currently registered patients in the UK had ethnicity recorded in primary care. For patients with multiple ethnicity records, mismatched ethnicity within individual primary and secondary care datasets was < 10%. Of English patients with ethnicity recorded in both CPRD and HES, 93.3% of records matched at the highest-level categorisation; however, the level of agreement was markedly lower in the 'mixed' and 'other' ethnic groups. CPRD-HES was less proportionately 'white' compared to the UK Census 2011 (80.3% vs. 87.2%) and experimental ONS2019 data (80.4% vs. 84.3%). CPRD-HES was aligned with the ethnic distribution from GDPPR-HES ('white' 80.4% vs. 80.7%); however, with a smaller proportion classified as 'other' (1.1% vs. 2.8%).

CONCLUSIONS

CPRD-HES has suitable representation of all ethnic categories with some overrepresentation of minority ethnic groups and a smaller proportion classified as 'other' compared to the UK general population from other data sources. CPRD-HES data is useful for studying health risks and outcomes in typically underrepresented groups.

Healthcare workers knowledge of cholera multi-stranded interventions and its determining factors in North-East Nigeria: planning and policy implications

BACKGROUND

Healthcare workers' (HCWs) knowledge of multi-stranded cholera interventions (including case management, water, sanitation, and hygiene (WASH), surveillance/laboratory methods, coordination, and vaccination) is crucial to the implementation of these interventions in healthcare facilities, especially in conflict-affected settings where cholera burden is particularly high. We aimed to assess Nigerian HCWs' knowledge of cholera interventions and identify the associated factors.

METHODS

We conducted a cross-sectional study using a structured interviewer-administered questionnaire with HCWs from 120 healthcare facilities in Adamawa and Bauchi States, North-East Nigeria. A knowledge score was created by assigning a point for each correct response. HCWs' knowledge of cholera interventions, calculated as a score, was recoded for ease of interpretation as follows: 0-50 (low); 51-70 (moderate); ≥ 71 (high). Additionally, we defined the inadequacy of HCWs' knowledge of cholera interventions based on a policy-relevant threshold of equal or lesser than 75 scores for an intervention. Multivariable logistic regression was used to identify the factors associated with the adequacy of knowledge score.

RESULTS

Overall, 490 HCWs participated in the study (254 in Adamawa and 236 in Bauchi), with a mean age of 35.5 years. HCWs' knowledge score was high for surveillance/laboratory methods, moderate for case management, WASH, and vaccination, and low for coordination. HCWs' knowledge of coordination improved with higher cadre, working in urban- or peri-urban-based healthcare facilities, and secondary education; cholera case management and vaccination knowledge improved with post-secondary education, working in Bauchi State and urban areas, previous training in cholera case management and response to a cholera outbreak-working in peri-urban areas had a negative effect. HCWs' knowledge of surveillance/laboratory methods improved with a higher cadre, 1-year duration in current position, secondary or post-secondary education, previous training in cholera case management and response to a cholera outbreak. However, HCWs' current position had both positive and negative impacts on their WASH knowledge.

CONCLUSIONS

HCWs in both study locations recorded a considerable knowledge of multi-stranded cholera interventions. While HCWs' demographic characteristics appeared irrelevant in determining their knowledge of cholera interventions, geographic location and experiences from the current position, training and involvement in cholera outbreak response played a significant role.

Quality of rheumatoid arthritis recording in United Kingdom Clinical Practice Research Datalink Aurum

PURPOSE

While several studies have assessed quality and completeness of recording acute medical events in Clinical Practice Research Datalink (CPRD) Aurum, evaluation of additional chronic conditions is warranted.

METHODS

We selected patients with a first diagnosis of rheumatoid arthritis (RA) coded in their CPRD Aurum record between 2005 and 2019. We assessed quality of RA diagnosis by evaluating additional information in the patient record that would corroborate the diagnosis. We report recording of diagnoses, prescriptions, labs, and referrals expected to be present based on NICE guidelines for RA management.

RESULTS

There were 53 083 patients with a first recorded RA diagnosis during the study period: 43606 (82%) patients had RA drug treatments in their record, 7596 (14%) had supporting codes without drug treatment, and 1881 (4%) patients had only a RA diagnoses recorded in their medical record with no supporting codes or RA treatments. Patients with RA diagnosis only were more likely to be first diagnosed in the earliest time period of study. Labs for diagnosing and monitoring RA were most common among patients with RA treatment. Analgesic and glucocorticoid prescriptions were common in all study patients but were highest among patients with RA treatment. Among patients with RA diagnosis only, the overwhelming majority had only one RA diagnosis recorded (76%).

CONCLUSIONS

Our findings suggest that codes expected for monitoring and treatment of RA are routinely recorded in CPRD Aurum. These results support previous assessments, which found data recorded in CPRD Aurum to be of good quality for use in research.

Epidemiology, diagnostics and factors associated with mortality during a cholera epidemic in Nigeria, October 2020-October 2021: a retrospective analysis of national surveillance data

OBJECTIVES

Nigeria reported an upsurge in cholera cases in October 2020, which then transitioned into a large, disseminated epidemic for most of 2021. This study aimed to describe the epidemiology, diagnostic performance of rapid diagnostic test (RDT) kits and the factors associated with mortality during the epidemic.

DESIGN

A retrospective analysis of national surveillance data.

SETTING

33 of 37 states (including the Federal Capital Territory) in Nigeria.

PARTICIPANTS

Persons who met cholera case definition (a person of any age with acute watery diarrhoea, with or without vomiting) between October 2020 and October 2021 within the Nigeria Centre for Disease Control surveillance data.

OUTCOME MEASURES

Attack rate (AR; per 100 000 persons), case fatality rate (CFR; %) and accuracy of RDT performance compared with culture using area under the receiver operating characteristic curve (AUROC). Additionally, individual factors associated with cholera deaths and hospitalisation were presented as adjusted OR with 95% CIs.

RESULTS

Overall, 93 598 cholera cases and 3298 deaths (CFR: 3.5%) were reported across 33 of 37 states in Nigeria within the study period. The proportions of cholera cases were higher in men aged 5-14 years and women aged 25-44 years. The overall AR was 46.5 per 100 000 persons. The North-West region recorded the highest AR with 102 per 100 000. Older age, male gender, residency in the North-Central region and severe dehydration significantly increased the odds of cholera deaths. The cholera RDT had excellent diagnostic accuracy (AUROC=0.91; 95% CI 0.87 to 0.96).

CONCLUSIONS

Cholera remains a serious public health threat in Nigeria with a high mortality rate. Thus, we recommend making RDT kits more widely accessible for improved surveillance and prompt case management across the country.

Systematic approach to outcome assessment from coded electronic healthcare records in the DaRe2THINK NHS-embedded randomized trial. Eur Heart J Digit Health 2022;3:426-436. [PMID: 36712153 PMCID: PMC9708037 DOI: 10.1093/ehjdh/ztac046]

Aims

Improving the efficiency of clinical trials is key to their continued importance in directing evidence-based patient care. Digital innovations, in particular the use of electronic healthcare records (EHRs), allow for large-scale screening and follow up of participants. However, it is critical these developments are accompanied by robust and transparent methods that can support high-quality and high clinical value research.

Methods and results

The DaRe2THINK trial includes a series of novel processes, including nationwide pseudonymized pre screening of the primary-care EHR across England, digital enrolment, remote e-consent, and 'no-visit' follow up by linking all primary- and secondary-care health data with patient-reported outcomes. DaRe2THINK is a pragmatic, healthcare-embedded randomized trial testing whether earlier use of direct oral anticoagulants in patients with prior or current atrial fibrillation can prevent thromboembolic events and cognitive decline (www.birmingham.ac.uk/dare2think). This study outlines the systematic approach and methodology employed to define patient information and outcome events. This includes transparency on all medical code lists and phenotypes used in the trial across a variety of national data sources, including Clinical Practice Research Datalink Aurum (primary care), Hospital Episode Statistics (secondary care), and the Office for National Statistics (mortality).

Conclusion

Co-designed by a patient and public involvement team, DaRe2THINK presents an opportunity to transform the approach to randomized trials in the setting of routine healthcare, providing high-quality evidence generation in populations representative of the community at risk.

Symptoms and risk factors for long COVID in non-hospitalized adults

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection is associated with a range of persistent symptoms impacting everyday functioning, known as post-COVID-19 condition or long COVID. We undertook a retrospective matched cohort study using a UK-based primary care database, Clinical Practice Research Datalink Aurum, to determine symptoms that are associated with confirmed SARS-CoV-2 infection beyond 12 weeks in non-hospitalized adults and the risk factors associated with developing persistent symptoms. We selected 486,149 adults with confirmed SARS-CoV-2 infection and 1,944,580 propensity score-matched adults with no recorded evidence of SARS-CoV-2 infection. Outcomes included 115 individual symptoms, as well as long COVID, defined as a composite outcome of 33 symptoms by the World Health Organization clinical case definition. Cox proportional hazards models were used to estimate adjusted hazard ratios (aHRs) for the outcomes. A total of 62 symptoms were significantly associated with SARS-CoV-2 infection after 12 weeks. The largest aHRs were for anosmia (aHR 6.49, 95% CI 5.02-8.39), hair loss (3.99, 3.63-4.39), sneezing (2.77, 1.40-5.50), ejaculation difficulty (2.63, 1.61-4.28) and reduced libido (2.36, 1.61-3.47). Among the cohort of patients infected with SARS-CoV-2, risk factors for long COVID included female sex, belonging to an ethnic minority, socioeconomic deprivation, smoking, obesity and a wide range of comorbidities. The risk of developing long COVID was also found to be increased along a gradient of decreasing age. SARS-CoV-2 infection is associated with a plethora of symptoms that are associated with a range of sociodemographic and clinical risk factors.

Completeness and representativeness of small area socioeconomic data linked with the UK Clinical Practice Research Datalink (CPRD)

BACKGROUND

The Clinical Practice Research Datalink (CPRD) holds primary care electronic healthcare records for 25% of the UK population. CPRD data can be linked via practice postcode in the UK, and additionally via patient postcode in England, to area-level socioeconomic status (SES) data including the Index of Multiple Deprivation (IMD), the Carstairs Index and the Townsend Deprivation Index; as well as rural-urban classification (RUC). This study aims to describe the completeness and representativeness of CPRD-linked SES and RUC data.

METHODS

Patients currently registered at general practices contributing data to the May 2021 snapshots of CPRD GOLD (n=445 587) and CPRD Aurum (n=13 278 825) were used to assess the completeness and representativeness of CPRD-linked SES and RUC data against the UK general population.

RESULTS

All currently registered patients had complete SES and RUC data at practice level across the UK. Most English patients in CPRD GOLD (78%), CPRD Aurum (94%) and combined (93%) had SES and RUC data at patient level. Patient-level SES data in CPRD for England were comparable to England's general population (average IMD decile in CPRD 5.52±0.00 vs 5.50±0.02). CPRD UK practices were on average in more deprived areas than the UK general population (6.06±0.07 vs 5.50±0.02). A slightly higher proportion of CPRD patients and practices were from urban areas (85%) as compared with the UK general population (82%).

CONCLUSION

Completeness of CPRD-linked SES and RUC data is high. The CPRD populations were broadly representative of the general populations in the UK in terms of SES and RUC.

Presence of Codes for Indication for Use in Clinical Practice Research Datalink Aurum: An Assessment of Benign Prostatic Hyperplasia Treatments

Background

Assessments of strengths and limitations of new data sources are critical for making decisions about suitability for specific research questions. For some studies, it is necessary to capture a drug’s indication for use.

Objective

To assess the presence of indications for prescription use in Clinical Practice Research Datalink (CPRD) Aurum (January 1988–June 2021) by describing the proportion of men in CPRD Aurum who had a recorded indication for use of prescriptions for 5-alpha reductase inhibitors (5-ARI), alpha blockers (AB), or tadalafil, which have multiple indications.

Methods

From a random sample of 154 practices of CPRD Aurum data, we selected 85,597 male patients with a prescription for a 5-ARI, an AB, or tadalafil. Among these patients, we described presence of codes indicating whether the patient had benign prostatic hyperplasia, hypertension, erectile dysfunction, or alopecia using three indication definitions: narrow (specific diagnoses recorded within one year before and up to 90 days after the prescription), broad (specific diagnoses or supporting clinical codes in the time period described above), and widest (diagnoses or supporting codes recorded at any time before the prescription and up to 90 days after the prescription).

Results

Using the narrow indication definition limited to diagnoses only, 39,861 (46.6%) patients’ records contained an indication for use. The broad definitions, which additionally included supporting codes, captured indications for 62,912 (73.5%) patients and the widest definition, which additionally included supporting codes and all available data before the first prescription date, captured indications for 71,478 (83.5%) patients. Indications were present more often for prescriptions in 2005 and later (85.9%).

Conclusion

The findings of this assessment suggest that CPRD Aurum can be used for studies that require information on treatment indications for BPH and potentially for treatments of other chronic diseases managed in the primary care setting.

Therapies for Long COVID in non-hospitalised individuals: from symptoms, patient-reported outcomes and immunology to targeted therapies (The TLC Study)

INTRODUCTION

Individuals with COVID-19 frequently experience symptoms and impaired quality of life beyond 4-12 weeks, commonly referred to as Long COVID. Whether Long COVID is one or several distinct syndromes is unknown. Establishing the evidence base for appropriate therapies is needed. We aim to evaluate the symptom burden and underlying pathophysiology of Long COVID syndromes in non-hospitalised individuals and evaluate potential therapies.

METHODS AND ANALYSIS

A cohort of 4000 non-hospitalised individuals with a past COVID-19 diagnosis and 1000 matched controls will be selected from anonymised primary care records from the Clinical Practice Research Datalink, and invited by their general practitioners to participate on a digital platform (Atom5). Individuals will report symptoms, quality of life, work capability and patient-reported outcome measures. Data will be collected monthly for 1 year.Statistical clustering methods will be used to identify distinct Long COVID-19 symptom clusters. Individuals from the four most prevalent clusters and two control groups will be invited to participate in the BioWear substudy which will further phenotype Long COVID symptom clusters by measurement of immunological parameters and actigraphy.We will review existing evidence on interventions for postviral syndromes and Long COVID to map and prioritise interventions for each newly characterised Long COVID syndrome. Recommendations will be made using the cumulative evidence in an expert consensus workshop. A virtual supportive intervention will be coproduced with patients and health service providers for future evaluation.Individuals with lived experience of Long COVID will be involved throughout this programme through a patient and public involvement group.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Solihull Research Ethics Committee, West Midlands (21/WM/0203). Research findings will be presented at international conferences, in peer-reviewed journals, to Long COVID patient support groups and to policymakers.

TRIAL REGISTRATION NUMBER

1567490.

COVID-19 mortality rate and its associated factors during the first and second waves in Nigeria

COVID-19 mortality rate has not been formally assessed in Nigeria. Thus, we aimed to address this gap and identify associated mortality risk factors during the first and second waves in Nigeria. This was a retrospective analysis of national surveillance data from all 37 States in Nigeria between February 27, 2020, and April 3, 2021. The outcome variable was mortality amongst persons who tested positive for SARS-CoV-2 by Reverse-Transcriptase Polymerase Chain Reaction. Incidence rates of COVID-19 mortality was calculated by dividing the number of deaths by total person-time (in days) contributed by the entire study population and presented per 100,000 person-days with 95% Confidence Intervals (95% CI). Adjusted negative binomial regression was used to identify factors associated with COVID-19 mortality. Findings are presented as adjusted Incidence Rate Ratios (aIRR) with 95% CI. The first wave included 65,790 COVID-19 patients, of whom 994 (1∙51%) died; the second wave included 91,089 patients, of whom 513 (0∙56%) died. The incidence rate of COVID-19 mortality was higher in the first wave [54∙25 (95% CI: 50∙98-57∙73)] than in the second wave [19∙19 (17∙60-20∙93)]. Factors independently associated with increased risk of COVID-19 mortality in both waves were: age ≥45 years, male gender [first wave aIRR 1∙65 (1∙35-2∙02) and second wave 1∙52 (1∙11-2∙06)], being symptomatic [aIRR 3∙17 (2∙59-3∙89) and 3∙04 (2∙20-4∙21)], and being hospitalised [aIRR 4∙19 (3∙26-5∙39) and 7∙84 (4∙90-12∙54)]. Relative to South-West, residency in the South-South and North-West was associated with an increased risk of COVID-19 mortality in both waves. In conclusion, the rate of COVID-19 mortality in Nigeria was higher in the first wave than in the second wave, suggesting an improvement in public health response and clinical care in the second wave. However, this needs to be interpreted with caution given the inherent limitations of the country's surveillance system during the study.

Lignocaine versus opioids in coronary intervention: assessing antiplatelet activity and ticagrelor levels (LOCAL) study

Background

Opioid analgesia impairs the bioavailability and antiplatelet effect of oral P2Y12 inhibitors prompting investigation of mitigation strategies including identifying alternative analgesic agents.

Purpose

To assess the impact of intravenous fentanyl and lignocaine on the bioavailability and antiplatelet effect of ticagrelor in patients with unstable angina and non-ST elevation myocardial infarction, as well as their procedural analgesic efficacy and safety.

Methods

The LOCAL trial was a prospective, single centre, double-blind, randomized, controlled trial where intravenous lignocaine was the experimental analgesic agent assessed in this trial compared to intravenous fentanyl as procedural analgesia during coronary angiography and percutaneous coronary intervention. Patients with an indication for dual antiplatelet therapy and no contraindication were given 180mg of ticagrelor orally as integral tablets with 250 mL of tap water at the end of the case. Blood was sampled at time 0, 0.5, 1, 2 and 4 hours post administration of ticagrelor for pharmacokinetic and comprehensive pharmacodynamic analysis.

Results

Seventy patients undergoing coronary angiography with an indication for ticagrelor loading were included in the pharmacokinetic and pharmacodynamic analysis. Plasma ticagrelor levels at 2 h post loading dose were significantly lower in the fentanyl compared to lignocaine treatment arm (476 vs. 792 ng/mL, p=0.02, see figure 1). The area under the plasma-time curves for ticagrelor (987 vs. 2189 ng.h/mL, p=0.001) and its active metabolite (173 vs. 394 ng.h/mL, p&lt;0.001) were both significantly lower in the fentanyl arm. Platelet reactivity assessed by the VerifyNow assay was higher at all time points after baseline in the fentanyl compared to lignocaine arm. The VASP flow cytometry assay demonstrated higher platelet reactivity at 2 hours in the fentanyl group (40% vs. 22% platelet reactivity index, p=0.001). The Multiplate Analyzer demonstrated higher platelet reactivity in the fentanyl arm at 60 minutes (43 vs. 26 area under the curve units, p=0.001) as did expression of activated platelet GpIIb/IIIa receptor (2829 vs. 1426 geometric mean fluorescence intensity (GMFI), p=0.006) and P-selectin (439 vs. 211 GMFI, p=0.001). High on-treatment platelet reactivity (HPR) was significantly higher in the fentanyl arm at 60 min using the MPA (41% vs. 9%, p=0.002) and 120 min using the VFN (30% vs. 3%, p=0.003) and VASP (37% vs. 6%, p=0.002) assays (see figure 2). Both drugs were well tolerated with a high level of patient satisfaction (fentanyl 94% vs. lignocaine 97%, p=0.56).

Conclusion(s)

Unlike fentanyl, lignocaine does not impair the bioavailability or delay the antiplatelet effect of ticagrelor. Both drugs were well tolerated and effective with a high level of patient satisfaction for procedural analgesia. Systemic pain medication during PCI should be reconsidered and if performed, lignocaine is a beneficial alternative to fentanyl.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): TBA Figure 1. Ticagrelor and AM pharmacokineticsFigure 2. Ticagrelor pharmacodynamics

Quality and Completeness of Myocardial Infarction Recording in Clinical Practice Research Datalink Aurum

Background

Validation studies of the Clinical Practice Research Datalink (CPRD) Aurum database in the UK are critical for making decisions about its suitability and validity for research purposes.

Objective

To examine data source agreement of myocardial infarction (MI) diagnoses recorded in CPRD Aurum compared with linked Hospital Episode Statistics (HES) data. This comparison provides information on CPRD Aurum data correctness (accuracy, validity) and completeness (presence, missingness).

Methods

Patients with MI diagnoses recorded in either data source were selected from a random sample of 50,000 patients in CPRD Aurum with HES linkage (1997–2017). Correctness was defined as the proportion of MI cases in CPRD Aurum with a concordant MI diagnosis recorded in HES or with strong supporting evidence in either data source. Completeness was defined as the proportion of patients with primary HES-coded MIs with strong supporting evidence that were also present in CPRD Aurum.

Results

There were 1260 patients with MI recorded in the CPRD Aurum sample. The overall correctness of the recorded MI diagnoses was 94%: 986 patients (78%) had concordant diagnoses in HES within 90 days; 123 (10%) were concordant with HES, but with an inconclusive date and another 71 (6%) had strong supporting evidence for being a true MI case. There were 1125 patients with MI recorded in HES primary diagnosis fields with strong supporting evidence in either data source. Of these, 880 (78%) were present in CPRD Aurum, with completeness somewhat higher in more recent years.

Conclusion

MI diagnoses recorded in CPRD Aurum were highly likely to be correct, supporting its use in clinical research studies. Completeness was lower, indicating the need for data linkage for some studies.

Assessing the capacity of symptom scores to predict COVID-19 positivity in Nigeria: a national derivation and validation cohort study

OBJECTIVES

This study aimed to develop and validate a symptom prediction tool for COVID-19 test positivity in Nigeria.

DESIGN

Predictive modelling study.

SETTING

All Nigeria States and the Federal Capital Territory.

PARTICIPANTS

A cohort of 43 221 individuals within the national COVID-19 surveillance dataset from 27 February to 27 August 2020. Complete dataset was randomly split into two equal halves: derivation and validation datasets. Using the derivation dataset (n=21 477), backward multivariable logistic regression approach was used to identify symptoms positively associated with COVID-19 positivity (by real-time PCR) in children (≤17 years), adults (18-64 years) and elderly (≥65 years) patients separately.

OUTCOME MEASURES

Weighted statistical and clinical scores based on beta regression coefficients and clinicians' judgements, respectively. Using the validation dataset (n=21 744), area under the receiver operating characteristic curve (AUROC) values were used to assess the predictive capacity of individual symptoms, unweighted score and the two weighted scores.

RESULTS

Overall, 27.6% of children (4415/15 988), 34.6% of adults (9154/26 441) and 40.0% of elderly (317/792) that had been tested were positive for COVID-19. Best individual symptom predictor of COVID-19 positivity was loss of smell in children (AUROC 0.56, 95% CI 0.55 to 0.56), either fever or cough in adults (AUROC 0.57, 95% CI 0.56 to 0.58) and difficulty in breathing in the elderly (AUROC 0.53, 95% CI 0.48 to 0.58) patients. In children, adults and the elderly patients, all scoring approaches showed similar predictive performance.

CONCLUSIONS

The predictive capacity of various symptom scores for COVID-19 positivity was poor overall. However, the findings could serve as an advocacy tool for more investments in resources for capacity strengthening of molecular testing for COVID-19 in Nigeria.

191Two approaches to teaching epidemiology online for capacity building in developing countries

Background

Contributing to a mission to build Public Health capacity in developing countries, two online epidemiology courses are offered: a tutor facilitated Master’s level module ‘Introduction to Epidemiology’, and a free self-study ‘Basic Epidemiology’ Open Online Course (OOC). We report differences between these two.

Methods

Student demographics on enrolled students were abstracted. A follow-up online survey of former students was performed in January 2020.

Results

Among 772 students on the Master’s and 619 students on the OOC courses: respectively 29% and 39% were female; 36% and 38% were medical practitioners; 80% and 43% were from Africa.

For 64% of OOC students this was their first time learning online; 17% completed the course. 82% of students formally enrolled on a Master’s programme passed the module.

The majority of survey respondents reported that the courses had helped with reading articles critically (81% Master’s; 67% OOC) and improving professional practice (75% Master’s; 67% OOC); though fewer felt that the courses helped them perform their own research (67% Master’s; 51% OOC). The majority (87% Masters; 79% OOC) would recommend the course to others.

Conclusions

Online epidemiology courses have the ability to reach a wide audience in the developing world and contribute to capacity building. While both Master’s facilitated and self-study online courses were evaluated positively by students, the completion and potential impact was higher for the former.

Key messages

Online courses reaching wide audiences can help build global capacity in epidemiology

Self-reported diseases and their associated risk factors among camp-dwelling conflict-affected internally displaced populations in Nigeria

Background Conflict in Nigeria displaced millions of people, and some settled in camp-like locations within the country. Evidence on the association between living conditions and health outcomes among these populations are limited. This study investigated the risk factors associated with illnesses among camp-dwelling internally displaced persons (IDPs) in northern Nigeria. Methods A cross-sectional study was conducted in nine camps in 2016. Self-reported data on socio-demography, resource utilization and disease outcomes were collected. Association between health conditions and various factors, including sanitation and healthcare access, was investigated. Results Data from 2253 IDPs showed 81.1% (CI = 79.5-82.7) experienced one or more health conditions; however, over 20% did not access healthcare services. Most common diseases were malaria, fever, typhoid and diarrhoea. Multivariable logistic regression presented as adjusted odds ratios(aOR) and 95% confidence intervals(CIs) showed factors significantly associated with increased likelihood of illnesses included being female (aOR = 1.53;CI = 1.19-1.96), overcrowding (aOR = 1.07;CI = 1.00-1.36), long-term conditions (aOR = 2.72;CI = 1.88-3.94), outdoor defecation (aOR = 2.37;CI = 1.14-4.94) and presence of disease-causing vectors (aOR = 3.71;CI = 1.60-8.60). Conclusion Most diseases in the camps were communicable. Modifiable risk factors such as overcrowding and poor toilet facilities were associated with increased poor health outcomes. This evidence highlights areas of high priority when planning humanitarian public health interventions.

Use of prescribing safety quality improvement reports in UK general practices: a qualitative assessment

Background

Quality improvement (QI) initiatives are increasingly used to improve the quality of care and reduce prescribing errors. The Royal College of General Practitioners (RCGP) and Clinical Practice Research Datalink (CPRD) QI initiative uses routinely collected electronic primary care data to provide bespoke practice-level reports on prescribing safety. The aim of this study was to explore how the QI reports were used, barriers and facilitators to use, long-term culture change and perceived impact on patient care and practices systems as a result of receiving the reports.

Methods

A qualitative study using purposive sampling of practices contributing to the CPRD, semi-structured interviews and inductive thematic analysis. We interviewed general practitioners, pharmacists, practice managers and research nurses.

Results

We conducted 18 interviews, and organised themes summarising the use of QI reports in practice: receiving the report, facilitators and barriers to acting upon the reports, acting upon the report, and how the reports contribute to a quality culture. Effective dissemination of reports, and a positive attitude to audit and the perceived relevance of the clinical topic facilitated use. Lack of time and failure to see or act upon the reports meant they were not used. Factors influencing use of the reports included the structure of the report, ease of identifying cases, and perceptions about coding accuracy. GPs and pharmacists used the reports to conduct case reviews and directly contact patients to discuss unsafe prescribing and patient medication preferences. Finally, the reports contributed to the development of a quality culture within practices through promoting audit activity and acting as a reminder of good prescribing behaviours, promoting future patient safety initiatives, contributing to continuing professional development and improving local networks.

Conclusions

This study found the reports facilitated individual case review leading to an enhanced sense of quality culture in practices where they were utilised. Our findings demonstrate that the reports were generally considered useful and have been used to support patient safety and clinical practice in specific cases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06417-0.

Patient characteristics associated with COVID-19 positivity and fatality in Nigeria: retrospective cohort study

OBJECTIVE

Despite the increasing disease burden, there is a dearth of context-specific evidence on the risk factors for COVID-19 positivity and subsequent death in Nigeria. Thus, the study objective was to identify context-specific factors associated with testing positive for COVID-19 and fatality in Nigeria.

DESIGN

Retrospective cohort study.

SETTING

COVID-19 surveillance and laboratory centres in 36 states and the Federal Capital Territory reporting data to the Nigeria Centre for Disease Control.

PARTICIPANTS

Individuals who were investigated for SARS-CoV-2 using real-time PCR testing during the study period 27 February-8 June 2020.

METHODS

COVID-19 positivity and subsequent mortality. Multivariable logistic regression analyses were performed to identify factors independently associated with both outcome variables, and findings are presented as adjusted ORs (aORs) and 95% CIs.

RESULTS

A total of 36 496 patients were tested for COVID-19, with 10 517 confirmed cases. Of 3215 confirmed cases with available clinical outcomes, 295 died. Factors independently associated with COVID-19 positivity were older age (p value for trend<0.0001), male sex (aOR 1.11, 95% CI 1.04 to 1.18) and the following presenting symptoms: cough (aOR 1.23, 95% CI 1.13 to 1.32), fever (aOR 1.45, 95% CI 1.45 to 1.71), loss of smell (aOR 7.78, 95% CI 5.19 to 11.66) and loss of taste (aOR 2.50, 95% CI 1.60 to 3.90). An increased risk of mortality following COVID-19 was observed in those aged ≥51 years, patients in farming occupation (aOR 7.56, 95% CI 1.70 to 33.53) and those presenting with cough (aOR 2.06, 95% CI 1.41 to 3.01), breathing difficulties (aOR 5.68, 95% CI 3.77 to 8.58) and vomiting (aOR 2.54, 95% CI 1.33 to 4.84).

CONCLUSION

The significant risk factors associated with COVID-19 positivity and subsequent mortality in the Nigerian population are similar to those reported in studies from other countries and should guide clinical decisions for COVID-19 testing and specialist care referrals.

Generating high-fidelity synthetic patient data for assessing machine learning healthcare software

There is a growing demand for the uptake of modern artificial intelligence technologies within healthcare systems. Many of these technologies exploit historical patient health data to build powerful predictive models that can be used to improve diagnosis and understanding of disease. However, there are many issues concerning patient privacy that need to be accounted for in order to enable this data to be better harnessed by all sectors. One approach that could offer a method of circumventing privacy issues is the creation of realistic synthetic data sets that capture as many of the complexities of the original data set (distributions, non-linear relationships, and noise) but that does not actually include any real patient data. While previous research has explored models for generating synthetic data sets, here we explore the integration of resampling, probabilistic graphical modelling, latent variable identification, and outlier analysis for producing realistic synthetic data based on UK primary care patient data. In particular, we focus on handling missingness, complex interactions between variables, and the resulting sensitivity analysis statistics from machine learning classifiers, while quantifying the risks of patient re-identification from synthetic datapoints. We show that, through our approach of integrating outlier analysis with graphical modelling and resampling, we can achieve synthetic data sets that are not significantly different from original ground truth data in terms of feature distributions, feature dependencies, and sensitivity analysis statistics when inferring machine learning classifiers. What is more, the risk of generating synthetic data that is identical or very similar to real patients is shown to be low.

An audit of healthcare provision in internally displaced population camps in Nigeria

BACKGROUND

Armed conflict in Nigeria resulted in more than 2 million internally displaced persons (IDPs). IDPs live in poor conditions lacking basic resources with variable provision across different locations. This audit aimed to determine the health-related resources available to IDPs in camp-like settings in Nigeria and whether these met international standards.

METHODS

Using a cross-sectional study approach, information was collected in nine camps across seven states from camp managers, and direct observation in September-October 2016. The Sphere minimum standards in humanitarian crises were used as the audit standards.

FINDINGS

The 5 of 15 assessed standards were met to some extent, including the availability of water and shelter. Sanitation and vaccination were unmet in five camps, with severe overcrowding in five camps, and inadequate waste disposal in all camps. Health programme implementation was uneven, and especially poor in self-settled and dispersed settlements.

CONCLUSION

Inequality in distribution of humanitarian support was observed across different settings, which could lead to a higher likelihood of water, food and air-related diseases and thereby, a poorer quality of life for IDPs. Ensuring standardized health assessments could promote a more even distribution of resources across IDP locations.

Using a mobile application to detect health needs among children and adolescents who are newly arrived migrants in Europe

BACKGROUND

Unprecedented numbers of migrants have arrived in Europe, including children and adolescents. Little is known about their unique health needs. Prospective data collection has been sparse. Mobile applications may help to facilitate global health surveillance.

METHODS

A pre-validated survey instrument was converted into a mobile application covering self-reported exposures and disruptions of healthcare before/during migration, communicable and non-communicable diseases. Participation was voluntary, anonymous and confidential.

RESULTS

Data were obtained from 405 migrant children and adolescents in Berlin, Germany, between 7 October 2015 and 15 March 2016 (median age 19 years, range: 1-24; 80.7% males) with the majority from Syria (62.5%), Afghanistan (9.1%) and Iraq (8.2%). In total, 55% were without family, 64% registered asylum-seekers with access to healthcare; 54% had seen a doctor since arrival, with colds or respiratory complaints (37.5 and 13.6%), followed by pain (26.7%) gastrointestinal (12.4%) and skin problems (11.1%). Underlying conditions were reported in 15.6%, predominantly asthma. Overall, 73% reported being up-to date on immunizations, but only 22% held a vaccination record with 46.4% having lost it during migration.

CONCLUSIONS

The lack of medical and immunization records among newly arrived migrants provides a challenge to healthcare systems. Mobile applications offer rapid screening tools in times of crisis, helping stakeholders with timely information.

Quality and completeness of diagnoses recorded in the new CPRD Aurum Database: evaluation of pulmonary embolism

PURPOSE

The Clinical Practice Research Datalink (CPRD) now provides a new medical record database, CPRD Aurum. This is the first of several studies being undertaken to assess the quality and completeness of CPRD Aurum data for research endeavors.

METHODS

We identified patients with a pulmonary embolism (PE) diagnosis from a random sample of 50 000 patients in CPRD Aurum and compared the diagnoses using data from Hospital Episode Statistics (HES). We calculated the proportion of PE cases recorded in CPRD Aurum who also had a PE diagnosis recorded in HES. We also evaluated completeness by identifying all PE diagnoses in HES and calculating the proportion also present in CPRD Aurum.

RESULTS

The study included 781 PE patients: 580 had a PE in CPRD Aurum, 632 had a PE in HES, and 431 had a PE in both. The proportion of patients with anticoagulated PE in CPRD Aurum confirmed by HES was 76.8%. The completeness of primary hospitalized PE HES events compared to CPRD Aurum was 79.1%. In most instances, there was a plausible explanation for the presence of a PE in only one of the two data sources.

CONCLUSIONS

The results of this study are reassuring and suggest that the correctness (eg, quality, accuracy) and completeness of diagnosis information in CPRD Aurum are promising with respect to serious acute conditions that require medical attention. Evaluation of other data elements will provide additional insight into this new data resource and its utility for medical research.

Ability of Primary Care Health Databases to Assess Medicinal Products Discussed by the European Union Pharmacovigilance Risk Assessment Committee

This study measured the exposure to different categories of medicinal products discussed by the European Union (EU) Pharmacovigilance Risk Assessment Committee from September to November 2018 in four electronic primary care health databases: IQVIA Medical Research Data‐UK, IQVIA Medical Research Data‐France, IQVIA Medical Research Data‐Germany, and Clinical Practice Research Datalink Aurum, in the entire lifespan of each database until August 31, 2018. The assessment of 83 centrally authorized products and 45 nationally authorized products showed that coverage was better for products marketed for longer duration and worse for orphan drugs. The ability to detect associations against hypothetical comparators was better for more common events and for larger effect sizes. Coverage of advanced therapies was worse for those typically administered in a specialized rather than primary care setting. This study shows that to enable better informed regulatory decisions there is a need to access complementary data sources, particularly capturing secondary care prescribing.

A content analysis of the UK press response to the diagnosis of Ebola in a British healthcare worker

Background

The Ebola epidemic led to considerable media attention, which may influence public risk perception. Therefore, this study analysed the UK press response following diagnosis of a British healthcare worker (HCW) with Ebola.

Methods

Using the Nexis database, the frequency of Ebola-related articles in UK national newspaper articles was mapped. This was followed by a content analysis of Ebola-related articles in the four newspapers with highest UK net readership from November 2014 to February 2015.

Results

During the 16-week study period, 1349 articles were found. The day with the highest number of Ebola-related articles was 31 December 2014, the day after the diagnosis of Ebola in a UK HCW. Seventy-seven articles were included in the content analysis. Content analysis demonstrated a shift from West African to UK-focused articles, increased discussion of border control, UK policy decisions and criticism, and an increased number of articles with a reassuring/threatening message.

Conclusions

UK press coverage of Ebola increased following a HCW's diagnosis, particularly regarding discussion of screening measures. This is likely to have increased risk perception of Ebola in the UK population and may have contributed to subsequent strengthening of UK screening policy beyond World Health Organisation requirements.

Partnering for enhanced digital surveillance of influenza-like disease and the effect of antivirals and vaccines (PEDSIDEA)

BACKGROUND

Standardised clinical outcome measures are urgently needed for the surveillance of influenza and influenza-like illness (ILI) based on individual patient data (IPD).

OBJECTIVES

We report a multicentre prospective cohort using a predefined disease severity score in routine care.

PATIENTS/METHODS

The Vienna Vaccine Safety initiative (ViVI) Disease Severity Score ("ViVI Score") was made available as an android-based mobile application to three paediatric hospitals in Berlin and Athens between 2013 and 2016. Healthcare professionals assessed ILI patients at the point of care including severity, risk factors and use of antibiotics/antivirals/vaccines. RT-PCR for influenza A/B viruses was performed at the Hellenic Pasteur Institute and the Robert Koch Institute. PCR testing was blinded to severity scoring and vice versa.

RESULTS

A total of 1615 children aged 0-5 years (54.4% males) were assessed at the three sites. The mean age was 1.7 years (SD 1.5; range 0-5.9). The success rate (completion of the scoring without disruption to the ER workflow) was 100%. ViVI Disease Severity Scores ranged from 0 to 35 (mean 13.72). Disease severity in the Berlin Cohort was slightly higher (mean 15.26) compared to the Athens Cohorts (mean 10.86 and 11.13). The administration of antibiotics was most prevalent in the Berlin Cohort, with 41.2% on antibiotics (predominantly cefuroxime) as opposed to only 0.5% on neuraminidase inhibitors. Overall, Risk-adjusted ViVI Scores were significantly linked to the prescription of both, antibiotics and antivirals.

CONCLUSIONS

The Risk-adjusted ViVI Score enables a precision medicine approach to managing ILI in multicentre settings. Using mobile applications, severity data will be obtained in real time with important implications for the evaluation of antiviral/vaccine use.

How Clinical Practice Research Datalink data are used to support pharmacovigilance

Pharmacovigilance can be defined as the science of monitoring medicines and vaccines after license for use, the purpose of which is to quantify and characterise the safety profile of a medicine, identify previously unknown adverse reactions, inform risk-benefit assessment, and support the development of actions that can be taken to reduce risks, optimise benefits and monitor their effectiveness. This review discusses the Clinical Practice Research Datalink (CPRD), which is the source of the largest research database in the UK with longitudinal, representative primary care data linked to data from other healthcare settings. CPRD supports international pharmacovigilance by providing a large, anonymised representative general population database with comprehensive capture of patient risk factors and outcomes to researchers within academic, regulatory and pharmaceutical organisations. The specific advantages of CPRD data are discussed in the context of the 'six Vs of big data' including volume, velocity, variety, veracity, validity and value. Examples of where CPRD data have been used for pharmacovigilance research and how these have fed into guidelines and policy are discussed.

Intraoperative dexamethasone does not increase the risk of postoperative wound infection: a propensity score-matched post hoc analysis of the ENIGMA-II trial (EnDEX)

BACKGROUND

In a post hoc analysis of the ENIGMA-II trial, we sought to determine whether intraoperative dexamethasone was associated with adverse safety outcomes.

METHODS

Inverse probability weighting with estimated propensity scores was used to determine the association of dexamethasone administration with postoperative infection, quality of recovery, and adverse safety outcomes for 5499 of the 7112 non-cardiac surgery subjects enrolled in ENIGMA-II.

RESULTS

Dexamethasone was administered to 2178 (40%) of the 5499 subjects included in this analysis and was not associated with wound infection [189 (8.7%) vs 275 (8.3%); propensity score-adjusted relative risk (RR) 1.10; 95% confidence interval (CI) 0.89-1.34; P=0.38], severe postoperative nausea and vomiting on day 1 [242 (7.3%) vs 189 (8.7%); propensity score-adjusted RR 1.06; 95% CI 0.86-1.30; P=0.59], quality of recovery score [median 14, interquartile range (IQR) 12-15, vs median 14, IQR 12-16, P=0.10), length of stay in the postanaesthesia care unit [propensity score-adjusted median (IQR) 2.0 (1.3, 2.9) vs 1.9 (1.3, 3.1), P=0.60], or the primary outcome of the main trial. Dexamethasone administration was associated with a decrease in fever on days 1-3 [182 (8.4%) vs 488 (14.7%); RR 0.61; 95% CI 0.5-0.74; P<0.001] and shorter lengths of stay in hospital [propensity score-adjusted median (IQR) 5.0 (2.9, 8.2) vs 5.3 (3.1, 9.1), P<0.001]. Neither diabetes mellitus nor surgical wound contamination status altered these outcomes.

CONCLUSION

Dexamethasone administration to high-risk non-cardiac surgical patients did not increase the risk of postoperative wound infection or other adverse events up to day 30, and appears to be safe in patients either with or without diabetes mellitus.

CLINICAL TRIAL REGISTRATION

NCT00430989.

A comparative analysis of psychological trauma experienced by children and young adults in two scenarios: evacuation after a natural disaster vs forced migration to escape armed conflict

OBJECTIVES

Little is known about the psychological trauma experienced by children and young adults (CYAs) following displacement after natural disasters vs migration from conflict zones. In both instances, the decision to leave is usually cast by the family, and the life of CYAs is suddenly disrupted by external circumstances.

STUDY DESIGN

An anonymous survey.

METHODS

The same survey instrument, provided by the National Child Traumatic Stress Network (NCTSN), was used to survey self-reported health needs among CYAs during the aftermath of Hurricane Katrina (Health Survey for Children and Adolescents After Katrina) in October 2005-February 2006 and again during the peak of refugee arrivals in Berlin between October 2015 and March 2016. A weighted index to measure cumulative exposure to traumatic stresses during migration was developed along with an unweighted psychological impact score based on the 22-item NCTS psychological impact questionnaire. Spearman's correlation coefficient (rho) was used to assess the correlation between age and the two psychological impact indices. The two-tailed t-test was used to investigate differences in trauma experienced and psychological impact by gender. Logistic regression was used to investigate differences in types of traumatic stress experienced and psychological impact among CYAs displaced because of Hurricane Katrina and those seeking asylum in Berlin.

RESULTS

The Katrina cohort included a total of 1133 CYAs, the Berlin cohort, a total of 405 CYAs. The median age in the Katrina cohort was 6.73 years (standard deviation [SD] 5.67, range 0-24; 50.13% males) compared with 17.64 years (SD, range 0-24; 83% males) in the Berlin cohort. Comparative analyses were adjusted to age and gender and revealed significant differences between the two cohorts, both with regards to the amount of trauma experienced and the psychological impact. A statistically significant and moderate positive correlation was observed between trauma experienced and psychological impact of migration in the refugee population (rho = 0.4955, P < 0.001); the correlation was less pronounced but still significant in the Katrina cohort (rho = 0.0942, P = 0.0015). Free-text responses revealed that in addition to common concerns about health, housing and safety, refugees were also pre-occupied with language acquisition and the adaptation to a new culture.

CONCLUSIONS

The observed differences in the experience and the consequences of trauma in displaced CYAs warrant additional investigation. It was replicated that human-made disaster seems to show more traumatising potential than natural disaster. Stakeholders need to be aware of the potential medium and long-term consequences of migration/evacuation and allocate resources accordingly.

The portrayal of infant feeding in British women's magazines: a qualitative and quantitative content analysis

Background

Exclusive breastfeeding is the best start an infant can receive. However, in many high-income countries breastfeeding rates are low and this may be a reflection of social norms which in turn may be influenced by the media. This study therefore explored the portrayal of infant feeding in women's general interest magazines.

Methods

The five top selling women's weekly magazines in Britain and Ireland for 2013 over a 4-month period were included. A quantitative and qualitative content analysis was conducted for both written and visual content.

Results

In 58 magazines, there were 90 references to infant feeding with an average of 1.5 (range: 0-5) per magazine. Breastfeeding and formula feeding references were present in equal number and both were predominantly portrayed positively. There was only 1 visual representation of breast feeding compared with 11 of bottle feeding. Potential drivers for breastfeeding included its role in post-pregnancy weight loss and celebrity endorsement while family routine, the role of males in the house and concerns about adverse health effects were identified as barriers to breastfeeding.

Conclusion

An improvement in visual representations of breast feeding and factual information in women's weekly magazines may be helpful in re-defining social norms regarding infant feeding. Keywords: food and nutrition, health promotion, public health.

Influenza and other respiratory viruses: standardizing disease severity in surveillance and clinical trials

INTRODUCTION

Influenza-Like Illness is a leading cause of hospitalization in children. Disease burden due to influenza and other respiratory viral infections is reported on a population level, but clinical scores measuring individual changes in disease severity are urgently needed. Areas covered: We present a composite clinical score allowing individual patient data analyses of disease severity based on systematic literature review and WHO-criteria for uncomplicated and complicated disease. The 22-item ViVI Disease Severity Score showed a normal distribution in a pediatric cohort of 6073 children aged 0-18 years (mean age 3.13; S.D. 3.89; range: 0 to 18.79). Expert commentary: The ViVI Score was correlated with risk of antibiotic use as well as need for hospitalization and intensive care. The ViVI Score was used to track children with influenza, respiratory syncytial virus, human metapneumovirus, human rhinovirus, and adenovirus infections and is fully compliant with regulatory data standards. The ViVI Disease Severity Score mobile application allows physicians to measure disease severity at the point-of care thereby taking clinical trials to the next level.

Healthcare benefits linked with Below Poverty Line registration in India: Observations from Maharashtra Anaemia Study (MAS)

A 2015 Lancet paper by Patel et al. on healthcare access in India comprehensively discussed national health programmes where some benefits are linked with the country’s Below Poverty Line (BPL) registration scheme. BPL registration aims to support poor families by providing free/subsidised healthcare. Technical issues in obtaining BPL registration by poor families have been previously reported in the Indian literature; however there are no data on family assets of BPL registrants. Here, we provide evidence of family-level assets among BPL registration holders (and non-BPL households) using original research data from the Maharashtra Anaemia Study (MAS).

Social and health data from 287 pregnant women and 891 adolescent girls (representing 1178 family households) across 34 villages in Maharashtra state, India, were analysed. Several assets were shown to be similarly distributed between BPL and non-BPL households; a large proportion of families who would probably be eligible were not registered, whereas BPL-registered families often had significant assets that should not make them eligible. This is likely to be the first published evidence where asset distribution such as agricultural land, housing structures and livestock are compared between BPL and non-BPL households in a rural population. These findings may help planning BPL administration to allocate health benefits equitably, which is an integral part of national health programmes.

Factors associated with preterm delivery and low birth weight: a study from rural Maharashtra, India

Background: Although preterm delivery and low birth weight (LBW) have been studied in India, findings may not be generalisable to rural areas such as the Marathwada region of Maharashtra state. There is limited information available on maternal and child health indicators from this region. We aimed to present some local estimates of preterm delivery and LBW in the Osmanabad district of Marathwada and assess available maternal risk factors.

Methods: The study used routinely collected data on all in-hospital births in the maternity department of Halo Medical Foundation’s hospital from 1 ^st January 2008 to 31 ^st December 2014. Multivariable logistic regression analysis provided odds ratios (OR) with 95% confidence intervals (CI) for preterm delivery and LBW according to each maternal risk factor.

Results: We analysed 655 live births, of which 6.1% were preterm deliveries. Of the full term births (N=615), 13.8% were LBW (<2.5 kilograms at birth). The odds of preterm delivery were three times higher (OR=3.23, 95% CI 1.36 to 7.65) and the odds of LBW were double (OR=2.03, 95% CI 1.14 to 3.60) among women <22 years of age compared with older women. The odds of both preterm delivery and LBW were reduced in multigravida compared with primigravida women regardless of age. Anaemia (Hb<11g/dl), which was prevalent in 91% of women tested, was not significantly related to these birth outcomes.

Conclusions: The odds of preterm delivery and LBW were much higher in mothers under 22 years of age in this rural Indian population. Future studies should explore other related risk factors and the reasons for poor birth outcomes in younger mothers in this population, to inform the design of appropriate public health policies that address this issue.