Cannabis use and the risk of tuberculosis: a systematic review.

BACKGROUND: Cannabis has been identified as a possible risk factor in some tuberculosis (TB) outbreaks. As the most widely used (largely) illegal substance in Western countries this may be an important public health concern. We aim to systematically review the evidence on the association between cannabis use and TB (latent infection and active disease) to inform ongoing and future TB prevention and control strategies. METHODS: We conducted a systematic review. We searched Ovid Medline, Embase and PsycInfo, together with the World Health Organization website and Google Scholar, for all years to January 2018. Reference lists and conference abstracts were hand-searched, a forward citation search was conducted on the Web of Science, and experts were contacted. Two authors independently screened studies for inclusion, extracted data and assessed risk of bias using an adapted version of ROBINS-I ("Risk of Bias in Non-randomised Studies - of Interventions"). Data were narratively synthesised. RESULTS: Of 377 records identified, 11 studies were eligible. Study designs were heterogeneous. Six studies utilised a relevant comparator group. Four of these investigated the association between cannabis use and latent TB infection; all provided some evidence of an association, although only two of these had adjusted for confounders. The remaining two comparator studies investigated the association between cannabis use and active TB disease; neither found evidence of an association after adjusting for confounding. All six studies were at "Serious" risk of bias. The five studies which did not utilise a relevant comparator group were all indicative of TB outbreaks occurring among cannabis users, but the quality of the evidence was very weak. CONCLUSIONS: Evidence for an association between cannabis use and TB acquisition is weak. The topic warrants further robust primary research including the collection of consistent and accurate exposure information, including cannabis use practices, dose and frequency, and adjustment for confounders.

Implementing a toolkit for the prevention, management and control of carbapenemase-producing Enterobacteriaceae in English acute hospitals trusts: a qualitative evaluation.

BACKGROUND: Antimicrobial resistance is an increasing problem in hospitals world-wide. Following other countries, English hospitals experienced outbreaks of carbapenemase-producing Enterobacteriaceae (CPE), a bacterial infection commonly resistant to last resort antibiotics. One way to improve CPE prevention, management and control is the production of guidelines, such as the CPE toolkit published by Public Health England in December 2013. The aim of this research was to investigate the implementation of the CPE toolkit and to identify barriers and facilitators to inform future policies. METHODS: Acute hospital trusts (N = 12) were purposively sampled based on their self-assessed CPE colonisation rates and time point of introducing local CPE action plans. Following maximum variation sampling, 44 interviews with hospital staff were conducted between April and August 2017 using a semi-structured topic guide based on the Capability, Opportunity, Motivation and Behaviour Model and the Theoretical Domains Framework, covering areas of influences on behaviour. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis. RESULTS: The national CPE toolkit was widely disseminated within infection prevention and control teams (IPCT), but awareness was rare among other hospital staff. Local plans, developed by IPCTs referring to the CPE toolkit while considering local circumstances, were in place in all hospitals. Implementation barriers included: shortage of isolation facilities for CPE patients, time pressures, and competing demands. Facilitators were within hospital and across-hospital collaborations and knowledge sharing, availability of dedicated IPCTs, leadership support and prioritisation of CPE as an important concern. Participants using the CPE toolkit had mixed views, appreciating its readability and clarity about patient management, but voicing concerns about the lack of transparency on the level of evidence and the practicality of implementation. They recommended regular updates, additional clarifications, tailored information and implementation guidance. CONCLUSIONS: There were problems with the awareness and implementation of the CPE toolkit and frontline staff saw room for improvement, identifying implementation barriers and facilitators. An updated CPE toolkit version should provide comprehensive and instructive guidance on evidence-based CPE prevention, management and control procedures and their implementation in a modular format with sections tailored to hospitals' CPE status and to different staff groups.

Knowledge and behaviors in relation to antibiotic use among rural residents in Anhui, China.

OBJECTIVES: To examine antibiotic-related knowledge and behaviors in rural Anhui, identify factors associated with knowledge, and explore the relationship between knowledge and antibiotic use. METHODS: Cross-sectional study of a random sample of 2760 residents of rural China using structured interviews. RESULTS: The response rate was 94.6%. A total of 2390 respondents (91.6%) believed that antibiotics can control viruses; 2007 (77.5%) respondents thought that a combination of antibiotics is more effective than a single class; and 590 (22.6%) were able to name at least one disbenefit of using antibiotics. Multivariate analysis revealed those with a higher educational level and younger age group had greater knowledge of antibiotics (OR 2.54 and 0.77, respectively). Self-medication was common with 1052 (out of 2274 responses, 46.3%) of participants use over the counter or leftover medicines for common infections. Greater knowledge was associated with buying drugs without prescription (aOR 2.02; 95% CI, 1.29-3.17) and using leftover medication (aOR 2.80; 95% CI, 1.55-5.06). CONCLUSION: Knowledge about antibiotics was low and reported use high. Worryingly those with greater knowledge had less desirable behaviors that highlights the urgent need for multifaceted interventions to change behavior.

Primary care system-level training and support programme for the secondary prevention of domestic violence and abuse: a cost-effectiveness feasibility model.

OBJECTIVES: This study aimed to evaluate the prospective cost-effectiveness of the Identification and Referral to Improve Safety plus (IRIS+) intervention compared with usual care using feasibility data derived from seven UK general practice sites. METHOD: A cost-utility analysis was conducted to assess the potential cost-effectiveness of IRIS+, an enhanced model of the UK's usual care. IRIS+ assisted primary care staff in identifying, documenting and referring not only women, but also men and children who may have experienced domestic violence/abuse as victims, perpetrators or both. A perpetrator group programme was not part of the intervention per se but was linked to the IRIS+ intervention via a referral pathway and signposting. A Markov model was constructed from a societal perspective to estimate mean incremental costs and quality-adjusted life years (QALYs) of IRIS+ compared with to usual care over a 10-year time horizon. RESULTS: The IRIS+ intervention saved £92 per patient and produced QALY gains of 0.003. The incremental net monetary benefit was positive (£145) and the IRIS+ intervention was cost-effective in 55% of simulations at a cost-effectiveness threshold of £20 000 per QALY. CONCLUSION: The IRIS+ intervention could be cost-effective or even cost saving from a societal perspective in the UK, though there are large uncertainties, reflected in the confidence intervals and simulation results.

Feasibility of a reconfigured domestic violence and abuse training and support intervention responding to affected women, men, children and young people through primary care.

BACKGROUND: Identification in UK general practice of women affected by domestic violence and abuse (DVA) is increasing, but men and children/young people (CYP) are rarely identified and referred for specialist support. To address this gap, we collaborated with IRISi (UK social enterprise) to strengthen elements of the IRIS + intervention which included the identification of men, direct engagement with CYP, and improved guidance on responding to information received from other agencies. IRIS + was an adaptation of the national IRIS (Identification and Referral to Improve Safety) model focused on the needs of women victim-survivors of DVA. Without diminishing the responses to women, IRIS + also responded to the needs of men experiencing or perpetrating DVA, and CYP living with DVA and/or experiencing it in their own relationships. Our study tested the feasibility of the adapted IRIS + intervention in England and Wales between 2019-21. METHODS: We used mixed method analysis to triangulate data from various sources (pre/post intervention questionnaires with primary care clinicians; data extracted from medical records and DVA agencies; semi-structured interviews with clinicians, service providers and referred adults and children) to assess the feasibility and acceptability of the IRIS + intervention. RESULTS: The rate of referral for women doubled (21.6/year/practice) from the rate (9.29/year/practice) in the original IRIS trial. The intervention also enabled identification and direct referral of CYP (15% of total referrals) and men (mostly survivors, 10% of total referrals). Despite an increase in self-reported clinician preparedness to respond to all patient groups, the intervention generated a low number of men perpetrator referrals (2% of all referrals). GPs were the principal patient referrers. Over two-thirds of referred women and CYP and almost half of all referred men were directly supported by the service. Many CYP also received IRIS + support indirectly, via the referred parents. Men and CYP supported by IRIS + reported improved physical and mental health, wellbeing, and confidence. CONCLUSIONS: Although the study showed acceptability and feasibility, there remains uncertainty about the effectiveness, cost-effectiveness, and scalability of IRIS + . Building on the success of this feasibility study, the next step should be trialling the effectiveness of IRIS + implementation to inform service implementation decisions.

General practice as a place to receive help for domestic abuse during the COVID-19 pandemic: a qualitative interview study in England and Wales.

BACKGROUND: General practice is an important place for patients experiencing or perpetrating domestic violence and abuse (DVA), and for their children to seek and receive help. While the incidence of DVA may have increased during the COVID- 19 pandemic, there has been a reduction in DVA identifications and referrals to specialist services from general practice. Concurrently there has been the imposition of lockdown measures and a shift to remote care in general practices in the UK. AIM: To understand the patient perspective of seeking and receiving help for DVA in general practice during the COVID-19 pandemic. This was then compared with experiences of general practice healthcare professionals. DESIGN AND SETTING: A qualitative interview study in seven urban general practices in England and Wales, as part of a feasibility study of IRIS+, an integrated primary care DVA system-level training and support intervention. METHOD: Semi-structured interviews with 21 patients affected by DVA and 13 general practice healthcare professionals who had received IRIS+ training. Analysis involved a Framework approach. RESULTS: Patients recounted positive experiences of seeking help for DVA in general practice during the pandemic. However, there have been perceived problems with the availability of general practice and a strong preference for face-to-face consultations, over remote consultations, for the opportunities of non- verbal communication. There were also concerns from healthcare professionals regarding the invisibility of children affected by DVA. CONCLUSION: Perspectives of patients and their families affected by DVA should be prioritised in general practice service planning, including during periods of transition and change.

A proposal to embed patient and public involvement within qualitative data collection and analysis phases of a primary care based implementation study.

BACKGROUND: Patient and public involvement (PPI) is increasingly seen as essential to health service research. There are strong moral and ethical arguments for good quality PPI. Despite the development of guidance aimed at addressing the inconsistent reporting of PPI activities within research, little progress has been made in documenting the steps taken to undertake PPI and how it influences the direction of a study. Without this information, there are minimal opportunities to share learnings across projects and strengthen future PPI practices. The aim of this paper is to present details on the processes and activities planned to integrate PPI into the qualitative research component of a mixed-methods, multi-site study evaluating the implementation of a smart template to promote personalised primary care for patients with multiple long-term conditions. METHODS: This proposal describes the processes and activities planned to integrate PPI into the development and piloting of qualitative data collection tools (topic guides for both practice staff and patients) and a tailored data analysis package developed for PPI members incorporating broad concepts and specific methods of qualitative data analysis. DISCUSSION: Outputs relating to PPI activity may include clear, concise and suitably worded topic guides for qualitative interviews. Piloting of the topic guides via mock interviews will further develop researchers' skills including sensitisation to the experiences of participants being interviewed. Working with PPI members when analysing the qualitative data aims to provide reciprocal learning opportunities and may contribute to improving the overall rigour of the data analysis. The intent of publishing proposed PPI activities within this project is to inform the future delivery of high quality PPI.

Patient and public involvement (PPI) improves healthcare research, however, there is little published evidence of proposed PPI activities within a research study. The aim of this article is to describe the proposed PPI activities which are to be integrated into a study implementing a smart template to promote personalised care for people with multiple long-term conditions within primary care in the United Kingdom. The proposal describes the ways in which PPI members will be included within the data collection and analysis phases of a research study which includes interviews with primary care staff and patients. PPI members will be asked to develop questions for these interviews and to take part in a mock interview whereby a researcher interviews a PPI member. The proposal also provides details on qualitative data analysis workshops which will be specifically developed for PPI members. The impact of PPI activities could include clear, concise and suitably worded questions used within the interviews. Piloting of these questions via mock interviews may enable researchers to further develop their interviewing skills. It is anticipated that involving PPI members when analysing qualitative data will provide opportunities for reciprocal learning and lead to rich interpretations of the data, inclusive of the PPI members' perspectives. Publishing a record of planned PPI activities and potential impacts demonstrates the rationale and considerations made by the team to ensure that involvement in this study is meaningful and has potential benefits for all involved. The team hopes this proposal will support others with the planning and delivery of PPI activities. In future publications, we will reflect on the learnings, challenges, and outcomes from the PPI activities detailed in this proposal.

Quality standards for child and adolescent mental health in primary care.

BACKGROUND: Child and adolescent mental health problems are common in primary healthcare settings. However, few parents of children with mental health problems express concerns about these problems during consultations. Based on parental views, we aimed to create quality of care measures for child and adolescent mental health in primary care and develop consensus about the importance of these quality standards within primary care. METHODS: Quality Standards were developed using an iterative approach involving four phases: 1) 34 parents with concerns about their child's emotional health or behaviour were recruited from a range of community settings including primary care practices to participate in focus group discussions, followed by validation groups or interviews. 2) Preliminary Quality Standards were generated that fully represented the parents' experiences and were refined following feedback from an expert parent nominal group. 3) 55 experts, including parents and representatives from voluntary organisations, across five panels participated in a modified two-stage Delphi study to develop consensus on the importance of the Quality Standards. The panels comprised general practitioners, other community-based professionals, child and adolescent psychiatrists, other child and adolescent mental health professionals and public health and policy specialists. 4) The final set of Quality Standards was piloted with 52 parents in primary care. RESULTS: In the Delphi process, all five panels agreed that 10 of 31 Quality Standards were important. Although four panels rated 25-27 statements as important, the general practitioner panel rated 12 as important. The final 10 Quality Standards reflected healthcare domains involving access, confidentiality for young people, practitioner knowledge, communication, continuity of care, and referral to other services. Parents in primary care agreed that all 10 statements were important. CONCLUSIONS: It is feasible to develop a set of Quality Standards to assess mental healthcare provision for children and adolescents seen within primary healthcare services. Primary care practitioners should be aware of parental perspectives about quality of care as these may influence help-seeking behaviours.

How do women feel about their cervical cytology samples being used for research?

BACKGROUND AND METHODOLOGY: The introduction of liquid-based cytology (LBC) for cervical screening in the UK has enabled research into human papillomavirus as an adjunct to screening and provides potential opportunities for population-based research into women's health. The authors explored women's views on the use of remnant LBC samples for sexual and reproductive health research. A pilot study was conducted to assess the acceptability of collecting and storing remnant LBC specimens for future use in sexual and reproductive health research. Women attending a clinic for their routine smear test were recruited to the study. Semi-structured interviews were conducted with a subsample of the women to explore acceptability issues. RESULTS: Of women invited to participate (n=369), 86% (n=316) consented to the storage and use of their remnant sample for research. Of these, 96% (n=304) consented to their sample being linked to reproductive health records. Women interviewed (n=23) were happy with the research process although unclear about what future research might be conducted on their specimen and what health records would be accessed. DISCUSSION AND CONCLUSION: As research becomes technically and ethically more complex the challenge remains to find the right balance between providing sufficient relevant information to ensure informed consent and allay participant's fears, while guarding against the inclusion of excessive detail. The introduction of LBC for cervical screening across the UK brings a new opportunity to integrate research studies within a national cervical screening programme. Our study suggests this is acceptable to women.

Identifying key influences on antibiotic use in China: a systematic scoping review and narrative synthesis.

INTRODUCTION: The inappropriate use of antibiotics is a key driver of antimicrobial resistance. In China, antibiotic prescribing and consumption exceed recommended levels and are relatively high internationally. Understanding the influences on antibiotic use is essential to informing effective evidence-based interventions. We conducted a scoping review to obtain an overview of empirical research about key behavioural, cultural, economic and social influences on antibiotic use in China. METHODS: Searches were conducted in Econlit, Medline, PsycINFO, Social Science citation index and the Cochrane Database of Systematic Reviews for the period 2003 to early 2018. All study types were eligible including observational and intervention, qualitative and quantitative designs based in community and clinical settings. Two authors independently screened studies for inclusion. A data extraction form was developed incorporating details on study design, behaviour related to antibiotic use, influences on behaviour and information on effect (intervention studies only). RESULTS: Intervention studies increased markedly from 2014, and largely focused on the impact of national policy and practice directives on antibiotic use in secondary and tertiary healthcare contexts in China. Most studies used pragmatic designs, such as before and after comparisons. Influences on antibiotic use clustered under four themes: antibiotic prescribing; adherence to antibiotics; self-medicating behaviour and over-the-counter sale of antibiotics. Many studies highlighted the use of antibiotics without a prescription for common infections, which was facilitated by availability of left-over medicines and procurement from local pharmacies. CONCLUSIONS: Interventions aimed at modifying antibiotic prescribing behaviour show evidence of positive impact, but further research using more robust research designs, such as randomised trials, and incorporating process evaluations is required to better assess outcomes. The effect of national policy at the primary healthcare level needs to be evaluated and further exploration of the influences on antibiotic self-medicating is required to develop interventions that tackle this behaviour.

Parental help-seeking in primary care for child and adolescent mental health concerns: qualitative study.

BACKGROUND: Child and adolescent mental health problems are common in primary care. However, few parents of children with mental health problems express concerns about these problems during consultations. AIMS: To explore the factors influencing parental help-seeking for children with emotional or behavioural difficulties. METHOD: Focus group discussions with 34 parents from non-specialist community settings who had concerns about their child's mental health. All groups were followed by validation groups or semi-structured interviews. RESULTS: Most children had clinically significant mental health symptoms or associated impairment in function. Appointment systems were a key barrier, as many parents felt that short appointments did not allow sufficient time to address their child's difficulties. Continuity of care and trusting relationships with general practitioners (GPs) who validated their concerns were perceived to facilitate help-seeking. Parents valued GPs who showed an interest in their child and family situation. Barriers to seeking help included embarrassment, stigma of mental health problems, and concerns about being labelled or receiving a diagnosis. Some parents were concerned about being judged a poor parent and their child being removed from the family should they seek help. CONCLUSIONS: Primary healthcare is a key resource for children and young people with emotional and behavioural difficulties and their families. Primary care services should be able to provide ready access to health professionals with an interest in children and families and appointments of sufficient length so that parents feel able to discuss their mental health concerns.

Cross-sectional study of the use of antimicrobials following common infections by rural residents in Anhui, China.

OBJECTIVE: To describe help seeking behaviour from a medical doctor and antimicrobial use for common infections among rural residents of Anhui province, China. DESIGN: A cross-sectional retrospective household survey. SETTING: 12 administrative villages from rural Anhui, China. PARTICIPANTS: 2760 rural residents selected through cluster-randomised sampling using an interviewer administered questionnaire. METHOD: Logistic regression models were used to estimate associations between exposures (health insurance and antimicrobial-related knowledge), adjusted for confounders (sex, age and education), and help-seeking behaviour from a medical doctor and antimicrobial use following common infections, including acute respiratory tract infections (ARTIs), gastrointestinal tract infections (GTIs) and urinary tract infections (UTIs). RESULTS: In total 2611 (94.6%) rural residents completed the questionnaire. Help seeking from a medical doctor was highest for ARTIs (59.4%) followed by GTIs (42.1%), and UTIs (27.8%). Around two-thirds (82.3% for ARTIs, 87.0% for GTIs and 66.0% for UTIs) of respondents sought help within 3 days following symptom onset and over three quarters (88% for ARTIs, 98% for GTIs and 77% for UTIs) reported complete recovery within 7 days. Of the help-seeking respondents, 94.5% with ARTI symptoms recalled being prescribed either oral or intravenous antimicrobials (GTIs 81.7% and UTIs 70.4%). Use of antimicrobials bought from medicine shops without prescriptions ranged from 8.8% for GTIs to 17.2% for ARTIs; while use of antimicrobials leftover from previous illnesses or given by a relative ranged from 7.6% for UTIs to 13.4% for ARTIs. Multivariate logistic regression analysis revealed that respondents with a higher antimicrobial-related knowledge score and lack of insurance were associated with lower levels of help-seeking for ARTIs; while respondents with a higher antimicrobial-related knowledge score were less likely to be prescribed either oral or intravenous antimicrobials. CONCLUSIONS: Excessive antimicrobial use in the studied primary care settings is still prevalent.

Pathways to optimising antibiotic use in rural China: identifying key determinants in community and clinical settings, a mixed methods study protocol.

INTRODUCTION: This study aims to investigate patterns of antibiotic treatment-seeking, describe current levels of and drivers for antibiotic use for common infections (respiratory tract and urinary tract infections) and test the feasibility of determining the prevalence and epidemiology of antimicrobial resistance (AMR) in rural areas of Anhui province, in order to identify potential interventions to promote antibiotic stewardship and reduce the burden of AMR in China. METHODS AND ANALYSIS: We will conduct direct observations, structured and semistructured interviews in retail pharmacies, village clinics and township health centres to investigate treatment-seeking and antibiotic use. Clinical isolates from 1550 sputum, throat swab and urine samples taken from consenting patients at village and township health centres will be analysed to identify bacterial pathogens and ascertain antibiotic susceptibilities. Healthcare records will be surveyed for a subsample of those recruited to the study to assess their completeness and accuracy. ETHICS AND DISSEMINATION: The full research protocol has been reviewed and approved by the Biomedical Ethics Committee of Anhui Medical University (reference number: 20170271). Participation of patients and doctors is voluntary and written informed consent is sought from all participants. Findings from the study will be disseminated through academic routes including peer-reviewed publications and conference presentations, via tailored research summaries for health professionals, health service managers and policymakers and through an end of project impact workshop with local and regional stakeholders to identify key messages and priorities for action.

Qualitative study of Ebola screening at ports of entry to the UK.

INTRODUCTION: In response to the 2013-2016 West African outbreak of the Ebola virus disease (EVD), Public Health England introduced enhanced screening at major UK ports of entry. Our aim was to explore screeners' and screened travellers' perceptions of screening as part of an evaluation of the screening programme. METHODS: We undertook qualitative focus groups and semistructured interviews with screeners and travellers who had returned from affected countries before and after the introduction of screening in England. The study was conducted in two airports: one international rail terminal and one military airport. Research topic guides explored perceptions of the purpose and implementation of the process, potential improvements and reactions to screening. The data were analysed using the framework method. RESULTS: Twenty-four screeners participated in 4 focus groups (one for each port of entry) and 23 travellers participated in interviews. Three themes are presented: 'Context', 'Screeners' experience of the programme' and 'Screening purpose and experiences'. The programme was implemented rapidly, refined over time and adapted to individual ports. Screeners reported diverse experiences of screening including negative impacts on their normal roles, difficult interactions with passengers and pressure to identify positive EVD cases. Screening was considered unlikely to identify individuals with symptoms of EVD, and some participants suggested it was driven by political concerns rather than empirical evidence. The screening process was valued for its provision of information and reassurance. CONCLUSION: This qualitative study found that the UK EVD screening process was perceived to be acceptable to assess individual risk and provide information and advice to travellers. Future programmes should have clear objectives and streamlined processes to minimise disruption, tailored to the nature of the threat and developed with the needs of humanitarian workers as well as general travellers in mind.

Children at risk of neglect: challenges faced by child protection practitioners in Guatemala City.

OBJECTIVES: The objectives were to (1) delineate the definition, common forms, and perceived risk factors contributing to child neglect in Guatemala from the perspective of different stakeholders and (2) identify the challenges faced by child protection practitioners in identifying children at risk of neglect within the context of Guatemala. METHODS: A range of qualitative methods were used: semi-structured interviews (SSI) with key stakeholders involved in child neglect (n=9); semi-structured interviews with professionals working in the child protection services (n=14); focus group discussions (FGDs) with professionals, voluntary workers and children (n=60), and the group consensus method with key informants (KI, n=10). Data analysis was conducted using the framework approach. RESULTS: Participants described child neglect as a complex social phenomenon combining parental omission of care and an indifferent or negative attitude towards the child compounded by governmental neglect. The main factors which were perceived as contributing to neglect were poverty, societal and cultural norms, and importantly, gender roles and relations. These contextual factors complicate the identification of neglect and raise a number of difficult dilemmas for child protection workers that are exacerbated by limited Guatemalan legislation on neglect and restricted alternative care options. CONCLUSION: Stakeholder perspectives were found to be useful for providing contextual information and highlighting associated challenges related to assessing child neglect in Guatemala.

Risk of nosocomial respiratory syncytial virus infection and effectiveness of control measures to prevent transmission events: a systematic review.

Respiratory syncytial virus (RSV) causes a significant public health burden, and outbreaks among vulnerable patients in hospital settings are of particular concern. We reviewed published and unpublished literature from hospital settings to assess: (i) nosocomial RSV transmission risk (attack rate) during outbreaks, (ii) effectiveness of infection control measures. We searched the following databases: MEDLINE, EMBASE, CINAHL, Cochrane Library, together with key websites, journals and grey literature, to end of 2012. Risk of bias was assessed using the Cochrane risk of bias tool or Newcastle-Ottawa scale. A narrative synthesis was conducted. Forty studies were included (19 addressing research question one, 21 addressing question two). RSV transmission risk varied by hospital setting; 6-56% (median: 28·5%) in neonatal/paediatric settings (n = 14), 6-12% (median: 7%) in adult haematology and transplant units (n = 3), and 30-32% in other adult settings (n = 2). For question two, most studies (n = 13) employed multi-component interventions (e.g. cohort nursing, personal protective equipment (PPE), isolation), and these were largely reported to be effective in reducing nosocomial transmission. Four studies examined staff PPE; eye protection appeared more effective than gowns and masks. One study reported on RSV prophylaxis for patients (RSV-Ig/palivizumab); there was no statistical evidence of effectiveness although the sample size was small. Overall, risk of bias for included studies tended to be high. We conclude that RSV transmission risk varies widely during hospital outbreaks. Although multi-component control strategies appear broadly successful, further research is required to disaggregate the effectiveness of individual components including the potential role of palivizumab prophylaxis.

Characteristics of people dying by suicide after job loss, financial difficulties and other economic stressors during a period of recession (2010-2011): A review of coroners׳ records.

BACKGROUND: Suicide rates increase during periods of economic recession, but little is known about the characteristics of people whose deaths are related to recession, the timing of risk in relation to job loss, the nature of financial stresses and the sources of help individuals used. METHODS: We extracted information on social and economic circumstances, mental health and help-seeking from the coroners׳ records of 286 people who died by suicide in 2010 and 2011 in four areas of England. We graded each death on a 5-point scale of 'recession-relatedness', measuring the extent to which recession, employment and financial problems contributed to the death. RESULTS: Financial and employment-related issues contributed substantially to 38 (13%) of the deaths and were thought to be the key contributing factor in 11 (4%). Individuals whose deaths were thought to be related to the recession were less likely to have previously self-harmed but were more likely to be employed (61% vs. 43%), have financial difficulties (76% vs. 23%) and financial dependents (55% vs. 23%). Amongst the subset of 11 people where financial/employment issues were the key contributory factor, only two (18%) had ever had contact with psychiatric services. LIMITATIONS: Details on finances and employment were not systematically recorded by coroners. We found richer information was usually available for people who were living with other people. CONCLUSIONS: Financial difficulties, little past psychiatric history, low levels of service contact and having financial dependents were more common in 'recession-related' deaths. This suggests that interventions to prevent recession-related rises in suicide should be focused on non-clinical agencies and initiatives.

Suicide and the 2008 economic recession: who is most at risk? Trends in suicide rates in England and Wales 2001-2011.

The negative impacts of previous economic recessions on suicide rates have largely been attributed to rapid rises in unemployment in the context of inadequate social and work protection programmes. We have investigated trends in indicators of the 2008 economic recession and trends in suicide rates in England and Wales in men and women of working age (16-64 years old) for the period 2001-2011, before, during and after the economic recession, our aim was to identify demographic groups whose suicide rates were most affected. We found no clear evidence of an association between trends in female suicide rates and indicators of economic recession. Evidence of a halt in the previous downward trend in suicide rates occurred for men aged 16-34 years in 2006 (95% CI Quarter 3 (Q3) 2004, Q3 2007 for 16-24 year olds & Q1 2005, Q4 2006 for 25-34 year olds), whilst suicide rates in 35-44 year old men reversed from a downward to upward trend in early 2010 (95% CI Q4 2008, Q2 2011). For the younger men (16-34 years) this change preceded the sharp increases in redundancy and unemployment rates of early 2008 and lagged behind rising trends in house repossessions and bankruptcy that began around 2003. An exception were the 35-44 year old men for whom a change in suicide rate trends from downwards to upwards coincided with peaks in redundancies, unemployment and rises in long-term unemployment. Suicide rates across the decade rose monotonically in men aged 45-64 years. Male suicide in the most-to-medium deprived areas showed evidence of decreasing rates across the decade, whilst in the least-deprived areas suicide rates were fairly static but remained much lower than those in the most-deprived areas. There were small post-recession increases in the proportion of suicides in men in higher management/professional, small employer/self-employed occupations and fulltime education. A halt in the downward trend in suicide rates amongst men aged 16-34 years, may have begun before the 2008 economic recession whilst for men aged 35-44 years old increased suicide rates mirrored recession related unemployment. This evidence suggests indicators of economic strain other than unemployment and redundancies, such as personal debt and house repossessions may contribute to increased suicide rates in younger-age men whilst for men aged 35-44 years old job loss and long-term unemployment is a key risk factor.