Environmental Public Health practice: designing and delivering a locally desirable service.

OBJECTIVES: We reviewed environmental public health practice at a local level (roles, responsibilities, interaction with partner agencies) to establish what and how an integrated approach to the service, as found in Cheshire and Merseyside, North West England, should be delivered, if at all, and at what footprint. STUDY DESIGN: Mixed methods approach. METHODS: We triangulated: qualitative interviews with relevant professionals to gain an in-depth understanding of their interest and vision for any health protection input to health risks and outcomes from environmental issues; an electronic questionnaire assessing experience, interest, vision and comfort zones of a wider range of professionals involved in environmental health issues; a half-day workshop to review study findings and agree ways forward. RESULTS: Stakeholders value their local health protection team's input, but environmental public-health knowledge and skills also exist in local authority teams. Regional health protection teams can provide environmental public-health expertise to local partners and agencies. They harness national input and evidence with local frontline professionals practice, enabling locally grounded approaches, integrating science into local contexts, to answer difficult, often incorrigible, problems. CONCLUSIONS: Specialist leadership by experienced Consultants in Health Protection is of value to local authority public health and environmental teams and should be based on a footprint that is appropriate to enhance local relationships without compromising available expert knowledge and skills.

COVID-19 outbreaks in care homes during the first wave: are Care Quality Commission ratings a good predictor of at-risk homes?

BACKGROUND: COVID-19 placed a significant burden on the care home population during the first wave. Care Quality Commission's care quality ratings are given to all English care homes and could be used to identify whether care homes are at risk of COVID-19 outbreaks. METHODS: An audit was performed, April 2020, of Liverpool care homes to identify associations between COVID-19 status and care quality ratings from the Care Quality Commission. Univariable logistic regression was performed to identify whether the Care Quality Commissions ratings were associated with a care home experiencing a COVID-19 outbreak, or a home having asymptomatic cases. FINDINGS: Over half of the care homes (53.2%, n=41), had laboratory-confirmed clinical cases and 39 (95.1%) of these were reported as outbreaks. A small number of care homes (10.4%, n=8) had asymptomatic cases and over a third had no clinical or asymptomatic cases (36.4%, n=28). There was no significant difference between the overall Care Quality Commission rating of Liverpool and English care homes (p=0.57). There was no significant association between any of the Care Quality Commission rating domains and the presence of COVID-19 outbreaks and/or asymptomatic cases. CONCLUSIONS: During the first wave of the COVID-19 pandemic, Care Quality Commission ratings were not associated with COVID-19 outbreaks or asymptomatic cases in care homes. Infection prevention and control components of Care Quality Commission ratings need to be strengthened to identify care homes at a potential risk of infectious disease outbreaks that may require targeted support. Further large-scale studies will be required to test the findings from this study.

COVID-19 testing in outbreak-free care homes: what are the public health benefits?

BACKGROUND: COVID-19 care home outbreaks represent a significant proportion of COVID-19 morbidity and mortality in the UK. National testing initially focused on symptomatic care home residents, before extending to asymptomatic cohorts. AIM: The aim was to describe the epidemiology and transmission of COVID-19 in outbreak free care homes. METHODS: A two-point prevalence survey of COVID-19, in 34 Liverpool care homes, was performed in April and May 2020. Changes in prevalence were analysed. Associations between care home characteristics, reported infection, prevention and control interventions, and COVID-19 status were described and analysed. FINDINGS: No resident developed COVID-19 symptoms during the study. There was no significant difference between: the number of care homes containing at least one test positive resident between the first (17.6%, 95% confidence interval (CI) 6.8-34.5) and second round (14.7%, 95% CI 5.0-31.1) of testing (p>0.99); and the number of residents testing positive between the first (2.1%, 95% CI 1.2-3.4) and second round (1.0%, 95% CI 0.5-2.1) of testing (P=0.11). Care homes providing nursing care (risk ratio (RR) 7.99, 95% CI 1.1-57.3) and employing agency staff (RR 8.4, 95% CI 1.2-60.8) were more likely to contain test positive residents. Closing residents shared space was not associated with residents testing positive (RR 2.63, 95% CI 0.4-18.5). CONCLUSIONS: Asymptomatic COVID-19 care homes showed no evidence of disease transmission or development of outbreaks; suggesting that current infection prevention and control measures are effective in preventing transmission. Repeat testing at two to three weeks had limited or no public health benefits over regular daily monitoring of staff and residents for symptoms. These results should inform policies calling for regular testing of asymptomatic residents.

Factors associated with influenza-like illness in care homes in Cheshire and Merseyside during the 2017-2018 influenza season.

OBJECTIVES: The aim of the study was to identify care home characteristics associated with reported care home influenza outbreaks and factors associated with increased transmission of influenza-like illness (ILI) in care homes in Cheshire and Merseyside during the 2017-2018 influenza season. STUDY DESIGN: This is a matched case-control study comparing characteristics between care homes with and without a declared influenza outbreak and a retrospective risk factor analysis of care home residents with ILI. METHODS: Routinely collected outbreak surveillance data on symptomatic residents and staff, antiviral prophylaxis and influenza vaccination history, which were reported to Public Health England, were extracted from health protection electronic records. Further care home characteristics were extracted from the Care Quality Commission (CQC) website. Care homes with declared influenza outbreaks were matched with care homes without outbreaks. Chi-squared tests and logistic regression were used to examine associations between care home factors and ILI. RESULTS: There were no significant differences in characteristics between 77 care homes with declared influenza outbreaks and 77 matched care homes without outbreaks. Of 2,744 residents from the homes with a declared outbreak, 644 (24%) developed an ILI. The care home risk factors were having a low CQC score and activation of antiviral prophylaxis and the protective factors were having higher numbers of residents, specializing in dementia care and having the highest CQC score. Significantly more cases occurred in residential homes than in nursing homes, in homes with lower CQC scores and in homes where eligible residents were given antiviral prophylaxis. CONCLUSIONS: In homes with declared outbreaks, certain characteristics including activation of antiviral prophylaxis were associated with an increased risk of ILI. Further research is needed, particularly focussing on temporality between provision of prophylactic antivirals and the onset of ILI.

Use of prophylactic antivirals and care home characteristics associated with influenza in care homes with confirmed outbreaks.

OBJECTIVES: To assess the association of antiviral prophylaxis and care home characteristics with the spread and severity of influenza-like illness in care homes with influenza outbreaks in North West England in the 2017/2018 influenza season. STUDY DESIGN: This is a retrospective observational study. METHODS: Routinely collected outbreak surveillance data reported to Public Health England were extracted from health protection electronic records. Data included use of antiviral prophylaxis, influenza-like illness or confirmed influenza, hospital admissions and deaths. Care home characteristics were obtained from the Care Quality Commission website. Single variable analysis and multivariable logistic regression were used to examine associations between care home characteristics, antiviral prophylaxis and influenza-related outcomes. RESULTS: In the 109 homes, there were 3498 residents; of whom, 855 (24%) developed an influenza-like illness. Antiviral prophylaxis was given to residents of 67 of the 109 care homes with outbreaks (61%). A significantly higher attack rate was observed among residents of homes given antiviral prophylaxis (27%) than among residents of homes not given antivirals (20%) (P < 0.001). Significantly more deaths occurred in homes for people with learning disabilities and homes that received antiviral prophylaxis (P < 0.001). CONCLUSIONS: In homes given antiviral prophylaxis, there were a higher number of residents with influenza-like illness and deaths. To improve our understanding of the impact of antiviral prophylaxis use in real life, enhanced and timely data collection is needed for identification of temporal associations between exposure and administration of antiviral prophylaxis. Consideration needs also to be given to ensure people with learning disabilities are protected through the seasonal influenza vaccine and timely antiviral prophylaxis when appropriate.

Adapting the Structured Operational Research Training Initiative (SORT IT) for high-income countries.

SORT IT (Structured Operational Research Training InitiaTive) is a successful capacity building programme started 10 years ago to develop operational research skills in low- and middle-income countries. Public Health England (PHE) aims to embed a culture of research in front-line staff, and SORT IT has been adapted to train frontline health protection professionals at PHE North West (PHE NW) to collate, analyse and interpret routinely collected data for evidence-informed decision-making. Six participants from the PHE NW Health Protection team were selected to attend a two-module course in Liverpool, UK, in May and in November 2018. Five participants finished the course with completed papers on characteristics and burden of influenza-like illness in elderly care homes (two papers), use of dried blood spots for blood-borne virus screening in prisons, uptake of meningococcal ACWY (groups A, C, W-135 and Y) vaccine in schoolchildren and fires in waste management sites. The SORT IT course led to 1) new evidence being produced to inform health protection practice, and 2) agreement within PHE NW to continue SORT IT with two courses per year, and 3) showed how a research capacity building initiative for low- and middle-income countries that combines 'learning with doing' can be adapted and used in a high-income country.

SORT IT (Structured Operational Research Training InitiaTive) est un programme fructueux de renforcement des capacités qui a démarré il y a 10 ans afin de développer des compétences en recherche opérationnelle dans les pays à revenu faible et moyen. Public Health England (PHE) vise à incorporer une culture de recherche au sein du personnel de première ligne. SORT IT a été adapté afin de former les professionnels de protection de la santé de première ligne à PHE-North West (PHE-NW) pour compiler, analyser et interpréter les données recueillies en routine en vue de prises de décisions basées sur des preuves. Six participants de l'équipe de PHE-NW Health Protection ont été choisis pour participer à un cours de deux modules à Liverpool, Royaume-Uni, en mai 2018 et en novembre 2018 respectivement. Cinq participants ont terminé le cours avec des articles achevés sur les caractéristiques et le fardeau des syndromes grippaux dans les maisons de retraite (deux articles), l'utilisation de gouttes de sang séché pour le dépistage des virus transmis par le sang dans les prisons, la couverture du vaccin anti-méningococcique ACWY (groupes A, C, W-135 and Y) chez les écoliers et les incendies dans les dépôts d'ordures. Les résultats et l'impact de cette approche incluent 1) la production de nouvelles preuves visant à informer les pratiques de protection de la santé ; 2) un accord au sein de PHE-NW pour poursuivre SORT IT avec deux cours par an ; et 3) la démonstration de la manière dont une initiative de renforcement des capacités de recherche destinée aux pays à revenu faible et moyen, qui combine « l'apprentissage par la pratique ¼, peut être adaptée et utilisée dans un pays à haut revenu.

El programa SORT IT (por Structured Operational Research Training InitiaTive) es una iniciativa eficaz de fortalecimiento de la capacidad, orientada a crear competencias en investigación operativa en los países de ingresos bajos y medianos, que se inició hace 10 años. La finalidad del organismo inglés de salud pública (PHE, por Public Health England) consiste en incorporar la cultura de la investigación en la práctica del personal de primera línea; el programa SORT IT se adaptó con miras a capacitar a los profesionales que prestan directamente la protección de la salud en el PHE-NW (noroccidente) para recopilar, analizar e interpretar los datos recogidos de manera sistemática y fundamentar así la adopción de decisiones basadas en la evidencia. Se escogieron seis participantes del equipo de protección de salud del PHE-NW para que asistieran a un curso en dos módulos en Liverpool, RU, en mayo del 2018 y noviembre del 2018. Cinco de los participantes terminaron el curso con la elaboración de artículos sobre las características y la carga de morbilidad por síndrome gripal en los hogares de ancianos (dos artículos), la utilización en las prisiones de muestras de manchas de sangre seca para el tamizaje de los virus de transmisión sanguínea, la aceptación de la vacuna ACWY (grupos A, C, W-135 and Y) contra el meningococo en los niños de edad escolar y los incendios en los centros de gestión de desechos. Los resultados y el impacto de esta iniciativa fueron los siguientes 1) se obtuvo nueva evidencia para fundamentar las prácticas de la protección de la salud; 2) se acordó continuar el programa SORT IT en el PHE-NW con dos cursos por año; y 3) se demostró cómo se puede adaptar una iniciativa de fortalecimiento de la capacidad en investigación dirigida a países de ingresos bajos y medianos, que asocia "aprender con hacer" para utilizarla en un país de ingresos altos.

An outbreak of multidrug-resistant Pseudomonas aeruginosa in a burns service in the North of England: challenges of infection prevention and control in a complex setting.

BACKGROUND: Burns patients are at high risk of nosocomial infection, and Pseudomonas aeruginosa is one of the most common causes of wound and systemic infections resulting in significant morbidity and mortality in burns patients. AIM: To describe an outbreak of multidrug-resistant P. aeruginosa (MDR-Pa) at a specialist burns service and highlight the challenges in identifying the reservoir of infection despite extensive epidemiological, microbiological, and environmental investigations. METHODS: Multi-disciplinary outbreak control investigation. FINDINGS: Following an inter-hospital transfer of a burns patient from another country, an admission screen revealed that the patient was colonized with MDR-Pa. Subsequently nine more patients contracted MDR-Pa in the period from November 2015 to September 2017. Given the relatively long gap between confirmation of the index and subsequent cases, it was not possible to identify with certainty the reservoirs and mechanisms of spread of infection, although contamination of the burns service environment and equipment are likely to be contributory factors. CONCLUSION: Preventing infection transmission in specialist burns services is highly challenging, and it may not always be possible to identify and eradicate the reservoirs of infection for P. aeruginosa outbreaks. Our study supports the literature, providing additional evidence that inanimate, common contact surfaces play an important role in nosocomial transmission of P. aeruginosa. These surfaces should either be decontaminated efficiently between patient contacts or be single patient use. Enhanced vigilance is crucial, and, with strict adherence to infection prevention and control procedures, it is possible to reduce the risk of acquisition and spread of infection in patients.

Reasons for measles cases not being vaccinated with MMR: investigation into parents' and carers' views following a large measles outbreak.

Uptake rates for the combined measles, mumps and rubella (MMR) vaccine have been below the required 95% in the UK since a retracted and discredited article linking the MMR vaccine with autism and inflammatory bowel disease was released in 1998. This study undertook semi-structured telephone interviews among parents or carers of 47 unvaccinated measles cases who were aged between 13 months and 9 years, during a large measles outbreak in Merseyside. Results showed that concerns over the specific links with autism remain an important cause of refusal to vaccinate, with over half of respondents stating this as a reason. A quarter stated child illness during scheduled vaccination time, while other reasons included general safety concerns and access issues. Over half of respondents felt that more information or a discussion with a health professional would help the decision-making process, while a third stated improved access. There was clear support for vaccination among respondents when asked about current opinions regarding MMR vaccine. The findings support the hypothesis that safety concerns remain a major barrier to MMR vaccination, and also support previous evidence that experience of measles is an important determinant in the decision to vaccinate.

Effect of socioeconomic deprivation on uptake of measles, mumps and rubella vaccination in Liverpool, UK over 16 years: a longitudinal ecological study.

Suboptimal uptake of the measles, mumps and rubella (MMR) vaccine by certain socioeconomic groups may have contributed to recent large measles outbreaks in the UK. We investigated whether socioeconomic deprivation was associated with MMR vaccine uptake over 16 years. Using immunization data for 72,351 children born between 1995 and 2012 in Liverpool, UK, we examined trends in vaccination uptake. Generalized linear models were constructed to examine the relative effect of socioeconomic deprivation and year of birth on MMR uptake. Uptake of MMR1 by age 24 months ranged between 82·5% in 2003 [95% confidence interval (CI) 81·2-83·7] and 93·4% in 2012 (95% CI 92·7-94·2). Uptake of MMR2 by age 60 months ranged between 65·3% (95% CI 64·4-67·4) in 2006 and 90·3% (95% CI 89·4-91·2) in 2012. In analysis adjusted for year of birth and sex, children in the most deprived communities were at significantly greater risk of not receiving MMR1 [risk ratio (RR) 1·70, 95% CI 1·45-1·99] and MMR2 (RR 1·36, 95% CI 1·22-1·52). Higher unemployment and lower household income were significantly associated with low uptake. Contrary to concerns about lower MMR uptake in affluent families, over 16 years, children from the most socioeconomically deprived communities have consistently had the lowest MMR uptake. Targeted catch-up campaigns and strategies to improve routine immunization uptake in deprived areas are needed to minimize the risk of future measles outbreaks.

Risk factors for transmission of measles during an outbreak: matched case-control study.

BACKGROUND: In 2012, an outbreak of measles occurred in Merseyside, UK with 359 confirmed cases by 30 June. Numerous cases reported visits to healthcare and social settings. AIM: To identify risk factors associated with measles transmission during the outbreak. METHODS: In April 2012, a retrospective matched case-control study was conducted. Fifty-five confirmed cases and 55 community controls, matched 1:1 for age and geography, were selected at random. Data on exposures in the two weeks before illness, including attendance at a healthcare setting, were collected via telephone interview. Univariate and multi-variate analyses were conducted and odds ratios were calculated. FINDINGS: Forty-two cases and 42 matched controls were contacted successfully. Univariate exact conditional logistic regression analysis identified that cases were more likely to have attended an emergency department, been admitted to hospital and be incompletely vaccinated (for age). Multi-variate analysis found three factors to be independently associated with measles infection: incomplete/partial vaccination for age [adjusted odds ratio (aOR) 22.1, 95% confidence interval (CI) 3.8-∞, P < 0.001], under age for routine vaccination (aOR 20.4, 95% CI 2.0-∞, P = 0.009) and hospital admission (aOR 20.2, 95% CI 1.4-∞, P = 0.025). CONCLUSIONS: Incomplete/partial vaccination, under age for routine vaccination and hospital admission were associated with measles infection. These findings highlight the importance of timely vaccination of eligible individuals, early diagnosis, timely isolation of cases, and implementation of strict infection control measures.

Outbreak of measles in Central and Eastern Cheshire, UK, October 2008-February 2009.

We describe the largest outbreak of measles in Central and Eastern Cheshire (North West England) since the MMR vaccine was introduced in 1988, the majority of cases were not vaccinated and more than 20% of the cases belonged to the travelling community. Over 4 months,147 clinical cases of measles were notified locally to the Cheshire & Merseyside Health Protection Unit (CMHPU). Of these, 67 (45.6%) were laboratory confirmed, 42 (28.6%) were negative, and one was equivocal, leaving 23 probable and 14 possible cases. The primary case was probably an 8-year-old unvaccinated travelling child, symptomatic on 1 October 2008. Measles spread locally and within school-aged children until early February 2009. Most of Central and Eastern Cheshire, including 23 educational institutions (playgroups, nurseries, primary schools, secondary schools, colleges), were affected, showing that there were enough susceptible/unvaccinated children to sustain an outbreak. Nearly a quarter of the confirmed cases (15/67, 22.4%) were aged <13 months and too young to be vaccinated under the UK immunization schedule. This outbreak is a reminder of the importance of achieving herd immunity to prevent spread and protect those at risk of severe illness or complications. There were no fatalities in this outbreak and no significant complications were reported.

An ongoing large outbreak of measles in Merseyside, England, January to June 2012.

From 1 January to 30 June 2012, 359 confirmed and 157 probable cases of measles were reported in Merseyside, England. The most affected age groups were children under five years and young adults from 15 years of age. Most cases have been sporadic. There have been few outbreaks in nurseries; however, no outbreaks have been reported in schools. Of the cases eligible for vaccination, only 3% of the confirmed cases were fully immunised.

How complete and accurate is meningococcal disease notification?

Effective public health control of meningococcal disease (meningococcal meningitis and septicaemia) is dependent on complete, accurate and speedy notification. Using capture-recapture techniques this study assesses the completeness, accuracy and timeliness of meningococcal notification in a health authority. The completeness of meningococcal disease notification was 94.8% (95% confidence interval 93.2% to 96.2%); 91.2% of cases in 2001 were notified within 24 hours of diagnosis, but 28.0% of notifications in 2001 were false positives. Clinical staff need to be aware of the public health implications of a notification of meningococcal disease, and of failure of, or delay in notification. Incomplete or delayed notification not only leads to inaccurate data collection but also means that important public health measures may not be taken. A clinical diagnosis of meningococcal disease should be carefully considered between the clinician and the consultant in communicable disease control (CCDC). Otherwise, prophylaxis may be given unnecessarily, disease incidence inflated, and the benefits of control measures underestimated. Consultants in communicable disease control (CCDCs), in conjunction with clinical staff, should de-notify meningococcal disease if the diagnosis changes.

MMR vaccine uptake rates: a data validation study.

As part of our investigation into the decrease in the measles, mumps and rubella (MMR) vaccine uptake rates, we validated MMR vaccination records of all children born between 01/09/1998 and 31/08/1999 in our area (North Cheshire, South Cheshire, and Wirral). A significant number of children had received their MMR vaccine but were not recorded as such by the Child Health Computer System (CHCS). Reported COVER (cover of vaccination evaluated rapidly) data uptake (combined) for North Cheshire, South Cheshire, and Wirral Health Authorities for the period covered by the data validation study was 90.5%, the corrected uptake following the validation was 92.6%, 2.1% higher than the reported coverage. If the coverage data were to continue to form part of the NHS indicators of PCT performance, action by all PCTs to improve accuracy of immunisation data would be highly desirable. Electronic transfer of information from practices to the CHCS and between CHCSs, i.e. across boundaries, could improve data accuracy.

Effectiveness of home-based food storage training: a community development approach.

A community-based home hygiene training initiative, funded by Merseyside Health Action Zone, was piloted in Dingle, a deprived area of Liverpool, UK, during Spring and early Summer 2000. The project actively involved the community, and home-based domestic hygiene training was delivered by community-based facilitators to households in Dingle, Liverpool. During the project the community-based facilitators visited 904 households on two separate occasions. During the first visit, the community-based facilitators completed a questionnaire and an 'action sheet' which had been designed to measure participants' prior knowledge and behaviour, in relation to a range of important food hygiene issues, and delivered the home-based food hygiene training. Within 8 weeks of the first visit, the community-based facilitators returned to the participating households and completed a second questionnaire and action sheet. Home-based training is effective in raising awareness, and community development approach has the advantage of facilitating access to households which otherwise would have been difficult to reach.

Provision of services to asylum seekers. Are there lessons from the experience with Kosovan refugees?

Arrangements that were made to receive and support Kosovan refugees in the United Kingdom should be applied to asylum seekers arriving in the country.

A review of induced abortion rates in England and Wales, 1969-1994.

This study examines trends in induced abortion rates in England and Wales, from 1969 to 1994. A comparison of the trends between the different age groups shows contrasting changes and interesting features. The only age group to show a continuous increase since 1969 has been females aged 11 to 14 years. This may be due to birth cohort effect, as younger women begin sexual activity in a social environment of higher risk than previous cohorts. These considerations have important implications for the organisation of preventive services particularly health education. In spite of the availability of improved and better contraceptive services and sex education, the cohort analysis suggests that induced abortion rates in each successive cohort was higher than the preceding cohort.

PIP: The annual number of induced abortions performed on residents of England and Wales increased in a nonlinear manner from 50,000 in 1969 to 157,000 in 1994. The present study used data from the Office of Population Censuses and Surveys to investigate age-specific abortion trends during this period. Between 1969 and 1994, the induced abortion rate (per 1000) changed from 0.25 to 0.76 among 11-14 year olds, from 5.4 to 18.9 among 15-19 year olds, from 6.9 to 25.4 among 20-24 year olds, from 6.0 to 18.0 among 25-29 year olds, from 5.6 to 12.7 among 30-34 year olds, from 4.5 to 8.0 among 35-39 year olds, from 1.9 to 3.0 among 40-44 year olds, and from 0.16 to 0.24 among 45-49 year olds. The only age group to show a continuous increase since 1969 was that comprising 11-14 year olds. The peak age at abortion declined from 30-34 years in the 1940 birth cohort to 20-24 years in the 1960 cohort. The finding of higher abortion rates in each successive age cohort may reflect factors such as concerns about the side effects of oral contraceptives, increased availability of abortion services, economic pressures associated with child rearing, the reduction in family planning clinics and sessions, declines in age at first coitus, and more permissive societal attitudes toward premarital sex.