Haemolytic uraemic syndrome in children England, Wales, Northern Ireland, and Ireland: A prospective cohort study.

Haemolytic uraemic syndrome (HUS) caused by infection with Shiga toxin-producing Escherichia coli (STEC) is a relatively rare but potentially fatal multisystem syndrome clinically characterised by acute kidney injury. This study aimed to provide robust estimates of paediatric HUS incidence in England, Wales, Northern Ireland, and the Republic of Ireland by using data linkage and case reconciliation with existing surveillance systems, and to describe the characteristics of the condition. Between 2011 and 2014, 288 HUS patients were included in the study, of which 256 (89.5%) were diagnosed as typical HUS. The crude incidence of paediatric typical HUS was 0.78 per 100,000 person-years, although this varied by country, age, gender, and ethnicity. The majority of typical HUS cases were 1 to 4 years old (53.7%) and female (54.0%). Clinical symptoms included diarrhoea (96.5%) and/or bloody diarrhoea (71.9%), abdominal pain (68.4%), and fever (41.4%). Where STEC was isolated (59.3%), 92.8% of strains were STEC O157 and 7.2% were STEC O26. Comparison of the HUS case ascertainment to existing STEC surveillance data indicated an additional 166 HUS cases were captured during this study, highlighting the limitations of the current surveillance system for STEC for monitoring the clinical burden of STEC and capturing HUS cases.

The incidence rate of planned and emergency physical health hospital admissions in people diagnosed with severe mental illness: a cohort study.

BACKGROUND: People with severe mental illness (SMI) have more physical health conditions than the general population, resulting in higher rates of hospitalisations and mortality. In this study, we aimed to determine the rate of emergency and planned physical health hospitalisations in those with SMI, compared to matched comparators, and to investigate how these rates differ by SMI diagnosis. METHODS: We used Clinical Practice Research DataLink Gold and Aurum databases to identify 20,668 patients in England diagnosed with SMI between January 2000 and March 2016, with linked hospital records in Hospital Episode Statistics. Patients were matched with up to four patients without SMI. Primary outcomes were emergency and planned physical health admissions. Avoidable (ambulatory care sensitive) admissions and emergency admissions for accidents, injuries and substance misuse were secondary outcomes. We performed negative binomial regression, adjusted for clinical and demographic variables, stratified by SMI diagnosis. RESULTS: Emergency physical health (aIRR:2.33; 95% CI 2.22-2.46) and avoidable (aIRR:2.88; 95% CI 2.60-3.19) admissions were higher in patients with SMI than comparators. Emergency admission rates did not differ by SMI diagnosis. Planned physical health admissions were lower in schizophrenia (aIRR:0.80; 95% CI 0.72-0.90) and higher in bipolar disorder (aIRR:1.33; 95% CI 1.24-1.43). Accident, injury and substance misuse emergency admissions were particularly high in the year after SMI diagnosis (aIRR: 6.18; 95% CI 5.46-6.98). CONCLUSION: We found twice the incidence of emergency physical health admissions in patients with SMI compared to those without SMI. Avoidable admissions were particularly elevated, suggesting interventions in community settings could reduce hospitalisations. Importantly, we found underutilisation of planned inpatient care in patients with schizophrenia. Interventions are required to ensure appropriate healthcare use, and optimal diagnosis and treatment of physical health conditions in people with SMI, to reduce the mortality gap due to physical illness.

Incidence and associations of hospital delirium diagnoses in 85,979 people with severe mental illness: A data linkage study.

INTRODUCTION: Delirium is an acute neuro-psychiatric disturbance precipitated by a range of physical stressors, with high morbidity and mortality. Little is known about its relationship with severe mental illness (SMI). METHODS: We conducted a retrospective cohort study using linked data analyses of the UK Clinical Practice Research Datalink (CPRD) and Hospital Episodes Statistics (HES) databases. We ascertained yearly hospital delirium incidence from 2000 to 2017 and used logistic regression to identify associations with delirium diagnosis in a population with SMI. RESULTS: The cohort included 249,047 people with SMI with median follow-up time in CPRD of 6.4 years. A total of 85,979 patients were eligible for linkage to HES. Delirium incidence increased from 0.04 (95% CI 0.02-0.07) delirium associated admissions per 100 person-years in 2000 to 1.05 (95% CI 0.93-1.17) per 100 person-years in 2017, increasing most notably from 2010 onwards. Delirium was associated with older age at study entry (OR 1.05 per year, 95% CI 1.05-1.06), SMI diagnosis of bipolar affective disorder (OR 1.66, 95% CI 1.44-1.93) or other psychosis (OR 1.56, 95% CI 1.35-1.80) relative to schizophrenia, and more physical comorbidities (OR 1.08 per additional comorbidity of the Charlson Comorbidity Index, 95% CI 1.02-1.14). Patients with delirium received more antipsychotic medication during follow-up (1-2 antipsychotics OR 1.65, 95% CI 1.44-1.90; >2 antipsychotics OR 2.49, 95% CI 2.12-2.92). CONCLUSIONS: The incidence of recorded delirium diagnoses in people with SMI has increased in recent years. Older people prescribed more antipsychotics and with more comorbidities have a higher incidence. Linked electronic health records are feasible for exploring hospital diagnoses such as delirium in SMI.

The impact of comorbid severe mental illness and common chronic physical health conditions on hospitalisation: A systematic review and meta-analysis.

BACKGROUND: People with severe mental illness (SMI) are at higher risk of physical health conditions compared to the general population, however, the impact of specific underlying health conditions on the use of secondary care by people with SMI is unknown. We investigated hospital use in people managed in the community with SMI and five common physical long-term conditions: cardiovascular diseases, COPD, cancers, diabetes and liver disease. METHODS: We performed a systematic review and meta-analysis (Prospero: CRD42020176251) using terms for SMI, physical health conditions and hospitalisation. We included observational studies in adults under the age of 75 with a diagnosis of SMI who were managed in the community and had one of the physical conditions of interest. The primary outcomes were hospital use for all causes, physical health causes and related to the physical condition under study. We performed random-effects meta-analyses, stratified by physical condition. RESULTS: We identified 5,129 studies, of which 50 were included: focusing on diabetes (n = 21), cardiovascular disease (n = 19), COPD (n = 4), cancer (n = 3), liver disease (n = 1), and multiple physical health conditions (n = 2). The pooled odds ratio (pOR) of any hospital use in patients with diabetes and SMI was 1.28 (95%CI:1.15-1.44) compared to patients with diabetes alone and pooled hazard ratio was 1.19 (95%CI:1.08-1.31). The risk of 30-day readmissions was raised in patients with SMI and diabetes (pOR: 1.18, 95%CI:1.08-1.29), SMI and cardiovascular disease (pOR: 1.27, 95%CI:1.06-1.53) and SMI and COPD (pOR:1.18, 95%CI: 1.14-1.22) compared to patients with those conditions but no SMI. CONCLUSION: People with SMI and five physical conditions are at higher risk of hospitalisation compared to people with that physical condition alone. Further research is warranted into the combined effects of SMI and physical conditions on longer-term hospital use to better target interventions aimed at reducing inappropriate hospital use and improving disease management and outcomes.

Cancer rates and mortality in people with severe mental illness: Further evidence of lack of parity.

BACKGROUND: Severe mental illness (SMI) is associated with poorer physical health, however the relationship between SMI and cancer is complex and previous study findings are inconsistent. Low incidence of cancer in those with SMI has been attributed to premature mortality, though evidence for this is lacking. We aimed to investigate the relationship between SMI and cancer incidence and mortality, and to assess the effect of premature mortality on cancer incidence rates. METHODS: In this UK-wide matched cohort study using primary care records we calculated incidence and mortality rates of all-cancer, and bowel, lung, breast or prostate cancer, in patients with SMI, compared to matched patients without SMI. We used competing risks regression to account for mortality from other causes. FINDINGS: 69,632 patients had an SMI diagnosis. The rate of all-cancer diagnoses was reduced in those with SMI (Hazard ratio (HR):0·95; 95%CI 0·93-0·98) compared to those without SMI, and particularly in those with schizophrenia (HR:0·82; 95%CI 0·77-0·88) compared to those without SMI. When accounting for the competing risk of premature mortality, incidence remained lower only in patients with schizophrenia. All-cause mortality after cancer was increased in the SMI group, and cancer-specific mortality was increased in those with schizophrenia (hazard ratio: 1.96; 95%CI 1.57-2.44). INTERPRETATION: Patients with schizophrenia have lower rates of cancer diagnosis but higher all-cause and cancer-specific mortality rates following diagnosis compared to those without SMI. Premature mortality does not explain these differences, suggesting the findings reflect barriers to cancer diagnosis and treatment, which need to be identified and addressed.

The temporal relationship between severe mental illness diagnosis and chronic physical comorbidity: a UK primary care cohort study of disease burden over 10 years.

BACKGROUND: Despite increased rates of physical health problems in people with schizophrenia, bipolar disorder, and other psychotic illnesses, the temporal relationship between physical disease acquisition and diagnosis of a severe mental illness remains unclear. We aimed to determine the cumulative prevalence of 24 chronic physical conditions in people with severe mental illness from 5 years before to 5 years after their diagnosis. METHODS: In this cohort study, we used the UK Clinical Practice Research Datalink (CPRD) to identify patients aged 18-100 years who were diagnosed with severe mental illness between Jan 1, 2000, and Dec 31, 2018. Each patient with severe mental illness was matched with up to four individuals in the CPRD without severe mental illness by sex, 5-year age band, primary care practice, and year of primary care practice registration. Individuals in the matched cohort were assigned an index date equal to the date of severe mental illness diagnosis in the patient with severe mental illness to whom they were matched. Our primary outcome was the cumulative prevalence of 24 physical health conditions, based on the Charlson and Elixhauser comorbidity indices, at 5 years, 3 years, and 1 year before and after severe mental illness diagnosis and at the time of diagnosis. We used logistic regression to compare people with severe mental illness with the matched cohort, adjusting for key variables such as age, sex, and ethnicity. FINDINGS: We identified 68 789 patients diagnosed with a severe mental illness between Jan 1, 2000, and Dec 31, 2018, and we matched them to 274 827 patients without a severe mental illness diagnosis. In both cohorts taken together, the median age was 40·90 years (IQR 29·46-56·00), 175 138 (50·97%) people were male, and 168 478 (49·03%) were female. The majority of patients were of White ethnicity (59 867 [87·03%] patients with a severe mental illness and 244 566 [88·99%] people in the matched cohort). The most prevalent conditions at the time of diagnosis in people with severe mental illness were asthma (10 581 [15·38%] of 68 789 patients), hypertension (8696 [12·64%]), diabetes (4897 [7·12%]), neurological disease (3484 [5·06%]), and hypothyroidism (2871 [4·17%]). At diagnosis, people with schizophrenia had increased odds of five of 24 chronic physical conditions compared with matched controls, and nine of 24 conditions were diagnosed less frequently than in matched controls. Individuals with bipolar disorder and other psychoses had increased odds of 15 conditions at diagnosis. At 5 years after severe mental illness diagnosis, these numbers had increased to 13 conditions for schizophrenia, 19 for bipolar disorder, and 16 for other psychoses. INTERPRETATION: Elevated odds of multiple conditions at the point of severe mental illness diagnosis suggest that early intervention on physical health parameters is necessary to reduce morbidity and premature mortality. Some physical conditions might be under-recorded in patients with schizophrenia relative to patients with other severe mental illness subtypes. FUNDING: UK Office For Health Improvement and Disparities.

Clustering of physical health multimorbidity in people with severe mental illness: An accumulated prevalence analysis of United Kingdom primary care data.

BACKGROUND: People with severe mental illness (SMI) have higher rates of a range of physical health conditions, yet little is known regarding the clustering of physical health conditions in this population. We aimed to investigate the prevalence and clustering of chronic physical health conditions in people with SMI, compared to people without SMI. METHODS AND FINDINGS: We performed a cohort-nested accumulated prevalence study, using primary care data from the Clinical Practice Research Datalink (CPRD), which holds details of 39 million patients in the United Kingdom. We identified 68,783 adults with a primary care diagnosis of SMI (schizophrenia, bipolar disorder, or other psychoses) from 2000 to 2018, matched up to 1:4 to 274,684 patients without an SMI diagnosis, on age, sex, primary care practice, and year of registration at the practice. Patients had a median of 28.85 (IQR: 19.10 to 41.37) years of primary care observations. Patients with SMI had higher prevalence of smoking (27.65% versus 46.08%), obesity (24.91% versus 38.09%), alcohol misuse (3.66% versus 13.47%), and drug misuse (2.08% versus 12.84%) than comparators. We defined 24 physical health conditions derived from the Elixhauser and Charlson comorbidity indices and used logistic regression to investigate individual conditions and multimorbidity. We controlled for age, sex, region, and ethnicity and then additionally for health risk factors: smoking status, alcohol misuse, drug misuse, and body mass index (BMI). We defined multimorbidity clusters using multiple correspondence analysis (MCA) and K-means cluster analysis and described them based on the observed/expected ratio. Patients with SMI had higher odds of 19 of 24 conditions and a higher prevalence of multimorbidity (odds ratio (OR): 1.84; 95% confidence interval [CI]: 1.80 to 1.88, p < 0.001) compared to those without SMI, particularly in younger age groups (males aged 30 to 39: OR: 2.49; 95% CI: 2.27 to 2.73; p < 0.001; females aged 18 to 30: OR: 2.69; 95% CI: 2.36 to 3.07; p < 0.001). Adjusting for health risk factors reduced the OR of all conditions. We identified 7 multimorbidity clusters in those with SMI and 7 in those without SMI. A total of 4 clusters were common to those with and without SMI; while 1, heart disease, appeared as one cluster in those with SMI and 3 distinct clusters in comparators; and 2 small clusters were unique to the SMI cohort. Limitations to this study include missing data, which may have led to residual confounding, and an inability to investigate the temporal associations between SMI and physical health conditions. CONCLUSIONS: In this study, we observed that physical health conditions cluster similarly in people with and without SMI, although patients with SMI had higher burden of multimorbidity, particularly in younger age groups. While interventions aimed at the general population may also be appropriate for those with SMI, there is a need for interventions aimed at better management of younger-age multimorbidity, and preventative measures focusing on diseases of younger age, and reduction of health risk factors.

Management Of Community-Acquired Pneumonia: An Observational Study In UK Primary Care.

PURPOSE: In primary care, initial diagnosis of community-acquired pneumonia (CAP) is made on clinical judgment without radiological confirmation or knowledge of the causative organism. Use of CRB65 score has been recommended for assessing the severity of CAP and thereby determining clinical management, but it is not known how frequently these scores are used in primary care. PATIENTS AND METHODS: Primary care consultations in adults with a diagnostic code for CAP between 1 January 2009 and 31 December 2016 were extracted from the Optimum Patient Care Research Database, which at the time of data extraction had over 3.4 million patients in the UK. Episodes without antibiotic prescription on day of diagnosis were excluded, as were records describing past events. Patients admitted to hospital on day of diagnosis were excluded, but were included in exploratory analysis of CRB65 recording. RESULTS: In total, 4734 episodes of CAP in adults managed in primary care between 1 January 2009 and 31 December 2016 were included. A range of investigations/observations were recorded, including pulse rate (10.7%), chest examinations (9.1%) and blood tests (5.4%). CRB65 scores were recorded in 19 (0.4%) episodes of CAP, 17 of which were after the publication of the NICE guidelines in December 2014. CRB65 recording was no more frequent in 3819 episodes referred to hospital (12, 0.3%; p=0.63), but where recorded, CRB65 scores were higher (Median: 1.0 [interquartile range: 0.5-1.0] vs 2.0 [interquartile range: 1.0-2.0], p=0.04). The most commonly prescribed antibiotic was amoxicillin (40.3%), and 85.9% of episodes had a prescription length of seven days. CONCLUSION: CRB65 scores are seldom recorded in UK primary care. Given that these scores are embedded in UK guidelines, further work is required to assess feasibility and barriers to use of CRB65 scores in primary care.

The characterisation of interstitial lung disease multidisciplinary team meetings: a global study.

Multidisciplinary team (MDT) diagnosis of interstitial lung disease (ILD) has been proposed as a gold standard, but there are no formal recommendations for MDT process or composition and limited knowledge regarding prevalence in routine practice. We performed a systematic evaluation of ILD diagnostic practice across a range of healthcare settings around the world. Electronic questionnaires were distributed across all global regions via society and collaborators networks. Responses from 457 unique centres across 64 countries were included in the analysis. Of the 350 (76.6%) centres holding formal meetings, the majority held face-to-face MDT meetings (80%), for a minimum of 30 min (93%), and discussed diagnosis (96.9%) and patient management (94.9%) at the meetings. Compared with non-academic and academic non-ILD centres, ILD academic centres reported a higher ILD caseload, held more formal MDT meetings, and were more likely to include histopathology and rheumatology specialists in their diagnostic team. Of the centres holding MDT meetings, 5.5% routinely discussed all new cases at such meetings. An MDT approach to ILD diagnosis is consistently interpreted and widely implemented across a range of routine care settings around the world. This observation will inform future ILD diagnostic agreement studies and diagnostic pathway recommendations.

Public Health Investigation of Two Outbreaks of Shiga Toxin-Producing Escherichia coli O157 Associated with Consumption of Watercress.

An increase in the number of cases of Shiga toxin-producing Escherichia coli (STEC) O157 phage type 2 (PT2) in England in September 2013 was epidemiologically linked to watercress consumption. Whole-genome sequencing (WGS) identified a phylogenetically related cluster of 22 cases (outbreak 1). The isolates comprising this cluster were not closely related to any other United Kingdom strain in the Public Health England WGS database, suggesting a possible imported source. A second outbreak of STEC O157 PT2 (outbreak 2) was identified epidemiologically following the detection of outbreak 1. Isolates associated with outbreak 2 were phylogenetically distinct from those in outbreak 1. Epidemiologically unrelated isolates on the same branch as the outbreak 2 cluster included those from human cases in England with domestically acquired infection and United Kingdom domestic cattle. Environmental sampling using PCR resulted in the isolation of STEC O157 PT2 from irrigation water at one implicated watercress farm, and WGS showed this isolate belonged to the same phylogenetic cluster as outbreak 2 isolates. Cattle were in close proximity to the watercress bed and were potentially the source of the second outbreak. Transfer of STEC from the field to the watercress bed may have occurred through wildlife entering the watercress farm or via runoff water. During this complex outbreak investigation, epidemiological studies, comprehensive testing of environmental samples, and the use of novel molecular methods proved invaluable in demonstrating that two simultaneous outbreaks of STEC O157 PT2 were both linked to the consumption of watercress but were associated with different sources of contamination.

Epidemiology and microbiology of Shiga toxin-producing Escherichia coli other than serogroup O157 in England, 2009-2013.

The implementation of direct testing of clinical faecal specimens for gastrointestinal (GI) pathogens by PCR offers a sensitive and comprehensive approach for the detection of Shiga toxin-producing Escherichia coli (STEC). The introduction of a commercial PCR assay, known as GI PCR, for the detection of GI pathogens at three frontline hospital laboratories in England between December 2012 and December 2013 led to a significant increase in detection of STEC other than serogroup O157 (non-O157 STEC). In 2013, 47 isolates were detected in England, compared with 57 in the preceding 4 years (2009-2012). The most common non-O157 STEC serogroup detected was O26 (23.2 %). A total of 47 (47.5 %) STEC isolates had stx2 only, 28 (28.3 %) carried stx1 and stx2, and the remaining 24 (24.2 %) had stx1 only. Stx2a (64.0 %) was the most frequently detected Stx2 subtype. The eae (intimin) gene was detected in 52 (52.5 %) non-O157 STEC isolates. Six strains of STEC O104 had aggR, but this gene was not detected in any other STEC serogroups in this study. Haemolytic ureamic syndrome was significantly associated with STEC strains possessing eae [odds ratio (OR) 5.845, P = 0.0235] and/or stx2a (OR 9.56, P = 0.0034) subtypes. A matched case-control analysis indicated an association between non-O157 STEC cases and contact with farm animals. Widespread implementation of the PCR approach in England will determine the true incidence of non-O157 STEC infection, highlight the burden in terms of morbidity and mortality, and facilitate the examination of risk factors to indicate whether there are niche risk exposures for particular strains.

Self-reported stomach upset in travellers on cruise-based and land-based package holidays.

BACKGROUND: International travellers are at a risk of infectious diseases not seen in their home country. Stomach upsets are common in travellers, including on cruise ships. This study compares the incidence of stomach upsets on land- and cruise-based holidays. METHODS: A major British tour operator has administered a Customer Satisfaction Questionnaire (CSQ) to UK resident travellers aged 16 or more on return flights from their holiday abroad over many years. Data extracted from the CSQ was used to measure self-reported stomach upset in returning travellers. RESULTS: From summer 2000 through winter 2008, 6,863,092 questionnaires were completed; 6.6% were from cruise passengers. A higher percentage of land-based holiday-makers (7.2%) reported stomach upset in comparison to 4.8% of cruise passengers (RR = 1.5, p<0.0005). Reported stomach upset on cruises declined over the study period (7.1% in 2000 to 3.1% in 2008, p<0.0005). Over 25% of travellers on land-based holidays to Egypt and the Dominican Republic reported stomach upset. In comparison, the highest proportion of stomach upset in cruise ship travellers were reported following cruises departing from Egypt (14.8%) and Turkey (8.8%). CONCLUSIONS: In this large study of self-reported illness both demographic and holiday choice factors were shown to play a part in determining the likelihood of developing stomach upset while abroad. There is a lower cumulative incidence and declining rates of stomach upset in cruise passengers which suggest that the cruise industry has adopted operations (e.g. hygiene standards) that have reduced illness over recent years.

Evaluation of travel medicine practice by yellow fever vaccination centers in England, Wales, and Northern Ireland.

BACKGROUND: The National Travel Health Network and Centre (NaTHNaC) introduced a program of registration, training, standards, and audit for yellow fever vaccination centers (YFVCs) in England, Wales, and Northern Ireland (EWNI) in 2005. Prior to rolling out the program, NaTHNaC surveyed YFVCs in England. OBJECTIVES: To reassess the practice of YFVCs in 2009, 4 years after the institution of the NaTHNaC program, to identify areas for ongoing support, and to assess the impact of the program. METHODS: In 2009, all YFVCs in EWNI were asked to complete a questionnaire on type of practice, administration of travel vaccines, staff training, vaccine storage and patient record keeping, use of travel health information, evaluation of NaTHNaC yellow fever (YF) training, and resource and training needs. Data were analyzed using Microsoft Excel® and STATA 9®. RESULTS: The questionnaire was completed by 1,438 YFVCs (41.5% of 3,465 YFVCs). Most YFVCs were based in General Practice (87.4%). In nearly all YFVCs (97.0%), nurses advised travelers and administered YF vaccine. An annual median of 50 doses of YF vaccine was given by each YFVC. A total of 96.7% of nurses had received training in travel medicine, often through study days run by vaccine manufacturers. The internet was frequently used for information during travel consultations (84.8%) and NaTHNaC's on-line and telephone advice resources were highly rated. Following YF training, 95.8% of attendees expressed improved confidence regarding YF vaccination issues. There was excellent adherence to vaccination standards: ≥ 94% correctly stored vaccines, recorded refrigerator temperatures, and maintained YF vaccination records. CONCLUSIONS: In the 4 years since institution of the NaTHNaC program for YFVCs, there has been improved adherence to basic standards of immunization practice and increased confidence of health professionals in YF vaccination. The NaTHNaC program could be a model for other national public health bodies, as they establish a program for YF centers.

Quality improvement in travel medicine: a programme for yellow fever vaccination centres in England, Wales and Northern Ireland.

BACKGROUND: The National Travel Health Network and Centre (NaTHNaC), a United Kingdom public health body, is responsible for designating nearly 3500 Yellow Fever Vaccination Centres (YFVCs) in England, Wales and Northern Ireland (EWNI). In 2005, NaTHNaC established a programme of registration, training, clinical standards and audit for YFVCs following the mandate of International Health Regulations (IHR, 2005). ASSESSMENT OF PROBLEM: Administration of yellow fever (YF) vaccine is complex because of the changing epidemiology of YF and the risk of rare, severe adverse events following vaccination. Additionally, there is little formal assessment of providers of travel medicine, particularly in the area of YF vaccination. In 2004, prior to introducing their programme, NaTHNaC sent a questionnaire to all YFVCs in England to assess their practice. This highlighted a need for training and institution of standards to reinforce best practice in vaccination and knowledge about YF. STRATEGIES FOR CHANGE: In 2005, NaTHNaC introduced its programme for all YFVCs. It was expected that training, adherence to standards and access to resources would lead to increased confidence and consistency of practice by YF vaccine providers. EFFECTS OF CHANGE: In 2009, a questionnaire was sent to all YFVCs in EWNI to evaluate the impact of the NaTHNaC programme. Among respondents who attended NaTHNaC training 95.8% of respondents indicated that it improved their confidence about YF vaccination. Furthermore, 68.5% of centres made changes to their practice, and improved adherence to core standards was observed. NEXT STEPS AND LESSONS LEARNED: The NaTHNaC programme has led to improved standards in YFVCs and increased confidence in health professionals who administer the YF vaccine. Although this has not been tested, it is expected that this will translate to more consistent and better care for the international traveller. Elements of the NaTHNaC programme could be a model for improvement of clinical standards and for other countries as they seek to implement IHR (2005) and improve the practice of travel medicine.