Introducing human papillomavirus (HPV) primary testing in the age of HPV vaccination: projected impact on colposcopy services in Wales.

OBJECTIVE: To determine the demand for colposcopy in the Cervical Screening Wales programme after the introduction of human papillomavirus (HPV) cervical screening, which coincided with the start of screening of women vaccinated against HPV types 16/18. DESIGN: The study used a computational model that assigns screening and screening-related colposcopy events to birth cohorts in individual calendar years. SETTING: Cervical Screening Wales. POPULATION: Women aged 25-64 years from birth cohorts 1953-2007. METHODS AND MAIN OUTCOME MEASURES: We estimated the numbers of colposcopies and high-grade cervical intraepithelial lesions (CIN2+) within Cervical Screening Wales in 2018-32, using official population projections for Wales and published estimates of the effects of HPV screening and vaccination. RESULTS: Vaccination will reduce the number of colposcopies by 10% within the first 3-4 years after the national roll-out of HPV screening, and by about 20% thereafter. The number of screening colposcopies is estimated to increase from 6100 in 2018 and peak at 8000 (+31%) in 2021, assuming current screening intervals are maintained. The numbers of CIN2+ lesions follow similar patterns, stabilising at around 1000 diagnoses per year by 2026, approximately 60% lower than at present. Extending the screening intervals to 5 years for all women shows similar trends but introduces peaks and troughs over the years. CONCLUSIONS: Vaccination will not fully prevent an increase in colposcopies and detected CIN2+ lesions during the first 2-3 years of HPV-based screening but the numbers are expected to decrease substantially after 5-6 years. TWEETABLE ABSTRACT: HPV-based cervical screening will initially increase colposcopy referral. In 6 years, this increase will be reversed, partly by HPV vaccination.

Do community pharmacists add value to routine immunization programmes? A review of the evidence from the UK.

Background: Community pharmacies are an important setting for the provision of preventative health services in the UK. There has been debate over the value of delivering routine immunizations in a pharmacy setting, though government policy supports this initiative and in 2015 the first nationally commissioned community pharmacy vaccination service was launched for seasonal influenza vaccination. The impact of these vaccination services needs to be evaluated to inform future policy. Methods: We conducted a comprehensive review of peer-reviewed studies and unpublished evaluations of community pharmacy-based vaccination services implemented in the UK between 2000 and 2015. We assessed evidence of their impact on acceptability, uptake, cost-effectiveness and addressing inequalities. Results: We identified 28 evaluations of pharmacy immunization programmes in the UK, only three of which were published in peer-reviewed journals. These showed no evidence of increased vaccination uptake, and weak evidence of widening access to individuals who had not previously been vaccinated. There was good evidence that pharmacies were acceptable and convenient venues for vaccination. Cost-effectiveness was not assessed in any of the included studies. Conclusions: Our review challenges an assumption that pharmacy provision of immunizations will simultaneously improve patient choice, increase uptake and widen access. These are important findings for policy makers.

Quality of in-hospital care for adults with acute bacterial meningitis: a national retrospective survey.

BACKGROUND: Most adults with bacterial meningitis and meningococcal septicaemia present to junior doctors who have limited experience of these conditions. In contrast to paediatric practice, data from industrialized countries with regard to current hospital management practice are lacking. AIM: To examine whether current practice meets recommended standards in hospital management of community-acquired bacterial meningitis and meningococcal septicaemia among adults. DESIGN: National audit of medical records. METHODS: We conducted a survey of all patients with acute bacterial meningitis and meningococcal septicaemia admitted to 18 randomly selected acute hospitals in England and Wales between 1 January 2000 and 31 December 2001. All stages of care, including pre-hospital management, initial hospital assessment, record keeping, and ongoing hospital and public health management, were assessed. RESULTS: We identified 212 cases of bacterial meningitis and meningococcal septicaemia; 190 cases remained in the final analysis. Clinical record keeping did not meet acceptable standards in 33% of cases. Parenteral antibiotics were given within 1 h of hospital arrival in 56% of cases, increasing to 79% among those with an initial differential diagnosis that included bacterial meningitis or meningococcal septicaemia. A full severity of illness assessment was made in 27%. The quality of clinical practice varied widely between hospitals. This was most pronounced in the timeliness of consultant review (p < 0.0005). DISCUSSION: The quality of adult clinical practice for bacterial meningitis and meningococcal septicaemia needs improvement. This study provides a tool for developing targeted interventions to improve quality of care and outcome among adults with life-threatening infections, both in the UK and in other countries.

Changing epidemiology of bacterial meningitis among adults in England and Wales 1991-2002.

We examined the epidemiology of community-acquired bacterial meningitis among adults in England and Wales between 1991 and 2002. Among 3169 cases, meningococcal infection was predominant among young adults and pneumococcal meningitis among older adults. Whilst infection due to most causes decreased, the incidence of tuberculous (TB) meningitis doubled over the 12 years. The mortality rate among meningococcal and pneumococcal infections fell from 0.45/10(5) to 0.31/10(5) (P=0.0001). This study demonstrates important changes in the epidemiology of bacterial meningitis among UK adults. Improvements in clinical management, childhood vaccination programmes and the re-emergence of tuberculosis are likely to be drivers of these changes.