Emergency department attendances and inpatient admissions due to mpox infection, England, 2022.

OBJECTIVES: In 2022, a global outbreak of mpox was reported. In the UK, it predominantly affected gay, bisexual and men who have sex with men (GBMSM). The study objectives were to describe the impact of the mpox outbreak on healthcare service usage in England in 2022, particularly emergency department (ED) attendance, inpatient admission and a number of bed days. Additionally, we wanted to explore whether pre-exposure prophylaxis (PrEP) usage, as a marker of condomless anal intercourse, which increases the risk of sexually transmitted infections associated with compromised skin integrity, was associated with higher ED attendance or hospital attendance. METHODS: Data on adult males with laboratory-confirmed mpox were linked with hospital records and described. Using routinely collected data and self-reported exposure data (including PrEP usage) from surveillance questionnaires, multinomial regression was used to estimate adjusted relative risk ratios (aRRRs) with 95% CIs for ED attendance and hospital admission compared with those not admitted. RESULTS: Among 3542 adult males with mpox during May to December 2022, 544 (15.4%) attended ED and 202 (5.7%) were admitted to the hospital. London had the most cases (2393, 68.7%), ED attendances (391, 71.9%) and hospital admissions (121, 59.9%). In multinomial regression, we found strong evidence that compared with people living with HIV, the aRRR for hospital admissions was higher in those not using PrEP (6.9 (95% CI 2.3 to 20.6) vs 4.9 (95% CI 1.7 to 14.1)). The aRRR for ED attendance was 0.63 (95% CI 0.36 to 1.1) for those not using PrEP versus 0.49 (95% CI 0.31 to 0.79). CONCLUSIONS: This outbreak had a considerable impact on health services, particularly in high-incidence areas. Commissioners of sexual and healthcare services should review plans for healthcare provision for similar sexually transmitted infection or novel outbreaks among GBMSM or naïve populations in the future. Further studies are needed to confirm and identify reasons for the higher likelihood of hospital admission seen for GBMSM without HIV infection.

Attribution of nosocomial seeding to long-term care facility COVID-19 outbreaks.

Residents of long-term care facilities (LTCFs) were disproportionately affected by the COVID-19 pandemic. We assessed the extent to which hospital-associated infections contributed to COVID-19 LTCF outbreaks in England. We matched addresses of cases between March 2020 and June 2021 to reference databases to identify LTCF residents. Linkage to health service records identified hospital-associated infections, with the number of days spent in hospital before positive specimen date used to classify these as definite or probable. Of 149,129 cases in LTCF residents during the study period, 3,748 (2.5%) were definite or probable hospital-associated and discharged to an LTCF. Overall, 431 (0.3%) were identified as index cases of potentially nosocomial-seeded outbreaks (2.7% (431/15,797) of all identified LTCF outbreaks). These outbreaks involved 4,521 resident cases and 1,335 deaths, representing 3.0% and 3.6% of all cases and deaths in LTCF residents, respectively. The proportion of outbreaks that were potentially nosocomial-seeded peaked in late June 2020, early December 2020, mid-January 2021, and mid-April 2021. Nosocomial seeding contributed to COVID-19 LTCF outbreaks but is unlikely to have accounted for a substantial proportion. The continued identification of such outbreaks after the implementation of preventative policies highlights the challenges of preventing their occurrence.

Influence of SARS-CoV-2 surveillance outputs produced by the UK health security agency (UKHSA) outbreak surveillance team on decision-making by local stakeholders.

BACKGROUND: The UK Health Security Agency (UKHSA) COVID-19 Outbreak Surveillance Team (OST) was established in June 2020 to provide Local Authorities (LAs) in England with surveillance intelligence to aid their response to the SARS-CoV-2 epidemic. Reports were produced using standardised metrics in an automated format. Here we evaluate how the SARS-CoV-2 surveillance reports influenced decision making, how resources evolved and how they could be refined to meet the requirements of stakeholders in the future. METHODS: Public health professionals (n = 2,400) involved in the COVID-19 response from the 316 English LAs were invited to take part in an online survey. The questionnaire covered five themes: (i) report use; (ii) influence of surveillance outputs on local intervention strategies; (iii) timeliness; (iv) current and future data requirements; and (v) content development. RESULTS: Of the 366 respondents to the survey, most worked in public health, data science, epidemiology, or business intelligence. Over 70% of respondents used the LA Report and Regional Situational Awareness Report daily or weekly. The information had been used by 88% to inform decision making within their organisations and 68% considered that intervention strategies had been instituted as a result of these decisions. Examples of changes instigated included targeted communications, pharmaceutical and non-pharmaceutical interventions, and the timing of interventions. Most responders considered that the surveillance content had reacted well to evolving demands. The majority (89%) said that their information requirements would be met if the surveillance reports were incorporated into the COVID-19 Situational Awareness Explorer Portal. Additional information suggested by stakeholders included vaccination and hospitalisation data as well as information on underlying health conditions, infection during pregnancy, school absence and wastewater testing. CONCLUSIONS: The OST surveillance reports were a valuable information resource used by local stakeholders in their response to the SARS-CoV-2 epidemic. Control measures that affect disease epidemiology and monitoring requirements need to be considered in the continuous maintenance of surveillance outputs. We identified areas for further development and, since the evaluation, information on repeat infections and vaccination data have been included in the surveillance reports. Furthermore, timeliness of publications has been improved by updating the data flow pathways.

The contribution of hospital-acquired infections to the COVID-19 epidemic in England in the first half of 2020.

BACKGROUND: SARS-CoV-2 is known to transmit in hospital settings, but the contribution of infections acquired in hospitals to the epidemic at a national scale is unknown. METHODS: We used comprehensive national English datasets to determine the number of COVID-19 patients with identified hospital-acquired infections (with symptom onset > 7 days after admission and before discharge) in acute English hospitals up to August 2020. As patients may leave the hospital prior to detection of infection or have rapid symptom onset, we combined measures of the length of stay and the incubation period distribution to estimate how many hospital-acquired infections may have been missed. We used simulations to estimate the total number (identified and unidentified) of symptomatic hospital-acquired infections, as well as infections due to onward community transmission from missed hospital-acquired infections, to 31st July 2020. RESULTS: In our dataset of hospitalised COVID-19 patients in acute English hospitals with a recorded symptom onset date (n = 65,028), 7% were classified as hospital-acquired. We estimated that only 30% (range across weeks and 200 simulations: 20-41%) of symptomatic hospital-acquired infections would be identified, with up to 15% (mean, 95% range over 200 simulations: 14.1-15.8%) of cases currently classified as community-acquired COVID-19 potentially linked to hospital transmission. We estimated that 26,600 (25,900 to 27,700) individuals acquired a symptomatic SARS-CoV-2 infection in an acute Trust in England before 31st July 2020, resulting in 15,900 (15,200-16,400) or 20.1% (19.2-20.7%) of all identified hospitalised COVID-19 cases. CONCLUSIONS: Transmission of SARS-CoV-2 to hospitalised patients likely caused approximately a fifth of identified cases of hospitalised COVID-19 in the "first wave" in England, but less than 1% of all infections in England. Using time to symptom onset from admission for inpatients as a detection method likely misses a substantial proportion (> 60%) of hospital-acquired infections.

Outbreak of Clostridium perfringens food poisoning linked to leeks in cheese sauce: an unusual source.

Between 11-13 December 2018, local public health authorities in the West Midlands, England were alerted to 34 reports of diarrhoea with abdominal cramps. Symptom onset was ~10 h after diners ate Christmas meals at a restaurant between 7-9 December 2018. A retrospective case-control study, environmental and microbiological investigations were undertaken to determine the source and control the outbreak. An analytical study was undertaken with odds ratios (OR) and 95% confidence intervals (CI). Forty persons were recruited to the analytical study (28/40 cases). Multivariable analysis found that leeks in cheese sauce was the only item associated with illness (aOR 51.1; 95% CI 4.13-2492.1). Environmental investigations identified significant lapses in food safety, including lapses in temperature control during cooking and hot holding, likely cross-contamination between raw and cooked foods and the reuse of leftover cheese sauce for the next day's service. No food samples were taken during the exposure period. Two faecal samples were positive for Clostridium perfringens with one confirming the enterotoxigenic gene. Cheese sauce is an unusual vehicle for the organism and the first time this has been reported in England.

Improving feedback of surveillance data on antimicrobial consumption, resistance and stewardship in England: putting the data at your Fingertips.

The provision of better access to and use of surveillance data is a key component of the UK 5 Year Antimicrobial Resistance (AMR) Strategy. Since April 2016, PHE has made data on practice (infection prevention and control; antimicrobial stewardship) and outcome (prevalence of AMR, antibiotic use and healthcare-associated infections) available through Fingertips, a publicly accessible web tool (https://fingertips.phe.org.uk/profile/amr-local-indicators). Fingertips provides access to a wide range of public health data presented as thematic profiles, with the above data being available through the 'AMR local indicators' profile. Local data on a range of indicators can be viewed at the level of National Health Service acute trusts, Clinical Commissioning Groups or general practitioner practices, all of which can be compared with the corresponding aggregate values for England to allow benchmarking. The data can be viewed in a range of formats including an overview showing counts and rates, interactive maps, spine charts and graphs that show temporal trends over a range of time scales or allow correlations between pairs of indicators. The aim of the AMR local indicators profile on Fingertips is to support the development of local action plans to optimize antibiotic prescribing and reduce AMR and healthcare-associated infections. Provision of access to relevant information in an easy to use format will help local stakeholders, including healthcare staff, commissioners, Directors of Public Health, academics and the public, to benchmark relevant local AMR data and to monitor the impact of local initiatives to tackle AMR over time.

A process evaluation of the UK-wide Antibiotic Guardian campaign: developing engagement on antimicrobial resistance.

Background: Public Health England developed and led a new UK-wide pledge campaign aiming to improve behaviours around the prudent use and prescription of antibiotics. This paper presents a process evaluation for the first season of the campaign to determine the impact of the campaign and inform future campaigns. Methods: Data were collected from AntibioticGuardian.com and Google analytics between August 2014 and January 2015. The primary outcome was the decision to pledge and was assessed according to target audience, location, source and route of referral to the website. Results: There were 47 158 unique visits to the website and 12 509 visitors made a pledge (26.5%) to become Antibiotic Guardians (AGs); 69% were healthcare professionals. Social media directed the most traffic to the website (24% of the public that signed up cited social media as how they discovered the campaign), other acquisition routes such as self-directed, email or website referral, were more effective at encouraging visitors to pledge. Conclusions: The campaign completed its goal of 10 000 AGs in the first year. Further work is required to improve engagement with target audiences and determine whether this campaign has an impact on antibiotic consumption and prescribing behaviour among the public and healthcare professionals.

The Antibiotic Guardian campaign: a qualitative evaluation of an online pledge-based system focused on making better use of antibiotics.

BACKGROUND: The Antibiotic Guardian Campaign was developed to increase commitment to reducing Antimicrobial Resistance (AMR), change behaviour and increase knowledge through an online pledge system for healthcare professionals and members of the public to become Antibiotic Guardians (AG). This qualitative evaluation aimed to understand AG experiences of the campaign and perceived impact on behaviour. METHODS: Ninety-four AGs (48 via a survey and 46 who had agreed to future contact) were invited to participate in a telephone semi-structured interview. The sample was based on self-identification as a healthcare professional or a member of the public, pledge group (e.g. adults, primary care prescribers etc.), pledge and gender. Interviews explored how participants became aware of the campaign, reasons for joining, pledge choices, responses to joining and views about the campaign's implementation. Interviews were analysed using the Framework Method. RESULTS: Twenty-two AGs (10 healthcare professionals and 12 members of the public) were interviewed. AGs became aware of the campaign through professional networks and social media, and were motivated to join by personal and professional concern for AMR. Choice of pledge group and pledge were attributed to relevance and potential impact on AMR and the behaviour of others through pledge enactment and promotion of the campaign. Most AGs could not recall their pledge unprompted. Most felt they fulfilled their pledge, although this reflected either behaviour change or the pledge reinforcing pre-existing behaviour. The campaign triggered AGs to reflect on AMR related behaviour and reinforced pre-existing beliefs. Several AGs promoted the campaign to others. Responding collectively as part of the campaign was thought to have a greater impact than individual action. However, limited campaign visibility was observed and the campaign was perceived to have restricted ability to reach those unaware of AMR. CONCLUSIONS: AGs were motivated to reduce AMR and most felt they fulfilled their pledges although for many this appeared to be through reinforcement of existing behaviours. We recommend that the campaign engages those without pre-existing knowledge of AMR by increasing its visibility, capitalising on the diffusion of its message and including more awareness-raising content for those with limited AMR knowledge.

Impact of a United Kingdom-wide campaign to tackle antimicrobial resistance on self-reported knowledge and behaviour change.

BACKGROUND: As part of the 2014 European Antibiotic Awareness Day plans, a new campaign called Antibiotic Guardian (AG) was launched in the United Kingdom, including an online pledge system to increase commitment from healthcare professionals and members of the public to reduce antimicrobial resistance (AMR). The aim of this evaluation was to determine the impact of the campaign on self-reported knowledge and behaviour around AMR. METHODS: An online survey was sent to 9016 Antibiotic Guardians (AGs) to assess changes in self-reported knowledge and behaviour (outcomes) following the campaign. Logistic regression models, adjusted for variables including age, sex and pledge group (pledging as member of public or as healthcare professional), were used to estimate associations between outcomes and AG characteristics. RESULTS: 2478 AGs responded to the survey (27.5 % response rate) of whom 1696 (68.4 %) pledged as healthcare professionals and 782 (31.6 %) as members of public (similar proportions to the total number of AGs). 96.3 % of all AGs who responded had prior knowledge of AMR. 73.5 % of participants were female and participants were most commonly between 45 and 54 years old. Two thirds (63.4 %) of participants reported always acting according to their pledge. Members of the public were more likely to act in line with their pledge than professionals (Odds Ratio (OR) =3.60, 95 % Confidence Interval (CI): 2.88-4.51). Approximately half of participants (44.5 %) (both healthcare professionals and members of public) reported that they acquired more knowledge about AMR post-campaign. People that were confused about AMR prior to the campaign acquired more knowledge after the campaign (OR = 3.10, 95 % CI: 1.36-7.09). More participants reported a sense of personal responsibility towards tackling AMR post-campaign, increasing from 58.3 % of participants pre-campaign to 70.5 % post-campaign. CONCLUSION: This study demonstrated that the campaign increased commitment to tackling AMR in both healthcare professional and member of the public, increased self-reported knowledge and changed self-reported behaviour particularly among people with prior AMR awareness. Online pledge schemes can be an effective and inexpensive way to engage people with the problem of AMR especially among those with prior awareness of the topic.

Quantifying the contribution of pathways of nosocomial acquisition of COVID-19 in English hospitals.

BACKGROUND: Despite evidence of the nosocomial transmission of novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in hospitals worldwide, the contributions of the pathways of transmission are poorly quantified. METHODS: We analysed national records of hospital admissions and discharges, linked to data on SARS-CoV-2 testing, using an individual-based model that considers patient-to-patient, patient-to-healthcare worker (HCW), HCW-to-patient and HCW-to-HCW transmission. RESULTS: Between 1 March 2020 and 31 December 2020, SARS-CoV-2 infections that were classified as nosocomial were identified in 0.5% (0.34-0.74) of patients admitted to an acute National Health Service trust. We found that the most likely route of nosocomial transmission to patients was indirect transmission from other infected patients, e.g. through HCWs acting as vectors or contaminated fomites, followed by direct transmission between patients in the same bay. The risk of transmission to patients from HCWs over this time period is low, but can contribute significantly when the number of infected inpatients is low. Further, the risk of a HCW acquiring SARS-CoV-2 in hospital is approximately equal to that in the community, thereby doubling their overall risk of infection. The most likely route of transmission to HCWs is transmission from other infected HCWs. CONCLUSIONS: Current control strategies have successfully reduced the transmission of SARS-CoV-2 between patients and HCWs. In order to reduce the burden of nosocomial COVID-19 infections on health services, stricter measures should be enforced that would inhibit the spread of the virus between bays or wards in the hospital. There should also be a focus on inhibiting the spread of SARS-CoV-2 between HCWs. The findings have important implications for infection-control procedures in hospitals.

The contribution of hospital-acquired infections to the COVID-19 epidemic in England in the first half of 2020.

Background SARS-CoV-2 is known to transmit in hospital settings, but the contribution of infections acquired in hospitals to the epidemic at a national scale is unknown. Methods We used comprehensive national English datasets to determine the number of COVID-19 patients with identified hospital-acquired infections (with symptom onset >7 days after admission and before discharge) in acute English hospitals up to August 2020. As patients may leave the hospital prior to detection of infection or have rapid symptom onset, we combined measures of the length of stay and the incubation period distribution to estimate how many hospital-acquired infections may have been missed. We used simulations to estimate the total number (identified and unidentified) of symptomatic hospital-acquired infections, as well as infections due to onward community transmission from missed hospital-acquired infections, to 31 st July 2020. Results In our dataset of hospitalised COVID-19 patients in acute English hospitals with a recorded symptom onset date (n = 65,028), 7% were classified as hospital-acquired. We estimated that only 30% (range across weeks and 200 simulations: 20-41%) of symptomatic hospital-acquired infections would be identified, with up to 15% (mean, 95% range over 200 simulations: 14.1%-15.8%) of cases currently classified as community-acquired COVID-19 potentially linked to hospital transmission. We estimated that 26,600 (25,900 to 27,700) individuals acquired a symptomatic SARS-CoV-2 infection in an acute Trust in England before 31st July 2020, resulting in 15,900 (15,200-16,400) or 20.1% (19.2%-20.7%) of all identified hospitalised COVID-19 cases. Conclusions Transmission of SARS-CoV-2 to hospitalised patients likely caused approximately a fifth of identified cases of hospitalised COVID-19 in the "first wave" in England, but less than 1% of all infections in England. Using time to symptom onset from admission for inpatients as a detection method likely misses a substantial proportion (>60%) of hospital-acquired infections.

The impact of testing and infection prevention and control strategies on within-hospital transmission dynamics of COVID-19 in English hospitals.

Nosocomial transmission of SARS-CoV-2 is a key concern, and evaluating the effect of testing and infection prevention and control strategies is essential for guiding policy in this area. Using a within-hospital SEIR transition model of SARS-CoV-2 in a typical English hospital, we estimate that between 9 March 2020 and 17 July 2020 approximately 20% of infections in inpatients, and 73% of infections in healthcare workers (HCWs) were due to nosocomial transmission. Model results suggest that placing suspected COVID-19 patients in single rooms or bays has the potential to reduce hospital-acquired infections in patients by up to 35%. Periodic testing of HCWs has a smaller effect on the number of hospital-acquired COVID-19 cases in patients, but reduces infection in HCWs by as much as 37% and results in only a small proportion of staff absences (approx. 0.3% per day). This is considerably less than the 20-25% of staff that have been reported to be absent from work owing to suspected COVID-19 and self-isolation. Model-based evaluations of interventions, informed by data collected so far, can help to inform policy as the pandemic progresses and help prevent transmission in the vulnerable hospital population. This article is part of the theme issue 'Modelling that shaped the early COVID-19 pandemic response in the UK'.

Healthcare-associated COVID-19 in England: A national data linkage study.

OBJECTIVES: Nosocomial transmission was an important aspect of SARS-CoV-1 and MERS-CoV outbreaks. Healthcare-associated SARS-CoV-2 infection has been reported in single and multi-site hospital-based studies in England, but not nationally. METHODS: Admission records for all hospitals in England were linked to SARS-CoV-2 national test data for the period 01/03/2020 to 31/08/2020. Case definitions were: community-onset community-acquired, first positive test <14 days pre-admission, up to day 2 of admission; hospital-onset indeterminate healthcare-associated, first positive on day 3-7; hospital-onset probable healthcare-associated, first positive on day 8-14; hospital-onset definite healthcare-associated, first positive from day 15 of admission until discharge; community-onset possible healthcare-associated, first positive test ≤14 days post-discharge. RESULTS: One-third (34.4%, 100,859/293,204) of all laboratory-confirmed COVID-19 cases were linked to a hospital record. Hospital-onset probable and definite cases represented 5.3% (15,564/293,204) of all laboratory-confirmed cases and 15.4% (15,564/100,859) of laboratory-confirmed cases among hospital patients. Community-onset community-acquired and community-onset possible healthcare-associated cases represented 86.5% (253,582/293,204) and 5.1% (14,913/293,204) of all laboratory-confirmed cases, respectively. CONCLUSIONS: Up to 1 in 6 SARS-CoV-2 infections among hospitalised patients with COVID-19 in England during the first 6 months of the pandemic could be attributed to nosocomial transmission, but these represent less than 1% of the estimated 3 million COVID-19 cases in this period.