Infant Hospitalizations and Fatalities Averted by the Maternal Pertussis Vaccination Program in England, 2012-2017: Post-implementation Economic Evaluation.

In October 2012, a maternal pertussis vaccination program was implemented in England following an increased incidence and mortality in infants. We evaluated the cost-effectiveness of the program by comparing pertussis-related infant hospitalizations and deaths in 2012-2017 with nonvaccination scenarios. Despite considerable uncertainties, findings support the cost-effectiveness of the program.

Access of non-specialist sexual health services by men who have sex with men: do they differ from those attending specialist services?

OBJECTIVES: Men who have sex with men (MSM) bear a disproportionate burden of STIs. While routine STI surveillance data suggest MSM regularly access specialist genitourinary medicine (GUM) clinics for their sexual healthcare, the extent to which MSM attend non-specialist sexual health services (SHSs) is unclear. METHODS: We used data from the GUM Clinic Activity Data Set (GUMCADv2), the national STI surveillance system, to compare the characteristics, service usage and STI outcomes of MSM accessing specialist and non-specialist (non-GUM) SHSs in England in 2014. Pearson's χ2, Student's t-test and logistic regression analysis were used. RESULTS: Where sexual orientation was recorded (92%), 11% (4552/41 597) of non-GUM attendances were among MSM compared with 28% (280 466/999 331) of GUM attendances (p<0.001). Compared with those attending GUM services, MSM attending non-GUM services were younger (mean age: 30.2 years vs 37.7 years; p<0.001) and were more likely to be of mixed ethnicity (4.9% vs 3.5%; p<0.001), to have had a full sexual health screen (chlamydia, gonorrhoea, syphilis and HIV tests) (48.0% vs 37.0%; p<0.001) and to be diagnosed with chlamydia (7.4% vs 4.1%; p<0.001) and gonorrhoea (8.5% vs 6.5%: p<0.001). MSM attending non-GUM services had slightly lower HIV test uptake (87.0% vs 95.0%; p=0.157) and were less likely to be diagnosed with HIV (0.5% vs 0.8%; p=0.019), compared with those attending GUM clinics. CONCLUSIONS: Non-specialist SHSs play an important role in the care of MSM and should ensure services meet their needs.

Live attenuated influenza vaccine effectiveness against hospitalisation due to laboratory-confirmed influenza in children two to six years of age in England in the 2015/16 season.

The United Kingdom is introducing a universal annual influenza vaccination programme for children. Live attenuated influenza vaccine (LAIV) effectiveness (VE) against laboratory-confirmed influenza hospitalisation in 2 to 6 year-olds in England was measured in 2015/16 using the screening method. VE adjusted for age, geography and month was 54.5% (95% confidence interval (CI): 31.5% to 68.4%) for all influenza types combined; 48.3% (95% CI: 16.9% to 67.8%) for A(H1N1)pdm09 and 70.6% (95% CI: 33.2% to 87.1%) for B. The findings support on-going programme roll-out.

Filling in the gaps: estimating numbers of chlamydia tests and diagnoses by age group and sex before and during the implementation of the English National Screening Programme, 2000 to 2012.

To inform mathematical modelling of the impact of chlamydia screening in England since 2000, a complete picture of chlamydia testing is needed. Monitoring and surveillance systems evolved between 2000 and 2012. Since 2012, data on publicly funded chlamydia tests and diagnoses have been collected nationally. However, gaps exist for earlier years. We collated available data on chlamydia testing and diagnosis rates among 15-44-year-olds by sex and age group for 2000-2012. Where data were unavailable, we applied data- and evidence-based assumptions to construct plausible minimum and maximum estimates and set bounds on uncertainty. There was a large range between estimates in years when datasets were less comprehensive (2000-2008); smaller ranges were seen hereafter. In 15-19-year-old women in 2000, the estimated diagnosis rate ranged between 891 and 2,489 diagnoses per 100,000 persons. Testing and diagnosis rates increased between 2000 and 2012 in women and men across all age groups using minimum or maximum estimates, with greatest increases seen among 15-24-year-olds. Our dataset can be used to parameterise and validate mathematical models and serve as a reference dataset to which trends in chlamydia-related complications can be compared. Our analysis highlights the complexities of combining monitoring and surveillance datasets.

Participatory Syndromic Surveillance of Influenza in Europe.

The growth of digital communication technologies for public health is offering an unconventional means to engage the general public in monitoring community health. Here we present Influenzanet, a participatory system for the syndromic surveillance of influenza-like illness (ILI) in Europe. Through standardized online surveys, the system collects detailed profile information and self-reported symptoms volunteered by participants resident in the Influenzanet countries. Established in 2009, it now includes 10 countries representing more than half of the 28 member states of the European Union population. The experience of 7 influenza seasons illustrates how Influenzanet has become an adjunct to existing ILI surveillance networks, offering coherence across countries, inclusion of nonmedically attended ILI, flexibility in case definition, and facilitating individual-level epidemiological analyses generally not possible in standard systems. Having the sensitivity to timely detect substantial changes in population health, Influenzanet has the potential to become a viable instrument for a wide variety of applications in public health preparedness and control.

Increase in Sexually Transmitted Infections among Men Who Have Sex with Men, England, 2014.

Surveillance data from sexual health clinics indicate recent increases in sexually transmitted infections, particularly among men who have sex with men. The largest annual increase in syphilis diagnoses in a decade was reported in 2014. Less condom use may be the primary reason for these increases.

Identifying and interpreting spatiotemporal variation in diagnoses of infectious syphilis among men, England: 2009 to 2013.

OBJECTIVES: Spatial clusters and variations in the trajectory of local epidemics were explored in relation to sexual orientation, demographic factors, stage of syphilis infection and HIV serostatus. METHODS: Kulldorff's scan statistics (SaTScan) was used to distinguish endemic and temporary clusters using a two-stage analysis. RESULTS: Endemic areas were found in London, Manchester, Brighton and Blackpool. Up to 40% of diagnoses were found within an 11 km radius of central London. Of men diagnosed with syphilis in London, 80% were men who have sex with men (MSM). Annual incidence in London increased from 24 cases (95% CI 23 to 26) per 100 000 male population in 2009 to 36 cases (95% CI 34 to38) in 2013. In comparison with clusters, endemic areas were characterised by a significantly higher (p<0.05) proportion of MSM (83% compared with 73%), increased HIV positivity (41% vs 15%), age 35 to 44 years (34% vs 23%), a lower proportion of patients born in the UK (50% vs 79%) and a lower proportion of primary stage infection (40% vs 47%). Space-time clusters outside endemic areas occurred in urban and rural areas and diagnoses fluctuated below 10 per month. Exponential increases in diagnoses resembling point source outbreaks were seen at two locations. CONCLUSION: Control of syphilis in endemic areas has proved elusive and clusters present unique intervention opportunities. Investigating the diversity of local epidemics provides information that can be used to predict outbreak structure, plan and evaluate sexual health services and guide public health investigation, hypothesis generation and research.

Epidemiology of Sexually Transmitted Infections in Visitors for the London 2012 Olympic Games: A Review of Attendees at Sexual Health Services.

BACKGROUND: Mass gatherings and large sporting events, such as the Olympics, may potentially pose a risk of increased sexually transmitted infection (STI) transmission and increase burden on local STI services. The objectives of this analysis were to assess whether the STI profile of Olympic visitors differed from that of the local STI clinic population and to investigate what impact these visitors had on local STI services. METHODS: Self-administered questionnaires (completed by 29,292 patients) were used to determine the visitor status of patients attending 20 STI clinics, between July 20, 2012, and September 16, 2012, in the host cities, London and Weymouth. Using routine surveillance data from the Genitourinary Medicine Clinic Activity Dataset version 2, Olympic visitors were compared with usual attendees (local residents and non-Olympic visitors) in terms of their demographic characteristics, services utilized, and STIs diagnosed using univariate and multivariate methods. RESULTS: Compared with usual attendees, Olympic visitors were more likely to be heterosexual males (56.0% vs. 34.9%, P = 0.001), aged between 15 and 24 years of age (47.1% vs. 34.0%, P = 0.001), of white ethnicity (81.9% vs. 66.4%, P = 0.001), and born in Australasia, Asia, North America, or South America (18.8% vs. 12.0%, P = 0.006). Olympic visitors constituted 1% of new clinic attendances and were less likely to be diagnosed as having a new STI (adjusted odds ratio, 0.69; 95% confidence interval, 0.48-0.98; P = 0.040). CONCLUSIONS: In this first multisite study to examine the effect of Olympic visitors on local sexual health services, the 2012 Olympic Games was found to have minimal impact. This suggests that a "business as usual" approach would have been sufficient.

Internet testing for Chlamydia trachomatis in England, 2006 to 2010.

BACKGROUND: In recent years there has been interest in websites as a means of increasing access to free chlamydia tests through the National Chlamydia Screening Programme (NCSP) in England. We aimed to describe and evaluate online access to chlamydia testing within the NCSP. METHODS: We analysed NCSP chlamydia testing data (2006-2010) for 15-24 year olds from the 71/95 programme areas in England where site codes were available to identify tests ordered through the internet. The characteristics of people using online testing services in 2010 were compared with those testing in general practice (GP) or community sexual and reproductive health (SRH) services. We evaluated 58 websites offering free chlamydia tests through the NCSP, and 32 offering kits on a commercial basis for signposting to clinical service and health promotion advice offered. RESULTS: Between 2006 and 2010, 5% of all tests in the included programme areas were accessed through the internet. The number of internet tests increased from 18 (<1% of all tests) in 2006 to 59,750 in 2010 (6% of all NCSP tests). In 2010 the proportion of NCSP tests accessed online by programme area ranged from <1% to 38%. The proportion of tests with a positive result on the internet was higher than tests from general practice and comparable to those from community SRH services (internet 7.6%; GP 5.6%; Community SRH 8.2%). A higher proportion of people accessing online testing were male, aged 20-24 and reported >1 sexual partner in the past year. Provision of sexual health information and appropriate signposting for those in need of clinical services varied between websites. Service provision within the NCSP was fragmented with multiple providers serving specific geographical catchment areas. CONCLUSION: Internet testing reaches a population with a relatively high risk of chlamydia infection and appears acceptable to young men, a group that has been difficult to engage with chlamydia testing. In order to maximise the potential benefit of these services, websites should be consistent with national guidelines and adhere to minimum standards for signposting to clinical care and health promotion information. The current system with multiple providers servicing geographically specific catchment areas is contrary to the geographically unrestricted nature of the internet and potentially confusing for clients.

Effectiveness of oral aciclovir in preventing maternal chickenpox: A comparison with VZIG.

OBJECTIVES: Although often presenting as a self-limiting childhood disease, chickenpox can have serious consequences if acquired in pregnancy. Until April 2022, the UK recommendations were that varicella immunoglobulin (VZIG) should be administered intramuscularly to susceptible pregnant women exposed to chickenpox prior to 20 weeks gestation. Oral aciclovir or VZIG was recommended if exposure occurred at 20+ weeks gestation. Our objective was to compare the effectiveness of oral aciclovir to VZIG in preventing maternal and neonatal chickenpox. METHODS: We identified and followed up 186 pregnant women who were exposed to chickenpox and compared their outcomes. RESULTS: 171/186 (91.9%) of these women received either VZIG or oral aciclovir. Of the 145 women who received VZIG, 53/145 (36.6%) went on to develop chickenpox compared to 8 of the 26 (30.8%) women who received oral aciclovir (p = 0.32). No statistical difference was found between the oral aciclovir and VZIG groups even after controlling for maternal age, gestational stage, type of exposure and IgG titre (adjusted OR:0.83; 95%CI:0.26-2.65; p = 0.75). CONCLUSIONS: These findings support the use of oral aciclovir as first-line prophylaxis in pregnant women exposed to varicella as they suggest its effectiveness at preventing maternal chickenpox is either better or equal to VZIG.

Evaluating the impact of a continued maternal pertussis immunisation programme in England: A modelling study and cost-effectiveness analysis.

INTRODUCTION: An unexpected resurgence of pertussis cases and infant deaths was observed in some countries that had switched to acellular pertussis vaccines in the primary immunisation schedule. In response to the outbreaks, maternal pertussis vaccination programmes in pregnant women have been adopted worldwide, including the USA in 2011 and the UK in 2012. Following the success of the programme in England, we evaluated the health and economic impact of stopping versus continuing the maternal pertussis immunisation to inform public health policy making. METHODS: We used a mathematical model to estimate the number of infant hospitalisations and deaths related to pertussis in England over 2019-2038. Losses in quality-adjusted life years, QALYs, were considered for infants (aged 0-2 months) who survived or died from pertussis, bereaved parents (of infants who died from pertussis), and women with pertussis (aged 20-44 years). Direct medical costs to the National Health Service included infant hospitalisations, maternal vaccinations, and disease in women. Costs and QALYs were discounted at 3.5%. Changes in the incremental cost-effectiveness ratio, ICER, were explored in sensitivity analyses. RESULTS: The model supports continuing the maternal pertussis immunisation programme as a cost-effective intervention at an ICER of £14,500/QALY (2.5% and 97.5%-quantile: £7,300/QALY to £32,400/QALY). Stopping versus continuing the maternal programme results in an estimated mean of 972 (range 582 to 1489) versus 308 (184 to 471) infant hospitalisations annually. Results were most sensitive to the number of hospitalisations and deaths when stopping the maternal programme. At a cost-effectiveness threshold of £30,000/QALY, the probability of the maternal programme being cost-effective was 96.2%. CONCLUSION: Our findings support continuing the maternal pertussis vaccination programme as otherwise higher levels of disease activity and infant mortality are expected to return. These results have led policy makers to decide to continue the maternal programme in the UK routine immunisation schedule.

Impact of the herpes zoster vaccination programme on hospitalised and general practice consulted herpes zoster in the 5 years after its introduction in England: a population-based study.

OBJECTIVES: To assess the impact of herpes zoster vaccination in the 5 years after introduction for 70- to 79-year-olds in England in September 2013. DESIGN: Population based ecological impact assessment. SETTING: Hospitals covering the whole English population for the period 2008 to 2018 and 293 general practices (GP) for the period 2005 to 2018, in England. PARTICIPANTS: Over the period the population contributed 117·5 million person-years for hospitalisation events and 6.96 million person-years for GP events in individuals aged 60 to 89. INTERVENTIONS: Live attenuated herpes zoster vaccination (Zostavax), first used on 1st September 2013, in 70- and 79-year-olds with continued use in new 70 year-olds and with a staged catch-up of those aged 71 to 78 years in 2013. OUTCOME MEASURES: Herpes zoster and postherpetic neuralgia (PHN) consultation and hospitalisation rates in age-cohorts according to vaccine eligibility. Incidence rate ratios in age-cohorts eligible for vaccination compared with those non-eligible were calculated by Poisson regression. This was used to estimate prevented cases and, along with vaccine coverage, to estimate vaccine effectiveness. RESULTS: Large and prolonged reductions in herpes zoster and PHN consultations and hospitalisations were observed in the 5 years post-implementation. For example, in 79 year-olds first eligible in 2013, the incidence rate ratio for consultations 5 years later was 0·65 (95% CI: 0·52 to 0·81). Over the whole period an estimated 40 500 fewer zoster consultations and 1840 fewer zoster hospitalisations occurred because of the vaccination programme. These reductions were consistent with effectiveness in the routine cohorts (vaccinated aged 70) of between 37% (for hospitalised zoster) and 75% (for PHN consultations) and, in catch up cohorts (vaccinated aged 78 to 79) of between 49% (for hospitalised PHN) and 66% (for PHN consultations). CONCLUSION: Given the clear and sustained impact of herpes zoster vaccination over the 5-year period since introduction, optimising vaccination coverage is important to attain maximum benefit.

Spatial clusters of gonorrhoea in England with particular reference to the outcome of partner notification: 2012 and 2013.

BACKGROUND: This study explored spatial-temporal variation in diagnoses of gonorrhoea to identify and quantify endemic areas and clusters in relation to patient characteristics and outcomes of partner notification (PN) across England, UK. METHODS: Endemic areas and clusters were identified using a two-stage analysis with Kulldorff's scan statistics (SaTScan). RESULTS: Of 2,571,838 tests, 53,547 diagnoses were gonorrhoea positive (positivity = 2.08%). The proportion of diagnoses in heterosexual males was 1.5 times that in heterosexual females. Among index cases, men who have sex with men (MSM) were 8 times more likely to be diagnosed with gonorrhoea than heterosexual males (p<0.0001). After controlling for age, gender, ethnicity and deprivation rank, 4 endemic areas were identified including 11,047 diagnoses, 86% of which occurred in London. 33 clusters included 17,629 diagnoses (34% of total diagnoses in 2012 and 2013) and spanned 21 locations, some of which were dominated by heterosexually acquired infection, whilst others were MSM focused. Of the 53,547 diagnoses, 14.5% (7,775) were the result of PN. The proportion of patients who attended services as a result of PN varied from 0% to 61% within different age, gender and sexual orientation cohorts. A third of tests resulting from PN were positive for gonorrhoea. 25% of Local Authorities (n = 81, 95% CI: 20.2, 29.5) had a higher than expected proportion for female PN diagnoses as compared to 16% for males (n = 52, 95% CI: 12.0, 19.9). CONCLUSIONS: The English gonorrhoea epidemic is characterised by spatial-temporal variation. PN success varied between endemic areas and clusters. Greater emphasis should be placed on the role of PN in the control of gonorrhoea to reduce the risk of onward transmission, re-infection, and complications of infection.

'We All Work Together to Vaccinate the Child': A Formative Evaluation of a Community-Engagement Strategy Aimed at Closing the Immunization Gap in North-West Ethiopia.

The role of community engagement (CE) in improving demand for immunization merits investigation. The International Rescue Committee developed a CE strategy to implement a vaccine defaulter-tracing tool and a color-coded health calendar aimed at increasing uptake of immunization services in north-west Ethiopia ('The Fifth Child Project'). We report findings from a formative evaluation of this project. In May/June 2016 we conducted 18 participant observations of project activities, 46 semi-structured interviews and 6 focus groups with caregivers, health workers, community members/leaders. Audio-recordings and fieldnotes were transcribed, anonymized, translated and analyzed thematically using inductive and deductive coding. Additional data was collected in November 2016 to verify findings. The project was suitably integrated within the health extension program and established a practical system for defaulter-tracing. The calendar facilitated personalized interactions between health workers and caregivers and was a catalyst for health discussions within homes. At the community level, a regulation exercise of sanctions was observed, which served as a deterrent against vaccine default. Pre-existing community accountability mechanisms supported the CE, although varying levels of engagement between leaders and health workers were observed. The benefits of shared responsibility for immunization were evident; however, more transparency was required about community self-regulatory measures to ensure health-related discussions remain positive.