Designing, piloting and evaluating (through a matched pre- and post-implementation survey) a targeted e-learning resource on antimicrobial resistance for public health professionals.

BACKGROUND: Antimicrobial resistance (AMR) is a significant global public health threat and key priority for the public health, especially health protection, workforce to lead by example. There is a paucity of learning resources on this for public health professionals (PHPs) in the UK. This project aimed to develop and disseminate a tailored interactive learning resource and evaluate impact on self-reported intention to change behaviour. METHODS: Learning objectives were agreed, content developed by the multi-disciplinary team and piloted by PHPs in 2022 alongside a matched pre- and post-implementation evaluation survey. Questions were mapped to the capability-opportunity-motivation-behaviour change model. Before and after responses were calculated to compare change in self-reported knowledge, understanding and behaviour. Significance of change in binary responses was estimated. RESULTS: The resource was delivered using an interactive, user-friendly and cost-free internal platform. Thirty-one PHPs completed the pilot e-learning and survey. Perceived and actual knowledge increased in parallel. Actual knowledge on AMR burden increased from 6.45 to 35.48% (P = 0.004). Self-reported confidence to explain AMR to others improved by 0.71 (95% CI; 0.38-1.04: P = 0.0001) Likert points on a five-point scale. Motivation to advocate for antimicrobial stewardship (AMS) in day-to-day work, improved by 0.71 (95% CI; 0.34-1.08: P < 0.00001) Likert points. Case scenarios were well-received as an effective way to apply theory to practice. CONCLUSION: Ensuring a well-informed and confident public health workforce is vital for reducing the AMR threat and advocating for AMS with the public and partner organizations. This targeted e-learning module is an effective additional learning medium in contributing to PHPs knowledge, understanding and self-reported intention to change behaviours.

Factors associated with return of home oral fluid kits by suspected cases of measles, cohort study, London and South East of England, 2016-2018.

A testing rate for measles above 80% is required by the WHO European Region Measles Elimination strategy to verify elimination. To comply with this rate, we explored factors associated with the return of oral fluid kits (OFK) by suspected measles cases. We described the cases and conducted a mixed-effects analysis to assess the relationship between socio-demographic and public health management characteristics and the likelihood of returning an OFK to the reference laboratory. Of 3,929 cases who were sent a postal OFK, 2,513 (67%) returned the kit. Adjusting for confounding, registration with a general practitioner (GP) (aOR:1.48, 95%CI:1.23-1.76) and living in a less deprived area (aOR:1.35, 95%CI:1.04-1.74) were associated with an increased likelihood of returning the OFK. The odds of returning the OFK also increased if the HPT contacted the parents/guardians of all cases prior to sending the kit and confirmed their address (aOR:2.01, 95%CI:1.17-3.42). Cases notified by a hospital (aOR:1.94, 95%CI:1.31-2.87) or GP (aOR:1.52; 95%CI:1.06-2.16) also had higher odds of returning the OFK. HPTs may want to consider these factors when managing suspected cases of measles since this may help in increasing the testing rates to the WHO-recommended level.

Invasive Group A Streptococcus Outbreaks Associated with Home Healthcare, England, 2018-2019.

Healthcare-associated invasive group A Streptococcus (iGAS) outbreaks are common worldwide, but only England has reported outbreaks associated with home healthcare (HHC). We describe 10 outbreaks during 2018-2019 in England. A total of 96 iGAS cases (range 2-39 per outbreak) and 28 deaths (case-fatality rate 29%) occurred. Outbreak duration ranged from 3-517 days; median time between sequential cases was 20.5 days (range 1-225 days). Outbreak identification was difficult, but emm typing and whole-genome sequencing improved detection. Network analyses indicated multiple potential transmission routes. Screening of 366 HHC workers from 9 outbreaks identified group A Streptococcus carriage in just 1 worker. Outbreak control required multiple interventions, including improved infection control, equipment decontamination, and antimicrobial prophylaxis for staff. Transmission routes and effective interventions are not yet clear, and iGAS outbreaks likely are underrecognized. To improve patient safety and reduce deaths, public health agencies should be aware of HHC-associated iGAS.

Severe acute respiratory coronavirus virus 2 (SARS-CoV-2) nosocomial transmission dynamics, a retrospective cohort study of two healthcare-associated coronavirus disease 2019 (COVID-19) clusters in a district hospital in England during March and April 2020.

OBJECTIVE: To understand the transmission dynamics of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) in a hospital outbreak to inform infection control actions. DESIGN: Retrospective cohort study. SETTING: General medical and elderly inpatient wards in a hospital in England. METHODS: Coronavirus disease 2019 (COVID-19) patients were classified as community or healthcare associated by time from admission to onset or positivity using European Centre for Disease Prevention and Control definitions. COVID-19 symptoms were classified as asymptomatic, nonrespiratory, or respiratory. Infectiousness was calculated from 2 days prior to 14 days after symptom onset or positive test. Cases were defined as healthcare-associated COVID-19 when infection was acquired from the wards under investigation. COVID-19 exposures were calculated based on symptoms and bed proximity to an infectious patient. Risk ratios and adjusted odds ratios (aORs) were calculated from univariable and multivariable logistic regression. RESULTS: Of 153 patients, 65 were COVID-19 patients and 45 of these were healthcare-associated cases. Exposure to a COVID-19 patient with respiratory symptoms was associated with healthcare-associated infection irrespective of proximity (aOR, 3.81; 95% CI, 1.6.3-8.87). Nonrespiratory exposure was only significant within 2.5 m (aOR, 5.21; 95% CI, 1.15-23.48). A small increase in risk ratio was observed for exposure to a respiratory patient for >1 day compared to 1 day from 2.04 (95% CI, 0.99-4.22) to 2.36 (95% CI, 1.44-3.88). CONCLUSIONS: Respiratory exposure anywhere within a 4-bed bay was a risk, whereas nonrespiratory exposure required bed distance ≤2.5 m. Standard infection control measures required beds to be >2 m apart. Our findings suggest that this may be insufficient to stop SARS-CoV-2 transmission. We recommend improving cohorting and further studies into bed distance and transmission factors.

Retrospective cohort study investigating extent of pertussis transmission during a boarding school outbreak, England, December 2017 to June 2018.

On 1 May 2018, a pertussis outbreak was declared and widespread vaccination recommended at an all-female secondary boarding school in southern England. We conducted a retrospective cohort study to determine the extent of pertussis transmission and identify risk factors in this semi-closed population. Of 504 students and staff assessed before post-exposure vaccination, 48% (n = 240) had evidence of pertussis. A sub-analysis of 409 students found that both residential dormitory (p = 0.05) and school year (p = 0.03) were associated with pertussis, with odds decreasing by 11% for each increase in school year (95% confidence interval: 0.7-20.2). Odds of pertussis were 1.7 times higher in those assumed to have received acellular vaccines for their primary course compared with those assumed to have received whole-cell vaccines (based on date of birth), although this difference was not significant (p = 0.12). Our findings support the need for timely, widespread vaccination following identification of cases among adolescents in a semi-closed United Kingdom (UK) setting and to review the evidence for the introduction of an adolescent pertussis booster to the UK routine vaccination programme.

Influenza in carehome residents: applying a conceptual framework to describe barriers to the implementation of guidance on treatment and prophylaxis.

BACKGROUND: The European Centre for Disease Prevention and Control, National Institute for Health and Care Excellence and Public Health England have all endorsed the use of antivirals for the treatment and prophylaxis of influenza for care home residents. However, implementing these guidelines in practice is often challenging. This article aims to explore what factors impact the management of care home flu outbreaks in England according to national guidelines and highlight opportunities for change. METHODS: Qualitative data from notified outbreaks between September 2017 to April 2018 in the South East of England were analyzed, applying the Greenhalgh framework for barriers to guideline implementation. Summary statistics on outbreak characteristics were generated. Stakeholders were mapped out using Eden and Ackermann's grid of interest and influence. A process map was developed to describe operational pathways. RESULTS: There was often a delay in notifying potential outbreaks to Public Health England. Clinicians cited a lack of robust evidence for the use of antivirals and the available guidelines being too unwieldy as reasons for not implementing prescribing guidance. Many high interests and high influence stakeholders are involved in the sometimes complex care pathway, requiring coordinated work and agreement before antivirals can be prescribed. CONCLUSIONS: Our findings highlight points in the care pathway that stakeholders can target to improve quality of care and increase the likelihood of national guidance being implemented. The principles described in this article can also be applied to other challenges of translating evidence into practice and cross-organisational working.

Increased Risk for Invasive Group A Streptococcus Disease for Household Contacts of Scarlet Fever Cases, England, 2011-2016.

The incidence of scarlet fever in England and Wales is at its highest in 50 years. We estimated secondary household risk for invasive group A Streptococcus (iGAS) disease within 60 days after onset of scarlet fever. Reports of scarlet fever in England during 2011-2016 were matched by residential address to persons with laboratory-confirmed iGAS infections. We identified 11 iGAS cases in ≈189,684 household contacts and a 60-day incidence rate of 35.3 cases/100,000 person-years, which was 12.2-fold higher than the background rate (2.89). Infants and contacts >75 years of age were at highest risk. Three cases were fatal; sepsis and cellulitis were the most common manifestations. Typing for 6 iGAS cases identified emm 1.0 (n = 4), emm 4.0 (n = 1), and emm 12.0 (n = 1). Although absolute risk in household contacts was low, clinicians assessing household contacts should be aware of the risk to expedite diagnosis and initiate life-saving treatment.

Household transmission of invasive group A Streptococcus infections in England: a population-based study, 2009, 2011 to 2013.

Invasive group A streptococcal infection has a 15% case fatality rate and a risk of secondary transmission. This retrospective study used two national data sources from England; enhanced surveillance (2009) and a case management system (2011-2013) to identify clusters of severe group A streptococcal disease. Twenty-four household pairs were identified. The median onset interval between cases was 2 days (range 0-28) with simultaneous onset in eight pairs. The attack rate during the 30 days after first exposure to a primary case was 4,520 per 100,000 person-years at risk (95% confidence interval (CI): 2,900-6,730) a 1,940 (95% CI: 1,240-2,880) fold elevation over the background incidence. The theoretical number needed to treat to prevent one secondary case using antibiotic prophylaxis was 271 overall (95% CI: 194-454), 50 for mother-neonate pairs (95% CI: 27-393) and 82 for couples aged 75 years and over (95% CI: 46-417). While a dramatically increased risk of infection was noted in all household contacts, increased risk was greatest for mother-neonate pairs and couples aged 75 and over, suggesting targeted prophylaxis could be considered. Offering prophylaxis is challenging due to the short time interval between cases emphasising the importance of immediate notification and assessment of contacts.

Barriers to hand hygiene in ophthalmic outpatients in Uganda: a mixed methods approach.

BACKGROUND: Healthcare-associated infection rates are high in low-income countries and are associated with significant morbidity. There is a paucity of published data on infection control practice, attitudes or resources in these settings, particularly in ophthalmology. The aim of this study is to understand current hand washing practices, barriers to hand washing and facilities available in two Ugandan specialist eye hospitals. This study was undertaken through non-participant observations of healthcare worker hand washing practices, documentation of hand hygiene facilities and semi-strucutured interviews with clinical staff. RESULTS: Eighty percent of the WHO opportunities for hand washing were missed through lack of attempted hand hygiene measures. Facilities for hand hygiene were inadequate with some key clinical areas having no provisions for hand hygiene. Training on effective hand hygiene varied widely with some staff reporting no training at all. The staff did not perceive the lack of facilities to be a barrier to hand washing but reported forgetfulness, lack of time and a belief that they could predict when transmission might occur and therefore did not wash hands as often as recommended. CONCLUSIONS: Hand hygiene at the two observed sites did not comply with WHO-recommended standards. The lack of facilities, variable training and staff perceptions were observable barriers to effective hand hygiene. Simple, low-cost interventions to improve hand hygiene could include increased provision of hand towels and running water and improved staff education to challenge their views and perceived barriers to hand hygiene.