Impact of an influenza information pamphlet on vaccination uptake among Polish pupils in Edinburgh, Scotland and the role of social media in parental decision making.

BACKGROUND: In Edinburgh, Scotland, lower influenza vaccine uptake has been observed in primary school children in the Polish community. METHODS: To address this disparity, the Polish-language version of the NHS Health Scotland influenza information pamphlet was updated and distributed in 2018 to all identified Polish pupils attending three pilot schools. The impact of the revised pamphlet was evaluated by examining changes in vaccine uptake in these schools as compared to a control group of schools, and a questionnaire was issued to all Polish parents in the pilot schools to explore their opinions of the pamphlet and preferred sources of immunisation information. RESULTS: On average uptake was 7.4% (95% CI 1.0-13.8%, p < 0.05) higher in the three pilot schools in which the Polish-language pamphlet was distributed (28.7%) than control schools (21.3%). The questionnaire feedback was that 37.3% of respondents felt better-informed about the influenza vaccine following the pamphlet. The respondents reported that the most important information source in deciding whether to vaccinate is previous experience. Healthcare professionals were ranked lower in importance when making a decision. Parents, who refused consent (n = 65) were more likely to source information from social media, friends and family, and Polish websites compared with those who consented (n = 45). CONCLUSIONS: These findings suggest that issuing new Polish health literature was associated with a large increase in consent form return rate and a modest increase in uptake of the influenza vaccine by Polish pupils in the pilot schools. Social media and Polish websites were found to have a greater influence over Polish parents' decision to immunise than UK healthcare staff and health authority information. Intensive effort is required to encourage parents towards information sources where more accurate pro-vaccination messages can be promulgated by national health services and independent expert groups. The role of social media for migrant communities requires careful consideration, especially for vaccine programmes not delivered in their country of birth.

Recurrent outbreaks of mumps in Lothian and the impact of waning immunity.

Another large outbreak of mumps occurred in Lothian from October 2017, which coincided with the commencement of the higher education term. During this period 324 cases were notified, most of whom were aged 18-22 years old. Although previous outbreaks had a focus in student populations, 43% of current cases reported that they were not a student. There has been increases in private student housing where students from all universities live, which may have contributed to the wide spread of the outbreak and complicated outbreak control. Information on vaccination status was available for 244 cases (75%), of whom the majority (75.8%) reported having two MMR doses. To investigate potential waning vaccine immunity the mean length of time since last mumps containing vaccine was calculated as 14.3 years. The outbreak was declared over in May 2018 after case numbers returned to background levels. This outbreak highlighted that mumps outbreaks occur cyclically coinciding with new cohorts of susceptible students entering the Lothian population. The lessons from this outbreak are to encourage students to have two MMR doses and also be prepared for mumps outbreaks in the near future. In future outbreaks the utility of a third MMR for outbreak control could be examined.

Comparing vaccination hesitancy in Polish migrant parents who accept or refuse nasal flu vaccination for their children.

This study investigates the background to low uptake of nasal influenza vaccination in Polish pupils in Edinburgh, Scotland. In autumn 2018, one week after their child's nasal flu vaccination sessions, 365 Polish parents were sent a questionnaire exploring influences on their vaccination choices. The questionnaire included a series of 10 vaccine hesitancy questions recommended by the WHO SAGE Working Group on Vaccine Hesitancy. 128 questionnaires were returned representing 43.4% of vaccinated, 41.9% of refusing and 23.8% of non-consent form returning parents. Responses highlighted concerns about side effects, new vaccines and the accuracy of professional advice and information sources. There was complacency expressed about vaccination against diseases that are not common any more. Vaccine refusers were consistently more negative about all aspects vaccination and more likely to answer 'don't know'. Almost half of refusers were uncertain about the quality of health information offered to them. Polish migrants in Scotland come with their beliefs about vaccination and modify these as they acculturate to the UK system. They also continue to be influenced by developments and opinions, norms and values from their home country, as well as diaspora media. We have highlighted issues of concern among Polish migrants as a group and gained additional insights by comparing responses of parents who have refused or accepted vaccination. These insights can inform and target messages and strategies to build confidence and encourage immunisation, which should lead to improved vaccine uptake among ethnic population groups.

A qualitative study of vaccination behaviour amongst female Polish migrants in Edinburgh, Scotland.

Vaccine hesitancy is increasing and failure to vaccinate is well-recognised in Europe as a contributing factor to outbreaks of infectious diseases. In Lothian and Scotland, low vaccine uptake has been seen in migrants - notably in the Polish group who have arrived since 2004. The recent Vaccine Confidence in European Union report highlights a concerning recent decline in vaccine confidence in Poland. We held three focus groups containing 13 Polish women about the childhood vaccination programme in Lothian, with specific focus on influenza and Human Papillomavirus vaccinations. Key emergent themes were: trust in the national vaccination policy, trust in the vaccination providers (health professionals), trust in the individual vaccines, balancing the risk of disease, and language and communication. Polish norms, beliefs and behaviours shape how Polish migrants navigate the UK health system and its vaccination programme. While not confident in the Scottish primary care model and its generalist practitioners, the participants liked the ethos of informed consent in Scotland and compared this favourably with the compulsory vaccination policy in Poland. There was a belief that vaccines in Scotland were of higher quality than Poland and with fewer adverse effects. Respondents reported returning to Poland for specialist clinical appointments and diagnostic testing. They regularly access Polish clinical expertise and their opinions about health are influenced by Polish friends and family. They say they have difficulty finding official UK Government and health authority vaccination material and often access Polish media, online resources and information. They are familiar with anti-vaccination activities in Poland. Consequently, there are important unmet information needs for this group of parents who may not be making truly informed choices about vaccination. This requires further investigation especially as migration continues and declining immunisation uptake is reported in many countries across Europe.

Evidence of decreased HPV vaccine acceptance in Polish communities within Scotland.

Human papillomavirus (HPV) vaccines are currently utilised globally in national immunisation programmes. Many new European migrants have settled in the United Kingdom (UK) since the 2004 European Union expansion with approximately 91,000 Polish people resident in Scotland. Following anecdotal reports from several NHS Boards within Scotland of lower HPV vaccine uptake in Polish communities compared with other ethnic minorities, an extract containing both forename and surname, was taken from the Scottish Immunisation Recall System (SIRS) for all girls in S2 and S3 in school years 2014/15 to 2016/17. We then used the OnoMap algorithm software to derive ethnicity. OnoMap identified between 289 and 321 age-eligible girls as Polish with significant disparity noted for completed HPV vaccine uptake between UK (87.2-89.8%) and Polish ethnicities (69.7-77.2%) (P < 0.01). Preliminary discussions with Polish families suggest that vaccine programme differences, trust in medical/healthcare practitioners, and cultural influences may be important drivers of acceptance.

Low uptake of nasal influenza vaccine in Polish and other ethnic minority children in Edinburgh, Scotland.

Failure to vaccinate is well-recognised in Europe as a contributing factor to outbreaks of infectious diseases. Low immunisation rates are often associated with religious, social and ethnic minorities, including refugees or migrant groups. Polish people form Scotland's newest and largest migrant group. They have moved to Scotland since 2004, joining established ethnic minorities from China, the Indian subcontinent and Africa. Scotland has had a seasonal influenza nasal vaccination programme for all primary school children since 2013. We investigated three primary schools in Edinburgh, which had reported low influenza vaccination uptake rates in 2016 and 2017 and found that these schools contained many pupils from ethnic minorities, the majority of whom were Polish. Pupils were categorized as one of three ethnic groupings: White British, Polish and Other Identified Ethnic Minority (OIEM). We ascertained ethnicity using NHS and Education Department information sources and name recognition. We examined vaccine acceptance, declination and non-return of consent forms. In 2017, nasal influenza vaccine uptake was 70.7% (65.2-75.6%, p < 0.001) in White British, 60.9% (53.9-67.6%%, p < 0.001) in other identified ethnic minorities and 25.0% (20.9-29.6%, p > 0.001) in Polish children. White British children were more likely to return completed forms (78.9%) than other groups (OIEM 68.2% and Polish 61.8%). 36.8% of Polish families completed a consent form declining vaccination compared to 6.2% of White British families. These findings demonstrate that significant differences exist in nasal influenza vaccination uptake rates, which have important implications for the trans-national study of vaccine hesitancy. Further qualitative work and an investigation of uptake rates of other childhood immunisations in Polish and other migrant groups is required to assess differences in uptake and behaviours.

Imported case of measles in a university setting leading to an outbreak of measles in Edinburgh, Scotland from September to December 2016.

In September 2016, an imported case of measles in Edinburgh in a university student resulted in a further 17 confirmed cases during October and November 2016. All cases were genotype D8 and were associated with a virus strain most commonly seen in South East Asia. Twelve of the 18 cases were staff or students at a university in Edinburgh and 17 cases had incomplete or unknown measles mumps rubella (MMR) vaccination status. The public health response included mass follow-up of all identified contacts, widespread communications throughout universities in Edinburgh and prompt vaccination clinics at affected campuses. Imported cases of measles pose a significant risk to university student cohorts who may be undervaccinated, include a large number of international students and have a highly mobile population. Public health departments should work closely with universities to promote MMR uptake and put in place mass vaccination plans to prevent rapidly spreading measles outbreaks in higher educational settings in future.

Molecular and epidemiological evidence of patient-to-patient hepatitis C virus transmission in a Scottish emergency department.

BACKGROUND: Transmission of hepatitis C virus (HCV) in the healthcare setting is rare. Routine infection prevention and control measures mean that this should be a preventable 'never event'. AIM: To investigate the diagnosis of acute healthcare-associated HCV infection. METHODS: Epidemiological and molecular investigation of a case of acute HCV infection associated with nosocomial exposure. FINDINGS: Detailed investigation of the treatment history of a patient with acute HCV infection identified transmission from a co-attending patient in an emergency department as the likely source; this possibility was confirmed by virus sequence analysis. The precise route of transmission was not identified, though both patient and source had minimally invasive healthcare interventions. Review of infection, prevention and control identified potentially contributory factors in the causal pathway including hand hygiene, inappropriate use of personal protective equipment, and blood contamination of the surface of the departmental blood gas analyser. CONCLUSION: We provide molecular and epidemiological evidence of HCV transmission between patients in an emergency department that was made possible by environmental contamination. Patients with HCV infection are higher users of emergency care than the general population and a significant proportion of those affected remain unknown and/or infectious. Equipment, departmental design, staff behaviour, and patient risk require regular review to minimize the risk of nosocomial HCV transmission.

An outbreak of mumps with genetic strain variation in a highly vaccinated student population in Scotland.

An outbreak of mumps within a student population in Scotland was investigated to assess the effect of previous vaccination on infection and clinical presentation, and any genotypic variation. Of the 341 cases, 79% were aged 18-24. Vaccination status was available for 278 cases of whom 84% had received at least one dose of mumps containing vaccine and 62% had received two. The complication rate was 5·3% (mainly orchitis), and 1·2% were admitted to hospital. Genetic sequencing of mumps virus isolated from cases across Scotland classified 97% of the samples as genotype G. Two distinct clusters of genotype G were identified, one circulating before the outbreak and the other thereafter, suggesting the virus that caused this outbreak was genetically different from the previously circulating virus. Whilst the poor vaccine effectiveness we found may be due to waning immunity over time, a contributing factor may be that the current mumps vaccine is less effective against some genotypes. Although the general benefits of the measles-mumps-rubella (MMR) vaccine should continue to be promoted, there may be value in reassessing the UK vaccination schedule and the current mumps component of the MMR vaccine.

Hepatitis E virus is the leading cause of acute viral hepatitis in Lothian, Scotland.

Acute viral hepatitis affects all ages worldwide. Hepatitis E virus (HEV) is increasingly recognized as a major cause of acute hepatitis in Europe. Because knowledge of its characteristics is limited, we conducted a retrospective study to outline demographic and clinical features of acute HEV in comparison to hepatitis A, B and C in Lothian over 28 months (January 2012 to April 2014). A total of 3204 blood samples from patients with suspected acute hepatitis were screened for hepatitis A, B and C virus; 913 of these samples were also screened for HEV. Demographic and clinical information on patients with positive samples was gathered from electronic patient records. Confirmed HEV samples were genotyped. Of 82 patients with confirmed viral hepatitis, 48 (59%) had acute HEV. These patients were older than those infected by hepatitis A, B or C viruses, were more often male and typically presented with jaundice, nausea, vomiting and/or malaise. Most HEV cases (70%) had eaten pork or game meat in the few months before infection, and 14 HEV patients (29%) had a recent history of foreign travel. The majority of samples were HEV genotype 3 (27/30, 90%); three were genotype 1. Acute HEV infection is currently the predominant cause of acute viral hepatitis in Lothian and presents clinically in older men. Most of these infections are autochthonous, and further studies confirming the sources of infection (i.e. food or blood transfusion) are required.

Determining the effect of social deprivation on the prevalence of healthcare-associated infections in acute hospitals: a multivariate analysis of a linked data set.

BACKGROUND: Healthcare-associated infections (HCAIs) endanger safety by increasing morbidity, mortality, and hospital stay. Studies identifying risk factors for HCAI rarely address the wider determinants of health. However, a well-characterized association exists between increasing social deprivation and poor health outcomes. Therefore it is important to determine whether HCAIs are associated with social deprivation. AIM: To determine the association between social deprivation and the prevalence of HCAI, in all inpatients in an acute hospital in Scotland on a single day across September and October 2011. METHODS: This study linked Scottish data from the 2011 European Point Prevalence Survey of HCAI and Antimicrobial Prescribing to the Scottish Morbidity Record 01, a national dataset with Scottish Index of Multiple Deprivation (SIMD) included. Multivariate logistic regression was used to model HCAI prevalence against SIMD quintile. FINDINGS: No overall association was found between SIMD quintile and prevalence of HCAI in all inpatients. A significant difference was found between HCAI prevalence across SIMD quintile in patients undergoing surgical procedures, with higher prevalence observed with increasing deprivation (P = 0.0071). Variables associated with HCAI prevalence were: intensive care specialty, psychiatric and medical specialties, minimum invasive surgery, and all categories of length of stay. CONCLUSION: This study found a significant difference in HCAI prevalence across SIMD quintile in patients undergoing surgery. To our knowledge this was the first study to examine the overall association between HCAI and SIMD. The findings highlight the broad and comprehensive nature of social deprivation in determining health outcomes.

Increased number of parvovirus B19 infections in southeast Scotland in 2012-2013.

Parvovirus B19 (B19V) infections are a common but under-investigated and under-reported cause of intrauterine infections. An increased number of acute B19V infections was identified in the Edinburgh area in 2012-2013, with 123 infections diagnosed in 33 pregnant women, 76 non-pregnant women and 14 men. All except one pregnant woman were asymptomatic. An overall infection rate of 18% was measured in pregnant women who were tested following B19V exposure (26/141). Furthermore, a 7% seroconversion rate was recorded in non-immune pregnant women who were re-tested after exposure (7/104). A high fetal loss rate (25%; 3/12) was observed in those who had acute B19V infection in early pregnancy (<11 weeks) whereas all pregnancies progressed to term in those where acute infection occurred after a gestational age of 12 weeks. These results suggest that more efforts should be targeted to investigate suspected B19V infections in early pregnancy during epidemic seasons.

Atypical hand, foot, and mouth disease associated with coxsackievirus A6 infection, Edinburgh, United Kingdom, January to February 2014.

In January to February 2014, 16 hand, foot and mouth disease (HFMD) cases were identified in Edinburgh, United Kingdom. All presented with atypical features, with most (n=13) resembling eczema herpeticum or chickenpox. Coxsackievirus A6 (CV-A6) was identified in all the typed cases (n=11). As atypical forms of HFMD associated with CV-A6 are likely to emerge throughout Europe, clinicians should be alert to unusual clinical presentations of HFMD and virologists aware of effective diagnostic testing and enterovirus typing methods.

Cluster of non-tuberculous mycobacteraemia associated with water supply in a haemato-oncology unit.

Non-tuberculous mycobacteria (NTM) are ubiquitous environmental organisms but rarely cause infections. Clinical, microbiological and epidemiological investigations and subsequent management of a cluster of NTM bacteraemia on a haemato-oncology unit are reported. From October 2007 to July 2008, five patients being managed for haematological malignancies developed pyrexia and general malaise. Mycobacterium mucogenicum (four patients) and Mycobacterium neoaurum (one patient) were identified from their blood cultures. The environment, in particular the water system, was investigated to identify the source of the infection and multiple water samples were cultured according to established criteria. NTM were also isolated from the hospital water system. Central venous catheters (CVCs) were removed and the patients were successfully treated with antibiotics. Environmental measures and changes in CVC care were introduced to prevent further episodes of NTM bacteraemia in these patients. Despite these measures, NTM continued to be present in the water system, but new clinical cases were not identified. NTM are common environmental organisms and are recognized as being difficult to remove from water systems. CVCs were presumed to be the portal of entry in this cluster of NTM bacteraemia, and the implementation of changes to CVC care protocols was successful in preventing further infections in this immunocompromised patient group.

Meningococcal disease in a backpackers hostel in Scotland: a risk assessment for prophylaxis.

This paper outlines the risk assessment and communication strategy carried out by the Lothian Health Protection Team after notification of a probable case of meningococcal disease (later confirmed as Neisseria meningitidis) in a resident of a city centre backpackers hostel. Six close contacts were identified from the hostel and given rifampicin prophylaxis. Two days after commencing rifampicin one of these contacts was admitted to hospital with a purpuric/petechial rash and thrombocytopenia. The final diagnosis for this contact was thrombocytopenia, either idiopathic or secondary to rifampicin. This example and the potential side effects of administering rifampicin prophylaxis highlight the importance of a thorough risk assessment of contacts of a case to avoid prescribing prophylaxis to anyone other than those at highest risk of becoming a subsequent case.

Can syndromic surveillance data detect local outbreaks of communicable disease? A model using a historical cryptosporidiosis outbreak.

A national UK surveillance system currently uses data from a health helpline (NHS Direct) in an attempt to provide early warning of a bio-terrorist attack, or an outbreak caused by a more common infection. To test this syndromic surveillance system we superimposed data from a historical outbreak of cryptosporidiosis onto a statistical model of NHS Direct call data. We modelled whether calls about diarrhoea (a proxy for cryptosporidiosis) exceeded a statistical threshold, thus alerting the surveillance team to the outbreak. On the date that the public health team were first notified of the outbreak our model predicted a 4% chance of detection when we assumed that one-twentieth of cryptosporidiosis cases telephoned the helpline. This rose to a 72% chance when we assumed nine-tenths of cases telephoned. The NHS Direct surveillance system is currently unlikely to detect an event similar to the cryptosporidiosis outbreak used here and may be most suited to detecting more widespread rises in syndromes in the community, as previously demonstrated. However, the expected rise in NHS Direct call rates, should improve early warning of outbreaks using call data.

Monitoring the uptake of HIV testing among first attendees at GUM clinics in the East of England region.

This study was conducted to determine the extent to which genitourinary medicine clinics in the East of England region are monitoring the uptake of HIV testing. Ninety-four per cent of GUM clinics in the region offer HIV testing to all new patients. The uptake varied around the region, but all clinics are able to monitor uptake and the majority of clinics can audit uptake. The overall regional uptake has already exceeded the target for 2004.

Outcome of invasive pneumococcal disease: a UK based study. Oxford Pneumococcal Surveillance Group.

METHODS: The records of 106 children aged less than 5 years with invasive disease caused by Streptococcus pneumoniae were reviewed. RESULTS: The clinical manifestations were meningitis (37%), upper respiratory tract infection (24%), pneumonia (19%), and occult bacteraemia (18%). One child died and seven had persisting neurological impairment. Five serotypes caused 83% of disease and 92% of the serotypes are included in the seven valent conjugate vaccines which are undergoing trials. CONCLUSIONS: These data suggest that S pneumoniae infection is associated with a low case fatality rate but substantial morbidity in the UK.

Laboratory policies on testing for rotavirus affect surveillance data. PHLS East Epidemiology and Virology Subcommittees.

The effect of different laboratory testing policies on the surveillance of rotavirus was assessed in eight laboratories between 1995 and 1998. In 1995, five laboratories tested all faecal specimens from children aged 5 years and under all year, two tested all specimens from children aged 4 years and under all year, and one tested all specimens from children aged 3 years and under between November and May only. Five laboratories changed their testing policy between 1995 and 1998. By 1998, three tested all specimens from children aged 5 years and under all year and two from the same age group during the 'season' only. Three laboratories had unique policies: one tested all specimens from children aged 2 years and under between January and June, one tested all specimens from children aged 4 years and under all year, and one tested specimens only on clinical request. The onset date of the rotavirus infection 'season' as determined by retrospective scrutiny of reported cases varied by up to 15 weeks between laboratories, starting as early as week 45 (November) and as late as week 13 (March). Laboratories with more restrictive testing policies yielded fewer reports of rotavirus and changes in policy within a particular laboratory affected the number of reports. Temporal and geographic trends were visible, even within the relatively small area covered by this study, and showed how laboratory testing policies affect surveillance data.

Compliance with advice to boil drinking water during an outbreak of cryptosporidiosis. Outbreak Investigation Team.

All 2000 employees of a hospital in an area of the North Thames region where 300,000 households were advised to boil tap water before consumption during a large outbreak of cryptosporidiosis were surveyed about compliance with and adverse events linked to the boil water notice. Eighty-five per cent (408/479) of respondents who lived in the boil water area said that they used boiled water while the notice was in place, 72% (347) used bottled water, and 12% (59) did not continue to boil water for the whole 16 days. Although 88% believed that they were following the advice, 20% washed food that would be eaten raw in unboiled tap water and 57% used it to clean their teeth. If a boil water notice is applied for more than a few days it may be helpful to issue a detailed follow up letter.