Outcomes of TB contact tracing and predictors of success: a 10-year retrospective cohort analysis in Birmingham, UK.

BACKGROUND: Contacts of TB cases in Birmingham and Solihull, UK, are offered screening for TB infection. Between 1990 and 2010, only 59.1% of contacts completed screening. The service has since increased screening staff numbers, changed screening locations and increased screening follow-up. Our primary aim was to identify whether screening completion rates have improved. Our secondary aim was to identify predictors of screening completion.METHODS: This was a retrospective analysis of all contacts of TB patients in Birmingham and Solihull between 1 January 2011 and 31 December 2020, stratified by pulmonary and extrapulmonary TB (PTB or EPTB) index infection. Multiple logistic regression analysis for predictors of screening completion was performed.RESULTS: A total of 3,255 index cases and 27,820 contacts were identified. TB incidence has declined, in keeping with national trends. Screening completion has improved from 59.1% of contacts to 74.9% overall since service improvements were made, with improvement in screening completion for contacts of both PTB and EPTB index cases (OR 1.087, 95% CI 1.074-1.101; P < 0.001) and (OR 1.048, 95% CI 1.019-1.078; P = 0.001), respectively.CONCLUSIONS: Changes made to the TB service have improved screening outcomes over the last decade. Significant predictors of screening completion have been identified, highlighting areas for targeted resource allocation.

Validation of dried blood spot sampling for detecting SARS-CoV-2 antibodies and total immunoglobulins in a large cohort of asymptomatic young adults.

BACKGROUND: Detecting antibody responses following infection with SARS-CoV-2 is necessary for sero-epidemiological studies and assessing the role of specific antibodies in disease, but serum or plasma sampling is not always viable due to logistical challenges. Dried blood spot sampling (DBS) is a cheaper, simpler alternative and samples can be self-collected and returned by post, reducing risk for SARS-CoV-2 exposure from direct patient contact. The value of large-scale DBS sampling for the assessment of serological responses to SARS-CoV-2 has not been assessed in depth and provides a model for examining the logistics of using this approach to other infectious diseases. The ability to measure specific antigens is attractive for remote outbreak situations where testing may be limited or for patients who require sampling after remote consultation. METHODS: We compared the performance of SARS-CoV-2 anti-spike and anti-nucleocapsid antibody detection from DBS samples with matched serum collected by venepuncture in a large population of asymptomatic young adults (N = 1070) living and working in congregate settings (military recruits, N = 625); university students, N = 445). We also compared the effect of self-sampling (ssDBS) with investigator-collected samples (labDBS) on assay performance, and the quantitative measurement of total IgA, IgG and IgM between DBS eluates and serum. RESULTS: Baseline seropositivity for anti-spike IgGAM antibody was significantly higher among university students than military recruits. Strong correlations were observed between matched DBS and serum samples in both university students and recruits for the anti-spike IgGAM assay. Minimal differences were found in results by ssDBS and labDBS and serum by Bland Altman and Cohen kappa analyses. LabDBS achieved 82.0% sensitivity and 98.2% specificity and ssDBS samples 86.1% sensitivity and 96.7% specificity for detecting anti-spike IgGAM antibodies relative to serum samples. For anti-SARS-CoV-2 nucleocapsid IgG there was qualitatively 100% agreement between serum and DBS samples and weak correlation in ratio measurements. Strong correlations were observed between serum and DBS-derived total IgG, IgA, and IgM. CONCLUSIONS: This is the largest validation of DBS against paired serum for SARS-CoV-2 specific antibody measurement and we have shown that DBS retains performance from prior smaller studies. There were no significant differences regarding DBS collection methods, suggesting that self-collected samples are a viable sampling collection method. These data offer confidence that DBS can be employed more widely as an alternative to classical serology.

Deployment of whole genome next-generation sequencing of SARS-CoV-2 in a military maritime setting.

BACKGROUND: SARS-CoV-2 can spread rapidly on maritime platforms. Several outbreaks of SARS-CoV-2 have been reported on warships at sea, where transmission is facilitated by living and working in close quarters. Core components of infection control measures such as social distancing, patient isolation and quarantine of exposed persons are extremely difficult to implement. Whole genome sequencing (WGS) of SARS-CoV-2 has facilitated epidemiological investigations of outbreaks, impacting on outbreak management in real time by identifying transmission patterns, clusters of infection and guiding control measures. We suggest such a capability could mitigate against the impact of SARS-CoV-2 in maritime settings. METHODS: We set out to establish SARS-CoV-2 WGS using miniaturised nanopore sequencing technology aboard the Royal Fleet Auxiliary ARGUS while at sea. Objectives included designing a simplified protocol requiring minimal reagents and processing steps, the use of miniaturised equipment compatible for use in limited space, and a streamlined and standalone data analysis capability to allow rapid in situ data acquisition and interpretation. RESULTS: Eleven clinical samples with blinded SARS-CoV-2 status were tested at sea. Following viral RNA extraction and ARTIC sequencing library preparation, reverse transcription and ARTIC PCR-tiling were performed. Samples were subsequently barcoded and sequenced using the Oxford Nanopore MinION Mk1B. An offline version of the MinKNOW software was used followed by CLC Genomics Workbench for downstream analysis for variant identification and phylogenetic tree construction. All samples were correctly classified, and relatedness identified. CONCLUSIONS: It is feasible to establish a small footprint sequencing capability to conduct SARS-CoV-2 WGS in a military maritime environment at sea with limited access to reach-back support. This proof-of-concept study has highlighted the potential of deploying such technology in the future to military environments, both maritime and land-based, to provide meaningful clinical data to aid outbreak investigations.

The 2022 monkeypox outbreak: A UK military perspective.

With the emergence of SARS-CoV-2 and now monkeypox, the UK Defence Medical Services have been required to provide rapid advice in the management of patients with airborne high consequence infectious diseases (A-HCID). The Defence Public Health Network (DPHN) cadre, consisting of closely aligned uniformed and civilian public health specialists have worked at pace to provide evidence-based recommendations on the clinical management, public health response and policy for monkeypox, with military medicine and pathology clinicians (primarily infectious disease physicians and medical microbiologists). Military environments can be complicated and nuanced requiring specialist input and advice to non-specialists as well as unit commanders both in the UK and overseas. DPHN and military infection clinicians have close links with the UK National Health Service (NHS) and the UK Health Security Agency (UKHSA), allowing for a dynamic two-way relationship that encompasses patient management, public health response, research and development of both UK military and national guidelines. This is further demonstrated with the Royal Air Force (RAF) Air Transport Isolator (ATI) capability, provided by Defence to support the UK Government and UKHSA. Military infectious disease clinicians are also embedded within NHS A-HCID units. In this manuscript we provide examples of the close interdisciplinary working of the DPHN and Defence clinicians in managing military monkeypox patients, co-ordinating the public health response, advising the Command and developing monkeypox policy for Defence through cross-government partnership. We also highlight the co-operation between civilian and military medical authorities in managing the current outbreak.

Spatial Analysis and Lead-Risk Assessment of Philadelphia, USA.

Childhood lead poisoning is an issue that continues to plague major U.S. cities. Despite efforts by the Philadelphia Department of Public Health to curtail systemic childhood lead poisoning, children continue to be identified with elevated blood lead levels. The persistence of elevated blood lead levels in children is concerning because lead poisoning has been linked to decreases in academic achievement and IQ, with associated repercussions for entire communities. This paper reports the results of an analysis of the spatial distribution of houses with lead paint (i.e., pre-1978), demolitions, and occurrence of historic smelters, in West and North Philadelphia, relative to elevated blood lead level data, to determine which lead sources act as primary lead-risk factors. The presence of lead paint in homes and the number of demolitions of older properties were found to have the highest correlations to elevated blood lead levels for children in Philadelphia. Using lead-risk factors including lead paint, housing code violations, demolitions, and owner-occupied housing units, a lead-risk assessment was performed at the census tract level to identify future soil sampling sites and high-risk neighborhoods in Philadelphia. These sites of high risk for lead exposure, and in particular the census tracts 175 and 172, should be prioritized for lead poisoning prevention initiatives.

A Rare Case of Signet Ring Cell Colon Cancer Presenting as Adult Colorectal Intussusception.

Signet ring cell carcinoma of the rectum is rare and typically presents with advanced disease. We report a case of a 68-year-old man who presented with left lower quadrant pain and was found to have signet ring cell carcinoma with intussusception. This case is unusual because of its polypoid growth pattern and apparent early pathological stage. We discuss the differential diagnoses and prognosis.

Does vitamin D supplementation prevent SARS-CoV-2 infection in military personnel? Review of the evidence.

For most individuals residing in Northwestern Europe, maintaining replete vitamin D status throughout the year is unlikely without vitamin D supplementation and deficiency remains common. Military studies have investigated the association with vitamin D status, and subsequent supplementation, with the risk of stress fractures particularly during recruit training. The expression of nuclear vitamin D receptors and vitamin D metabolic enzymes in immune cells additionally provides a rationale for the potential role of vitamin D in maintaining immune homeostasis. One particular area of interest has been in the prevention of acute respiratory tract infections (ARTIs). The aims of this review were to consider the evidence of vitamin D supplementation in military populations in the prevention of ARTIs, including SARS-CoV-2 infection and consequent COVID-19 illness. The occupational/organisational importance of reducing transmission of SARS-CoV-2, especially where infected young adults may be asymptomatic, presymptomatic or paucisymptomatic, is also discussed.

Staphylococcus aureus colonization and acquisition of skin and soft tissue infection among Royal Marines recruits: a prospective cohort study.

OBJECTIVES: Skin and soft tissue infections (SSTIs) are a serious health issue for military personnel. Of particular importance are those caused by methicillin-resistant Staphylococcus aureus and Panton-Valentine leucocidin (PVL)-positive S. aureus (PVL-SA), as they have been associated with outbreaks of SSTIs. A prospective observational study was conducted in Royal Marine (RM) recruits to investigate the prevalence of PVL-SA carriage and any association with SSTIs. METHODS: A total of 1012 RM recruits were followed through a 32-week training programme, with nose and throat swabs obtained at weeks 1, 6, 15 and 32. S. aureus isolates were characterized by antibiotic susceptibility testing, spa typing, presence of mecA/C and PVL genes. Retrospective review of the clinical notes for SSTI acquisition was conducted. RESULTS: S. aureus colonization decreased from Week 1 to Week 32 (41% to 26%, p < 0.0001). Of 1168 S. aureus isolates, three out of 1168 (0.3%) were MRSA and ten out of 1168 (0.9%) PVL-positive (all MSSA) and 169 out of 1168 (14.5%) were resistant to clindamycin. Isolates showed genetic diversity with 238 different spa types associated with 25 multi-locus sequence type (MLST) clonal complexes. SSTIs were seen in 35% (351/989) of recruits with 3 training days lost per recruit. SSTI acquisition rate was reduced amongst persistent carriers (p < 0.0283). CONCLUSIONS: Nose and throat carriage of MRSA and PVL-SA was low among recruits, despite a high incidence of SSTIs being reported, particularly cellulitis. Carriage strains were predominantly MSSA with a marked diversity of genotypes. Persistent nose and/or throat carriage was not associated with SSTI acquisition. Putative person-to-person transmission within troops was identified based on spa typing requiring further research to confirm and explore potential transmission routes.

Barriers and facilitators to adoption, implementation and sustainment of obesity prevention interventions in schoolchildren- a DEDIPAC case study.

BACKGROUND: The aim of the study was to explore the implementation of school based diet and physical activity interventions with respect to the barriers and facilitators to adoption, implementation and sustainability; supportive actions required for implementation and recommendations to overcome identified barriers. Two interventions rolled out nationally in Ireland were chosen; Food Dudes, a programme to encourage primary school children to consume more fruit and vegetables and Green Schools Travel (GST), an active travel to school programme in primary and secondary schools. Trained school coordinators (teachers) cascade the programmes to other teaching staff. METHODS: Multiple case study design using qualitative semi-structured interviews with key stakeholders: primary and secondary school teachers, school coordinators, project coordinators/managers, funders and intermediaries. Fifteen interviews were conducted. Data were coded using a common categorization matrix. Thematic analysis was undertaken using the Adoption, Implementation and Maintenance elements of the RE-AIM implementation framework. RESULTS: Good working relationships within and across government departments, intermediaries and schools were critical for intervention adoption, successful implementation and sustainability. Organisational and leadership ability of coordinators were essential. Provision of participation incentives acted as motivators to engage children's interest. A deep understanding of the lives of the target children was an important contextual factor. The importance of adaptation without compromising core components in enhancing intervention sustainability emerged. Successful implementation was hindered by: funding insecurity, school timetable constraints, broad rather than specific intervention core components, and lack of agreement on conduct of programme evaluation. Supportive actions for maintenance included ongoing political support, secure funding and pre-existing healthy lifestyle policies. CONCLUSIONS: Successful implementation and scale up of public health anti-obesity interventions in schools is dependent on good contextual fit, engagement and leadership at multiple levels and secure funding. Recommendations to overcome barriers include: capacity to deliver within an already overcrowded curriculum and clear specification of intervention components within a conceptual framework to facilitate evaluation. Our findings are generalisable across different contexts and are highly relevant to those involved in the development or adaptation, organisation or execution of national public health interventions: policy makers, guidelines developers, and staff involved in local organisation and delivery.

Health system changes needed to support people consulting general practice out of hours services in Ireland.

BACKGROUND: Mental illness acts as a barrier to accessing and obtaining effective medical care. It has been shown that out of hours services are an important first stop for emergency care for people experiencing mental health difficulties. However, little is in fact known about the use of out of hours general practice services by people experiencing mental health difficulties. AIM: To establish the number and range of consultations that have a primary or related mental health issue attending general practitioner (GP) out of hours and to document adherence to their follow-up care referral. DESIGN AND SETTING: Descriptive study in one large out of hours primary care service in the South East of Ireland (Caredoc). METHODS: An anonymous extraction of retrospective data from 1 year of the out of hours' electronic database was undertaken. Patients who attended the out of hours with a possible mental health issue and were referred to the psychiatric services or back to their own GP, were tracked via phone follow-up with hospitals and GPs over 6 months to establish if they attended for the recommend follow-up care. RESULTS: Over a 1 year period, there were 3844 out of hours presentations with a mental health component. Overall, 9.3% were referred by the out of hours GP for follow-up to a hospital emergency department (ED) or were advised to attend their own GP. A total of 104 patients who were advised to attend their GP or ED following their consultation with the out of hours GP were tracked. Twenty-seven patients were referred back to their GP of which the follow-up call to the GP revealed that 44.5% did not attend. Seventy-seven patients were referred to the hospital services, of whom 37.7% did not attend. CONCLUSIONS: There are significant challenges at the interface of primary care and secondary mental health services in Ireland. As expounded by the WHO and WONCA, in order to be effective and efficient, care for mental health must be coordinated with services at different levels of care complemented by the broader health system.

Enhanced case management can be delivered for patients with EVD in Africa: Experience from a UK military Ebola treatment centre in Sierra Leone.

BACKGROUND: Limited data exist describing supportive care management, laboratory abnormalities and outcomes in patients with Ebola virus disease (EVD) in West Africa. We report data which constitute the first description of the provision of enhanced EVD case management protocols in a West African setting. METHODS: Demographic, clinical and laboratory data were collected by retrospective review of clinical and laboratory records of patients with confirmed EVD admitted between 5 November 2014 and 30 June 2015. RESULTS: A total of 44 EVD patients were admitted (median age 37 years (range 17-63), 32/44 healthcare workers), and excluding those evacuated, the case fatality rate was 49% (95% CI 33%-65%). No pregnant women were admitted. At admission 9/44 had stage 1 disease (fever and constitutional symptoms only), 12/44 had stage 2 disease (presence of diarrhoea and/or vomiting) and 23/44 had stage 3 disease (presence of diarrhoea and/or vomiting with organ failure), with case fatality rates of 11% (95% CI 1%-58%), 27% (95% CI 6%-61%), and 70% (95% CI 47%-87%) respectively (p = 0.009). Haemorrhage occurred in 17/41 (41%) patients. The majority (21/40) of patients had hypokalaemia with hyperkalaemia occurring in 12/40 patients. Acute kidney injury (AKI) occurred in 20/40 patients, with 14/20 (70%, 95% CI 46%-88%) dying, compared to 5/20 (25%, 95% CI 9%-49%) dying who did not have AKI (p = 0.01). Ebola virus (EBOV) PCR cycle threshold value at baseline was mean 20.3 (SD 4.3) in fatal cases and 24.8 (SD 5.5) in survivors (p = 0.007). Mean national early warning score (NEWS) at admission was 5.5 (SD 4.4) in fatal cases and 3.0 (SD 1.9) in survivors (p = 0.02). Central venous catheters were placed in 37/41 patients and intravenous fluid administered to 40/41 patients (median duration of 5 days). Faecal management systems were inserted in 21/41 patients, urinary catheters placed in 27/41 and blood component therapy administered to 20/41 patients. CONCLUSIONS: EVD is commonly associated life-threatening electrolyte imbalance and organ dysfunction. We believe that the enhanced levels of protocolized care, scale and range of medical interventions we report, offer a blueprint for the future management of EVD in resource-limited settings.

A Cost Minimisation Analysis of NOACs Compared to Warfarin to Attain Therapeutic Anticoagulation amongst AF Patients, Pre- and Post- Cardioversion.

Atrial fibrillation can be managed with anticoagulation and restoration of normal sinus rhythm using direct current cardioversion (DCCV). To reduce the risk of thromboembolism, anticoagulation pre-and-post DCCV is recommended. This study investigates the cost effectiveness of using NOACs compared to warfarin to attain therapeutic anticoagulation amongst AF patients pre-and-post DCCV. Propensity score matching revealed no statistically significant difference in outcomes from using NOACs and Warfarin. A cost minimisation study was performed; demonstrating a cost differential of €209 between those administered NOACs and warfarin pre- and post-DCCV. This study demonstrates how using NOACs compared to warfarin to attain therapeutic anticoagulation amongst AF patients pre-and-post DCCV is cost effective.

A 2-year review of the general internal medicine admissions to the British Role 3 Hospital in Camp Bastion, Afghanistan.

BACKGROUND: Detailed knowledge of the likely volume and nature of the diseases presenting to deployed secondary care facilities aids operational planning. Now the British operation in Afghanistan has ended and a record of the experience is useful to preserve the lessons learned. METHODS: Over a 2-year period from April 2011, prospective demographic and clinical data were collected on consecutive general internal medicine admissions to the Role 3 Hospital in Camp Bastion, Afghanistan. Up to four different symptoms and diagnoses were coded using the WHO International Classification of Disease, V.10 for each patient. RESULTS: A total of 1368 medical patients were admitted. Of 1131 military admissions, 612 were from the UK (54.1%) and the remainder from 13 allied countries; 237 civilians came from 23 countries. Civilians were older than the military patients (p<0.001) but included five children. The 20 most frequent presenting symptoms were identified and there were 1626 diagnoses made. The 10 most frequent diagnoses were infectious gastroenteritis (12.6%), heat illness (4.3%), pneumonia (3.6%), epilepsy (2.6%), cellulitis (2.7%), migraine (1.8%), peptic ulcer disease (1.2%), myocardial infarction (1.2%), venous thromboembolism (1.2%) and pericarditis (0.7%). In 252 cases (18.4%) a firm diagnosis was not reached and a symptom was recorded. The five most frequent of these were undifferentiated febrile illnesses (4.6%), syncope (3.7%), chest pain (2.8%), headache (0.8%) and palpitations (0.7%). The mean hospital length of stay was 1.59 days and 72.2% of UK military patients were 'returned to unit'. Three civilian patients died in hospital or following aeromedical evacuation and there were no deaths of any military patients. DISCUSSION: This study demonstrates the wide variety of presentations seen by physicians at an established military field hospital. This information informs the core syllabus of military physician training and will help facilitate planning for future medical support to similar military operations. TRIAL REGISTRATION NUMBER: RCDM/Res/Audit/1036/12/0305.

Use of an ultraviolet tracer in simulation training for the clinical management of Ebola virus disease.

In October 2014 the UK military deployed to Sierra Leone to provide care for healthcare workers affected by Ebola virus disease. A training package designed by the Army Medical Services Training Centre prepared the deploying personnel in the required infection prevention and control measures. The training used ultraviolet tracer to provide validation of the skills required when treating patients with Ebola and to confirm subsequent decontamination. This training construct provided useful feedback to clinicians on their infection control measures and would be useful in the context of any infection spread by droplets and fomites.

Comorbidity, health-related quality of life and self-care in type 2 diabetes: a cross-sectional study in an outpatient population.

BACKGROUND: Comorbid conditions may be related (concordant) or unrelated (discordant) to diabetes. Comorbidity in patients with type 2 diabetes (T2DM) is associated with reduced health-related quality of life (HRQoL) and self-care. AIM: To examine the impact of comorbidity on HRQoL and self-care in T2DM patients attending an outpatient setting. METHODS: A cross-sectional questionnaire was sent to 498 patients with T2DM, aged 25-80 years, previously attending (August 2011-July 2012) an outpatient diabetes service in a Dublin hospital. The EuroQoL-5 Dimension (EQ-5D) and a modified summary of diabetes self-care activities scale were used to assess HRQoL and self-care, respectively. Comorbidity was assessed using a simplified version of the self-administered comorbidity Questionnaire. Mann-Whitney and Kruskal-Wallis tests were used to examine the association between EQ-5D index scores or self-care, and the number and type of comorbidities. Multiple linear regression, adjusting for age and sex, was used to examine the association between EQ-5D score, comorbidity score and type. RESULT: EQ-5D scores decreased with an increasing number of comorbidities and with discordant comorbidity (P = 0.0001). Comorbidity type was associated with physical activity. The highest level of physical activity was reported in respondents with no comorbidity (median 4.5 IQR 3-6), while the lowest was in patients with both concordant and discordant comorbidity (median 2.5 IQR 0-5). CONCLUSIONS: Health professionals should be aware of the fall in HRQoL associated with comorbidity. This should be taken into account in the management of patients. Patients with discordant comorbidity should be advised and supported to maintain levels of physical activity.

Regional variation in medication-taking behaviour of new users of oral anti-hyperglycaemic therapy in Ireland.

BACKGROUND: Few studies have investigated regional variation in medication-taking behaviour. The purpose of this study was to investigate whether there are regional differences in non-persistence and non-adherence to oral anti-hyperglycaemic agents in patients initiating therapy and examine if any association exists between different types of comorbidity in terms of medication-taking behaviour. METHODS: The Irish Health Services Executive (HSE) pharmacy claims database was used to identify new users of metformin or sulphonylureas, aged ≥25 years, initiating therapy between June 2009 and December 2010. Non-persistence and non-adherence were examined up to 12 months post-initiation. Comorbidity was assessed using modified RxRisk and RxRisk-V indices, and classified as either concordant and/or discordant with diabetes. Adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs) for non-persistence were determined in relation to both HSE region and comorbidity type using Cox proportional hazards model, adjusting for age, sex and initial OAH prescribed. Logistic regression analysis, adjusting for these covariates, was used to determine the adjusted odds ratios (ORs) and 95% CIs for non-adherence for both HSE region and comorbidity type. RESULTS: Results showed little overall difference between regions. The largest reduction for both non-persistence (HR 0.86, 95% CI 0.80, 0.94) and non-adherence (OR 0.83, 95% CI 0.74, 0.93) was observed in the south. Any comorbidity was associated with a reduced risk of non-persistence and non-adherence. CONCLUSIONS: Interventions to optimise medication-taking in patients with T2DM should be implemented nationally to improve the overall level of adherence and persistence, especially in patients with no comorbidity.