Novel methods for estimating the instantaneous and overall COVID-19 case fatality risk among care home residents in England.

The COVID-19 pandemic has had high mortality rates in the elderly and frail worldwide, particularly in care homes. This is driven by the difficulty of isolating care homes from the wider community, the large population sizes within care facilities (relative to typical households), and the age/frailty of the residents. To quantify the mortality risk posed by disease, the case fatality risk (CFR) is an important tool. This quantifies the proportion of cases that result in death. Throughout the pandemic, CFR amongst care home residents in England has been monitored closely. To estimate CFR, we apply both novel and existing methods to data on deaths in care homes, collected by Public Health England and the Care Quality Commission. We compare these different methods, evaluating their relative strengths and weaknesses. Using these methods, we estimate temporal trends in the instantaneous CFR (at both daily and weekly resolutions) and the overall CFR across the whole of England, and dis-aggregated at regional level. We also investigate how the CFR varies based on age and on the type of care required, dis-aggregating by whether care homes include nursing staff and by age of residents. This work has contributed to the summary of measures used for monitoring the UK epidemic.

Case-control study to estimate odds of death within 28 days of positive test for SARS-CoV-2 prior to vaccination for residents of long-term care facilities in England, 2020-2021.

BACKGROUND: Persons living in long-term care facilities (LTCFs) are presumed to be at higher risk of adverse outcomes from SARS-CoV-2 infection due to increasing age and frailty, but the magnitude of increased risk is not well quantified. METHODS: After linking demographic and mortality data for cases with confirmed SARS-CoV-2 infection between March 2020 and January 2021 in England, a random sample of 6000 persons who died and 36 000 who did not die within 28 days of a positive test was obtained from the dataset of 3 020 800 patients. Based on an address-matching process, the residence type of each case was categorised into one of private home and residential or nursing LTCF. Univariable and multivariable logistic regression analysis was conducted. RESULTS: Multivariable analysis showed that an interaction effect between age and residence type determined the outcome. Compared with a 60-year-old person not living in LTCF, the adjusted OR (aOR) for same-aged persons living in residential and nursing LTCFs was 1.77 (95% CI 1.21 to 2.6, p=0.0017) and 3.95 (95% CI 2.77 to 5.64, p<0.0001), respectively. At 90 years of age, aORs were 0.87 (95% CI 0.72 to 1.06, p=0.21) and 0.74 (95% CI 0.61 to 0.9, p=0.001), respectively. The model had an overall accuracy of 94.2% (94.2%) when applied to the full dataset of 2 978 800 patients. CONCLUSION: This study found that residents of LTCFs in England had higher odds of death up to 80 years of age. Beyond 80 years, there was no difference in the odds of death for LTCF residents compared with those in the wider community.

Outbreaks in care homes may lead to substantial disease burden if not mitigated.

The number of COVID-19 outbreaks reported in UK care homes rose rapidly in early March of 2020. Owing to the increased co-morbidities and therefore worse COVID-19 outcomes for care home residents, it is important that we understand this increase and its future implications. We demonstrate the use of an SIS model where each nursing home is an infective unit capable of either being susceptible to an outbreak (S) or in an active outbreak (I). We use a generalized additive model to approximate the trend in growth rate of outbreaks in care homes and find the fit to be improved in a model where the growth rate is proportional to the number of current care home outbreaks compared with a model with a constant growth rate. Using parameters found from the outbreak-dependent growth rate, we predict a 73% prevalence of outbreaks in UK care homes without intervention as a reasonable worst-case planning assumption. This article is part of the theme issue 'Modelling that shaped the early COVID-19 pandemic response in the UK'.

Can syndromic surveillance help forecast winter hospital bed pressures in England?

BACKGROUND: Health care planners need to predict demand for hospital beds to avoid deterioration in health care. Seasonal demand can be affected by respiratory illnesses which in England are monitored using syndromic surveillance systems. Therefore, we investigated the relationship between syndromic data and daily emergency hospital admissions. METHODS: We compared the timing of peaks in syndromic respiratory indicators and emergency hospital admissions, between 2013 and 2018. Furthermore, we created forecasts for daily admissions and investigated their accuracy when real-time syndromic data were included. RESULTS: We found that syndromic indicators were sensitive to changes in the timing of peaks in seasonal disease, especially influenza. However, each year, peak demand for hospital beds occurred on either 29th or 30th December, irrespective of the timing of syndromic peaks. Most forecast models using syndromic indicators explained over 70% of the seasonal variation in admissions (adjusted R square value). Forecast errors were reduced when syndromic data were included. For example, peak admissions for December 2014 and 2017 were underestimated when syndromic data were not used in models. CONCLUSION: Due to the lack of variability in the timing of the highest seasonal peak in hospital admissions, syndromic surveillance data do not provide additional early warning of timing. However, during atypical seasons syndromic data did improve the accuracy of forecast intensity.

Challenges of investigating a large food-borne norovirus outbreak across all branches of a restaurant group in the United Kingdom, October 2016.

During October and November 2016, over 1,000 customers and staff reported gastroenteritis after eating at all 23 branches of a restaurant group in the United Kingdom. The outbreak coincided with a new menu launch and norovirus was identified as the causative agent. We conducted four retrospective cohort studies; one among all restaurant staff and three in customers at four branches. We investigated the dishes consumed, reviewed recipes, interviewed chefs and inspected restaurants to identify common ingredients and preparation methods for implicated dishes. Investigations were complicated by three public health agencies concurrently conducting multiple analytical studies, the complex menu with many shared constituent ingredients and the high media attention. The likely source was a contaminated batch of a nationally distributed ingredient, but analytical studies were unable to implicate a single ingredient. The most likely vehicle was a new chipotle chilli product imported from outside the European Union, that was used uncooked in the implicated dishes. This outbreak exemplifies the possibility of rapid spread of infectious agents within a restaurant supply chain, following introduction of a contaminated ingredient. It underlines the importance of appropriate risk assessments and control measures being in place, particularly for new ingredients and ready-to-eat foods.

Detection in the United Kingdom of the Neisseria gonorrhoeae FC428 clone, with ceftriaxone resistance and intermediate resistance to azithromycin, October to December 2018.

We describe detection in the United Kingdom (UK) of the drug-resistant Neisseria gonorrhoeae FC428 clone, with ceftriaxone resistance and intermediate azithromycin resistance. Two female patients developed infection following contact with UK-resident men from the same sexual network linked to travel to Ibiza, Spain. One case failed treatment with ceftriaxone, and azithromycin and gentamicin, before successful treatment with ertapenem. Both isolates had indistinguishable whole-genome sequences. Urgent action is essential to contain this drug-resistant strain.

An unusual outbreak of norovirus associated with a Halloween-themed swimming pool party in England, 2016.

In October 2016, an outbreak of norovirus occurred among attendees of a Halloween-themed party at a public swimming pool in the south-east of England. Norovirus genogroup II was confirmed in 11 cases. In the retrospective cohort study of pool users, 68 individuals (37 female and 31 male), with a median age of 11 years (range: 0-50 years), met the case definition of developing diarrhoea or vomiting between 6 and 72 h after the pool visit. Multivariable analysis showed that increasing age was associated with a reduced risk of illness (odds ratio = 0.91; 95% confidence interval: 0.83-0.99). Pool behaviours (swallowing water) and the timing of visit (attending pool party after automatic dosing system was switched off) were independently associated with increased risk. Environmental investigations revealed that the automatic dosing system was switched off to reduce chlorine levels to an intended range of 0.5-1 parts per million to facilitate the use of a commercial red dye. There was a lack of compliance with the operator's own pool operating procedures, particularly on maintaining effective chlorine levels in pool water, recording of test results and recording of actions undertaken. This outbreak highlights the risks of lowering chlorine levels when using pool water colourants.

Evaluation of equity in diabetes health care in relation to African and Caribbean ethnicity.

OBJECTIVE: Many US studies have shown that ethnic minority groups have less access to health care. We evaluated whether black African and black Caribbean people with diabetes in the UK gain access to diabetes health care on an equitable basis compared with white people. DESIGN: Cross-sectional questionnaire survey set in 29 general practices in south London. Main measures were self-reported morbidity, SF-36 scores and utilisation of health care. Analyses of utilisation variables were adjusted for age, sex, ethnic group, duration of diabetes, and socio-economic and health status. RESULTS: There were 1,899 respondents (64%) from 2,983 individuals registered with diabetes. These included 799 white, 522 black Caribbean, 163 black African and 415 other subjects with type 2 diabetes. After adjusting for need, black Caribbeans reported higher utilisation of health care than white subjects for four of nine utilisation variables, and black Africans for two. For the remaining variables utilisation was equivalent in different ethnic groups. Black Caribbean subjects were more likely to be treated for hypertension if hypertensive (odds ratio 1.84, 95% CI 1.05 to 3.22), to use blood or urine self-monitoring (1.40, 1.04 to 1.88) and to have attended a diabetes nurse (1.34, 1.04 to 1.74) or dietician (1.49, 1.19 to 1.86). Black Africans were more likely to have attended a dietician (2.15, 1.40 to 3.29) or an ophthalmologist (1.72, 1.10 to 2.70) in the past year. CONCLUSION: There was no evidence from this study that black African or black Caribbean subjects had less access to diabetes health care in relation to need.

Beware the BCG failures: a review of one institution's results.

OBJECTIVE: To review the outcome of all superficial transitional cell (TCC) bladder cancer treated with intravesical Bacille Calmette-Guerin (BCG) at one institution and, in particular, the prognosis for those patients who gained little benefit from BCG therapy. PATIENTS AND METHODS: The notes of 122 patients treated with BCG over a nine-year period were reviewed. The following details were recorded: time of diagnosis; time of decision to treat with BCG; results of cystoscopies before and after BCG; duration of follow up; time of progression if occurred, mortality and cause of death. RESULTS: Complete follow up data was available for 112 patients. At a median follow up of 23 months (range 3-107) 57 patients (51%) remained free of tumour, 30 (27%) had progressed and 18 (16%) had died of transitional cell carcinoma. There was a significant association between a positive initial check cystoscopy and subsequent progression (p<0.001) and disease specific mortality (p<0.001). Of the 35 patients who had a positive cystoscopy after BCG treatment 21 (60%) progressed and 14 (40%) died of transitional cell carcinoma compared with 9 (12%) and 4 (5%) of the 77 with a negative cystoscopy. Adjusted odds ratios for progression and death from TCC for patients with a positive initial check cystoscopy were 21 and 13, respectively. CONCLUSION: In our series the patients found to have tumour at the initial check cystoscopy following intravesical BCG had a poor prognosis. This should be remembered when considering treatment options and counselling patients. Follow up of all BCG patients need to be rigorous and protocols would help to unify the treatment patients receive.