A prospective, mixed-methods, before and after study to identify the evidence base for the core components of an effective Paediatric Early Warning System and the development of an implementation package containing those core recommendations for use in the UK: Paediatric early warning system - utilisation and mortality avoidance- the PUMA study protocol.

BACKGROUND: In hospital, staff need to routinely monitor patients to identify those who are seriously ill, so that they receive timely treatment to improve their condition. A Paediatric Early Warning System is a multi-faceted socio-technical system to detect deterioration in children, which may or may not include a track and trigger tool. It functions to monitor, detect and prompt an urgent response to signs of deterioration, with the aim of preventing morbidity and mortality. The purpose of this study is to develop an evidence-based improvement programme to optimise the effectiveness of Paediatric Early Warning Systems in different inpatient contexts, and to evaluate the feasibility and potential effectiveness of the programme in predicting deterioration and triggering timely interventions. METHODS: This study will be conducted in two district and two specialist children's hospitals. It deploys an Interrupted Time Series (ITS) design in conjunction with ethnographic cases studies with embedded process evaluation. Informed by Translational Mobilisation Theory and Normalisation Process Theory, the study is underpinned by a functions based approach to improvement. Workstream (1) will develop an evidence-based improvement programme to optimise Paediatric Early Warning System based on systematic reviews. Workstream (2) consists of observation and recording outcomes in current practice in the four sites, implementation of the improvement programme and concurrent process evaluation, and evaluation of the impact of the programme. Outcomes will be mortality and critical events, unplanned admission to Paediatric Intensive Care (PICU) or Paediatric High Dependency Unit (PHDU), cardiac arrest, respiratory arrest, medical emergencies requiring immediate assistance, reviews by PICU staff, and critical deterioration, with qualitative evidence of the impact of the intervention on Paediatric Early Warning System and learning from the implementation process. DISCUSSION: This paper presents the background, rationale and design for this mixed methods study. This will be the most comprehensive study of Paediatric Early Warning Systems and the first to deploy a functions-based approach to improvement in the UK with the aim to improve paediatric patient safety and reduce mortality. Our findings will inform recommendations about the safety processes for every hospital treating paediatric in-patients across the NHS. TRIAL REGISTRATION: Sponsor: Cardiff University, 30-36 Newport Road, Cardiff, CF24 0DE Sponsor ref.: SPON1362-14. Funder: National Institute for Health Research, Health Services & Delivery Research Programme (NIHR HS&DR) Funder reference: 12/178/17. Research Ethics Committee reference: 15/SW/0084 [13/04/2015]. PROSPERO reference: CRD42015015326 [23/01/2015]. ISRCTN: 94228292 https://doi.org/10.1186/ISRCTN94228292 [date of application 13/05/2015; date of registration: 18/08/2015]. Prospective registration prior to data collection and participant consent commencing in September 2014.

Insidious Risk of Severe Mycobacterium chimaera Infection in Cardiac Surgery Patients.

BACKGROUND: An urgent UK investigation was launched to assess risk of invasive Mycobacterium chimaera infection in cardiothoracic surgery and a possible association with cardiopulmonary bypass heater-cooler units following alerts in Switzerland and The Netherlands. METHODS: Parallel investigations were pursued: (1) identification of cardiopulmonary bypass-associated M. chimaera infection through national laboratory and hospital admissions data linkage; (2) cohort study to assess patient risk; (3) microbiological and aerobiological investigations of heater-coolers in situ and under controlled laboratory conditions; and (4) whole-genome sequencing of clinical and environmental isolates. RESULTS: Eighteen probable cases of cardiopulmonary bypass-associated M. chimaera infection were identified; all except one occurred in adults. Patients had undergone valve replacement in 11 hospitals between 2007 and 2015, a median of 19 months prior to onset (range, 3 months to 5 years). Risk to patients increased after 2010 from <0.2 to 1.65 per 10000 person-years in 2013, a 9-fold rise for infections within 2 years of surgery (rate ratio, 9.08 [95% CI, 1.81-87.76]). Endocarditis was the most common presentation (n = 11). To date, 9 patients have died. Investigations identified aerosol release through breaches in heater-cooler tanks. Mycobacterium chimaera and other pathogens were recovered from water and air samples. Phylogenetic analysis found close clustering of strains from probable cases. CONCLUSIONS: We identified low but escalating risk of severe M. chimaera infection associated with heater-coolers with cases in a quarter of cardiothoracic centers. Our investigations strengthen etiological evidence for the role of heater-coolers in transmission and raise the possibility of an ongoing, international point-source outbreak. Active management of heater-coolers and heightened clinical awareness are imperative given the consequences of infection.

Evaluation of recruitment and selection for specialty training in public health: interim results of a prospective cohort study to measure the predictive validity of the selection process.

BACKGROUND: The recruitment process for public health specialty training includes an assessment centre (AC) with three components, Rust Advanced Numerical Reasoning Appraisal (RANRA), Watson-Glaser Critical Thinking Appraisal (WGCT) and a Situation Judgement Test (SJT), which determines invitation to a selection centre (SC). The scores are combined into a total recruitment (TR) score that determines the offers of appointment. METHODS: A prospective cohort study using anonymous record linkage to investigate the association between applicant's scores in the recruitment process and registrar's progress through training measured by results of Membership Faculty Public Health (MFPH) examinations and outcomes of the Annual Review of Competence Progression (ARCP). RESULTS: Higher scores in RANRA, WGCT, AC, SC and TR were all significantly associated with higher adjusted odds of passing Part A MFPH exam at the first attempt. Higher scores in AC, SC and TR were significantly associated with passing Part B exam at the first attempt. Higher scores in SJT, AC and SC were significantly associated with satisfactory ARCP outcomes. CONCLUSIONS: The current UK national recruitment and selection process for public health specialty training has good predictive validity. The individual components of the process are testing different skills and abilities and together they are providing additive value.

Cluster of atypical adult Guillain-Barré syndrome temporally associated with neurological illness due to EV-D68 in children, South Wales, United Kingdom, October 2015 to January 2016.

We report a cluster of atypical Guillain-Barré syndrome in 10 adults temporally related to a cluster of four children with acute flaccid paralysis, over a 3-month period in South Wales, United Kingdom. All adult cases were male, aged between 24 and 77 years. Seven had prominent facial diplegia at onset. Available electrophysiological studies showed axonal involvement in five adults. Seven reported various forms of respiratory disease before onset of neurological symptoms. The ages of children ranged from one to 13 years, three of the four were two years old or younger. Enterovirus testing is available for three children; two had evidence of enterovirus D68 infection in stool or respiratory samples. We describe the clinical features, epidemiology and state of current investigations for these unusual clusters of illness.

Risk factors for outbreaks of COVID-19 in care homes following hospital discharge: A national cohort analysis.

BACKGROUND: The population of adult residential care homes has been shown to have high morbidity and mortality in relation to COVID-19. METHODS: We examined 3115 hospital discharges to a national cohort of 1068 adult care homes and subsequent outbreaks of COVID-19 occurring between 22 February and 27 June 2020. A Cox proportional hazards regression model was used to assess the impact of time-dependent exposure to hospital discharge on incidence of the first known outbreak, over a window of 7-21 days after discharge, and adjusted for care home characteristics, including size and type of provision. RESULTS: A total of 330 homes experienced an outbreak, and 544 homes received a discharge over the study period. Exposure to hospital discharge was not associated with a significant increase in the risk of a new outbreak (hazard ratio 1.15, 95% CI 0.89, 1.47, P = .29) after adjusting for care home characteristics. Care home size was the most significant predictor. Hazard ratios (95% CI) in comparison with homes of <10 residents were as follows: 3.40 (1.99, 5.80) for 10-24 residents; 8.25 (4.93, 13.81) for 25-49 residents; and 17.35 (9.65, 31.19) for 50+ residents. When stratified for care home size, the outbreak rates were similar for periods when homes were exposed to a hospital discharge, in comparison with periods when homes were unexposed. CONCLUSION: Our analyses showed that large homes were at considerably greater risk of outbreaks throughout the epidemic, and after adjusting for care home size, a discharge from hospital was not associated with a significant increase in risk.

Observations and monitoring: routine practices on the ward.

AIM: To review routine observations on all children admitted to the Children's Hospital for Wales and the feasibility of implementing an early warning score for children developing critical illness. METHOD: Nursing staff, while performing their routine duties, recorded the physiological observations of temperature, heart rate, respiratory rate and blood pressure, as well as identifying airway threat, recording oxygen saturation levels, level of consciousness using the AVPU scale (alert, responds to voice, responds to pain, unresponsive) and identifying if they had concerns about a child on a new paediatric observation chart. The clinical care policy for each ward determined the frequency of recording observations. RESULTS: Data were collected for 1,000 patients on whom 9,075 sets of observations were performed. Of those 9,075 sets, temperature was the most frequently recorded observation at 88.4% (95% confidence interval (CI) 87.7-89), followed by heart rate at 86.8% (95% CI 86.1-87.5), respiratory rate at 79.7% (95% CI 78.9-80.5), AVPU at 36.4% (95% CI 35.4-37.4) and blood pressure at 25.1% (95% CI 24.2-26.0). A complete set of observations needed for the Cardiff and Vale Paediatric Early Warning System to trigger effectively were only recorded in 52.7% (95% CI 52.4-53.1) of patients. CONCLUSION: There were variations in the frequency, type and recording of observations. This issue needs to be addressed if scoring systems are to be implemented. The findings of this observational study suggest that the required basic observations of acutely ill children are not being carried out.

Validity and effectiveness of paediatric early warning systems and track and trigger tools for identifying and reducing clinical deterioration in hospitalised children: a systematic review.

OBJECTIVE: To assess (1) how well validated existing paediatric track and trigger tools (PTTT) are for predicting adverse outcomes in hospitalised children, and (2) how effective broader paediatric early warning systems are at reducing adverse outcomes in hospitalised children. DESIGN: Systematic review. DATA SOURCES: British Nursing Index, Cumulative Index of Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effectiveness, EMBASE, Health Management Information Centre, Medline, Medline in Process, Scopus and Web of Knowledge searched through May 2018. ELIGIBILITY CRITERIA: We included (1) papers reporting on the development or validation of a PTTT or (2) the implementation of a broader early warning system in paediatric units (age 0-18 years), where adverse outcome metrics were reported. Several study designs were considered. DATA EXTRACTION AND SYNTHESIS: Data extraction was conducted by two independent reviewers using template forms. Studies were quality assessed using a modified Downs and Black rating scale. RESULTS: 36 validation studies and 30 effectiveness studies were included, with 27 unique PTTT identified. Validation studies were largely retrospective case-control studies or chart reviews, while effectiveness studies were predominantly uncontrolled before-after studies. Metrics of adverse outcomes varied considerably. Some PTTT demonstrated good diagnostic accuracy in retrospective case-control studies (primarily for predicting paediatric intensive care unit transfers), but positive predictive value was consistently low, suggesting potential for alarm fatigue. A small number of effectiveness studies reported significant decreases in mortality, arrests or code calls, but were limited by methodological concerns. Overall, there was limited evidence of paediatric early warning system interventions leading to reductions in deterioration. CONCLUSION: There are several fundamental methodological limitations in the PTTT literature, and the predominance of single-site studies carried out in specialist centres greatly limits generalisability. With limited evidence of effectiveness, calls to make PTTT mandatory across all paediatric units are not supported by the evidence base. PROSPERO REGISTRATION NUMBER: CRD42015015326.

Preventing household transmission of Shiga toxin-producing Escherichia coli O157 infection: promptly separating siblings might be the key.

BACKGROUND: Preventing household transmission of Shiga toxin-producing Escherichia coli O157 (STEC O157) infection is important because of the ease of interpersonal transmission and the potential disease severity. METHODS: We conducted a retrospective cohort study of households associated with an outbreak of STEC O157 infection in South Wales, United Kingdom, in autumn 2005. We investigated whether characteristics of the primary case patient or the household were predictors for secondary household transmission of STEC O157 infection. Furthermore, we estimated the proportion of cases that might be prevented by isolation (e.g., hospitalization) of the primary case patient immediately after the microbiological diagnosis and the number of patients with STEC O157 who would need to be isolated to prevent 1 case of hemolytic uremic syndrome. Based on dates of symptom onset, case patients in households were classified as having primary, coprimary, or secondary infection. Secondary cases were considered to be preventable if the secondary case patient's symptoms started >1 incubation period (4 days) after the date of microbiological diagnosis of the primary case. RESULTS: Eighty-nine (91%) of 98 eligible households were enrolled. Among 20 households (22%), 25 secondary cases were ascertained. Thirteen secondary cases (56%) occurred in siblings of the primary case patients; hemolytic uremic syndrome developed in 4 of these siblings. Presence of a sibling (risk ratio, 3.8; 95% confidence interval, 0.99-14.6) and young age (<5 years) of the primary case patient (risk ratio, 2.03; 95% confidence interval, 0.99-41.6) were independent predictors for households in which secondary cases occurred. Of the 15 secondary cases for which complete information was available, 7 (46%) might have been prevented. When restricting isolation to primary case patients who were aged <10 years and who had a sibling, we estimated the number of patients who would need to be isolated to prevent 1 case of hemolytic uremic syndrome to be 47 patients (95% confidence interval, 16-78 patients). CONCLUSIONS: Promptly separating pediatric patients with STEC O157 infection from their young siblings should be considered.

Containing antibiotic resistance: decreased antibiotic-resistant coliform urinary tract infections with reduction in antibiotic prescribing by general practices.

BACKGROUND: GPs are urged to prescribe antibiotics less frequently, despite lack of evidence linking reduced antibiotic prescribing with reductions in resistance at a local level. AIM: To investigate associations between changes in antibiotic dispensing and changes in antibiotic resistance at general-practice level. DESIGN OF STUDY: Seven-year study of dispensed antibiotics and antibiotic resistance in coliform isolates from urine samples routinely submitted from general practice. SETTING: General practices in Wales. METHOD: Multilevel modelling of trends in resistance to ampicillin and trimethoprim, and changes in practice total antibiotic dispensing and amoxicillin and trimethoprim dispensing. RESULTS: The primary analysis included data on 164 225 coliform isolates from urine samples submitted from 240 general practices over the 7-year study period. These practices served a population of 1.7 million patients. The quartile of practices that had the greatest decrease in total antibiotic dispensing demonstrated a 5.2% reduction in ampicillin resistance over the 7-year period with changes of 0.4%, 2.4%, and -0.3% in the other three quartiles. There was a statistically significant overall decrease in ampicillin resistance of 1.03% (95% confidence interval [CI] = 0.37 to 1.67%) per decrease of 50 amoxicillin items dispensed per 1000 patients per annum. There were also significant reductions in trimethoprim resistance in the two quartiles of practices that reduced total antibiotic dispensing most compared with those that reduced it least, with an overall decrease in trimethoprim resistance of 1.08% (95% CI = 0.065 to 2.10%) per decrease of 20 trimethoprim items dispensed per 1000 patients per annum. Main findings were confirmed by secondary analyses of 256 370 isolates from 527 practices that contributed data at some point during the study period. CONCLUSION: Reducing antibiotic dispensing at general-practice level is associated with reduced local antibiotic resistance. These findings should further encourage clinicians and patients to use antibiotics conservatively.

Long-term health effects after resolution of acute Cryptosporidium parvum infection: a 1-year follow-up of outbreak-associated cases.

We describe a longitudinal study carried out in an adult outbreak-associated cohort to investigate health effects, including post-infectious irritable bowel syndrome, occurring after resolution of acute Cryptosporidium parvum infection. New symptoms self-reported up to 12 months included: weight loss (31 %), abdominal pain (38 %), diarrhoea (33 %), eye pain (9 %), joint pain (33 %), fatigue (22 %) and symptoms consistent with irritable bowel syndrome (IBS) (28 %). Two people were medically diagnosed with IBS. This study describes for the first time sequelae reported by patients up to 12 months after infection with C. parvum, which appear to be similar to those described with C. hominis.

Fusidic acid resistance in community isolates of methicillin susceptible Staphylococcus aureus and the use of topical fusidic acid: a retrospective case-control study.

Resistance to fusidic acid among community methicillin susceptible Staphylococcus aureus (MSSA) isolates in the United Kingdom and prescriptions for fusidic acid have both doubled over the past 6 years. A retrospective case-control study was undertaken to test the hypothesis that the use of topical fusidic acid is associated with the isolation of resistant organisms. A statistically significant association was found between fusidic acid resistance in MSSA isolates and exposure to topical fusidic acid (odds ratio: 2.77, 95% CI 1.01-7.93, P = 0.027). This study demonstrates for the first time an association between the use of topical fusidic acid and resistance at the individual patient level and supports the hypothesis that the observed increase in resistance is causally associated with the increased use of topical fusidic acid.

Enter the dragon--China's journey to the hearing world.

CONTEXT: China's population of 1.3 billion represents nearly 20% of the world's population. The current live birth rate in China is 17 million per year, compared with 4.1 million in the USA in 2009. Ministry of Health figures from China identify 115,000 children under the age of 7 years with severe-to-profound deafness and 30,000 babies born each year with hearing impairment. NEWBORN SCREENING: Universal Newborn Hearing Screening (UNHS) has been implemented in China since 1999. By 2010 UNHS was implemented in 20 of the 32 Chinese provinces. In large cities 95% of babies are screened in hospital-based programs. In more remote areas babies with high-risk factors for hearing loss are referred to screening centers within 1 month of birth and leaflets about identifying deafness are distributed. COCHLEAR IMPLANTS: Since 1995 more than 10,000 people in China have received cochlear implants (CIs) and 85% of these implant recipients have been children under the age of 7 years. FINANCING OF CIs: China is in the process of developing a national reimbursement scheme for medical care. The first multichannel implant was performed in 1995. In 2005, a private financier provided more than 1500 implants for children under the age of 5 years. In 2009, the Chinese government set up a project to implant 1500 children aged 1-5 years over the next 3 years, with provision of the equivalent of US$65.4 million to pay for the devices, surgery, mapping, and rehabilitation. By 2011, the government had agreed to fund implants for an additional 17,000 children over 4 years. TRAINING OF PROFESSIONALS: Schemes have been developed to train surgeons, Audiologists, and those involved in rehabilitation of implanted children in China. OUTCOME ASSESSMENT: Standardized outcome tests are being developed for CI recipients. There are two large-scale ongoing outcome studies in progress. CI penetration in China is currently less than 5% of potential pediatric candidates, but cochlear implantation is continuing to expand at great speed, and it is hoped that the infrastructure and capacity will continue to grow and develop.

The transmission of tuberculosis in schools involving children 3 to 11 years of age.

Little is known about the risk of tuberculosis transmission from children. We reviewed the published literature on the transmission of tuberculosis during outbreaks involving children 3 to 11 years of age and report that transmission rates among close contacts in school outbreaks are on average higher (weighted average 69.8% vs. 39.3%) if the index case is a child than an adult.

Selection into specialty training in public health: performance of the Medical Training Application Service shortlisting.

OBJECTIVE: To assess the performance of shortlisting against appointability to public health specialty training under the Medical Training Application Service (MTAS) selection methodology using multiple modality in person assessment. METHODS: Candidates who had applied to public health specialty training programme in Wales and East of England and shortlisted were assessed in the first assessment round. Further to MTAS review, candidates not previously short listed were offered assessment in the second round. Receiver operating characteristic (ROC) analysis was done. RESULTS: In both the programmes, the shortlisting scores of candidates considered appointable were substantially higher than those considered not appointable, a score difference of 13.0 (95% confidence interval (CI) 3.0-23.0) and 13.5 (95% CI 3.4-23.5) respectively. The area under the ROC curve (ROCAUC) was 0.88 (95% CI 0.63-1.00) in Wales and 0.77 (95% CI 0.57-0.97) in East of England. The shortlisting scores of the two programmes that gave an optimum performance (maximum sum of the sensitivity and specificity) were comparable (scores of 62 and 63 respectively). CONCLUSION: MTAS shortlisting undertaken in two independent public health specialty training programmes discriminated well between appointable and not appointable candidates.

Surveillance of influenza immunisation uptake in people aged under 65 years with chronic disease.

Historically, it has been difficult to obtain population based data on the uptake of influenza immunisation in people aged under 65 years who are at risk of serious illness or death from influenza and its complications. Data obtained electronically from 96% of all practices in Wales demonstrated that uptake in this group is low, with only a quarter of eligible patients immunised. Uptake varies considerably between patient groups and between geographical areas. This suggests an opportunity for significant health gain from targeted interventions to improve uptake.

When do general practitioners request urine specimens for microbiology analysis? The applicability of antibiotic resistance surveillance based on routinely collected data.

OBJECTIVES: We do not know how representative reported levels of resistance to antibiotics in urinary tract infections (UTIs) are as there is wide variation in the rate of urine specimens submitted to microbiology laboratories by general practices. We used a questionnaire to investigate variation in sampling for patients with suspected UTI to explore any systematic bias that may influence interpretation of surveillance data based on routine data. METHODS: We sent a questionnaire to a stratified random sample of general practitioners (GPs) in Wales for self-completion. The GPs were presented with six clinical scenarios and asked about their proposed clinical management. RESULTS: We found that nearly all of the GPs indicated they would request a specimen for scenarios representing a probable UTI in a female child and a probable asymptomatic UTI in pregnancy. There was some variation between the GPs about sampling in a situation of treatment failure in an older woman and recurrent UTI in a male diabetic, with 90% and 81%, respectively, indicating they would request a specimen for these scenarios. The greatest variation was in relation to scenarios concerning the management of a probable uncomplicated UTI, and early patient symptoms with pressure to prescribe, with 56% and 33% of GPs, respectively, indicating they would request a urine specimen for laboratory analysis. CONCLUSIONS: In the light of this reported sampling behaviour, it is likely that there is a systematic bias in surveillance data based on routinely collected data, with samples from cases of uncomplicated UTI being under represented, potentially leading to an overestimation of true resistance rates.

Immunisation status in the public care system: a comparative study.

Children in public care have poor health outcomes despite statutory health assessments. Incomplete immunisation of children entering the care system has been reported. Does this health disadvantage persist for those established in the care system? The immunisation status of 119 children in public care for at least 6 months was compared to that noted in 119 age and sex matched children living in their own homes. Children in public care were significantly less likely to have received immunisations against diphtheria, tetanus, pertussis and polio, than the comparison group. This represents a persisting health disadvantage, which requires remedial action.

Fusidic acid resistance in community isolates of methicillin-susceptible Staphylococcus aureus and fusidic acid prescribing.

The level of resistance to fusidic acid among community methicillin-susceptible Staphylococcus aureus (MSSA) isolates in the UK and prescriptions for fusidic acid have both doubled over the past 6 years. It is hypothesized that selective pressure arising from topical use of fusidic acid in the community accounts for this increase. A significant correlation was found between prescribing of fusidic acid and resistance at the practice level (Spearman's rho = 0.46, 95% confidence interval 0.11-0.71, P = 0.01). Further controlled studies are required to determine whether this association is causal.

Enhanced surveillance of primary measles mumps and rubella (MMR) immunisation in Wales.

In England and Wales routinely available data measure uptake of the measles mumps and rubella (MMR) vaccine at 2 years. This results in a delay in detecting change in uptake of the vaccine, which is scheduled at 12 months of age. The predictive value of uptake at 15-17 months is limited by the greater variability in uptake between quarters at the younger age. This can be overcome by presenting the data as a four-quarter annual rolling average. Uptake of the MMR vaccine at 2 years of age in Wales is predicted to stabilise at around 84% in the first three quarters of 2002.

Q fever outbreak in industrial setting.

An outbreak of Q fever occurred in South Wales, United Kingdom, from July 15 through September 30, 2002. To investigate the outbreak a cohort and nested case-control study of persons who had worked at a cardboard manufacturing plant was conducted. The cohort included 282 employees and subcontractors, of whom 253 (90%) provided blood samples and 214 (76%) completed questionnaires. Ninety-five cases of acute Q fever were identified. The epidemic curve and other data suggested an outbreak source likely occurred August 5-9, 2002. Employees in the factory's offices were at greatest risk for infection (odds ratio 3.46; 95% confidence interval 1.38-9.06). The offices were undergoing renovation work around the time of likely exposure and contained straw board that had repeatedly been drilled. The outbreak may have been caused by aerosolization of Coxiella burnetii spore-like forms during drilling into contaminated straw board.