Wastewater monitoring for detection of public health markers during the COVID-19 pandemic: Near-source monitoring of schools in England over an academic year.

BACKGROUND: Schools are high-risk settings for infectious disease transmission. Wastewater monitoring for infectious diseases has been used to identify and mitigate outbreaks in many near-source settings during the COVID-19 pandemic, including universities and hospitals but less is known about the technology when applied for school health protection. This study aimed to implement a wastewater surveillance system to detect SARS-CoV-2 and other public health markers from wastewater in schools in England. METHODS: A total of 855 wastewater samples were collected from 16 schools (10 primary, 5 secondary and 1 post-16 and further education) over 10 months of school term time. Wastewater was analysed for SARS-CoV-2 genomic copies of N1 and E genes by RT-qPCR. A subset of wastewater samples was sent for genomic sequencing, enabling determination of the presence of SARS-CoV-2 and emergence of variant(s) contributing to COVID-19 infections within schools. In total, >280 microbial pathogens and >1200 AMR genes were screened using RT-qPCR and metagenomics to consider the utility of these additional targets to further inform on health threats within the schools. RESULTS: We report on wastewater-based surveillance for COVID-19 within English primary, secondary and further education schools over a full academic year (October 2020 to July 2021). The highest positivity rate (80.4%) was observed in the week commencing 30th November 2020 during the emergence of the Alpha variant, indicating most schools contained people who were shedding the virus. There was high SARS-CoV-2 amplicon concentration (up to 9.2x106 GC/L) detected over the summer term (8th June - 6th July 2021) during Delta variant prevalence. The summer increase of SARS-CoV-2 in school wastewater was reflected in age-specific clinical COVID-19 cases. Alpha variant and Delta variant were identified in the wastewater by sequencing of samples collected from December to March and June to July, respectively. Lead/lag analysis between SARS-CoV-2 concentrations in school and WWTP data sets show a maximum correlation between the two-time series when school data are lagged by two weeks. Furthermore, wastewater sample enrichment coupled with metagenomic sequencing and rapid informatics enabled the detection of other clinically relevant viral and bacterial pathogens and AMR. CONCLUSIONS: Passive wastewater monitoring surveillance in schools can identify cases of COVID-19. Samples can be sequenced to monitor for emerging and current variants of concern at the resolution of school catchments. Wastewater based monitoring for SARS-CoV-2 is a useful tool for SARS-CoV-2 passive surveillance and could be applied for case identification and containment, and mitigation in schools and other congregate settings with high risks of transmission. Wastewater monitoring enables public health authorities to develop targeted prevention and education programmes for hygiene measures within undertested communities across a broad range of use cases.

Impact of the COVID-19 pandemic on antimicrobial stewardship support for general practices in England: a qualitative interview study.

BACKGROUND: In England, Clinical Commissioning Group (CCG) (now replaced by Integrated Care Systems (ICS)) and Primary Care Network (PCN) professionals support primary care prescribers to optimise antimicrobial stewardship (AMS). AIM: To explore views and experiences of CCG/PCN staff in supporting AMS, and the impact of COVID-19 on this support. DESIGN AND SETTING: Qualitative interview study in primary care in England. METHOD: Semi-structured interviews-with staff from CCG/PCNs responsible for AMS-at two time-points, via telephone interviews. These were audio-recorded, transcribed, and analysed thematically. RESULTS: Twenty-seven interviews were conducted with 14 participants (nine CCG, five PCN) in Dec 2020/Jan 2021 and Feb/Mar 2021.We found that AMS support was 1) deprioritised- to keep general practice operational and deliver COVID-19 vaccines; 2) disrupted-as social distancing made it harder to build relationships, conduct routine AMS activities, and challenge prescribing decisions; and 3) adapted-with opportunities identified for greater use of technology and from changed patient/public perceptions of viruses and self-care. We also found that resources to support AMS were valued if they were both novel, to counter AMS 'fatigue', and sufficiently familiar to fit with existing/future AMS. CONCLUSION: AMS needs to be reprioritised in general practice in the post-pandemic era and within the new ICS in England. This should include interventions/strategies that combine novel elements with already familiar strategies to refresh prescribers' motivation and opportunity for AMS. Behaviour change interventions should be aimed at improving the culture and processes for how PCN pharmacists voice concerns about AMS to prescribers in general practice and take advantage of the changed patient/public perceptions of viruses and self-care.

Impact of COVID-19 vaccination on COVID-19 hospital admissions in England during 2021: an observational study.

OBJECTIVES: To examine the impact of COVID-19 vaccination on hospital admissions in England in 2021. DESIGN: Observational study of emergency admissions for COVID-19 by vaccination status in people 16 years and over in England. SETTING: Hospitals in England. PARTICIPANTS: A total of 48.1 million people registered with an English GP, aged ≥16 years with a recent NHS contact. MAIN OUTCOME MEASURES: Emergency hospital admissions with a primary diagnosis of COVID-19 between 1 January and 31 December 2021. Monthly admission rates were directly standardised for age, sex, risk category and vaccination dose to estimate vaccine effectiveness (VE) over time, between vaccine doses, age groups and risk groups. RESULTS: A total of 192,047 hospital admissions were included. The unvaccinated admission rate was higher in December 2021 (6.1 admissions per 100,000 person-days; 95% CI: 5.9 to 6.3) than January 2021 (4.9; 95% CI: 4.9 to 5.0). Vaccinated admission rates were ≤1 per 100,000 from February to December. Doses 1 and 2 VE waned over time, particularly in older and clinically vulnerable groups (although this may reflect that they were vaccinated earlier). Dose 3 VE remained above 93%. CONCLUSIONS: COVID-19 hospitalisations were consistently highest in the unvaccinated. Despite high case rates at the end of 2021, overall admission rates remained stable, driven by low admission rates among vaccinated people. There is population-level waning in VE, recovering after subsequent doses, potentially more marked in older and at-risk groups. The findings support JCVI (Joint Committee on Vaccination and Immunisation) guidance for an ongoing booster programme, especially in older people and higher clinical risk groups.

Characteristics associated with influenza vaccination uptake in pregnancy: a retrospective cohort study.

BACKGROUND: Pregnant women are at increased risk from influenza, yet maternal influenza vaccination levels remain suboptimal. AIM: To estimate associations between sociodemographic and health characteristics and seasonal influenza vaccination uptake among pregnant women, and to understand trends over time to inform interventions to improve vaccine coverage. DESIGN AND SETTING: Retrospective cohort study using linked electronic health records of women in North West London with a pregnancy overlapping an influenza season between September 2010 and February 2020. METHOD: A multivariable mixed-effects logistic regression model was used to identify associations between characteristics of interest and the primary outcome of influenza vaccination. RESULTS: In total, 451 954 pregnancies, among 260 744 women, were included. In 85 376 (18.9%) pregnancies women were vaccinated against seasonal influenza. Uptake increased from 8.4% in 2010/11 to 26.4% in 2017/18, dropping again to 21.1% in 2019/20. Uptake was lowest among women aged 15-19 years (11.9%; reference category) or ≥40 years (15.2%; odds ratio [OR] 1.17, 95% confidence interval [CI] = 1.10 to 1.24); of Black (14.1%; OR 0.55, 95% CI = 0.53 to 0.57) or unknown ethnicity (9.9%; OR 0.42, 95% CI = 0.39 to 0.46); who lived in more deprived areas (OR least versus most deprived [reference category] 1.16, 95% CI = 1.11 to 1.21); or with no known risk factors for severe influenza. CONCLUSION: Seasonal influenza vaccine uptake in pregnant women increased in the decade before the COVID-19 pandemic, but remained suboptimal. Targeted approaches are recommended to reducing inequalities in access to vaccination and should focus on women of Black ethnicity, younger and older women, and women living in deprived areas.

A qualitative study of factors influencing COVID-19 vaccine hesitancy among South Asians in London.

Objectives: This qualitative study sought to elicit the views and experiences of patients and health-care professionals to identify the factors associated with COVID-19 vaccine hesitancy among South Asians in London. Design: In-depth semi-structured telephone and virtual interviews. Setting: UK. Participants: Convenience and purposive sample of 12 individuals including patients, clinicians, and a medical receptionist. Main Outcome Measures: Our dataset identifies and explains the reasons for distinguishing between those individuals who are COVID-19 vaccine-hesitant, and those who are COVID-19 vaccine-anxious. Results: COVID-19 vaccine hesitancy and the decision on whether to - or not to - vaccinate against COVID-19 involves ongoing and unresolved inner conflict about COVID-19 vaccines. Our findings therefore suggest that some individuals may be existing in a state of inbetweeness; where they are neither pro nor anti vaccination, while simultaneously questioning the many 'truths' surrounding COVID-19 and not just one truth such as the safety of COVID-19 vaccines. We argue that this in-between state is intensified by technology and social media; culminating in the Rashomon Effect, whereby a combination of truths, fractured truths, subjective realities, and unreliable or contradictory sources impact on our perceptions of COVID-19. Conclusions: Given the complexities arising from the multiple factors influencing vaccine hesitancy and scepticism, 'quick fixes' and 'one size fits all' solutions to address COVID-19 vaccine hesitancy will be ineffective. Therefore, promoting trust and prioritising good after-care as well as on-going care as a response to the effects of the pandemic is vital.

How did the first covid-19 lockdown affect general practitioner contacts with children and young people?

AimsTo examine the impact of the covid-19 pandemic on total, face to face and remote general practitioner (GP) contacts with children and young people aged under 25 years in England before and after the first lockdown in the United Kingdom (March to June 2020).MethodsLongitudinal trends analysis using electronic health records from the nationally representative Clinical Practice Research Datalink Aurum database. We included all children and young people aged <25 years registered with a GP anytime during the study period (January 2015 to October 2020). We assigned their GP contacts according to their age (years) on the date of the contact: <1, 1-4, 5-9, 10-14, 15-19, 20-24.Our main outcomes were total, face-to-face and remote weekly contacts with a GP. Secondary outcomes were weekly contacts with GPs for respiratory illnesses (upper respiratory tract infections, lower respiratory tract infections and asthma) and common non-transmissible conditions (urinary tract infections, diabetes, epilepsy and appendicitis). For all outcomes, we compared the number of contacts during the first UK lockdown (March to June 2020) with the mean number of contacts for comparable weeks from 2015 to 2019.ResultsOur study population included 4 307 120 million children and young people who had 47 607 765 GP contacts. Total GP contacts fell by 40.7% (95% CI: 40.7, 40.8) during the first lockdown compared with previous years. Children aged 1-14 years had greater falls in total contacts (>50%) compared with infants and those aged 15-24 years. Face-to-face contacts fell by 88.3% (95% CI: 88.2, 88.4) for all ages. The greatest falls in face-to-face contacts occurred among children aged 1-14 (> 90%), whereas face-to-face contacts with infants fell by 76.8% (95% CI: 76.6, 77.0). Remote contacts more than doubled, increasing most in infants (over 2.5 fold). Total contacts for respiratory illnesses fell by 74% whereas contacts for common non-transmissible conditions shifted largely to remote and fell by 31%.ConclusionChildren and young people’s contact with GPs fell, particularly for face-to-face assessment during the first pandemic lockdown, with notably fewer contacts for respiratory illnesses. This change reflects a combination of altered healthcare seeking behaviour, lower prevalence of some conditions (notably fewer respiratory illnesses due to fewer social contacts), and changes in service provision. A major shift from face-to-face to remote contacts for common non-transmissible conditions mitigated overall falls.

Modification and Validation of an mHealth App Quality Assessment Methodology for International Use: Cross-sectional and eDelphi Studies.

BACKGROUND: Over 325,000 mobile health (mHealth) apps are available to download across various app stores. However, quality assurance in this field of medicine remains relatively undefined. Globally, around 84% of the population have access to mobile broadband networks. Given the potential for mHealth app use in health promotion and disease prevention, their role in patient care worldwide is ever apparent. Quality assurance regulations both nationally and internationally will take time to develop. Frameworks such as the Mobile App Rating Scale and Enlight Suite have demonstrated potential for use in the interim. However, these frameworks require adaptation to be suitable for international use. OBJECTIVE: This study aims to modify the Enlight Suite, a comprehensive app quality assessment methodology, to improve its applicability internationally and to assess the preliminary validity and reliability of this modified tool in practice. METHODS: A two-round Delphi study involving 7 international mHealth experts with varied backgrounds in health, technology, and clinical psychology was conducted to modify the Enlight Suite for international use and to improve its content validity. The Modified Enlight Suite (MES) was then used by 800 health care professionals and health care students in Ireland to assess a COVID-19 tracker app in an online survey. The reliability of the MES was assessed using Cronbach alpha, while the construct validity was evaluated using confirmatory factor analysis. RESULTS: The final version of the MES has 7 sections with 32 evaluating items. Of these items, 5 were novel and based on consensus for inclusion by Delphi panel members. The MES has satisfactory reliability with a Cronbach alpha score of .925. The subscales also demonstrated acceptable internal consistency. Similarly, the confirmatory factor analysis demonstrated a positive and significant factor loading for all 32 items in the MES with a modestly acceptable model fit, thus indicating the construct validity of the MES. CONCLUSIONS: The Enlight Suite was modified to improve its international relevance to app quality assessment by introducing new items relating to cultural appropriateness, accessibility, and readability of mHealth app content. This study indicates both the reliability and validity of the MES for assessing the quality of mHealth apps in a high-income country, with further studies being planned to extrapolate these findings to low- and middle-income countries.

Monitoring occurrence of SARS-CoV-2 in school populations: A wastewater-based approach.

Clinical testing of children in schools is challenging, with economic implications limiting its frequent use as a monitoring tool of the risks assumed by children and staff during the COVID-19 pandemic. Here, a wastewater-based epidemiology approach has been used to monitor 16 schools (10 primary, 5 secondary and 1 post-16 and further education) in England. A total of 296 samples over 9 weeks have been analysed for N1 and E genes using qPCR methods. Of the samples returned, 47.3% were positive for one or both genes with a detection frequency in line with the respective local community. WBE offers a low cost, non-invasive approach for supplementing clinical testing and can provide longitudinal insights that are impractical with traditional clinical testing.

Patient outcomes following emergency admission to hospital for COVID-19 compared with influenza: retrospective cohort study.

BACKGROUND: We examine differences in posthospitalisation outcomes, and health system resource use, for patients hospitalised with COVID-19 during the UK's first pandemic wave in 2020, and influenza during 2018 and 2019. METHODS: This retrospective cohort study used routinely collected primary and secondary care data. Outcomes, measured for 90 days follow-up after discharge were length of stay in hospital, mortality, emergency readmission and primary care activity. RESULTS: The study included 5132 patients admitted to hospital as an emergency, with COVID-19 and influenza cohorts comprising 3799 and 1333 patients respectively. Patients in the COVID-19 cohort were more likely to stay in hospital longer than 10 days (OR 3.91, 95% CI 3.14 to 4.65); and more likely to die in hospital (OR 11.85, 95% CI 8.58 to 16.86) and within 90 days of discharge (OR 7.92, 95% CI 6.20 to 10.25). For those who survived, rates of emergency readmission within 90 days were comparable between COVID-19 and influenza cohorts (OR 1.07, 95% CI 0.89 to 1.29), while primary care activity was greater among the COVID-19 cohort (incidence rate ratio 1.30, 95% CI 1.23 to 1.37). CONCLUSIONS: Patients admitted for COVID-19 were more likely to die, more likely to stay in hospital for over 10 days and interact more with primary care after discharge, than patients admitted for influenza. However, readmission rates were similar for both groups. These findings, while situated in the context of the first wave of COVID-19, with the associated pressures on the health system, can inform health service planning for subsequent waves of COVID-19, and show that patients with COVID-19 interact more with healthcare services as well as having poorer outcomes than those with influenza.

Impact of COVID-19 on primary care contacts with children and young people in England: longitudinal trends study 2015-2020.

BACKGROUND: The NHS response to COVID-19 altered provision and access to primary care. AIM: To examine the impact of COVID-19 on GP contacts with children and young people (CYP) in England. DESIGN AND SETTING: A longitudinal trends analysis was undertaken using electronic health records from the Clinical Practice Research Datalink (CPRD) Aurum database. METHOD: All CYP aged <25 years registered with a GP in the CPRD Aurum database were included. The number of total, remote, and face-to-face contacts during the first UK lockdown (March to June 2020) were compared with the mean contacts for comparable weeks from 2015 to 2019. RESULTS: In total, 47 607 765 GP contacts with 4 307 120 CYP were included. GP contacts fell 41% during the first lockdown compared with previous years. Children aged 1-14 years had greater falls in total contacts (≥50%) compared with infants and those aged 15-24 years. Face-to-face contacts fell by 88%, with the greatest falls occurring among children aged 1-14 years (>90%). Remote contacts more than doubled, increasing most in infants (over 2.5-fold). Total contacts for respiratory illnesses fell by 74% whereas contacts for common non-transmissible conditions shifted largely to remote contacts, mitigating the total fall (31%). CONCLUSION: During the COVID-19 pandemic, CYP's contact with GPs fell, particularly for face-to-face assessments. This may be explained by a lower incidence of respiratory illnesses because of fewer social contacts and changing health-seeking behaviour. The large shift to remote contacts mitigated total falls in contacts for some age groups and for common non-transmissible conditions.

General practitioners' perceptions of using virtual primary care during the COVID-19 pandemic: An international cross-sectional survey study.

With the onset of COVID-19, general practitioners (GPs) and patients worldwide swiftly transitioned from face-to-face to digital remote consultations. There is a need to evaluate how this global shift has impacted patient care, healthcare providers, patient and carer experience, and health systems. We explored GPs' perspectives on the main benefits and challenges of using digital virtual care. GPs across 20 countries completed an online questionnaire between June-September 2020. GPs' perceptions of main barriers and challenges were explored using free-text questions. Thematic analysis was used to analyse the data. A total of 1,605 respondents participated in our survey. The benefits identified included reducing COVID-19 transmission risks, guaranteeing access and continuity of care, improved efficiency, faster access to care, improved convenience and communication with patients, greater work flexibility for providers, and hastening the digital transformation of primary care and accompanying legal frameworks. Main challenges included patients' preference for face-to-face consultations, digital exclusion, lack of physical examinations, clinical uncertainty, delays in diagnosis and treatment, overuse and misuse of digital virtual care, and unsuitability for certain types of consultations. Other challenges include the lack of formal guidance, higher workloads, remuneration issues, organisational culture, technical difficulties, implementation and financial issues, and regulatory weaknesses. At the frontline of care delivery, GPs can provide important insights on what worked well, why, and how during the pandemic. Lessons learned can be used to inform the adoption of improved virtual care solutions and support the long-term development of platforms that are more technologically robust and secure.

To what extent do callers follow the advice given by a non-emergency medical helpline (NHS 111): A retrospective cohort study.

National Health Service (NHS) 111 helpline was set up to improve access to urgent care in England, efficiency and cost-effectiveness of first-contact health services. Following trusted, authoritative advice is crucial for improved clinical outcomes. We examine patient and call-related characteristics associated with compliance with advice given in NHS 111 calls. The importance of health interactions that are not face-to-face has recently been highlighted by COVID-19 pandemic. In this retrospective cohort study, NHS 111 call records were linked to urgent and emergency care services data. We analysed data of 3,864,362 calls made between October 2013 and September 2017 relating to 1,964,726 callers across London. A multiple logistic regression was used to investigate associations between compliance with advice given and patient and call characteristics. Caller's action is 'compliant with advice given if first subsequent service interaction following contact with NHS 111 is consistent with advice given. We found that most calls were made by women (58%), adults aged 30-59 years (33%) and people in the white ethnic category (36%). The most common advice was for caller to contact their General Practitioner (GP) or other local services (18.2%) with varying times scales. Overall, callers followed advice given in 49% of calls. Compliance with triage advice was more likely in calls for children aged <16 years, women, those from Asian/Asian British ethnicity, and calls made out of hours. The highest compliance was among callers advised to self-care without the need to contact any other healthcare service. This is one of the largest studies to describe pathway adherence following telephone advice and associated clinical and demographic features. These results could inform attempts to improve caller compliance with advice given by NHS 111, and as the NHS moves to more hybrid way of working, the lessons from this study are key to the development of remote healthcare services going forward.

Defining the determinants of vaccine uptake and undervaccination in migrant populations in Europe to improve routine and COVID-19 vaccine uptake: a systematic review.

Understanding why some migrants in Europe are at risk of underimmunisation and show lower vaccination uptake for routine and COVID-19 vaccines is critical if we are to address vaccination inequities and meet the goals of WHO's new Immunisation Agenda 2030. We did a systematic review (PROSPERO: CRD42020219214) exploring barriers and facilitators of vaccine uptake (categorised using the 5As taxonomy: access, awareness, affordability, acceptance, activation) and sociodemographic determinants of undervaccination among migrants in the EU and European Economic Area, the UK, and Switzerland. We searched MEDLINE, CINAHL, and PsycINFO from 2000 to 2021 for primary research, with no restrictions on language. 5259 data sources were screened, with 67 studies included from 16 countries, representing 366 529 migrants. We identified multiple access barriers-including language, literacy, and communication barriers, practical and legal barriers to accessing and delivering vaccination services, and service barriers such as lack of specific guidelines and knowledge of health-care professionals-for key vaccines including measles-mumps-rubella, diphtheria-pertussis-tetanus, human papillomavirus, influenza, polio, and COVID-19 vaccines. Acceptance barriers were mostly reported in eastern European and Muslim migrants for human papillomavirus, measles, and influenza vaccines. We identified 23 significant determinants of undervaccination in migrants (p<0·05), including African origin, recent migration, and being a refugee or asylum seeker. We did not identify a strong overall association with gender or age. Tailored vaccination messaging, community outreach, and behavioural nudges facilitated uptake. Migrants' barriers to accessing health care are already well documented, and this Review confirms their role in limiting vaccine uptake. These findings hold immediate relevance to strengthening vaccination programmes in high-income countries, including for COVID-19, and suggest that tailored, culturally sensitive, and evidence-informed strategies, unambiguous public health messaging, and health system strengthening are needed to address access and acceptance barriers to vaccination in migrants and create opportunities and pathways for offering catch-up vaccinations to migrants.

General Practice in England: The Current Crisis, Opportunities, and Challenges.

General practice or family medicine has historically been lauded as the "jewel in the crown" of the English National Health Service (NHS) (M. Marshall, 2015). General practice, at the heart of primary care, has continued to contribute to the high ranking of the NHS in international comparisons (M. S. Razai & A. Majeed, 2021) and evidence from several decades of research has shown that general practice in the UK has improved the nation's health (Royal College of General Practitioners, 2013). Furthermore, it has provided equitable, cost-effective, and accessible care for all with the flexibility to adapt rapidly to a changing society and political climates, such as during the COVID-19 pandemic when there was rapid implementation of remote consultation models (Royal College of General Practitioners, 2013). However, this much-admired public sector service has recently come under unprecedented political and media spotlight instigated by the pressures of the current pandemic on the NHS (M. S. Razai & A. Majeed, 2021). This coupled with collapsing morale among general practitioners (GPs), a shrinking GP workforce, inexorable demands, increasing workload, and decreasing real-terms per capita funding have caused many to sound alarm on a general practice in "crisis" (C. Gerada, 2021). In this article, we describe the evolving nature of general practice and the current crisis, as well as potential solutions and opportunities going forward.