'A system that is struggling': understanding health protection resilience in England during the COVID-19 pandemic through the experiences of local health protection responders.

BACKGROUND: Local health protection systems play a crucial role in infectious disease prevention and control and were critical to COVID-19 pandemic responses. Despite this vital function, few studies have explored the lived experience of health protection responders managing COVID-19. We provide new insights by examining how COVID-19 shaped infectious disease prevention and control in local health protection systems in England. METHODS: Semi-structured interviews were conducted with twenty local health protection responders from three contrasting local authority areas, and Public Health England (PHE) health protection teams, in England between June 2021 - March 2022. Participants were from: PHE health protection teams (n=6); local authority public health teams (n=5); local authority Public Protection Services (n=7); and local authority commissioned Infection Prevention and Control Teams (n=2). Data were analysed using reflexive thematic analysis. RESULTS: First, participants acknowledged the pandemic caused an unprecedented workload and disruption to local health protection service delivery. There was not enough capacity within existing local health protection systems to manage the increased workload. PHE health protection teams therefore transferred some COVID-19 related health protection tasks to other staff, mainly those employed by local authorities. Second, health protection responders highlighted how COVID-19 drew attention to the weaknesses in local health protection systems already stressed by reduced funding in the years leading up to the pandemic. Injecting money into the COVID-19 response did not completely overcome former losses in specialist health protection workforce. Third, health protection responders described how pandemic management raised the profile of public health, especially infectious disease prevention and control. Managing COVID-19 strengthened collaborative working, resulting in enhanced capacity of local health protection systems at the time. CONCLUSION: The COVID-19 pandemic challenged the public health preparedness of all countries. Health protection responders in this study also expressed many challenges. There was insufficient resilience in these local health protection systems and an inability to scale up the specialist health protection workforce, as required in a pandemic situation. The UK needs to learn from the pandemic experience by acknowledging and addressing the challenges faced by local health protection responders so that it can more effectively respond to future threats.

COVID-19 vaccine hesitancy in care home staff: A survey of Liverpool care homes.

Uptake of COVID-19 vaccine first doses in UK care homes has been higher among residents compared to staff. We aimed to identify causes of lower COVID-19 vaccine uptake amongst care home staff within Liverpool. An anonymised online survey was distributed to all care home managers, between the 21st and the 29th January 2021. 53 % of 87 care homes responded. The overall COVID-19 vaccination rate was 52.6 % (n = 1119). Reasons, identified by care home managers for staff being unvaccinated included: concerns about lack of vaccine research (37.0 %), staff being off-site during vaccination sessions (36.5 %), pregnancy and fertility concerns (5.6 %), and allergic reactions concerns (3.2 %). Care home managers wanted to tackle vaccine hesitancy through conversations with health professionals, and provision of evidence dispelling vaccine misinformation. Vaccine hesitancy and logistical issues were the main causes for reduced vaccine uptake among care home staff. The former could be addressed by targeted training, and public health communication campaigns to build confidence and acceptance of COVID-19 vaccines.

Development and Implementation of an Antimicrobial Stewardship Checklist in Sub-Saharan Africa: A Co-Creation Consensus Approach.

Antimicrobial stewardship (AMS) initiatives promote the responsible use of antimicrobials in healthcare settings as a key measure to curb the global threat of antimicrobial resistance (AMR). Defining the core elements of AMS is essential for developing and evaluating comprehensive AMS programmes. This project used co-creation and Delphi consensus procedures to adapt and extend the existing published international AMS checklist. The overall objective was to arrive at a contextualised checklist of core AMS elements and key behaviours for use within healthcare settings in Sub-Saharan Africa, as well as to implement the checklist in health institutions in four African countries. The AMS checklist tool was developed using a modified Delphi approach to achieve local expert consensus on the items to be included on the checklist. Fourteen healthcare/public health professionals from Tanzania, Zambia, Uganda, Ghana and the UK were invited to review, score and comment on items from a published global AMS checklist. Following their feedback, 8 items were rephrased, and 25 new items were added to the checklist. The final AMS checklist tool was deployed across 19 healthcare sites and used to assess AMS programmes before and after an AMS intervention in 14 of the 19 sites. The final tool comprised 54 items. Across the 14 sites, the completed checklists consistently showed improvements for all the AMS components following the intervention. The greatest improvements observed were the presence of formal multidisciplinary AMS structures (79%) and the execution of a point-prevalence survey (72%). The elements with the least improvement were access to laboratory/imaging services (7%) and the presence of adequate financial support for AMS (14%). In addition to capturing the quantitative and qualitative changes associated with the AMS intervention, project evaluation suggested that administering the AMS checklist made unique contributions to ongoing AMS activities. Furthermore, 29 additional AMS activities were reported as a direct result of the prompting checklist questions. Contextualised, co-created AMS tools are necessary for managing antimicrobial use across healthcare settings and increasing local AMS ownership and commitment. This study led to the development of a new AMS checklist, which proved successful in capturing AMS improvements in Tanzania, Zambia, Uganda, and Ghana. The tool also made unique contributions to furthering local AMS efforts. This study extends the existing AMS materials for low- and middle-income countries and provides empirical evidence for successful use in practice.

A brief review of influenza virus infection.

Influenza is an acute viral respiratory infection that affects all age groups and is associated with high mortality during pandemics, epidemics, and sporadic outbreaks. Nearly 10% of the world's population is affected by influenza annually, with about half a million deaths each year. Influenza vaccination is the most effective method for preventing influenza infection and its complications. The influenza vaccine's efficacy varies each season based on the circulating influenza strains and vaccine uptake rates. Currently, three antiviral drugs targeting the influenza virus surface glycoprotein neuraminidase are available for treatment and prophylaxis of disease. Given the significant burden of influenza infection globally, this review is focused on the latest findings in the etiology, epidemiology, transmission, clinical manifestation, diagnosis, prevention, and treatment of influenza.

Implementation of a Delayed Prescribing Model to Reduce Antibiotic Prescribing for Suspected Upper Respiratory Tract Infections in a Hospital Outpatient Department, Ghana.

Background: High levels of antimicrobial resistance (AMR) in Ghana require the exploration of new approaches to optimise antimicrobial prescribing. This study aims to establish the feasibility of implementation of different delayed/back-up prescribing models on antimicrobial prescribing for upper respiratory tract infections (URTIs). Methods: This study was part of a quality improvement project at LEKMA Hospital, Ghana, (Dec 2019-Feb 2020). Patients meeting inclusion criteria were assigned to one of four groups (Group 0: No prescription given; Group 1; Patient received post-dated antibiotic prescription; Group 2: Offer of a rapid reassessment of patient by a nurse practitioner after 3 days; and Group 3: Post-dated prescription forwarded to hospital pharmacy). Patients were contacted 10 days afterwards to ascertain wellbeing and actions taken, and patients were asked rate the service on a Likert scale. Post-study informal discussions were conducted with hospital staff. Results: In total, 142 patients met inclusion criteria. Groups 0, 1, 2 and 3 had 61, 16, 44 and 21 patients, respectively. Common diagnosis was sore throat (73%). Only one patient took antibiotics after 3 days. Nearly all (141/142) patients were successfully contacted on day 10, and of these, 102 (72%) rated their experiences as good or very good. Informal discussions with staff revealed improved knowledge of AMR. Conclusions: Delayed/back-up prescribing can reduce antibiotic consumption amongst outpatient department patients with suspected URTIs. Delayed/back-up prescribing can be implemented safely in low and middle-income countries (LMICs).

Responding to measles outbreaks in underserved Roma and Romanian populations in England: the critical role of community understanding and engagement.

Since 2016, the European Region has experienced large-scale measles outbreaks. Several measles outbreaks in England during 2017/18 specifically affected Romanian and Romanian Roma communities. In this qualitative interview study, we looked at the effectiveness of outbreak responses and efforts to promote vaccination uptake amongst these underserved communities in three English cities: Birmingham, Leeds and Liverpool. Semi-structured in-depth interviews were conducted with 33 providers involved in vaccination delivery and outbreak management in these cities. Interviews were analysed thematically and factors that influenced the effectiveness of responses were categorised into five themes: (1) the ability to identify the communities, (2) provider knowledge and understanding of the communities, (3) the co-ordination of response efforts and partnership working, (4) links to communities and approaches to community engagement and (5) resource constraints. We found that effective partnership working and community engagement were key to the prevention and management of vaccine-preventable disease outbreaks in the communities. Effective engagement was found to be compromised by cuts to public health spending and services for underserved communities. To increase uptake in under-vaccinated communities, local knowledge and engagement are vital to build trust and relationships. Local partners must work proactively to identify, understand and build connections with communities.

Two cases of monkeypox imported to the United Kingdom, September 2018.

In early September 2018, two cases of monkeypox were reported in the United Kingdom (UK), diagnosed on 7 September in Cornwall (South West England) and 11 September in Blackpool (North West England). The cases were epidemiologically unconnected and had recently travelled to the UK from Nigeria, where monkeypox is currently circulating. We describe the epidemiology and the public health response for the first diagnosed cases outside the African continent since 2003.

An Outbreak of Pseudomonas Aeruginosa Infection Linked to a "Black Friday" Piercing Event.

INTRODUCTION: Outbreaks linked to cosmetic piercing are rare, but can cause significant illness. We report the investigation and management of a point-source outbreak that occurred during a Black Friday promotional event in North West England. METHODS: Outbreak investigation was led by Public Health England, and included active case finding among individuals pierced at a piercing premises between 25/11/2016 (Black Friday) and 7/12/2016. Detailed epidemiological, environmental (including inspection and sampling), and microbiological investigation was undertaken. RESULTS: During the Black Friday event (25/11/2016), 45 people were pierced (13 by a newly-appointed practitioner). Eleven cases were identified (7 microbiologically-confirmed, 2 probable, and 2 possible). All cases had clinical signs of infection around piercing sites, and five required surgical intervention, with varying degrees of post-operative disfigurement. All confirmed and probable cases had a scaffold piercing placed with a guide bar by the newly-appointed practitioner. Pseudomonas aeruginosa, indistinguishable at nine-locus variable-number tandem repeat loci, was isolated from four of the confirmed cases, and from pre- and post-flush samples from five separate water taps (three sinks) in the premises. Water samples taken after remedial plumbing work confirmed elimination of Pseudomonas contamination. DISCUSSION: Although high levels of Pseudomonas water contamination and some poor infection control procedures were identified, infection appeared to require additional exposure to an inexperienced practitioner, and the more invasive scaffold piercing. A proactive collaborative approach between piercers and health and environmental officials is required to reduce outbreak risk, particularly when unusually large events are planned.

Measles outbreaks in the UK, is it when and where, rather than if? A database cohort study of childhood population susceptibility in Liverpool, UK.

OBJECTIVES: There was a large outbreak of measles in Liverpool, UK, in 2012-2013, despite measles, mumps and rubella (MMR) immunisation uptake rates that were higher than the national average. We estimated measles susceptibility of a cohort of children born in Liverpool between 1995 and 2012 to understand whether there was a change in susceptibility before and after the outbreak and to inform vaccination strategy. DESIGN: Retrospective cohort study. SETTING: The city of Liverpool, North West UK. PARTICIPANTS: All children born in Liverpool (72 101) between 1995 and 2012 inclusive who were identified using the Child Health Information System (CHIS) and were still resident within Liverpool in 2014. PRIMARY AND SECONDARY OUTCOME MEASURES: We estimated cohort age-disaggregated and neighbourhood-disaggregated measles susceptibility according to WHO thresholds before and after the outbreak for children aged 1-17 years. RESULTS: Susceptibility to measles was above WHO elimination thresholds before and after the measles outbreak in the 10+ age group. The proportion of children susceptible before and after outbreak, respectively: age 1-4 years 15.0% before and 14.9% after; age 5-9 years 9.9% before and 7.7% after; age 10+ years 8.6% before and 8.5% after. Despite an intensive MMR immunisation catch-up campaign after the 2012-2013 measles outbreak, the overall proportion of children with no MMR remains high at 6.1% (4390/72 351). Across all age groups and before and after the outbreak, measles susceptibility was clustered by neighbourhood, with deprived areas having the greatest proportion of susceptible children. CONCLUSIONS: The risk of sustained measles outbreaks remains, especially as large pools of susceptible older children will start leaving secondary education and continue to aggregate in higher education, employment and other community settings and institutions resulting in the potential for a propagated measles outbreak.

Influenza vaccination for healthcare workers in the UK: appraisal of systematic reviews and policy options.

BACKGROUND: The UK Department of Health recommends annual influenza vaccination for healthcare workers, but uptake remains low. For staff, there is uncertainty about the rationale for vaccination and evidence underpinning the recommendation. OBJECTIVES: To clarify the rationale, and evidence base, for influenza vaccination of healthcare workers from the occupational health, employer and patient safety perspectives. DESIGN: Systematic appraisal of published systematic reviews. RESULTS: The quality of the 11 included reviews was variable; some included exactly the same trials but made conflicting recommendations. 3 reviews assessed vaccine effects in healthcare workers and found 1 trial reporting a vaccine efficacy (VE) of 88%. 6 reviews assessed vaccine effects in healthy adults, and VE was consistent with a median of 62% (95% CI 56 to 67). 2 reviews assessed effects on working days lost in healthcare workers (3 trials), and 3 reported effects in healthy adults (4 trials). The meta-analyses presented by the most recent reviews do not reach standard levels of statistical significance, but may be misleading as individual trials suggest benefit with wide variation in size of effect. The 2013 Cochrane review reported absolute effects close to 0 for laboratory-confirmed influenza, and hospitalisation for patients, but excluded data on clinically suspected influenza and all-cause mortality, which had shown potentially important effects in previous editions. A more recent systematic review reports these effects as a 42% reduction in clinically suspected influenza (95% CI 27 to 54) and a 29% reduction in all-cause mortality (95% CI 15 to 41). CONCLUSIONS: The evidence for employer and patient safety benefits of influenza vaccination is not straightforward and has been interpreted differently by different systematic review authors. Future uptake of influenza vaccination among healthcare workers may benefit from a fully transparent guideline process by a panel representing all relevant stakeholders, which clearly communicates the underlying rationale, evidence base and judgements made.

The economic cost of measles: Healthcare, public health and societal costs of the 2012-13 outbreak in Merseyside, UK.

BACKGROUND: Measles is a highly contagious vaccine-preventable infection that caused large outbreaks in England in 2012 and 2013 in areas which failed to achieve herd protection levels (95%) consistently. We sought to quantify the economic costs associated with the 2012-13 Merseyside measles outbreak, relative to the cost of extending preventative vaccination to secure herd protection. METHODS: A costing model based on a critical literature review was developed. A workshop and interviews were held with key stakeholders in the Merseyside outbreak to understand the pathway of a measles case and then quantify healthcare activity and costs for the main NHS providers and public health team incurred during the initial four month period to May 2012. These data were used to model the total costs of the full outbreak to August 2013, comprising those to healthcare providers for patient treatment, public health and societal productivity losses. The modelled total cost of the full outbreak was compared to the cost of extending the preventative vaccination programme to achieve herd protection. FINDINGS: The Merseyside outbreak included 2458 reported cases. The estimated cost of the outbreak was £ 4.4m (sensitivity analysis £ 3.9 m to £ 5.2m) comprising 15% (£ 0.7 m) NHS patient treatment costs, 40% (£ 1.8m) public health costs and 44% (£ 2.0m) for societal productivity losses. In comparison, over the previous five years in Cheshire and Merseyside a further 11,793 MMR vaccinations would have been needed to achieve herd protection at an estimated cost of £ 182,909 (4% of the total cost of the measles outbreak). INTERPRETATION: Failure to consistently reach MMR uptake levels of 95% across all localities and sectors (achieve herd protection) risks comparatively higher economic costs associated with the containment (including healthcare costs) and implementation of effective public health management of outbreaks. FUNDING: Commissioned by the Cheshire and Merseyside Public Health England Centre.

Some factors affecting rubella seronegative prevalence among pregnant women in a North West England region between April 2011 and March 2013.

BACKGROUND: Rubella is usually a mild viral illness, but during pregnancy, it can have potentially devastating effects causing fetal losses and severe congenital malformations (congenital rubella syndrome). Rubella is now rare in most developed countries following a successful vaccination programme. We aimed to investigate differences in epidemiological profile of pregnant women screened antenatally in Liverpool to identify risk factors for rubella immunity. METHODS: All samples were tested with the Elecsys Rubella IgG immunoassay kit. A result <10 IU/ml was considered to be seronegative. RESULTS: The seronegativity prevalence among pregnant women in Liverpool (6.3%) is higher than average value for the North West region (3.7%). The seronegative rates varied with age (15.4% for <15 years, 18.7% for 15-20 years, compared with 2% for 30-35 years). The areas with the highest seronegative rates correspond with areas of Liverpool with high pockets of socioeconomic deprivation. CONCLUSION: The highest proportion of seronegative women were among the youngest age groups. Local areas with highest level of deprivation should be given priority and additional resources to develop targeted programmes and pathways to implement appropriate interventions such as MMR catch-up programmes and put in place arrangements for offering MMR vaccination in maternity units.

Perceptions of mumps and MMR vaccination among university students in England: an online survey.

Mumps is easily preventable through vaccination. Investigation of a number of recent mumps outbreaks in universities in the North West of England, however, found that affected students were either not vaccinated or only partially vaccinated. An online survey of students (n=2456) attending five universities in the region was undertaken during 2010 to establish MMR vaccination status, knowledge of mumps and willingness to take up vaccination if offered. Regression analysis was undertaken to identify characteristics of unimmunized students to ascertain likely target groups for future vaccination campaigns. Students least likely to be fully vaccinated with MMR included males; those not registered with a GP; first year students; mature students; and those with poor knowledge of mumps. A high proportion of students were willing to accept MMR vaccination if offered at university. Those least likely to take up vaccination included students not registered with a GP; mature students; and those who did not consider mumps to be a serious disease. The survey also highlighted that misconceptions remain about both the MMR vaccine safety and perceptions of risk/benefit of the vaccine. Encouraging registration with a GP and awareness raising should be a key part of campaigns to improve vaccination uptake among university students.

Referrals to a pediatric immunization service: Findings from a practice-based audit of a UK specialist immunization clinic.

Against a background of new developments and updated clinical guidelines, health care professionals (HCPs) administering childhood and adolescent immunizations require access to expert advice and support when appropriate. The clinical records of all pediatric referrals seen at a UK-based facility-the Stockport Specialist Immunization Clinic (SS IC)-between 01/10/2006 and 31/03/2007 were reviewed to determine the stated reason(s) for referral to a specialist immunization service and the outcome of that process. During the 6 month audit period, 430 case notes were identified and 410 (95%) were audited. Reasons for referral were primarily due to the medical condition of the child [118/410 (29%)], the child having experienced a previous vaccine adverse event [86/410 (21%)], or preterm birth of the child [86/410 (21%)]. The majority of referrals were from primary care [234/410 (57%)]. A total of 351 (85.6%) cases were categorized as appropriate referrals and 36 (11.6%) and 23 (5.6%) were categorized as inappropriate and equivocal, respectively. Four hundred and eight children completed a primary program; for two children the parents declined the advice offered. National data show that a small number of children remain susceptible to vaccine preventable diseases because they fail to access or complete immunization programs through their General Practitioner (GP) and this may be in part because the HCP is unsure about vaccine indications/contra-indications. Clearly a number of referring HCP s in this audit had some level of uncertainty when immunizing children with a pre-existing medical condition or a previous history of vaccine associated AEFI in the child/family, and this may be indicative of a more general problem among HCPs. A consistent approach to providing expert advice and support to primary care professionals in the UK would therefore be expected to make a significant impact on the immunization service by building confidence for parents/guardian, professionals and organizations involved in delivering it. The authors recommend a dedicated specialist immunization clinical service be considered as one approach to achieving this.

Vaccinating premature infants in a Special Care Baby Unit in the UK: results of a prospective, non-inferiority based, pragmatic case series study.

Premature infants are at greater risk of infections in part because of impaired functioning of external barriers, innate and adaptive systems. For similar immunological reasons, diminished responses to particular vaccines have also been reported. This study, utilising a prospective, pragmatic case series approach was designed to show non-inferiority of antibody response in premature infants to diphtheria, tetanus, Haemophilus influenzae type b conjugate (Hib), meningococcal C conjugate (MenC) and pneumococcal conjugate (PnC) vaccines between immunization in a routine clinical situation rather than a vaccine trial. A secondary objective was to determine the effect of gestational age on antibody response to these vaccines. The case series comprised 131 infants born at ≤ 32 weeks gestation and managed on the Special Care Baby Unit (SCBU) of a District General Hospital in Stockport, UK. For diphtheria and tetanus, 98.3% and 100% of premature infants respectively developed a minimum protective antibody response; 86.6% were protected against Men C. However, only 67.8% preterm infants achieved anti-polyribosylribitolphosphate (PRP) antibodies >0.15µg against Hib, with only 34.7% having a level ≥1.0µg, and responses to the different pneumococcal serogroups ranged from 67.5% against serotype 6B to 92.5% against serogroup 19F. In comparison to term infants, preterm infants were less likely to achieve protective levels against MenC and Hib: there were no significant differences in the proportions of infants protected against diphtheria and tetanus. Protection was inferior to expected based on published premature infant clinical trial data for Hib and particular pneumococcal serotypes; data for Men C were also lower than expected.

Intradermal recombinant hepatitis B vaccination (IDRV) for non-responsive healthcare workers (HCWs).

This was an observational study of non-responsive HCWs who were referred to Stockport Specialist Immunisation Clinic (SSIC) between 1(st) January 2003 and 31(st) May 2006. Anti-HBs titres were determined 4-6 weeks after each intradermal recombinant vaccine (IDRV). Median anti-HBs titres were compared using the exact Wilcoxon rank sum test. In total, 23 eligible non-responding HCWs were identified. Protective anti-HBs titres (> or =10 mlU/ml) were induced in the majority of non-responders [21/23 (91.3%)] following two doses of IDRVs. HCWs who responded to the 1(st) IDRV with anti-HBs levels > or =10 mlU/ml were significantly younger and received their 1(st) IDRV more than six months after the last IM dose. Two HCWs (41 and 45 year old females) anti-HBs titres remained below 10 mlU/ml even after a 3(rd) dose. Anti-HBs titres were available for 40% (9/23) of the HCWs six or more months after the last maximum anti-HBs titres were achieved. None of the nine HCWs anti-HBs titres declined to less than 10 mlU/ml six or more months after the last maximum anti-HBs titres were achieved. However, a larger study with long-term follow-up is needed to determine the duration of protection following IDRV. HCWs with anti-HBs titres <10 mlU/ml after two full courses of intramuscular recombinant vaccine (IMRV) should be offered two doses of IDRVs followed by assessment of anti-HBs titres one to four months after the second dose in order to identify persistent non-responders. No significant adverse events were noted with IDRV being well tolerated and acceptable to HCWs.