Development and use of a directed acyclic graph (DAG) for conceptual framework and study protocol development exploring relationships between dwelling characteristics and household transmission of COVID-19 – England, 2020

Background: Household settings are high risk for COVID-19 transmission. Understanding transmission factors associated with environmental dwelling characteristics is important in informing public health and building design recommendations. We aimed to develop a directed acyclic graph (DAG) to inform a novel analytical study examining the effect of dwelling environmental characteristics on household transmission of COVID-19. Methods: Key demographic, behavioural and environmental dwelling characteristics were identified by a multidisciplinary team. Using the DAG to visually display risk factors, and using expert knowledge of available datasets we reached a consensus on the factors included and directionality of relationships to build the final conceptual framework. Factors were displayed as nodes and relationships as pathways. Results: Of 34 potential factors, 16 were included in the DAG, with 13 causal and three biasing pathways. Three variables were not measurable using retrospective datasets. The DAG enabled us to select data sources for the pilot study period and to inform the analysis plan. Key exposure nodes were energy efficiency or dwelling age; dwelling type or number of storeys; and dwelling size. We determined direct and proxy confounders which we could adjust for, potential interactions terms we could test in model building, and co-linear variables to omit in the same model. Conclusions: The DAG helped identify key variables and datasets. It prioritised key nodes and pathways to formalise complex relationships between variables. It was pivotal in identifying unobserved variables, confounders, co-linearity and potential interactions. It has supported data selection and design of a retrospective pilot study analysis plan

Future priorities of acute hospitals for surgical site infection surveillance in England

BACKGROUND: Since the launch of the national surgical site infection (SSI) surveillance service in 1997, successive expansions of the programme provided hospitals with increasing flexibility in procedures to target through surveillance. Ensuring the programme continues to meet hospitals' needs remains essential. AIM: As a means to inform the future direction of the service, a survey of all acute NHS Trusts was undertaken to assess and understand priorities for surveillance. METHODS: A web-based survey was circulated to acute NHS Trust infection control teams in England asking them to identify and rank i) reasons for undertaking current SSI surveillance ii) priority surgical categories for future SSI surveillance and iii) reasons for prioritising these categories. FINDINGS: Of the 161 Trusts surveyed, 84 (52%) responded. Assessment of quality of care was identified as the most common driver for SSI surveillance activity. Considerable heterogeneity in priority areas was observed, with 24 different surgical categories selected as top priority. Of the procedures undertaken by 15 or more Trusts, Caesarean section (2.7), hip replacement (2.8) and coronary artery bypass graft (2.9) were highest ranked. All 17 categories in the current surveillance programme were selected as a top priority by one or more Trusts. CONCLUSION: Whilst the majority of hospitals' priorities for SSI surveillance are included in the current programme, the top ranked priority, Caesarean section, is not included. Given the diversity of priority areas, maintaining a comprehensive spectrum of categories in the national programme is essential to assist hospitals in addressing local prioritie

Peer-education as a tool to educate on antibiotics, resistance and use in 16–18-year-olds: A feasibility study

© 2020 by the authors. Licensee MDPI, Basel, Switzerland. Peer education (PE) interventions may help improve knowledge and appropriate use of antibiotics in young adults. In this feasibility study, health-care students were trained to educate 16–18 years old biology students, who then educated their non-biology peers, using e-Bug antibiotic lessons. Knowledge was assessed by questionnaires, and antibiotic use by questionnaire, SMS messaging and GP record searches. Five of 17 schools approached participated (3 PE and 2 control (usual lessons)). 59% (10/17) of university students and 28% (15/54) of biology students volunteered as peer-educators. PE was well-received; 30% (38/127) intervention students and 55% (66/120) control students completed all questionnaires. Antibiotic use from GP medical records (54/136, 40% of students’ data available), student SMS (69/136, 51% replied) and questionnaire (109/136, 80% completed) data showed good agreement between GP and SMS (kappa = 0.72), but poor agreement between GP and questionnaires (kappa = 0.06). Median knowledge scores were higher post-intervention, with greater improvement for non-biology students. Delivering and evaluating e-Bug PE is feasible with supportive school staff. Single tiered PE by university students may be easier to regulate and manage due to time constraints on school students. SMS collection of antibiotic data is easier and has similar accuracy to GP data

Carbapenem-resistant Enterobacteriaceae dispersal from sinks is linked to drain position and drainage rates in a laboratory model system.

BACKGROUND: Hospital sinks, waste traps and drains can harbour carbapenem-resistant Enterobacteriaceae (CRE). AIM: To investigate the dispersal of CRE from sinks in which water delivered from the tap flows directly into the drain and from clinical handwash basins with the drain at the rear. The effect of fast and slow drainage rates was also assessed. METHODS: Waste traps, known to be colonized with CRE, were taken from a hospital and installed within a model laboratory system. New waste traps were also installed and artificially inoculated with CRE. The potential for bacteria to be dispersed from sinks was assessed using cyclone air samplers and/or settle plates. FINDINGS: When the waste traps were artificially contaminated and CRE colonization was confined to the waste trap water, significantly fewer bacteria were dispersed from sinks that drained quickly (P = 0.004) and/or from rear-draining sinks (P = 0.002). When the waste traps were naturally contaminated and CRE colonized the trap, pipework and drain, there was significant interaction between sink drainage and position of the drain (P < 0.001). When drainage was slow, dispersal from rear-draining sinks was almost 30-fold less than from sinks with the drain underneath the tap (P < 0.001). When drainage was fast, rear-draining sinks again released comparatively fewer CRE, although, in this case, the difference was not statistically significant (P = 0.7). Contaminated splashes travelled up to 1 m from the sink. CONCLUSION: Slow drainage rates and sink designs with the drain directly underneath the tap increase the risk of CRE present in waste traps and drains contaminating the ward environment

Trends in coagulase-negative staphylococci (CoNS), England, 2010-2021.

OBJECTIVE: To review the epidemiology of coagulase-negative staphylococci (CoNS) in England over the recent 12 year period. METHODS: Laboratory-confirmed CoNS reported from sterile sites in patients in England to the UK Health Security Agency (UKHSA) between 2010 and 2021 were extracted from the national laboratory database and analysed. RESULTS: Overall, 668 857 episodes of CoNS were reported. Unspeciated CoNS accounted for 56 % (374 228) of episodes, followed by Staphylococcus epidermidis (26 %; 174 050), S. hominis (6.5 %; 43 501) and S. capitis (3.9 %; 25 773). Unspeciated CoNS increased by 8.2 % (95 % CI, 7.1-9.3) annually between 2010 and 2016, then decreased annually by 6.4 % (95 % CI: -4.8 to -7.9) until 2021. Speciated CoNS increased by 47.6 % (95 % CI, 44.5-50.9) annually between 2010 and 2016 and increased annually by 8.9 % (95 % CI: 5.1 to 12.8) until 2021. Antimicrobial susceptibility profiles differed by species. CONCLUSIONS: Reports of CoNS from normally sterile body sites in patients in England increased between 2010 and 2016 and remained stable between 2017 and 2021. There has been a striking improvement in species-level identification of CoNS in recent years. Monitoring trends in CoNS epidemiology is crucial for development of observational and clinical intervention studies on individual species

Live-attenuated influenza vaccine effectiveness against hospitalization in children aged 2-6 years, the first three seasons of the childhood influenza vaccination program in England, 2013/14-2015/16.

INTRODUCTION: In 2013, the United Kingdom began to roll-out a universal annual influenza vaccination program for children. An important component of any new vaccination program is measuring its effectiveness. Live-attenuated influenza vaccines (LAIVs) have since shown mixed results with vaccine effectiveness (VE) varying across seasons and countries elsewhere. This study aims to assess the effectiveness of influenza vaccination in children against severe disease during the first three seasons of the LAIV program in England. METHODS: Using the screening method, LAIV vaccination coverage in children hospitalized with laboratory-confirmed influenza infection was compared with vaccination coverage in 2-6-year-olds in the general population to estimate VE in 2013/14-2015/16. RESULTS: The overall LAIV VE, adjusted for age group, week/month and geographical area, for all influenza types pooled over the three influenza seasons was 50.1% (95% confidence interval [CI] 31.2, 63.8). By age, there was evidence of protection against hospitalization from influenza vaccination in both the pre-school (2-4-year-olds) (48.1%, 95% CI 27.2, 63.1) and school-aged children (5-6-year-olds) (62.6%, 95% CI 2.6, 85.6) over the three seasons. CONCLUSION: LAIV vaccination in children provided moderate annual protection against laboratory-confirmed influenza-related hospitalization in England over the three influenza seasons. This study contributes further to the limited literature to date on influenza VE against severe disease in children

Daily use of lateral flow devices by contacts of confirmed COVID-19 cases to enable exemption from isolation compared with standard self-isolation to reduce onward transmission of SARS-CoV-2 in England:a randomised, controlled, non-inferiority trial

Background: In the UK, during the study period all COVID-19 contacts were required to self-isolate for 10 days, which had adverse impacts. Avoiding the need to self-isolate for those who remain uninfected would be beneficial to society. We investigated whether using daily lateral flow devices (LFDs) to test for COVID-19 with removal of self-isolation for 24 hours if negative was a safe alternative to self-isolation by determining tertiary attack rates (proportion being infected) in study groups.Methods: We conducted a non-inferiority randomised controlled trial (Research Registry ID:6809) in adult contacts identified during COVID-19 contact tracing. Consented participants were randomised to self-isolation (SI; single PCR, 10 days isolation) or daily contact-testing (DCT; 7 LFDs, 2 PCRs, no isolation if negative on LFD);participants from a household were assigned to the same arm. Participants were prospectively followed-up with the impact of each intervention on onward transmission determined from routinely collected contact tracing data for COVID-19 participants, and tertiary cases arising from their contacts. Attack rates were derived from cluster-robust standard error Bernoulli regression models. Questionnaires were sent at recruitment and at the end of testing/self-isolation to assess behaviours.Findings: 49,623 individuals consented to participate with final arm allocations of 26,123 DCT (52.6%) and 23,500 SI participants (47.4%). Overall. 4,561 participants tested positive by PCR (secondary cases); 2,359 (10.0%) in the SI arm and 2,202 (8.4%) in the DCT arm. Tertiary attack rates (among secondary contacts) were 7.5% in SI arm and 6.4% in DCT arm (difference of -1.1 % (95% Confidence Interval -2.2% to -0.03%)), significantly lower than the non-inferiority margin of 1.9%.124,010 valid LFD results were reported from 20,795 (79.6%) DCT participants with 1,132 (5.4%) reporting a positive result. Interpretation: DCT with 24-hour exemption from self-isolation for essential activities appears to be non-inferior to self-isolation.Interpretation: DCT with 24-hour exemption from self-isolation for essential activities appears to be non-inferior to self-isolation.<br/

The effect of static scanning and mobility training on mobility in people with hemianopia after stroke: A randomized controlled trial comparing standardized versus non-standardized treatment protocols

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