Risk factors for drug resistant tuberculosis in Leicestershire - poor adherence to treatment remains an important cause of resistance

In the light of rising numbers of tuberculosis (TB) cases in the United Kingdom, the problem of anti-tubercular drug resistance remains a significant concern. Drug resistant TB cases are more difficult and costly to treat, and require appropriate treatment and control mechanisms. This matched case control study aimed to investigate risk factors for resistance in Leicestershire, using data for laboratory isolates of Mycobacterium tuberculosis identified from 1993 to 1998. Each case, defined as culture positive laboratory isolates resistant to at least one first-line drug, was matched to four fully sensitive controls on age, sex and ethnic group. Twenty-three cases and 81 controls were included in the analysis. Drug resistance in Leicestershire was found to be associated with poor adherence to treatment (OR 4(.)8, 95% CI 1(.)6-14(.)4, P=0(.)005) and with previous TB (OR 3(.)7, 95% CI 1(.)2-11(.)8, P=0(.)022). These findings emphasize the need to provide support to patients taking treatment in order to maximize adherence

DotMapper: an open source tool for creating interactive disease point maps

BACKGROUND: Molecular strain typing of tuberculosis isolates has led to increased understanding of the epidemiological characteristics of the disease and improvements in its control, diagnosis and treatment. However, molecular cluster investigations, which aim to detect previously unidentified cases, remain challenging. Interactive dot mapping is a simple approach which could aid investigations by highlighting cases likely to share epidemiological links. Current tools generally require technical expertise or lack interactivity. RESULTS: We designed a flexible application for producing disease dot maps using Shiny, a web application framework for the statistical software, R. The application displays locations of cases on an interactive map colour coded according to levels of categorical variables such as demographics and risk factors. Cases can be filtered by selecting combinations of these characteristics and by notification date. It can be used to rapidly identify geographic patterns amongst cases in molecular clusters of tuberculosis in space and time; generate hypotheses about disease transmission; identify outliers, and guide targeted control measures. CONCLUSIONS: DotMapper is a user-friendly application which enables rapid production of maps displaying locations of cases and their epidemiological characteristics without the need for specialist training in geographic information systems. Enhanced understanding of tuberculosis transmission using this application could facilitate improved detection of cases with epidemiological links and therefore lessen the public health impacts of the disease. It is a flexible system and also has broad international potential application to other investigations using geo-coded health information

Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial

Objective To determine whether vaccination of care home staff against influenza indirectly protects residents.Design Pair matched cluster randomised controlled trial.Setting Large private chain of UK care homes during the winters of 2003-4 and 2004-5.Participants Nursing home staff (n = 1703) and residents (n = 2604) in 44 care homes (22 intervention homes and 22 matched control homes).Interventions Vaccination offered to staff in intervention homes but not in control homes.Main outcome measures The primary outcome was all cause mortality of residents. Secondary outcomes were influenza-like illness and health service use in residents.Results In 2003-4 vaccine coverage in full time staff was 48.2% (407/884) in intervention homes and 5.9% (51/859) in control homes. In 2004-5 uptake rates were 43.2% (365/844) and 3.5% (28/800). National influenza rates were substaritially below average in 2004-5. In the 2003-4 period of influenza activity significant decreases were found in mortality of residents in intervention homes compared with control homes (rate difference - 5.0 per 100 residents, 95% confidence interval - 7.0 to - 2.0) and in influenza-like illness (P = 0.004), consultations with general practitioners for influenza-like illness (P = 0.008), and admissions to hospital with influenza-like illness (P = 0.009). No significant differences were found in 2004-5 or during periods of no influenza activity in 2003-4.Conclusions Vaccinating care home staff against influenza can prevent deaths, health service use, and influenza-like illness in residents during periods of moderate influenza activity

Accuracy of Probabilistic Linkage Using the Enhanced Matching System for Public Health and Epidemiological Studies

The Enhanced Matching System (EMS) is a probabilistic record linkage program developed by the tuberculosis section at Public Health England to match data for individuals across two datasets. This paper outlines how EMS works and investigates its accuracy for linkage across public health datasets

Incidence and recurrence of boils and abscesses within the first year: a cohort study in UK primary care

Background Boils and abscesses are common in primary care but the burden of recurrent infection is unknown. Aim To investigate the incidence of and risk factors for recurrence of boil or abscess for individuals consulting primary care. Design and setting Cohort study using electronic health records from primary care in the UK. Method The Health Improvement Network (THIN) database was used to identify patients who had consulted their GP for a boil or abscess. Poisson regression was used to examine the relationship between age, sex, social deprivation, and consultation and to calculate the incidence of, and risk factors for, repeat consultation for a boil or abscess. Results Overall, 164 461 individuals were identified who consulted their GP for a boil or abscess between 1995 and 2010. The incidence of first consultation for a boil or abscess was 512 (95% CI = 509 to 515) per 100 000 person-years in females and 387 (95% CI = 385 to 390) per 100 000 person-years in males. First consultations were most frequent in younger age groups (16–34 years) and those with the greatest levels of social deprivation. The rate of repeat consultation for a new infection during follow up was 107.5 (95% confidence interval [CI] = 105.6 to 109.4) per 1000 person-years. Obesity (relative risk [RR] 1.3, 95% CI = 1.2 to 1.3), diabetes (RR 1.3, 95% CI = 1.2 to 1.3), smoking (RR 1.3, 95% CI = 1.2 to 1.4), age <30 years (RR 1.2, 95% CI = 1.2 to 1.3), and prior antibiotic use (RR 1.4, 95% CI = 1.3–1.4) were all associated with repeat consultation for a boil or abscess. Conclusion Ten percent of patients with a boil or abscess develop a repeat boil or abscess within 12 months. Obesity, diabetes, young age, smoking, and prescription of an antibiotic in the 6 months before initial presentation were independently associated with recurrent infection, and may represent options for prevention

Determinants of non-adherence to treatment for tuberculosis in high-income and middle-income settings: a systematic review protocol

INTRODUCTION: Treatment for tuberculosis (TB) is highly effective if taken according to prescribed schedules. However, many people have difficulty adhering to treatment which can lead to poorer clinical outcomes, the development of drug resistance, increased duration of infectivity and consequent onward transmission of infection. A range of approaches are available to support adherence but in order to target these effectively a better understanding of the predictors of poor adherence is needed. This review aims to highlight the personal, sociocultural and structural factors that may lead to poor adherence in high-income and middle-income settings. METHODS AND ANALYSIS: Seven electronic databases, Medline, EMBASE, CINAHL, PsycInfo, The Cochrane Library, Scopus and Web of Science, will be searched for relevant articles using a prespecified search strategy. Observational studies will be targeted to explore factors that influence adherence to treatment in individuals diagnosed with TB. Screening title and abstract followed by full-text screening and critical appraisal will be conducted by two researchers. Data will be extracted using the Population, Exposure, Comparator, Outcomes, Study characteristics framework. For cross-study assessment of strength of evidence for particular risk factors affecting adherence we will use the Grading of Recommendations, Assessment, Development and Evaluation tool modified for prognostic studies. A narrative synthesis of the studies will be compiled. A meta-analysis will be considered if there are sufficient numbers of studies that are homogenous in study design, population and outcomes. DISSEMINATION: A draft conceptual framework will be identified that (A) identifies key barriers to adherence at each contextual level (eg, personal, sociocultural, health systems) and (B) maps the relationships, pathways and mechanisms of effect between these factors and adherence outcomes for people with TB. The draft conceptual framework will guide targeting of adherence interventions and further research. PROSPERO REGISTRATION NUMBER: CRD42017061049

Predictors of self and parental vaccination decisions in England during the 2009 H1N1 pandemic: Analysis of the Flu Watch pandemic cohort data

During the 2009 H1N1 pandemic, UK uptake of the pandemic influenza vaccine was very low. Furthermore, attitudes governing UK vaccination uptake during a pandemic are poorly characterised. To the best of our knowledge, there is no published research explicitly considering predictors of both adult self-vaccination and decisions regarding whether or not to vaccinate one’s children among the UK population during the H1N1 pandemic. We therefore aimed to identify predictors of both self-vaccination decisions and parental vaccination decisions using data collected during the H1N1 pandemic as part of the Flu Watch cohort study. Data were analysed separately for 798 adults and 85 children: exploratory factor analysis facilitated reduction of 16 items on attitudes to pandemic vaccine into a smaller number of factors. Single variable analyses with vaccine uptake as the outcome were used to identify variables that were predictive of vaccination in children and adults. Potential predictors were: attitudinal factors created by data reduction, age group, sex, region, deprivation, ethnicity, chronic condition, vocation, healthcare-related occupation and previous influenza vaccination. Consistent with previous literature concerning adult self-vaccination decisions, we found that vaccine efficacy/safety and perceived risk of pandemic influenza were significant predictors of both self-vaccination decisions and parental vaccination decisions. This study provides the first systematic attempt to understand both the predictors of self and parental vaccination uptake among the UK general population during the H1N1 pandemic. Our findings indicate that concerns about vaccine safety, and vaccine effectiveness may be a barrier to increased uptake for both self and parental vaccination

Optimising spatial accessibility to inform rationalisation of specialist health services

BACKGROUND: In an era of budget constraints for healthcare services, strategies for provision of services that improve quality whilst saving costs are highly valued. A proposed means to achieve this is consolidation of services into fewer specialist centres, but this may lead to reduced spatial accessibility. We describe a methodology which includes implementing a combinatorial optimisation algorithm to derive combinations of services which optimise spatial accessibility in the context of service rationalisation, and demonstrate its use through the exemplar of tuberculosis clinics in London. METHODS: Our methodology involves (1) identifying the spatial distribution of the patient population using the service; (2) calculating patient travel times to each service location, and (3) using a combinatorial optimisation algorithm to identify subsets of locations that minimise overall travel time. We estimated travel times for tuberculosis patients notified in London between 2010 and 2013 to each of 29 clinics in the city. Travel time estimates were derived from the Transport for London Journey Planner service. We identified the subset of clinics that would provide the shortest overall travel time for each possible number of clinic subsets (1-28). RESULTS: Based on the 29 existing clinic locations, mean estimated travel time to clinics used by 12,061 tuberculosis patients in London was 33 min; and mean time to their nearest clinics was 28 min. Using optimum combinations of clinic locations, and assuming that patients attended their nearest clinics, a mean travel time of less than 45 min could be achieved with three clinics; of 34 min with ten clinics, and of less than 30 min with 18 clinics. CONCLUSIONS: We have developed a methodological approach to optimise spatial accessibility which can be used to inform rationalisation of health services. In urban conurbations, this may enable service reorganisation which increases quality and efficiency without substantially affecting spatial accessibility. This approach could be used to inform planning of service reorganisations, but may not be generalisable to rural areas or smaller urban centres

Multiple large clusters of tuberculosis in London: a cross-sectional analysis of molecular and spatial data

Large outbreaks of tuberculosis (TB) represent a particular threat to disease control because they reflect multiple instances of active transmission. The extent to which long chains of transmission contribute to high TB incidence in London is unknown. We aimed to estimate the contribution of large clusters to the burden of TB in London and identify risk factors. We identified TB patients resident in London notified between 2010 and 2014, and used 24-locus mycobacterial interspersed repetitive units-variable number tandem repeat strain typing data to classify cases according to molecular cluster size. We used spatial scan statistics to test for spatial clustering and analysed risk factors through multinomial logistic regression. TB isolates from 7458 patients were included in the analysis. There were 20 large molecular clusters (with n>20 cases), comprising 795 (11%) of all cases; 18 (90%) large clusters exhibited significant spatial clustering. Cases in large clusters were more likely to be UK born (adjusted odds ratio 2.93, 95% CI 2.28-3.77), of black-Caribbean ethnicity (adjusted odds ratio 3.64, 95% CI 2.23-5.94) and have multiple social risk factors (adjusted odds ratio 3.75, 95% CI 1.96-7.16). Large clusters of cases contribute substantially to the burden of TB in London. Targeting interventions such as screening in deprived areas and social risk groups, including those of black ethnicities and born in the UK, should be a priority for reducing transmission

Influenza vaccination, inverse care and homelessness: cross-sectional survey of eligibility and uptake during the 2011/12 season in London

Background: Influenza vaccination eligibility and uptake among homeless adults has not been previously assessed in the UK. This cross-sectional survey aimed to measure the proportion of homeless people visited by an NHS outreach service (Find and Treat) who were eligible for and had received vaccination during 2011/12. Methods: A cross-sectional survey was carried out in 27 separate homeless hostels, day centres and drug services in London between July and August in 2012. Eligibility for the survey was by virtue of being in attendance at one of 27 venues visited by Find and Treat. No specific exclusion criteria were used. Results: 455 clients took part in the survey out of 592 approached (76.9%). A total of 190 homeless people (41.8%; 95% CI: 34.5,50.5) were eligible for influenza vaccination. In those aged 16–64, eligibility due to clinical risk factors was 38.9% (95% CI: 31.5,48.2). Uptake of vaccination in homeless 16–64 year olds with a clinical risk factor during the 2011/12 influenza season was 23.7% (95% CI: 19.8,28.3) compared to national levels of 53.2% (excluding pregnant women). In those aged over 65, uptake was 42.9% (95% CI: 16.7,100.0) compared with 74.0% nationally. Conclusions: This study demonstrates that the homeless population have high levels of chronic health problems predisposing them to severe complications of influenza, but vaccine uptake levels that are less than half those seen among eligible GP patient groups in England. It provides a clear example of the health inequalities and inverse care law that impact this population. The results of this study provide strong justification for intensifying efforts to ensure homeless people have access to influenza vaccination