Preventing malaria in international travellers: an evaluation of published English-language guidelines

Background People intending to travel may seek information on malaria prevention from a range of sources. To ensure the best protection, this information needs to be reliable, up-to-date, consistent, and useful to their decision making. This study appraises current international and national guidelines written in English for malaria prevention in travellers, and whether any recommendations conflict. Methods We systematically identified national or international English-language guidelines on malaria prevention in travellers to July 2013 using standard and multiple searching methods. We critically appraised guidelines using the AGREE II tool, and report inconsistent recommendations within guidelines. Results We identified five sets of English-language guidelines on preventing malaria for travellers. Assessment against AGREE II indicate that all of the guidelines fall short of internationally accepted standards in guideline development: none include a transparent description of methods; only one describes sources of funding or potential conflicts of interest; and only one includes formal presentation of the evidence alongside transparent assessment of the quality of that evidence. There were a number of important discrepancies between guidelines, and some omit information about effectiveness, safety and adverse effects of chemoprophylaxis options. Conclusions The methods used for developing guidelines for malaria prevention in travellers lags behind current internationally recognized standards. Healthcare professionals as well as travellers themselves could be better informed if guidelines were more systematic and transparent summaries of the current knowledge on drug interventions in relation to effects, safety, administration and contra-indications

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: 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. Three reviews assessed vaccine effects in healthcare workers and found one trial reporting a vaccine efficacy of 88%. Six reviews assessed vaccine effects in healthy adults and vaccine efficacy was consistent with a median of 62% (95% CI 56 to 67). Two reviews assessed effects on working days lost in healthcare workers (three trials), and three reported effects in healthy adults (four 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 zero for laboratory-confirmed influenza, and hospitalization 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

Mosquito repellents for malaria prevention

Background Malaria is an important cause of illness and death across endemic regions. Considerable success against malaria has been achieved within the past decade mainly through long-lasting insecticide-treated nets (LLINs). However, elimination of the disease is proving difficult as current control methods do not protect against mosquitoes biting outdoors and when people are active. Repellents may provide a personal protection solution during these times. Objectives To assess the impact of topical repellents, insecticide-treated clothing, and spatial repellents on malaria transmission. Search methods We searched the following databases up to 26 June 2017: the Cochrane Infectious Diseases Group Specialized Register; the Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library; MEDLINE; Embase; US AFPMB; CAB Abstracts; and LILACS. We also searched trial registration platforms and conference proceedings; and contacted organizations and companies for ongoing and unpublished trials. Selection criteria We included randomized controlled trials (RCTs) and cluster-randomized controlled trials of topical repellents proven to repel mosquitoes; permethrin-treated clothing; and spatial repellents such as mosquito coils. We included trials that investigated the use of repellents with or without LLINs, referred to as insecticide-treated nets. Data collection and analysis Two review authors independently reviewed trials for inclusion, extracted the data, and assessed the risk of bias. A third review author resolved any discrepancies. We analysed data by conducting meta-analysis and stratified by whether the trials had included LLINs. We combined results from cRCTs with individually RCTs by adjusting for clustering and presented results using forest plots. We used GRADE to assess the certainty of the evidence. Main results Eight cRCTs and two RCTs met the inclusion criteria. Six trials investigated topical repellents, two trials investigated insecticide-treated clothing, and two trials investigated spatial repellents. Topical repellents Six RCTS, five of them cluster-randomized, investigated topical repellents involving residents of malaria-endemic regions. Four trials used topical repellents in combination with nets, but two trials undertaken in displaced populations used topical repellents alone. It is unclear if topical repellents can prevent clinical malaria (RR 0.65, 95% CI 0.4 to 1.07, very low certainty evidence) or malaria infection (RR 0.84, 95% CI 0.64 to 1.12, low-certainty evidence) caused by P. falciparum. It is also unclear if there is any protection against clinical cases of P. vivax (RR 1.32, 95% CI 0.99 to 1.76, low-certainty evidence) or incidence of infections (RR 1.07, 95% CI 0.80 to 1.41, low-certainty evidence). Subgroup analysis of trials including insecticide-treated nets did not show a protective effect of topical repellents against malaria. Only two studies did not include insecticide-treated nets, and they measured different outcomes; one reported a protective effect against clinical cases of P. falciparum (RR 0.40, 95% CI 0.23 to 0.71); but the other study measured no protective effect against malaria infection incidence caused by either P. falciparum or P. vivax. Insecticide-treated clothing Insecticide-treated clothing were investigated in trials conducted in refugee camps in Pakistan and amongst military based in the Colombian Amazon. Neither study provided participants with insecticide-treated nets. In the absence of nets, treated clothing may reduce the incidence of clinical malaria caused by P. falciparum by approximately 50% (RR 0.49, 95% CI 0.29 to 0.83, low-certainty evidence) and P. vivax (RR 0.64, 95% CI 0.40 to 1.01, low-certainty evidence). Spatial repellents Two cluster-randomized RCTs investigated mosquito coils for malaria prevention. We do not know the effect of spatial repellents on malaria prevention (RR 0.24, 95% CI 0.03 to 1.72, very low certainty evidence). There was large heterogeneity between studies and one study had high risk of bias. Authors' conclusions There is insufficient evidence to conclude topical or spatial repellents can prevent malaria. There is a need for better designed trials to generate higher certainty of evidence before well-informed recommendations can be made. Adherence to daily compliance remains a major limitation. Insecticide-treated clothing may reduce risk of malaria infection in the absence of insecticide-treated nets; further studies on insecticide-treated clothing in the general population should be done to broaden the applicability of the results

supplementary_material – Supplemental material for Sexualised drug taking among men who have sex with men: a systematic review

<p>Supplemental material, supplementary_material for Sexualised drug taking among men who have sex with men: a systematic review by Andrew Tomkins, Ryan George and Merav Kliner in Perspectives in Public Health</p

Adapting the Structured Operational Research Training Initiative (SORT IT) for high-income countries

This item is not available on ChesterRep.SORT IT (Structured Operational Research Training InitiaTive) is a successful capacity building programme started 10 years ago to develop operational research skills in low- and middle-income countries. Public Health England (PHE) aims to embed a culture of research in front-line staff, and SORT IT has been adapted to train frontline health protection professionals at PHE North West (PHE NW) to collate, analyse and interpret routinely collected data for evidence-informed decision-making. Six participants from the PHE NW Health Protection team were selected to attend a two-module course in Liverpool, UK, in May and in November 2018. Five participants finished the course with completed papers on characteristics and burden of influenza-like illness in elderly care homes (two papers), use of dried blood spots for blood-borne virus screening in prisons, uptake of meningococcal ACWY (groups A, C, W-135 and Y) vaccine in schoolchildren and fires in waste management sites. The SORT IT course led to 1) new evidence being produced to inform health protection practice, and 2) agreement within PHE NW to continue SORT IT with two courses per year, and 3) showed how a research capacity building initiative for low- and middle-income countries that combines ‘learning with doing’ can be adapted and used in a high-income country