Reasons for non-vaccination: Parental vaccine hesitancy and the childhood influenza vaccination school pilot programme in England.

INTRODUCTION: In 2013, the annual influenza immunisation programme in England was extended to children to reduce the burden of influenza, but uptake was sub-optimal at 53.2%. AIM: To explore the reasons some parents decided not to vaccinate their child against influenza as part of the pilot programme offered in schools. METHODS: Cross-sectional qualitative study conducted between February and July 2015. 913 parents whose children were not vaccinated against influenza in the school pilots in West Yorkshire and Greater Manchester, England, were asked to comment on their reasons for non-vaccination and invited to take part in a semi-structured interview. 138 parents returned response forms, of which 38 were eligible and interested in participating and 25 were interviewed. Interview transcripts were coded by theme in NVivo. RESULTS: A third of parents who returned response forms had either vaccinated their child elsewhere, intended to have them vaccinated, or had not vaccinated them due to medical reasons (valid or perceived). Most interviewees were not convinced of the need to vaccinate their child against influenza. Parents expressed concerns about influenza vaccine effectiveness and vaccine side effects. Several parents interviewed declined the vaccine for faith reasons due to the presence of porcine gelatine in the vaccine. CONCLUSIONS: To significantly decrease the burden of influenza in England, influenza vaccination coverage in children needs to be >60%. Hence, it is important to understand the reasons why parents are not vaccinating their children, and to tailor the communication and immunisation programme accordingly. Our finding that a third of parents, who did not consent to their child being vaccinated as part of the school programme, had actually vaccinated their child elsewhere, intended to have their child vaccinated, or had not vaccinated them due to medical reasons, illustrates the importance of including additional questions or data sources when investigating under-vaccination

Routine care of peripheral intravenous catheters versus clinically indicated replacement: randomised controlled trial

Objective To compare routine replacement of intravenous peripheral catheters with replacement only when clinically indicated

Is flu vaccination opt-out feasible? Evidence from vaccination programme implementers and managers in the English National Health Service.

BACKGROUND: In 2018/19, English NHS trusts (NHSTs) implemented an 'opt-out' policy for seasonal flu vaccination in frontline healthcare workers (HCWs). HCWs declining the vaccination were asked to sign an opt-out form and provide a reason for their decision. In addition, HCWs working in higher risk hospital environments (e.g. oncology) were asked to inform their manager about their declination decision. The policy aimed to provide greater insight into reasons for vaccination decline and information from HCWs in higher risk areas was intended for use in considering HCW redeployment. This study investigated the feasibility, acceptability, and perceived value of the policy during the 2018/19 flu vaccination season. METHODS: We conducted semi-structured interviews across 9 NHSTs in England with different levels of HCW flu vaccination uptake in 2017/18. We interviewed 30 vaccination programme implementers and 27 managers. FINDINGS: The purpose of the policy was poorly understood, and interviewees did not know how data on decliners was being used. Most NHSTs tried to collect the personal details of decliners and, in some instances, these were recorded in Electronic Staff Records and reported to line-managers for action. This created strain on employer-employee relationships, leading to decliners refusing to complete opt-out forms and some vaccinators not implementing the policy. None of the NHSTs had a redeployment policy for decliners, arguing that this was impractical due to strain on staffing levels. CONCLUSION: A flu-vaccination opt-out approach for HCWs did not appear acceptable in our sampled NHSTs, due to a lack of clear messaging about its purpose and complicated implementation. To promote an opt-out approach effectively, there needs to be clear communication of its purpose, which should be to explore reasons for decline rather than identify and 'push' decliners to vaccinate, so as not to damage staff relationships. NHSTs should involve their workforce in developing flu vaccination approaches

Measurements of iron status and survival in African iron overload

No Abstract

Optimising informed consent in school-based adolescent vaccination programmes in England: A multiple methods analysis.

The process of obtaining informed consent for school-based adolescent immunisation provides an opportunity to engage families. However, the fact that parental consent needs to be obtained remotely adds complexity to the process and can have a detrimental effect on vaccine uptake. We conducted a multiple methods analysis to examine the practice of obtaining informed consent in adolescent immunisation programmes. This involved a thematic analysis of consent related data from 39 interviews with immunisation managers and providers collected as part of a 2017 service evaluation of the English adolescent girls' HPV vaccine programme and a descriptive statistical analysis of data from questions related to consent included in a 2017 survey of parents' and adolescents' attitudes to adolescent vaccination. The findings indicated that the non-return of consent forms was a significant logistical challenge for immunisation teams, and some were piloting opt-out consent mechanisms, increasing the proportion of adolescents consenting for their own immunisations, and introducing electronic consent. Communicating vaccine related information to parents and schools and managing uncertainties about obtaining adolescent self-consent for vaccination were the main practical challenges encountered. Survey data showed that parents and adolescents generally agreed on vaccine decisions although only 32% of parents discussed vaccination with their teenager. Parental awareness about the option for adolescents to self-consent for vaccination was limited and adolescents favoured leaving the decision-making to parents. From the interviews and variability of consent forms it was evident that health professionals were not always clear about the best way to manage the consent process. Some were also unfamiliar with self-consent processes and lacked confidence in assessing for 'Gillick competency'. Developing pathways and related interventions to improve the logistics and practice of consent in school-based adolescent immunisation programmes could help improve uptake

The topobiology of chemical elements in seabird feathers

The highly organized morphogenesis of bird feathers holds important phylo- and ontogenetic information on the evolution of birds, organogenesis, tissue regeneration, and the health status of individual animals. Altered topobiological patterns are regularly used as retrospective evidence for disturbed developmental trajectories due to the past exposure to environmental stressors. Using the most advanced high-resolution (5-70 μm) X-ray fluorescence microscopy (XFM), we describe in the feathers from three species of Procellariiformes hitherto unknown, depositions of elements (Zn, Ca, Br, Cu, Fe) that are independent of pigmentation or any underlying variation in density or polymer structure. In the case of Zn, the pattern across several species of Procellariiformes, but not other species, consisted of highly regular bands of Zn numbering 30-32, which may reflect the estimated number of days of active feather growth or the duration of the moult period. Thus, speculatively, the highly consistent Zn pattern might be the result of a so far unknown diurnal systemic regulation rather than local heterogeneity amongst the follicular stem cells

Organisational factors affecting performance in delivering influenza vaccination to staff in NHS Acute Hospital Trusts in England: A qualitative study.

Health care workers are a priority group for seasonal influenza vaccination, which is recommended by the World Health Organisation. There is a wide variation in uptake between and within countries. England has achieved 69.5% of health care workers vaccinated overall in 2017/18 across NHS acute and community health care settings, but it varies between Trusts from 50% to over 92.3%. While attitudinal factors have been well researched, there is limited evidence on organisational factors associated with high uptake. In England, most NHS Trusts are now implementing a similar range of interventions as part of their flu programme, and it remains unclear why performance remains so variable. This qualitative study is the first to explore reasons for this variation and provide recommendations for lower performing Trusts on how to improve. Fifty-seven interviews of managers and vaccinators were conducted in nine hospitals with flu vaccination uptake ranging from just over 55% to above 90%. Our study found that while Trusts deployed a wide range of both demand generating and supply interventions to increase uptake, there were marked differences in the organisational and delivery models utilised. Our study suggests that organisational culture was possibly the most important ingredient when trying to differentiate between high and low performing Trusts. We found that a positive culture aimed at fostering continuous improvement and favouring non-coercion on balance yielded more adherence from staff. Where influenza vaccination was embedded in the organisation wellbeing strategy, rather than executed as a siloed seasonal programme, this tended to foster good performance. Improving performance of influenza vaccination in health care workers will involve not only deploying the right interventions, and following "best practices". It will require the adaptation of flu progamme delivery strategies to the organisation context, and embedding vaccination into the organisational culture, thus supporting the normalisation of yearly vaccination

Stroke Epidemiology in an Australian Rural Cohort (SEARCH)

Copyright © 2016 World Stroke Organization. Reprinted by permission of SAGE PublicationsBackground Stroke rates in Australia and New Zealand have been declining since 1990 but all studies have been completed in large urban centers. Aim We report the first Australasian stroke incidence study in a rural population. Methods The authors applied the principle of complete ascertainment, used the WHO standard definition of stroke and classified ischemic stroke by the TOAST criteria. Data were collected from five rural centers defined by postcode of residence, over a 2-year period with 12 months of follow up of all cases. Results There were 217 strokes in 215 individuals in a population of 96,036 people, over 2 years, giving a crude attack rate of 113 per 100,000 per year. The 181 first-ever strokes (83% of total), standardized to the WHO world population, occurred at a rate of 50/100,000 (95% CI: 43–58). The 28-day fatality for first-ever strokes was 24% (95% CI: 18–31) and 77% (95% CI: 71–83) were classified as ischemic (140/181), 15% (95% CI: 10–21) intracerebral hemorrhage, 3% (95% CI: 1–6) due to subarachnoid hemorrhage and 5% (95% CI: 2–9) were unknown. A high proportion of first-ever ischemic strokes (44%) were cardioembolic, mostly (77%) due to atrial arrhythmias. Of the 38 with known atrial arrhythmias prior to stroke, only six (16%) were therapeutically anticoagulated. Conclusions This rural companion study of a recent Australian urban stroke incidence study confirms the downward trend of stroke incidence in Australia, and reiterates that inadequate anticoagulation of atrial arrhythmia remains a preventable cause of ischemic stroke

Coronary CT Angiography and 5-Year Risk of Myocardial Infarction.

BACKGROUND: Although coronary computed tomographic angiography (CTA) improves diagnostic certainty in the assessment of patients with stable chest pain, its effect on 5-year clinical outcomes is unknown. METHODS: In an open-label, multicenter, parallel-group trial, we randomly assigned 4146 patients with stable chest pain who had been referred to a cardiology clinic for evaluation to standard care plus CTA (2073 patients) or to standard care alone (2073 patients). Investigations, treatments, and clinical outcomes were assessed over 3 to 7 years of follow-up. The primary end point was death from coronary heart disease or nonfatal myocardial infarction at 5 years. RESULTS: The median duration of follow-up was 4.8 years, which yielded 20,254 patient-years of follow-up. The 5-year rate of the primary end point was lower in the CTA group than in the standard-care group (2.3% [48 patients] vs. 3.9% [81 patients]; hazard ratio, 0.59; 95% confidence interval [CI], 0.41 to 0.84; P=0.004). Although the rates of invasive coronary angiography and coronary revascularization were higher in the CTA group than in the standard-care group in the first few months of follow-up, overall rates were similar at 5 years: invasive coronary angiography was performed in 491 patients in the CTA group and in 502 patients in the standard-care group (hazard ratio, 1.00; 95% CI, 0.88 to 1.13), and coronary revascularization was performed in 279 patients in the CTA group and in 267 in the standard-care group (hazard ratio, 1.07; 95% CI, 0.91 to 1.27). However, more preventive therapies were initiated in patients in the CTA group (odds ratio, 1.40; 95% CI, 1.19 to 1.65), as were more antianginal therapies (odds ratio, 1.27; 95% CI, 1.05 to 1.54). There were no significant between-group differences in the rates of cardiovascular or noncardiovascular deaths or deaths from any cause. CONCLUSIONS: In this trial, the use of CTA in addition to standard care in patients with stable chest pain resulted in a significantly lower rate of death from coronary heart disease or nonfatal myocardial infarction at 5 years than standard care alone, without resulting in a significantly higher rate of coronary angiography or coronary revascularization. (Funded by the Scottish Government Chief Scientist Office and others; SCOT-HEART ClinicalTrials.gov number, NCT01149590 .)

Sortase anchored proteins of Streptococcus uberis play major roles in the pathogenesis of bovine mastitis in dairy cattle

Streptococcus uberis, strain 0140J, contains a single copy sortase A (srtA), encoding a transamidase capable of covalently anchoring specific proteins to peptidoglycan. Unlike the wild-type, an isogenic mutant carrying an inactivating ISS1 insertion within srtA was only able to infect the bovine mammary gland in a transient fashion. For the first 24 h post challenge, the srtA mutant colonised at a similar rate and number to the wild type strain, but unlike the wild type did not subsequently colonise in higher numbers. Similar levels of host cell infiltration were detected in response to infection with both strains, but only in those mammary quarters infected with the wild type strain were clinical signs of disease evident. Mutants that failed to express individual sortase substrate proteins (sub0135, sub0145, sub0207, sub0241, sub0826, sub0888, sub1095, sub1154, sub1370, and sub1730) were isolated and their virulence determined in the same challenge model. This revealed that mutants lacking sub0145, sub1095 and sub1154 were attenuated in cattle. These data demonstrate that a number of sortase anchored proteins each play a distinct, non-redundant and important role in pathogenesis of S. uberis infection within the lactating bovine mammary gland