The Impact of Heatwaves on Community Morbidity and Healthcare Usage: A Retrospective Observational Study Using Real-Time Syndromic Surveillance.

We investigated the impact of a moderate heatwave on a range of presenting morbidities in England. Asthma, difficulty breathing, cerebrovascular accident, and cardiovascular symptoms were analysed using general practitioner in hours (GPIH), out of hours (GPOOH) and emergency department (ED) syndromic surveillance systems. Data were stratified by age group and compared between a heatwave year (2013) and non-heatwave years (2012, 2014). Incidence rate ratios were calculated to estimate the differential impact of heatwave compared to non-heatwave summers: there were no apparent differences for the morbidities tested between the 2013 heatwave and non-heatwave years. A subset of GPIH data were used to study individuals at higher risk from heatwaves based on their pre-existing disease. Higher risk patients were not more likely to present at GPs or ED than other individuals. Comparing GPIH consultations and ED attendances for myocardial infarction/ischaemia (MI), there was evidence of a fall in the presentation of MI during the heatwave, which was particularly noted in the 65-74 years age group (and over 75 years in ED attendances). These results indicate the difficulty in identifying individuals at risk from non-fatal health effects of heatwaves and hot weather

Interpreting specific and general respiratory indicators in syndromic surveillance

ObjectiveTo improve understanding of the relative burden of differentcausative respiratory pathogens on respiratory syndromic indicatorsmonitored using syndromic surveillance systems in England.IntroductionPublic Health England (PHE) uses syndromic surveillance systemsto monitor for seasonal increases in respiratory illness. Respiratoryillnesses create a considerable burden on health care services andtherefore identifying the timing and intensity of peaks of activity isimportant for public health decision-making. Furthermore, identifyingthe incidence of specific respiratory pathogens circulating in thecommunity is essential for targeting public health interventionse.g. vaccination. Syndromic surveillance can provide early warningof increases, but cannot explicitly identify the pathogens responsiblefor such increases.PHE uses a range of general and specific respiratory syndromicindicators in their syndromic surveillance systems, e.g. “allrespiratory disease”, “influenza-like illness”, “bronchitis” and“cough”. Previous research has shown that “influenza-like illness”is associated with influenza circulating in the community1whilst“cough” and “bronchitis” syndromic indicators in children under 5are associated with respiratory syncytial virus (RSV)2, 3. However, therelative burden of other pathogens, e.g. rhinovirus and parainfluenzais less well understood. We have sought to further understand therelationship between specific pathogens and syndromic indicators andto improve estimates of disease burden. Therefore, we modelled theassociation between pathogen incidence, using laboratory reports andhealth care presentations, using syndromic data.MethodsWe used positive laboratory reports for the following pathogens as aproxy for community incidence in England: human metapneumovirus(HMPV), RSV, coronavirus, influenza strains, invasivehaemophilusinfluenzae, invasivestreptococcus pneumoniae, mycoplasmapneumoniae, parainfluenza and rhinovirus. Organisms were chosenthat were found to be important in previous work2and were availablefrom routine laboratory testing. Syndromic data included consultationswith family doctors (called General Practitioners or GPs), calls to anational telephone helpline “NHS 111” and attendances at emergencydepartments (EDs). Associations between laboratory reports andsyndromic data were examined over four winter seasons (weeks40 to 20), between 2011 and 2015. Multiple linear regression was usedto model correlations and to estimate the proportion of syndromicconsultations associated with specific pathogens. Finally, burdenestimates were used to infer the proportion of patients affected byspecific pathogens that would be diagnosed with different symptoms.ResultsInfluenza and RSV exhibited the greatest seasonal variation andwere responsible for the strongest associated burden on generalrespiratory infections. However, associations were found with theother pathogens and the burden ofstreptococcus pneumoniaewasimportant in adult age groups (25 years and over).The model estimates suggested that only a small proportion ofpatients with influenza receive a specific diagnosis that is coded toan “influenza-like illness” syndromic indicator, (6% for both GPin-hours consultations and for emergency department attendances),compared to a more general respiratory diagnosis. Also, patients withinfluenza calling NHS 111 were more likely to receive a diagnosisof fever or cough than cold/flu. Despite these findings, the specificsyndromic indicators remained more sensitive to changes in influenzaincidence than the general indicators.ConclusionsThe majority of patients affected by a seasonal respiratory pathogenare likely to receive a non-specific respiratory diagnosis. Therefore,estimates of community burden using more specific syndromicindicators such as “influenza-like illness” are likely to be a severeunderestimate. However, these specific indicators remain importantfor detecting changes in incidence and providing added intelligenceon likely causative pathogens.Specific syndromic indicators were associated with multiplepathogens and we were unable to identify indicators that were goodmarkers for pathogens other than influenza or RSV. However, futurework focusing on differences between ages and the relative levels ofa range of pathogens may be able to provide estimates for the mix ofpathogens present in the community in real-time

Towards understanding the influence of porosity on mechanical and fracture behaviour of quasi-brittle materials:experiments and modelling

In this work, porosity-property relationships of quasi-brittle materials are explored through a combined experimental and numerical approach. In the experimental part, hemihyrate gypsum plaster powder (CaSO 4 ⋅1/2H 2 O CaSO4⋅1/2H2O) and expanded spherical polystyrene beads (1.5–2.0 mm dia.) have been mixed to form a model material with controlled additions of porosity. The expanded polystyrene beads represent pores within the bulk due to their light weight and low strength compared with plaster. Varying the addition of infill allows the production of a material with different percentages of porosity: 0, 10, 20, 30 and 31 vol%. The size and location of these pores have been characterised by 3D X-ray computed tomography. Beams of the size of 20×20×150 20×20×150 mm were cast and loaded under four-point bending to obtain the mechanical characteristics of each porosity level. The elastic modulus and flexural strength are found to decrease with increased porosity. Fractography studies have been undertaken to identify the role of the pores on the fracture path. Based on the known porosity, a 3D model of each microstructure has been built and the deformation and fracture was computed using a lattice-based multi-scale finite element model. This model predicted similar trends as the experimental results and was able to quantify the fractured sites. The results from this model material experimental data and the lattice model predictions are discussed with respect to the role of porosity on the deformation and fracture of quasi-brittle materials

Aloidendron barberae

Aloidendron is a very small genus of seven tree aloes in the family Asphodelaceae, described as recently as 2013, ranging from South Africa to Mozambique, with a large disjunction to Somalia, Yemen and Saudi Arabia. Aloidendron barberae is recorded from South Africa, Swaziland and southern Mozambique. However, the records for Mozambique are queried here and it is suggested that these actually relate to its closest relative, Aloidendron tongaense, a smaller tree only 4-8 m tall, which may be endemic to Mozambique. Aloidendron barberae is the largest alooid, growing to 20 m tall and is copiously dichotomously branched. Its taxonomic and nomenclatural history are outlined. Its habitat, natural distribution, ecology and cultivation are discussed, accompanied by a full description and reproduction of a specially commissioned watercolour painting

Using emergency department syndromic surveillance to investigate the impact of a national vaccination program: A retrospective observational study

BackgroundRotavirus infection is a common cause of gastroenteritis in children worldwide, with a high mortality burden in developing countries, particularly during the first two years of life. Rotavirus vaccination was introduced into the United Kingdom childhood vaccination schedule in July 2013, with high coverage (>90%) achieved by June 2016. We used an emergency department (ED) syndromic surveillance system to assess the impact of the rotavirus vaccination programme, specifically through the demonstration of any immediate and continuing impact on ED gastroenteritis visits in England.MethodsThis retrospective, observational study used syndromic surveillance data collected from 3 EDs in the two years before (July 2011-June 2013) and 3 years post (July 2013-June 2016) introduction of rotavirus vaccination. The weekly levels of ED visits for gastroenteritis (by age group and in total) during the period before rotavirus vaccination was first described alongside the findings of laboratory surveillance of rotavirus during the same period. An interrupted time-series analysis was then performed to demonstrate the impact of rotavirus vaccination introduction on gastroenteritis ED visit levels.ResultsDuring the two years before vaccine introduction ED visits for gastroenteritis in total and for the 0-4 years age group were seen to rise and fall in line with the seasonal rotavirus increases reported by laboratory surveillance. ED gastroenteritis visits by young children were lower in the three years following introduction of rotavirus vaccination (reduced from 8% of visits to 6% of visits). These attendance levels in young children (0-4years) remained higher than in older age groups, however the previously large seasonal increases in children were greatly reduced, from peaks of 16% to 3-10% of ED visits per week.ConclusionsED syndromic surveillance demonstrated a reduction in gastroenteritis visits following rotavirus vaccine introduction. This work establishes ED syndromic surveillance as a platform for rapid impact assessment of future vaccine programmes

<i>Kalanchoe beharensis</i>. Crassulaceae: Kalanchooideae

Kalanchoe beharensis is one of the largest species of the diverse genus, reaching a height of about 3 m, one of only a few that can be regarded as truly arborescent. The species is discussed in detail in terms of its history, taxonomy, relationships, distribution, habitat, variability and cultivation. It is described in full and illustrated with a water-colour painting and colour photos. This species is endemic to and fairly widespread in western, central and eastern Madagascar including Behara after which it is named. It has been introduced to several mild-climate parts of the world and is now widespread in cultivation

Machine learning to refine decision making within a syndromic surveillance service

Background: Worldwide, syndromic surveillance is increasingly used for improved and timely situational awareness and early identification of public health threats. Syndromic data streams are fed into detection algorithms, which produce statistical alarms highlighting potential activity of public health importance. All alarms must be assessed to confirm whether they are of public health importance. In England, approximately 100 alarms are generated daily and, although their analysis is formalised through a risk assessment process, the process requires notable time, training, and maintenance of an expertise base to determine which alarms are of public health importance. The process is made more complicated by the observation that only 0.1% of statistical alarms are deemed to be of public health importance. Therefore, the aims of this study were to evaluate machine learning as a tool for computer-assisted human decision-making when assessing statistical alarms. Methods: A record of the risk assessment process was obtained from Public Health England for all 67505 statistical alarms between August 2013 and October 2015. This record contained information on the characteristics of the alarm (e.g. size, location). We used three Bayesian classifiers- naïve Bayes, tree-augmented naïve Bayes and Multinets - to examine the risk assessment record in England with respect to the final ‘Decision’ outcome made by an epidemiologist of ‘Alert’, ‘Monitor’ or ‘No-action’. Two further classifications based upon tree-augmented naïve Bayes and Multinets were implemented to account for the predominance of ‘No-action’ outcomes. Results: The attributes of each individual risk assessment were linked to the final decision made by an epidemiologist, providing confidence in the current process. The naïve Bayesian classifier performed best, correctly classifying 51.5% of ‘Alert’ outcomes. If the ‘Alert’ and ‘Monitor’ actions are combined then performance increases to 82.6% correctly classified. We demonstrate how a decision support system based upon a naïve Bayes classifier could be operationalised within an operational syndromic surveillance system. Conclusions: Within syndromic surveillance systems, machine learning techniques have the potential to make risk assessment following statistical alarms more automated, robust, and rigorous. However, our results also highlight the importance of specialist human input to the process

Alkyl Phenols and Diethylhexyl Phthalate in Tissues of Sheep Grazing Pastures Fertilized with Sewage Sludge or Inorganic Fertilizer

We studied selected tissues from ewes and their lambs that were grazing pastures fertilized with either sewage sludge (treated) or inorganic fertilizer (control) and determined concentrations of alkylphenols and phthalates in these tissues. Mean tissue concentrations of alkylphenols were relatively low (< 10–400 μg/kg) in all animals and tissues. Phthalates were detected in tissues of both control and treated animals at relatively high concentrations (> 20,000 μg/kg in many tissue samples). The use of sludge as a fertilizer was not associated with consistently increased concentrations of either alkylphenols or phthalates in the tissues of animals grazing treated pastures relative to levels in control animal tissues. Concentrations of the two classes of chemicals differed but were of a similar order of magnitude in liver and muscle as well as in fat. Concentrations of each class of compound were broadly similar in tissues derived from ewes and lambs. Although there were significant differences (p < 0.01 or p < 0.001) between years (cohorts) in mean tissue concentrations of both nonylphenol (NP) and phthalate in each of the tissues from both ewes and lambs, the differences were not attributable to either the age (6 months or 5 years) of the animal or the duration of exposure to treatments. Octylphenol concentrations were generally undetectable. There was no consistent cumulative outcome of prolonged exposure on the tissue concentrations of either class of pollutant in any ewe tissue. Mean tissue concentrations of phthalate were higher (p < 0.001) in the liver and kidney fat of male compared with female lambs. We suggest that the addition of sewage sludge to pasture is unlikely to cause large increases in tissue concentrations of NP and phthalates in sheep and other animals with broadly similar diets and digestive systems (i.e., domestic ruminants) grazing such pasture

Can syndromic surveillance help forecast winter hospital bed pressures in England?

BACKGROUND: Health care planners need to predict demand for hospital beds to avoid deterioration in health care. Seasonal demand can be affected by respiratory illnesses which in England are monitored using syndromic surveillance systems. Therefore, we investigated the relationship between syndromic data and daily emergency hospital admissions. METHODS: We compared the timing of peaks in syndromic respiratory indicators and emergency hospital admissions, between 2013 and 2018. Furthermore, we created forecasts for daily admissions and investigated their accuracy when real-time syndromic data were included. RESULTS: We found that syndromic indicators were sensitive to changes in the timing of peaks in seasonal disease, especially influenza. However, each year, peak demand for hospital beds occurred on either 29th or 30th December, irrespective of the timing of syndromic peaks. Most forecast models using syndromic indicators explained over 70% of the seasonal variation in admissions (adjusted R square value). Forecast errors were reduced when syndromic data were included. For example, peak admissions for December 2014 and 2017 were underestimated when syndromic data were not used in models. CONCLUSION: Due to the lack of variability in the timing of the highest seasonal peak in hospital admissions, syndromic surveillance data do not provide additional early warning of timing. However, during atypical seasons syndromic data did improve the accuracy of forecast intensity