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The purpose of syndromic surveillance is to provide early warning of public health incidents, real-time situational awareness during incidents and emergencies, and reassurance of the lack of impact on the population, particularly during mass gatherings. The United Kingdom Health Security Agency (UKHSA) currently coordinates a real-time syndromic surveillance service that encompasses 6 national syndromic surveillance systems reporting on daily health care usage across England. Each working day, UKHSA analyzes syndromic data from over 200,000 daily patient encounters with the National Health Service, monitoring over 140 unique syndromic indicators, risk assessing over 50 daily statistical exceedances, and taking and recommending public health action on these daily. This English syndromic surveillance service had its origins as a small exploratory pilot in a single region of England in 1999 involving a new pilot telehealth service, initially reporting only on "cold or flu" calls. This pilot showed the value of syndromic surveillance in England, providing advanced warning of the start of seasonal influenza activity over existing laboratory-based surveillance systems. Since this initial pilot, a program of real-time syndromic surveillance has evolved from the single-system, -region, -indicator pilot (using manual data transfer methods) to an all-hazard, multisystem, automated national service. The suite of systems now monitors a wide range of syndromes, from acute respiratory illness to diarrhea to cardiac conditions, and is widely used in routine public health surveillance and for monitoring seasonal respiratory disease and incidents such as the COVID-19 pandemic. Here, we describe the 25-year evolution of the English syndromic surveillance system, focusing on the expansion and improvements in data sources and data management, the technological and digital enablers, and novel methods of data analytics and visualization., (©Alex J Elliot, Helen E Hughes, Sally E Harcourt, Sue Smith, Paul Loveridge, Roger A Morbey, Amardeep Bains, Obaghe Edeghere, Natalia R Jones, Daniel Todkill, Gillian E Smith. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 17.09.2024.)

Since November 2023, the absolute number of attendances at emergency departments for pneumonia among children aged 5-14 years in England have been above expected levels for the time of year. This increased signal peaked during March 2024 but then persisted into early summer 2024 despite decreases in prevalence of seasonal respiratory pathogens. Record linkage between emergency department and laboratory databases points to this unusual activity being driven largely by Mycoplasma pneumoniae .

The underreporting of laboratory-reported cases of community-based gastrointestinal (GI) infections poses a challenge for epidemiologists understanding the burden and seasonal patterns of GI pathogens. Syndromic surveillance has the potential to overcome the limitations of laboratory reporting through real-time data and more representative population coverage. This systematic review summarizes the utility of syndromic surveillance for early detection and surveillance of GI infections. Relevant articles were identified using the following keyword combinations: 'early warning', 'detection', 'gastrointestinal activity', 'gastrointestinal infections', 'syndrome monitoring', 'real-time monitoring', 'syndromic surveillance'. In total, 1820 studies were identified, 126 duplicates were removed, and 1694 studies were reviewed. Data extraction focused on studies reporting the routine use and effectiveness of syndromic surveillance for GI infections using relevant GI symptoms. Eligible studies ( n = 29) were included in the narrative synthesis. Syndromic surveillance for GI infections has been implemented and validated for routine use in ten countries, with emergency department attendances being the most common source. Evidence suggests that syndromic surveillance can be effective in the early detection and routine monitoring of GI infections; however, 24% of the included studies did not provide conclusive findings. Further investigation is necessary to comprehensively understand the strengths and limitations associated with each type of syndromic surveillance system.

Background: Norovirus is associated with approximately 18% of the global burden of gastroenteritis and affects all age groups. There is currently no licensed vaccine or available antiviral treatment. However, well-designed early warning systems and forecasting can guide nonpharmaceutical approaches to norovirus infection prevention and control., Objective: This study evaluates the predictive power of existing syndromic surveillance data and emerging data sources, such as internet searches and Wikipedia page views, to predict norovirus activity across a range of age groups across England., Methods: We used existing syndromic surveillance and emerging syndromic data to predict laboratory data indicating norovirus activity. Two methods are used to evaluate the predictive potential of syndromic variables. First, the Granger causality framework was used to assess whether individual variables precede changes in norovirus laboratory reports in a given region or an age group. Then, we used random forest modeling to estimate the importance of each variable in the context of others with two methods: (1) change in the mean square error and (2) node purity. Finally, these results were combined into a visualization indicating the most influential predictors for norovirus laboratory reports in a specific age group and region., Results: Our results suggest that syndromic surveillance data include valuable predictors for norovirus laboratory reports in England. However, Wikipedia page views are less likely to provide prediction improvements on top of Google Trends and Existing Syndromic Data. Predictors displayed varying relevance across age groups and regions. For example, the random forest modeling based on selected existing and emerging syndromic variables explained 60% variance in the ≥65 years age group, 42% in the East of England, but only 13% in the South West region. Emerging data sets highlighted relative search volumes, including "flu symptoms," "norovirus in pregnancy," and norovirus activity in specific years, such as "norovirus 2016." Symptoms of vomiting and gastroenteritis in multiple age groups were identified as important predictors within existing data sources., Conclusions: Existing and emerging data sources can help predict norovirus activity in England in some age groups and geographic regions, particularly, predictors concerning vomiting, gastroenteritis, and norovirus in the vulnerable populations and historical terms such as stomach flu. However, syndromic predictors were less relevant in some age groups and regions likely due to contrasting public health practices between regions and health information-seeking behavior between age groups. Additionally, predictors relevant to one norovirus season may not contribute to other seasons. Data biases, such as low spatial granularity in Google Trends and especially in Wikipedia data, also play a role in the results. Moreover, internet searches can provide insight into mental models, that is, an individual's conceptual understanding of norovirus infection and transmission, which could be used in public health communication strategies., (©Nikola Ondrikova, John P Harris, Amy Douglas, Helen E Hughes, Miren Iturriza-Gomara, Roberto Vivancos, Alex J Elliot, Nigel A Cunliffe, Helen E Clough. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 08.05.2023.)

Background: Seasonal epidemics of respiratory syncytial virus (RSV) cause a clinically significant burden of disease among young children. Non-pharmaceutical interventions targeted at SARS-CoV-2 have affected the activity of other respiratory pathogens. We describe changes in the epidemiology of RSV among children younger than 5 years in England since 2020., Methods: Surveillance data on RSV infections, comprising laboratory-confirmed cases, proportion of positive tests, hospital admissions for RSV-attributable illness, and syndromic indicators for RSV-associated disease (emergency department attendances for acute bronchitis or bronchiolitis, non-emergency health advice telephone service [NHS 111] calls for cough, general practitioner [GP] in-hours consultations for respiratory tract infections, and GP out-of-hours contacts for acute bronchitis or bronchiolitis) were analysed from Dec 29, 2014 to March 13, 2022, for children younger than 5 years. Data were extracted from national laboratory, clinical, and syndromic surveillance systems. Time-series analyses using generalised linear models were used to estimate the effect of non-pharmaceutical interventions targeting SARS-CoV-2 on RSV indicators, with absolute and relative changes calculated by comparing observed and predicted values., Findings: RSV-associated activity was reduced for all RSV indicators during winter 2020-21 in England, with 10 280 (relative change -99·5% [95% prediction interval -100·0 to -99·1]) fewer laboratory-confirmed cases, 22·2 (-99·6%) percentage points lower test positivity, 92 530 (-80·8% [-80·9 to -80·8]) fewer hospital admissions, 96 672 (-73·7% [-73·7 to -73·7]) fewer NHS 111 calls, 2924 (-88·8% [-90·4 to -87·2]) fewer out-of-hours GP contacts, 91 304 (-89·9% [-90·0 to -89·9]) in-hours GP consultations, and 27 486 (-85·3% [-85·4 to -85·2]) fewer emergency department attendances for children younger than 5 years compared with predicted values based on winter seasons before the COVID-19 pandemic. An unprecedented summer surge of RSV activity occurred in 2021, including 11 255 (1258·3% [1178·3 to 1345·8]) extra laboratory-confirmed cases, 11·6 percentage points (527·3%) higher test positivity, 7604 (10·7% [10·7 to 10·8]) additional hospital admissions, 84 425 (124·8% [124·7 to 124·9]) more calls to NHS 111, 409 (39·0% [36·6 to 41·8]) more out-of-hours GP contacts, and 9789 (84·9% [84·5 to 85·4]) more emergency department attendances compared with the predicted values, although there were 21 805 (-34·1% [-34·1 to -34·0]) fewer in-hours GP consultations than expected. Most indicators were also lower than expected in winter 2021-22, although to a lesser extent than in winter 2020-21., Interpretation: The extraordinary absence of RSV during winter 2020-21 probably resulted in a cohort of young children without natural immunity to RSV, thereby raising the potential for increased RSV incidence, out-of-season activity, and health-service pressures when measures to restrict SARS-CoV-2 transmission were relaxed., Funding: None., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: The COVID-19 pandemic has resulted in an unprecedented impact on the day-to-day lives of people, with several features potentially adversely affecting mental health. There is growing evidence of the size of the impact of COVID-19 on mental health, but much of this is from ongoing population surveys using validated mental health scores., Objective: This study investigated the impact of the pandemic and control measures on mental health conditions presenting to a spectrum of national health care services monitored using real-time syndromic surveillance in England., Methods: We conducted a retrospective observational descriptive study of mental health presentations (those calling the national medical helpline, National Health Service [NHS] 111; consulting general practitioners [GPs] in and out-of-hours; calling ambulance services; and attending emergency departments) from January 1, 2019, to September 30, 2020. Estimates for the impact of lockdown measures were provided using an interrupted time series analysis., Results: Mental health presentations showed a marked decrease during the early stages of the pandemic. Postlockdown, attendances for mental health conditions reached higher than prepandemic levels across most systems-a rise of 10% compared to that expected for NHS 111 and 21% for GP out-of-hours service-while the number of consultations to GP in-hours service was 13% lower compared to the same time previous year. Increases were observed in calls to NHS 111 for sleep problems., Conclusions: These analyses showed marked changes in the health care attendances and prescribing for common mental health conditions across a spectrum of health care provision, with some of these changes persisting. The reasons for such changes are likely to be complex and multifactorial. The impact of the pandemic on mental health may not be fully understood for some time, and therefore, these syndromic indicators should continue to be monitored., (©Gillian E Smith, Sally E Harcourt, Uy Hoang, Agnieszka Lemanska, Alex J Elliot, Roger A Morbey, Helen E Hughes, Iain Lake, Obaghe Edeghere, Isabel Oliver, Julian Sherlock, Richard Amlôt, Simon de Lusignan. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 03.08.2022.)

Background: In the 2016/2017 influenza season, England was in its fourth season of the roll-out of a live-attenuated influenza vaccine (LAIV) targeted at healthy children aged two to less than 17 years. For the first time, all healthy children aged 2 to 8 years were offered LAIV at national level in 2016/2017. Since the commencement of the programme in 2013/2014, a series of geographically discrete pilot areas have been in place where quadrivalent LAIV was also offered to all school age children. In 2016/2017, these were children aged 8 to 11 years, other than those targeted by the national programme., Methods: We evaluated the overall and indirect impact of vaccinating primary school age children, on the population of England, by measuring vaccine uptake levels and comparing cumulative disease incidence through various influenza surveillance schemes, in targeted and non-targeted age groups in pilot and non-pilot areas in 2016/2017., Results: Our findings indicate that cumulative primary care influenza-like consultations, primary and secondary care swab positivity, influenza confirmed hospitalisations and emergency department attendances in pilot areas were overall lower than those observed in non-pilot areas; however, significant differences were not always observed in both targeted and non-targeted age groups. Excess mortality was higher in pilot areas compared with non-pilot areas., Conclusions: These results are similar to earlier seasons of the programme indicating the importance and continuing support of vaccinating all primary school children with LAIV to reduce influenza related illness across the population, although further work is needed to understand the differences in excess mortality., (© 2021 Crown copyright. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd. This article is published with the permission of the Controller of HMSO and the Queen's Printer for Scotland.)

Thunderstorm asthma is often characterised by a sudden surge in patients presenting with exacerbated symptoms of asthma linked to thunderstorm activity. Here, we describe a large spike in asthma and difficulty breathing symptoms observed across parts of England on 17 June 2021. The number of healthcare presentations during the asthma event was compared to expected levels for the overall population and across specific regions. Across affected geographical areas, emergency department attendances for asthma increased by 560% on 17 June compared to the average number of weekday daily attendances during the previous 4 weeks. General practitioner out of hours contacts increased by 349%, National Health Service (NHS) 111 calls 193%, NHS 111 online assessments 581% and ambulance call outs 54%. Increases were particularly noted in patient age groups 5-14 and 15-44 years. In non-affected regions, increases were small (<10%) or decreased, except for NHS 111 online assessments where there was an increase of 39%. A review of the meteorological conditions showed several localised, weak, or moderate thunderstorms specifically across parts of Southeast England on the night of June 16. In this unprecedented episode of asthma, the links to meteorologically defined thunderstorm activity were not as clear as previous episodes, with less evidence of 'severe' thunderstorm activity in those areas affected, prompting further discussion about the causes of these events and implications for public health management of the risk.

This study describes the development of a pilot sentinel school absence syndromic surveillance system. Using data from a sample of schools in England the capability of this system to monitor the impact of disease on school absences in school-aged children is shown, using the coronavirus disease 2019 (COVID-19) pandemic period as an example. Data were obtained from an online app service used by schools and parents to report their children absent, including reasons/symptoms relating to absence. For 2019 and 2020, data were aggregated into daily counts of 'total' and 'cough' absence reports. There was a large increase in the number of absence reports in March 2020 compared to March 2019, corresponding to the first wave of the COVID-19 pandemic in England. Absence numbers then fell rapidly and remained low from late March 2020 until August 2020, while lockdown was in place in England. Compared to 2019, there was a large increase in the number of absence reports in September 2020 when schools re-opened in England, although the peak number of absences was smaller than in March 2020. This information can help provide context around the absence levels in schools associated with COVID-19. Also, the system has the potential for further development to monitor the impact of other conditions on school absence, e.g. gastrointestinal infections.

Background: Since the end of January 2020, the coronavirus (COVID-19) pandemic has been responsible for a global health crisis. In England a number of non-pharmaceutical interventions have been introduced throughout the pandemic, including guidelines on healthcare attendance (for example, promoting remote consultations), increased handwashing and social distancing. These interventions are likely to have impacted the incidence of non-COVID-19 conditions as well as healthcare seeking behaviour. Syndromic Surveillance Systems offer the ability to monitor trends in healthcare usage over time., Methods: This study describes the indirect impact of COVID-19 on healthcare utilisation using a range of syndromic indicators including eye conditions, mumps, fractures, herpes zoster and cardiac conditions. Data from the syndromic surveillance systems monitored by Public Health England were used to describe the number of contacts with NHS 111, general practitioner (GP) In Hours (GPIH) and Out-of-Hours (GPOOH), Ambulance and Emergency Department (ED) services over comparable periods before and during the pandemic., Results: The peak pandemic period in 2020 (weeks 13-20), compared to the same period in 2019, displayed on average a 12% increase in NHS 111 calls, an 11% decrease in GPOOH consultations, and a 49% decrease in ED attendances. In the GP In Hours system, conjunctivitis consultations decreased by 64% and mumps consultations by 31%. There was a 49% reduction in attendance at EDs for fractures, and there was no longer any weekend increase in ED fracture attendances, with similar attendance patterns observed across each day of the week. There was a decrease in the number of ED attendances with diagnoses of myocardial ischaemia., Conclusion: The COVID-19 pandemic drastically impacted healthcare utilisation for non-COVID-19 conditions, due to a combination of a probable decrease in incidence of certain conditions and changes in healthcare seeking behaviour. Syndromic surveillance has a valuable role in describing and understanding these trends., (© 2021. The Author(s).)

Background: Syndromic surveillance provides public health intelligence to aid in early warning and monitoring of public health impacts (e.g. seasonal influenza), or reassurance when an impact has not occurred. Using information collected during routine patient care, syndromic surveillance can be based on signs/symptoms/preliminary diagnoses. This approach makes syndromic surveillance much timelier than surveillance requiring laboratory confirmed diagnoses. The provision of healthcare services and patient access to them varies globally. However, emergency departments (EDs) exist worldwide, providing unscheduled urgent care to people in acute need. This provision of care makes ED syndromic surveillance (EDSyS) a potentially valuable tool for public health surveillance internationally. The objective of this study was to identify and describe the key characteristics of EDSyS systems that have been established and used globally., Methods: We systematically reviewed studies published in peer review journals and presented at International Society of Infectious Disease Surveillance conferences (up to and including 2017) to identify EDSyS systems which have been created and used for public health purposes. Search criteria developed to identify "emergency department" and "syndromic surveillance" were applied to NICE healthcare, Global Health and Scopus databases., Results: In total, 559 studies were identified as eligible for inclusion in the review, comprising 136 journal articles and 423 conference abstracts/papers. From these studies we identified 115 EDSyS systems in 15 different countries/territories across North America, Europe, Asia and Australasia. Systems ranged from local surveillance based on a single ED, to comprehensive national systems. National EDSyS systems were identified in 8 countries/territories: 2 reported inclusion of ≥85% of ED visits nationally (France and Taiwan)., Conclusions: EDSyS provides a valuable tool for the identification and monitoring of trends in severe illness. Technological advances, particularly in the emergency care patient record, have enabled the evolution of EDSyS over time. EDSyS reporting has become closer to 'real-time', with automated, secure electronic extraction and analysis possible on a daily, or more frequent basis. The dissemination of methods employed and evidence of successful application to public health practice should be encouraged to support learning from best practice, enabling future improvement, harmonisation and collaboration between systems in future., Prospero Number: CRD42017069150 .

Background: Rotavirus 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., Methods: This 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., Results: During 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., Conclusions: ED 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., Competing Interests: Roberto Vivancos and Daniel Hungerford have worked in an evaluation of the childhood rotavirus vaccination programme in Merseyside which was partly funded by GlaxoSmithKline Biologicals. Daniel Hungerford is in receipt of research grant support from Sanofi Pasteur-MSD (SPMSD). This does not alter our adherence to PLOS ONE policies on sharing data and materials.

On 12 March 2020 the UK entered the 'delay phase' of the COVID-19 pandemic response. The Public Health England Emergency Department Syndromic Surveillance System (EDSSS) carries out daily (near real-time) public health surveillance of emergency department (ED) attendances across England. This retrospective observational analysis of EDSSS data aimed to describe changes in ED attendances during March-April 2020, and identify the attendance types with the largest impact. Type 1 ED attendances were selected from 109 EDs that reported data to EDSSS for the period 1 January 2019 to 26 April 2020. The daily numbers of attendances were plotted by age group and acuity of presentation. The 2020 'COVID-19' period (12 March 2020 to 26 April 2020) attendances were compared with the equivalent 2019 'pre-COVID-19' period (14 March 2019 to 28 April 2019): in total; by hour and day of the week; age group(<1, 1-4, 15-14, 15-44, 45-64 and 65+ years); gender; acuity; and for selected syndromic indicators(acute respiratory infection, gastroenteritis, myocardial ischaemia). Daily ED attendances up to 11 March 2020 showed regular trends, highest on a Monday and reduced in children during school holidays. From 12 March 2020 ED attendances decreased across all age groups, all acuity levels, on all days and times. Across age groups the greatest percentage reductions were seen in school age children (5-14 years). By acuity, the greatest reduction occurred in the less severe presentations. Syndromic indicators showed that the greatest reductions were in non-respiratory indicators, which fell by 44-67% during 2020 COVID-19, while acute respiratory infection was reduced by -4.4% (95% CI -9.5% to 0.6%). ED attendances in England have been particularly affected during the COVID-19 pandemic due to changes in healthcare seeking behaviour. EDSSS has enabled real-time daily monitoring of these changes, which are made publicly available to facilitate action. The EDSSS provides valuable surveillance of ED attendances in England. The flexibility of EDSSS allowed rapid development of new indicators (including COVID-19-like) and reporting methods., Competing Interests: Competing interests: TCH is a director of L2S2 Ltd., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

The COVID-19 pandemic is exerting major pressures on society, health and social care services and science. Understanding the progression and current impact of the pandemic is fundamental to planning, management and mitigation of future impact on the population. Surveillance is the core function of any public health system, and a multi-component surveillance system for COVID-19 is essential to understand the burden across the different strata of any health system and the population. Many countries and public health bodies utilise 'syndromic surveillance' (using real-time, often non-specific symptom/preliminary diagnosis information collected during routine healthcare provision) to supplement public health surveillance programmes. The current COVID-19 pandemic has revealed a series of unprecedented challenges to syndromic surveillance including: the impact of media reporting during early stages of the pandemic; changes in healthcare-seeking behaviour resulting from government guidance on social distancing and accessing healthcare services; and changes in clinical coding and patient management systems. These have impacted on the presentation of syndromic outputs, with changes in denominators creating challenges for the interpretation of surveillance data. Monitoring changes in healthcare utilisation is key to interpreting COVID-19 surveillance data, which can then be used to better understand the impact of the pandemic on the population. Syndromic surveillance systems have had to adapt to encompass these changes, whilst also innovating by taking opportunities to work with data providers to establish new data feeds and develop new COVID-19 indicators. These developments are supporting the current public health response to COVID-19, and will also be instrumental in the continued and future fight against the disease.

Major sporting events may influence attendance levels at hospital emergency departments (ED). Previous research has focussed on the impact of single games, or wins/losses for specific teams/countries, limiting wider generalisations. Here we explore the impact of the Euro 2016 football championships on ED attendances across four participating nations (England, France, Northern Ireland, Wales), using a single methodology. Match days were found to have no significant impact upon daily ED attendances levels. Focussing upon hourly attendances, ED attendances across all countries in the four hour pre-match period were statistically significantly lower than would be expected (OR 0.97, 95% CI 0.94-0.99) and further reduced during matches (OR 0.94, 95% CI 0.91-0.97). In the 4 hour post-match period there was no significant increase in attendances (OR 1.01, 95% CI 0.99-1.04). However, these impacts were highly variable between individual matches: for example in the 4 hour period following the final, involving France, the number of ED attendances in France increased significantly (OR 1.27, 95% CI 1.13-1.42). Overall our results indicate relatively small impacts of major sporting events upon ED attendances. The heterogeneity observed makes it difficult for health providers to predict how major sporting events may affect ED attendances but supports the future development of compatible systems in different countries to support cross-border public health surveillance., Competing Interests: The authors have declared that no competing interests exist.

The 2015/16 influenza season was the third season of the introduction of an intra-nasally administered live attenuated influenza vaccine (LAIV) for children in England. All children aged 2‒6 years were offered LAIV, and in addition, a series of geographically discrete areas piloted vaccinating school-age children 7‒11 years old. Influenza A(H1N1)pdm09 was the dominant circulating strain during 2015/16 followed by influenza B. We measured influenza vaccine uptake and the overall and indirect effect of vaccinating children of primary school -age, by comparing cumulative disease incidence in targeted and non-targeted age groups in vaccine pilot and non-pilot areas in England. Uptake of 57.9% (range: 43.6-72.0) was achieved in the five pilot areas for children aged 5‒11 years. In pilot areas, cumulative emergency department respiratory attendances, influenza-confirmed hospitalisations and intensive care unit admissions were consistently lower, albeit mostly non-significantly, in targeted and non-targeted age groups compared with non-pilot areas. Effect sizes were less for adults and more severe endpoints. Vaccination of healthy primary school-age children with LAIV at moderately high levels continues to be associated with population-level reductions in influenza-related respiratory illness. Further work to evaluate the population-level impact of the programme is required.

Introduction: Poor air quality (AQ) is a global public health issue and AQ events can span across countries. Using emergency department (ED) syndromic surveillance from England and France, we describe changes in human health indicators during periods of particularly poor AQ in London and Paris during 2014., Methods: Using daily AQ data for 2014, we identified three periods of poor AQ affecting both London and Paris. Anonymised near real-time ED attendance syndromic surveillance data from EDs across England and France were used to monitor the health impact of poor AQ.Using the routine English syndromic surveillance detection methods, increases in selected ED syndromic indicators (asthma, difficulty breathing and myocardial ischaemia), in total and by age, were identified and compared with periods of poor AQ in each city. Retrospective Wilcoxon-Mann-Whitney tests were used to identify significant increases in ED attendance data on days with (and up to 3 days following) poor AQ., Results: Almost 1.5 million ED attendances were recorded during the study period (27 February 2014 to 1 October 2014). Significant increases in ED attendances for asthma were identified around periods of poor AQ in both cities, especially in children (aged 0-14 years). Some variation was seen in Paris with a rapid increase during the first AQ period in asthma attendances among children (aged 0-14 years), whereas during the second period the increase was greater in adults., Discussion: This work demonstrates the public health value of syndromic surveillance during air pollution incidents. There is potential for further cross-border harmonisation to provide Europe-wide early alerting to health impacts and improve future public health messaging to healthcare services to provide warning of increases in demand., Competing Interests: Competing interests: None declared., (© Crown copyright 2018. Reproduced with the permission of the Controller of Her Majesty’s Stationery Office/Queen’s Printer for Scotland and Public Health England.)

Background: Introduction of infant oral rotavirus vaccination in the UK in July 2013 has resulted in decreased hospitalisations and Emergency Department (ED) visits for acute gastroenteritis (AGE), for both adults and children. We investigated reductions in AGE incidence seen in primary care in the two years after vaccine introduction, and estimated the healthcare costs averted across healthcare settings in the first year of the vaccination programme., Methods: We used primary care data from the Clinical Practice Research Datalink and age-stratified time-series analyses to derive adjusted incidence rate ratios (IRR a ) for AGE in the first two years of the post-vaccination era (July 2013-April 2015) compared to the pre-vaccination era (July 2008-June 2013). We estimated cases averted among children aged <5years in the first year of the vaccination programme by comparing observed numbers of AGE cases in 2013-2014 to numbers predicted from the time-series models. We then estimated the healthcare costs averted for general practice consultations, ED visits and hospitalisations., Results: In general practice, AGE rates in infants (the target group for vaccination) decreased by 15% overall after vaccine introduction (IRR a =0.85; 95%CI=0.76-0.95), and by 41% in the months of historically high rotavirus circulation (IRR a =0.59; 95%CI=0.53-0.66). Rates also decreased in other young children and to a lesser degree in older individuals, indicating herd immunity. Across all three settings (general practice, EDs, and hospitalisations) an estimated 87,376 (95% prediction interval: 62,588-113,561) AGE visits by children aged <5years were averted in 2013-14, associated with an estimated £12.5million (9,209-16,198) reduction in healthcare costs., Conclusions: The marked decreases in the general practice AGE burden after rotavirus vaccine introduction mirror decreases seen in other UK healthcare settings. Overall, these decreases are associated with substantial averted healthcare costs., (Copyright © 2016. Published by Elsevier Ltd.)

Introduction In preparation for the London 2012 Olympic Games, existing syndromic surveillance systems operating in England were expanded to include daily general practitioner (GP) out-of-hours (OOH) contacts and emergency department (ED) attendances at sentinel sites (the GP OOH and ED syndromic surveillance systems: GPOOHS and EDSSS). Hypothesis/Problem The further development of syndromic surveillance systems in time for the London 2012 Olympic Games provided a unique opportunity to investigate the impact of a large mass-gathering event on public health and health services as monitored in near real-time by syndromic surveillance of GP OOH contacts and ED attendances. This can, in turn, aid the planning of future events., Methods: The EDSSS and GPOOHS data for London and England from July 13 to August 26, 2012, and a similar period in 2013, were divided into three distinct time periods: pre-Olympic period (July 13-26, 2012); Olympic period (July 27 to August 12); and post-Olympic period (August 13-26, 2012). Time series of selected syndromic indicators in 2012 and 2013 were plotted, compared, and risk assessed by members of the Real-time Syndromic Surveillance Team (ReSST) in Public Health England (PHE). Student's t test was used to test any identified changes in pattern of attendance., Results: Very few differences were found between years or between the weeks which preceded and followed the Olympics. One significant exception was noted: a statistically significant increase (P value = .0003) in attendances for "chemicals, poisons, and overdoses, including alcohol" and "acute alcohol intoxication" were observed in London EDs coinciding with the timing of the Olympic opening ceremony (9:00 pm July 27, 2012 to 01:00 am July 28, 2012)., Conclusions: Syndromic surveillance was able to provide near to real-time monitoring and could identify hourly changes in patterns of presentation during the London 2012 Olympic Games. Reassurance can be provided to planners of future mass-gathering events that there was no discernible impact in overall attendances to sentinel EDs or GP OOH services in the host country. The increase in attendances for alcohol-related causes during the opening ceremony, however, may provide an opportunity for future public health interventions. Todkill D , Hughes HE , Elliot AJ , Morbey RA , Edeghere O , Harcourt S , Hughes T , Endericks T , McCloskey B , Catchpole M , Ibbotson S , Smith G . An observational study using English syndromic surveillance data collected during the 2012 London Olympics - what did syndromic surveillance show and what can we learn for future mass-gathering events? Prehosp Disaster Med. 2016;31(6):628-634.

During August 2015, a boil water notice (BWN) was issued across parts of North West England following the detection of Cryptosporidium oocysts in the public water supply. Using prospective syndromic surveillance, we detected statistically significant increases in the presentation of cases of gastroenteritis and diarrhoea to general practitioner services and related calls to the national health telephone advice service in those areas affected by the BWN. In the affected areas, average in-hours general practitioner consultations for gastroenteritis increased by 24.8% (from 13.49 to 16.84) during the BWN period; average diarrhoea consultations increased by 28.5% (from 8.33 to 10.71). Local public health investigations revealed no laboratory reported cases confirmed as being associated with the water supply. These findings suggest that the increases reported by syndromic surveillance of cases of gastroenteritis and diarrhoea likely resulted from changes in healthcare seeking behaviour driven by the intense local and national media coverage of the potential health risks during the event. This study has further highlighted the potential for media-driven bias in syndromic surveillance, and the challenges in disentangling true increases in community infection from those driven by media reporting., Competing Interests: Conflicts of Interest: None declared., (This article is copyright of The Authors, 2016.)

The 2014/15 influenza season was the second season of roll-out of a live attenuated influenza vaccine (LAIV) programme for healthy children in England. During this season, besides offering LAIV to all two to four year olds, several areas piloted vaccination of primary (4-11 years) and secondary (11-13 years) age children. Influenza A(H3N2) circulated, with strains genetically and antigenically distinct from the 2014/15 A(H3N2) vaccine strain, followed by a drifted B strain. We assessed the overall and indirect impact of vaccinating school age children, comparing cumulative disease incidence in targeted and non-targeted age groups in vaccine pilot to non-pilot areas. Uptake levels were 56.8% and 49.8% in primary and secondary school pilot areas respectively. In primary school age pilot areas, cumulative primary care influenza-like consultation, emergency department respiratory attendance, respiratory swab positivity, hospitalisation and excess respiratory mortality were consistently lower in targeted and non-targeted age groups, though less for adults and more severe end-points, compared with non-pilot areas. There was no significant reduction for excess all-cause mortality. Little impact was seen in secondary school age pilot only areas compared with non-pilot areas. Vaccination of healthy primary school age children resulted in population-level impact despite circulation of drifted A and B influenza strains.

Heatwaves are a seasonal threat to public health. During July 2013 England experienced a heatwave; we used a suite of syndromic surveillance systems to monitor the impact of the heatwave. Significant increases in heatstroke and sunstroke were observed during 7-10 July 2013. Syndromic surveillance provided an innovative and effective service, supporting heatwave planning and providing early warning of the impact of extreme heat thereby improving the public health response to heatwaves., (Crown Copyright © 2014. Published by Elsevier Inc. All rights reserved.)

Background: The London 2012 Olympic and Paralympic Games is a mass gathering event that will present a major public health challenge. The Health Protection Agency, in collaboration with the College of Emergency Medicine, has established the Emergency Department Sentinel Syndromic Surveillance System (EDSSS) to support the public health surveillance requirements of the Games., Methods: This feasibility study assesses the usefulness of EDSSS in monitoring indicators of disease in the community. Daily counts of anonymised attendance data from six emergency departments across England were analysed by patient demographics (age, gender, partial postcode), triage coding and diagnosis codes. Generic and specific syndromic indicators were developed using aggregations of diagnosis codes recorded during each attendance., Results: Over 339,000 attendances were recorded (26 July 2010 to 25 July 2011). The highest attendances recorded on weekdays between 10:00 and 11:00 and on weekends between 12:00 and 13:00. The mean daily attendance per emergency department was 257 (range 38-435). Syndromic indicators were developed including: respiratory, gastrointestinal, cardiac, acute respiratory infection, gastroenteritis and myocardial ischaemia. Respiratory and acute respiratory infection indicators peaked during December 2010, concomitant with national influenza activity, as monitored through other influenza surveillance systems., Conclusions: The EDSSS has been established to provide an enhanced surveillance system for the London 2012 Olympics. Further validation of the data will be required; however, the results from this initial descriptive study demonstrate the potential for identifying unusual and/or severe outbreaks of infectious disease, or other incidents with public health impact, within the community.

We identified 266 individuals with intragenic NSD1 mutations or 5q35 microdeletions encompassing NSD1 (referred to as "NSD1-positive individuals"), through analyses of 530 subjects with diverse phenotypes. Truncating NSD1 mutations occurred throughout the gene, but pathogenic missense mutations occurred only in functional domains (P < 2 x 10(-16)). Sotos syndrome was clinically diagnosed in 99% of NSD1-positive individuals, independent of the molecular analyses, indicating that NSD1 aberrations are essentially specific to this condition. Furthermore, our data suggest that 93% of patients who have been clinically diagnosed with Sotos syndrome have identifiable NSD1 abnormalities, of which 83% are intragenic mutations and 10% are 5q35 microdeletions. We reviewed the clinical phenotypes of 239 NSD1-positive individuals. Facial dysmorphism, learning disability, and childhood overgrowth were present in 90% of the individuals. However, both the height and head circumference of 10% of the individuals were within the normal range, indicating that overgrowth is not obligatory for the diagnosis of Sotos syndrome. A broad spectrum of associated clinical features was also present, the occurrence of which was largely independent of genotype, since individuals with identical mutations had different phenotypes. We compared the phenotypes of patients with intragenic NSD1 mutations with those of patients with 5q35 microdeletions. Patients with microdeletions had less-prominent overgrowth (P = .0003) and more-severe learning disability (P = 3 x 10(-9)) than patients with mutations. However, all features present in patients with microdeletions were also observed in patients with mutations, and there was no correlation between deletion size and the clinical phenotype, suggesting that the deletion of additional genes in patients with 5q35 microdeletions has little specific effect on phenotype. We identified only 13 familial cases. The reasons for the low vertical transmission rate are unclear, although familial cases were more likely than nonfamilial cases (P = .005) to carry missense mutations, suggesting that the underlying NSD1 mutational mechanism in Sotos syndrome may influence reproductive fitness.

Sotos syndrome is an overgrowth condition predominantly caused by truncating mutations, missense mutations restricted to functional domains, or deletions of NSD1. NSD1 is a member of a protein family that includes NSD2 and NSD3, both of which show 70-75% sequence identity with NSD1. This strong sequence similarity suggests that abrogation of NSD2 or NSD3 function may cause non-NSD1 Sotos cases or other overgrowth phenotypes. To evaluate this hypothesis, we mutationally screened NSD2 and NSD3 in 78 overgrowth syndrome cases in which NSD1 mutations and deletions had been excluded. Additionally, we used microsatellite markers within the vicinity of the genes to look for whole gene deletions. No truncating mutations or gene deletions were identified in either gene. We identified two conservative missense NSD2 alterations in two non-Sotos overgrowth cases but neither was within a functional domain. We identified three synonymous and two intronic variants in NSD2 and two synonymous base substitutions in NSD3. Our results suggest that despite strong sequence similarity between NSD1, NSD2 and NSD3, the latter genes are unlikely to be making a substantial contribution to overgrowth phenotypes and thus may operate in distinct functional pathways from NSD1.

Sotos syndrome is a childhood overgrowth syndrome characterized by a distinctive facial appearance, height and head circumference >97th percentile, advanced bone age, and developmental delay. Weaver syndrome is characterized by the same criteria but has its own distinctive facial gestalt. Recently, a 2.2-Mb chromosome 5q35 microdeletion, encompassing NSD1, was reported as the major cause of Sotos syndrome, with intragenic NSD1 mutations identified in a minority of cases. We evaluated 75 patients with childhood overgrowth, for intragenic mutations and large deletions of NSD1. The series was phenotypically scored into four groups, prior to the molecular analyses: the phenotype in group 1 (n=37) was typical of Sotos syndrome; the phenotype in group 2 (n=13) was Sotos-like but with some atypical features; patients in group 3 (n=7) had Weaver syndrome, and patients in group 4 (n=18) had an overgrowth condition that was neither Sotos nor Weaver syndrome. We detected three deletions and 32 mutations (13 frameshift, 8 nonsense, 2 splice-site, and 9 missense) that are likely to impair NSD1 functions. The truncating mutations were spread throughout NSD1, but there was evidence of clustering of missense mutations in highly conserved functional domains between exons 13 and 23. There was a strong correlation between presence of an NSD1 alteration and clinical phenotype, in that 28 of 37 (76%) patients in group 1 had NSD1 mutations or deletions, whereas none of the patients in group 4 had abnormalities of NSD1. Three patients with Weaver syndrome had NSD1 mutations, all between amino acids 2142 and 2184. We conclude that intragenic mutations of NSD1 are the major cause of Sotos syndrome and account for some Weaver syndrome cases but rarely occur in other childhood overgrowth phenotypes.