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The improvements in high throughput sequencing technologies (HTS) made clinical sequencing projects such as ClinSeq and Genomics England feasible. Although there are significant improvements in accuracy and reproducibility of HTS based analyses, the usability of these types of data for diagnostic and prognostic applications necessitates a near perfect data generation. To assess the usability of a widely used HTS platform for accurate and reproducible clinical applications in terms of robustness, we generated whole genome shotgun (WGS) sequence data from the genomes of two human individuals in two different genome sequencing centers. After analyzing the data to characterize SNPs and indels using the same tools (BWA, SAMtools, and GATK), we observed significant number of discrepancies in the call sets. As expected, the most of the disagreements between the call sets were found within genomic regions containing common repeats and segmental duplications, albeit only a small fraction of the discordant variants were within the exons and other functionally relevant regions such as promoters. We conclude that although HTS platforms are sufficiently powerful for providing data for first-pass clinical tests, the variant predictions still need to be confirmed using orthogonal methods before using in clinical applications. [ABSTRACT FROM AUTHOR]

Background: Models that forecast non-communicable disease rates are poorly designed to predict future changes in trend because they are based on exogenous measures of disease rates. We introduce microPRIME, which forecasts myocardial infarction (MI) incidence, events and prevalence in England to 2035. microPRIME can forecast changes in trend as all MI rates emerge from competing trends in risk factors and treatment. Materials and methods: microPRIME is a microsimulation of MI events within a sample of 114,000 agents representative of England. We simulate 37 annual time points from 1998 to 2035, where agents can have an MI event, die from an MI, or die from an unrelated cause. The probability of each event is a function of age, sex, BMI, blood pressure, cholesterol, smoking, diabetes and previous MI. This function does not change over time. Instead population-level changes in MI rates are due to competing trends in risk factors and treatment. Uncertainty estimates are based on 450 model runs that use parameters calibrated against external measures of MI rates between 1999 and 2011. Findings: Forecasted MI incidence rates fall for men and women of different age groups before plateauing in the mid 2020s. Age-standardised event rates show a similar pattern, with a non-significant upturn by 2035, larger for men than women. Prevalence in men decreases for the oldest age groups, with peaks of prevalence rates in 2019 for 85 and older at 25.8% (23.3–28.3). For women, prevalence rates are more stable. Prevalence in over 85s is estimated as 14.5% (12.6–16.5) in 2019, and then plateaus thereafter. Conclusion: We may see an increase in event rates from MI in England for men before 2035 but increases for women are unlikely. Prevalence rates may fall in older men, and are likely to remain stable in women over the next decade and a half. [ABSTRACT FROM AUTHOR]

Background: There is uncertainty around the health impact and economic costs of the recent slowing of the historical decline in cardiovascular disease (CVD) incidence and the future impact on dementia and disability. Methods: Previously validated IMPACT Better Ageing Markov model for England and Wales, integrating English Longitudinal Study of Ageing (ELSA) data for 17,906 ELSA participants followed from 1998 to 2012, linked to NHS Hospital Episode Statistics. Counterfactual design comparing two scenarios: Scenario 1. CVD Plateau—age-specific CVD incidence remains at 2011 levels, thus continuing recent trends. Scenario 2. CVD Fall—age-specific CVD incidence goes on declining, following longer-term trends. The main outcome measures were age-related healthcare costs, social care costs, opportunity costs of informal care, and quality adjusted life years (valued at £60,000 per QALY). Findings: The total 10 year cumulative incremental net monetary cost associated with a persistent plateauing of CVD would be approximately £54 billion (95% uncertainty interval £14.3-£96.2 billion), made up of some £13 billion (£8.8-£16.7 billion) healthcare costs, £1.5 billion (-£0.9-£4.0 billion) social care costs, £8 billion (£3.4-£12.8 billion) informal care and £32 billion (£0.3-£67.6 billion) value of lost QALYs. Interpretation: After previous, dramatic falls, CVD incidence has recently plateaued. That slowdown could substantially increase health and social care costs over the next ten years. Healthcare costs are likely to increase more than social care costs in absolute terms, but social care costs will increase more in relative terms. Given the links between COVID-19 and cardiovascular health, effective cardiovascular prevention policies need to be revitalised urgently. [ABSTRACT FROM AUTHOR]

Introduction: Prevalence of tobacco smoking among adults in substance misuse treatment is much higher than the wider population, yet limited research is available, and residential treatment services have been overlooked as a potential setting for cessation interventions. Exploring the perceptions of service users about smoking cessation in residential rehabilitation is important to gain better understanding of this issue and identify ways to inform future intervention development. Methods: Ten semi-structured interviews were conducted in the Northwest of England in 2017 with adults (7 male, 3 female) who were currently or had previously been in residential treatment for substance misuse. Five participants were current smokers, three had never smoked, and two were former smokers. Participants were asked about their smoking behaviours, factors relating to smoking and smoking cessation and the relationship between smoking and substance use. All interviews were transcribed and data was analysed thematically. Results: Study findings highlighted a general consensus amongst participants that residential treatment services offered an ideal opportunity for cessation but there were concerns that doing so might jeopardise recovery. Smoking in substance use treatment services is still the norm and factors such as perceived social and psychological benefits, normative behaviours and lack of perceived risk or prioritisation pose challenges for implementing smoking cessation within this setting, although facilitators such as motivation to change and appropriateness of the setting were also identified. Conclusions: This study suggests that service users perceive residential treatment services as suitable environments to introduce smoking cessation. To address the needs of adults who smoke and are in recovery from substance use, further research and cooperation from treatment organisations is needed to integrate substance misuse and smoking cessation services. More conclusive evidence on the effectiveness of tackling both issues at the same time is also required. [ABSTRACT FROM AUTHOR]

Clinical testing of children in schools is challenging, with economic implications limiting its frequent use as a monitoring tool of the risks assumed by children and staff during the COVID-19 pandemic. Here, a wastewater-based epidemiology approach has been used to monitor 16 schools (10 primary, 5 secondary and 1 post-16 and further education) in England. A total of 296 samples over 9 weeks have been analysed for N1 and E genes using qPCR methods. Of the samples returned, 47.3% were positive for one or both genes with a detection frequency in line with the respective local community. WBE offers a low cost, non-invasive approach for supplementing clinical testing and can provide longitudinal insights that are impractical with traditional clinical testing. [ABSTRACT FROM AUTHOR]

Background: A proportionate universal (PU) approach to early years' service provision has been advocated to improve children's health and development and to reduce health inequality, by ensuring that services provide timely and high-quality parenting support commensurate with need. Process-oriented research is critical to examine the factors that contribute to, or hinder, the effective delivery/implementation of such a model in community-based family services. This study aimed to assess the delivery, acceptability and feasibility of a new PU parenting intervention model (called E-SEE Steps), using the Incredible Years® (IY) parent program, when delivered by trained health/family service staff in three "steps"—one universal step (the IY Babies Book), and two targeted steps (group-based IY Infant and Toddler programs). Methods: An embedded mixed-methods process evaluation within a pragmatic parallel two-arm, assessor blinded, randomized controlled trial was conducted in community services in four local authorities in England. The process evaluation used qualitative data gathered via interviews and focus groups with intervention arm parents who were offered the targeted steps (n = 29), practitioners (n = 50), service managers (n = 7) and IY program mentors (n = 3). This was supplemented by quantitative data collected using group leader pre-training (n = 50) and post-delivery (n = 39) questionnaires, and research notes of service design decisions. Results: The E-SEE Steps model was acceptable to most parents, particularly when it was accompanied by engagement strategies that supported attendance, such as providing childcare. Practitioners also highlighted the positive development opportunities provided by the IY training and supervision. However, participant views did not support the provision of the IY Babies book as a standalone universal component, and there were barriers to eligible parents—particularly those with low mood—taking up the targeted programs. Service providers struggled to align the PU model with their commissioned service contracts and with their staff capacity to engage appropriate parents, including tackling common barriers to attendance. Conclusions: Despite general enthusiasm and support for delivering high-quality parenting programs in community services in the England, several barriers exist to successfully delivering IY in a proportionate universal model within current services/systems. [ABSTRACT FROM AUTHOR]

Objectives: To determine the psychometric validity, using Rasch analysis, of summing the three constituent parts of the Glasgow Coma Scale (GCS). Design: National (registry-based) retrospective study. Setting: England and Wales. Patients: All individuals who sustained a traumatic injury and were: admitted for more than three days; required critical care resources; transferred for specialist management; or who died from their injuries. Main outcomes and measures: Demographic information (i.e., age at time of injury, and sex), item sub-scores of the first available GCS (either completed by the attending paramedics or on arrival to hospital), injury severity as denoted by the Injury Severity Scale (ISS), and outcome (survival to hospital discharge or 30-days post-injury, whichever is earliest). Results: 321,203 cases between 2008 and 2017. 55.9% were male, the median age was 62.7 years (IQR 44.2–80.8), the median ISS was 9 (IQR 9 to 17), and 6.6% were deceased at 30 days. The reliability statistics suggest that when the extreme scores (i.e. 3 and 15) are accounted for, that there is only sufficient consistency to support the separation of injuries into 3 broad categories, e.g. mild, moderate and severe. As extreme scores don't impact Rasch item calibrations, subsequent analysis was restricted to the 48,417 non-extreme unique cases. Overall fit to the Rasch model was poor across all analyses (p < 0.0001). Through a combination of empirical evidence and clinical reasoning, item response categories were collapsed to provide a post-hoc scoring amendment. Whilst the modifications improved the function of the individual items, there is little evidence to support them meaningfully contributing to a total score that can be interpreted on an interval scale. Conclusion and relevance: The GCS does not perform in a psychometrically robust manner in a national retrospective cohort of individuals who have experienced a traumatic injury, even after post-hoc correction. [ABSTRACT FROM AUTHOR]

Objectives: While there has been significant research on the pressures facing acute hospitals during the COVID-19 pandemic, there has been less interest in downstream community services which have also been challenged in meeting demand. This study aimed to estimate the theoretical cost-optimal capacity requirement for 'step down' intermediate care services within a major healthcare system in England, at a time when considerable uncertainty remained regarding vaccination uptake and the easing of societal restrictions. Methods: Demand for intermediate care was projected using an epidemiological model (for COVID-19 demand) and regressing upon public mobility (for non-COVID-19 demand). These were inputted to a computer simulation model of patient flow from acute discharge readiness to bedded and home-based Discharge to Assess (D2A) intermediate care services. Cost-optimal capacity was defined as that which yielded the lowest total cost of intermediate care provision and corresponding acute discharge delays. Results: Increased intermediate care capacity is likely to bring about lower system-level costs, with the additional D2A investment more than offset by substantial reductions in costly acute discharge delays (leading also to improved patient outcome and experience). Results suggest that completely eliminating acute 'bed blocking' is unlikely economical (requiring large amounts of downstream capacity), and that health systems should instead target an appropriate tolerance based upon the specific characteristics of the pathway. Conclusions: Computer modelling can be a valuable asset for determining optimal capacity allocation along the complex care pathway. With results supporting a Business Case for increased downstream capacity, this study demonstrates how modelling can be applied in practice and provides a blueprint for use alongside the freely-available model code. [ABSTRACT FROM AUTHOR]

Background: Recent studies indicate that vitamin D supplementation may decrease respiratory tract infections, but the association between vitamin D and COVID-19 is still unclear. Objective: To explore the association between vitamin D status and infections, hospitalisation, and mortality due to COVID-19. Methods: We used UK Biobank, a nationwide cohort of 500,000 individuals aged between 40 and 69 years at recruitment between 2006 and 2010. We included people with at least one serum vitamin D test, living in England with linked primary care and inpatient records. The primary exposure was serum vitamin D status measured at recruitment, defined as deficiency at <25 nmol/L, insufficiency at 25–49 nmol/L and sufficiency at ≥ 50 nmol/L. Secondary exposures were self-reported or prescribed vitamin D supplements. The primary outcome was laboratory-confirmed or clinically diagnosed SARS-CoV-2 infections. The secondary outcomes included hospitalisation and mortality due to COVID-19. We used multivariable Cox regression models stratified by summertime months and non-summertime months, adjusting for demographic factors and underlying comorbidities. Results: We included 307,512 participants (54.9% female, 55.9% over 70 years old) in our analysis. During summertime months, weak evidence existed that the vitamin D deficiency group had a lower hazard of being diagnosed with COVID-19 (hazard ratio [HR] = 0.86, 95% confidence interval [CI] = 0.77–0.95). During non-summertime, the vitamin D deficiency group had a higher hazard of COVID-19 compared with the vitamin D sufficient group (HR = 1.14, 95% CI = 1.01–1.30). No evidence was found that vitamin D deficiency or insufficiency was associated with either hospitalisation or mortality due to COVID-19 in any time strata. Conclusion: We found no evidence of an association between historical vitamin D status and hospitalisation or mortality due to COVID-19, along with inconsistent results for any association between vitamin D and diagnosis of COVID-19. However, studies using more recent vitamin D measurements and systematic COVID-19 testing are needed. [ABSTRACT FROM AUTHOR]

Background: Skin cancer, including melanoma and non-melanoma (keratinocyte), is increasing in incidence in the UK. Accounting for half of all cancers in England and Wales, the disease significantly impacts overstretched dermatology services. Research suggests that 86% of melanoma is preventable with modified sun exposure. Educating children about sun safety in schools can help prevent skin cancer and is recommended by major health organisations. In England, teaching sun safety in primary schools is compulsory, while in Wales this is left to school discretion. Aims: Understand how primary schools in Wales are responding to growing skin cancer rates and explore the effectiveness of sun safety policies in schools on knowledge and behaviour. Methods: Sunproofed is a mixed-methods scoping study comprising 5 work packages (WP) using survey and routine electronic health record (EHR) data supplemented by qualitative case studies. Objective(s) are to: WP1: Discover if primary schools in Wales have sun safety policies; policy characteristics; determine factors that may influence their presence and identify areas where schools need support. WP2: Determine what EHR data is available regarding the incidence of sunburn in primary school children and the feasibility of using this data to evaluate the impact of sun safety policies. WP3: Understand the impact of sun safety policies on sun-safe knowledge and behaviour amongst children, parents, teachers, and school management; identify barriers and facilitators to schools implementing sun safety policies. WP4: Co-produce guidance regarding sun safety policies and best methods for implementation in schools. WP5: Disseminate guidance and findings widely to ensure impact and uptake. Discussion: Skin cancer rates are increasing in the UK, straining limited resources. Sunproofed has the potential to inform the development of future prevention activities, both in Wales and beyond. This could reduce the number of skin cancer cases in the future and keep people healthier for longer. [ABSTRACT FROM AUTHOR]

Background: During the first wave of the COVID-19 pandemic, the United Kingdom experienced one of the highest per-capita death tolls worldwide. It is debated whether this may partly be explained by the relatively late initiation of voluntary social distancing and mandatory lockdown measures. In this study, we used simulations to estimate the number of cases and deaths that would have occurred in England by 1 June 2020 if these interventions had been implemented one or two weeks earlier, and the impact on the required duration of lockdown. Methods: Using official reported data on the number of Pillar 1 lab-confirmed cases of COVID-19 and associated deaths occurring in England from 3 March to 1 June, we modelled: the natural (i.e. observed) growth of cases, and the counterfactual (i.e. hypothetical) growth of cases that would have occurred had measures been implemented one or two weeks earlier. Under each counterfactual condition, we estimated the expected number of deaths and the time required to reach the incidence observed under natural growth on 1 June. Results: Introducing measures one week earlier would have reduced by 74% the number of confirmed COVID-19 cases in England by 1 June, resulting in approximately 21,000 fewer hospital deaths and 34,000 fewer total deaths; the required time spent in full lockdown could also have been halved, from 69 to 35 days. Acting two weeks earlier would have reduced cases by 93%, resulting in between 26,000 and 43,000 fewer deaths. Conclusions: Our modelling supports the claim that the relatively late introduction of social distancing and lockdown measures likely increased the scale, severity, and duration of the first wave of COVID-19 in England. Our results highlight the importance of acting swiftly to minimise the spread of an infectious disease when case numbers are increasing exponentially. [ABSTRACT FROM AUTHOR]

Background: Inter-organisational collaborations (IOCs) in healthcare have been viewed as an effective approach to performance improvement. However, there remain gaps in our understanding of what helps IOCs function, as well as how and why contextual elements affect their implementation. A realist review of evidence drawing on 86 sources has sought to elicit and refine context-mechanism-outcome configurations (CMOCs) to understand and refine these phenomena, yet further understanding can be gained from interviewing those involved in developing IOCs. Methods: We used a realist evaluation methodology, adopting prior realist synthesis findings as a theoretical framework that we sought to refine. We drew on 32 interviews taking place between January 2020 and May 2021 with 29 stakeholders comprising IOC case studies, service users, as well as regulatory perspectives in England. Using a retroductive analysis approach, we aimed to test CMOCs against these data to explore whether previously identified mechanisms, CMOCs, and causal links between them were affirmed, refuted, or revised, and refine our explanations of how and why interorganisational collaborations are successful. Results: Most of our prior CMOCs and their underlying mechanisms were supported in the interview findings with a diverse range of evidence. Leadership behaviours, including showing vulnerability and persuasiveness, acted to shape the core mechanisms of collaborative functioning. These included our prior mechanisms of trust, faith, and confidence, which were largely ratified with minor refinements. Action statements were formulated, translating theoretical findings into practical guidance. Conclusion: As the fifth stage in a larger project, our refined theory provides a comprehensive understanding of the causal chain leading to effective collaborative inter-organisational relationships. These findings and recommendations can support implementation of IOCs in the UK and elsewhere. Future research should translate these findings into further practical guidance for implementers, researchers, and policymakers. [ABSTRACT FROM AUTHOR]

Rehabilitation services have a key role in ensuring integrated and comprehensive mental health (MH) care in the community for people suffering from long-term and severe mental disorders. MH-supported accommodation services aim to promote service users' autonomy and independence. Given the complexity associated with MH-supported accommodation services in England, a comparative evaluation of critical performance indicators, including service provision and quality of care, seems to be necessary in designing evidence-informed policies. This study aims to explore the influence of service quality indicators on the performance of MH-supported accommodation services in England. The analysed sample includes supported accommodation services from 14 nationally representative local authorities in England from the QuEST study grouped by three main types of care: residential care homes (divided into two subgroups: move-on and non-move-on oriented), supported housing and floating outreach. EDeS-MH (efficient decision support-mental health) was used to assess the performance indicators for the selected services by combining a Monte Carlo simulation engine, data envelopment analysis and a fuzzy inference engine for integrating expert knowledge. Depending on the type of care, six/seven quality domains were sequentially included after a baseline scenario (only technical) was analysed. Relative technical efficiency scores for the baseline scenarios revealed high performance in all the selected supported accommodation services, but the statistical variability was high. Quality domains significantly improved performance in every type of care. The inclusion of quality indicators has a positive impact on the global performance of each type of care. Remaining at the corresponding services more than expected for two years has a negative impact on performance. These findings can be considered from a planning perspective to facilitate the design of pathways of care with more realistic expectations about gaining autonomy in two years. [ABSTRACT FROM AUTHOR]

Background: People living with a long-term condition, such as chronic kidney disease (CKD), often suffer from multiple symptoms simultaneously, making symptom management challenging. This study aimed to identify symptom clusters in adults with CKD across treatment groups and investigate their association with people's ability to perform their usual activities. Methods: We conducted a secondary analysis of both cross-sectional and longitudinal data collected as part of a national service improvement programme in 14 kidney centres in England, UK. This data included symptom severity (17 items, POS-S Renal) and the extent to which people had problems performing their usual activities (single item, EQ-5D-5L). We categorised data by treatment group: haemodialysis (n = 1,462), transplantation (n = 866), peritoneal dialysis (n = 127), or CKD without kidney replacement therapy (CKD non-KRT; n = 684). We used principal component analysis to identify symptom clusters per treatment group, and proportional odds models to assess the association between clusters and usual activities. Results: Overall, clusters related to: lack of energy and mobility; gastrointestinal; skin; and mental health. Across groups, the 'lack of energy and mobility' clusters were associated with having problems with usual activities, with odds ratios (OR) ranging between 1.24 (95% confidence interval [CI], 1.21–1.57) for haemodialysis and 1.56 for peritoneal dialysis (95% CI, 1.28–1.90). This association was confirmed longitudinally in haemodialysis (n = 399) and transplant (n = 249) subgroups. Implications: Our findings suggest that healthcare professionals should consider routinely assessing symptoms in the 'lack of energy & mobility' cluster in all people with CKD, regardless of whether they volunteer this information; not addressing these symptoms is likely to be related to them having problems with performing usual activities. Future studies should explore why symptoms within clusters commonly co-occur and how they interrelate. This will inform the development of cluster-level symptom management interventions with enhanced potential to improve outcomes for people with CKD. [ABSTRACT FROM AUTHOR]

Introduction: The objective of this study was to use a prospective error analysis method to examine the process of dispensing medication in community pharmacy settings and identify remedial solutions to avoid potential errors, categorising them as strong, intermediate, or weak based on an established patient safety action hierarchy tool. Method: Focus group discussions and non-participant observations were undertaken to develop a Hierarchical Task Analysis (HTA), and subsequent focus group discussions applied the Systematic Human Error Reduction and Prediction Approach (SHERPA) focusing on the task of dispensing medication in community pharmacies. Remedial measures identified through the SHERPA analysis were then categorised as strong, intermediate, or weak based on the Veteran Affairs National Centre for Patient Safety action hierarchy. Non-participant observations were conducted at 3 pharmacies, totalling 12 hours, based in England. Additionally, 7 community pharmacists, with experience ranging from 8 to 38 years, participated in a total of 4 focus groups, each lasting between 57 to 85 minutes, with one focus group discussing the HTA and three applying SHERPA. A HTA was produced consisting of 10 sub-tasks, with further levels of sub-tasks within each of them. Results: Overall, 88 potential errors were identified, with a total of 35 remedial solutions proposed to avoid these errors in practice. Sixteen (46%) of these remedial measures were categorised as weak, 14 (40%) as intermediate and 5 (14%) as strong according to the Veteran Affairs National Centre for Patient Safety action hierarchy. Sub-tasks with the most potential errors were identified, which included 'producing medication labels' and 'final checking of medicines'. The most common type of error determined from the SHERPA analysis related to omitting a check during the dispensing process which accounted for 19 potential errors. Discussion: This work applies both HTA and SHERPA for the first time to the task of dispensing medication in community pharmacies, detailing the complexity of the task and highlighting potential errors and remedial measures specific to this task. Future research should examine the effectiveness of the proposed remedial solutions to improve patient safety. [ABSTRACT FROM AUTHOR]

There are substantial geographic variations in coronary heart disease (CHD) mortality rates in England that may in part be due to differences in climate and air pollution. An ecological cross-sectional multi-level analysis of male and female CHD mortality rates in all wards in England (1999-2004) was conducted to estimate the relative strength of the association between CHD mortality rates and three aspects of the physical environment - temperature, hours of sunshine and air quality. Models were adjusted for deprivation, an index measuring the healthiness of the lifestyle of populations, and urbanicity. In the fully adjusted model, air quality was not significantly associated with CHD mortality rates, but temperature and sunshine were both significantly negatively associated (p<0.05), suggesting that CHD mortality rates were higher in areas with lower average temperature and hours of sunshine. After adjustment for the unhealthy lifestyle of populations and deprivation, the climate variables explained at least 15% of large scale variation in CHD mortality rates. The results suggest that the climate has a small but significant independent association with CHD mortality rates in England. [ABSTRACT FROM AUTHOR]

Background: There has been a shift in focus of international dementia policies from improving diagnostic rates to enhancing the post-diagnostic support provided to people with dementia and their carers. There is, however, little agreement over what constitutes good post-diagnostic support. This study aimed to identify the components of post-diagnostic dementia support. Methods: We adopted a qualitative design using interviews, focus groups and observation to explore the perspectives of key stakeholders on the content of post-diagnostic dementia support. Purposive sampling was used to identify sites in England and Wales recognised as delivering good practice. Participants included 17 people with dementia, 31 carers, 68 service managers or funders, and 78 frontline staff. Interviews and focus groups were audio recorded and transcribed for analysis. Forty-eight sessions of observation were completed and recorded in fieldnotes. Components were identified through an inductive, thematic approach and cross-checked against national guidelines and existing frameworks; they were subsequently critically reviewed by a range of experts and our mixed stakeholder panel. Results: Twenty distinct components of post-diagnostic support were identified, related to five themes: timely identification and management of needs; understanding and managing dementia; emotional and psychological wellbeing; practical support; and integrating support. The first and last of these were cross-cutting themes facilitating the delivery of a unique constellation of components of post-diagnostic support to each individual living with dementia or dyad at a particular time. Conclusions: Our work offers an empirically based framework to inform the development and delivery of holistic, integrated and continuous dementia care from diagnosis to end of life. It highlights the relevance of many components to both people living with dementia and their carers. Since the framework was developed in England and Wales, further research is needed to explore the relevance of our components to other sectors, countries and care systems. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic's first wave in England during spring 2020 resulted in an approximate 50% increase in all-cause mortality. Previously, risk factors such as age and ethnicity, were identified by studying COVID-related deaths only, but these were under-recorded during this period. Objective: To use a large electronic primary care database to estimate the impact of risk factors (RFs) on excess mortality in England during the first wave, compared with the impact on total mortality during 2015–19. Methods: Medical history, ethnicity, area-based deprivation and vital status data were extracted for an average of 4.8 million patients aged 30–104 years, for each year between 18-March and 19-May over a 6-year period (2015–2020). We used Poisson regression to model total mortality adjusting for age and sex, with interactions between each RF and period (pandemic vs. 2015–19). Total mortality during the pandemic was partitioned into "usual" and "excess" components, assuming 2015–19 rates represented "usual" mortality. The association of each RF with the 2020 "excess" component was derived as the excess mortality ratio (EMR), and compared with the usual mortality ratio (UMR). Results: RFs where excess mortality was greatest and notably higher than usual were age >80, non-white ethnicity (e.g., black vs. white EMR = 2.50, 95%CI 1.97–3.18; compared to UMR = 0.92, 95%CI 0.85–1.00), BMI>40, dementia, learning disability, severe mental illness, place of residence (London, care-home, most deprived). By contrast, EMRs were comparable to UMRs for sex. Although some co-morbidities such as cancer produced EMRs significantly below their UMRs, the EMRs were still >1. In contrast current smoking has an EMR below 1 (EMR = 0.80, 95%CI 0.65–0.98) compared to its UMR = 1.64. Conclusions: Studying risk factors for excess mortality during the pandemic highlighted differences from studying cause-specific mortality. Our approach illustrates a novel methodology for evaluating a pandemic's impact by individual risk factor without requiring cause-specific mortality data. [ABSTRACT FROM AUTHOR]

Although there has been extensive research on pharmaceutical industry payments to healthcare professionals, healthcare organisations with key roles in health systems have received little attention. We seek to contribute to addressing this gap in research by examining drug company payments to General Practices in England in 2015. We combine a publicly available payments database managed by the pharmaceutical industry with datasets covering key practice characteristics. We find that practices were an important target of company payments, receiving £2,726,018, equivalent to 6.5% of the value of payments to all healthcare organisations in England. Payments to practices were highly concentrated and specific companies were also highly dominant. The top 10 donors and the top 10 recipients amassed 87.9% and 13.6% of the value of payments, respectively. Practices with more patients, a greater proportion of elderly patients, and those in more affluent areas received significantly more payments on average. However, the patterns of payments were similar across England's regions. We also found that company networks–established by making payments to the same practices–were largely dominated by a single company, which was also by far the biggest donor. Greater policy attention is required to the risk of financial dependency and conflicts of interests that might arise from payments to practices and to organisational conflicts of interests more broadly. Our research also demonstrates that the comprehensiveness and quality of payment data disclosed via industry self-regulatory arrangements needs improvement. More interconnectivity between payment data and other datasets is needed to capture company marketing strategies systematically. [ABSTRACT FROM AUTHOR]

Invasive meningococcal disease (IMD), caused by Neisseria meningitidis, can have a fatality rate as high as 10%, even with appropriate treatment. In the UK, penicillin is administered to patients in primary care whilst third generation cephalosporins, cefotaxime and ceftriaxone, are administered in secondary care. The first-choice antibiotic for chemoprophylaxis of close contacts is ciprofloxacin, followed by rifampicin. Immunocompromised individuals are often recommended antibiotic chemoprophylaxis and vaccination due to a greater risk of IMD. Resistance to antibiotics among meningococci is relatively rare, however reduced susceptibility and resistance to penicillin are increasing globally. Resistance to third generation cephalosporins is seldom reported, however reduced susceptibility to both cefotaxime and ceftriaxone has been observed. Rifampicin resistance has been reported among meningococci, mainly following prophylaxis, and ciprofloxacin resistance, whilst uncommon, has also been reported across the globe. The Public Health England Meningococcal Reference Unit receives and characterises the majority of isolates from IMD cases in England, Wales and Northern Ireland. This study assessed the distribution of antibiotic resistance to penicillin, rifampicin, ciprofloxacin and cefotaxime among IMD isolates received at the MRU from 2010/11 to 2018/19 (n = 4,122). Out of the 4,122 IMD isolates, 113 were penicillin-resistant, five were ciprofloxacin-resistant, two were rifampicin-resistant, and one was cefotaxime-resistant. Penicillin resistance was due to altered penA alleles whilst rifampicin and ciprofloxacin resistance was due to altered rpoB and gyrA alleles, respectively. Cefotaxime resistance was observed in one isolate which had an altered penA allele containing additional mutations to those harboured by the penicillin-resistant isolates. This study identified several isolates with resistance to antibiotics used for current treatment and prophylaxis of IMD and highlights the need for continued surveillance of resistance among meningococci to ensure continued effective use. [ABSTRACT FROM AUTHOR]

Comparison of the severity, frequency and self-reporting of pollution incidents by water and sewerage companies is made difficult by differences in environmental and operational conditions. In England, the deterioration in pollution incident performance makes it important to investigate common trends that could be addressed to improve pollution management. This study presents the first external analysis of available national pollution incident data, obtained through Environmental Information Regulations 2004 requests to the English Environment Agency. The study aimed to assess and compare the pollution incident performance of water and sewerage companies in England. Results indicated that there were significant variations in numbers of pollution incidents reported and the severity of the impact on the water environment for different asset types (operational property). There were significant positive relationships between the self-reporting percentages and total numbers of reported pollution incidents per 10,000 km sewer length for pumping stations and sewage treatment works. These results indicate that in at least these asset types, an estimated 5% of pollution incidents could go unreported. Pollution events that go unreported can lead to more severe impacts to the water environment, so rapid and consistent reporting of incidents is crucial for limiting damage. The results have significance for the water industry internationally, because the issues presented here are not restricted to England. In the short-term, research should focus on investigating best practice and standardising reporting of pollution incidents, so that an accurate baseline of the number of pollution incidents occurring can be determined. [ABSTRACT FROM AUTHOR]

Objectives: To investigate whether partner bereavement is associated with adverse cardiovascular and kidney-related events in people with reduced kidney function. Design: Two parallel matched cohort studies using linked routinely collected health data. Setting: England (general practices and hospitals using linked Clinical Practice Research Datalink, Hospital Episode Statistics, and Office of National Statistics) and Denmark (hospitals and community pharmacies using the Danish National Patient, Prescription and Education Registries and the Civil Registration System). Participants: Bereaved people with reduced kidney function (estimated glomerular filtration rate (eGFR) <60mL/min/1.73m2 (England) or hospital-coded chronic kidney disease (Denmark)) and non-bereaved people with reduced kidney function similarly defined, matched on age, sex, general practice (England), and county of residence (Denmark) and followed-up from the bereavement date of the exposed person. Main outcome measures: Cardiovascular disease (CVD) or acute kidney injury (AKI) hospitalization, or death. Results: In people with reduced kidney function, we identified 19,820 (England) and 5,408 (Denmark) bereaved individuals and matched them with 134,828 (England) and 35,741 (Denmark) non-bereaved individuals. Among the bereaved, the rates of hospitalizations (per 1000 person-years) with CVD were 31.7 (95%-CI: 30.5–32.9) in England and 78.8 (95%-CI: 74.9–82.9) in Denmark; the rates of hospitalizations with AKI were 13.2 (95%-CI: 12.5–14.0) in England and 11.2 (95%-CI: 9.9–12.7) in Denmark; and the rates of death were 70.2 (95%-CI: 68.5–72.0) in England and 126.4 (95%-CI: 121.8–131.1) in Denmark. After adjusting for confounders, we found increased rates of CVD (England, HR 1.06 [95%-CI: 1.01–1.12]; Denmark, HR 1.10 [95%-CI: 1.04–1.17]), of AKI (England, HR 1.20 [95%-CI: 1.10–1.31]; Denmark HR 1.36 [95%-CI: 1.17–1.58]), and of death (England, HR 1.10 [95%-CI: 1.05–1.14]; Denmark HR 1.20 [95%-CI: 1.15–1.25]) in bereaved compared with non-bereaved people. Conclusions: Partner bereavement is associated with an increased rate of CVD and AKI hospitalization, and death in people with reduced kidney function. Additional supportive care for this at-risk population may help prevent serious adverse events. [ABSTRACT FROM AUTHOR]

Reinfection and multiple viral strains are among the latest challenges in the current COVID-19 pandemic. In contrast, epidemic models often consider a single strain and perennial immunity. To bridge this gap, we present a new epidemic model that simultaneously considers multiple viral strains and reinfection due to waning immunity. The model is general, applies to any viral disease and includes an optimal control formulation to seek a trade-off between the societal and economic costs of mitigation. We validate the model, with and without mitigation, in the light of the COVID-19 epidemic in England and in the state of Amazonas, Brazil. The model can derive optimal mitigation strategies for any number of viral strains, whilst also evaluating the effect of distinct mitigation costs on the infection levels. The results show that relaxations in the mitigation measures cause a rapid increase in the number of cases, and therefore demand more restrictive measures in the future. [ABSTRACT FROM AUTHOR]

Background: The Mental Capacity Act (MCA, 2005) and its accompanying Code of Practice (2007), govern research participation for adults with capacity and communication difficulties in England and Wales. We conducted a systematic review and narrative synthesis to investigate the application of these provisions from 2007 to 2019. Methods and findings: We included studies with mental capacity in their criteria, involving participants aged 16 years and above, with capacity-affecting conditions and conducted in England and Wales after the implementation of the MCA. Clinical trials of medicines were excluded. We searched seven databases: Academic Search Complete, ASSIA, MEDLINE, CINAHL, PsycArticles, PsycINFO and Science Direct. We used narrative synthesis to report our results. Our review follows Preferred Reporting Items for Systematic Reviews and is registered on PROSPERO, CRD42020195652. 28 studies of various research designs met our eligibility criteria: 14 (50.0%) were quantitative, 12 (42.9%) qualitative and 2 (7.1%) mixed methods. Included participants were adults with intellectual disabilities (n = 12), dementia (n = 9), mental health disorders (n = 2), autism (n = 3) and aphasia after stroke (n = 2). We found no studies involving adults with acquired brain injury. Diverse strategies were used in the recruitment of adults with capacity and communication difficulties with seven studies excluding individuals deemed to lack capacity. Conclusions: We found relatively few studies including adults with capacity and communication difficulties with existing regulations interpreted variably. Limited use of consultees and exclusions on the basis of capacity and communication difficulties indicate that this group continue to be under-represented in research. If health and social interventions are to be effective for this population, they need to be included in primary research. The use of strategic adaptations and accommodations during the recruitment process, may serve to support their inclusion. [ABSTRACT FROM AUTHOR]

Background: The reopening of schools during the COVID-19 pandemic has raised concerns about widespread infection and transmission of SARS-CoV-2 in educational settings. In June 2020, Public Health England (PHE) initiated prospective national surveillance of SARS-CoV-2 in primary schools across England (sKIDs). We used this opportunity to assess the feasibility and agreeability of large-scale surveillance and testing for SARS-CoV-2 infections in school among staff, parents and students. Methods: Staff and students in 131 primary schools were asked to complete a questionnaire at recruitment and provide weekly nasal swabs for SARS-CoV-2 RT-PCR testing (n = 86) or swabs with blood samples for antibody testing (n = 45) at the beginning and end the summer half-term. In six blood sampling schools, students were asked to complete a pictorial questionnaire before and after their investigations. Results: In total, 135 children aged 4–7 years (n = 40) or 8–11 years (n = 95) completed the pictorial questionnaire fully or partially. Prior to sampling, oral fluid sampling was the most acceptable test (107/132, 81%) followed by throat swabs (80/134, 59%), nose swabs (77/132, 58%), and blood tests (48/130, 37%). Younger students were more nervous about all tests than older students but, after completing their tests, most children reported a "better than expected" experience with all the investigations. Students were more likely to agree to additional testing for nose swabs (93/113, 82%) and oral fluid (93/114, 82%), followed by throat swabs (85/113, 75%) and blood tests (72/108, 67%). Parents (n = 3,994) and staff (n = 2,580) selected a preference for weekly testing with nose swabs, throat swabs or oral fluid sampling, although staff were more flexible about testing frequency. Conclusions: Primary school staff and parents were supportive of regular tests for SARS-CoV-2 and selected a preference for weekly testing. Children preferred nose swabs and oral fluids over throat swabs or blood sampling. [ABSTRACT FROM AUTHOR]

Objectives: The Covid-19 pandemic is hitting societies hard, and people living in disadvantaged circumstances are among the most affected. We investigate the combined effects of the Covid-19 crisis and living in a deprived neighbourhood on two dimensions of subjective well-being: hedonic (i.e. mental health) and evaluative (i.e. life satisfaction) subjective well-being. Methods: We use longitudinal data from the Understanding Society UK panel. We combine data gathered in the main survey between 2015 and 2019 with very recent data from the Covid-19 online survey between April and July 2020. Leveraging a sample of nearly 9,600 English individuals, we first run a set of cross-sectional OLS regressions to analyse changes over time in the relationship between neighbourhood deprivation and subjective well-being. Then, as our main model of interest, we use a fixed effect difference-in-differences model to provide more robust evidence. Results: Since the beginning of the crisis, both levels of hedonic and evaluative well-being have decreased as a result of the pandemic and lockdown. However, for those living in more deprived neighbourhoods the level of hedonic well-being decreased more than for those living in better areas. We found no such difference for evaluative well-being. Conclusion: Our results highlight the importance of reducing neighbourhood inequalities as the spatial clustering of disadvantages has increased by the pandemic. [ABSTRACT FROM AUTHOR]

Background: We identify socioeconomic disparities by region in cancer morbidity and mortality in England for all-cancer and type-specific cancers, and use incidence data to quantify the impact of cancer diagnosis delays on cancer deaths between 2001–2016. Methods and findings: We obtain population cancer morbidity and mortality rates at various age, year, gender, deprivation, and region levels based on a Bayesian approach. A significant increase in type-specific cancer deaths, which can also vary among regions, is shown as a result of delay in cancer diagnoses. Our analysis suggests increase of 7.75% (7.42% to 8.25%) in female lung cancer mortality in London, as an impact of 12-month delay in cancer diagnosis, and a 3.39% (3.29% to 3.48%) increase in male lung cancer mortality across all regions. The same delay can cause a 23.56% (23.09% to 24.30%) increase in male bowel cancer mortality. Furthermore, for all-cancer mortality, the highest increase in deprivation gap happened in the East Midlands, from 199 (186 to 212) in 2001, to 239 (224 to 252) in 2016 for males, and from 114 (107 to 121) to 163 (155 to 171) for females. Also, for female lung cancer, the deprivation gap has widened with the highest change in the North West, e.g. for incidence from 180 (172 to 188) to 272 (261 to 282), whereas it has narrowed for prostate cancer incidence with the biggest reduction in the South West from 165 (139 to 190) in 2001 to 95 (72 to 117) in 2016. Conclusions: The analysis reveals considerable disparities in all-cancer and some type-specific cancers with respect to socioeconomic status. Furthermore, a significant increase in cancer deaths is shown as a result of delays in cancer diagnoses which can be linked to concerns about the effect of delay in cancer screening and diagnosis during the COVID-19 pandemic. Public health interventions at regional and deprivation level can contribute to prevention of cancer deaths. [ABSTRACT FROM AUTHOR]

This study estimated the potential impact of early diagnosis programs on health outcomes in England. Specifically, if advising individuals to visit their family doctor due to a suspected case of mild hypertension would result in (i) an increase in the diagnosis and treatment of high blood pressure; (ii) an improved lifestyle reflected in objective measures such as the body-mass-index and blood pressure levels; (iii) a reduced probability of the onset of other cardiovascular diseases, such as diabetes. To address potential selection bias in screening, a feature of the English Longitudinal Study of Ageing is exploited, motivating a regression discontinuity design. If respondents' blood pressure measurements are above a standard clinical threshold, they are advised to visit their family doctor to confirm hypertension. Two years after the protocol, there is evidence of an increase in diagnosis (5.7 pp, p-val = 0.06) and medication use (6 pp, p-val = 0.007) for treating the condition. However, four years after the protocol, the difference in diagnosis and medication disappeared (4 pp, p-val = 0.384; 3.4 pp, p-val = 0.261). Moreover, there are no differences on observed blood pressure levels (systolic 0.026 mmHg, p-val = 0.815; diastolic -0.336 mmHg, p-val = 0.765), or Body-Mass-Index ((0.771, p-val = 0.154)). There are also no differences on diagnosis of diabetes (1.7 pp, p-val = 0.343) or heart related conditions (3.6 pp, p-value = 0.161). In conclusion, the nudge produces an earlier diagnosis of around two years, but there are no perceivable gains in health outcomes after four years. [ABSTRACT FROM AUTHOR]

Background: Small-area estimation models are regularly commissioned by public health bodies to identify areas of greater inequality and target areas for intervention in a range of behaviours and outcomes. Such local modelling has not been completed for diet consumption in England despite diet being an important predictor of health status. The study sets out whether aspects of adult diet can be modelled from previously collected data to define and evaluate area-level interventions to address obesity and ill-health. Methods: Adults aged 16 years and over living in England. Consumption of fruit, vegetables, and sugar-sweetened beverages (SSB) are modelled using small-area estimation methods in English neighbourhoods (Middle Super Output Areas [MSOA]) to identify areas where reported portions are significantly different from recommended levels of consumption. The selected aspects of diet are modelled from respondents in the National Diet and Nutrition Survey using pooled data from 2008–2016. Results: Estimates indicate that the average prevalence of adults consuming less than one portion of fruit, vegetables or 100% juice each day by MSOA is 6.9% (range of 4.3 to 14.7%, SE 0.06) and the average prevalence of drinking more than 330ml/day of SSB is 11.5% (range of 5.7 to 30.5%, SE 0.03). Credible intervals around the estimates are wider for SSB consumption. The results identify areas including regions in London, urban areas in the North of England and the South coast which may be prioritised for targeted interventions to support reduced consumption of SSB and/or an increase in portions of fruit and vegetables. Conclusion: These estimates provide valuable information at a finer spatial scale than is presently feasible, allowing for within-country and locality prioritisation of resources to improve diet. Local, targeted interventions to improve fruit and vegetable consumption such as subsidies or voucher schemes should be considered where consumption of these foods is predicted to be low. [ABSTRACT FROM AUTHOR]

Introduction: COVID-19 is primarily a respiratory illness, and smoking adversely impacts the respiratory and immune systems; this confluence may therefore incentivize smokers to quit. The present study, conducted in four high-income countries during the first global wave of COVID-19, examined the association between COVID-19 and: (1) thoughts about quitting smoking; (2) changes in smoking (quit attempt, reduced or increased smoking, or no change); and (3) factors related to a positive change (making a quit attempt or reducing smoking) based on an adapted framework of the Health Belief Model. Methods: This cross-sectional study included 6870 adult smokers participating in the Wave 3 (2020) ITC Four Country Smoking and Vaping Survey conducted in Australia, Canada, England, and United States (US). These four countries had varying responses to the pandemic by governments and public health, ranging from advising voluntary social distancing to implementing national and subnational staged lockdowns. Considering these varying responses, and the differences in the number of confirmed cases and deaths (greatest in England and the US and lowest in Australia), smoking behaviours related to COVID-19 may have differed between countries. Other factors that may be related to changes in smoking because of COVID-19 were also explored (e.g., sociodemographics, nicotine dependence, perceptions about personal and general risks of smoking on COVID-19). Regression analyses were conducted on weighted data. Results: Overall, 46.7% of smokers reported thinking about quitting because of COVID-19, which differed by country (p<0.001): England highest (50.9%) and Australia lowest (37.6%). Thinking about quitting smoking because of COVID-19 was more frequent among: females, ethnic minorities, those with financial stress, current vapers, less dependent smokers (non-daily and fewer cigarettes smoked/day), those with greater concern about personal susceptibility of infection, and those who believe COVID-19 is more severe for smokers. Smoking behaviour changes due to COVID-19 were: 1.1% attempted to quit, 14.2% reduced smoking, and 14.6% increased smoking (70.2% reported no change). Positive behaviour change (tried to quit/reduced smoking) was reported by 15.5% of smokers, which differed by country (p = 0.02), where Australia had significantly lower rates than the other three countries. A positive behavioural smoking change was more likely among smokers with: lower dependence, greater concern about personal susceptibility to infection, and believing that COVID-19 is more severe for smokers. Conclusions: Though nearly half of smokers reported thinking about quitting because of COVID-19, the vast majority did not change their smoking behaviour. Smokers were more likely to try and quit or reduce their smoking if they had greater concern about susceptibility and severity of COVID-19 related to smoking. Smokers in Australia were least likely to reduce or try to quit smoking, which could be related to the significantly lower impact of COVID-19 during the early phase of the pandemic relative to the other countries. [ABSTRACT FROM AUTHOR]

Background: Many people with dementia reach the end-of-life without an advance care plan. Many are not ready to have conversations about end-of-life, and decision-making is left to their families and professionals when they no longer have capacity. Carers may benefit from further support with decision-making. To develop this support, it is important to understand the decision-making process. Aim: Explore with family carers and people living with dementia the decision-making process and factors that influence decision-making in dementia end of life care, to produce a model of decision-making in the context of dementia end-of-life care. Methods: Semi-structured interviews with 21 family carers and 11 people with dementia in England (2018–2019) from memory clinics, general practice and carer organisations. Interviews were analysed using thematic analysis and findings were mapped onto the Interprofessional Shared Decision Making model, refined to produce a modified model of decision-making in dementia. Results: Participants described five key decisions towards the end-of-life as examples of decision making. We used these experiences to produce a modified model of decision-making in dementia end-of-life-care. The model considers the contextual factors that influence the decision-making process, including: personal preferences; advance care planning and Lasting Power of Attorney; capacity and health and wellbeing of the person with dementia; support from others and clarity of roles. The decision-making process consists of seven inter-linked stages: 1) identifying the decision maker or team; 2) sharing and exchanging information; 3) clarifying values and preferences; 4) managing and considering emotions; 5) considering the feasibility of options; 6) balancing preferred choice and the actual choice; and 7) implementation and reflecting on outcomes. Conclusions: The modified model breaks down the decision-making process and attempts to simplify the process while capturing the subtle nuances of decision making. It provides a framework for conversations and supporting decisions by carers. [ABSTRACT FROM AUTHOR]

Background: Prognosis in Palliative care Study (PiPS) models predict survival probabilities in advanced cancer. PiPS-A (clinical observations only) and PiPS-B (additionally requiring blood results) consist of 14- and 56-day models (PiPS-A14; PiPS-A56; PiPS-B14; PiPS-B56) to create survival risk categories: days, weeks, months. The primary aim was to compare PIPS-B risk categories against agreed multi-professional estimates of survival (AMPES) and to validate PiPS-A and PiPS-B. Secondary aims were to assess acceptability of PiPS to patients, caregivers and health professionals (HPs). Methods and findings: A national, multi-centre, prospective, observational, cohort study with nested qualitative sub-study using interviews with patients, caregivers and HPs. Validation study participants were adults with incurable cancer; with or without capacity; recently referred to community, hospital and hospice palliative care services across England and Wales. Sub-study participants were patients, caregivers and HPs. 1833 participants were recruited. PiPS-B risk categories were as accurate as AMPES [PiPS-B accuracy (910/1484; 61%); AMPES (914/1484; 61%); p = 0.851]. PiPS-B14 discrimination (C-statistic 0.837) and PiPS-B56 (0.810) were excellent. PiPS-B14 predictions were too high in the 57–74% risk group (Calibration-in-the-large [CiL] -0.202; Calibration slope [CS] 0.840). PiPS-B56 was well-calibrated (CiL 0.152; CS 0.914). PiPS-A risk categories were less accurate than AMPES (p<0.001). PiPS-A14 (C-statistic 0.825; CiL -0.037; CS 0.981) and PiPS-A56 (C-statistic 0.776; CiL 0.109; CS 0.946) had excellent or reasonably good discrimination and calibration. Interviewed patients (n = 29) and caregivers (n = 20) wanted prognostic information and considered that PiPS may aid communication. HPs (n = 32) found PiPS user-friendly and considered risk categories potentially helpful for decision-making. The need for a blood test for PiPS-B was considered a limitation. Conclusions: PiPS-B risk categories are as accurate as AMPES made by experienced doctors and nurses. PiPS-A categories are less accurate. Patients, carers and HPs regard PiPS as potentially helpful in clinical practice. Study registration: ISRCTN13688211. [ABSTRACT FROM AUTHOR]

Objective: To assess implementation of the Saving Babies Lives (SBL) Care Bundle, a collection of practice recommendations in four key areas, to reduce stillbirth in England. Design: A retrospective cohort study of 463,630 births in 19 NHS Trusts in England using routinely collected electronic data supplemented with case note audit (n = 1,658), and surveys of service users (n = 2,085) and health care professionals (n = 1,064). The primary outcome was stillbirth rate. Outcome rates two years before and after the nominal SBL implementation date were derived as a measure of change over the implementation period. Data were collected on secondary outcomes and process outcomes which reflected implementation of the SBL care bundle. Results: The total stillbirth rate, declined from 4.2 to 3.4 per 1,000 births between the two time points (adjusted Relative Risk (aRR) 0.80, 95% Confidence Interval (95% CI) 0.70 to 0.91, P<0.001). There was a contemporaneous increase in induction of labour (aRR 1.20 (95%CI 1.18–1.21), p<0.001) and emergency Caesarean section (aRR 1.10 (95%CI 1.07–1.12), p<0.001). The number of ultrasound scans performed (aRR 1.25 (95%CI 1.21–1.28), p<0.001) and the proportion of small for gestational age infants detected (aRR 1.59 (95%CI 1.32–1.92), p<0.001) also increased. Organisations reporting higher levels of implementation had improvements in process measures in all elements of the care bundle. An economic analysis estimated the cost of implementing the care bundle at ~£140 per birth. However, neither the costs nor changes in outcomes could be definitively attributed to implementation of the SBL care bundle. Conclusions: Implementation of the SBL care bundle increased over time in the majority of sites. Implementation was associated with improvements in process outcomes. The reduction in stillbirth rates in participating sites exceeded that reported nationally in the same timeframe. The intervention should be refined to identify women who are most likely to benefit and minimise unwarranted intervention. Trial registration: The study was registered on (NCT03231007); www.clinicaltrials.gov. [ABSTRACT FROM AUTHOR]

Purpose: We examined the association between the school policy, social and physical environment and change in adolescent physical activity (PA) and explored how sex and socioeconomic status modified potential associations. Methods: Data from the GoActive study were used for these analyses. Participants were adolescents (n = 1765, mean age±SD 13.2±0.4y) from the East of England, UK. Change in longitudinal accelerometer assessed moderate-to-vigorous physical activity (MVPA) was the outcome. School policy, social and physical environment features (n = 267) were exposures. The least absolute shrinkage and selection operator variable selection method (LASSO) was used to determine exposures most relevant to the outcome. Exposures selected by the LASSO were added to a multiple linear regression model with estimates of change in min/day of MVPA per 1-unit change in each exposure reported. Post-hoc analyses, exploring associations between change in variables selected by the LASSO and change in MVPA, were undertaken to further explain findings. Findings: No school policy or physical environment features were selected by the LASSO as predictors of change in MVPA. The LASSO selected two school social environment variables (participants asking a friend to do physical activity; friend asking a participant to do physical activity) as potential predictors of change in MVPA but no significant associations were found in subsequent linear regression models for all participants (β [95%CI] -1.01 [-2.73;0.71] and 0.65 [-2.17;0.87] min/day respectively). In the post-hoc analyses, for every unit increase in change in participants asking a friend to do PA and change in a friend asking participants to do PA, an increase in MVPA of 2.78 (1.55;4.02) and 1.80 (0.48;3.11) min/day was predicted respectively. Conclusions: The school social environment is associated with PA during adolescence. Further exploration of how friendships during adolescence may be leveraged to support effective PA promotion in schools is warranted. [ABSTRACT FROM AUTHOR]

Objectives: To explore the effect of introducing 24/7 resident labour ward consultant presence on neonatal and maternal outcomes in a large obstetric unit in England. Design: Retrospective time sequence analysis of routinely collected data. Setting: Obstetric unit of large teaching hospital in England. Participants: Women and babies delivered between1 July 2011 and 30 June 2017. Births <24 weeks gestation or by planned caesarean section were excluded. Main outcome measures: The primary composite outcome comprised intrapartum stillbirth, neonatal death, babies requiring therapeutic hypothermia, or admission to neonatal intensive care within three hours of birth. Secondary outcomes included markers of neonatal and maternal morbidity. Planned subgroup analyses investigated gestation (<34 weeks; 34–36 weeks; ≥37 weeks) and time of day. Results: 17324 babies delivered before and 16110 after 24/7 consultant presence. The prevalence of the primary outcome increased by 0.65%, from 2.07% (359/17324) before 24/7 consultant presence to 2.72% (438/16110, P < 0.001) after 24/7 consultant presence which was consistent with an upward trend over time already well established before 24/7 consultant presence began (OR 1.09 p.a.; CI 1.04 to 1.13). Overall, there was no change in this trend associated with the transition to 24/7. However, in babies born ≥37 weeks gestation, the upward trend was reversed after implementation of 24/7 (OR 0.67 p.a.; CI 0.49 to 0.93; P = 0.017). No substantial differences were shown in other outcomes or subgroups. Conclusions: Overall, resident consultant obstetrician presence 24/7 on labour ward was not associated with a change in a pre-existing trend of increasing adverse infant outcomes. However, 24/7 presence was associated with a reversal in increasing adverse outcomes for term babies. [ABSTRACT FROM AUTHOR]

Lung cancer (LC) generally lacks unique core symptoms or signs. However, there are a multitude of bodily sensations that are often non-specific, not easily understood, and many times initially not recognized as indicative of LC by the affected person, which often leads to late diagnosis. In this international qualitative study, we inductively analyzed retrospective accounts of 61 people diagnosed with LC in Denmark, England and Sweden. Using the bodily sensations they most commonly spoke about (tiredness, breathlessness, pain, and cough), we constructed four sensation-based cases to understand the pre-diagnostic processes of reasoning and practice triggered by these key indicators of LC. We thereafter critically applied Hay's model of sensations to symptoms transformation, examining its central concepts of duration, disability and vulnerability, to support understanding of these processes. We found that while duration and disability are clearly relevant, vulnerability is more implicitly expressed in relation to perceived threat. Tiredness, even when of long duration and causing disability, was often related to normal aging, rather than a health threat. Regardless of duration, breathlessness was disturbing and threatening enough to lead to care-seeking. Pain varied by location, duration and degree of disability, and thus also varied in degree of threat perceived. Preconceived, but unmet expectations of what LC-related cough and pain would entail could cause delays by misleading participants; if cough lasted long enough, it could trigger health care contact. Duration, disability, and sense of threat, rather than vulnerability, were found to be relevant concepts for understanding the trajectory to diagnosis for LC among these participants. The process by which an individual, their family and health care providers legitimize sensations, allowing them to be seen as potential symptoms of disease, is also an essential, but varying part of the diagnostic processes described here. [ABSTRACT FROM AUTHOR]

Objective: To determine the cost-utility of a multi-professional simulation training programme for obstetric emergencies–Practical Obstetric Multi-Professional Training (PROMPT)–with a particular focus on its impact on permanent obstetric brachial plexus injuries (OBPIs). Design: A model-based cost-utility analysis. Setting: Maternity units in England. Population: Simulated cohorts of individuals affected by permanent OBPIs. Methods: A decision tree model was developed to estimate the cost-utility of adopting annual, PROMPT training (scenario 1a) or standalone shoulder dystocia training (scenario 1b) in all maternity units in England compared to current practice, where only a proportion of English units use the training programme (scenario 2). The time horizon was 30 years and the analysis was conducted from an English National Health Service (NHS) and Personal Social Services perspective. A probabilistic sensitivity analysis was performed to account for uncertainties in the model parameters. Main outcome measures: Outcomes for the entire simulated period included the following: total costs for PROMPT or shoulder dystocia training (including costs of OBPIs), number of OBPIs averted, number of affected adult/parental/dyadic quality adjusted life years (QALYs) gained and the incremental cost per QALY gained. Results: Nationwide PROMPT or shoulder dystocia training conferred significant savings (in excess of £1 billion ($1.5 billion)) compared to current practice, resulting in cost-savings of at least £1 million ($1.5 million) per any type of QALY gained. The probabilistic sensitivity analysis demonstrated similar findings. Conclusion: In this model, national implementation of multi-professional simulation training for obstetric emergencies (or standalone shoulder dystocia training) in England appeared to both be cost-saving when evaluating their impact on permanent OBPIs. [ABSTRACT FROM AUTHOR]

Industry-led culling of badgers has occurred in England to reduce the incidence of bovine tuberculosis in cattle for a number of years. Badger vaccination is also possible, and a move away from culling was "highly desirable" in a recent report to the UK government. Here we used an established simulation model to examine badger control option in a post-cull environment in England. These options included no control, various intermittent culling, badger vaccination and use of a vaccine combined with fertility control. The initial simulated cull led to a dramatic reduction in the number of infected badgers present, which increased slowly if there was no further badger management. All three approaches led to a further reduction in the number of infected badgers, with little to choose between the strategies. We do note that of the management strategies only vaccination on its own leads to a recovery of the badger population, but also an increase in the number of badgers that need to be vaccinated. We conclude that vaccination post-cull, appears to be particularly effective, compared to vaccination when the host population is at carrying capacity. [ABSTRACT FROM AUTHOR]

Spatial datasets of building footprint polygons are becoming more widely available and accessible for many areas in the world. These datasets are important inputs for a range of different analyses, such as understanding the development of cities, identifying areas at risk of disasters, and mapping the distribution of populations. The growth of high spatial resolution imagery and computing power is enabling automated procedures to extract and map building footprints for whole countries. These advances are enabling coverage of building footprint datasets for low and middle income countries which might lack other data on urban land uses. While spatially detailed, many building footprints lack information on structure type, local zoning, or land use, limiting their application. However, morphology metrics can be used to describe characteristics of size, shape, spacing, orientation and patterns of the structures and extract additional information which can be correlated with different structure and settlement types or neighbourhoods. We introduce the foot package, a new set of open-source tools in a flexible R package for calculating morphology metrics for building footprints and summarising them in different spatial scales and spatial representations. In particular our tools can create gridded (or raster) representations of morphology summary metrics which have not been widely supported previously. We demonstrate the tools by creating gridded morphology metrics from all building footprints in England, Scotland and Wales, and then use those layers in an unsupervised cluster analysis to derive a pattern-based settlement typology. We compare our mapped settlement types with two existing settlement classifications. The results suggest that building patterns can help distinguish different urban and rural types. However, intra-urban differences were not well-predicted by building morphology alone. More broadly, though, this case study demonstrates the potential of mapping settlement patterns in the absence of a housing census or other urban planning data. [ABSTRACT FROM AUTHOR]

Little is known of how community assets can play a role in multimorbidity care provision. Using a rapid ethnographic approach, the study explored perceptions of the role of community assets in how multimorbidity is managed within Southwark and Lambeth in Southeast London, England. The scoping work comprised of four micro-studies covering (1) Rapid review of the literature (2) Documentary analysis of publicly available local policy documents (3) Thematic analysis of community stories and (4) Semi-structured stakeholder interviews. The data were analysed using framework thematic analysis. Themes are presented for each of the microstudies. The literature review analysis highlights the role of attitudes and understandings in the management of multiple long-term conditions and the need to move beyond silos in their management. Documentary analysis identifies a resource poor climate, whilst recognising the role of community assets and solution-focussed interventions in the management of multimorbidity. Community patient stories underline the lack of joined up care, and psychosocial issues such as the loss of control and reducing isolation. The stakeholder interview analysis reveals again a sense of disjointed care, the need for holism in the understanding and treatment of multimorbidity, whilst recognising the important role of community-based approaches, beyond the biomedical model. Recommendations stemming from the study's findings are proposed. Upholding access to and resourcing community assets have key practical importance. [ABSTRACT FROM AUTHOR]

Inequalities in alcohol-related health harms have been repeatedly identified. However, the socioeconomic distribution of alcohol-related violence (violence committed by a person under the influence of alcohol)–and of subtypes such as alcohol-related domestic violence–remains under-examined. To examine this, data are drawn from nationally representative victimisation survey, the Crime Survey for England and Wales, from years 2013/14 to 2017/18. Socioeconomic status specific incidence and prevalence rates for alcohol-related violence (including subtypes domestic, stranger, and acquaintance violence) were created. Binomial logistic regressions were performed to test whether the likelihood of experiencing these incidents was affected by socioeconomic status when controlling for a range of pre-established risk factors associated with violence victimisation. Findings generally show lower socioeconomic groups experience higher prevalence rates of alcohol-related violence overall, and higher incidence and prevalence rates for alcohol-related domestic and acquaintance violence. Binomial logistic regression results show that the likelihood of experiencing these types of violence is affected by a person's socioeconomic status–even when other risk factors known to be associated with violence are held constant. Along with action to address environmental and economic drivers of socioeconomic inequality, provision of publicly funded domestic violence services should be improved, and alcohol pricing and availability interventions should be investigated for their potential to disproportionately benefit lower socioeconomic groups. [ABSTRACT FROM AUTHOR]

Children and young people in the UK have worse health outcomes than in many similar western countries and child health inequalities are persistent and increasing. Systems thinking has emerged as a promising approach to addressing complex public health issues. We report on a systems approach to mapping the determinants of child health inequalities at the local level in England for young people aged 0–25, and describe the resulting map. Qualitative group concept mapping workshops were held in two contrasting English local authorities with a range of stakeholders: professionals (N = 35); children and young people (N = 33) and carers (N = 5). Initial area maps were developed, and augmented using data from qualitative interviews with professionals (N = 16). The resulting local maps were reviewed and validated by expert stakeholders in each area (N = 9; N = 35). Commonalities between two area-specific system maps (and removal of locality-specific factors) were used to develop a map that could be applied in any English local area. Two rounds of online survey (N = 21; N = 8) experts in public health, local governance and systems science refined the final system map displaying the determinants of child health inequalities. The process created a map of over 150 factors influencing inequalities in health outcomes for children aged 0–25 years at the local area level. The system map has six domains; physical environment, governance, economic, social, service, and personal. To our knowledge this is the first study taking a systems approach to addressing inequalities across all aspects of child health. The study shows how group concept mapping can support systems thinking at the local level. The resulting system map illustrates the complexity of factors influencing child health inequalities, and it may be a useful tool in demonstrating to stakeholders the importance of policies that tackle the systemic drivers of child health inequalities beyond those traditionally associated with public health. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting about 1.6% of the population in England. Novel oral anticoagulants (NOACs) are approved AF treatments that reduce stroke risk. In this study, we estimate the equality in individual NOAC prescriptions with high spatial resolution in Clinical Commissioning Groups (CCGs) across England from 2014 to 2019. Methods: A Bayesian spatio-temporal model will be used to estimate and predict the individual NOAC prescription trend on 'prescription data' as an indicator of health services utilisation, using a small area analysis methodology. The main dataset in this study is the "Practice Level Prescribing in England," which contains four individual NOACs prescribed by all registered GP practices in England. We will use the defined daily dose (DDD) equivalent methodology, as recommended by the World Health Organization (WHO), to compare across space and time. Four licensed NOACs datasets will be summed per 1,000 patients at the CCG-level over time. We will also adjust for CCG-level covariates, such as demographic data, Multiple Deprivation Index, and rural-urban classification. We aim to employ the extended BYM2 model (space-time model) using the RStan package. Discussion: This study suggests a new statistical modelling approach to link prescription and socioeconomic data to model pharmacoepidemiologic data. Quantifying space and time differences will allow for the evaluation of inequalities in the prescription of NOACs. The methodology will help develop geographically targeted public health interventions, campaigns, audits, or guidelines to improve areas of low prescription. This approach can be used for other medications, especially those used for chronic diseases that must be monitored over time. [ABSTRACT FROM AUTHOR]

Background: The cumulative (dis)advantage (CAD) perspective more and more is examined in a comparative way, to highlight the role of context in generating inequality over the life course. This study adds to this field of research by examining trajectories of activities of daily living (ADL) in later life by educational level in a country comparison of England and Germany, emphasizing differing institutional conditions. Method: Data used are the English Longitudinal Study of Ageing (ELSA; 11,352 individuals) and the German subsample of the Survey of Health and Retirement in Europe (SHARE; 5,573 individuals). Using population averaged Poisson panel regression models, 12-year trajectories of six birth cohorts are investigated, covering the age range of 50 to 90 years. Results: Respondents in England have a higher level of limitations at age 50, and more limited increases over age than in Germany. An educational gradient exists in both countries at age 50. Notably, the educational gradient increases for more recently born cohorts, but declines with increasing age in England, while in Germany educational differences increase for more recently born cohort only. Discussion: The current study indicates that CAD processes between educational groups are context sensitive. While England showed convergence of disparities with increasing age, in Germany no differential development was found. [ABSTRACT FROM AUTHOR]

Background: National birth cohorts derived from administrative health databases constitute unique resources for child health research due to whole country coverage, ongoing follow-up and linkage to other data sources. In England, a national birth cohort can be developed using Hospital Episode Statistics (HES), an administrative database covering details of all publicly funded hospital activity, including 97% of births, with longitudinal follow-up via linkage to hospital and mortality records. We present methods for developing a national birth cohort using HES and assess the impact of changes to data collection over time on coverage and completeness of linked follow-up records for children. Methods: We developed a national cohort of singleton live births in 1998–2015, with information on key risk factors at birth (birth weight, gestational age, maternal age, ethnicity, area-level deprivation). We identified three changes to data collection, which could affect linkage of births to follow-up records: (1) the introduction of the "NHS Numbers for Babies (NN4B)", an on-line system which enabled maternity staff to request a unique healthcare patient identifier (NHS number) immediately at birth rather than at civil registration, in Q4 2002; (2) the introduction of additional data quality checks at civil registration in Q3 2009; and (3) correcting a postcode extraction error for births by the data provider in Q2 2013. We evaluated the impact of these changes on trends in two outcomes in infancy: hospital readmissions after birth (using interrupted time series analyses) and mortality rates (compared to published national statistics). Results: The cohort covered 10,653,998 babies, accounting for 96% of singleton live births in England in 1998–2015. Overall, 2,077,929 infants (19.5%) had at least one hospital readmission after birth. Readmission rates declined by 0.2% percentage points per annual quarter in Q1 1998 to Q3 2002, shifted up by 6.1% percentage points (compared to the expected value based on the trend before Q4 2002) to 17.7% in Q4 2002 when NN4B was introduced, and increased by 0.1% percentage points per annual quarter thereafter. Infant mortality rates were under-reported by 16% for births in 1998–2002 and similar to published national mortality statistics for births in 2003–2015. The trends in infant readmission were not affected by changes to data collection practices in Q3 2009 and Q2 2013, but the proportion of unlinked mortality records in HES and in ONS further declined after 2009. Discussion: HES can be used to develop a national birth cohort for child health research with follow-up via linkage to hospital and mortality records for children born from 2003 onwards. Re-linking births before 2003 to their follow-up records would maximise potential benefits of this rich resource, enabling studies of outcomes in adolescents with over 20 years of follow-up. [ABSTRACT FROM AUTHOR]

A Delphi consensus methodology was used to adapt a screening tool, the Social Responsiveness Scale– 2 (SRS-2), for use with deaf children including those whose preferred communication method is sign language. Using this approach; 27 international experts (The Delphi International Expert Panel), on the topic of autism spectrum disorder (ASD) in deaf people, contributed to the review of item content. A criterion for agreement was set at 80% of experts on each item (with 75% acceptable in the final fourth round). The agreed modifications are discussed. The modified SRS-2 research adaptation for deaf people (referred to here as the "SRS-2 Deaf adaptation") was then translated into British Sign Language using a robust translation methodology and validated in England in a sample of 198 deaf children, 76 with Autism Spectrum Disorders (ASD) and 122 without ASD. The SRS-2 Deaf adaptation was compared blind to a NICE (National Institute for Health and Care Excellence) guideline standard clinical assessment. The area under the Receiver Operating (ROC) curve was 0.811 (95% CI: 0.753, 0.869), with an optimal cut-off value of 73, which gave a sensitivity of 82% and a specificity of 67%. The Cronbach Alpha coefficient was 0.968 suggesting high internal consistency. The Intraclass Correlation Coefficient was 0.897, supporting test-retest reliability. This performance is equivalent to similar instruments used for screening ASD in the hearing population. [ABSTRACT FROM AUTHOR]

This study aimed to extend previous research on the experiences and factors that impact law enforcement personnel when working with distressing materials such as child sexual abuse content. A sample of 22 law enforcement personnel working within one law enforcement organisation in England, United Kingdom participated in anonymous semi-structured interviews. Results were explored thematically and organised in the following headings: "Responses to the material", "Impact of working with distressing evidence", "Personal coping strategies" and "Risks and mitigating factors". Law enforcement professionals experienced heightened affective responses to personally relevant material, depictions of violence, victims' displays of emotions, norm violations and to various mediums. These responses dampened over time due to desensitisation. The stress experienced from exposure to the material sometimes led to psychological symptoms associated with Secondary Traumatic Stress. Job satisfaction, self-care activities, the coping strategies used when viewing evidence, detachment from work outside working hours, social support and reducing exposure to the material were found to mediate law enforcement professionals' resilience. Exposure to distressing material and the risks associated with this exposure were also influenced by specific organisational procedures implemented as a function of the funding available and workload. Recommendations for individual and organisational practices to foster resilience emerged from this research. These recommendations are relevant to all organisations where employees are required to view distressing content. [ABSTRACT FROM AUTHOR]

Background: Emergency responders are routinely exposed to traumatic critical incidents and other occupational stressors that place them at higher risk of mental ill health compared to the general population. There is some evidence to suggest that resilience training may improve emergency responders' wellbeing and related health outcomes. The aim of this study was to evaluate the effectiveness of a tertiary service resilience intervention compared to psychoeducation for improving psychological outcomes among emergency workers. Methods: We conducted a multicentre, parallel-group, randomised controlled trial. Minim software was used to randomly allocate police, ambulance, fire, and search and rescue services personnel, who were not suffering from depression or post-traumatic stress disorder, to Mind's group intervention or to online psychoeducation on a 3:1 basis. The resilience intervention was group-based and included stress management and mindfulness tools for reducing stress. It was delivered by trained staff at nine centres across England in six sessions, one per week for six weeks. The comparison intervention was psychoeducation about stress and mental health delivered online, one module per week for six weeks. Primary outcomes were assessed by self-report and included wellbeing, resilience, self-efficacy, problem-solving, social capital, confidence in managing mental health, and number of days off work due to illness. Follow-up was conducted at three months. Blinding of participants, researchers and outcome assessment was not possible due to the type of interventions. Results: A total of 430 participants (resilience intervention N = 317; psychoeducation N = 113) were randomised and included in intent-to-treat analyses. Linear Mixed-Effects Models did not show a significant difference between the interventions, at either the post-intervention or follow-up time points, on any outcome measure. Conclusions: The limited success of this intervention is consistent with the wider literature. Future refinements to the intervention may benefit from targeting predictors of resilience and mental ill health. Trial registration: ISRCTN registry, ISRCTN79407277. [ABSTRACT FROM AUTHOR]

Introduction: Although the direct oral anticoagulant rivaroxaban is recommended for stroke prevention in patients with non-valvular atrial fibrillation based on Phase III clinical trials, there is still a need for additional safety data from everyday clinical practice. The ROSE study was initiated to collect further information on the safety and utilisation of rivaroxaban in a broader range of patient groups in routine clinical practice. Methods and results: The ROSE study was conducted in hospitals in England and Wales. Consenting adults with non-valvular atrial fibrillation newly started on rivaroxaban were eligible and followed up for 12 weeks. Data was derived through secondary use of medical records. The primary outcome was major bleeding within gastrointestinal, urogenital and intracranial sites. A total of 4846 patients were enrolled in the study September 2013 to January 2016, 965 of which were treated with rivaroxaban for non-valvular atrial fibrillation. The median age in the rivaroxaban non-valvular atrial fibrillation cohort was 76 years, 53.6% were male. The median HAS-BLED score was 2 and the median CHA2DS2-VASc score was 4. The risk of major bleeding within each of the primary sites of gastrointestinal, urogenital and intracranial during the 12 week observation period was low (0.2%; n = 2). The risk of major bleeding in all sites was 1.0% (n = 10) at a rate of 5.5 events per 100 patient years. Conclusion: In terms of the primary outcome risk of major bleeding within gastrointestinal, urogenital and intracranial sites during the 12 week observation period, the risk estimates in the non-valvular atrial fibrillation rivaroxaban user population were low (<1%), and consistent with risk estimated from clinical trial data and in routine clinical practice. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]