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Objectives: With a projected rise in care home residency and the disproportionate impact of epilepsy and seizures on older adults, understanding seizure-related needs in this population is crucial. Data silos and inconsistent recording of residence status make this challenging. We thus leveraged ambulance data to investigate seizure call-out incidence, characteristics, management and costs in care homes compared with the wider community., Design: Retrospective analysis of dispatch data from a regional English ambulance service over four 9-month periods between 2014/2015 and 2021/2022. Suspected seizures in adults (≥16 years) were identified, with data on location, patient age, severity and management extracted. Incidence rates, trends over time and case characteristics were compared. Costs of ambulance response were estimated, and factors influencing emergency department (ED) conveyance were analysed using logistic regression., Setting: North West Ambulance Service National Health Service Trust, serving an adult population of ~5.5 million., Participants: Dispatch data for 98 752 suspected seizure cases., Results: Care homes, accommodating ~0.8% of the regional population, accounted for 7.2% of seizure call-outs. Incidence was higher in care homes than the wider community (55.71 vs 5.97 per 1000 person/year in 2021/2022) and increased over time. Care home cases peaked around 8:00-9:00. Despite similar or lower severity, they had a higher ED conveyance rate (78.3% vs 70.6%). Conveyance likelihood was influenced by factors beyond severity: reduced in homes specialising in learning disabilities (adjusted OR=0.649) and increased in homes with nursing provision (adjusted OR=1.226). Care homes accounted for 7.26% of the £24 million cost., Conclusions: This study highlights the growing seizure-related needs in care homes. Despite similar severity, most cases result in ED conveyance. Future research should examine the appropriateness and implications of these transfers, ensuring specialist services support the care home population effectively., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: The UK was the first country to launch a national pandemic COVID-19 vaccination programme, which was implemented swiftly despite significant vaccine supply constraints. The delivery strategy used a combination of mass vaccination sites operated by NHS secondary care providers and local sites led by Primary Care Networks, and local pharmacies. Despite nation-wide rollout, persistent gaps in coverage continued to affect particular populations, including ethnic minority and marginalised social groups., Aim: The study examined sub-national immunisation commissioners and providers' perspectives on how the COVID-19 vaccine programme was operationalised, and how delivery strategies impacted inequalities in access to vaccination services and uptake. The study aimed to inform national programme implementation, sustainability and future pandemic preparedness., Methods: Qualitative research was conducted in eight local NHS areas in 4 regions of England. Semi-structured interviews were performed with 82 sub-national NHS and public health vaccine providers and commissioners., Results: England's COVID-19 vaccination programme was described as top down, centralised and highly political. The programme gradually morphed from a predominantly mass vaccination strategy into more locally driven and tailored approaches able to respond more effectively to inequalities in uptake. Over time more flexibility was introduced, as providers adapted services by "working around" the national systems for vaccine supply and appointment booking. The constant change faced by providers and commissioners was mitigated by high staff motivation and resilience, local collaboration and pragmatism. Opportunities for efficient implementation were missed because priority was given to achieving national performance targets at the expense of a more flexible sub-national tailored delivery., Conclusion: Pandemic vaccination delivery models need to be adapted for underserved and hesitant groups, working in collaboration with local actors. Learnings from the initial COVID-19 vaccine roll-out in England and elsewhere is important to inform future pandemic responses, in tailoring strategies to local communities, and improve large-scale vaccination programmes., Competing Interests: Tracey Chantler, Sadie Bell, Ben Kasstan, Pauline Paterson and Sandra Mounier-Jack report that they were in receipt of funding from the National Institute of Health and Care Research while conducting this research. Pauline Paterson also receives research funding from Place-based Climate Action Network (PCAN) and the Innovation and Technology Commission, Hong Kong. Louise Letley worked for Public Health England and UKHSA for the duration of this research., (Copyright: © 2023 Mounier-Jack et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: A national SARS-CoV-2 vaccination programme was implemented in England from 8th December 2020, adopting a series of local level service delivery models to maximise rollout. The evidence base informing service design programme at inception was limited. We examined the real-world implementation of the programme through an assessment of sub-national providers' and commissioners' perspectives on the service delivery models used, to strengthen evidence on the acceptability, effectiveness and efficiency of the service delivery approaches used for SARS-CoV-2 vaccination in England or elsewhere., Methods: Qualitative, cross-sectional analysis based on semi-structured interviews conducted with 87 stakeholders working in SARS-CoV-2 vaccination delivery across four regions in England. Localities were selected according to geography and population socio-economic status. Participants were purposively sampled from health service providers, commissioners and other relevant bodies. Interviews were conducted between February and October 2021, and transcripts were thematically analysed using inductive and deductive approaches., Results: Various service delivery models were implemented over the course of the programme, beginning with hospital hubs and mass vaccination sites, before expanding to incorporate primary care-led services, mobile and other outreach services. Each had advantages and drawbacks but primary care-led models, and to some extent pharmacies, were perceived to offer a better combination of efficiency and community reach for equitable delivery. Common factors for success included availability of a motivated workforce, predictability in vaccine supply chains and strong community engagement. However, interviewees noted a lack of coordination between service providers in the vaccination programme, linked to differing financial incentives and fragmentated information systems, among other factors., Conclusion: A range of delivery models are needed to enable vaccine rollout at pace and scale, and to mitigate effects on routine care provision. However, primary care-led services offer a tried-and-trusted framework for vaccine delivery at scale and pace and should be central to planning for future pandemic responses. Mass vaccination sites can offer delivery at scale but may exacerbate inequalities in vaccination coverage and are unlikely to offer value for money. Policymakers in England should prioritise measures to improve collaboration between service providers, including better alignment of IT systems., (© 2023. The Author(s).)

Background: Deferrals due to low hemoglobin are time-consuming and costly for blood donors and donation services. Furthermore, accepting donations from those with low hemoglobin could represent a significant safety issue. One approach to reduce them is to use hemoglobin concentration alongside donor characteristics to inform personalized inter-donation intervals., Study Design and Methods: We used data from 17,308 donors to inform a discrete event simulation model comparing personalized inter-donation intervals using "post-donation" testing (i.e., estimating current hemoglobin from that measured by a hematology analyzer at last donation) versus the current approach in England (i.e., pre-donation testing with fixed intervals of 12-weeks for men and 16-weeks for women). We reported the impact on total donations, low hemoglobin deferrals, inappropriate bleeds, and blood service costs. Personalized inter-donation intervals were defined using mixed-effects modeling to estimate hemoglobin trajectories and probability of crossing hemoglobin donation thresholds., Results: The model had generally good internal validation, with predicted events similar to those observed. Over 1 year, a personalized strategy requiring ≥90% probability of being over the hemoglobin threshold, minimized adverse events (low hemoglobin deferrals and inappropriate bleeds) in both sexes and costs in women. Donations per adverse event improved from 3.4 (95% uncertainty interval 2.8, 3.7) under the current strategy to 14.8 (11.6, 19.2) in women, and from 7.1 (6.1, 8.5) to 26.9 (20.8, 42.6) in men. In comparison, a strategy incorporating early returns for those with high certainty of being over the threshold maximized total donations in both men and women, but was less favorable in terms of adverse events, with 8.4 donations per adverse event in women (7.0, 10,1) and 14.8 (12.1, 21.0) in men., Discussion: Personalized inter-donation intervals using post-donation testing combined with modeling of hemoglobin trajectories can help reduce deferrals, inappropriate bleeds, and costs., (© 2023 The Authors. Transfusion published by Wiley Periodicals LLC on behalf of AABB.)

Objectives: In England, older adults (aged ≥50 years) are at greater risk of being diagnosed with advanced stage HIV infection than younger adults. We explored journeys to testing and diagnosis among older adults, examining factors associated with late HIV diagnosis in this age group., Methods: Semi-structured qualitative interviews were performed with 12 adults diagnosed with HIV at age 50+ years and 12 health care professionals working in sexual health/HIV services. Data were analysed thematically, using the Model of Pathways to Treatment as a framework for analysis., Results: Older adults were often found to experience non-linear and complex diagnostic journeys. Pathways to diagnosis were affected by 6 factors: (i) the non-specific nature of HIV symptoms and their misattribution as being age-related; (ii) symptom severity, impact, and visibility; (iii) HIV health literacy; (iv) perceptions of HIV risk; (v) geographical location; and (vi) assessment in non-specialist settings., Conclusions: Older adults appear to encounter additional barriers to HIV testing compared with younger people, particularly when they are not part of a group targeted in HIV prevention and testing campaigns. To diagnose HIV more promptly in adults aged 50+ years, HIV knowledge and risk perception must increase in both older people and health care professionals. Health care professionals need to look beyond the 'high risk' groups that are most affected by HIV and consider HIV more readily in the diagnostic process.

Objective: To explore parents' and guardians' views and experiences of accessing National Health Service (NHS) general practices for routine childhood vaccinations during the coronavirus (COVID-19) pandemic in England., Design: Mixed methods approach involving an online cross-sectional survey (conducted between 19th April and 11th May 2020) and semi-structured telephone interviews (conducted between 27th April and 27th May 2020)., Participants: 1252 parents and guardians (aged 16+ years) who reported living in England with a child aged 18 months or under completed the survey. Nineteen survey respondents took part in follow-up interviews., Results: The majority of survey respondents (85.7%) considered it important for their children to receive routine vaccinations on schedule during the COVID-19 pandemic; however, several barriers to vaccination were identified. These included a lack of clarity around whether vaccination services were operating as usual, particularly amongst respondents from lower income households and those self-reporting as Black, Asian, Chinese, Mixed or Other ethnicity; difficulties in organising vaccination appointments; and fears around contracting COVID-19 while attending general practice. Concerns about catching COVID-19 while accessing general practice were weighed against concerns about children acquiring a vaccine-preventable disease if they did not receive scheduled routine childhood vaccinations. Many parents and guardians felt their child's risk of acquiring a vaccine-preventable disease was low as the implementation of stringent physical distancing measures (from March 23rd 2020) meant they were not mixing with others., Conclusion: To promote routine childhood vaccination uptake during the current COVID-19 outbreak, further waves of COVID-19 infection, and future pandemics, prompt and sustained national and general practice level communication is needed to raise awareness of vaccination service continuation and the importance of timely vaccination, and invitation-reminder systems for vaccination need to be maintained. To allay concerns about the safety of accessing general practice, practices should communicate the measures being implemented to prevent COVID-19 transmission., Competing Interests: The authors have declared that no competing interests exist.

Background: The availability of a COVID-19 vaccine has been heralded as key to controlling the COVID-19 pandemic. COVID-19 vaccination programme success will rely on public willingness to be vaccinated., Methods: We used a multi-methods approach - involving an online cross-sectional survey and semi-structured interviews - to investigate parents' and guardians' views on the acceptability of a future COVID-19 vaccine. 1252 parents and guardians (aged 16 + years) who reported living in England with a child aged 18 months or under completed the survey. Nineteen survey participants were interviewed., Findings: Most survey participants reported they would likely accept a COVID-19 vaccine for themselves (Definitely 55.8%; Unsure but leaning towards yes 34.3%) and their child/children (Definitely 48.2%; Unsure but leaning towards yes 40.9%). Less than 4% of survey participants reported that they would definitely not accept a COVID-19 vaccine. Survey participants were more likely to accept a COVID-19 vaccine for themselves than their child/children. Participants that self-reported as Black, Asian, Chinese, Mixed or Other ethnicity were almost 3 times more likely to reject a COVID-19 vaccine for themselves and their children than White British, White Irish and White Other participants. Survey participants from lower-income households were also more likely to reject a COVID-19 vaccine. In open-text survey responses and interviews, self-protection from COVID-19 was reported as the main reason for vaccine acceptance. Common concerns identified in open-text responses and interviews were around COVID-19 vaccine safety and effectiveness, mostly prompted by the newness and rapid development of the vaccine., Conclusion: Information on how COVID-19 vaccines are developed and tested, including their safety and efficacy, must be communicated clearly to the public. To prevent inequalities in uptake, it is crucial to understand and address factors that may affect COVID-19 vaccine acceptability in ethnic minority and lower-income groups who are disproportionately affected by COVID-19., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Improving children and young people's provision for mental health is a current health priority in England. Secondary school teachers have worse mental health outcomes than the general working population, which the Wellbeing in Secondary Education (WISE) cluster randomised controlled trial aimed to improve. The WISE intervention comprised a Mental Health First Aid (MHFA) training package delivered to at least 16% of staff, a short mental health awareness session to all teachers and development of a staff peer support service. Twenty-five schools were randomised to intervention or control arms. This paper reports findings regarding the extent of uptake and fidelity of the intervention., Methods: Mixed methods data collection comprised researcher observations of training delivery, training participant evaluation forms, trainer and peer supporter interviews, peer supporter feedback meetings, logs of support provided, and teacher questionnaires. Quantitative data were summarised descriptively, while thematic analysis was applied to the qualitative data., Results: In the 12 schools assigned to the intervention arm, 113 (8.6%) staff completed the 2-day standard MHFA training course, and a further 146 (11.1%) staff completed the 1-day MHFA for schools and colleges training. In seven (58.3%) schools, the required 8% of staff completed the MHFA training packages. A 1-h mental health awareness-raising session was attended by 666 (54.5%) staff. Delivery of the MHFA training package was achieved with high levels of fidelity and quality across schools. All schools set up the peer support service following training, with a majority adhering to most of the operational guidelines developed from the pilot study at the outset. Teachers reported limited use of the peer support service during follow-up. At the 1-year follow-up, only three (25.0%) schools indicated they had re-advertised the service and there was evidence of a reduction in support from senior leadership., Conclusion: The MHFA training package was delivered with reasonably high fidelity, and a staff peer support service was established with general, but not complete, adherence to guidelines. In some schools, insufficient staff received MHFA training and levels of delivery of the peer support service compromised intervention dose and reach., Trial Registration: ISRCTN 95909211 . Registered on 15 January 2016.

Background: In 2018/19, English NHS trusts (NHSTs) implemented an 'opt-out' policy for seasonal flu vaccination in frontline healthcare workers (HCWs). HCWs declining the vaccination were asked to sign an opt-out form and provide a reason for their decision. In addition, HCWs working in higher risk hospital environments (e.g. oncology) were asked to inform their manager about their declination decision. The policy aimed to provide greater insight into reasons for vaccination decline and information from HCWs in higher risk areas was intended for use in considering HCW redeployment. This study investigated the feasibility, acceptability, and perceived value of the policy during the 2018/19 flu vaccination season., Methods: We conducted semi-structured interviews across 9 NHSTs in England with different levels of HCW flu vaccination uptake in 2017/18. We interviewed 30 vaccination programme implementers and 27 managers., Findings: The purpose of the policy was poorly understood, and interviewees did not know how data on decliners was being used. Most NHSTs tried to collect the personal details of decliners and, in some instances, these were recorded in Electronic Staff Records and reported to line-managers for action. This created strain on employer-employee relationships, leading to decliners refusing to complete opt-out forms and some vaccinators not implementing the policy. None of the NHSTs had a redeployment policy for decliners, arguing that this was impractical due to strain on staffing levels., Conclusion: A flu-vaccination opt-out approach for HCWs did not appear acceptable in our sampled NHSTs, due to a lack of clear messaging about its purpose and complicated implementation. To promote an opt-out approach effectively, there needs to be clear communication of its purpose, which should be to explore reasons for decline rather than identify and 'push' decliners to vaccinate, so as not to damage staff relationships. NHSTs should involve their workforce in developing flu vaccination approaches., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Health care workers are a priority group for seasonal influenza vaccination, which is recommended by the World Health Organisation. There is a wide variation in uptake between and within countries. England has achieved 69.5% of health care workers vaccinated overall in 2017/18 across NHS acute and community health care settings, but it varies between Trusts from 50% to over 92.3%. While attitudinal factors have been well researched, there is limited evidence on organisational factors associated with high uptake. In England, most NHS Trusts are now implementing a similar range of interventions as part of their flu programme, and it remains unclear why performance remains so variable. This qualitative study is the first to explore reasons for this variation and provide recommendations for lower performing Trusts on how to improve. Fifty-seven interviews of managers and vaccinators were conducted in nine hospitals with flu vaccination uptake ranging from just over 55% to above 90%. Our study found that while Trusts deployed a wide range of both demand generating and supply interventions to increase uptake, there were marked differences in the organisational and delivery models utilised. Our study suggests that organisational culture was possibly the most important ingredient when trying to differentiate between high and low performing Trusts. We found that a positive culture aimed at fostering continuous improvement and favouring non-coercion on balance yielded more adherence from staff. Where influenza vaccination was embedded in the organisation wellbeing strategy, rather than executed as a siloed seasonal programme, this tended to foster good performance. Improving performance of influenza vaccination in health care workers will involve not only deploying the right interventions, and following "best practices". It will require the adaptation of flu progamme delivery strategies to the organisation context, and embedding vaccination into the organisational culture, thus supporting the normalisation of yearly vaccination., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: [Tracey Chantler, Sadie Bell, Pauline Paterson and Sandra Mounier-Jack report that they were in receipt of funding from the National Institute of Health Research while conducting this research. Pauline Paterson has received research funding from GlaxoSmithKline, and has received honorariums from Sanofi Pasteur and Pfizer. Angela Edwards and Joanne Yarwood worked for Public Health England for the duration of this research. Douglas Gilbert worked at NHS England and NHS Improvement during the duration of the study.], (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Since 2016, large scale measles outbreaks have heavily affected countries across Europe. In England, laboratory confirmed measles cases increased almost four-fold between 2017 and 2018, from 259 to 966 cases. Several of the 2017-18 measles outbreaks in England particularly affected Romanian and Roma Romanian communities, with the first outbreaks in these communities occurring in Birmingham, Leeds and Liverpool. This study explored factors influencing vaccination behaviours amongst Romanian and Roma Romanian communities in these three cities., Methods: Across Birmingham, Leeds and Liverpool, we conducted semi-structured interviews with 33 key providers to explore their experience in delivering vaccinations and managing the outbreak response. We also interviewed 9 Romanian women in one of the cities to explore their vaccination attitudes and behaviours. To categorise factors affecting vaccination we applied the 5As Taxonomy for Determinants of Vaccine Uptake (Access, Affordability, Awareness, Acceptance and Activation) during data analysis., Results: Factors related to access and acceptance, such as language and literacy, ease of registering with a general practice, and trust in health services, were reported as the main barriers to vaccination amongst the communities. Concerns around vaccination safety and importance were reported but these appeared to be less dominant contributing factors to vaccination uptake. The active decline of vaccinations amongst interviewed community members was linked to distrust in healthcare services, which were partly rooted in negative experiences of healthcare in Romania and the UK., Conclusion: Access and acceptance, dominant barriers to vaccination, can be improved through the building of trust with communities. To establish trust providers must find ways to connect with and develop a greater understanding of the communities they serve. To achieve this, cultural and linguistic barriers need to be addressed. Better provider-service user relationships are crucial to reducing vaccination inequalities and tackling broader disparities in health service access.

Objectives: This study explored vaccination attitudes and behaviours among Polish and Romanian communities, and related access to primary healthcare services., Design: A qualitative study using in-depth semistructured interviews with Polish and Romanian community members (CMs) and healthcare workers (HCWs) involved in vaccination in areas with large Polish and Romanian communities. CMs discussed their vaccination attitudes and their experiences of accessing vaccinations in England. HCWs shared their experiences in vaccinating Polish and Romanian communities., Setting: Recruitment focused on three geographical areas in England with large Polish and Romanian populations (in London, Lincolnshire and Berkshire)., Participants: 20 Polish and 10 Romanian CMs, and 20 HCWs. Most CMs were mothers or pregnant women and were recruited from London or Lincolnshire. HCWs included practice nurses, health visitors and school nurses recruited from the targeted geographical areas., Results: Although most CMs reported vaccinating according to the UK schedule, obstacles to vaccination were highlighted. CMs experienced difficulties navigating and trusting the English primary healthcare system, and challenges in accessing credible vaccination information in Polish and Romanian. CM vaccination expectations, largely built on knowledge and experiences from Poland and Romania, were often unmet. This was driven by differences in vaccination scheduling and service provision in England, such as nurses delivering vaccines instead of doctors. CMs reported lower acceptance of the influenza vaccine, largely due to perceptions around the importance and efficacy of this vaccine. HCWs reported challenges translating and understanding vaccination histories, overcoming verbal communication barriers and ensuring vaccination schedule completeness among families travelling between England and Poland or Romania., Conclusions: This study identified vaccination uptake and delivery issues and recommendations for improvement. HCWs should discuss health service expectations, highlight differences in vaccination scheduling and delivery between countries, and promote greater understanding of the English primary healthcare system in order to encourage vaccination in these communities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Psychiatric morbidity is high in the prison population and prisoners with mental health problems present with complex needs. Working within the stressful prison environment and exposure to traumatic events may make prison mental health staff and correctional officers vulnerable to burnout, compassion fatigue, and reduced compassion satisfaction. This issue has not previously been explored in the prison setting. In this exploratory study, 36 mental health professionals and correctional officers were recruited from a prison in England and completed a series of questionnaires on their demographic and professional characteristics, exposure to traumatic events, support from managers and colleagues and on levels of burnout, compassion fatigue, and compassion satisfaction. Staff had high levels of exposure to traumatic events and the level of support provided by managers and colleagues was mixed. The majority of staff were not at high risk of burnout, compassion fatigue and reduced compassion satisfaction but higher levels of burnout, compassion fatigue and reduced compassion satisfaction were found to be associated with a range of factors including staff characteristics, exposure to traumatic events, and working environment. These findings should be interpreted with the small sample size and limited power in mind and larger surveys of staff working in prison mental health settings are needed to confirm these results across a wider number of sites but nonetheless this study highlights the need for providers to consider staff's exposure to traumatic events and to promote supportive working environments.

Older adults with HIV are at increased risk of late diagnosis. We aimed to explore the association between age and HIV testing rates in sexual health clinics in England using Public Health England data for 2009-2014. We investigated associations between attendee age and likelihood of HIV test offer, acceptance, and coverage. For each year, increasing age was associated with reduced likelihood of test offer (R s -0.797 to -0.958, p < 0·01). Offer rates were highest for men who have sex with men (MSM), and lowest for heterosexual females (HSFs). HSFs had the greatest decline in offer rates with age (from 86.2% for age 25-29 to 52.1% for age 70+ in 2014). Odds ratios for test offer in 2014 for attendees aged 15-49 compared with attendees aged 50+ were 1.94 (95%CI: 1.88, 2.00) for heterosexual males (HSMs), 1.86 (95%CI: 1.81, 1.91) for HSFs, and 1.54 (95%CI: 1.45, 1.64) for MSM. Overall, there was no significant association between age and test acceptance in any year (R s -0.070 to -0.547; p > 0·05). The strongest determinant of acceptance was sexual orientation; for attendees aged 50+, compared with HSMs, acceptance was higher for MSM (OR: 1.10; 95%CI: 1.06, 1.13) and lower for HSFs (OR: 0.30; 95%CI: 0.30, 0.31).

Background: The English national health system experienced a major reorganisation in April 2013. This mixed methods study examined how staff managed to deliver the national immunisation programme within a new health infrastructure and explored the role and contribution of 'partnership working' to programme implementation., Methods: A cross-sectional online questionnaire survey and a qualitative evaluation of an urban immunisation board were conducted in 2016. The questionnaire included 38 questions about immunisation responsibilities, collaboration, service evaluation and programme support. It was completed by 199 immunisation providers and 70 people involved in the management of the immunisation programme. The evaluation involved 12 semi-structured interviews, 3 observations of forum meetings and the review of forum meeting minutes. Descriptive statistical analysis of the survey data was performed using SPSS version 23 and qualitative data from both study components were uploaded to NVivo 11 and analysed thematically., Results: Screening and Immunisation Teams were cited as responsible for programme leadership by 56% of survey respondents, but concerns were raised about their capacity to oversee larger geographies and a case made for decentralised accountability mechanisms. Only 44% of immunisation managers stated that poor performance was addressed adequately, and half of respondents thought that support given to providers was inadequate. Managers reported that partnership working improved the organisation (83%) and performance (78%) of immunisation, but stated it was more beneficial for information-sharing than implementation. A preference for a "locality working approach" with committees covering smaller health economies rather than larger commissioning areas was voiced. The immunisation board examined in the qualitative evaluation sought to achieve this by forging links with locally based steering committees, but also had to address internal challenges related to the role of the board and contribution of members to programmatic decision-making., Conclusions: Key challenges in delivering the immunisation programme were rooted in the new health infrastructure, which had created greater distance between commissioners and providers and resulted in the fragmentation of programme responsibilities. Partnership working bridged gaps but more needs to be done to strengthen accountability mechanisms and ensure that collaborative activities are outcome oriented and sustainable in the shifting environment of reorganisation.

Background: For the same quantity of cigarettes smoked, relative to more affluent people, socioeconomically disadvantaged people have higher levels of smoking biomarkers. This may be ascribed to inhaling cigarette smoke more deeply and more frequently and/or choosing higher tar-containing brands. We investigated whether this increased tobacco load, as captured using cotinine measurements, is associated with a greater risk of mortality in lower social groups., Methods: We used Cox proportional hazards models stratified by socioeconomic position to calculate hazard ratios in a pooled sample of 15 English and Scottish prospective cohort studies (N = 81,476)., Results: During a mean (SD) follow-up of 10.3 (4.4) years, 8234 deaths occurred. Risk of total mortality (hazard ratio; 95% confidence interval) for smokers relative to never-smokers in the high (2.5; 2.1, 3.1), intermediate (2.1; 1.8, 2.4), and low (2.0; 1.9, 2.2) educational groups did not differ markedly (P for interaction=0.61). Similar findings emerged when using cause-specific outcomes and occupational social class and housing tenure as socioeconomic indices., Conclusion: Contrary to our hypothesis, we found no indication that chronic disease mortality associated with smoking was higher in disadvantaged people.

Background: Factors within the school environment may impact young people's mental health and wellbeing. The aim of this study was to understand the association between teacher and student mental health and wellbeing. Further, it seeked to identify possible explanations by examining whether the strength of any association is weakened once quality of teacher-student relationships, teacher presenteeism and absence are considered., Methods: Cross-sectional data were collected from 3216 year 8 (aged 12-13 years) students and from 1182 teachers in 25 secondary schools in England and Wales. The association between teacher wellbeing (measured by Warwick Edinburgh Mental Wellbeing Scale (WEMWBS)) with student wellbeing (WEMWBS) and with student psychological distress (Total Difficulties Score (TDS)) was assessed using Random Effects Mixed Models. Analyses were repeated using teacher depression (measured by Patient Health Questionnaire) as the explanatory variable., Results: Better teacher wellbeing was associated with i) better student wellbeing (standardised effect = 0·07, 95% CI = 0·02 to 0·12) and ii) lower student psychological distress (standardised effect = -0·10, 95% CI = -0·16 to -0·04). Teacher presenteeism and the quality of the teacher-student relationship appeared to be on the pathway of these relationships. Higher levels of teacher depressive symptoms were associated with poorer student wellbeing and psychological distress (standardised effect = -0·06, 95% CI = -0·11 to -0·01 & 0·09, 95% CI = 0·03 to 0·15). This association did not withstand adjustment for teacher presenteeism., Limitations: Cross sectional in design so unable to establish temporal associations., Conclusions: Associations were found between teacher wellbeing and student wellbeing and psychological distress. There were also an association between teacher depression and student wellbeing. Both may be partially explained by teacher presenteeism and quality of teacher-student relationships., (Copyright © 2018. Published by Elsevier B.V.)

Objective: To examine the prospective relation between animal companionship and biomarkers of ageing in older people., Design: Analyses of data from the English Longitudinal Study of Ageing, an ongoing, open, prospective cohort study initiated in 2002-03., Setting: Nationally representative study from England., Participants: 8785 adults (55% women) with a mean age of 67 years (SD 9) at pet ownership assessment in 2010-11 (wave 5)., Main Outcome Measure: Established biomarkers of ageing in the domains of physical, immunological, and psychological function, as assessed in 2012-13 (wave 6)., Results: One third of study members reported pet ownership: 1619 (18%) owned a dog, 1077 (12%) a cat, and 274 (3%) another animal. After adjustment for a range of covariates, there was no evidence of a clear association of any type of pet ownership with walking speed, lung function, chair rise time, grip strength, leg raises, balance, three markers of systemic inflammation, memory, or depressive symptoms., Conclusion: In this population of older adults, the companionship of creatures great and small seems to essentially confer no relation with standard ageing phenotypes., Competing Interests: Ethical approval: Data collection for this study was approved by the London Multicentre Research Ethics Committee., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Purpose: Harmful alcohol consumption among the ageing population is an important public health issue. Very few studies ask drinkers why they change their consumption in later life. The aim of this paper was to determine whether a group of people aged over 60 years increased or decreased their alcohol consumption over the past decade and to determine the reasons for their change. We also examined whether the responses varied by age, sex and socio-economic position (SEP)., Subjects and Methods: Data were taken from 6,011 participants (4,310 men, 1,701 women, age range 61 to 85 years) who completed questionnaires at phase 11 (2012-2013) of the Whitehall II Cohort Study., Results: Over half the study members reported a change in alcohol consumption over the past decade (40% decreased, 11% increased). The most common reasons given for decreases were as a health precaution and fewer social occasions. Common reasons for increases were more social occasions and fewer responsibilities. The lowest SEP group was less likely to increase consumption compared to high SEP (RR 0.57, 95% CI 0.40 to 0.81). Women were more likely to increase consumption in response to stress/depression than men (RR1.53, 95% CI 1.04 to 2.25). Compared to high SEP, the lowest SEP group was less likely to reduce as a health precaution (RR 0.61, 95% CI 0.38 to 0.76)., Conclusions: Alcohol consumption in late life is not fixed. Reasons for change vary by age, sex and SEP. Such information could be used to tailor intervention strategies to reduce harmful consumption.

Background: Process evaluations are useful for understanding how interventions are implemented in trial settings. This is important for interpreting main trial results and indicating how the intervention might function beyond the trial. The purpose of this study was to examine the reach, dose, fidelity, acceptability, and sustainability of the implementation of an educational hand washing intervention in primary schools, and to explore views regarding acceptability and sustainability of the intervention., Methods: Process evaluation within a cluster randomised controlled trial, including focus groups with pupils aged 6 to 11, semi-structured interviews with teachers and external staff who coordinated the intervention delivery, and school reports and direct observations of the intervention delivery., Results: The educational package was delivered in 61.4% of schools (85.2% of intervention schools, 37.8% of control schools following completion of the trial). Teachers and pupils reacted positively to the intervention, although concerns were raised about the age-appropriateness of the resources. Teachers adapted the resources to suit their school setting and pupils. Staff coordinating the intervention delivery had limited capacity to follow up and respond to schools., Conclusions: The hand washing intervention was acceptable to schools, but its reach outside of a randomised trial, evidenced in the low proportion of schools in the control arm who received it after the trial had ended, suggests that the model of delivery may not be sustainable., Trial Registration: ISRCTN: ISRCTN93576146.

Objective: The aim of our study was to examine cross-sectional and longitudinal associations between cigarette smoking and alcohol drinking, in a representative sample of English pupils., Method: Data from 13,635 school pupils in the Longitudinal Study of Young People in England (LSYPE) on usage of cigarettes from 2004 (typical age 14) to 2006 (age 16) and alcohol from 2004 to 2007 (age 17), analyzed with latent growth curve models., Results: The weighted percentage of pupils drinking alcohol increased from 26% at age 14 to 71% by age 17, smoking from 12% to 27% by age 16. Pupils with lower socio-economic status were more likely to smoke but less likely to drink alcohol regularly. Both behaviors were positively correlated at age 14, adjusted for several confounding factors. The rate of increase over time was also positively correlated., Conclusion: Cigarette smoking and alcohol drinking are already correlated by age 14, are socio-economically patterned, and 'move together' during adolescence. Future studies and interventions should be targeted at a younger age range, to identify early smoking and potentially hazardous alcohol drinking patterns., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Cryptosporidiosis was investigated on two alpaca (Lama pacos) holdings in the South-West of England. Diagnosis was initially confirmed in a cria with diarrhoea from each holding. Cohort faeces samples were subsequently collected and examined for presence of Cryptosporidium oocysts by immunofluorescence microscopy. On the first holding, 30 samples (24 adults, 6 crias) were tested, and oocysts were detected in three of the cria samples but in none of the adults. On the second holding, 14 floor faeces samples representing apparently healthy crias and one faeces sample from a cria with diarrhoea were collected. Oocysts were detected in four of the "healthy" faeces samples and the sample of diarrhoeic faeces. All isolates were confirmed as Cryptosporidium parvum using polymerase chain reaction restriction fragment length polymorphism of the cryptosporidium oocyst wall protein (COWP) and ssu rRNA genes. Sequence analysis of a 741bp region of ssu rDNA was carried out on nine of these and revealed high sequence homology with previously reported C. parvum isolates. This investigation highlights the possibility of alpaca crias subclinically shedding oocysts, which has implications for epidemiology and transmission in animals as well as raising zoonotic concerns for human contacts. Gene sequencing of UK isolates from South American camelids is also described for the first time.

Epidemiology data on multiple myeloma (MM) occurrence and outcome is inconsistent whilst a major limitation of randomized controlled trials is selection bias. We present a population-based analysis of patients diagnosed with MM in the South Thames area, which comprises 5.4 million adult inhabitants. A total of 855 cases of MM were ascertained between 1999 and 2000 in a collaborative project involving haematologists and the Thames Cancer Registry. The age-standardized rate was 3.29 per 100 000 and 4.82 cases per 100 000 (World Standard and European Population respectively). The median age was 73 years. The median survival for the whole group was 24 months whist it was 42 and 18 months in those aged less than 65 years and greater than 65 years respectively (P < 0.001). This population study has shown a higher incidence than previously reported in the UK and Europe and provides a benchmark for future studies. If survival is to be improved, future clinical trials and health care planning should consider patients over 65 years of age.

Twenty thousand, eight hundred and twenty-nine babies were screened for neuroblastoma at 6 months of age by measuring homovanillic (HVA) and vanillylmandelic (VMA) acid in urine and rationing these to creatinine. Using a "cut off" of the mean + 3 SD, 10 were found to be positive. Two were found on evaluation to have neuroblastoma and in the remaining 8 the raised levels of HVA and/or VMA returned to normal. Only one of the 8 false positive babies was absolutely normal, most having a chronic disorder or illness. Utilising new centiles which relate HVA and VMA to creatinine, only 3 of the 8 would have remained positive, a false positive rate of 0.01%. The false negative rate would have remained unchanged.

Objective: To determine the feasibility of establishing a system of screening for neuroblastoma., Design: Prospective study of mass screening in four clearly defined geographical areas., Setting: Four health districts of the Northern region of England., Subjects: 20,829 babies aged 6 months, 92% of target population., Interventions: Collection of urine on filter paper for analysis of content of homovanillic and vanillylmandelic acid in relation to urinary creatinine concentrations., Main Outcome Measures: Derivation of reference range. Identification of babies with homovanillic or vanillylmandelic acid > 3 SD above the mean (positive cases). Investigation of positive cases for evidence of neuroblastoma., Results: The upper limit of normal (3 SD above the mean) for vanillylmandelic acid was 15 mumol/mmol creatinine and for homovanillic acid 24 mumol/mmol creatinine. Of the 20,829 babies screened, 2537 (12.2%) required a second sample to be taken because the first sample was inadequate. Of these, 527 (2.5%) provided a liquid urine specimen and 10 (0.04%) had positive results for neuroblastoma. Two of them had neuroblastoma (true positives) and eight did not (false positives). A further three children from the cohort were subsequently found to have neuroblastoma; they had raised homovanillic acid or vanillylmandelic acid values, or both, but screened negative at 6 months., Conclusions: Screening for neuroblastoma is possible in the health care system of the United Kingdom. Evaluation of the efficacy of screening in reducing the mortality from neuroblastoma requires a controlled trial.

A pilot study has been carried out to assess the feasibility of screening for neuroblastoma in 6-month-old infants in the north of England. A total of 20,829 infants were screened. Two true-positive cases were found, along with eight false-positive and three false-negative cases. It was shown that the concentrations of catecholamine metabolites in the urine are dependent on the creatinine content; centiles have been established to allow this relationship to be taken into account. Five of the eight false-positive cases would have been correctly assessed as normal if the new centiles had been used. Preliminary results lend support to the need for a well-designed study of neuroblastoma screening to be carried out, with death from this disease as the only end point.

Our pilot study for neuroblastoma screening started in 1986. The study has progressed through several phases, with use of several analytical methods to a procedure based primarily on the use of automated gas chromatography mass spectrometry. The northern region of England has a relatively static population of approximately 3.5 million, with an annual birth rate of 41,000. The region consists of 16 administrative health districts. In 4 years, we have screened 20,829 infants from four health districts. In this program, we screen all children at 6 months of age. A urine sample is collected on filter paper by a health visitor, either at the time of the infant's routine clinic visit or during the health visitor's follow-up visit at home. In the laboratory, the sample is dried and processed for analysis of homovanillic acid (HVA) and vanillylmandelic acid (VMA), using a benchtop Hewlett Packard gas chromatograph mass spectrometer. The results are related to the creatinine content of the urine. Using cut-off limits of 39 micrograms/mg of creatinine for HVA and 25 micrograms/mg of creatinine for VMA, 2,537 infants (12.2%) required a second paper sample and 527 infants (2.5%) were observed with a liquid urine collection. Of these, the conditions of nine infants with elevated levels of HVA or VMA were investigated clinically for the possible presence of neuroblastoma. Two infants were found to have neuroblastoma; the other seven showed no evidence of tumor. In addition, there were three children who, when screened at 6 months of age, had normal levels of HVA and VMA but in whom neuroblastoma subsequently developed.