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Introduction: Technology has played a key role in enabling public health to respond to the COVID-19 pandemic at a pace and scale never seen before. The Digital Health and Care Innovation Centre (DHI) assisted with development of two new digital services to enable testing and contact tracing at scale using innovative methods.\ud \ud Methods: The DHI employed a design innovation approach by bringing all relevant stakeholders together to co-design new technology services to identify the ‘preferred future’. Workshops were used to identify the preferred solutions. The innovative methods for development of digital health tools included adopting an iterative approach, addressing the situational requirements posed by COVID-19, and democratising technology for purposes of pandemic control.\ud \ud Results: A National Notification Service (NNS) for automation of delivery and feedback (if results messages were viewed) was developed and adopted by five of the 14 health boards in Scotland, processing over 7 million results since inception.\ud \ud The Simple Tracing Tools (STT) is an open-platform web-based app that is designed for data entry by contact tracing teams. STT was adopted by all local health protection teams and informed development of the national case management system.\ud \ud Discussion: The Cynefin framework can be used to understand the design innovation process when facing the challenges of designing digital tools during a pandemic. There are significant opportunities for public health to engage with digital health to transform the pandemic response and derive benefit for tackling future population health challenges.

Introduction and Aims: \ud Reducing the legal drink‐drive limit from 0.08% to 0.05% blood alcohol concentration (BAC) can reduce road traffic accidents and deaths if properly enforced. Reduced limits may be opposed by alcohol retail and manufacturing industries on the basis of commercial impact. Our aim was to qualitatively explore how a reduction in the drink‐drive limit from 0.08% to 0.05% BAC in Scotland, was experienced by bar owners or managers, including any resultant changes in customer drinking or business practice. This is the first study of this type.\ud \ud Design and Methods: \ud Semi‐structured interviews were conducted with 16 owners and managers of on‐trade premises in Scotland in 2018, approximately three years after the drink‐drive limit was reduced. Data were analysed using thematic analysis.\ud \ud Results: \ud Most participants reported no long‐term financial impact on their business, but a few, mainly from rural areas, reported some reduction in alcohol sales. Observed drinking changes included fewer people drinking after work or leaving premises earlier on weekdays. Adaptations to businesses included improving the range of no/low‐alcohol drinks and food offered. Changes such as these were seen as key to minimising economic impact.\ud \ud Discussion and Conclusions: \ud Opposition to legislative measures that impact on commercial interests is often strong and receives significant public attention. This study found that Scottish businesses that adapted to the drink‐drive limit change reported little long‐term economic impact. These findings are of international relevance as potential BAC limit reductions in several other jurisdictions remain the subject of debate, including regarding the impact on business.

BackgroundPeople affected by homelessness, imprisonment, substance use, sex work or severe mental illness experience substantial excess ill health and premature death. Though these experiences often co-occur, health outcomes associated with their overlap have not previously been reviewed. We synthesised existing evidence on mortality, morbidity, self-rated health and quality of life among people affected by more than one of these experiences.MethodsIn this systematic review and meta-analysis, we searched Medline, Embase, and PsycINFO for peer-reviewed English-language observational studies from high-income countries published between 1 January 1998 and 11 June 2018. Two authors undertook independent screening, with risk of bias assessed using a modified Newcastle-Ottawa Scale. Findings were summarised by narrative synthesis and random-effect meta-analysis.ResultsFrom 15 976 citations, 2517 studies underwent full-text screening, and 444 were included. The most common exposure combinations were imprisonment/substance use (31% of data points) and severe mental illness/substance use (27%); only 1% reported outcomes associated with more than two exposures. Infections were the most common outcomes studied, with blood-borne viruses accounting for 31% of all data points. Multiple exposures were associated with poorer outcomes in 80% of data points included (sign test for effect direction, pConclusionPeople affected by multiple exclusionary processes experience profound health inequalities, though there are important gaps in the research landscape. Addressing the health needs of these populations is likely to require co-ordinated action across multiple sectors, such as healthcare, criminal justice, drug treatment, housing and social security.PROSPERO registration numberCRD42018097189.

We report two cases of respiratory toxigenic Corynebacterium diphtheriae infection in fully vaccinated UK born adults following travel to Tunisia in October 2019. Both patients were successfully treated with antibiotics and neither received diphtheria antitoxin. Contact tracing was performed following a risk assessment but no additional cases were identified. This report highlights the importance of maintaining a high index of suspicion for re-emerging infections in patients with a history of travel to high-risk areas outside Europe.

Background People with a history of homelessness, imprisonment, substance use, sex work, or serious mental illness experience much higher rates of ill-health and premature death than the general population. There is substantial overlap in these experiences in the population, and they may interact in important ways to influence health. However, the health outcomes associated with these experiences in combination have not previously been reviewed. We therefore aimed to synthesise existing evidence on all-cause mortality; cause-specific mortality; morbidity from conditions appearing in ICD-10; self-rated health; and quality of life among people with lifetime exposure to more than one of the following: homelessness; imprisonment; substance use; sex work; or serious mental illness. Methods We searched Medline, Embase, and Psycinfo using search terms for the above exposures and outcomes, in consultation with a medical librarian. Eligible studies comprised peer-reviewed English-language articles from high-income countries published since 1998 reporting at least one relevant outcome for people with lifetime exposure to two or more exposures of interest, in comparison to people with one or no exposures. Screening was undertaken independently by two authors using Covidence, with risk of bias assessed using a modified Newcastle-Ottawa Scale. Findings were summarised using a pre-specified narrative synthesis plan. The protocol was registered with PROSPERO (CRD42018097189). Results Searches retrieved 15,948 unique citations. After full text screening of 1,583 studies, initial results from 293 studies for which data extraction has been completed are presented here. Of these, 73% were cross-sectional studies. The most common exposure combinations were imprisonment & substance use (33%) and serious mental illness & substance use (26%); only 11 data points (1%) reported outcomes associated with >2 exposures. Infectious diseases were by far the most common outcomes studied (44%): blood-borne viruses alone accounted for 33% of all data points. The next most common outcomes were external causes, injury, and poisoning (16%) and mental disorders (14%): together with infections, these categories accounted for 73% of all data points. Conclusion Existing research on the health of people experiencing multiple forms of social exclusion is dominated by cross-sectional studies examining a relatively limited set of exposures and outcomes. The lack of data on more than two exposures in combination; self-rated health or quality of life; or non-communicable diseases (e.g. cardiovascular disease and cancer) suggests that research to date may not reflect the true burden of ill-health in these populations. Limitations include restriction to peer-reviewed studies and risk of publication bias.

In vitro methods were used to assess the full potential for decomposition (measured as biogas formation) from pit latrine samples taken from the top layer of 15 Tanzanian latrines. We found considerable variability in the decomposition rate and extent. This was compared with decomposition in the same latrines, measured by comparing top layer composition with fresh stools and deeper (older) layers, to assess whether this potential was realised in situ. Results showed a close match between the extent of organic material breakdown in situ and in vitro, indicating that anaerobic digestion is the dominant pathway in latrines. The average potential decrease in chemical oxygen demand (COD) (determined as methane production in vitro within 60 days) and actual measured decrease in situ are 68.9% ± 11.3 and 69.7% ± 19.4, respectively. However in the in vitro tests, where samples were diluted in water, full decomposition was achieved in 2 months, whereas in situ it can take years; this suggests that water addition may offer a simple route to improving latrine performance. The results also allowed us to estimate, for the first time to our knowledge using experimental data, the contribution that latrines make to greenhouse gas emissions globally. This amounts to ∼2% of annual US emissions.

BackgroundRecent regulatory changes in the system by which premises are licensed to sell alcohol, have given health representatives a formal role in the process in England and Scotland. The degree to which local public health teams engage with this process varies by locality in both nations, which have different licensing regimes. This study aims to critically assess the impact on alcohol-related harms - and mechanisms - of public health stakeholders’ engagement in alcohol premises licensing from 2012 to 2018, comparing local areas with differing types and intensities of engagement, and examining practice in Scotland and England.MethodsThe study will recruit 20 local authority areas where public health stakeholders have actively engaged with the alcohol premises licensing system (the ‘intervention’) and match them to a group of 20 lower activity areas using genetic matching. Four work packages are included: (1) Structured interviews and documentary analysis will examine the type and level of intervention activity from 2012 to 2018, creating a novel composite measure of the intensity of such activity and will assess the local licensing system and potential confounding activities over the same period. In-depth interviews with public health, licensing, police and others will explore perceived mechanisms of change, acceptability, and impact. (2) Using longitudinal growth models and time series analyses, the study will evaluate the impact of high and low levels of activity on alcohol-related harms using routine data from baseline 2009 to 2018. (3) Intervention costs, estimated National Health Service cost savings and health gains will be evaluated using the Sheffield Alcohol Policy Model to estimate impact on alcohol consumption and health inequalities. (4) The study will engage public health teams to create a new theory of change for public health involvement in the licensing process using our data. We will share findings with local, national and international stakeholders.DiscussionThis interdisciplinary study examines, for the first time, whether and how public health stakeholders’ involvement in alcohol licensing impacts on alcohol harms. Using mixed methods and drawing on complex systems thinking, it will make an important contribution to an expanding literature evaluating interventions not suited to traditional epidemiological research.

BACKGROUND: Contraception provides significant benefits for women's and children's health, yet an estimated 225 million women had an unmet need for modern contraceptive methods in 2014. Interventions delivered by mobile phone have been demonstrated to be effective in other health areas, but their effects on use of contraception have not been established. OBJECTIVES: To assess the effects of mobile phone‐based interventions for improving contraception use. SEARCH METHODS: We searched for randomised controlled trials (RCTs) of client‐provider interventions delivered by mobile phone to improve contraception use compared with standard care or another intervention. We searched the electronic databases Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Global Health, PsycINFO, POPLINE, Africa‐Wide Information and Latin American Caribbean Health Sciences Literature (LILACS) from January 1993 to October 2014, as well as clinical trials registries, online mHealth resources and abstracts from key conferences. SELECTION CRITERIA: Randomised controlled trials of mobile phone‐based interventions to improve any form of contraception use amongst users or potential users of contraception. Outcome measures included uptake of contraception, measures of adherence, pregnancy and abortion. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts of studies retrieved using the search strategy and extracted data from the included studies. We calculated the Mantel‐Haenszel risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes, together with 95% confidence intervals (CIs). Differences in interventions and outcome measures did not permit us to undertake meta‐analysis. MAIN RESULTS: Five RCTs met our inclusion criteria. Three trials aimed to improve adherence to a specific method of contraception amongst existing or new contraception users by comparing automated text message interventions versus standard care. Two trials aimed to improve both uptake and adherence, not limited to one method, in both users and non‐users of contraception. No trials were at low risk of bias in all areas assessed. One trial in the USA reported improved self reported oral contraceptive (OC) continuation at six months from an intervention comprising a range of uni‐directional and interactive text messages (RR 1.19, 95% CI 1.05 to 1.35). One trial in Cambodia reported increased self reported use of effective contraception at four months post abortion from an intervention comprising automated interactive voice messages and phone counsellor support (RR 1.39, 95% CI 1.17 to 1.66). One feasibility trial in the USA reported a lower mean number of days between scheduled and completed attendance for the first but not subsequent Depo‐Provera appointments using clinic records from an intervention comprising reminders and healthy self management text messages (mean difference (MD) ‐8.60 days, 95% CI ‐16.74 to ‐0.46). Simple text message OC reminders had no effect on missed pills as assessed by electronic medication monitoring in a small trial in the USA (MD 0.5 missed pills, 95% CI ‐1.08 to 2.08). No effect on self reported contraception use was noted amongst isotretinoin users from an intervention that provided health information via two uni‐directional text messages and mail (RR 1.26, 95% CI 0.84 to 1.89). One trial assessed potential adverse effects of the intervention and reported no evidence of road traffic accidents or domestic abuse. AUTHORS' CONCLUSIONS: Our review provides limited evidence that interventions delivered by mobile phone can improve contraception use. Whilst evidence suggests that a series of interactive voice messages and counsellor support can improve post‐abortion contraception, and that a mixture of uni‐directional and interactive daily educational text messages can improve OC adherence, the cost‐effectiveness and long‐term effects of these interventions remain unknown. Further high‐quality trials are required to robustly establish the effects of interventions delivered by mobile phone to improve contraception use.

Background. Epstein-Barr Virus (EBV) is involved in a wide range of malignancies, particularly in immunocompromised subjects. In Africa, EBV primary infection occurs during early childhood, but little is known about the EBV load in Human Immunodeficiency Virus type 1 (HIV-1)-infected children. Methods. Blood samples from 213 HIV-1-infected children, 140 of whom were receiving antiretroviral therapy (ART), were collected at the Nsambya Hospital in Kampala, Uganda, and obtained for dried blood spot analysis. Nucleic acids were extracted and analyzed for quantification of EBV types 1 and 2; 16S ribosomal DNA (rDNA), a marker of microbial translocation; and HIV-1 RNA. Results. Ninety-two of 140 children (66%) receiving ART and 57 of 73 ART-naive children (78%) had detectable EBV DNA levels. Coinfection with both EBV types was less frequent in ART-treated children than in ART-naive children (odds ratio, 0.54 [95% confidence interval {CI},.30-.98]; P = .042). Mean EBV DNA levels (+/- standard deviation) were lower in the former (3.99 +/- 0.59 vs 4.22 +/- 0.54 log(10) copies/mL; P = .006) and tended to be inversely associated with ART duration. EBV DNA levels were higher in children with an HIV-1 RNA load of > 3 log(10) copies/mL of blood (regression coefficient, 0.32 [95% CI,.05-. 59]; P = .020) and correlated with circulating 16S rDNA levels (r(s) = 0.25 [95% CI,.02-.46]; P = .031). Conclusions. These findings suggest that ART, by limiting HIV-1 replication, microbial translocation, and related immune activation, prevents superinfection with both EBV types and keeps EBV viremia down, thus potentially reducing the risk of EBV-associated lymphomas.

OBJECTIVES: Increasingly, English local authorities have encouraged the implementation of an intervention called 'Reducing the Strength' (RtS) whereby off-licences voluntarily stop selling inexpensive 'super-strength' (≥6.5% alcohol by volume (ABV)) beers and ciders. We conceptualised RtS as an event within a complex system in order to identify pathways by which the intervention may lead to intended and unintended consequences. DESIGN: A qualitative study including a focus group and semistructured interviews. SETTING: An inner-London local authority characterised by a high degree of residential mobility, high levels of social inequality and a large homeless population. Intervention piloted in three areas known for street drinking with a high alcohol outlet density. PARTICIPANTS: Alcohol service professionals, homeless hostel employees, street-based services managers and hostel dwelling homeless alcohol consumers (n=30). RESULTS: Participants describe a range of potential substitution behaviours to circumvent alcohol availability restrictions including consuming different drinks, finding alternative shops, using drugs or committing crimes to purchase more expensive drinks. Service providers suggested the intervention delivered in this local authority missed opportunities to encourage engagement between the council, alcohol services, homeless hostels and off-licence stores. Some participants believed small-scale interventions such as RtS may facilitate new forms of engagement between public and private sector interests and contribute to long-term cultural changes around drinking, although they may also entrench the view that 'problem drinking' only occurs in certain population groups. CONCLUSIONS: RtS may have limited individual-level health impacts if the target populations remain willing and able to consume alternative means of intoxication as a substitute for super-strength products. However, RtS may also lead to wider system changes not directly related to the consumption of super-strengths and their assumed harms.

Background Strategies to reduce alcohol-related health and social harms may include restrictions on alcohol availability. ‘Reducing the Strength’ (RtS) is a local-level intervention whereby off-licence stores voluntarily stop selling inexpensive ‘super-strength’ (≥6.5% alcohol by volume) beers and ciders. The intervention aims to reduce alcohol consumption, crime and disorder, notably amongst homeless and street drinkers. As part of a broader evaluation, we explored the mechanisms by which RtS may affect these populations in one urban English local authority. Methods We conducted one large focus group with alcohol treatment professionals (N = 11) and semi-structured interviews with professionals working in homeless hostels (N = 6), alcohol services (N = 2) and street outreach teams (N = 2). Service providers were recruited following introductions from a local authority hostel commissioning manager and a public health strategist. After undertaking interviews with hostel staff, interviews were conducted with residents (N = 9) at two hostels. Data were analysed thematically utilising NVivo 10 for data management. Results Professionals and drinkers generally concurred that street drinkers and homeless drinkers were distinct, but intersecting subgroups and many, but not all, consume super-strength products. Some questioned whether availability could be substantially reduced by a voluntary scheme in a small, densely-populated area. Many highlighted the often reciprocal relationships between drinkers and shopkeepers, which may impact shops’ willingness to comply with the initiative. In the intervention area there was some evidence that super-strength drinkers might consume less alcohol by using their limited income to purchase (still available) weaker beer. However, other drinkers talked about finding shops that still sold the product within or, given the small scale of the intervention, outside the intervention area. They also described increasing begging, switching to drinks with even higher alcohol contents or using illegal substances. Many professionals and drinkers participants argued street drinking was already being tackled directly through enforcement-related initiatives. The majority of professionals believed that intervention effectiveness depends on clear linkages to services that address the complex underlying reasons for excessive alcohol consumption. Conclusion This study underscores the challenges faced when intervening in a complex social system. The feasibility of local initiatives to reduce alcohol-related harms is affected by the ability to identify the target population and the products they consume, intervention scale, compliance and linking of services. There may also be unintended, and potentially harmful, responses to the removal of specific products amongst a target population characterised by multiple risk behaviours.

BackgroundDiffering approaches to menstrual hygiene management (MHM) have been associated with a wide range of health and psycho-social outcomes in lower income settings. This paper systematically collates, summarizes and critically appraises the available evidence.MethodsFollowing the PRISMA guidelines a structured search strategy was used to identify articles investigating the effects of MHM on health and psycho-social outcomes. The search was conducted in May 2012 and had no date limit. Data was extracted and quality of methodology was independently assessed by two researchers. Where no measure of effect was provided, but sufficient data were available to calculate one, this was undertaken. Meta-analysis was conducted where sufficient data were available.Results14 articles were identified which looked at health outcomes, primarily reproductive tract infections (RTI). 11 articles were identified investigating associations between MHM, social restrictions and school attendance. MHM was found to be associated with RTI in 7 papers. Methodologies however varied greatly and overall quality was low. Meta-analysis of a subset of studies found no association between confirmed bacterial vaginosis and MHM (OR: 1.07, 95% CI: 0.52-2.24). No other substantial associations with health outcomes were found. Although there was good evidence that educational interventions can improve MHM practices and reduce social restrictions there was no quantitative evidence that improvements in management methods reduce school absenteeism.ConclusionThe management of menstruation presents significant challenges for women in lower income settings; the effect of poor MHM however remains unclear. It is plausible that MHM can affect the reproductive tract but the specific infections, the strength of effect, and the route of transmission, remain unclear. There is a gap in the evidence for high quality randomised intervention studies which combine hardware and software interventions, in particular for better understanding the nuanced effect improving MHM may have on girls' attendance at school.