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Background: The impact of neuraminidase inhibitor (NAI) treatment on clinical outcomes of public health importance during the 2009-2010 pandemic has not been firmly established.Methods: We conducted a systematic review and meta-analysis, searching 11 databases (2009 through April 2012) for relevant studies. We used standard methods conforming to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using random effects models.Results: Regarding mortality we observed a nonsignificant reduction associated with NAI treatment (at any time) versus none (OR, 0.72 [95% CI, .51-1.01]). However we observed significant reductions for early treatment (≤48 hours after symptom onset) versus late (OR, 0.38 [95% CI, .27-.53]) and for early treatment versus none (OR, 0.35 [95% CI, .18-.71]). NAI treatment (at any time) versus none was associated with an elevated risk of severe outcome (OR, 1.76 [95% CI, 1.22-2.54]), but early versus late treatment reduced the likelihood (OR, 0.41 [95% CI, .30-.56]).Conclusions: During the 2009-2010 influenza A(H1N1) pandemic, early initiation of NAI treatment reduced the likelihood of severe outcomes compared with late or no treatment.Prospero Registration: CRD42011001273. [ABSTRACT FROM AUTHOR]

Background: Although generally mild, the 2009-2010 influenza A/H1N1 pandemic caused two major surges in hospital admissions in the UK. The characteristics of patients admitted during successive waves are described.Methods: Data were systematically obtained on 1520 patients admitted to 75 UK hospitals between May 2009 and January 2010. Multivariable analyses identified factors predictive of severe outcome.Results: Patients aged 5-54 years were over-represented compared with winter seasonal admissions for acute respiratory infection, as were non-white ethnic groups (first wave only). In the second wave patients were less likely to be school age than in the first wave, but their condition was more likely to be severe on presentation to hospital and they were more likely to have delayed admission. Overall, 45% had comorbid conditions, 16.5% required high dependency (level 2) or critical (level 3) care and 5.3% died. As in 1918-1919, the likelihood of severe outcome by age followed a W-shaped distribution. Pre-admission antiviral drug use decreased from 13.3% to 10% between the first and second waves (p=0.048), while antibiotic prescribing increased from 13.6% to 21.6% (p<0.001). Independent predictors of severe outcome were age 55-64 years, chronic lung disease (non-asthma, non-chronic obstructive pulmonary disease), neurological disease, recorded obesity, delayed admission (≥5 days after illness onset), pneumonia, C-reactive protein ≥100 mg/litre, and the need for supplemental oxygen or intravenous fluid replacement on admission.Conclusions: There were demographic, ethnic and clinical differences between patients admitted with pandemic H1N1 infection and those hospitalised during seasonal influenza activity. Despite national policies favouring use of antiviral drugs, few patients received these before admission and many were given antibiotics. [ABSTRACT FROM AUTHOR]

Background: Improving caregivers' recognition of childhood malaria and pneumonia is crucial to early treatment and improving outcomes. The objective of this study was to assess the accuracy and reliability of caregivers' recognition of malaria and pneumonia (lay diagnosis) as compared to the revised IMCI guidelines., Methods: A cross-sectional study design was used to recruit 903 children aged 2-59 months who were assessed for malaria and pneumonia by health workers at five primary healthcare centres in Benin City, Nigeria. Accuracy of lay diagnosis as compared to the revised IMCI guidelines was assessed using sensitivity, specificity, positive and negative predictive values and area under the receiver operating characteristic curve (AUROC) values., Results: The accuracy of caregivers' ability to recognise malaria (AUROC: 0.60; 95% CI: 0.57-0.64) and pneumonia (AUROC: 0.54; 95% CI: 0.50-0.58) was, respectively, moderate and poor as compared to the IMCI guidelines. Caregivers were better able to identify children without than those with malaria and pneumonia. Agreement between caregivers and the IMCI guidelines for malaria and pneumonia diagnosis was poor (k = 0.14, 95% CI: 0.09-0.19; P = 0.0001)., Conclusion: Caregivers' ability to recognise these childhood diseases as compared to the IMCI guidelines was poor overall, which was partly due to the approach used to ascertain lay diagnosis., (© The Author(s) 2020. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: The effectiveness of inactivated influenza vaccine in people with autoimmune rheumatic disease (AIRDs) is not known. We investigated whether the influenza vaccine is effective in preventing respiratory morbidity, mortality and all-cause mortality in AIRD patients., Methods: Adults with AIRDs treated with DMARDs prior to 1 September of each year between 2006 and 2009, and 2010 and 2015 were identified from the Clinical Practice Research Datalink. Exposure and outcome data were extracted. Data from multiple seasons were pooled. Propensity score (PS) for vaccination was calculated. Cox-proportional hazard ratios (HRs) and 95% CIs were calculated, and were (i) adjusted, (ii) matched for PS for vaccination., Results: Data for 30 788 AIRD patients (65.7% female, 75.5% with RA, 61.1% prescribed MTX) contributing 125 034 influenza cycles were included. Vaccination reduced risk of influenza-like illness [adjusted HR (aHR) 0.70], hospitalization for pneumonia (aHR 0.61) and chronic obstructive pulmonary disease exacerbations (aHR 0.67), and death due to pneumonia (aHR 0.56) on PS-adjusted analysis in the influenza active periods (IAPs). The associations were of similar magnitude and remained statistically significant on PS-matched analysis except for protection from influenza-like illness, which became non-significant. Sub-analysis restricted to pre-IAP, IAP and post-IAP did not yield evidence of residual confounding on influenza-like illness and death due to pneumonia. Vaccination reduced risk of all-cause mortality, although IAP-restricted analysis demonstrated residual confounding for this outcome., Conclusion: Influenza vaccine associates with reduced risk of respiratory morbidity and mortality in people with AIRDs. These findings call for active promotion of seasonal influenza vaccination in immunosuppressed people with AIRDs by healthcare professionals., (© The Author(s) 2020. Published by Oxford University Press on behalf of the British Society for Rheumatology.)

Background: Lay diagnosis is a widely used diagnostic approach for home management of common illnesses in Nigeria. This study aimed to explore the perspectives of caregivers and healthcare professionals on lay diagnosis of childhood malaria and pneumonia. Aligned to this, the study sought to explore the feasibility of training caregivers in the Integrated Management of Childhood Illness (IMCI) guidelines for improved recognition and treatment of these diseases., Methods: A qualitative study using individual face-to-face semi-structured interviews was conducted in Benin City, Nigeria. Participants included 13 caregivers with children under 5 years and 17 healthcare professionals (HPs). An inductive approach to thematic analysis was used to generate themes and analyses., Results: Caregivers relied on lay diagnosis but recognised its limitations. The perceived severity of malaria and pneumonia significantly influenced caregivers' preference for reliance on lay diagnosis practices, health-seeking behaviour and willingness to undertake training in IMCI guidelines for home management of diseases. Safety and potential unintended misuse of medications were recognised by caregivers and HPs as the main challenges., Conclusions: The high level of acceptance among caregivers to receive IMCI training could help improve effective management of childhood malaria and pneumonia at the community level through early recognition and prompt treatment., (© The Author(s) 2020. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The effect of neuraminidase inhibitor (NAI) treatment on length of stay (LoS) in patients hospitalized with influenza is unclear., Methods: We conducted a one-stage individual participant data (IPD) meta-analysis exploring the association between NAI treatment and LoS in patients hospitalized with 2009 influenza A(H1N1) virus (A[H1N1]pdm09) infection. Using mixed-effects negative binomial regression and adjusting for the propensity to receive NAI, antibiotic, and corticosteroid treatment, we calculated incidence rate ratios (IRRs) and 95% confidence intervals (CIs). Patients with a LoS of <1 day and those who died while hospitalized were excluded., Results: We analyzed data on 18 309 patients from 70 clinical centers. After adjustment, NAI treatment initiated at hospitalization was associated with a 19% reduction in the LoS among patients with clinically suspected or laboratory-confirmed influenza A(H1N1)pdm09 infection (IRR, 0.81; 95% CI, .78-.85), compared with later or no initiation of NAI treatment. Similar statistically significant associations were seen in all clinical subgroups. NAI treatment (at any time), compared with no NAI treatment, and NAI treatment initiated <2 days after symptom onset, compared with later or no initiation of NAI treatment, showed mixed patterns of association with the LoS., Conclusions: When patients hospitalized with influenza are treated with NAIs, treatment initiated on admission, regardless of time since symptom onset, is associated with a reduced LoS, compared with later or no initiation of treatment., (© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: Quality improvement (QI) is a priority for general practice, and GPs are expected to participate in and provide evidence of QI activity. There is growing interest in harnessing the potential of electronic health records (EHR) to improve patient care by supporting practices to find cases that could benefit from a medicines review., Aim: To develop scalable and reproducible prescribing safety reports using patient-level EHR data., Design and Setting: UK general practices that contribute de-identified patient data to the Clinical Practice Research Datalink (CPRD)., Method: A scoping phase used stakeholder consultations to identify primary care QI needs and potential indicators. QI reports containing real data were sent to 12 pilot practices that used Vision GP software and had expressed interest. The scale-up phase involved automating production and distribution of reports to all contributing practices that used both Vision and EMIS software systems. Benchmarking reports with patient-level case review lists for two prescribing safety indicators were sent to 457 practices in December 2017 following the initial scale-up (Figure 2)., Results: Two indicators were selected from the Royal College of General Practitioners Patient Safety Toolkit following stakeholder consultations for the pilot phase involving 12 GP practices. Pilot phase interviews showed that reports were used to review individual patient care, implement wider QI actions in the practice, and for appraisal and revalidation., Conclusion: Electronic health record data can be used to provide standardised, reproducible reports that can be delivered at scale with minimal resource requirements. These can be used in a national QI initiative that impacts directly on patient care., (© British Journal of General Practice 2019.)

ObjectivesTo examine the association between inactivated influenza vaccine (IIV) administration and primary care consultation for joint pain, rheumatoid arthritis (RA) flare, corticosteroid prescription, vasculitis and unexplained fever in people with autoimmune rheumatic diseases (AIRDs)., Methods: We undertook within-person comparisons using self-controlled case-series methodology. AIRD cases who received the IIV and had an outcome of interest in the same influenza cycle were ascertained in Clinical Practice Research Datalink. The influenza cycle was partitioned into exposure periods (1-14 days prevaccination and 0-14, 15-30, 31-60 and 61-90 days postvaccination), with the remaining time-period classified as non-exposed. Incidence rate ratios (IRR) and 95% CI for different outcomes were calculated., Results: Data for 14 928 AIRD cases (69% women, 80% with RA) were included. There was no evidence for association between vaccination and primary care consultation for RA flare, corticosteroid prescription, fever or vasculitis. On the contrary, vaccination associated with reduced primary care consultation for joint pain in the subsequent 90 days (IRR 0.91 (95% CI 0.87 to 0.94))., Conclusion: This study found no evidence for a significant association between vaccination and primary care consultation for most surrogates of increased disease activity or vaccine adverse-effects in people with AIRDs. It adds to the accumulating evidence to support influenza vaccination in AIRDs., Competing Interests: Competing interests: CDM is funded by the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care West Midlands, the NIHR School for Primary Care Research and an NIHR Research Professorship in General Practice (NIHR-RP-2014-04-026). JSN-V-T acknowledges funding from the NIHR Biomedical Research Centre (acute respiratory infections), MD and AA acknowledge funding from the NIHR Biomedical Research Centre (musculoskeletal theme) Nottingham. Potential conflicts of interest: JSN-V-T is currently on secondment to the Department of Health and Social Care, England (DHSC). The views expressed in this paper are those of the authors and do not necessarily represent those of the National Health Service, NIHR or DHSC. All other authors have declared no conflicts of interest., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Background: Recent data suggest that beta blockers are associated with increased perioperative risk in hypertensive patients. We investigated whether beta blockers were associated with an increased risk in elderly patients with raised preoperative arterial blood pressure., Methods: We conducted a propensity-score-matched cohort study of primary care data from the UK Clinical Practice Research Datalink (2004-13), including 84 633 patients aged 65 yr or over. Conditional logistic regression models, including factors that were significantly associated with the outcome, were constructed for 30-day mortality after elective noncardiac surgery. The effects of beta blockers (primary outcome), renin-angiotensin system (RAS) inhibitors, calcium-channel blockers, thiazides, loop diuretics, and statins were investigated at systolic and diastolic arterial pressure thresholds., Results: Beta blockers were associated with increased odds of postoperative 30-day mortality in patients with systolic hypertension (defined as systolic BP >140 mm Hg; adjusted odds ratio [aOR]: 1.92; 95% confidence interval [CI]: 1.05-3.51). After excluding patients for whom prior data suggest benefit from perioperative beta blockade (patients with prior myocardial infarction or heart failure), rather than adjusting for them, the point estimate shifted slightly (aOR: 2.06; 95% CI: 1.09-3.89). Compared with no use, statins (aOR: 0.35; 95% CI: 0.17-0.75) and thiazides (aOR: 0.28; 95% CI: 0.10-0.78) were associated with lower mortality in patients with systolic hypertension., Conclusions: These data suggest that the safety of perioperative beta blockers may be influenced by preoperative blood pressure thresholds. A randomised controlled trial of beta-blocker withdrawal, in select populations, is required to identify a causal relationship., (Copyright © 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background: Many countries have acquired antiviral stockpiles for pandemic influenza mitigation and a significant part of the stockpile may be focussed towards community-based treatment., Methods: We developed a spreadsheet-based, decision tree model to assess outcomes averted and cost-effectiveness of antiviral treatment for outpatient use from the perspective of the healthcare payer in the UK. We defined five pandemic scenarios-one based on the 2009 A(H1N1) pandemic and four hypothetical scenarios varying in measures of transmissibility and severity., Results: Community-based antiviral treatment was estimated to avert 14-23% of hospitalizations in an overall population of 62.28 million. Higher proportions of averted outcomes were seen in patients with high-risk conditions, when compared to non-high-risk patients. We found that antiviral treatment was cost-saving across pandemic scenarios for high-risk population groups, and cost-saving for the overall population in higher severity influenza pandemics. Antiviral effectiveness had the greatest influence on both the number of hospitalizations averted and on cost-effectiveness., Conclusions: This analysis shows that across pandemic scenarios, antiviral treatment can be cost-saving for population groups at high risk of influenza-related complications., (Published by Oxford University Press on behalf of Faculty of Public Health [2018]. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

The co-existence of different types of medical systems (medical pluralism) is a typical feature of India's healthcare system. For conditions such as influenza-like illness (ILI), where non-specific disease signs/symptoms exist, clinical reasoning in the context of medical pluralism becomes crucial. Recognising this need, we undertook a qualitative study, which explored factors underpinning clinical decisions on diagnosis and management of ILI. The study involved semi-structured interviews including clinical vignettes with 20 healthcare practitioners (working within allopathy, homeopathy and Ayurveda) working in the private healthcare sector in Solapur city, India. An inquiry was conducted into criteria influencing the diagnosis, treatment, referral to specialist care and role of treatment guidelines for ILI. Thematic analysis was used to identify aspects relating to ILI diagnosis, treatment and referral. The diagnosis of influenza was based largely on clinical symptoms suggestive of influenza in the absence of other diagnoses. Referral for laboratory tests was only initiated if illness did not resolve, generally after 2-3 consultations. Antibiotics were often prescribed for persistent illness, with antivirals rarely considered. Some differences between practitioners from different medical systems were observed in relation to treatment and referral in case of persistent illness. A combination of analytical and intuitive clinical reasoning was used by the participants and clinical decisions were based on both social and clinical factors. Clinical decision-making was rarely a linear process and respondents felt that broad guidelines on influenza that allowed doctors to account for the sociocultural context within which they practised medicine would be helpful.

Objectives: To examine temporal trend in uptake of seasonal influenza vaccine (SIV) in the UK and explore disease and demographic factors associated with vaccination., Methods: From the Clinical Practice Research Datalink, 32 751 people with auto-immune rheumatic diseases prescribed DMARDs between 2006 and 2016 were identified. The proportion vaccinated between 1 September of one year and 31 March of the next year was calculated and stratified by age, other indications for vaccination, auto-immune rheumatic diseases type and number of DMARDs prescribed. Stata and Joinpoint regression programs were used., Results: SIV uptake was high in those aged ⩾65 years (82.3 and 80.7% in 2006-07 and 2015-16, respectively). It was significantly lower in other age groups, but improved over time with 51.9 and 61.9% in the 45-64 year age group, and 32.3 and 50.1% in the <45 year age group being vaccinated in 2006-07 and 2015-16, respectively. While 64.9% of the vaccinations in those ⩾65 years old occurred by 3 November, in time to mount a protective immune response before the influenza activity becomes substantial in the UK, only 38.9% in the 45-64 year and 26.2% in the <45 year age group without any other reason for vaccination received SIV by this date. Women, those with additional indications for vaccination, on multiple DMARDs and with SLE were more likely to be vaccinated., Conclusion: SIV uptake is low in the under 65s, and the majority of them are not vaccinated in time. Additional effort is required to promote timely uptake of SIV in this population.

Background: Evidence on the effectiveness of community-based interventions in improving vaccination uptake in migrant populations is limited. This study aims to evaluate the effectiveness of a community-based intervention to improve access to and uptake of childhood vaccinations among urban slum-dwelling migrant communities in Ludhiana, India., Methods: A mixed-methods evaluation was conducted involving a post-intervention comparison of vaccination uptake in six randomly selected intervention and control slum communities. Multilevel logistic regression to account for clustering of effects was used to investigate the impact of the intervention on vaccination uptake. Thematic analysis was used to analyse qualitative data., Results: Overall, vaccination uptake was significantly higher in the intervention clusters and the likelihood of full immunization by the age of 1 year was more than twice that in the control clusters [OR: 2.27 (95%CI: 1.12-4.60); P = 0.023]. Qualitative findings showed that stakeholders felt ownership of the intervention and that it was effective in increasing accessibility to and uptake of vaccinations. However, they emphasized the importance of continued government support for the intervention., Conclusions: Community-based interventions can significantly increase vaccination coverage in deprived populations with previously low uptake of childhood immunization but such initiatives need to be delivered in partnership with the government., (© The Author 2016. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Objective: The aim of this prospective study was to estimate the prevalence and risk factors for maternal anaemia and low birth weight (LBW) in pregnant women living in Maharashtra state, India., Study Design: This is a prospective study., Methods: Women between 3 and 5 months of pregnancy were recruited from 34 villages based in Maharashtra state. Baseline data collection, anthropometric measurements and blood investigations were performed. Participants were followed-up to record birth weight., Results: In total, 303 women were eligible, and 287 (95%) provided data. 77% were anaemic, defined as haemoglobin less than 11.0 g/dl at the time of recruitment, with a mean corpuscular volume of 80.5 fl/cell (standard deviation: 7.22, range: 53.4-93.8). The increased risk of anaemia was seen in women with consanguineous marriages (odds ratio [OR]: 2.41, 95% confidence interval [CI]: 1.16-5.01, P = 0.01) after adjustment for potential confounding factors. Postdelivery data from full-term singleton live births demonstrated a 7% prevalence of LBW. Consanguineous marriage was a major risk factor for LBW (OR: 4.10, 95% CI: 1.25-13.41, P = 0.02). The presence of maternal anaemia during 3-5 months of pregnancy was associated with lower risk of LBW (unadjusted OR: 0.34, 95% CI: 0.13-0.92, P = 0.03)., Conclusion: About 30% of our study participants were in a consanguineous marriage, which was identified as a potentially avoidable risk factor for both anaemia and LBW., (Copyright © 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Exposure to air pollution produced by cooking is common in developing countries, and represents a potentially avoidable cause of lung disease. Cross-sectional data were collected by the World Health Organization's Study on Global AGEing and Adult Health conducted in India between 2007 and 2010. Exposure to biomass cooking was also associated with a decrease in forced expiratory volume in 1 s (FEV1) (-70 ml, 95%CI -111 to -30) and FEV1/FVC (forced vital capacity) ratio (-0.025, 95%CI -0.035 to -0.015) compared to those who were not exposed. These associations were predominantly observed in males (P < 0.05 for interaction analyses). Intervention studies using non-biomass fuels in India are required to ascertain potential respiratory health benefits.

Background: While evidence exists to support the effectiveness of neuraminidase inhibitors (NAIs) in reducing mortality when given to hospitalized patients with A(H1N1)pdm09 virus infection, the impact of outpatient treatment on hospitalization has not been clearly established. We investigated the impact of outpatient NAI treatment on subsequent hospitalization in patients with A(H1N1)pdm09 virus infection., Methods: We assembled general community and outpatient data from 9 clinical centers in different countries collected between January 2009 and December 2010. We standardized data from each study center to create a pooled dataset and then used mixed-effects logistic regression modeling to determine the effect of NAI treatment on hospitalization. We adjusted for NAI treatment propensity and preadmission antibiotic use, including "study center" as a random intercept to account for differences in baseline hospitalization rate between centers., Results: We included 3376 patients with influenza A(H1N1)pdm09, of whom 3085 (91.4%) had laboratory-confirmed infection. Eight hundred seventy-three patients (25.8%) received outpatient or community-based NAI treatment, 928 of 2395 (38.8%) with available data had dyspnea or respiratory distress, and hospitalizations occurred in 1705 (50.5%). After adjustment for preadmission antibiotics and NAI treatment propensity, preadmission NAI treatment was associated with decreased odds of hospital admission compared to no NAI treatment (adjusted odds ratio, 0.24; 95% confidence interval, 0.20-0.30)., Conclusions: In a population with confirmed or suspected A(H1N1)pdm09 and at high risk of hospitalization, outpatient or community-based NAI treatment significantly reduced the likelihood of requiring hospital admission. These data suggest that community patients with severe influenza should receive NAI treatment., (© The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America.)

Background: Public health faces the paradox of being increasingly emphasized by the key health and social care regulators and stakeholders, while remaining a largely under-represented discipline in the context of medical curricula. Enhancing medical student engagement in public health teaching is one way to address this concern., Methods: We discuss four key solutions to the challenges faced by public health educators in medical schools, and present five case studies which demonstrate innovative approaches to engaging medical students in our discipline., Results: Four different approaches have been piloted by members of the Public Health Educators in Medical Schools (PHEMS) network: (i) ensuring social accountability, (ii) demonstrating clinical relevance, (iii) mapping the core curriculum, and (iv) using technology enhanced learning. Preliminary student feedback suggests that these approaches can be used to position public health as an enabler of modern medical practice, and promote a more holistic understanding of medicine by linking patient-centred care to the population level., Conclusions: The zeitgeist in both academia and the healthcare system supports the teaching of public health within the medical curriculum; there is also consensus at the political and pedagogical level. The challenge of ensuring engagement now needs to be met at the student-teacher interface.

Objective: Iron-deficiency anaemia (IDA) is the most common nutritional disorder observed in adolescent girls in India. Our aim was to investigate the prevalence and risk factors associated with IDA in rural Maharashtra, India, to address current evidence gaps., Study Design: Cross-sectional survey., Methods: The study recruited 13- to 17-year-old adolescent girls living in 34 villages of Osmanabad district. Data were collected on individual health, dietary, sociodemographic factors, and anthropometric measurements were taken. Haemoglobin (Hb) levels were measured using Sahli's haemometer. Logistic and linear regressions were used to identify risk factors associated with IDA and Hb levels, respectively., Results: Among 1010 adolescent girls (response rate 97.5%), the mean Hb was 10.1 g/dl (standard deviation = 1.3), and 87% had anaemia (Hb < 12 g/dl). The prevalence of mild (11.0-11.9 g/dl), moderate (8.0-10.9 g/dl) and severe (Hb ≤ 7.9 g/dl) anaemia was 17%, 65% and 5%, respectively. Anaemia likelihood increased significantly with age (odds ratio (OR): 1.41 per year, 95% confidence interval (CI): 1.17-1.70). Factors associated with decreased anaemia risk were mid-upper arm circumference (MUAC) ≥22 cm (OR: 0.51, 95% CI: 0.31-0.82), ≥3 days/week consumption of fruit (OR: 0.35, 95% CI: 0.23-0.54) or rice (OR: 0.39, 95% CI: 0.17-0.91), and incomplete schooling (OR: 0.47, 95% CI: 0.24-0.91). In the final model lower age, MUAC and fruit consumption were significantly associated with Hb level., Conclusion: Anaemia prevalence was extremely high among adolescent girls in rural areas of Maharashtra. Whilst we identified risk factors that could be used for targeting interventions, there is urgent need of comprehensive preventative interventions for the whole adolescent girl population., (Copyright © 2016 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Background: In India, chronic diseases are the leading cause of death and their prevalence has constantly increased over the last decade., Objective: This study aimed to identify risk factors associated with common chronic diseases among people aged 50 years and over in India., Materials and Methods: Data from Wave 1 of the 2007/2008 Indian Study on Global Ageing and Adult Health (SAGE) was used to investigate the association between lifestyle choices and chronic diseases using logistic regression., Result: The fully adjusted model showed that significant independent risk factors for angina included area of residence, being diagnosed with diabetes, chronic lung disease (CLD) [highest odds ratio (OR) 4.77, 95% confidence interval (CI): 2.95-7.70] and arthritis. For arthritis, risk factors included having underlying diabetes, CLD diagnosis, or angina (highest OR 2.32, 95% CI: 1.63-3.31). Risk factors associated with CLD included arthritis, angina (highest OR 4.76, 95% CI: 2.94-7.72), alcohol use, and tobacco use. Risk factors associated with diabetes included level of education, area of residence, socioeconomic status, angina (highest OR 3.59, 95% CI: 2.44-5.29), CLD, arthritis, stroke, and vegetable consumption. Finally, risk factors associated with stroke included diabetes and angina (highest OR 3.34, 95% CI: 1.72-6.50). The presence of any other comorbidity was significantly associated with all five chronic diseases studied., Conclusion: The results show that within the older population, the contribution of lifestyle risk factors to the common chronic diseases investigated in this study was limited. Our findings showed that the major health issue within the study population was multimorbidity., Competing Interests: There are no conflicts of interest.

Purpose: Bacterial superinfections, including pneumonia, are frequent complications of influenza-like illness (ILI). Clinical and laboratory evidence suggests that benzodiazepines and Z-drugs may influence susceptibility to infections and mortality. We investigated whether benzodiazepines and zopiclone modify the occurrence of ILI-related pneumonia and mortality., Methods: We obtained data on 804 051 ILI patients from a comprehensive primary care database, the Clinical Practice Research Datalink. The follow-up period started from the diagnosis of ILI for 30 days. Pneumonia and deaths occurring within the 30-day follow-up period were considered as potentially 'ILI related'. Exposure to benzodiazepines and zopiclone was determined in the period preceding a diagnosis of ILI with current use defined as a prescription for benzodiazepines in the month prior to ILI diagnosis. Cox regression was used for the analyses. Adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) are presented., Results: Influenza-like illness-related pneumonia and mortality were noted in 1117 and 707 ILI patients, respectively. Current exposure to benzodiazepines was associated with increased occurrence of both ILI-related pneumonia and mortality (ILI-related pneumonia adjusted HR 4.24, 95%CI [2.27, 7.95]; ILI-related mortality adjusted HR 20.69, 95%CI [15.54, 27.54]). A similar increase in ILI-related mortality but not pneumonia was observed with current zopiclone use (ILI-related mortality adjusted HR 10.86, 95%CI [6.93, 17.02]; ILI-related pneumonia adjusted HR 1.97, 95%CI [0.63, 6.12])., Conclusion: Benzodiazepines may increase the likelihood of pneumonia and mortality related to ILI. A cautionary approach to prescribing benzodiazepine is suggested in people known to be at increased risk of pneumonia or mortality. Copyright © 2016 John Wiley & Sons, Ltd., (Copyright © 2016 John Wiley & Sons, Ltd.)

Objectives : The stockpiling of neuraminidase inhibitor (NAI) antivirals as a defence against pandemic influenza is a significant public health policy decision that must be made despite a lack of conclusive evidence from randomised controlled trials regarding the effectiveness of NAIs on important clinical end points such as mortality. The objective of this study was to determine whether NAIs should be stockpiled for treatment of pandemic influenza on the basis of current evidence. Methods : A decision model for stockpiling was designed. Data on previous pandemic influenza epidemiology was combined with data on the effectiveness of NAIs in reducing mortality obtained from a recent individual participant meta-analysis using observational data. Evidence synthesis techniques and a bias modelling method for observational data were used to incorporate the evidence into the model. The stockpiling decision was modelled for adults (≥16 years old) and the United Kingdom was used as an example. The main outcome was the expected net benefits of stockpiling in monetary terms. Health benefits were estimated from deaths averted through stockpiling. Results : After adjusting for biases in the estimated effectiveness of NAIs, the expected net benefit of stockpiling in the baseline analysis was £444 million, assuming a willingness to pay of £20,000/QALY ($31,000/QALY). The decision would therefore be to stockpile NAIs. There was a greater probability that the stockpile would not be utilised than utilised. However, the rare but catastrophic losses from a severe pandemic justified the decision to stockpile. Conclusions : Taking into account the available epidemiological data and evidence of effectiveness of NAIs in reducing mortality, including potential biases, a decision maker should stockpile anti-influenza medication in keeping with the postulated decision rule., Competing Interests: Competing interests: JSN-V-T, PRM, and SV have co-authored the Muthuri et al. (2014) study which was supported by an unrestricted educational grant from F. Hoffman La Roche. PRM and JSN-V-T were MUGAS Review Board members that reviewed the oseltamivir data (both from randomised controlled trials and observational studies including data from the 2009/10 pandemic) and agreed on evidence gaps and a statistical analysis plan that would address these gaps. JSN-V-T is Chair of NERVTAG (New and Emerging Respiratory Virus Threat Advisory Group).

Background: The impact of neuraminidase inhibitors (NAIs) on influenza-related pneumonia (IRP) is not established. Our objective was to investigate the association between NAI treatment and IRP incidence and outcomes in patients hospitalised with A(H1N1)pdm09 virus infection., Methods: A worldwide meta-analysis of individual participant data from 20 634 hospitalised patients with laboratory-confirmed A(H1N1)pdm09 (n = 20 021) or clinically diagnosed (n = 613) 'pandemic influenza'. The primary outcome was radiologically confirmed IRP. Odds ratios (OR) were estimated using generalised linear mixed modelling, adjusting for NAI treatment propensity, antibiotics and corticosteroids., Results: Of 20 634 included participants, 5978 (29·0%) had IRP; conversely, 3349 (16·2%) had confirmed the absence of radiographic pneumonia (the comparator). Early NAI treatment (within 2 days of symptom onset) versus no NAI was not significantly associated with IRP [adj. OR 0·83 (95% CI 0·64-1·06; P = 0·136)]. Among the 5978 patients with IRP, early NAI treatment versus none did not impact on mortality [adj. OR = 0·72 (0·44-1·17; P = 0·180)] or likelihood of requiring ventilatory support [adj. OR = 1·17 (0·71-1·92; P = 0·537)], but early treatment versus later significantly reduced mortality [adj. OR = 0·70 (0·55-0·88; P = 0·003)] and likelihood of requiring ventilatory support [adj. OR = 0·68 (0·54-0·85; P = 0·001)]., Conclusions: Early NAI treatment of patients hospitalised with A(H1N1)pdm09 virus infection versus no treatment did not reduce the likelihood of IRP. However, in patients who developed IRP, early NAI treatment versus later reduced the likelihood of mortality and needing ventilatory support., (© 2015 The Authors. Influenza and Other Respiratory Viruses Published by John Wiley & Sons Ltd.)

Background. Cholesterol lowering drugs HMG-CoA reductase inhibitors (statins) and PPARα activators (fibrates) have been shown to reduce host inflammation via non-disease specific immunomodulatory mechanisms. Recent studies suggest that commonly prescribed drugs in general practice, statins and fibrates, may be beneficial in influenza-like illness related mortality. This retrospective cohort study examines the association between two lipid lowering drugs, statins and fibrates, and all-cause 30-day mortality following a medically attended acute respiratory illness (MAARI). Methods. Primary care patient data were retrospectively extracted from the UK Clinical Practice Research Datalink (CPRD) database. The sample comprised 201,179 adults aged 30 years or older experiencing a MAARI episode. Patient exposure to statins or fibrates was coded as separate dichotomous variables and deemed current if the most recent GP prescription was issued in the 30 days prior to MAARI diagnosis. Multivariable logistic regression and Cox regression were used for analyses. Adjustment was carried out for chronic lung disease, heart failure, metformin and glitazones, comorbidity burden, socio-demographic and lifestyle variables such as smoking status and body mass index (BMI). Statistical interaction tests were carried out to check for effect modification by gender, body mass index, smoking status and comorbidity. Results. A total of 1,096 (5%) patients died within the 30-day follow up period. Of this group, 213 (19.4%) were statin users and 4 (0.4%) were fibrate users. After adjustment, a significant 35% reduction in odds [adj OR; 0.65 (95% CI [0.52-0.80])] and a 33% reduction in the hazard [adj HR: 0.67 (95% CI [0.55-0.83])] of all-cause 30-day mortality following MAARI was observed in statin users. A significant effect modification by comorbidity burden was observed for the association between statin use and MAARI-related mortality. Fibrate use was associated with a non-significant reduction in 30-day MAARI-related mortality. Conclusion. This study suggests that statin use may be associated with a reduction in 30-day mortality following acute respiratory illness that is severe enough to merit medical consultation. Findings from this study support and strengthen similar observational research while providing a strong rationale for a randomised controlled trial investigating the potential role of statins in acute respiratory infections.

Background: During pandemics of novel influenza and outbreaks of emerging infections, surge in health-care demand can exceed capacity to provide normal standards of care. In such exceptional circumstances, triage tools may aid decisions in identifying people who are most likely to benefit from higher levels of care. Rapid research during the early phase of an outbreak should allow refinement and validation of triage tools so that in the event of surge a valid tool is available. The overarching study aim is to conduct a prospective near real-time analysis of structured clinical assessments of influenza-like illness (ILI) using primary care electronic health records (EHRs) during a pandemic. This abstract summarises the preparatory work, infrastructure development, user testing and proof-of-concept study., Objectives: (1) In preparation for conducting rapid research in the early phase of a future outbreak, to develop processes that allow near real-time analysis of general practitioner (GP) assessments of people presenting with ILI, management decisions and patient outcomes. (2) As proof of concept: conduct a pilot study evaluating the performance of the triage tools 'Community Assessment Tools' and 'Pandemic Medical Early Warning Score' to predict hospital admission and death in patients presenting with ILI to GPs during inter-pandemic winter seasons., Design: Prospective near real-time analysis of structured clinical assessments and anonymised linkage to data from EHRs. User experience was evaluated by semistructured interviews with participating GPs., Setting: Thirty GPs in England, Wales and Scotland, participating in the Clinical Practice Research Datalink., Participants: All people presenting with ILI., Interventions: None., Main Outcome Measures: Study outcome is proof of concept through demonstration of data capture and near real-time analysis. Primary patient outcomes were hospital admission within 24 hours and death (all causes) within 30 days of GP assessment. Secondary patient outcomes included GP decision to prescribe antibiotics and/or influenza-specific antiviral drugs and/or refer to hospital - if admitted, the need for higher levels of care and length of hospital stay., Data Sources: Linked anonymised data from a web-based structured clinical assessment and primary care EHRs., Results: In the 24 months to April 2015, data from 704 adult and 159 child consultations by 30 GPs were captured. GPs referred 11 (1.6%) adults and six (3.8%) children to hospital. There were 13 (1.8%) deaths of adults and two (1.3%) of children. There were too few outcome events to draw any conclusions regarding the performance of the triage tools. GP interviews showed that although there were some difficulties with installation, the web-based data collection tool was quick and easy to use. Some GPs felt that a minimal monetary incentive would promote participation., Conclusions: We have developed processes that allow capture and near real-time automated analysis of GP's clinical assessments and management decisions of people presenting with ILI., Future Work: We will develop processes to include other EHR systems, attempt linkage to data on influenza surveillance and maintain processes in readiness for a future outbreak., Study Registration: This study is registered as ISRCTN87130712 and UK Clinical Research Network 12827., Funding: The National Institute for Health Research Health Technology Assessment programme. MGS is supported by the UK NIHR Health Protection Research Unit in Emerging and Zoonotic Infections.

Purpose: To investigate the association between the gamma-aminobutyric acid (GABA)ergic drugs, benzodiazepines or zopiclone and the occurrence of asthma exacerbations and subsequent mortality in a cohort of asthma patients., Methods: The number of patients that were included were 105,747 for those without asthma exacerbation and 25,895 for those with exacerbated asthma. A nested case-control study probed the association between benzodiazepines or zopiclone and occurrence of asthma exacerbation (primary outcome) using conditional logistic regression. Cox regression was used to determine the association between the drugs and all-cause mortality in patients with recorded asthma exacerbation. Adjusted matched odds ratios (adj mOR) and adjusted hazard ratios (adj HR) with 95% confidence intervals (CI) are presented., Results: Current benzodiazepine use was associated with increased occurrence of asthma exacerbation (adj mOR 1.49; 95%CI [1.15, 1.93]; P = 0.001) as was current zopiclone use (adj mOR 1.59; 95%CI [1.37, 1.85]; P < 0.001). In patients with an asthma exacerbation, current benzodiazepine use was associated with increased all-cause mortality during a median follow-up of 2 years (adj HR 2.78; 95%CI [1.26, 6.12]; P = 0.011), and the association between zopiclone use and all-cause mortality showed borderline statistical significance (adj HR 1.58; 95%CI [0.98, 2.54]; P = 0.058)., Conclusion: Benzodiazepines and zopiclone may increase the likelihood of asthma exacerbation, and benzodiazepines may also increase the likelihood of mortality following exacerbation. These data suggest that caution should be exercised when prescribing benzodiazepines to patients with asthma., (Copyright © 2015 John Wiley & Sons, Ltd.)

Background: Reducing healthcare-associated infection (HCAI) is a UK national priority. Multiple national and regional interventions aimed at reduction have been implemented in National Health Service acute hospitals, but assessment of their effectiveness is methodologically challenging., Aim: To assess the effectiveness of national and regional interventions undertaken between 2004 and 2008 on rates of meticillin-resistant Staphylococcus aureus (MRSA) and meticillin-sensitive Staphylococcus aureus (MSSA) bacteraemia within acute hospitals in the East Midlands, using interrupted time-series analysis., Methods: We used segmented regression to compare rates of MRSA and MSSA bacteraemia in the pre-intervention, implementation, and post-intervention phases for combined intervention packages in eight acute hospitals., Findings: Most of the change in MSSA and MRSA rates occurred during the implementation phase. During this phase, there were significant downward trends in MRSA rates for seven of eight acute hospital groups; in four, this was a steeper quarter-on-quarter decline compared with the pre-intervention phase, and, in one, an upward trend in the pre-intervention phase was reversed. Regarding MSSA, there was a significant positive effect in four hospital groups: one upward trend during the pre-intervention phase was reversed, two upward trends plateaued, and in one hospital group an indeterminate trend decreased significantly. However, there were significant increasing trends in quarterly MSSA rates in four hospital groups during the implementation or post-intervention periods., Conclusion: The impact of interventions varied by hospital group but the overall results suggest that national and regional campaigns had a beneficial impact on MRSA and MSSA bacteraemia within the East Midlands., (Crown Copyright © 2015. Published by Elsevier Ltd. All rights reserved.)

Data were extracted from the case records of UK patients admitted with laboratory-confirmed influenza A(H1N1)pdm09. White and non-White patients were characterized by age, sex, socioeconomic status, pandemic wave and indicators of pre-morbid health status. Logistic regression examined differences by ethnicity in patient characteristics, care pathway and clinical outcomes; multivariable models controlled for potential confounders. Whites (n = 630) and non-Whites (n = 510) differed by age, socioeconomic status, pandemic wave of admission, pregnancy, recorded obesity, previous and current smoking, and presence of chronic obstructive pulmonary disease. After adjustment for a priori confounders non-Whites were less likely to have received pre-admission antibiotics [adjusted odds ratio (aOR) 0·43, 95% confidence interval (CI) 0·28-0·68, P < 0·001) but more likely to receive antiviral drugs as in-patients (aOR 1·53, 95% CI 1·08-2·18, P = 0·018). However, there were no significant differences by ethnicity in delayed admission, severity at presentation for admission, or likelihood of severe outcome.

Although the neuraminidase inhibitors (NIs), oseltamivir and zanamivir were first licensed in 1999, their clinical effectiveness is still hotly debated. Two rigorous systematic reviews and meta-analyses of the data from clinical trials conducted in community settings against relatively benign influenza, both suggest that reductions in symptom duration are extremely modest, under one day. Whilst one of these reviews could find no evidence of reductions in complications, the most recent review reported clinically meaningful and statistically significant reductions in the likelihood of requiring antibiotics (44%) and hospitalizations (63%) in adult patients with confirmed influenza, treated with oseltamivir. A further meta-analysis of observational data from the 2009 influenza A(H1N1) pandemic suggested that, in hospitalised patients, NIs significantly reduced mortality in adults by 25% overall, and by 62% if started within 48 hours of symptom onset, compared with no treatment. But, the effectiveness of NIs in children is far less clear. Taken together, these data suggest that NIs should be reserved for patients with influenza who are at high-risk of complications, or when clinically assessed found to be markedly unwell, or rapidly deteriorating. In such patients, treatment should be initiated empirically, as soon as possible, preferably with follow-on virological confirmation., (Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Neuraminidase inhibitors were widely used during the 2009-10 influenza A H1N1 pandemic, but evidence for their effectiveness in reducing mortality is uncertain. We did a meta-analysis of individual participant data to investigate the association between use of neuraminidase inhibitors and mortality in patients admitted to hospital with pandemic influenza A H1N1pdm09 virus infection., Methods: We assembled data for patients (all ages) admitted to hospital worldwide with laboratory confirmed or clinically diagnosed pandemic influenza A H1N1pdm09 virus infection. We identified potential data contributors from an earlier systematic review of reported studies addressing the same research question. In our systematic review, eligible studies were done between March 1, 2009 (Mexico), or April 1, 2009 (rest of the world), until the WHO declaration of the end of the pandemic (Aug 10, 2010); however, we continued to receive data up to March 14, 2011, from ongoing studies. We did a meta-analysis of individual participant data to assess the association between neuraminidase inhibitor treatment and mortality (primary outcome), adjusting for both treatment propensity and potential confounders, using generalised linear mixed modelling. We assessed the association with time to treatment using time-dependent Cox regression shared frailty modelling., Findings: We included data for 29,234 patients from 78 studies of patients admitted to hospital between Jan 2, 2009, and March 14, 2011. Compared with no treatment, neuraminidase inhibitor treatment (irrespective of timing) was associated with a reduction in mortality risk (adjusted odds ratio [OR] 0·81; 95% CI 0·70-0·93; p=0·0024). Compared with later treatment, early treatment (within 2 days of symptom onset) was associated with a reduction in mortality risk (adjusted OR 0·48; 95% CI 0·41-0·56; p<0·0001). Early treatment versus no treatment was also associated with a reduction in mortality (adjusted OR 0·50; 95% CI 0·37-0·67; p<0·0001). These associations with reduced mortality risk were less pronounced and not significant in children. There was an increase in the mortality hazard rate with each day's delay in initiation of treatment up to day 5 as compared with treatment initiated within 2 days of symptom onset (adjusted hazard ratio [HR 1·23] [95% CI 1·18-1·28]; p<0·0001 for the increasing HR with each day's delay)., Interpretation: We advocate early instigation of neuraminidase inhibitor treatment in adults admitted to hospital with suspected or proven influenza infection., Funding: F Hoffmann-La Roche., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

During severe influenza pandemics healthcare demand can exceed clinical capacity to provide normal standards of care. Community Assessment Tools (CATs) could provide a framework for triage decisions for hospital referral and admission. CATs have been developed based on evidence that supports the recognition of severe influenza and pneumonia in the community (including resource limited settings) for adults, children and infants, and serious feverish illness in children. CATs use six objective criteria and one subjective criterion, any one or more of which should prompt urgent referral and admission to hospital. A retrospective evaluation of the ability of CATs to predict use of hospital-based interventions and patient outcomes in a pandemic was made using the first recorded routine clinical assessment on or shortly after admission from 1520 unselected patients (800 female, 480 children <16 years) admitted with PCR confirmed A(H1N1)pdm09 infection (the FLU-CIN cohort). Outcome measures included: any use of supplemental oxygen; mechanical ventilation; intravenous antibiotics; length of stay; intensive or high dependency care; death; and "severe outcome" (combined: use of intensive or high dependency care or death during admission). Unadjusted and multivariable analyses were conducted for children (age <16 years) and adults. Each CATs criterion independently identified both use of clinical interventions that would in normal circumstances only be provided in hospital and patient outcome measures. "Peripheral oxygen saturation ≤ 92% breathing air, or being on oxygen" performed well in predicting use of resources and outcomes for both adults and children; supporting routine measurement of peripheral oxygen saturation when assessing severity of disease. In multivariable analyses the single subjective criterion in CATs "other cause for clinical concern" independently predicted death in children and in adults predicted length of stay, mechanical ventilation and "severe outcome"; supporting the role of clinical acumen as an important independent predictor of serious illness.

Objectives: Benzodiazepines have been associated with an increased incidence of infections, and mortality from sepsis, in the critically ill. Here, we determined the effect of community use of benzodiazepines on the occurrence of, and mortality following, pneumonia., Methods: A nested case-control study using 29 697 controls and 4964 cases of community-acquired pneumonia (CAP) from The Health Improvement Network, a UK primary care patient database (2001-2002), investigated the association between benzodiazepines and pneumonia occurrence using conditional logistic regression. Cox regression was then used to determine the impact of benzodiazepines on mortality in the 4964 cases of CAP. Results are presented as adjusted OR, adjusted HR and 95% CI., Results: Exposure to benzodiazepines was associated with an increased risk of pneumonia (OR 1.54, 95% CI 1.42 to 1.67). Individually diazepam, lorazepam and temazepam, but not chlordiazepoxide, were associated with an increased incidence of CAP. As a class, benzodiazepines were associated with increased 30-day (HR 1.22 (95% CI 1.06 to 1.39)) and long-term mortality (HR 1.32 (95% CI 1.19 to 1.47)) in patients with a prior diagnosis of CAP. Individually diazepam, chlordiazepoxide, lorazepam and temazepam affected long-term mortality in these patients., Conclusions: Benzodiazepines were associated with an increased risk of, and mortality from, CAP. These hypothesis generating data suggest further research is required into the immune safety profile of benzodiazepines.

Benzodiazepines are World Health Organisation essential medicines used in the treatment of alcohol withdrawal, anaesthesia, sedation, anxiolysis, behavioural disturbance, epilepsy, insomnia, palliative care, and muscle spasm. Despite their widespread use concerns remain over their long-term safety through both neuronal and non-neuronal effects. We conducted a systematic review to identify vulnerable populations of patients who may be at increased risk of harm from benzodiazepines. We identified three potentially "at risk" groups of patients, those with renal disease, lung disease and those recently hospitalised. However methodological limitations including selection bias, vague descriptors of benzodiazepine use and inappropriate grouping together of benzodiazepines with other medications, precluded definitive conclusions. Future studies should concentrate on these groups to identify the long-term safety of benzodiazepines in these patient groups.

Introduction: The Influenza Clinical Information Network (FLU-CIN) was established to gather detailed clinical and epidemiological information about patients with laboratory confirmed A(H1N1)pdm09 infection in UK hospitals. This report focuses on the clinical course and outcomes of infection in pregnancy., Methods: A standardised data extraction form was used to obtain detailed clinical information from hospital case notes and electronic records, for patients with PCR-confirmed A(H1N1)pdm09 infection admitted to 13 sentinel hospitals in five clinical 'hubs' and a further 62 non-sentinel hospitals, between 11th May 2009 and 31st January 2010.Outcomes were compared for pregnant and non-pregnant women aged 15-44 years, using univariate and multivariable techniques., Results: Of the 395 women aged 15-44 years, 82 (21%) were pregnant; 73 (89%) in the second or third trimester. Pregnant women were significantly less likely to exhibit severe respiratory distress at initial assessment (OR = 0.49 (95% CI: 0.30-0.82)), require supplemental oxygen on admission (OR = 0.40 (95% CI: 0.20-0.80)), or have underlying co-morbidities (p-trend <0.001). However, they were equally likely to be admitted to high dependency (Level 2) or intensive care (Level 3) and/or to die, after adjustment for potential confounders (adj. OR = 0.93 (95% CI: 0.46-1.92). Of 11 pregnant women needing Level 2/3 care, 10 required mechanical ventilation and three died., Conclusions: Since the expected prevalence of pregnancy in the source population was 6%, our data suggest that pregnancy greatly increased the likelihood of hospital admission with A(H1N1)pdm09. Pregnant women were less likely than non-pregnant women to have respiratory distress on admission, but severe outcomes were equally likely in both groups.

Triage tools have an important role in pandemics to identify those most likely to benefit from higher levels of care. We compared Community Assessment Tools (CATs), the CURB-65 score, and the Pandemic Medical Early Warning Score (PMEWS); to predict higher levels of care (high dependency--Level 2 or intensive care--Level 3) and/or death in patients at or shortly after admission to hospital with A/H1N1 2009 pandemic influenza. This was a case-control analysis using retrospectively collected data from the FLU-CIN cohort (1040 adults, 480 children) with PCR-confirmed A/H1N1 2009 influenza. Area under receiver operator curves (AUROC), sensitivity, specificity, positive predictive values and negative predictive values were calculated. CATs best predicted Level 2/3 admissions in both adults [AUROC (95% CI): CATs 0.77 (0.73, 0.80); CURB-65 0.68 (0.64, 0.72); PMEWS 0.68 (0.64, 0.73), p<0.001] and children [AUROC: CATs 0.74 (0.68, 0.80); CURB-65 0.52 (0.46, 0.59); PMEWS 0.69 (0.62, 0.75), p<0.001]. CURB-65 and CATs were similar in predicting death in adults with both performing better than PMEWS; and CATs best predicted death in children. CATs were the best predictor of Level 2/3 care and/or death for both adults and children. CATs are potentially useful triage tools for predicting need for higher levels of care and/or mortality in patients of all ages.

To determine clinical characteristics of patients hospitalized in the United Kingdom with pandemic (H1N1) 2009, we studied 1,520 patients in 75 National Health Service hospitals. We characterized patients who acquired influenza nosocomially during the pandemic (H1N1) 2009 outbreak. Of 30 patients, 12 (80%) of 15 adults and 14 (93%) of 15 children had serious underlying illnesses. Only 12 (57%) of 21 patients who received antiviral therapy did so within 48 hours after symptom onset, but 53% needed escalated care or mechanical ventilation; 8 (27%) of 30 died. Despite national guidelines and standardized infection control procedures, nosocomial transmission remains a problem when influenza is prevalent. Health care workers should be routinely offered influenza vaccine, and vaccination should be prioritized for all patients at high risk. Staff should remain alert to the possibility of influenza in patients with complex clinical problems and be ready to institute antiviral therapy while awaiting diagnosis during influenza outbreaks.

Background: Pneumonia is a common diagnosis in general practice in the United Kingdom and yet there is little known about the short- and long-term prognosis of people with a diagnosis of pneumonia in general practice. We investigated the short- and long-term survival of people with pneumonia diagnosed in general practice as compared to the general population for all ages., Methods: This was a general population-based cohort study. Data was obtained from a comprehensive general practice database called The Health Improvement Network (THIN) database which has computerized medical records from 300 general practice surgeries in the United Kingdom. We used Cox regression for our analyses., Results: For pneumonia cases the 30-day mortality was 18.5% and the 3-year mortality was 30.8%. The equivalent figures for the general population controls were 0.4% and 10.3% respectively. The adjusted hazard ratio (HR) for all-cause mortality (for total follow-up time) in pneumonia cases vs. general population was 4.64 (95% CI 4.35-4.95). For the first 30 days the risk of mortality in cases was 46 times more (adj. HR 45.90, 95% CI 36.80-55.20). Even in the period of follow-up 91 days after diagnosis cases were almost 20% more likely to die compared to general population (adj. HR 1.19, 95% CI 1.08-1.31)., Conclusion: People in general practice who have a diagnosis of pneumonia have a markedly increased mortality in the short-term but some increase in mortality persists during longer-term follow-up.

Background: Pneumonia is a common diagnosis in general practice in the United Kingdom. Previous studies suggest that commonly prescribed drugs in general practice may influence pneumonia mortality., Aim: We investigated whether statins, angiotensin converting enzyme inhibitors (ACEIs), proton pump inhibitors (PPIs) and histamine-2-receptor antagonists (H(2)RAs) have an impact on short-term and long-term mortality in pneumonia cases., Design of Study: Population-based cohort study SETTTING: United Kingdom, Methods: Data on 3681 pneumonia cases above the age of 40 years were obtained from a comprehensive database called the health improvement network (THIN) which has computerised medical records from 300 general practice surgeries in the United Kingdom. We used Cox regression for our analyses., Results: Current statin use was associated with a 67% decrease in 30-day mortality (adj. HR: 0.33, 95% CI: 0.19-0.58) and a 55% decrease in long-term mortality (adj. HR: 0.45, 95% CI: 0.32-0.62) over a median follow-up of 2.8 years as compared to no-use. Current ACEI use decreased the 30-day mortality risk by nearly 38% as compared to no-use (adj. HR: 0.62, 95% CI: 0.47-0.82) but was not associated with long-term mortality. No significant impact on mortality was observed for either gastric acid suppressant., Conclusion: The use of statins is associated with a lower risk of short- and long-term mortality following pneumonia whereas the use of ACEIs is associated with a decreased mortality risk only in the short-term., (Copyright 2009 John Wiley & Sons, Ltd.)

Despite being widely recognized as a significant public health problem there are surprisingly few contemporary data available on the incidence of pneumonia in the UK. We conducted a general population-based cohort study to determine the incidence of pneumonia in general practice in the United Kingdom. Data were obtained from The Health Improvement Network (THIN) - a computerized, longitudinal, general practice database. Recorded diagnoses of pneumonia between 1991 and 2003 were used to calculate the incidence of pneumonia stratified by year, sex, age group and deprivation score. The overall incidence of pneumonia was 233/100 000 person-years [95% confidence interval (CI) 231-235] and this rate was stable between 1991 and 2003. The incidence of pneumonia was slightly lower in females compared to males [age-adjusted incidence rate ratio (IRR) 0.88, 95% CI 0.86-0.89]. Pneumonia was most common in children aged <4 years and adults aged >65 years. There was an increased incidence of pneumonia with higher levels of socioeconomic disadvantage such that people living in the most deprived areas of the United Kingdom were 28% more likely to get pneumonia than those in the least deprived areas (age- and gender-adjusted IRR 1.28, 95% CI 1.24-1.32). In conclusion, pneumonia is an important public health problem and the incidence of pneumonia is higher in people at the extremes of age, men and people living in socially deprived areas.

Purpose: Previous studies have shown that treatment with gastric acid suppressants may be associated with an increased risk of pneumonia whilst the use of statins and ACE inhibitors (ACEI) may decrease the risk of acquiring pneumonia. The evidence is conflicting however. Our aim was to investigate the effect of these drugs on pneumonia using population-based data from the UK., Methods: We conducted a general population-based case-control study using the health improvement network (THIN), a comprehensive UK general practice database. Conditional multiple logistic regression was used to assess the association between the exposures and pneumonia., Results: After adjusting for potential confounders, a current prescription for statins was associated with a significant reduction in the risk of pneumonia (adjusted OR 0.78, 95% CI 0.65-0.94). Similarly, a current prescription for ACEI was associated with a reduction in the risk of pneumonia (adjusted OR 0.75, 95% CI 0.65-0.86). Contrary to previous study results we did not find a significant association between current prescription for histamine 2 receptor antagonist (H(2)RA) and pneumonia risk (adjusted OR 1.14, 95% CI 0.92-1.40) but current prescriptions for proton pump inhibitors (PPI) were associated with an increased risk of pneumonia (adjusted OR 1.55, 95% CI 1.38-1.77)., Conclusions: Statins and ACE inhibitors were associated with a lower risk of pneumonia but these effects were smaller than those observed in previous studies. People prescribed a PPI, but not an H(2)RA at an increased risk of acquiring pneumonia.