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Objectives The aim of the study was to identify care home characteristics associated with reported care home influenza outbreaks and factors associated with increased transmission of influenza-like illness (ILI) in care homes in Cheshire and Merseyside during the 2017–2018 influenza season. Study design This is a matched case-control study comparing characteristics between care homes with and without a declared influenza outbreak and a retrospective risk factor analysis of care home residents with ILI. Methods Routinely collected outbreak surveillance data on symptomatic residents and staff, antiviral prophylaxis and influenza vaccination history, which were reported to Public Health England, were extracted from health protection electronic records. Further care home characteristics were extracted from the Care Quality Commission (CQC) website. Care homes with declared influenza outbreaks were matched with care homes without outbreaks. Chi-squared tests and logistic regression were used to examine associations between care home factors and ILI. Results There were no significant differences in characteristics between 77 care homes with declared influenza outbreaks and 77 matched care homes without outbreaks. Of 2,744 residents from the homes with a declared outbreak, 644 (24%) developed an ILI. The care home risk factors were having a low CQC score and activation of antiviral prophylaxis and the protective factors were having higher numbers of residents, specializing in dementia care and having the highest CQC score. Significantly more cases occurred in residential homes than in nursing homes, in homes with lower CQC scores and in homes where eligible residents were given antiviral prophylaxis. Conclusions In homes with declared outbreaks, certain characteristics including activation of antiviral prophylaxis were associated with an increased risk of ILI. Further research is needed, particularly focussing on temporality between provision of prophylactic antivirals and the onset of ILI.

BACKGROUND: COVID-19 care home outbreaks represent a significant proportion of COVID-19 morbidity and mortality in the UK. National testing initially focused on symptomatic care home residents, before extending to asymptomatic cohorts.AIM: The aim was to describe the epidemiology and transmission of COVID-19 in outbreak free care homes.METHODS: A two-point prevalence survey of COVID-19, in 34 Liverpool care homes, was performed in April and May 2020. Changes in prevalence were analysed. Associations between care home characteristics, reported infection, prevention and control interventions, and COVID-19 status were described and analysed.FINDINGS: No resident developed COVID-19 symptoms during the study. There was no significant difference between: the number of care homes containing at least one test positive resident between the first (17.6%, 95% confidence interval (CI) 6.8-34.5) and second round (14.7%, 95% CI 5.0-31.1) of testing (p>0.99); and the number of residents testing positive between the first (2.1%, 95% CI 1.2-3.4) and second round (1.0%, 95% CI 0.5-2.1) of testing (P=0.11). Care homes providing nursing care (risk ratio (RR) 7.99, 95% CI 1.1-57.3) and employing agency staff (RR 8.4, 95% CI 1.2-60.8) were more likely to contain test positive residents. Closing residents shared space was not associated with residents testing positive (RR 2.63, 95% CI 0.4-18.5).CONCLUSIONS: Asymptomatic COVID-19 care homes showed no evidence of disease transmission or development of outbreaks; suggesting that current infection prevention and control measures are effective in preventing transmission. Repeat testing at two to three weeks had limited or no public health benefits over regular daily monitoring of staff and residents for symptoms. These results should inform policies calling for regular testing of asymptomatic residents.

BackgroundCOVID-19 has caused high morbidity and mortality in UK care homes. Vaccinating staff members and residents will protect care homes from severe clinical cases. Uptake of COVID-19 vaccine first doses in care homes has been higher among residents compared to staff members.MethodsWe aimed to identify causes of lower COVID-19 vaccine uptake amongst care home staff members within the Liverpool City Council region. An anonymised online survey was distributed to all care home managers between the 21st and the 29th of January 2021. Descriptive analysis was performed on responses.Results46/87 (53%) of Liverpool care homes responded. The mean staff vaccination rate per home was 51.4% (95% CI 43.9-58.8%). The most common reasons for staff not receiving the vaccine were: concerns about lack of vaccine research (37.0%), staff being off-site during vaccination sessions (36.5%), pregnancy and fertility concerns (5.6%), and concerns about allergic reactions (3.2%). Care home managers reported the necessity to combat vaccine hesitancy through meetings and conversations with health professionals, and provision of supporting evidence to dispel vaccine misinformation.ConclusionsVaccine hesitancy was the main cause for reduced vaccine uptake among care home staff members. These concerns could be addressed by targeted evidence-based training, and a public health communication campaign to build vaccine confidence and increase acceptance of COVID-19 vaccines. The speed of vaccination roll-out has also led to unexpected logistical issues that lowered vaccine uptake rates. Addressing both these challenges could increase uptake by more than 40%.Key PointsCOVID-19 vaccine uptake rates are lower in staff than residentsThree main causes of reduced uptake have been identified: vaccine hesitancy, logistical issues, and medical concerns.The main reasons for vaccine hesitancy were concerns about limited research into vaccine safety, and concerns about long-term impact on pregnancy and fertility.Addressing care home staff vaccination concerns should be given priority in these settings.

Summary Background Burns patients are at high risk of nosocomial infection, and Pseudomonas aeruginosa is one of the most common causes of wound and systemic infections resulting in significant morbidity and mortality in burns patients. Aim To describe an outbreak of multidrug-resistant P. aeruginosa (MDR-Pa) at a specialist burns service and highlight the challenges in identifying the reservoir of infection despite extensive epidemiological, microbiological, and environmental investigations. Methods Multi-disciplinary outbreak control investigation. Findings Following an inter-hospital transfer of a burns patient from another country, an admission screen revealed that the patient was colonized with MDR-Pa. Subsequently nine more patients contracted MDR-Pa in the period from November 2015 to September 2017. Given the relatively long gap between confirmation of the index and subsequent cases, it was not possible to identify with certainty the reservoirs and mechanisms of spread of infection, although contamination of the burns service environment and equipment are likely to be contributory factors. Conclusion Preventing infection transmission in specialist burns services is highly challenging, and it may not always be possible to identify and eradicate the reservoirs of infection for P. aeruginosa outbreaks. Our study supports the literature, providing additional evidence that inanimate, common contact surfaces play an important role in nosocomial transmission of P. aeruginosa. These surfaces should either be decontaminated efficiently between patient contacts or be single patient use. Enhanced vigilance is crucial, and, with strict adherence to infection prevention and control procedures, it is possible to reduce the risk of acquisition and spread of infection in patients.

To assess the association of antiviral prophylaxis and care home characteristics with the spread and severity of influenza-like illness in care homes with influenza outbreaks in North West England in the 2017/2018 influenza season.This is a retrospective observational study.Routinely collected outbreak surveillance data reported to Public Health England were extracted from health protection electronic records. Data included use of antiviral prophylaxis, influenza-like illness or confirmed influenza, hospital admissions and deaths. Care home characteristics were obtained from the Care Quality Commission website. Single variable analysis and multivariable logistic regression were used to examine associations between care home characteristics, antiviral prophylaxis and influenza-related outcomes.In the 109 homes, there were 3498 residents; of whom, 855 (24%) developed an influenza-like illness. Antiviral prophylaxis was given to residents of 67 of the 109 care homes with outbreaks (61%). A significantly higher attack rate was observed among residents of homes given antiviral prophylaxis (27%) than among residents of homes not given antivirals (20%) (P 0.001). Significantly more deaths occurred in homes for people with learning disabilities and homes that received antiviral prophylaxis (P 0.001).In homes given antiviral prophylaxis, there were a higher number of residents with influenza-like illness and deaths. To improve our understanding of the impact of antiviral prophylaxis use in real life, enhanced and timely data collection is needed for identification of temporal associations between exposure and administration of antiviral prophylaxis. Consideration needs also to be given to ensure people with learning disabilities are protected through the seasonal influenza vaccine and timely antiviral prophylaxis when appropriate.

SORT IT (Structured Operational Research Training InitiaTive) is a successful capacity building programme started 10 years ago to develop operational research skills in low- and middle-income countries. Public Health England (PHE) aims to embed a culture of research in front-line staff, and SORT IT has been adapted to train frontline health protection professionals at PHE North West (PHE NW) to collate, analyse and interpret routinely collected data for evidence-informed decision-making. Six participants from the PHE NW Health Protection team were selected to attend a two-module course in Liverpool, UK, in May and in November 2018. Five participants finished the course with completed papers on characteristics and burden of influenza-like illness in elderly care homes (two papers), use of dried blood spots for blood-borne virus screening in prisons, uptake of meningococcal ACWY (groups A, C, W-135 and Y) vaccine in schoolchildren and fires in waste management sites. The SORT IT course led to 1) new evidence being produced to inform health protection practice, and 2) agreement within PHE NW to continue SORT IT with two courses per year, and 3) showed how a research capacity building initiative for low- and middle-income countries that combines 'learning with doing' can be adapted and used in a high-income country.SORT IT (El programa SORT IT (por

SUMMARYSuboptimal uptake of the measles, mumps and rubella (MMR) vaccine by certain socioeconomic groups may have contributed to recent large measles outbreaks in the UK. We investigated whether socioeconomic deprivation was associated with MMR vaccine uptake over 16 years. Using immunization data for 72 351 children born between 1995 and 2012 in Liverpool, UK, we examined trends in vaccination uptake. Generalized linear models were constructed to examine the relative effect of socioeconomic deprivation and year of birth on MMR uptake. Uptake of MMR1 by age 24 months ranged between 82·5% in 2003 [95% confidence interval (CI) 81·2–83·7] and 93·4% in 2012 (95% CI 92·7–94·2). Uptake of MMR2 by age 60 months ranged between 65·3% (95% CI 64·4–67·4) in 2006 and 90·3% (95% CI 89·4–91·2) in 2012. In analysis adjusted for year of birth and sex, children in the most deprived communities were at significantly greater risk of not receiving MMR1 [risk ratio (RR) 1·70, 95% CI 1·45–1·99] and MMR2 (RR 1·36, 95% CI 1·22–1·52). Higher unemployment and lower household income were significantly associated with low uptake. Contrary to concerns about lower MMR uptake in affluent families, over 16 years, children from the most socioeconomically deprived communities have consistently had the lowest MMR uptake. Targeted catch-up campaigns and strategies to improve routine immunization uptake in deprived areas are needed to minimize the risk of future measles outbreaks.

Background Measles is a highly contagious vaccine-preventable infection that caused large outbreaks in England in 2012 and 2013 in areas which failed to achieve herd protection levels (95%) consistently. We sought to quantify the economic costs associated with the 2012–13 Merseyside measles outbreak, relative to the cost of extending preventative vaccination to secure herd protection. Methods A costing model based on a critical literature review was developed. A workshop and interviews were held with key stakeholders in the Merseyside outbreak to understand the pathway of a measles case and then quantify healthcare activity and costs for the main NHS providers and public health team incurred during the initial four month period to May 2012. These data were used to model the total costs of the full outbreak to August 2013, comprising those to healthcare providers for patient treatment, public health and societal productivity losses. The modelled total cost of the full outbreak was compared to the cost of extending the preventative vaccination programme to achieve herd protection. Findings The Merseyside outbreak included 2458 reported cases. The estimated cost of the outbreak was £4.4 m (sensitivity analysis £3.9 m to £5.2 m) comprising 15% (£0.7 m) NHS patient treatment costs, 40% (£1.8 m) public health costs and 44% (£2.0 m) for societal productivity losses. In comparison, over the previous five years in Cheshire and Merseyside a further 11,793 MMR vaccinations would have been needed to achieve herd protection at an estimated cost of £182,909 (4% of the total cost of the measles outbreak). Interpretation Failure to consistently reach MMR uptake levels of 95% across all localities and sectors (achieve herd protection) risks comparatively higher economic costs associated with the containment (including healthcare costs) and implementation of effective public health management of outbreaks. Funding Commissioned by the Cheshire and Merseyside Public Health England Centre.

SUMMARYUptake rates for the combined measles, mumps and rubella (MMR) vaccine have been below the required 95% in the UK since a retracted and discredited article linking the MMR vaccine with autism and inflammatory bowel disease was released in 1998. This study undertook semi-structured telephone interviews among parents or carers of 47 unvaccinated measles cases who were aged between 13 months and 9 years, during a large measles outbreak in Merseyside. Results showed that concerns over the specific links with autism remain an important cause of refusal to vaccinate, with over half of respondents stating this as a reason. A quarter stated child illness during scheduled vaccination time, while other reasons included general safety concerns and access issues. Over half of respondents felt that more information or a discussion with a health professional would help the decision-making process, while a third stated improved access. There was clear support for vaccination among respondents when asked about current opinions regarding MMR vaccine. The findings support the hypothesis that safety concerns remain a major barrier to MMR vaccination, and also support previous evidence that experience of measles is an important determinant in the decision to vaccinate.

Asplenic individuals are at increased risk of infection with Streptococcus pneumoniae. The immune response to pneumococcal conjugate vaccine has not been investigated in this clinical risk group. We investigated immune responses to pneumococcal vaccination in asplenic individuals. Eligible subjects agedor =4 years received one dose 7-valent pneumococcal conjugate vaccine (PCV7) and, if no prior 23-valent polysaccharide vaccine (PPV23) had been received within previous 5 years, one dose was given 6 months following PCV7. Pre- and post-vaccination blood samples were taken. Pneumococcal serotype-specific IgG levels were determined for 9 serotypes; the 7 in PCV7 plus serotypes1 and by standardized ELISA. One hundred and eleven asplenic individuals were recruited [median age 54.8 years, (18.1-81.8)]. Median age at splenectomy was 29.6 years (3.6-78.3); 108 (97.3%) individuals had previously received PPV23. Compliance with UK recommendations on immunization and prophylaxis in this group was poor, 91 (82%) subjects had received Haemophilus influenzae type b conjugate vaccine and only 68 (62%) had received meningococcal serogroup C conjugate vaccine. In total 61 (55%) subjects were taking antibiotic prophylaxis and 12 subjects had reported previous invasive pneumococcal disease, five episodes of which occurred post-splenectomy. High serotype-specific IgG concentrations were observed pre-PCV7, with significant increases (p0.01) in geometric mean concentrations pre- to post-PCV7 for the PCV7 serotypes. Post-PCV7, between 27% (serotype 14) and 69% (serotype 23F) of subjects had aor =2-fold rise in IgG. Pre-PCV7, the percentage of individuals with levelsor =0.35 microg/mL ranged between 77% (serotype 4) and 97% (serotypes 14, 19F), whilst post-PCV7 this was 90% (serotype 6B) and 99% (serotype 14). No significant increases were observed post-PPV23. Asplenic individuals responded well to PCV7, though protective levels were demonstrated pre-PCV7 in majority of participants due to prior PPV23. Although immunogenic, there is insufficient evidence here to recommend routine PCV7 immunization over PPV23 immunization in adult asplenic individuals.

Soon after qualifying in 1988 I was assigned to a remote health centre in Ethiopia. People would travel for days to reach the centre and then queue for hours to see a doctor. During this time I encountered an old man with his son who were to change my outlook on public health. The old man had brought his son to be treated. They were both diagnosed as having scabies and were given appropriate instructions and prescriptions. But the old …

From 1 January to 30 June 2012, 359 confirmed and 157 probable cases of measles were reported in Merseyside, England. The most affected age groups were children under five years and young adults from 15 years of age. Most cases have been sporadic. There have been few outbreaks in nurseries; however, no outbreaks have been reported in schools. Of the cases eligible for vaccination, only 3% of the confirmed cases were fully immunised.