Reported exposure to SARS-CoV-2 and relative perceived importance of different settings for SARS-CoV-2 acquisition in England and Wales: Analysis of the Virus Watch Community Cohort

We aimed to assess the relative importance of different settings for SARS-CoV-2 transmission in a large community cohort based on perceived location of infection for self-reported confirmed SARS-COV-2 cases. We demonstrate the importance of home, work and education as perceived venues for transmission. In children, education was most important and in older adults essential shopping was of high importance.  Our findings support public health messaging about infection control at home, advice on working from home and restrictions in different venues.

Design of financial incentive interventions to improve lifestyle behaviors and health outcomes: A systematic review

Background: Financial incentives may improve the initiation and engagement of behaviour change that reduce the negative outcomes associated with non-communicable diseases. There is still a paucity in guidelines or recommendations that help define key aspects of incentive-oriented interventions, including the type of incentive (e.g. cash rewards, vouchers), the frequency and magnitude of the incentive, and its mode of delivery.  We aimed to systematically review the literature on financial incentives that promote healthy lifestyle behaviours or improve health profiles, and focused on the methodological approach to define the incentive intervention and its delivery. The protocol was registered at PROSPERO on 26 July 2018 ( CRD42018102556). Methods: We sought studies in which a financial incentive was delivered to improve a health-related lifestyle behaviour (e.g., physical activity) or a health profile (e.g., HbA1c in people with diabetes). The search (which took place on March 3 rd 2018) was conducted using OVID (MEDLINE and Embase), CINAHL and Scopus. Results: The search yielded 7,575 results and 37 were included for synthesis. Of the total, 83.8% (31/37) of the studies were conducted in the US, and 40.5% (15/37) were randomised controlled trials. Only one study reported the background and rationale followed to develop the incentive and conducted a focus group to understand what sort of incentives would be acceptable for their study population. There was a degree of consistency across the studies in terms of the direction, form, certainty, and recipient of the financial incentives used, but the magnitude and immediacy of the incentives were heterogeneous. Conclusions: The available literature on financial incentives to improve health-related lifestyles rarely reports on the rationale or background that defines the incentive approach, the magnitude of the incentive and other relevant details of the intervention, and the reporting of this information is essential to foster its use as potential effective interventions.

Improving care transfers for homeless patients after hospital discharge: a realist evaluation

Background

In 2013, 70% of people who were homeless on admission to hospital were discharged back to the street without having their care and support needs addressed. In response, the UK government provided funding for 52 new specialist homeless hospital discharge schemes. This study employed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) guidelines between September 2015 and 2019 to undertake a realist evaluation to establish what worked, for whom, under what circumstances and why. It was hypothesised that delivering outcomes linked to consistently safe, timely care transfers for homeless patients would depend on hospital discharge schemes implementing a series of high-impact changes (resource mechanisms). These changes encompassed multidisciplinary discharge co-ordination (delivered through clinically led homeless teams) and ‘step-down’ intermediate care. These facilitated time-limited care and support and alternative pathways out of hospital for people who could not go straight home.

Methods

The realist hypothesis was tested empirically and refined through three work packages. Work package 1 generated seven qualitative case studies, comparing sites with different types of specialist homeless hospital discharge schemes (n = 5) and those with no specialist discharge scheme (standard care) (n = 2). Methods of data collection included interviews with 77 practitioners and stakeholders and 70 people who were homeless on admission to hospital. A ‘data linkage’ process (work package 2) and an economic evaluation (work package 3) were also undertaken. The data linkage process resulted in data being collected on > 3882 patients from 17 discharge schemes across England. The study involved people with lived experience of homelessness in all stages.

Results

There was strong evidence to support our realist hypothesis. Specialist homeless hospital discharge schemes employing multidisciplinary discharge co-ordination and ‘step-down’ intermediate care were more effective and cost-effective than standard care. Specialist care was shown to reduce delayed transfers of care. Accident and emergency visits were also 18% lower among homeless patients discharged at a site with a step-down service than at those without. However, there was an impact on the effectiveness of the schemes when they were underfunded or when there was a shortage of permanent supportive housing and longer-term care and support. In these contexts, it remained (tacitly) accepted practice (across both standard and specialist care sites) to discharge homeless patients to the streets, rather than delay their transfer. We found little evidence that discharge schemes fired a change in reasoning with regard to the cultural distance that positions ‘homeless patients’ as somehow less vulnerable than other groups of patients. We refined our hypothesis to reflect that high-impact changes need to be underpinned by robust adult safeguarding.

Strengths and limitations

To our knowledge, this is the largest study of the outcomes of homeless patients discharged from hospital in the UK. Owing to issues with the comparator group, the effectiveness analysis undertaken for the data linkage was limited to comparisons of different types of specialist discharge scheme (rather than specialist vs. standard care).

Future work

There is a need to consider approaches that align with those for value or alliance-based commissioning where the evaluative gaze is shifted from discrete interventions to understanding how the system is working as a whole to deliver outcomes for a defined patient population.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 17. See the NIHR Journals Library website for further project information.

Design of financial incentive interventions to improve lifestyle behaviors and health outcomes: A systematic review

Background: Financial incentives may improve the initiation and engagement of behaviour change that reduce the negative outcomes associated with non-communicable diseases. There is still a paucity in guidelines or recommendations that help define key aspects of incentive-oriented interventions, including the type of incentive (e.g. cash rewards, vouchers), the frequency and magnitude of the incentive, and its mode of delivery.  We aimed to systematically review the literature on financial incentives that promote healthy lifestyle behaviours or improve health profiles, and focused on the methodological approach to define the incentive intervention and its delivery. The protocol was registered at PROSPERO on 26 July 2018 ( CRD42018102556). Methods: We sought studies in which a financial incentive was delivered to improve a health-related lifestyle behaviour (e.g., physical activity) or a health profile (e.g., HbA1c in people with diabetes). The search (which took place on March 3 rd 2018) was conducted using OVID (MEDLINE and Embase), CINAHL and Scopus. Results: The search yielded 7,575 results and 37 were included for synthesis. Of the total, 83.8% (31/37) of the studies were conducted in the US, and 40.5% (15/37) were randomised controlled trials. Only one study reported the background and rationale followed to develop the incentive and conducted a focus group to understand what sort of incentives would be acceptable for their study population. There was a degree of consistency across the studies in terms of the direction, form, certainty, and recipient of the financial incentives used, but the magnitude and immediacy of the incentives were heterogeneous. Conclusions: The available literature on financial incentives to improve health-related lifestyles rarely reports on the rationale or background that defines the incentive approach, the magnitude of the incentive and other relevant details of the intervention, and the reporting of this information is essential to foster its use as potential effective interventions.

Risk factors, symptom reporting, healthcare-seeking behaviour and adherence to public health guidance: protocol for Virus Watch, a prospective community cohort study

INTRODUCTION

The coronavirus (COVID-19) pandemic has caused significant global mortality and impacted lives around the world. Virus Watch aims to provide evidence on which public health approaches are most likely to be effective in reducing transmission and impact of the virus, and will investigate community incidence, symptom profiles and transmission of COVID-19 in relation to population movement and behaviours.

METHODS AND ANALYSIS

Virus Watch is a household community cohort study of acute respiratory infections in England and Wales and will run from June 2020 to August 2021. The study aims to recruit 50 000 people, including 12 500 from minority ethnic backgrounds, for an online survey cohort and monthly antibody testing using home fingerprick test kits. Nested within this larger study will be a subcohort of 10 000 individuals, including 3000 people from minority ethnic backgrounds. This cohort of 10 000 people will have full blood serology taken between October 2020 and January 2021 and repeat serology between May 2021 and August 2021. Participants will also post self-administered nasal swabs for PCR assays of SARS-CoV-2 and will follow one of three different PCR testing schedules based on symptoms.

ETHICS AND DISSEMINATION

This study has been approved by the Hampstead National Health Service (NHS) Health Research Authority Ethics Committee (ethics approval number 20/HRA/2320). We are monitoring participant queries and using these to refine methodology where necessary, and are providing summaries and policy briefings of our preliminary findings to inform public health action by working through our partnerships with our study advisory group, Public Health England, NHS and government scientific advisory panels.

Peer advocacy and access to healthcare for people who are homeless in London, UK: a mixed method impact, economic and process evaluation protocol

INTRODUCTION

People who are homeless experience higher morbidity and mortality than the general population. These outcomes are exacerbated by inequitable access to healthcare. Emerging evidence suggests a role for peer advocates-that is, trained volunteers with lived experience-to support people who are homeless to access healthcare.

METHODS AND ANALYSIS

We plan to conduct a mixed methods evaluation to assess the effects (qualitative, cohort and economic studies); processes and contexts (qualitative study); fidelity; and acceptability and reach (process study) of Peer Advocacy on people who are homeless and on peers themselves in London, UK. People with lived experience of homelessness are partners in the design, execution, analysis and dissemination of the evaluation.

ETHICS AND DISSEMINATION

Ethics approval for all study designs has been granted by the National Health Service London-Dulwich Research Ethics Committee (UK) and the London School of Hygiene and Tropical Medicine's Ethics Committee (UK). We plan to disseminate study progress and outputs via a website, conference presentations, community meetings and peer-reviewed journal articles.

A new transdisciplinary research model to investigate and improve the health of the public

Transdisciplinary research approaches are being applied to today's complex health problems, including the climate crisis and widening inequalities. Diverse forms of disciplinary and experiential knowledge are required to understand these challenges and develop workable solutions. We aimed to create an updated model reflective of the strengths and challenges of current transdisciplinary health research that can be a guide for future studies. We searched Medline using terms related to transdisciplinary, health and research. We coded data deductively and inductively using thematic analysis to develop a preliminary model of transdisciplinary research. The model was tested and improved through: (i) a workshop with 27 participants at an international conference in Xiamen, China and (ii) online questionnaire feedback from included study authors. Our revised model recommends the following approach: (i) co-learning, an ongoing phase that recognizes the distributed nature of knowledge generation and learning across partners; (ii) (pre-)development, activities that occur before and during project initiation to establish a shared mission and ways of working; (iii) reflection and refinement to evaluate and improve processes and results, responding to emergent information and priorities as an ongoing phase; (iv) conceptualization to develop goals and the study approach by combining diverse knowledge; (v) investigation to conduct the research; (vi) implementation to use new knowledge to solve societal problems. The model includes linear and cyclical processes that may cycle back to project development. Our new model will support transdisciplinary research teams and their partners by detailing the necessary ingredients to conduct such research and achieve health impact.

Household transmission of seasonal coronavirus infections: Results from the Flu Watch cohort study

Background: In the context of the current coronavirus disease 2019 (COVID-19) pandemic, understanding household transmission of seasonal coronaviruses may inform pandemic control. We aimed to investigate what proportion of seasonal coronavirus transmission occurred within households, measure the risk of transmission in households, and describe the impact of household-related factors of risk of transmission.

Methods: Using data from three winter seasons of the UK Flu Watch cohort study, we measured the proportion of symptomatic infections acquired outside and within the home, the household transmission risk and the household secondary attack risk for PCR-confirmed seasonal coronaviruses. We present transmission risk stratified by demographic features of households.

Results: We estimated that the proportion of cases acquired outside the home, weighted by age and region, was 90.7% (95% CI 84.6- 94.5, n=173/195) and within the home was 9.3% (5.5-15.4, 22/195). Following a symptomatic coronavirus index case, 14.9% (9.8 - 22.1, 20/134) of households experienced symptomatic transmission to at least one other household member. Onward transmission risk ranged from 11.90% (4.84-26.36, 5/42) to 19.44% (9.21-36.49, 7/36) by strain. The overall household secondary attack risk for symptomatic cases was 8.00% (5.31-11.88, 22/275), ranging across strains from 5.10 (2.11-11.84, 5/98) to 10.14 (4.82- 20.11, 7/69). Median clinical onset serial interval was 7 days (IQR= 6-9.5). Households including older adults, 3+ children, current smokers, contacts with chronic health conditions, and those in relatively deprived areas had the highest transmission risks. Child index cases and male index cases demonstrated the highest transmission risks.

Conclusion: Most seasonal coronaviruses appear to be acquired outside the household, with relatively modest risk of onward transmission within households. Transmission risk following an index case appears to vary by demographic household features, with potential overlap between those demonstrating the highest point estimates for seasonal coronavirus transmission risk and COVID-19 susceptibility and poor illness outcomes.

Impact of baseline cases of cough and fever on UK COVID-19 diagnostic testing rates: estimates from the Bug Watch community cohort study

Background: Diagnostic testing forms a major part of the UK's response to the current coronavirus disease 2019 (COVID-19) pandemic with tests offered to anyone with a continuous cough, high temperature or anosmia. Testing capacity must be sufficient during the winter respiratory season when levels of cough and fever are high due to non-COVID-19 causes. This study aims to make predictions about the contribution of baseline cough or fever to future testing demand in the UK. Methods: In this analysis of the Bug Watch community cohort study, we estimated the incidence of cough or fever in England in 2018-2019. We then estimated the COVID-19 diagnostic testing rates required in the UK for baseline cough or fever cases for the period July 2020-June 2021. This was explored for different rates of the population requesting tests, four COVID-19 second wave scenarios and high and low baseline cough or fever incidence scenarios. Results: Under the high baseline cough or fever scenario, incidence in the UK is expected to rise rapidly from 250,708 (95%CI 181,095 - 347,080) cases per day in September to a peak of 444,660 (95%CI 353,084 - 559,988) in December. If 80% of these cases request tests, testing demand would exceed 1.4 million tests per week for five consecutive months. Demand was significantly lower in the low cough or fever incidence scenario, with 129,115 (95%CI 111,596 - 151,679) tests per day in January 2021, compared to 340,921 (95%CI 276,039 - 424,491) tests per day in the higher incidence scenario. Conclusions: Our results show that national COVID-19 testing demand is highly dependent on background cough or fever incidence. This study highlights that the UK's response to the COVID-19 pandemic must ensure that a high proportion of people with symptoms request tests, and that testing capacity is sufficient to meet the high predicted demand.

Migration health research in the United Kingdom: A scoping review

BACKGROUND

One in seven people living in the United Kingdom (UK) is an international migrant, rendering migrants an important population group with diverse and dynamic health and healthcare needs. However, there has been no attempt to map contemporary trends within migration health research conducted in the UK. The aim of this scoping review was to describe trends within migration health research and identify gaps for future research agendas.

METHODS

PubMed and Embase were systematically searched for empirical research with a primary focus on the concepts "health" and "migrants" published between 2001 and 2019. Findings were analysed using the UCL-Lancet Commission on Migration and Health Conceptual Framework for Migration and Health.

RESULTS

In total, 399 studies were included, with almost half (41.1%; 164/399) published in the last five years of the study period between 2015 and 2019 and a third (34.1%; 136/399) conducted in London. Studies included asylum seekers (14.8%; 59/399), refugees (12.3%; 49/399), and undocumented migrants or migrants with insecure status (3.5%; 14/399), but most articles (74.9%; 299/399) did not specify a migrant sub-group. The most studied health topics were specific disease outcomes such as infectious diseases (24.1% of studies) and mental health (19.1%) compared to examining systems or structures that impact health (27.8%), access to healthcare (26.3%), or specific exposures or behaviours (35.3%).

CONCLUSIONS

There has been a growing interest in migration health. Ensuring a diverse geographic distribution of research conducted in the UK and disaggregation by migrant sub-group is required for a nuanced and region-specific understanding of specific health needs, interventions and appropriate service delivery for different migrant populations. More research is needed to understand how migration policy and legislation intersect with both the social determinants of health and access to healthcare to shape the health of migrants in the UK.

Seasonality and immunity to laboratory-confirmed seasonal coronaviruses (HCoV-NL63, HCoV-OC43, and HCoV-229E): results from the Flu Watch cohort study

Background: There is currently a pandemic caused by the novel coronavirus SARS-CoV-2. The intensity and duration of this first and second waves in the UK may be dependent on whether SARS-CoV-2 transmits more effectively in the winter than the summer and the UK Government response is partially built upon the assumption that those infected will develop immunity to reinfection in the short term. In this paper we examine evidence for seasonality and immunity to laboratory-confirmed seasonal coronavirus (HCoV) from a prospective cohort study in England. Methods: In this analysis of the Flu Watch cohort, we examine seasonal trends for PCR-confirmed coronavirus infections (HCoV-NL63, HCoV-OC43, and HCoV-229E) in all participants during winter seasons (2006-2007, 2007-2008, 2008-2009) and during the first wave of the 2009 H1N1 influenza pandemic (May-Sep 2009). We also included data from the pandemic and 'post-pandemic' winter seasons (2009-2010 and 2010-2011) to identify individuals with two confirmed HCoV infections and examine evidence for immunity against homologous reinfection. Results: We tested 1,104 swabs taken during respiratory illness and detected HCoV in 199 during the first four seasons. The rate of confirmed HCoV infection across all seasons was 390 (95% CI 338-448) per 100,000 person-weeks; highest in the Nov-Mar 2008/9 season at 674 (95%CI 537-835) per 100,000 person-weeks. The highest rate was in February at 759 (95% CI 580-975) per 100,000 person-weeks. Data collected during May-Sep 2009 showed there was small amounts of ongoing transmission, with four cases detected during this period. Eight participants had two confirmed infections, of which none had the same strain twice. Conclusion: Our results provide evidence that HCoV infection in England is most intense in winter, but that there is a small amount of ongoing transmission during summer periods. We found some evidence of immunity against homologous reinfection.

COVID-19 among people experiencing homelessness in England: a modelling study

BACKGROUND

People experiencing homelessness are vulnerable to COVID-19 due to the risk of transmission in shared accommodation and the high prevalence of comorbidities. In England, as in some other countries, preventive policies have been implemented to protect this population. We aimed to estimate the avoided deaths and health-care use among people experiencing homelessness during the so-called first wave of COVID-19 in England-ie, the peak of infections occurring between February and May, 2020-and the potential impact of COVID-19 on this population in the future.

METHODS

We used a discrete-time Markov chain model of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection that included compartments for susceptible, exposed, infectious, and removed individuals, to explore the impact of the pandemic on 46 565 individuals experiencing homelessness: 35 817 living in 1065 hostels for homeless people, 3616 sleeping in 143 night shelters, and 7132 sleeping outside. We ran the model under scenarios varying the incidence of infection in the general population and the availability of prevention measures: specialist hotel accommodation, infection control in homeless settings, and mixing with the general population. We divided our scenarios into first wave scenarios (covering Feb 1-May 31, 2020) and future scenarios (covering June 1, 2020-Jan 31, 2021). For each scenario, we ran the model 200 times and reported the median and 95% prediction interval (2·5% and 97·5% quantiles) of the total number of cases, the number of deaths, the number hospital admissions, and the number of intensive care unit (ICU) admissions.

FINDINGS

Up to May 31, 2020, we calibrated the model to 4% of the homeless population acquiring SARS-CoV-2, and estimated that 24 deaths (95% prediction interval 16-34) occurred. In this first wave of SARS-CoV-2 infections in England, we estimated that the preventive measures imposed might have avoided 21 092 infections (19 777-22 147), 266 deaths (226-301), 1164 hospital admissions (1079-1254), and 338 ICU admissions (305-374) among the homeless population. If preventive measures are continued, we projected a small number of additional cases between June 1, 2020, and Jan 31, 2021, with 1754 infections (1543-1960), 31 deaths (21-45), 122 hospital admissions (100-148), and 35 ICU admissions (23-47) with a second wave in the general population. However, if preventive measures are lifted, outbreaks in homeless settings might lead to larger numbers of infections and deaths, even with low incidence in the general population. In a scenario with no second wave and relaxed measures in homeless settings in England, we projected 12 151 infections (10 718-13 349), 184 deaths (151-217), 733 hospital admissions (635-822), and 213 ICU admissions (178-251) between June 1, 2020, and Jan 31, 2021.

INTERPRETATION

Outbreaks of SARS-CoV-2 in homeless settings can lead to a high attack rate among people experiencing homelessness, even if incidence remains low in the general population. Avoidance of deaths depends on prevention of transmission within settings such as hostels and night shelters.

FUNDING

National Institute for Health Research, Wellcome, and Medical Research Council.

Discovery and validation of a personalized risk predictor for incident tuberculosis in low transmission settings

The risk of tuberculosis (TB) is variable among individuals with latent Mycobacterium tuberculosis infection (LTBI), but validated estimates of personalized risk are lacking. In pooled data from 18 systematically identified cohort studies from 20 countries, including 80,468 individuals tested for LTBI, 5-year cumulative incident TB risk among people with untreated LTBI was 15.6% (95% confidence interval (CI), 8.0-29.2%) among child contacts, 4.8% (95% CI, 3.0-7.7%) among adult contacts, 5.0% (95% CI, 1.6-14.5%) among migrants and 4.8% (95% CI, 1.5-14.3%) among immunocompromised groups. We confirmed highly variable estimates within risk groups, necessitating an individualized approach to risk stratification. Therefore, we developed a personalized risk predictor for incident TB (PERISKOPE-TB) that combines a quantitative measure of T cell sensitization and clinical covariates. Internal-external cross-validation of the model demonstrated a random effects meta-analysis C-statistic of 0.88 (95% CI, 0.82-0.93) for incident TB. In decision curve analysis, the model demonstrated clinical utility for targeting preventative treatment, compared to treating all, or no, people with LTBI. We challenge the current crude approach to TB risk estimation among people with LTBI in favor of our evidence-based and patient-centered method, in settings aiming for pre-elimination worldwide.

Health on the Move (HOME) Study: Using a smartphone app to explore the health and wellbeing of migrants in the United Kingdom

Background/Aim: We have a limited understanding of the broader determinants of health of international migrants and how these change over time since migration to the United Kingdom (UK). To address this knowledge gap, we aim to conduct a prospective cohort study with data acquisition via a smartphone application (app). In this pilot study, we aim to 1) determine the feasibility of the use of an app for data collection in international migrants, 2) optimise app engagement by quantifying the impact of specific design features on the completion rates of survey questionnaires and on study retention, 3) gather preliminary profile health status data, to begin to examine how risk factors for health are distributed among migrants. Methods: We will recruit 275 participants through a social media campaign and through third sector organisations that work with or support migrants in the UK. Following consent and registration, data will be collected via surveys. To optimise app engagement and study retention, we will quantify the impact of specific design features (i.e. the frequency of survey requests, the time of day for app notifications, the frequency of notifications, and the wording of notifications) via micro-randomised process evaluations. The primary outcome for this study is survey completion rates with numerator as the number of surveys completed and denominator as the total number of available surveys. Secondary outcomes are study retention rates and ratings of interest after app usage. Ethics and dissemination: We have obtained approval to use consented patient identifiable data from the University College London Ethics Committee. Improving engagement with the app and gathering preliminary health profile data will help us identify accessibility and usability issues and other barriers to app and study engagement prior to moving to a larger study.

A rapid review and meta-analysis of the asymptomatic proportion of PCR-confirmed SARS-CoV-2 infections in community settings

Background:Cross-sectional studies indicate thatup to 80% of active SARS-CoV-2 infections may be asymptomatic. However, accurate estimates of the asymptomatic proportion require systematic detection and follow-up to differentiate between truly asymptomatic and pre-symptomatic cases. We conducted a rapid review and meta-analysis of the asymptomatic proportion of PCR-confirmed SARS-CoV-2 infections based on methodologically appropriate studies in community settings.Methods:We searched Medline and EMBASE for peer-reviewed articles, and BioRxiv and MedRxiv for pre-prints published before 25/08/2020. We included studies based in community settings that involved systematic PCR testing on participants and follow-up symptom monitoring regardless of symptom status. We extracted data on study characteristics, frequencies of PCR-confirmed infections by symptom status, and (if available) cycle threshold/genome copy number values and/or duration of viral shedding by symptom status, and age of asymptomatic versus (pre)symptomatic cases. We computed estimates of the asymptomatic proportion and 95% confidence intervals for each study and overall using random effect meta-analysis. Results:We screened 1138 studies and included 21. The pooled asymptomatic proportion of SARS-CoV-2 infections was 23% (95% CI 16%-30%). When stratified by testing context, the asymptomatic proportion ranged from 6% (95% CI 0-17%) for household contacts to 47% (95% CI 21-75%) for non-outbreak point prevalence surveys with follow-up symptom monitoring. Estimates of viral load and duration of viral shedding appeared to be similar for asymptomatic and symptomatic cases based on available data, though detailed reporting of viral load and natural history of viral shedding by symptom status were limited. Evidence into the relationship between age and symptom status was inconclusive.Conclusion:Asymptomatic viral shedding comprises a substantial minority of SARS-CoV-2 infections when estimated using methodologically appropriate studies. Further investigation into variation in the asymptomatic proportion by testing context, the degree and duration of infectiousness for asymptomatic infections, and demographic predictors of symptom status are warranted.

Automated and partly automated contact tracing: a systematic review to inform the control of COVID-19

Evidence for the use of automated or partly automated contact-tracing tools to contain severe acute respiratory syndrome coronavirus 2 is scarce. We did a systematic review of automated or partly automated contact tracing. We searched PubMed, EMBASE, OVID Global Health, EBSCO Medical COVID Information Portal, Cochrane Library, medRxiv, bioRxiv, arXiv, and Google Advanced for articles relevant to COVID-19, severe acute respiratory syndrome, Middle East respiratory syndrome, influenza, or Ebola virus, published from Jan 1, 2000, to April 14, 2020. We also included studies identified through professional networks up to April 30, 2020. We reviewed all full-text manuscripts. Primary outcomes were the number or proportion of contacts (or subsequent cases) identified. Secondary outcomes were indicators of outbreak control, uptake, resource use, cost-effectiveness, and lessons learnt. This study is registered with PROSPERO (CRD42020179822). Of the 4036 studies identified, 110 full-text studies were reviewed and 15 studies were included in the final analysis and quality assessment. No empirical evidence of the effectiveness of automated contact tracing (regarding contacts identified or transmission reduction) was identified. Four of seven included modelling studies that suggested that controlling COVID-19 requires a high population uptake of automated contact-tracing apps (estimates from 56% to 95%), typically alongside other control measures. Studies of partly automated contact tracing generally reported more complete contact identification and follow-up compared with manual systems. Automated contact tracing could potentially reduce transmission with sufficient population uptake. However, concerns regarding privacy and equity should be considered. Well designed prospective studies are needed given gaps in evidence of effectiveness, and to investigate the integration and relative effects of manual and automated systems. Large-scale manual contact tracing is therefore still key in most contexts.

Management and control of tuberculosis control in socially complex groups: a research programme including three RCTs

Background

Socially complex groups, including people experiencing homelessness, prisoners and drug users, have very high levels of tuberculosis, often complicated by late diagnosis and difficulty in adhering to treatment.

Objective

To assess a series of interventions to improve tuberculosis control in socially complex groups.

Design

A series of observational surveys, evaluations and trials of interventions.

Setting

The pan-London Find&Treat service, which supports tuberculosis screening and case management in socially complex groups across London.

Participants

Socially complex groups with tuberculosis or at risk of tuberculosis, including people experiencing homelessness, prisoners, drug users and those at high risk of poor adherence to tuberculosis treatment.

Interventions and main outcome measures

We screened 491 people in homeless hostels and 511 people in prison for latent tuberculosis infection, human immunodeficiency virus, hepatitis B and hepatitis C. We evaluated an NHS-led prison radiographic screening programme. We conducted a cluster randomised controlled trial (2348 eligible people experiencing homelessness in 46 hostels) of the effectiveness of peer educators (22 hostels) compared with NHS staff (24 hostels) at encouraging the uptake of mobile radiographic screening. We initiated a trial of the use of point-of-care polymerase chain reaction diagnostics to rapidly confirm tuberculosis alongside mobile radiographic screening. We undertook a randomised controlled trial to improve treatment adherence, comparing face-to-face, directly observed treatment with video-observed treatment using a smartphone application. The primary outcome was completion of ≥ 80% of scheduled treatment observations over the first 2 months following enrolment. We assessed the cost-effectiveness of latent tuberculosis screening alongside radiographic screening of people experiencing homelessness. The costs of video-observed treatment and directly observed treatment were compared.

Results

In the homeless hostels, 16.5% of people experiencing homelessness had latent tuberculosis infection, 1.4% had current hepatitis B infection, 10.4% had hepatitis C infection and 1.0% had human immunodeficiency virus infection. When a quality-adjusted life-year is valued at £30,000, the latent tuberculosis screening of people experiencing homelessness was cost-effective provided treatment uptake was ≥ 25% (for a £20,000 quality-adjusted life-year threshold, treatment uptake would need to be > 50%). In prison, 12.6% of prisoners had latent tuberculosis infection, 1.9% had current hepatitis B infection, 4.2% had hepatitis C infection and 0.0% had human immunodeficiency virus infection. In both settings, levels of latent tuberculosis infection and blood-borne viruses were higher among injecting drug users. A total of 1484 prisoners were screened using chest radiography over a total of 112 screening days (new prisoner screening coverage was 43%). Twenty-nine radiographs were reported as potentially indicating tuberculosis. One prisoner began, and completed, antituberculosis treatment in prison. In the cluster randomised controlled trial of peer educators to increase screening uptake, the median uptake was 45% in the control arm and 40% in the intervention arm (adjusted risk ratio 0.98, 95% confidence interval 0.80 to 1.20). A rapid diagnostic service was established on the mobile radiographic unit but the trial of rapid diagnostics was abandoned because of recruitment and follow-up difficulties. We randomly assigned 112 patients to video-observed treatment and 114 patients to directly observed treatment. Fifty-eight per cent of those recruited had a history of homelessness, addiction, imprisonment or severe mental health problems. Seventy-eight (70%) of 112 patients on video-observed treatment achieved the primary outcome, compared with 35 (31%) of 114 patients on directly observed treatment (adjusted odds ratio 5.48, 95% confidence interval 3.10 to 9.68; p < 0.0001). Video-observed treatment was superior to directly observed treatment in all demographic and social risk factor subgroups. The cost for 6 months of treatment observation was £1645 for daily video-observed treatment, £3420 for directly observed treatment three times per week and £5700 for directly observed treatment five times per week.

Limitations

Recruitment was lower than anticipated for most of the studies. The peer advocate study may have been contaminated by the fact that the service was already using peer educators to support its work.

Conclusions

There are very high levels of latent tuberculosis infection among prisoners, people experiencing homelessness and drug users. Screening for latent infection in people experiencing homelessness alongside mobile radiographic screening would be cost-effective, providing the uptake of treatment was 25–50%. Despite ring-fenced funding, the NHS was unable to establish static radiographic screening programmes. Although we found no evidence that peer educators were more effective than health-care workers in encouraging the uptake of mobile radiographic screening, there may be wider benefits of including peer educators as part of the Find&Treat team. Utilising polymerase chain reaction-based rapid diagnostic testing on a mobile radiographic unit is feasible. Smartphone-enabled video-observed treatment is more effective and cheaper than directly observed treatment for ensuring that treatment is observed.

Future work

Trials of video-observed treatment in high-incidence settings are needed.

Trial registration

Current Controlled Trials ISRCTN17270334 and ISRCTN26184967.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 9. See the NIHR Journals Library website for further project information.

Impact of baseline cases of cough and fever on UK COVID-19 diagnostic testing rates: estimates from the Bug Watch community cohort study

Background: Diagnostic testing forms a major part of the UK's response to the current coronavirus disease 2019 (COVID-19) pandemic with tests offered to anyone with a continuous cough, high temperature or anosmia. Testing capacity must be sufficient during the winter respiratory season when levels of cough and fever are high due to non-COVID-19 causes. This study aims to make predictions about the contribution of baseline cough or fever to future testing demand in the UK. Methods: In this analysis of the Bug Watch prospective community cohort study, we estimated the incidence of cough or fever in England in 2018-2019. We then estimated the COVID-19 diagnostic testing rates required in the UK for baseline cough or fever cases for the period July 2020-June 2021. This was explored for different rates of the population requesting tests and four COVID-19 second wave scenarios. Estimates were then compared to current national capacity. Results: The baseline incidence of cough or fever in the UK is expected to rise rapidly from 154,554 (95%CI 103,083 - 231,725) cases per day in August 2020 to 250,708 (95%CI 181,095 - 347,080) in September, peaking at 444,660 (95%CI 353,084 - 559,988) in December. If 80% of baseline cough or fever cases request tests, average daily UK testing demand would exceed current capacity for five consecutive months (October 2020 to February 2021), with a peak demand of 147,240 (95%CI 73,978 - 239,502) tests per day above capacity in December 2020. Conclusions: Our results show that current national COVID-19 testing capacity is likely to be exceeded by demand due to baseline cough and fever alone. This study highlights that the UK's response to the COVID-19 pandemic must ensure that a high proportion of people with symptoms request tests, and that testing capacity is immediately scaled up to meet this high predicted demand.

Protocol for a systematic review of treatment adherence for HIV, hepatitis C and tuberculosis among homeless populations

BACKGROUND

Homelessness is a global issue and HIV, hepatitis C and tuberculosis are known to be prevalent in this group. Homeless populations face significant barriers to care. We aim to summarise evidence of treatment initiation and completion for homeless populations with these infections, and their associated factors, through a systematic review and meta-analysis.

METHODS

We will search MEDLINE, Embase and CINAHL for all study types and conference abstracts looking at either (1) treatment initiation in a cohort experiencing homelessness with at least one of HIV, hepatitis C, active tuberculosis and/or latent tuberculosis infection (LTBI); (2) treatment completion for those who initiated treatment. We will perform a meta-analysis of the proportion of those with each infection who initiate and complete treatment, as well as analysis of individual and health system factors that may affect adherence levels. We will evaluate the quality of research papers using the Newcastle-Ottawa scale.

DISCUSSION

Given the political emphasis on global elimination of these diseases, and the current lack of understanding of effective and equitable treatment adherence strategies in homeless populations, this review will provide insight to policy-makers and service providers aiming to improve homeless healthcare.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019153150.

Developing a smartphone app with UK migrants for UK migrants: lessons learned from focus group work

Background

In 2018, 14% of people living in the UK were born abroad, yet we have a limited understanding of the broader determinants of their health. To address this knowledge gap, the Health on the MovE (HOME) smartphone application (app) study was conceived. Through app-based surveys, the study will examine how risk factors for health and well-being are distributed among migrants and how these vary over time since migration to the UK. There is a lack of research addressing the development of apps for longitudinal data collection in the general population - and we did not find any in migrant groups.

Methods

To better inform the design of the HOME app study, three workshops were held in 2018 and 2019, involving both migrants and App development experts. We used a semi-structured interview schedule focused on five themes: smartphones, apps and research, HOME app wireframe (screen-by-screen review of the app), types of surveys and survey schedules, resource section content, and participant engagement strategies. The participants were purposively sampled to reflect the migrant population arriving in the UK from non-EU countries.

Results

Migrants reported high smartphone use and were positive about the app design and app-based research. Concerns around privacy and data protection were highlighted and limits were suggested for the frequency of surveys and the number of questions used. Mental health was identified as a key topic for research. Participants requested the inclusion of resources concerning asylum claim procedures and immigrant and labour laws. Migrants advised that study recruitment material should clearly state the purpose and scope of the research and requested regular feedback on study outcomes.

Conclusions

The workshops provided important feedback and facilitated the co-production of the HOME app. Overall findings suggest that the study would be both acceptable to the migrant population and feasible for real-time data collection.

Key messages

The process identified potential barriers to the acceptability and feasibility of an app-based study for real-time data collection in the UK migrant population. Organising workshops with migrants allowed for an iterative process of co-production of the HOME app. Their critical comments resulted in subsequent changes to the app design and study methodology.

Training the next generation in transdisciplinarity

Background

Transdisciplinarity is ideally suited to investigating the determinants of health, as it requires the understanding of multiple, interlinking factors such as poverty, culture, education, environment, and public policy. In this study, we set out to understand how others have taught transdisciplinary research methods to identify common teaching methods and best practices.

Methods

We conducted two separate literature reviews using OVID Medline. The first identified articles that conducted transdisciplinary research and the second focused on teaching transdisciplinary research. Studies from both searches were included if they described the methods used to teach transdisciplinary research. Data were extracted on teaching strategies, student assessment, and the cited benefits of both.

Results

Our search of transdisciplinary research papers provided 528 papers whilst our search on teaching transdisciplinary research methods identified 100. After screening, we included 23 papers. Forms of teaching transdisciplinary research were diverse, and included mentoring and multi-mentoring to learn from the experiences of others, small group work to develop interpersonal transdisciplinary skills, immersion in real-life experiences to develop research skills and peer discussion groups to facilitate peer-peer learning. Assessment methods included critical evaluations of past projects and group coursework.

Conclusions

Our review highlighted that a combination of interactive, problem-based discussion and hands-on learning experiences (assessed and non-assessed) were used for transdisciplinary learning and skills acquisition, which needs to be combined with an assortment of exposures to different disciplines in the forms of lectures, readings and learning material.

Key messages

Training the next generation in transdisciplinarity involves a diverse range of methods including immersion in real-life experiences. Transdisciplinary teaching involves an assortment of exposures to different disciplines in the forms of lectures, readings and learning material.

Left behind: the state of universal health coverage in Europe

Background

Barriers to access healthcare and lack of data undermine Universal Health Coverage (UHC) in Europe, despite the region's clear commitment to the Sustainable Development Goals and UHC. Current indicators measuring unmet healthcare needs in the European Union (EU) often exclude more marginalised groups, further rendering their health needs invisible and the data to inform policy flawed. For effective evaluation of UHC, comprehensive data on the health of these groups is needed.

Methods

We conducted an evaluation of humanitarian healthcare provision of people attending Médecins du Monde (MdM) programmes in seven countries in Europe (Belgium, France, Germany, Luxembourg, Sweden, Switzerland, and the United Kingdom). MdM is a humanitarian organisation, providing care to those excluded from mainstream healthcare services. We describe the characteristics of MdM service users, their determinants of health and healthcare access.

Results

A total of 29,359 people were seen between January 2017 and December 2018. Nearly all were migrants (97.2%, 21,591/22,136), with 66.3% (11,690/17,629) of people reported not having a right or permission to reside in the country they presented in. A majority were living below the poverty line (92.6%, 7,660/8,268), residing in insecure housing (44.3%, 8,895/20,097) or living as street homeless or in emergency shelters (20.4%, 4,107/20,097). Most people reported having no healthcare coverage (81.7%, 14,848/18,164). When asked about barriers to accessing healthcare, 20.8% of responses reported economic barriers (3,960/19,020) and 14.3% reported a lack of knowledge of health system/entitlements (2,718/19,020).

Conclusions

This humanitarian service evaluation highlights the intersecting vulnerabilities and barriers to access healthcare for people excluded from mainstream healthcare systems across Europe. Our findings provide a unique insight into the extent of unmet healthcare needs of migrants and other marginalised populations.

Key messages

UHC requires comprehensive data on the population groups who are many times left without access to health services and who are often excluded from national data collection and research. A majority of MdM service users do not have healthcare coverage and experience multiple and intersecting barriers to access healthcare across Europe.

Mobile-based and open-source infectious disease surveillance and outbreak management in Tanzania

Introduction

The PANDORA-ID-NET consortium aims to build capacity for effective outbreak response in sub-Saharan Africa. Part of this mission is to develop a real-time data sharing platform for disease outbreaks that leverages centralised data management and uses mobile technologies for data gathering and feedback. We have committed to using open-source technologies, so that the platform can be deployed on regional IT infrastructure and further developed by local staff, and collected data can be stored and processed in the region of origin. This abstract aims to describe how we identified a state of the art open-source system that fulfils these criteria, and the process of how we are extending it to function within the current infectious disease control framework in Tanzania, under our partnership with the Ifakara Health Institute (IHI).

Methods

To find state of the art open-source systems matching our criteria, we performed a rapid review of the literature. We screened 1022 articles and found 15 candidate systems, out of which only SORMAS satisfied the criteria. SORMAS was developed jointly by the Helmholtz Centre for Infection Research (HZI) and the Nigeria CDC, and was modeled on Nigeria's successful response to the Ebola outbreak. The system can be used for case management, contact tracing, surveillance, and laboratory sample management. Data is collected and synchronised using Android mobile devices (both online and offline) and data aggregation and analysis are performed in real-time via a web application

Results

Having chosen SORMAS, we established a collaboration between the SORMAS developer team and the PANDORA team. IHI are guiding ongoing work on adapting SORMAS to the Tanzanian health facility geography and the country's case definition guidelines for notifiable diseases.

Conclusions

Once adapted for Tanzania, SORMAS will fill an unoccupied niche in infectious disease control, improving the quality of collected case data and enabling better outbreak response

Key messages

A state of the art, mobile-based, open-source outbreak management and infectious disease surveillance system (SORMAS) is being deployed in Tanzania. We outline our experience with piloting SORMAS in Tanzania, building on the experience of our Nigerian and German partners, who rolled out this system nationally in Nigeria and other African countries.

Healthcare resource utilisation and mortality outcomes in international migrants to the UK: analysis protocol for a linked population-based cohort study using Clinical Practice Research Datalink (CPRD), Hospital Episode Statistics (HES) and the Office for National Statistics (ONS)

An estimated 14.2% (9.34 million people) of people living in the UK in 2019 were international migrants. Despite this, there are no large-scale national studies of their healthcare resource utilisation and little is known about how migrants access and use healthcare services. One ongoing study of migration health in the UK, the Million Migrants study, links electronic health records (EHRs) from hospital-based data, national death records and Public Health England migrant and refugee data. However, the Million Migrants study cannot provide a complete picture of migration health resource utilisation as it lacks data on migrants from Europe and utilisation of primary care for all international migrants. Our study seeks to address this limitation by using primary care EHR data linked to hospital-based EHRs and national death records.  Our study is split into a feasibility study and a main study. The feasibility study will assess the validity of a migration phenotype, a transparent reproducible algorithm using clinical terminology codes to determine migration status in Clinical Practice Research Datalink (CPRD), the largest UK primary care EHR. If the migration phenotype is found to be valid, the main study will involve using the phenotype in the linked dataset to describe primary care and hospital-based healthcare resource utilisation and mortality in migrants compared to non-migrants. All outcomes will be explored according to sub-conditions identified as research priorities through patient and public involvement, including preventable causes of inpatient admission, sexual and reproductive health conditions/interventions and mental health conditions. The results will generate evidence to inform policies that aim to improve migration health and universal health coverage.

Black, Asian and Minority Ethnic groups in England are at increased risk of death from COVID-19: indirect standardisation of NHS mortality data

Background: International and UK data suggest that Black, Asian and Minority Ethnic (BAME) groups are at increased risk of infection and death from COVID-19. We aimed to explore the risk of death in minority ethnic groups in England using data reported by NHS England. Methods: We used NHS data on patients with a positive COVID-19 test who died in hospitals in England published on 28th April, with deaths by ethnicity available from 1st March 2020 up to 5pm on 21 April 2020. We undertook indirect standardisation of these data (using the whole population of England as the reference) to produce ethnic specific standardised mortality ratios (SMRs) adjusted for age and geographical region. Results: The largest total number of deaths in minority ethnic groups were Indian (492 deaths) and Black Caribbean (460 deaths) groups. Adjusting for region we found a lower risk of death for White Irish (SMR 0.52; 95%CIs 0.45-0.60) and White British ethnic groups (0.88; 95%CIs 0.86-0.0.89), but increased risk of death for Black African (3.24; 95%CIs 2.90-3.62), Black Caribbean (2.21; 95%CIs 2.02-2.41), Pakistani (3.29; 95%CIs 2.96-3.64), Bangladeshi (2.41; 95%CIs 1.98-2.91) and Indian (1.70; 95%CIs 1.56-1.85) minority ethnic groups. Conclusion: Our analysis adds to the evidence that BAME people are at increased risk of death from COVID-19 even after adjusting for geographical region, but was limited by the lack of data on deaths outside of NHS settings and ethnicity denominator data being based on the 2011 census. Despite these limitations, we believe there is an urgent need to take action to reduce the risk of death for BAME groups and better understand why some ethnic groups experience greater risk. Actions that are likely to reduce these inequities include ensuring adequate income protection, reducing occupational risks, reducing barriers in accessing healthcare and providing culturally and linguistically appropriate public health communications.

From the micro to the macro to improve health: microorganism ecology and society in teaching infectious disease epidemiology

Chronic and emerging infectious diseases and antimicrobial resistance remain a substantial global health threat. Microbiota are increasingly recognised to play an important role in health. Infections also have a profound effect beyond health, especially on global and local economies. To maximise health improvements, the field of infectious disease epidemiology needs to derive learning from ecology and traditional epidemiology. New methodologies and tools are transforming understanding of these systems, from a better understanding of socioeconomic, environmental, and cultural drivers of infection, to improved methods to detect microorganisms, describe the immunome, and understand the role of human microbiota. However, exploiting the potential of novel methods to improve global health remains elusive. We argue that to exploit these advances a shift is required in the teaching of infectious disease epidemiology to ensure that students are well versed in a breadth of disciplines, while maintaining core epidemiological skills. We discuss the following key points using a series of teaching vignettes: (1) integrated training in classic and novel techniques is needed to develop future scientists and professionals who can work from the micro (interactions between pathogens, their cohabiting microbiota, and the host at a molecular and cellular level), with the meso (the affected communities), and to the macro (wider contextual drivers of disease); (2) teach students to use a team-science multidisciplinary approach to effectively integrate biological, clinical, epidemiological, and social tools into public health; and (3) develop the intellectual skills to critically engage with emerging technologies and resolve evolving ethical dilemmas. Finally, students should appreciate that the voices of communities affected by infection need to be kept at the heart of their work.

Black, Asian and Minority Ethnic groups in England are at increased risk of death from COVID-19: indirect standardisation of NHS mortality data

Background: International and UK data suggest that Black, Asian and Minority Ethnic (BAME) groups are at increased risk of infection and death from COVID-19. We aimed to explore the risk of death in minority ethnic groups in England using data reported by NHS England. Methods: We used NHS data on patients with a positive COVID-19 test who died in hospitals in England published on 28th April, with deaths by ethnicity available from 1st March 2020 up to 5pm on 21 April 2020. We undertook indirect standardisation of these data (using the whole population of England as the reference) to produce ethnic specific standardised mortality ratios (SMRs) adjusted for age and geographical region. Results: The largest total number of deaths in minority ethnic groups were Indian (492 deaths) and Black Caribbean (460 deaths) groups. Adjusting for region we found a lower risk of death for White Irish (SMR 0.52; 95%CIs 0.45-0.60) and White British ethnic groups (0.88; 95%CIs 0.86-0.0.89), but increased risk of death for Black African (3.24; 95%CIs 2.90-3.62), Black Caribbean (2.21; 95%CIs 2.02-2.41), Pakistani (3.29; 95%CIs 2.96-3.64), Bangladeshi (2.41; 95%CIs 1.98-2.91) and Indian (1.70; 95%CIs 1.56-1.85) minority ethnic groups. Conclusion: Our analysis adds to the evidence that BAME people are at increased risk of death from COVID-19 even after adjusting for geographical region. We believe there is an urgent need to take action to reduce the risk of death for BAME groups and better understand why some ethnic groups experience greater risk. Actions that are likely to reduce these inequities include ensuring adequate income protection (so that low paid and zero-hours contract workers can afford to follow social distancing recommendations), reducing occupational risks (such as ensuring adequate personal protective equipment), reducing barriers in accessing healthcare and providing culturally and linguistically appropriate public health communications.

Seasonality and immunity to laboratory-confirmed seasonal coronaviruses (HCoV-NL63, HCoV-OC43, and HCoV-229E): results from the Flu Watch cohort study

Background: There is currently a pandemic caused by the novel coronavirus SARS-CoV-2. The intensity and duration of this first wave in the UK may be dependent on whether SARS-CoV-2 transmits more effectively in the winter than the summer and the UK Government response is partially built upon the assumption that those infected will develop immunity to reinfection in the short term. In this paper we examine evidence for seasonality and immunity to laboratory-confirmed seasonal coronavirus (HCoV) from a prospective cohort study in England. Methods: In this analysis of the Flu Watch cohort, we examine seasonal trends for PCR-confirmed coronavirus infections (HCoV-NL63, HCoV-OC43, and HCoV-229E) in all participants during winter seasons (2006-2007, 2007-2008, 2008-2009) and during the first wave of the 2009 H1N1 influenza pandemic (May-Sep 2009). We also included data from the pandemic and 'post-pandemic' winter seasons (2009-2010 and 2010-2011) to identify individuals with two confirmed HCoV infections and examine evidence for immunity against homologous reinfection. Results: We tested 1,104 swabs taken during respiratory illness and detected HCoV in 199 during the first four seasons. The rate of confirmed HCoV infection across all seasons was 390 (95% CI 338-448) per 100,000 person-weeks; highest in the Nov-Mar 2008/9 season at 674 (95%CI 537-835). The highest rate was in February at 759 (95% CI 580-975). Data collected during May-Sep 2009 showed there was small amounts of ongoing transmission, with four cases detected during this period. Eight participants had two confirmed infections, of which none had the same strain twice. Conclusion: Our results provide evidence that HCoV infection in England is most intense in winter, but that there is a small amount of ongoing transmission during summer periods. We found some evidence of immunity against homologous reinfection.

Mobile-based and open-source case detection and infectious disease outbreak management systems: a review

In this paper we perform a rapid review of existing mobile-based, open-source systems for infectious disease outbreak data collection and management. Our inclusion criteria were designed to match the PANDORA-ID-NET consortium’s goals for capacity building in sub-Saharan Africa, and to reflect the lessons learned from the 2014–16 West African Ebola outbreak. We found eight candidate systems that satisfy some or most of these criteria, but only one (SORMAS) fulfils all of them. In addition, we outline a number of desirable features that are not currently present in most outbreak management systems.

Data-driven discovery of changes in clinical code usage over time: a case-study on changes in cardiovascular disease recording in two English electronic health records databases (2001-2015)

OBJECTIVES

To demonstrate how data-driven variability methods can be used to identify changes in disease recording in two English electronic health records databases between 2001 and 2015.

DESIGN

Repeated cross-sectional analysis that applied data-driven temporal variability methods to assess month-by-month changes in routinely collected medical data. A measure of difference between months was calculated based on joint distributions of age, gender, socioeconomic status and recorded cardiovascular diseases. Distances between months were used to identify temporal trends in data recording.

SETTING

400 English primary care practices from the Clinical Practice Research Datalink (CPRD GOLD) and 451 hospital providers from the Hospital Episode Statistics (HES).

MAIN OUTCOMES

The proportion of patients (CPRD GOLD) and hospital admissions (HES) with a recorded cardiovascular disease (CPRD GOLD: coronary heart disease, heart failure, peripheral arterial disease, stroke; HES: International Classification of Disease codes I20-I69/G45).

RESULTS

Both databases showed gradual changes in cardiovascular disease recording between 2001 and 2008. The recorded prevalence of included cardiovascular diseases in CPRD GOLD increased by 47%-62%, which partially reversed after 2008. For hospital records in HES, there was a relative decrease in angina pectoris (-34.4%) and unspecified stroke (-42.3%) over the same time period, with a concomitant increase in chronic coronary heart disease (+14.3%). Multiple abrupt changes in the use of myocardial infarction codes in hospital were found in March/April 2010, 2012 and 2014, possibly linked to updates of clinical coding guidelines.

CONCLUSIONS

Identified temporal variability could be related to potentially non-medical causes such as updated coding guidelines. These artificial changes may introduce temporal correlation among diagnoses inferred from routine data, violating the assumptions of frequently used statistical methods. Temporal variability measures provide an objective and robust technique to identify, and subsequently account for, those changes in electronic health records studies without any prior knowledge of the data collection process.

Premature mortality attributable to socioeconomic inequality in England between 2003 and 2018: an observational study

BACKGROUND

Low socioeconomic position is consistently associated with increased risk of premature death. The aim of this study is to measure the aggregate scale of inequality in premature mortality for the whole population of England.

METHODS

We used mortality records from the UK Office for National Statistics to study all 2 465 285 premature deaths (defined as those before age 75 years) in England between Jan 1, 2003, and Dec 31, 2018. Socioeconomic position was defined using deciles of the Index of Multiple Deprivation: a measure of neighbourhood income, employment, education levels, crime, health, availability of services, and local environment. We calculated the number of expected deaths by applying mortality in the least deprived decile to other deciles, within the strata of age, sex, and time. The mortality attributable to socioeconomic inequality was defined as the difference between the observed and expected deaths. We also used life table modelling to estimate years-of-life lost attributable to socioeconomic inequality.

FINDINGS

35·6% (95% CI 35·3-35·9) of premature deaths were attributable to socioeconomic inequality, equating to 877 082 deaths, or one every 10 min. The biggest contributors were ischaemic heart disease (152 171 excess deaths), respiratory cancers (111 083) and chronic obstructive pulmonary disease (83 593). The most unequal causes of death were tuberculosis, opioid use, HIV, psychoactive drugs use, viral hepatitis, and obesity, each with more than two-thirds attributable to inequality. Inequality was greater among men and peaked in early childhood and at age 40-49 years. The proportion of deaths attributable to inequality increased during the study period, particularly for women, because mortality rates among the most deprived women (excluding cardiovascular diseases) plateaued, and for some diseases increased. A mean of 14·4 months of life before age 75 years are lost due to socioeconomic inequality.

INTERPRETATION

One in three premature deaths are attributable to socioeconomic inequality, making this our most important public health challenge. Interventions that address upstream determinants of health should be prioritised.

FUNDING

National Institute of Health Research; Wellcome Trust.

Causes of hospital admission and mortality among 6683 people who use heroin: A cohort study comparing relative and absolute risks

BACKGROUND

Mortality in high-risk groups such as people who use illicit drugs is often expressed in relative terms such as standardised ratios. These measures are highest for diseases that are rare in the general population, such as hepatitis C, and may understate the importance of common long-term conditions.

POPULATION

6683 people in community-based treatment for heroin dependence between 2006 and 2017 in London, England, linked to national hospital and mortality databases with 55,683 years of follow-up.

METHOD

Age- and sex-specific mortality and hospital admission rates in the general population of London were used to calculate the number of expected events. We compared standardised ratios (relative risk) to excess deaths and admissions (absolute risk) across ICD-10 chapters and subcategories.

RESULTS

Drug-related diseases had the highest relative risks, with a standardised mortality ratio (SMR) of 48 (95% CI 42-54) and standardised admission ratio (SAR) of 293 (95% CI 282-304). By contrast, other diseases had an SMR of 4.4 (95% CI 4.0-4.9) and an SAR of 3.15 (95% CI 3.11-3.19). However, the majority of the 621 excess deaths (95% CI 569-676) were not drug-related (361; 58%). The largest groups were liver disease (75 excess deaths) and COPD (45). Similarly, 80% (11,790) of the 14,668 excess admissions (95% CI 14,382-14,957) were not drug-related. The largest groups were skin infections (1073 excess admissions), alcohol (1060), COPD (812) and head injury (612).

CONCLUSIONS

Although relative risks of drug-related diseases are very high, most excess morbidity and mortality in this cohort was caused by common long-term conditions.

The negative health effects of hostile environment policies on migrants: A cross-sectional service evaluation of humanitarian healthcare provision in the UK

Background: Recent UK 'hostile environment' immigration policies, including obligatory charging and sharing of confidential data between NHS Digital and the Home Office, have created an atmosphere of fear and exposed already highly marginalised and vulnerable groups to significant health risks by increasing barriers to accessing NHS care.  Methods:  This is a cross-sectional observational study of patients accessing healthcare at Doctors of the World (DOTW) in the UK. DOTW is a humanitarian organisation, providing care to those excluded from NHS healthcare. We aimed to describe population characteristics of individuals using DOTW services and identify groups at greatest risk of facing 'hostile environment'-related barriers to NHS care, specifically being denied healthcare or fear of arrest. Results: A total of 1474 adults were seen in 2016. Nearly all were non-EU/EEA nationals (97.8%; 1441/1474), living in poverty (68.6%; 1011/1474). DOTW saw a large number of undocumented migrants (57.1%; 841/1474) and asylum seekers (18.2%; 268/1474). 10.2% (151/1474) of adults seen had been denied NHS healthcare and 7.7% (114/1474) were afraid to access NHS services. Asylum seeker status was associated with the highest risk (adjusted odds ratio (OR): 2.48; 95% confidence interval (CI): 1.48-4.14) of being denied NHS healthcare and being undocumented was associated with the highest risk of fearing arrest (adjusted OR: 3.03; 95% CI: 1.70-5.40). Conclusions: Our findings make visible the multiple and intersecting vulnerabilities of individuals forced to seek care outside of the NHS, underlining the public health imperative for the government to urgently withdraw its 'hostile environment' policies and address their negative health impacts.

Our data, our society, our health: A vision for inclusive and transparent health data science in the United Kingdom and beyond

The last 6 years have seen sustained investment in health data science in the United Kingdom and beyond, which should result in a data science community that is inclusive of all stakeholders, working together to use data to benefit society through the improvement of public health and well-being. However, opportunities made possible through the innovative use of data are still not being fully realised, resulting in research inefficiencies and avoidable health harms. In this paper, we identify the most important barriers to achieving higher productivity in health data science. We then draw on previous research, domain expertise, and theory to outline how to go about overcoming these barriers, applying our core values of inclusivity and transparency. We believe a step change can be achieved through meaningful stakeholder involvement at every stage of research planning, design, and execution and team-based data science, as well as harnessing novel and secure data technologies. Applying these values to health data science will safeguard a social licence for health data research and ensure transparent and secure data usage for public benefit.

Occupational health outcomes among international migrant workers: a systematic review and meta-analysis

BACKGROUND

Globally, there are more than 150 million international migrant workers-individuals who are employed outside of their country of origin-comprising the largest international migrant group. A substantial number of migrants work in hazardous and exploitative environments, where they might be at considerable risk of injury and ill health. However, little data on occupational health outcomes of migrant workers exist, with which to inform global policy making and delivery of health services.

METHODS

For this systematic review and meta-analysis, we searched Embase, MEDLINE, Ovid Global Health, and PsychINFO databases for primary research published between Jan 1, 2008, and Jan 24, 2018, reporting occupational health outcomes among international migrant workers (defined as individuals who are or have been employed outside their country of origin), without language or geographical restrictions. We excluded studies containing mixed cohorts of migrants and native workers in which migrant data could not be disaggregated, and studies that did not explicitly report migrant status. The main outcome was prevalence of occupational health outcomes (defined as any injury, mortality, or physical or psychiatric morbidity due to an individual's work or workplace environment) among international migrant workers. Summary estimates were calculated using random-effects models. The study protocol has been registered with PROSPERO, number CRD42018099465.

FINDINGS

Of the 1218 studies identified by our search, 36 studies were included in our systematic review, and 18 studies were included in the meta-analysis. The systematic review included occupational health outcomes for 12 168 international migrant workers employed in 13 countries and territories, mostly employed in unskilled manual labour. Migrant workers originated from 25 low-income and middle-income countries, and worked in the following sectors: agriculture; domestic, retail, and service sectors; construction and trade; and manufacturing and processing. Migrant workers had various psychiatric and physical morbidities, and workplace accidents and injuries were relatively common. In the meta-analysis, among 7260 international migrant workers, the pooled prevalence of having at least one occupational morbidity was 47% (95% CI 29-64; I2=99·70%). Among 3890 migrant workers, the prevalence of having at least one injury or accident, including falls from heights, fractures and dislocations, ocular injuries, and cuts was 22% (7-37; I2=99·35%).

INTERPRETATION

International migrant workers are at considerable risk of work-related ill health and injury, and their health needs are critically overlooked in research and policy. Governments, policy makers, and businesses must enforce and improve occupational health and safety measures, which should be accompanied by accessible, affordable, and appropriate health care and insurance coverage to meet the care needs of this important working population.

FUNDING

Wellcome Trust.

Accuracy of an automated system for tuberculosis detection on chest radiographs in high-risk screening

SETTING:

Tuberculosis (TB) screening programmes can be optimised by reducing the number of chest radiographs (CXRs) requiring interpretation by human experts.

OBJECTIVE:

To evaluate the performance of computerised detection software in triaging CXRs in a high-throughput digital mobile TB screening programme.

DESIGN:

A retrospective evaluation of the software was performed on a database of 38 961 postero-anterior CXRs from unique individuals seen between 2005 and 2010, 87 of whom were diagnosed with TB. The software generated a TB likelihood score for each CXR. This score was compared with a reference standard for notified active pulmonary TB using receiver operating characteristic (ROC) curve and localisation ROC (LROC) curve analyses.

RESULTS:

On ROC curve analysis, software specificity was 55.71% (95%CI 55.21–56.20) and negative predictive value was 99.98% (95%CI 99.95–99.99), at a sensitivity of 95%. The area under the ROC curve was 0.90 (95%CI 0.86–0.93). Results of the LROC curve analysis were similar.

CONCLUSION:

The software could identify more than half of the normal images in a TB screening setting while maintaining high sensitivity, and may therefore be used for triage.

Health-related quality of life and prevalence of six chronic diseases in homeless and housed people: a cross-sectional study in London and Birmingham, England

OBJECTIVES

To compare health-related quality of life and prevalence of chronic diseases in housed and homeless populations.

DESIGN

Cross-sectional survey with an age-matched and sex-matched housed comparison group.

SETTING

Hostels, day centres and soup runs in London and Birmingham, England.

PARTICIPANTS

Homeless participants were either sleeping rough or living in hostels and had a history of sleeping rough. The comparison group was drawn from the Health Survey for England. The study included 1336 homeless and 13 360 housed participants.

OUTCOME MEASURES

Chronic diseases were self-reported asthma, chronic obstructive pulmonary disease (COPD), epilepsy, heart problems, stroke and diabetes. Health-related quality of life was measured using EQ-5D-3L.

RESULTS

Housed participants in more deprived neighbourhoods were more likely to report disease. Homeless participants were substantially more likely than housed participants in the most deprived quintile to report all diseases except diabetes (which had similar prevalence in homeless participants and the most deprived housed group). For example, the prevalence of chronic obstructive pulmonary disease was 1.1% (95% CI 0.7% to 1.6%) in the least deprived housed quintile; 2.0% (95% CI 1.5% to 2.6%) in the most deprived housed quintile; and 14.0% (95% CI 12.2% to 16.0%) in the homeless group. Social gradients were also seen for problems in each EQ-5D-3L domain in the housed population, but homeless participants had similar likelihood of reporting problems as the most deprived housed group. The exception was problems related to anxiety, which were substantially more common in homeless people than any of the housed groups.

CONCLUSIONS

While differences in health between housed socioeconomic groups can be described as a 'slope', differences in health between housed and homeless people are better understood as a 'cliff'.

Effects of non-health-targeted policies on migrant health: a systematic review and meta-analysis

BACKGROUND

Government policies can strongly influence migrants' health. Using a Health in All Policies approach, we systematically reviewed evidence on the impact of public policies outside of the health-care system on migrant health.

METHODS

We searched the PubMed, Embase, and Web of Science databases from Jan 1, 2000, to Sept 1, 2017, for quantitative studies comparing the health effects of non-health-targeted public policies on migrants with those on a relevant comparison population. We searched for articles written in English, Swedish, Danish, Norwegian, Finnish, French, Spanish, or Portuguese. Qualitative studies and grey literature were excluded. We evaluated policy effects by migration stage (entry, integration, and exit) and by health outcome using narrative synthesis (all included studies) and random-effects meta-analysis (all studies whose results were amenable to statistical pooling). We summarised meta-analysis outcomes as standardised mean difference (SMD, 95% CI) or odds ratio (OR, 95% CI). To assess certainty, we created tables containing a summary of the findings according to the Grading of Recommendations Assessment, Development, and Evaluation. Our study was registered with PROSPERO, number CRD42017076104.

FINDINGS

We identified 43 243 potentially eligible records. 46 articles were narratively synthesised and 19 contributed to the meta-analysis. All studies were published in high-income countries and examined policies of entry (nine articles) and integration (37 articles). Restrictive entry policies (eg, temporary visa status, detention) were associated with poor mental health (SMD 0·44, 95% CI 0·13-0·75; I2=92·1%). In the integration phase, restrictive policies in general, and specifically regarding welfare eligibility and documentation requirements, were found to increase odds of poor self-rated health (OR 1·67, 95% CI 1·35-1·98; I2=82·0%) and mortality (1·38, 1·10-1·65; I2=98·9%). Restricted eligibility for welfare support decreased the odds of general health-care service use (0·92, 0·85-0·98; I2=0·0%), but did not reduce public health insurance coverage (0·89, 0·71-1·07; I2=99·4%), nor markedly affect proportions of people without health insurance (1·06, 0·90-1·21; I2=54·9%).

INTERPRETATION

Restrictive entry and integration policies are linked to poor migrant health outcomes in high-income countries. Efforts to improve the health of migrants would benefit from adopting a Health in All Policies perspective.

FUNDING

Swedish Council for Health, Working Life, and Social Research; UK Medical Research Council; Scottish Government Chief Scientist Office.

Smartphone-enabled video-observed versus directly observed treatment for tuberculosis: a multicentre, analyst-blinded, randomised, controlled superiority trial

BACKGROUND

Directly observed treatment (DOT) has been the standard of care for tuberculosis since the early 1990s, but it is inconvenient for patients and service providers. Video-observed therapy (VOT) has been conditionally recommended by WHO as an alternative to DOT. We tested whether levels of treatment observation were improved with VOT.

METHODS

We did a multicentre, analyst-blinded, randomised controlled superiority trial in 22 clinics in England (UK). Eligible participants were patients aged at least 16 years with active pulmonary or non-pulmonary tuberculosis who were eligible for DOT according to local guidance. Exclusion criteria included patients who did not have access to charging a smartphone. We randomly assigned participants to either VOT (daily remote observation using a smartphone app) or DOT (observations done three to five times per week in the home, community, or clinic settings). Randomisation was done by the SealedEnvelope service using minimisation. DOT involved treatment observation by a health-care or lay worker, with any remaining daily doses self-administered. VOT was provided by a centralised service in London. Patients were trained to record and send videos of every dose ingested 7 days per week using a smartphone app. Trained treatment observers viewed these videos through a password-protected website. Patients were also encouraged to report adverse drug events on the videos. Smartphones and data plans were provided free of charge by study investigators. DOT or VOT observation records were completed by observers until treatment or study end. The primary outcome was completion of 80% or more scheduled treatment observations over the first 2 months following enrolment. Intention-to-treat (ITT) and restricted (including only patients completing at least 1 week of observation on allocated arm) analyses were done. Superiority was determined by a 15% difference in the proportion of patients with the primary outcome (60% vs 75%). This trial is registered with the International Standard Randomised Controlled Trials Number registry, number ISRCTN26184967.

FINDINGS

Between Sept 1, 2014, and Oct 1, 2016, we randomly assigned 226 patients; 112 to VOT and 114 to DOT. Overall, 131 (58%) patients had a history of homelessness, imprisonment, drug use, alcohol problems or mental health problems. In the ITT analysis, 78 (70%) of 112 patients on VOT achieved ≥80% scheduled observations successfully completed during the first 2 months compared with 35 (31%) of 114 on DOT (adjusted odds ratio [OR] 5·48, 95% CI 3·10-9·68; p<0·0001). In the restricted analysis, 78 (77%) of 101 patients on VOT achieved the primary outcome compared with 35 (63%) of 56 on DOT (adjusted OR 2·52; 95% CI 1·17-5·54; p=0·017). Stomach pain, nausea, and vomiting were the most common adverse events reported (in 16 [14%] of 112 on VOT and nine [8%] of 114 on DOT).

INTERPRETATION

VOT was a more effective approach to observation of tuberculosis treatment than DOT. VOT is likely to be preferable to DOT for many patients across a broad range of settings, providing a more acceptable, effective, and cheaper option for supervision of daily and multiple daily doses than DOT.

FUNDING

National Institute for Health Research.

Causes of death among homeless people: a population-based cross-sectional study of linked hospitalisation and mortality data in England

Background: Homelessness has increased by 165% since 2010 in England, with evidence from many settings that those affected experience high levels of mortality. In this paper we examine the contribution of different causes of death to overall mortality in homeless people recently admitted to hospitals in England with specialist integrated homeless health and care (SIHHC) schemes.  Methods: We undertook an analysis of linked hospital admission records and mortality data for people attending any one of 17 SIHHC schemes between 1st November 2013 and 30th November 2016. Our primary outcome was death, which we analysed in subgroups of 10th version international classification of disease (ICD-10) specific deaths; and deaths from amenable causes. We compared our results to a sample of people living in areas of high social deprivation (IMD5 group). Results: We collected data on 3,882 individual homeless hospital admissions that were linked to 600 deaths. The median age of death was 51.6 years (interquartile range 42.7-60.2) for SIHHC and 71.5 for the IMD5 (60.67-79.0).  The top three underlying causes of death by ICD-10 chapter in the SIHHC group were external causes of death (21.7%; 130/600), cancer (19.0%; 114/600) and digestive disease (19.0%; 114/600).  The percentage of deaths due to an amenable cause after age and sex weighting was 30.2% in the homeless SIHHC group (181/600) compared to 23.0% in the IMD5 group (578/2,512). Conclusion: Nearly one in three homeless deaths were due to causes amenable to timely and effective health care. The high burden of amenable deaths highlights the extreme health harms of homelessness and the need for greater emphasis on prevention of homelessness and early healthcare interventions.

Code sets for respiratory symptoms in electronic health records research: a systematic review protocol

INTRODUCTION

Asthma and chronic obstructive pulmonary disease (COPD) are common respiratory conditions, which result in significant morbidity worldwide. These conditions are associated with a range of non-specific symptoms, which in themselves are a target for health research. Such research is increasingly being conducted using electronic health records (EHRs), but computable phenotype definitions, in the form of code sets or code lists, are required to extract structured data from these large routine databases in a systematic and reproducible way. The aim of this protocol is to specify a systematic review to identify code sets for respiratory symptoms in EHRs research.

METHODS AND ANALYSIS

MEDLINE and Embase databases will be searched using terms relating to EHRs, respiratory symptoms and use of code sets. The search will cover all English-language studies in these databases between January 1990 and December 2017. Two reviewers will independently screen identified studies for inclusion, and key data will be extracted into a uniform table, facilitating cross-comparison of codes used. Disagreements between the reviewers will be adjudicated by a third reviewer. This protocol has been produced in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol guidelines.

ETHICS AND DISSEMINATION

As a review of previously published studies, no ethical approval is required. The results of this review will be submitted to a peer-reviewed journal for publication and can be used in future research into respiratory symptoms that uses electronic healthcare databases.

PROSPERO REGISTRATION NUMBER

CRD42018100830.