Trends, patterns and psychological influences on COVID-19 vaccination intention: Findings from a large prospective community cohort study in England and Wales (Virus Watch)

BACKGROUND

Vaccination intention is key to the success of any vaccination programme, alongside vaccine availability and access. Public intention to take a COVID-19 vaccine is high in England and Wales compared to other countries, but vaccination rate disparities between ethnic, social and age groups has led to concern.

METHODS

Online survey of prospective household community cohort study participants across England and Wales (Virus Watch). Vaccination intention was measured by individual participant responses to 'Would you accept a COVID-19 vaccine if offered?', collected in December 2020 and February 2021. Responses to a 13-item questionnaire collected in January 2021 were analysed using factor analysis to investigate psychological influences on vaccination intention.

RESULTS

Survey response rate was 56% (20,785/36,998) in December 2020 and 53% (20,590/38,727) in February 2021, with 14,880 adults reporting across both time points. In December 2020, 1,469 (10%) participants responded 'No' or 'Unsure'. Of these people, 1,266 (86%) changed their mind and responded 'Yes' or 'Already had a COVID-19 vaccine' by February 2021. Vaccination intention increased across all ethnic groups and levels of social deprivation. Age was most strongly associated with vaccination intention, with 16-24-year-olds more likely to respond "Unsure" or "No" versus "Yes" than 65-74-year-olds in December 2020 (OR: 4.63, 95 %CI: 3.42, 6.27 & OR 7.17 95 %CI: 4.26, 12.07 respectively) and February 2021 (OR: 27.92 95 %CI: 13.79, 56.51 & OR 17.16 95 %CI: 4.12, 71.55). The association between ethnicity and vaccination intention weakened, but did not disappear, over time. Both vaccine- and illness-related psychological factors were shown to influence vaccination intention.

CONCLUSIONS

Four in five adults (86%) who were reluctant or intending to refuse a COVID-19 vaccine in December 2020 had changed their mind in February 2021 and planned to accept, or had already accepted, a vaccine.

Serial interval of COVID-19 and the effect of Variant B.1.1.7: analyses from prospective community cohort study (Virus Watch)

Introduction: Increased transmissibility of B.1.1.7 variant of concern (VOC) in the UK may explain its rapid emergence and global spread. We analysed data from putative household infector - infectee pairs in the Virus Watch Community cohort study to assess the serial interval of COVID-19 and whether this was affected by emergence of the B.1.1.7 variant. Methods: The Virus Watch study is an online, prospective, community cohort study following up entire households in England and Wales during the COVID-19 pandemic. Putative household infector-infectee pairs were identified where more than one person in the household had a positive swab matched to an illness episode. Data on whether or not individual infections were caused by the B.1.1.7 variant were not available. We therefore developed a classification system based on the percentage of cases estimated to be due to B.1.1.7 in national surveillance data for different English regions and study weeks. Results: Out of 24,887 illnesses reported, 915 tested positive for SARS-CoV-2 and 186 likely 'infector-infectee' pairs in 186 households amongst 372 individuals were identified. The mean COVID-19 serial interval was 3.18 (95%CI: 2.55 - 3.81) days. There was no significant difference (p=0.267) between the mean serial interval for VOC hotspots (mean = 3.64 days, (95%CI: 2.55 - 4.73)) days and non-VOC hotspots, (mean = 2.72 days, (95%CI: 1.48 - 3.96)). Conclusions: Our estimates of the average serial interval of COVID-19 are broadly similar to estimates from previous studies and we find no evidence that B.1.1.7 is associated with a change in serial intervals.  Alternative explanations such as increased viral load, longer period of viral shedding or improved receptor binding may instead explain the increased transmissibility and rapid spread and should undergo further investigation.

161 THE ROLE OF THE GERIATRIC DAY HOSPITAL DURING THE COVID 19 PANDEMIC

Background

Methods

Results

Conclusion

163 EVALUATING THE ROLE OF THE GERIATRIC DAY HOSPITAL IN MEDICATION OPTIMISATION

Background

The geriatric day hospital (GDH) provides outpatient geriatric medical, nursing and rehabilitation care to older adults. The aim of this study was to assess whether medication optimisation occurs in this setting. We believe the GDH would be an ideal location for mediation optimisation due to the stable community dwelling patients and close follow up by specialised physicians.

Methods

Electronic patient records of the new patients ≥65 years seen in the GDH over a 3-month period were reviewed. Potentially inappropriate prescriptions (PIPs) and potentially prescribing omissions (PPOs) were identified using the STOPP/START prescribing tool on admission to the GDH and again at discharge from the GDH.

Results

One-hundred and sixty-seven patient records were reviewed; mean age 80.8 (SD6.5) years, 62.9% female, median clinical frailty scale score 6 (IQR5–6), mean number of conditions 5.79 (SD3), mean number of medications 7.57 (SD3.7). Patients had a median of 4 (IQR2–7) consultations. The number of patients prescribed at least 1 STOPP-PIP reduced by 10% (42.4% vs 38%; p < 0.001). Vasodilator drugs in patients with orthostatic hypotension were deprescribed most frequently (6.5% vs 3%; p < 0.001). PPOs were reduced by 36% (47.5% vs 30.6%;p < 0.001). The largest improvement was identified in the prescription of vitamin D in patients experiencing falls (17.4% vs 13.8%;p < 0.001). Logistic regression was performed to ascertain the influence of age, gender, falls, dementia, co-morbidity number and medication number on the likelihood of a patient experiencing a PIP or PPO. For every medication prescribed, the odds of experiencing a PIP increased by 11.8% (OR1.187, 95%CI 1.052–1.339). Being female increased the odds of experiencing a PPO by 21.7% (OR2.17, 95%CI 10.53–4.468).

Conclusion

Medication optimisation is key in avoiding side effects from potentially inappropriate medications. The frequency of patient attendances coupled with geriatricians’ expertise makes the GDH an ideal setting for medication optimisation in multi-morbid frail community-dwelling older adults.

Evaluation of a national smoke-free prisons policy using medication dispensing: an interrupted time-series analysis

BACKGROUND

Internationally, smoking prevalence among people in prison custody (ie, people on remand awaiting trial, awaiting sentencing, or serving a custodial sentence) is high. In Scotland, all prisons implemented a comprehensive smoke-free policy in 2018 after a 16-month anticipatory period. In this study, we aimed to use data on medication dispensing to assess the impact of this policy on cessation support, health outcomes, and potential unintended consequences among people in prison custody.

METHODS

We did an interrupted time-series analysis using dispensing data for 44 660 individuals incarcerated in 14 closed prisons in Scotland between March 30, 2014, and Nov 30, 2019. We estimated changes in dispensing rates associated with the policy announcement (July 17, 2017) and full implementation (Nov 30, 2018) using seasonal autoregressive integrated moving average models. Medication categories of primary interest were treatments for nicotine dependence (as an indicator of smoking cessation or abstinence attempts), acute smoking-associated illnesses, and mental health (antidepressants). We included antiepileptic medications as a negative control.

FINDINGS

A 44% step increase in dispensing of treatments for nicotine dependence was observed at implementation (2250 items per 1000 people in custody per fortnight, 95% CI 1875 to 2624) due primarily to a 42% increase in dispensing of nicotine replacement therapy (2109 items per 1000 people in custody per fortnight, 1701 to 2516). A 9% step decrease in dispensing for smoking-related illnesses was observed at implementation, largely accounted for by respiratory medications (-646 items per 1000 people in custody per fortnight, -1111 to -181). No changes associated with announcement or implementation were observed for mental health dispensing or antiepileptic medications (control).

INTERPRETATION

Smoke-free prison policies might improve respiratory health among people in custody and encourage smoking abstinence or cessation without apparent short-term adverse effects on mental health dispensing.

FUNDING

National Institute of Health Research Public Health Research programme, Scottish Government Chief Scientist Office, and UK Medical Research Council.

ReHouSED: A novel measurement of Veteran housing stability using natural language processing

Housing stability is an important determinant of health. The US Department of Veterans Affairs (VA) administers several programs to assist Veterans experiencing unstable housing. Measuring long-term housing stability of Veterans who receive assistance from VA is difficult due to a lack of standardized structured documentation in the Electronic Health Record (EHR). However, the text of clinical notes often contains detailed information about Veterans' housing situations that may be extracted using natural language processing (NLP). We present a novel NLP-based measurement of Veteran housing stability: Relative Housing Stability in Electronic Documentation (ReHouSED). We first develop and evaluate a system for classifying documents containing information about Veterans' housing situations. Next, we aggregate information from multiple documents to derive a patient-level measurement of housing stability. Finally, we demonstrate this method's ability to differentiate between Veterans who are stably and unstably housed. Thus, ReHouSED provides an important methodological framework for the study of long-term housing stability among Veterans receiving housing assistance.

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.

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.

Diet and Exercise for FRAILty (DEFRAIL): protocol for a study to examine the effect of a novel community-based group exercise and nutritional intervention, designed to reverse frailty in older adults

INTRODUCTION

Frailty refers to a multifaceted age-related loss of physiological reserve. Aside from the immediate challenges it presents, it is also associated with various adverse health outcomes. Given our ageing population, the healthcare and societal costs resulting from frailty present a significant and growing public health challenge. Rapidly accumulating evidence suggests that resistance exercise combined with protein supplementation can reverse frailty in older adults. However, translation of these findings into practice has proven difficult, due to either a lack of clarity regarding the interventions used or the use of interventions not suitable for widespread implementation. There remains an absence of evidence-based programmes suitable for delivery to frail older adults in the community.

METHODS AND ANALYSIS

This paper outlines the protocol for a study to examine the effect of a novel programme of exercise and protein supplementation. This intervention has been developed by an expert consensus group, specifically for delivery to frail older adults in a group setting in the community. The study will take the form of a within-subjects non-randomised trial. Participants will be assessed at baseline, then following an 8-week period of regular activity, then following the 8-week intervention. Frailty (according to the Fried Frailty criteria) will be the primary outcome measure, along with a range of secondary outcome measures (including physical performance measures, body mass composition, psychosocial assessments and frailty-related biomarkers). If shown to be feasible to implement and effective at reversing frailty, the Diet and Exercise for FRAILty (DEFRAIL) intervention may facilitate more widespread participation in resistance exercise for frail older adults.

ETHICS AND DISSEMINATION

This study received ethical approval from the Research Ethics committees of both the Health Service Executive South-Eastern Area and Waterford Institute of Technology. Its findings will be disseminated through journal publications, conference presentations and other forms of public engagement.

TRIAL REGISTRATION NUMBER

ISRCTN46458028; Pre-results.

Oncolytic Vaccinia Virus Gene Modification and Cytokine Expression Effects on Tumor Infection, Immune Response, and Killing

Oncolytic vaccinia viruses have promising efficacy and safety profiles in cancer therapy. Although antitumor activity can be increased by manipulating viral genes, the relative efficacy of individual modifications has been difficult to assess without side-by-side comparisons. This study sought to compare the initial antitumor activity after intravenous administration of five vaccinia virus variants of the same Western Reserve backbone and thymidine kinase gene deletion in RIP-Tag2 transgenic mice with spontaneous pancreatic neuroendocrine tumors. Tumors had focal regions of infection at 5 days after all viruses. Natural killer (NK) cells were restricted to these sites of infection, but CD8⁺ T cells and tumor cell apoptosis were widespread and varied among the viruses. Antitumor activity of virus VV-A34, bearing amino acid substitution A34^K151E to increase viral spreading, and virus VV-IL2v, expressing a mouse IL2 variant (mIL2v) with attenuated IL2 receptor alpha subunit binding, was similar to control virus VV-GFP. However, antitumor activity was significantly greater after virus VV-A34/IL2v, which expressed mIL2v together with A34^K151E mutation and viral B18R gene deletion, and virus VV-GMCSF that expressed mouse GM-CSF. Both viruses greatly increased expression of CD8 antigens Cd8a/Cd8b1 and cytotoxicity genes granzyme A, granzyme B, Fas ligand, and perforin-1 in tumors. VV-A34/IL2v led to higher serum IL2 and greater tumor expression of death receptor ligand TRAIL, but VV-GMCSF led to higher serum GM-CSF, greater expression of leukocyte chemokines and adhesion molecules, and more neutrophil recruitment. Together, the results show that antitumor activity is similarly increased by viral expression of GM-CSF or IL2v combined with additional genetic modifications.

Engaging vulnerable populations in drug treatment court: Six month outcomes from a co-occurring disorder wraparound intervention

OBJECTIVE

Although drug treatment courts (DTCs) have demonstrated positive outcomes, participants with co-occurring mental health and substance use disorders (CODs) are a high-risk group that often struggle with treatment engagement not previously examined. This pilot study fills this gap by looking at six-month behavioral health and criminal justice outcomes among a hard to engage DTC COD participant sample in two Massachusetts DTCs receiving a wraparound-treatment (Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking-Criminal Justice - MISSION-CJ).

METHODS

Participants were evaluated at baseline and at six-month follow-up. Bivariate analyses examined baseline differences between clients with higher versus low engagement were examined. A mixed analysis of variance (ANOVA) for repeated measures with time as the within subject factor, and level of engagement as the between subject factor was performed for criminal justice (CJ) and behavioral health outcomes.

RESULTS

Participants were primarily male (86.6%), White (90.6%), living in unstable housing (86.2%), had an average of 18.94 years of criminal justice involvement, had an average of 15.49 years of regular illicit substance use, and mild mental health symptoms as measured by the BASIS-32 average total score (0.51), with no statistically significant differences at baseline from bivariate analyses. Mixed ANOVA results demonstrated significant effect time of time in MISSION-CJ on reducing nights in jail (p = 0.0266), opioid use (p = 0.0013), and mental health symptom (p = 0.0349). Additional improvements in nights in jail p = 0.0139), illicit substance use (p = 0.0358), and opioid use (p = 0.0013), were observed for clients that had high engagement in MISSION-CJ.

CONCLUSIONS

Wraparound services, such as MISSION-CJ, alongside DTC programming for a chronic relapsing DTC population can improve engagement in treatment and CJ and behavioral health outcomes. Future research is needed with MISSION-CJ that includes a randomized trial and a larger sample.

Homelessness and Veteran Status in Relation to Nonfatal and Fatal Opioid Overdose in Massachusetts

BACKGROUND

Compared with non-Veterans, Veterans are at higher risk of experiencing homelessness, which is associated with opioid overdose.

OBJECTIVE

To understand how homelessness and Veteran status are related to risks of nonfatal and fatal opioid overdose in Massachusetts.

DESIGN

A cross-sectional study.

PARTICIPANTS

All residents aged 18 years and older during 2011-2015 in the Massachusetts Department of Public Health's Data Warehouse (Veterans: n=144,263; non-Veterans: n=6,112,340). A total of 40,036 individuals had a record of homelessness, including 1307 Veterans and 38,729 non-Veterans.

MAIN MEASURES

The main independent variables were homelessness and Veteran status. Outcomes included nonfatal and fatal opioid overdose.

RESULTS

A higher proportion of Veterans with a record of homelessness were older than 45 years (77% vs. 48%), male (80% vs. 62%), or receiving high-dose opioid therapy (23% vs. 15%) compared with non-Veterans. The rates of nonfatal and fatal opioid overdose in Massachusetts were 85 and 16 per 100,000 residents, respectively. Among individuals with a record of homelessness, these rates increased 31-fold to 2609 and 19-fold to 300 per 100,000 residents. Homelessness and Veteran status were independently associated with higher odds of nonfatal and fatal opioid overdose. There was a significant interaction between homelessness and Veteran status in their effects on risk of fatal overdose.

CONCLUSIONS

Both homelessness and Veteran status were associated with a higher risk of fatal opioid overdoses. An understanding of health care utilization patterns can help identify treatment access points to improve patient safety among vulnerable individuals both in the Veteran population and among those experiencing homelessness.

Predictors of Nursing Home Admission Among a Cohort of Homeless Older Adults Entering Emergency Shelter

OBJECTIVE

This study examined the extent and timing of nursing home admissions among older adults who had their first visit at an emergency shelter or re-entered after an extended absence. We assessed the relationships between demographic characteristics, health and behavioral health conditions, and health services utilization measures and the risk of nursing home admission.

METHODS

We linked administrative data from the emergency shelter system in Boston, MA to claims data from the Massachusetts Medicaid program. Using the linked data, we identified a cohort of 432 adults aged 55 and above who entered the shelter for the first time (or re-entered after an extended absence) between 2012 and 2015. We estimated Kaplan-Meier survival curves and hazard functions to describe the extent and timing of nursing home admissions in this population following the date of their initial shelter entry and Cox proportional hazards regression models to identify predictors of the risk of nursing home admission.

RESULTS

Roughly 12% of the study cohort had a nursing home admission within 4 years of their initial shelter entry and risk of shelter admission was highest in the first few months following shelter entry. Older age, diagnoses indicating alcohol use disorder, greater overall disease burden, and a prior history of nursing home admission were all associated with a higher risk of nursing home admission following shelter entry.

CONCLUSIONS

Amidst ongoing growth in the number of older homeless adults, our study findings have important implications for efforts to meet the housing and health needs of this population.

Phase IB study of sorafenib and evofosfamide in patients with advanced hepatocellular and renal cell carcinomas (NCCTG N1135, Alliance)

Background Sorafenib (Sor) remains a first-line option for hepatocellular carcinoma (HCC) or refractory renal cell carcinomas (RCC). PLC/PRF/5 HCC model showed upregulation of hypoxia with enhanced efficacy when Sor is combined with hypoxia-activated prodrug evofosfamide (Evo). Methods This phase IB 3 + 3 design investigated 3 Evo dose levels (240, 340, 480 mg/m² on days 8, 15, 22), combined with Sor 200 mg orally twice daily (po bid) on days 1-28 of a 28-day cycle. Primary objectives included determining maximum tolerated dose (MTD) and recommended phase II dose (RP2D) of Sor + Evo. Results Eighteen patients were enrolled (median age 62.5 years; 17 male /1 female; 12 HCC/6 RCC) across three dose levels (DL0: Sor 200 mg bid/Evo 240 mg/m² [n = 6], DL1:Sor 200 mg bid/Evo 480 mg/m² [n = 5], DL1a: Sor 200 mg bid/Evo 340 mg/m² [n = 7]). Two dose-limiting toxicities (DLTs) were reported with Evo 480 mg/m² (grade 3 mucositis, grade 4 hepatic failure). Grade 3 rash DLT was observed in one patient at Evo 240 mg/m². No DLTs were observed at Evo 340 mg/m². MTD and RP2D were established as Sor 200 mg/Evo 340 mg/m² and Sor 200/Evo 240 mg/m², respectively. The most common treatment-related adverse events included fatigue, hand-foot syndrome, hypertension, and nausea/vomiting. Two partial responses were observed, one each at DL0 and DL1a.; disease control rate was 55%. Conclusions RP2D was established as sorafenib 200 mg bid + Evo 240 mg/m². While preliminary anti-tumor activity was observed, future development must account for advances in immunotherapy in HCC/RCC.

Implementing a complex psychosocial intervention for unstably housed Veterans: A realist-informed evaluation case study

Background

Only 7% of individuals with co-occurring mental health and substance use disorder (COD) receive services for both conditions. We implemented and evaluated maintaining independence and sobriety through systems integration, outreach and networking-Veteran's edition (MISSION-Vet), an evidence-based manualized psychosocial intervention for Veterans with CODs. This paper identifies the generative mechanisms that explain "how, for whom, and under what conditions" MISSION-Vet adoption, implementation, and fidelity work when applied in a complex adaptive system with facilitation support.

Methods

Within two VA healthcare systems (Sites A and B), a hybrid III trial tested facilitation to implement MISSION-Vet. We conducted a two-site case study based on 42 semi-structured consolidated framework for implementation research (CFIR) guided interviews with site leadership, implementers (social workers, peer specialists), and team members (facilitators, site leads). Interviews were coded and CFIR constructs used to generate "Context  +  Mechanism  =  Outcome" configurations to understand the conditions of MISSION-Vet adoption, implementation, and fidelity.

Results

Site A was low, and Site B was high in adoption, implementation, and fidelity. Adoption hesitancy/eagerness (outcome) resulted from the interaction of "external policy" (context) dampening/encouraging a "tension for change" (mechanism). Implementation intensity (outcome) was based on how "peer pressure" or practice culture (context) activated staff "self-efficacy" (mechanism) to engage with MISSION-Vet and appraise its "relative advantage" over current practices (mechanism). Fidelity relied on how "staffing structure and availability" (context) activated/muted "facilitation" (mechanism) to result in strategy and intervention adaptation (outcome).

Conclusions

We delineated how specific contexts activated certain mechanisms to drive the different stages of implementation of a multi-faceted COD treatment intervention.

Trial registration

ClinicalTrials.gov, NCT02942979.

Plain language abstract

Implementation is inherently dynamic and influenced by interdependent factors operating at the individual, organizational, and system levels. This is especially true for complex interventions addressing co-occurring mental health and substance use disorders because such interventions involve multiple treatment modalities delivered simultaneously, in busy practice settings, with challenging populations. This paper pairs consolidated framework for implementation research (CFIR) constructs with a realist evaluation approached to generate configurations important to the adoption, implementation, and adaptation stages of a highly complex intervention addressing the behavioural health and housing needs of a vulnerable population. Each configuration describes how contextual factors trigger mechanisms to generate implementation outcomes and answers "what works for whom, in what circumstances and in what respects, and how?" These findings further our understanding of possible mechanisms of change and push us to be more precise about identifying causal relationships among constructs that contribute to the success of implementing complex interventions. This work also moves us to think theoretically and methodologically in a more dynamic fashion, thereby leading to more responsive implementation practice.

Intervention to address homelessness and all-cause and suicide mortality among unstably housed US Veterans, 2012-2016

BACKGROUND

People without stable housing-and Veterans specifically-are at increased risk of suicide. This study assessed whether unstably housed Veterans' participation in homeless services is associated with reduced risk of all-cause and suicide mortality.

METHODS

This retrospective cohort study used a sample of 169 221 Veterans across the US who self-reported housing instability between 1 October 2012 and 30 September 2016. Multivariable Cox regression models assessed the association between Veterans' utilisation of homeless services and all-cause and suicide mortality, adjusting for sociodemographics and severity of medical comorbidities.

RESULTS

More than one-half of unstably housed Veterans accessed homeless services during the observation period; utilisation of any homeless services was associated with a 6% reduction in hazards for all-cause mortality (adjusted HR[aHR]=0.94, 95% CI[CI]=0.90-0.98). An increasing number of homeless services used was associated with significantly reduced hazards of both all-cause (aHR=0.93, 95% CI=0.91-0.95) and suicide mortality (aHR=0.81, 95% CI=0.73-0.89).

CONCLUSIONS

The use of homeless services among Veterans reporting housing instability was significantly associated with reduced hazards of all-cause and suicide mortality. Addressing suicide prevention and homelessness together-and ensuring 'upstream' interventions-within the context of the VHA healthcare system holds promise for preventing suicide deaths among Veterans. Mental health treatment is critical for suicide prevention, but future research should investigate if social service programmes, by addressing unmet human needs, may also reduce suicide.

The Opioid Epidemic In Veterans Who Were Homeless Or Unstably Housed

Veterans who are homeless or unstably housed are at increased risk for opioid-related morbidity and mortality. However, there is a limited understanding of the scope of the opioid epidemic and gaps in care for these populations. We conducted a retrospective observational study to examine opioid use disorder (OUD) in a national sample of veterans who accessed specialized homeless programs in the Veterans Health Administration. Additionally, in a subgroup of veterans with a history of OUD, we examined several opioid-related measures: opioid dose, concomitant opioid-benzodiazepine prescribing, and receipt of medication for addiction treatment (MAT) and overdose prevention medication (naloxone). Rates of OUD history varied significantly across age, gender, and program type. Among the subgroup of homeless veterans with an OUD history, prescribing practices and rates of MAT and naloxone receipt varied significantly by age and specialized homeless program. Rates of receipt of MAT and naloxone were moderate and low, respectively, indicating opportunities for program-specific interventions.

Smokefree policy and medication dispensing for people in prison: interrupted time series analysis

Background

Previous evaluations of smokefree prison policies have suggested improvements in self-rated health and some smoking-related symptoms. No studies to date have investigated impacts on medication use as proxy measures of objective ill-health or as indicators of potential negative unintended consequences. These is limited evidence to date on these important outcomes.

Methods

We obtained from NHS National Services Scotland aggregate data on medication items dispensed in prisons, based on individual named patient medication records, and from the Scottish Prison Service data on the prison population, for the period Jan 2013-Nov 2019. Items of interest comprised those for smoking cessation (varenicline and buproprion); nicotine replacement; specific smoking-related health conditions (glyceryl trinitrate; inhaled bronchodilators and steroids; antibiotics; chloramphenicol eye drops; and proton pump inhibitors and H2 receptor antagonists), and potential unintended mental health consequences (anti-depressants). We also included a set of negative controls for which dispensing was not expected to be affected by the new smokefree policy (anticonvulsants, excluding pregabalin and gabapentin). Analyses were undertaken using AutoRegressive Integrated Moving Average (ARIMA) time series methods, with the dates of the policy's announcement and of implementation included as pre-specified breakpoints.

Results

The results of ARIMA modelling of medication dispensing are confidential until May 2020 due to their sensitivity and will be available to present at WCPH 2020.

Conclusions

The use of routinely available dispensing data as an indicator of objective health impacts and potential negative unintended consequences provides novel insights into the effectiveness of smokefree prison policies. Results will be of interest to international jurisdictions considering such policies and to those seeking to harness the potential of administrative data for natural experiments.

A classification model of homelessness using integrated administrative data: Implications for targeting interventions to improve the housing status, health and well-being of a highly vulnerable population

Homelessness is poorly captured in most administrative data sets making it difficult to understand how, when, and where this population can be better served. This study sought to develop and validate a classification model of homelessness. Our sample included 5,050,639 individuals aged 11 years and older who were included in a linked dataset of administrative records from multiple state-maintained databases in Massachusetts for the period from 2011-2015. We used logistic regression to develop a classification model with 94 predictors and subsequently tested its performance. The model had high specificity (95.4%), moderate sensitivity (77.8%) for predicting known cases of homelessness, and excellent classification properties (area under the receiver operating curve 0.94; balanced accuracy 86.4%). To demonstrate the potential opportunity that exists for using such a modeling approach to target interventions to mitigate the risk of an adverse health outcome, we also estimated the association between model predicted homeless status and fatal opioid overdoses, finding that model predicted homeless status was associated with a nearly 23-fold increase in the risk of fatal opioid overdose. This study provides a novel approach for identifying homelessness using integrated administrative data. The strong performance of our model underscores the potential value of linking data from multiple service systems to improve the identification of housing instability and to assist government in developing programs that seek to improve health and other outcomes for homeless individuals.

Clinical Outcomes of a Zika Virus Mother-Child Pair Cohort in Spain

Background: Zika virus (ZIKV) infection has been associated with congenital microcephaly and other neurodevelopmental abnormalities. There is little published research on the effect of maternal ZIKV infection in a non-endemic European region. We aimed to describe the outcomes of pregnant travelers diagnosed as ZIKV-infected in Spain, and their exposed children. Methods: This prospective observational cohort study of nine referral hospitals enrolled pregnant women (PW) who travelled to endemic areas during their pregnancy or the two previous months, or those whose sexual partners visited endemic areas in the previous 6 months. Infants of ZIKV-infected mothers were followed for about two years. Results: ZIKV infection was diagnosed in 163 PW; 112 (70%) were asymptomatic and 24 (14.7%) were confirmed cases. Among 143 infants, 14 (9.8%) had adverse outcomes during follow-up; three had a congenital Zika syndrome (CZS), and 11 other potential Zika-related outcomes. The overall incidence of CZS was 2.1% (95%CI: 0.4–6.0%), but among infants born to ZIKV-confirmed mothers, this increased to 15.8% (95%CI: 3.4–39.6%). Conclusions: A nearly 10% overall risk of neurologic and hearing adverse outcomes was found in ZIKV-exposed children born to a ZIKV-infected traveler PW. Longer-term follow-up of these children is needed to assess whether there are any later-onset manifestations.

The Emerging Crisis of Aged Homelessness in the US: Could Cost Avoidance in Health Care Fund Housing Solutions?

Background with rationale The US homeless population has had a fairly unique age structure for thirty years, with one-third concentrated among the 1955-1965 birth cohort. They are aging prematurely and are experiencing aging related morbidity and mortality in increasing numbers. This study uses demographic methods to project the growth in aged homelessness out to 2030. Using linked administrative data, historical patterns of health care, nursing home and shelter are used to estimate future costs. Potential offsets are estimated from anticipated reductions in excess services use associated with housing placement. Main Aim To determine if housing placement among future aged homeless adults could be offset by reduced health and social service costs. Methods/Approach Demographic methods are applied to historical shelter data in Los Angeles, New York and Boston to project the future growth in aged homelessness. Linked administrative data are used to estimate future age-related use of health and social services. Housing models are applied to meet population needs to estimate costs. Health and social service costs offsets are estimated from prior literature. The net cost is estimated based on the differential. Results Elderly homelessness will triple in the US over the next ten years. Average annual health and shelter costs will be $22-28,000 per person. Housing costs are estimated at $7-11,000 annually. Cost offsets yield a positive ROI of 1.13 in New York and Los Angeles; Boston results are closer to break-even. Conclusion Substantial public dollars will be spent on the aged homelessness problem as it triples over the next ten years. Some of those dollars could be shifted to housing solutions, reducing homelessness significantly, with little to no increase in public expenditures; positive returns on such investments are also possible.

257 Participants’ Experience of a Novel Group Exercise Program: Results from the DEFRAIL (Diet and Exercise for Frailty) Study Pilot

Background

DEFRAIL (Diet and Exercise for Frailty) is a translational study examining the effect of an eight-week multicomponent group exercise program and protein supplementation on frailty in older adults. As part of the development of this novel intervention, a four-week pilot was carried out to assess participants’ experience of the program, with a view to optimising the final format.

Methods

Inclusion in the DEFRAIL study requires a candidate to be deemed frail as per the Fried criteria. During the initial stages of recruitment for DEFRAIL, any individual who was identified as pre-frail was offered the opportunity to participate in the pilot trial (11 x 1-hour group sessions at a local sporting facility). Following its conclusion, a telephone interview using a standardised questionnaire was conducted on all participants to assess various aspects of their experience.

Results

Of 9 participants recruited for the pilot, 7 completed the four-week program (One participant failed to attend any sessions due to difficulties with transport and one participant withdrew after the first week, reporting excessive fatigue as the main issue). Amongst these 7 individuals, attendance was 90.9%. The only other adverse events recorded were delayed-onset muscle soreness (DOMS) in 4 out of 7 and aggravation of a pre-existing joint injury in one individual (neither of which prevented participation in subsequent classes). All attendees reporting enjoying the program with additional feedback obtained via the questionnaire regarding the timing, duration, frequency and intensity of classes, in addition to identifying potential barriers or enablers to participation.

Conclusion

This pilot of a novel exercise program for older adults was enjoyed and well-tolerated by pre-frail older adults. Participant feedback, both during the pilot and through a standardised questionnaire following completion, has had a meaningful impact on the final version of the exercise program that will be used for frail older adults in the DEFRAIL intervention.