An internet-delivered handwashing intervention to modify influenza-like illness and respiratory infection transmission (PRIMIT): a primary care randomised trial

A Framework for Analyzing and Measuring Usage and Engagement Data (AMUsED) in Digital Interventions: Viewpoint

Trials of digital interventions can yield extensive, in-depth usage data, yet usage analyses tend to focus on broad descriptive summaries of how an intervention has been used by the whole sample. This paper proposes a novel framework to guide systematic, fine-grained usage analyses that better enables understanding of how an intervention works, when, and for whom. The framework comprises three stages to assist in the following: (1) familiarization with the intervention and its relationship to the captured data, (2) identification of meaningful measures of usage and specifying research questions to guide systematic analyses of usage data, and (3) preparation of datasheets and consideration of available analytical methods with which to examine the data. The framework can be applied to inform data capture during the development of a digital intervention and/or in the analysis of data after the completion of an evaluation trial. We will demonstrate how the framework shaped preparation and aided efficient data capture for a digital intervention to lower transmission of cold and flu viruses in the home, as well as how it informed a systematic, in-depth analysis of usage data collected from a separate digital intervention designed to promote self-management of colds and flu. The Analyzing and Measuring Usage and Engagement Data (AMUsED) framework guides systematic and efficient in-depth usage analyses that will support standardized reporting with transparent and replicable findings. These detailed findings may also enable examination of what constitutes effective engagement with particular interventions.

Young People's Knowledge of Antibiotics and Vaccinations and Increasing This Knowledge Through Gaming: Mixed-Methods Study Using e-Bug

Background

e-Bug, led by Public Health England, educates young people about important topics: microbes, infection prevention, and antibiotics. Body Busters and Stop the Spread are 2 new e-Bug educational games.

Objective

This study aimed to determine students’ baseline knowledge, views on the games, and knowledge improvement.

Methods

Students in 5 UK educational provisions were observed playing 2 e-Bug games. Before and after knowledge and evaluation questionnaires were completed, and student focus groups were conducted.

Results

A total of 123 junior and 350 senior students completed the questionnaires. Vaccination baseline knowledge was high. Knowledge increased significantly about antibiotic use, appropriate sneezing behaviors, and vaccinations. In total, 26 student focus groups were conducted. Body Busters was engaging and enjoyable, whereas Stop the Spread was fast-paced and challenging but increased vaccination and health behavior intentions.

Conclusions

e-Bug games are an effective learning tool for students to enhance knowledge about microbes, infection prevention, and antibiotics. Game-suggested improvements should help increase enjoyment.

Effectiveness of hand hygiene practices in preventing influenza virus infection in the community setting: A systematic review

BACKGROUND

Hand hygiene is known to be an effective infection prevention and control measure in health care settings. However, the effectiveness of hand hygiene practices in preventing influenza infection and transmission in the community setting is not clear.

OBJECTIVE

To identify, review and synthesize available evidence on the effectiveness of hand hygiene in preventing laboratory-confirmed or possible influenza infection and transmission in the community setting.

METHODS

A systematic review protocol was established prior to conducting the review. Three electronic databases (MEDLINE, Embase and the Cochrane Library) were searched to identify relevant studies. Two reviewers independently screened the titles, abstracts and full-texts of studies retrieved from the database searches for potential eligibility. Data extraction and quality assessment of included studies were performed by a single reviewer and validated by a second reviewer. Included studies were synthesized and analyzed narratively.

RESULTS

A total of 16 studies were included for review. Studies were of low methodological quality and there was high variability in study design, setting, context and outcome measures. Nine studies evaluated the effectiveness of hand hygiene interventions or practices in preventing laboratory-confirmed or possible influenza infection in the community setting; six studies showed a significant difference, three studies did not. Seven studies assessed the effectiveness of hand hygiene practices in preventing laboratory-confirmed or possible influenza transmission in the community setting; two studies found a significant difference and five studies did not.

CONCLUSION

The effectiveness of hand hygiene against influenza virus infection and transmission in the community setting is difficult to determine based on the available evidence. In light of its proven effectiveness in other settings, there is no compelling evidence to stop using good hand hygiene practice to reduce the risk of influenza infection and transmission in the community setting.

Respiratory Tract Infections in Children in the Community: Prospective Online Inception Cohort Study

PURPOSE

Describe the duration of symptoms, proportion of parents seeking primary care consultations, and costs for respiratory tract infections (RTIs) of children in the community.

METHODS

Community-based, online, prospective inception cohort study. General practitioners from socioeconomically diverse practices posted study invitations to parents of 10,310 children aged ≥3 months and <15 years.

RESULTS

One parent of 485 (4.7%) children in 331 families consented, completed baseline data and symptom diaries, and agreed to medical record review. Compared with nonresponders, responding parent's children were younger (aged 4 vs 6 years) and less socioeconomically deprived. Between February and July 2016, 206 parents reported 346 new RTIs in 259 children. Among the 197 first RTIs reported per family, it took 23 days for 90% (95% CI, 85%-94%) of children to recover. Median symptom duration was longer: in children with primary care consultations (9 days) vs those without consultations (6 days, P = 0.06); children aged <3 years (11 days) vs >3 years (7 days, P <.01); and among children with reported lower RTI symptoms (12 days) vs those with only upper RTI symptoms (8 days, P <.001). Sixteen (8.1%; 95% CI, 4.7%-12.8%) of 197 children had primary care consultations at least once (total 19 consultations), and a similar proportion had time off school or nursery. Sixty of 188 (32%; 95% CI, 25%-39%) parents reported paying for medications for their child's illness.

CONCLUSIONS

Parents can be advised that RTI symptoms last up to 3 weeks. Policy makers should be aware that parents may seek primary care support in at least 1 in 12 illnesses.

Population-based paediatric respiratory infection surveillance: a prospective inception feasibility cohort study

Background

There is a need to reduce unnecessary general practitioner (GP) consultations and improve antibiotic stewardship in primary care. Respiratory tract infections (RTIs) in children are the most common reason for consulting and prescribing. Most RTI research is conducted at the point of consultation, leaving a knowledge gap regarding the population burden of RTIs.

Methods

Community-based, online prospective inception cohort study with nested qualitative study, to evaluate the feasibility and acceptability of collecting RTI symptom and microbiological data from children recruited prior to RTI onset.

Results

Parents of 10,310 children were invited. Three hundred thirty-one parents of 485 (4.7%) children responded and completed baseline data. Respondents were less socioeconomically deprived (p < 0.001) with younger (median ages 4 vs. 6 years, p < 0.001) children than non-respondents. The same parents reported 346 RTI episodes in 259 children, and 305 RTIs (in 225 children) were retained to parent-reported symptom resolution. Restricting analyses to the first RTI episode per family (to account for clustering effects), parents fully completed symptom diaries for 180 (87%) of 192 first illness episodes. Research nurses conducted home visits for 199 RTI episodes, collecting complete (symptomatic) swab sets in 195 (98%). Parents collected 194 (98% of 199 possible) symptomatic (during the nurse visit) and 282 (92% of 305 possible) asymptomatic swab sets (on symptom resolution, no nurse present). Interviews with 30 mothers and 11 children indicated study acceptability.

Conclusions

Invitation response rates were in the expected range. The high retention and qualitative evidence suggest that community-based paediatric syndromic and microbiological surveillance research is feasible.

Electronic supplementary material

The online version of this article (10.1186/s40814-018-0371-8) contains supplementary material, which is available to authorized users.

A mixed methods pilot of Beat the Bugs: A community education course on hygiene, self-care and antibiotics

Background

e-Bug is an international health education resource which support World Health Organization (WHO) public health recommendations by educating young people about microbes, hygiene and antibiotics use. The e-Bug team collaborated with Kingfisher Treasure Seekers to develop a six-session course for community groups called Beat the Bugs covering: microbes; hygiene; antibiotic use; and self-care. A pilot was used to inform further development and evaluation.

Methods

Pilot courses with 9-12 adults with learning difficulties and young parents were delivered by community leaders and observed by researchers. Participants completed before and after knowledge questionnaires. Two participant focus groups and two course leader interviews explored views on the course and retention of knowledge.

Results

Completed questionnaires and qualitative results showed an improvement in participant knowledge in each session; microbes and antibiotics sessions showed the greatest knowledge improvement. Self-care showed the greatest knowledge retention and participants reported behaviour change including an increase in appropriate hand-washing and tooth-brushing.

Conclusion

The Beat the Bugs course is a useful intervention for communities to give individuals the knowledge and confidence to manage their own infection and change behaviour around hygiene, self-care and antibiotics. Beat the Bugs is freely available to download.

Back to the Future: Lessons Learned From the 1918 Influenza Pandemic

2018 marks the 100-year anniversary of the 1918 influenza pandemic, which killed ~50 million people worldwide. The severity of this pandemic resulted from a complex interplay between viral, host, and societal factors. Here, we review the viral, genetic and immune factors that contributed to the severity of the 1918 pandemic and discuss the implications for modern pandemic preparedness. We address unresolved questions of why the 1918 influenza H1N1 virus was more virulent than other influenza pandemics and why some people survived the 1918 pandemic and others succumbed to the infection. While current studies suggest that viral factors such as haemagglutinin and polymerase gene segments most likely contributed to a potent, dysregulated pro-inflammatory cytokine storm in victims of the pandemic, a shift in case-fatality for the 1918 pandemic toward young adults was most likely associated with the host's immune status. Lack of pre-existing virus-specific and/or cross-reactive antibodies and cellular immunity in children and young adults likely contributed to the high attack rate and rapid spread of the 1918 H1N1 virus. In contrast, lower mortality rate in in the older (>30 years) adult population points toward the beneficial effects of pre-existing cross-reactive immunity. In addition to the role of humoral and cellular immunity, there is a growing body of evidence to suggest that individual genetic differences, especially involving single-nucleotide polymorphisms (SNPs), contribute to differences in the severity of influenza virus infections. Co-infections with bacterial pathogens, and possibly measles and malaria, co-morbidities, malnutrition or obesity are also known to affect the severity of influenza disease, and likely influenced 1918 H1N1 disease severity and outcomes. Additionally, we also discuss the new challenges, such as changing population demographics, antibiotic resistance and climate change, which we will face in the context of any future influenza virus pandemic. In the last decade there has been a dramatic increase in the number of severe influenza virus strains entering the human population from animal reservoirs (including highly pathogenic H7N9 and H5N1 viruses). An understanding of past influenza virus pandemics and the lessons that we have learnt from them has therefore never been more pertinent.

A mixed-method evaluation of peer-education workshops for school-aged children to teach about antibiotics, microbes and hygiene

Background

Delivering health topics in schools through peer education is known to be beneficial for all students involved. In this study, we have evaluated a peer-education workshop that aims to educate primary and secondary school students on hygiene, the spread of infection and antibiotics.

Methods

Four schools in south-west England, in a range of localities, took part in peer-education workshops, with students completing before, after and knowledge-retention questionnaires. Mixed-effect logistic regression and mixed-effect linear regression were used to analyse the data. Data were analysed by topic, region and peer/non-peer-educator status. Qualitative interviews and focus groups with students and educators were conducted to assess changes in participants' skills, confidence and behaviour.

Results

Qualitative data indicated improvements in peer-educator skills and behaviour, including confidence, team-working and communication. There was a significant improvement in knowledge for all topics covered in the intervention, although this varied by region. In the antibiotics topic, peer-educators' knowledge increased in the retention questionnaire, whereas non-peer-educators' knowledge decreased. Knowledge declined in the retention questionnaires for the other topics, although this was mostly not significant.

Conclusions

This study indicates that peer education is an effective way to educate young people on important topics around health and hygiene, and to concurrently improve communication skills. Its use should be encouraged across schools to help in the implementation of the National Institute for Health and Care Excellence (NICE) guidance that recommends children are taught in an age-appropriate manner about hygiene and antibiotics.

Using an Analysis of Behavior Change to Inform Effective Digital Intervention Design: How Did the PRIMIT Website Change Hand Hygiene Behavior Across 8993 Users?

Background

In designing digital interventions for healthcare, it is important to understand not just whether interventions work but also how and for whom—including whether individual intervention components have different effects, whether a certain usage threshold is required to change behavior in each intervention and whether usage differs across population subgroups.

Purpose

We investigated these questions using data from a large trial of the digital PRimary care trial of a website based Infection control intervention to Modify Influenza-like illness and respiratory tract infection Transmission) (PRIMIT) intervention, which aimed to reduce respiratory tract infections (RTIs) by increasing hand hygiene behavior.

Method

Baseline and follow-up questionnaires measured behaviors, intentions and attitudes in hand hygiene. In conjunction with objective measures of usage of the four PRIMIT sessions, we analysed these observational data to examine mechanisms of behavior change in 8993 intervention users.

Results

We found that the PRIMIT intervention changed behavior, intentions and attitudes, and this change was associated with reduced RTIs. The largest hand hygiene change occurred after the first session, with incrementally smaller changes after each subsequent session, suggesting that engagement with the core behavior change techniques included in the first session was necessary and sufficient for behavior change. The intervention was equally effective for men and women, older and younger people and was particularly effective for those with lower levels of education.

Conclusions

Our well-powered analysis has implications for intervention development. We were able to determine a ‘minimum threshold’ of intervention engagement that is required for hand hygiene change, and we discuss the potential implications this (and other analyses of this type) may have for further intervention development. We also discuss the application of similar analyses to other interventions.

Time to abandon the hygiene hypothesis: new perspectives on allergic disease, the human microbiome, infectious disease prevention and the role of targeted hygiene

Aims:

To review the burden of allergic and infectious diseases and the evidence for a link to microbial exposure, the human microbiome and immune system, and to assess whether we could develop lifestyles which reconnect us with exposures which could reduce the risk of allergic disease while also protecting against infectious disease.

Methods:

Using methodology based on the Delphi technique, six experts in infectious and allergic disease were surveyed to allow for elicitation of group judgement and consensus view on issues pertinent to the aim.

Results:

Key themes emerged where evidence shows that interaction with microbes that inhabit the natural environment and human microbiome plays an essential role in immune regulation. Changes in lifestyle and environmental exposure, rapid urbanisation, altered diet and antibiotic use have had profound effects on the human microbiome, leading to failure of immunotolerance and increased risk of allergic disease. Although evidence supports the concept of immune regulation driven by microbe–host interactions, the term ‘hygiene hypothesis’ is a misleading misnomer. There is no good evidence that hygiene, as the public understands, is responsible for the clinically relevant changes to microbial exposures.

Conclusion:

Evidence suggests a combination of strategies, including natural childbirth, breast feeding, increased social exposure through sport, other outdoor activities, less time spent indoors, diet and appropriate antibiotic use, may help restore the microbiome and perhaps reduce risks of allergic disease. Preventive efforts must focus on early life. The term ‘hygiene hypothesis’ must be abandoned. Promotion of a risk assessment approach (targeted hygiene) provides a framework for maximising protection against pathogen exposure while allowing spread of essential microbes between family members. To build on these findings, we must change public, public health and professional perceptions about the microbiome and about hygiene. We need to restore public understanding of hygiene as a means to prevent infectious disease.

Living with asthma and chronic obstructive airways disease: Using technology to support self-management - An overview

Long-term respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD) are common, and cause high levels of morbidity and mortality. Supporting self-management is advocated for both asthma and increasingly so for COPD, and there is growing interest in the potential role of a range of new technologies, such as smartphone apps, the web or telehealth to facilitate and promote self-management in these conditions. Treatment goals for both asthma and COPD include aiming to control symptoms, maintain activities, achieve the best possible quality of life and minimize risks of exacerbation. To do this, health professionals should be (a) helping patients to recognize deteriorating symptoms and act appropriately; (b) promoting adherence to maintenance therapy; (c) promoting a regular review where triggers can be established, and strategies for managing such triggers discussed; and (d) promoting healthy lifestyles and positive self-management of symptoms. In particular, low uptake of asthma action plans is a modifiable contributor to morbidity and possibly also to mortality in those with asthma and should be addressed as a priority. Using technology to support self-management is an evolving strategy that shows promise. This review provides an overview of self-management support and discusses how newer technologies may help patients and health professionals to meet key treatment goals.

Promising approaches for the treatment and prevention of viral respiratory illnesses

Viral respiratory tract infections are the most common human ailments, leading to enormous health and economic burden. Hundreds of viral species and subtypes have been associated with these conditions, with influenza viruses, respiratory syncytial virus, and rhinoviruses being the most frequent and with the highest burden. When considering prevention or treatment of viral respiratory tract infections, potential targets include the causative pathogens themselves but also the immune response, disease transmission, or even just the symptoms. Strategies targeting all these aspects are developing concurrently, and several novel and promising approaches are emerging. In this perspective we overview the entire range of options and highlight some of the most promising approaches, including new antiviral agents, symptomatic or immunomodulatory drugs, the re-emergence of natural remedies, and vaccines and public health policies toward prevention. Wide-scale prevention through immunization appears to be within reach for respiratory syncytial virus and promising for influenza virus, whereas additional effort is needed in regard to rhinovirus, as well as other respiratory tract viruses.

Guided and unguided internet-based vestibular rehabilitation versus usual care for dizzy adults of 50 years and older: a protocol for a three-armed randomised trial

INTRODUCTION

Dizziness is a common symptom in general practice with a high prevalence among older adults. The most common cause of dizziness in general practice is peripheral vestibular disease. Vestibular rehabilitation (VR) is a safe and effective treatment for peripheral vestibular disease that entails specific exercises to maximise the central nervous system compensation for the effects of vestibular pathology. An internet-based VR intervention has recently been shown to be safe and effective. Online interventions are low cost and easily accessible, but prone to attrition and non-adherence. A combination of online and face-to-face therapy, known as blended care, may balance these advantages and disadvantages.

METHODS AND ANALYSIS

A single-blind, three-arm, randomised controlled trial among patients aged 50 years and over presenting with dizziness of vestibular origin in general practice will be performed. In this study, we will compare the clinical and cost-effectiveness of stand-alone internet-based VR and internet-based VR with physiotherapeutic support ('blended care') with usual care during 6 months of follow-up. We will use a translated Dutch version of a British online VR intervention. Randomisation will be stratified by dizziness severity. The primary outcome measure is the Vertigo Symptoms Scale-Short Form. Intention-to-treat analysis will be performed, adjusting for confounders. The economic evaluation will be conducted from a societal perspective. We will perform an additional analysis on the data to identify predictors of successful treatment in the same population to develop a clinical decision rule for general practitioners.

ETHICS AND DISSEMINATION

The ethical committee of the VU University Medical Center approved ethics and dissemination of the study protocol. The insights and results of this study will be widely disseminated through international peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

Pre-results, NTR5712.

Designing and Undertaking a Health Economics Study of Digital Health Interventions

This paper introduces and discusses key issues in the economic evaluation of digital health interventions. The purpose is to stimulate debate so that existing economic techniques may be refined or new methods developed. The paper does not seek to provide definitive guidance on appropriate methods of economic analysis for digital health interventions. This paper describes existing guides and analytic frameworks that have been suggested for the economic evaluation of healthcare interventions. Using selected examples of digital health interventions, it assesses how well existing guides and frameworks align to digital health interventions. It shows that digital health interventions may be best characterized as complex interventions in complex systems. Key features of complexity relate to intervention complexity, outcome complexity, and causal pathway complexity, with much of this driven by iterative intervention development over time and uncertainty regarding likely reach of the interventions among the relevant population. These characteristics imply that more-complex methods of economic evaluation are likely to be better able to capture fully the impact of the intervention on costs and benefits over the appropriate time horizon. This complexity includes wider measurement of costs and benefits, and a modeling framework that is able to capture dynamic interactions among the intervention, the population of interest, and the environment. The authors recommend that future research should develop and apply more-flexible modeling techniques to allow better prediction of the interdependency between interventions and important environmental influences.

Self-reported illness among Boston-area international travelers: A prospective study

BACKGROUND

The Boston Area Travel Medicine Network surveyed travelers on travel-related health problems.

METHODS

Travelers were recruited 2009-2011 during pre-travel consultation at three clinics. The investigation included pre-travel data, weekly during-travel diaries, and a post-travel questionnaire. We analyzed demographics, trip characteristics, health problems experienced, and assessed the relationship between influenza vaccination, influenza prevention advice, and respiratory symptoms.

RESULTS

Of 987 enrolled travelers, 628 (64%) completed all surveys, of which 400 (64%) reported health problems during and/or after travel; median trip duration was 12 days. Diarrhea affected the most people during travel (172) while runny/stuffy nose affected the most people after travel (95). Of those with health problems during travel, 25% stopped or altered plans; 1% were hospitalized. After travel, 21% stopped planned activities, 23% sought physician or other health advice; one traveler was hospitalized. Travelers who received influenza vaccination and influenza prevention advice had lower rates of respiratory symptoms than those that received influenza prevention advice alone (18% vs 28%, P = 0.03).

CONCLUSIONS

A large proportion of Boston-area travelers reported health problems despite pre-travel consultation, resulting in inconveniences. The combination of influenza prevention advice and influenza immunization was associated with fewer respiratory symptoms than those who received influenza prevention advice alone.

Effect of Vitamin D3 Supplementation on Respiratory Tract Infections in Healthy Individuals: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective

Vitamin D supplementation may be a simple preventive measure against respiratory tract infections (RTIs) but evidence from randomized controlled trials is inconclusive. We aimed to systematically summarize results from interventions studying the protective effect of vitamin D supplementation on clinical and laboratory confirmed RTIs in healthy adults and children.

Methods

Medline, EMBASE, CENTRAL, and CINAHL were screened from inception until present (last updated in January 2016) completed by a search of the grey literature, clinical trial registers and conference abstracts. We included randomized trials comparing vitamin D versus placebo or no treatment. Two independent reviewers were responsible for study selection and data extraction. Cochrane’s risk of bias tool and the GRADE approach were used for quality assessment. Estimates were pooled with random-effects models. Heterogeneity was explored by sub-group and meta-regression analyses.

Results

Of 2627 original hits, 15 trials including 7053 individuals were ultimately eligible. All used oral cholecalciferol. We found a 6% risk reduction with vitamin D3 supplementation on clinical RTIs, but the result was not statistically significant (RR 0.94; 95% CI 0.88 to 1.00). Heterogeneity was large (I-square 57%) and overall study quality was low. There were too few studies to reliably assess a potential risk reduction of laboratory confirmed RTI. Evidence was insufficient to demonstrate an association between vitamin D supplementation and risk of clinical RTI in sub-groups with vitamin D deficiency.

Conclusions

In previously healthy individuals vitamin D supplementation does not reduce the risk of clinical RTIs. However, this conclusion is based on a meta-analysis where the included studies differed with respect to population, baseline vitamin D levels and study length. This needs to be considered when interpreting the results. Future trials should focus on vitamin D deficient individuals and apply more objective and standardized outcome measurements.

'No action today means no cure tomorrow': the threat of antimicrobial resistance

Antimicrobial resistance is a major concern for UK healthcare professionals, following growing evidence of multi-resistant pathogens. Poor prescribing practices, partly driven by patient demand, and poor patient adherence to prescribed regimens are two of the causes of growing antimicrobial resisitance. Improved infection prevention and control practices will not only reduce healthcare-acquired infections, but also reduce the necessity for antimicrobials. Community nurses can also support their clients to promote their own health and wellbeing, increasing resilience to infections through a healthy lifestyle which includes a well-balanced diet, good personal hygiene and the take up of offered vaccinations.