The burden of seasonal respiratory infections on a national telehealth service in England

Early Detection and Monitoring of Gastrointestinal Infections Using Syndromic Surveillance: A Systematic Review

The underreporting of laboratory-reported cases of community-based gastrointestinal (GI) infections poses a challenge for epidemiologists understanding the burden and seasonal patterns of GI pathogens. Syndromic surveillance has the potential to overcome the limitations of laboratory reporting through real-time data and more representative population coverage. This systematic review summarizes the utility of syndromic surveillance for early detection and surveillance of GI infections. Relevant articles were identified using the following keyword combinations: 'early warning', 'detection', 'gastrointestinal activity', 'gastrointestinal infections', 'syndrome monitoring', 'real-time monitoring', 'syndromic surveillance'. In total, 1820 studies were identified, 126 duplicates were removed, and 1694 studies were reviewed. Data extraction focused on studies reporting the routine use and effectiveness of syndromic surveillance for GI infections using relevant GI symptoms. Eligible studies (n = 29) were included in the narrative synthesis. Syndromic surveillance for GI infections has been implemented and validated for routine use in ten countries, with emergency department attendances being the most common source. Evidence suggests that syndromic surveillance can be effective in the early detection and routine monitoring of GI infections; however, 24% of the included studies did not provide conclusive findings. Further investigation is necessary to comprehensively understand the strengths and limitations associated with each type of syndromic surveillance system.

Machine learning forecasts for seasonal epidemic peaks: Lessons learnt from an atypical respiratory syncytial virus season

Seasonal peaks in infectious disease incidence put pressures on health services. Therefore, early warning of the timing and magnitude of peak activity during seasonal epidemics can provide information for public health practitioners to take appropriate action. Whilst many infectious diseases have predictable seasonality, newly emerging diseases and the impact of public health interventions can result in unprecedented seasonal activity. We propose a Machine Learning process for generating short-term forecasts, where models are selected based on their ability to correctly forecast peaks in activity, and can be useful during atypical seasons. We have validated our forecasts using typical and atypical seasonal activity, using respiratory syncytial virus (RSV) activity during 2019-2021 as an example. During the winter of 2020/21 the usual winter peak in RSV activity in England did not occur but was 'deferred' until the Spring of 2021. We compare a range of Machine Learning regression models, with alternate models including different independent variables, e.g. with or without seasonality or trend variables. We show that the best-fitting model which minimises daily forecast errors is not the best model for forecasting peaks when the selection criterion is based on peak timing and magnitude. Furthermore, we show that best-fitting models for typical seasons contain different variables to those for atypical seasons. Specifically, including seasonality in models improves performance during typical seasons but worsens it for the atypical seasons.

Burden of respiratory syncytial virus in adults in the United Kingdom: A systematic literature review and gap analysis

Despite the growing recognition of a potentially significant respiratory syncytial virus (RSV) disease burden in adults, relevant evidence in the United Kingdom (UK) is limited. This systematic literature review (SLR) aimed to identify the disease burden of RSV in UK adults, including certain high-risk subgroups and existing evidence gaps. Published studies (2011 onwards) reporting epidemiological, economic and clinical burden outcomes in UK adults (≥15 years) with RSV were identified from indexed databases, including MEDLINE, Embase and the Cochrane library. High-risk groups included elderly (≥65 years), immunocompromised, co-morbid and co-infected patients. Outcomes included RSV incidence/prevalence, mortality, clinical presentation and direct/indirect resource use/costs. Twenty-eight publications on 28 unique studies were identified, mostly in general/respiratory indicator (n = 17), elderly (n = 10) and immunocompromised (n = 6) cohorts. Main outcomes reported in the general/respiratory indicator cohort were RSV infection incidence (seasonal/annual: 0.09-17.9%/6.6-15.1%), mortality (8,482 deaths/season) and direct resource use (including mean general practitioner [GP] episodes/season: 487,247). Seasonal/annual incidence was 14.6-26.5%/0.7-16% in high-risk cohorts. Attributed to RSV in the elderly were 7,915 deaths/season and 175,070 mean GP episodes/season. Only two studies reported on co-morbid cohorts. Clinical burden outcomes were only reported in general and immunocompromised patients, and no evidence was found in any cohort on indirect economic burden or RSV complications. Evidence captured suggests that RSV may have a substantial burden in UK adults. However, available data were limited and highly heterogenous, with further studies needed to characterise the burden of RSV in adults and to validate our findings.

Epidemiology of respiratory syncytial virus in children younger than 5 years in England during the COVID-19 pandemic, measured by laboratory, clinical, and syndromic surveillance: a retrospective observational study

BACKGROUND

Seasonal epidemics of respiratory syncytial virus (RSV) cause a clinically significant burden of disease among young children. Non-pharmaceutical interventions targeted at SARS-CoV-2 have affected the activity of other respiratory pathogens. We describe changes in the epidemiology of RSV among children younger than 5 years in England since 2020.

METHODS

Surveillance data on RSV infections, comprising laboratory-confirmed cases, proportion of positive tests, hospital admissions for RSV-attributable illness, and syndromic indicators for RSV-associated disease (emergency department attendances for acute bronchitis or bronchiolitis, non-emergency health advice telephone service [NHS 111] calls for cough, general practitioner [GP] in-hours consultations for respiratory tract infections, and GP out-of-hours contacts for acute bronchitis or bronchiolitis) were analysed from Dec 29, 2014 to March 13, 2022, for children younger than 5 years. Data were extracted from national laboratory, clinical, and syndromic surveillance systems. Time-series analyses using generalised linear models were used to estimate the effect of non-pharmaceutical interventions targeting SARS-CoV-2 on RSV indicators, with absolute and relative changes calculated by comparing observed and predicted values.

FINDINGS

RSV-associated activity was reduced for all RSV indicators during winter 2020-21 in England, with 10 280 (relative change -99·5% [95% prediction interval -100·0 to -99·1]) fewer laboratory-confirmed cases, 22·2 (-99·6%) percentage points lower test positivity, 92 530 (-80·8% [-80·9 to -80·8]) fewer hospital admissions, 96 672 (-73·7% [-73·7 to -73·7]) fewer NHS 111 calls, 2924 (-88·8% [-90·4 to -87·2]) fewer out-of-hours GP contacts, 91 304 (-89·9% [-90·0 to -89·9]) in-hours GP consultations, and 27 486 (-85·3% [-85·4 to -85·2]) fewer emergency department attendances for children younger than 5 years compared with predicted values based on winter seasons before the COVID-19 pandemic. An unprecedented summer surge of RSV activity occurred in 2021, including 11 255 (1258·3% [1178·3 to 1345·8]) extra laboratory-confirmed cases, 11·6 percentage points (527·3%) higher test positivity, 7604 (10·7% [10·7 to 10·8]) additional hospital admissions, 84 425 (124·8% [124·7 to 124·9]) more calls to NHS 111, 409 (39·0% [36·6 to 41·8]) more out-of-hours GP contacts, and 9789 (84·9% [84·5 to 85·4]) more emergency department attendances compared with the predicted values, although there were 21 805 (-34·1% [-34·1 to -34·0]) fewer in-hours GP consultations than expected. Most indicators were also lower than expected in winter 2021-22, although to a lesser extent than in winter 2020-21.

INTERPRETATION

The extraordinary absence of RSV during winter 2020-21 probably resulted in a cohort of young children without natural immunity to RSV, thereby raising the potential for increased RSV incidence, out-of-season activity, and health-service pressures when measures to restrict SARS-CoV-2 transmission were relaxed.

FUNDING

None.

Disparities in patient portal access by US adults before and during the COVID-19 pandemic

OBJECTIVE

Online patient portals become important during disruptions to in-person health care, like when cases of coronavirus disease 2019 (COVID-19) and other respiratory viruses rise, yet underlying structural inequalities associated with race, socio-economic status, and other socio-demographic characteristics may affect their use. We analyzed a population-based survey to identify disparities within the United States in access to online portals during the early period of COVID-19 in 2020.

MATERIALS AND METHODS

The National Cancer Institute fielded the 2020 Health and Information National Trends Survey from February to June 2020. We conducted multivariable analysis to identify socio-demographic characteristics of US patients who were offered and accessed online portals, and reasons for nonuse.

RESULTS

Less than half of insured adult patients reported accessing an online portal in the prior 12 months, and this was less common among patients who are male, are Hispanic, have less than a college degree, have Medicaid insurance, have no regular provider, or have no internet. Reasons for nonuse include: wanting to speak directly to a provider, not having an online record, concerns about privacy, and discomfort with technology.

DISCUSSION

Despite the rapid expansion of digital health technologies due to COVID-19, we found persistent socio-demographic disparities in access to patient portals. Ensuring that digital health tools are secure, private, and trustworthy would address some patient concerns that are barriers to portal access.

CONCLUSION

Expanding the use of online portals requires explicitly addressing fundamental inequities to prevent exacerbating existing disparities, particularly during surges in cases of COVID-19 and other respiratory viruses that tax health care resources.

Patient perceptions of vulnerability to recurrent respiratory tract infections and prevention strategies: a qualitative study

OBJECTIVES

Respiratory tract infections (RTIs) are extremely common, usually self-limiting, but responsible for considerable work sickness absence, reduced quality of life, inappropriate antibiotic prescribing and healthcare costs. Patients who experience recurrent RTIs and those with certain comorbid conditions have higher personal impact and healthcare costs and may be more likely to suffer disease exacerbations, hospitalisation and death. We explored how these patients experience and perceive their RTIs to understand how best to engage them in prevention behaviours.

DESIGN

A qualitative interview study.

SETTING

Primary care, UK.

METHODS

23 participants who reported recurrent RTIs and/or had relevant comorbid health conditions were interviewed about their experiences of RTIs. Interviews took place as the COVID-19 pandemic began. Data were analysed using inductive thematic analysis.

RESULTS

Three themes were developed: Understanding causes and vulnerability, Attempting to prevent RTIs, Uncertainty and ambivalence about prevention, along with an overarching theme; Changing experiences because of COVID-19. Participants' understandings of their susceptibility to RTIs were multifactorial and included both transmission via others and personal vulnerabilities. They engaged in various approaches to try to prevent infections or alter their progression yet perceived they had limited personal control. The COVID-19 pandemic had improved their understanding of transmission, heightened their concern and motivation to avoid RTIs and extended their repertoire of protective behaviours.

CONCLUSIONS

Patients who experience frequent or severe RTIs are likely to welcome and benefit from advice and support regarding RTI prevention. To engage people effectively, those developing interventions or delivering health services must consider their beliefs and concerns about susceptibility and prevention.

Demographic and socioeconomic patterns in healthcare-seeking behaviour for respiratory symptoms in England: a comparison with non-respiratory symptoms and between three healthcare services

OBJECTIVE

This study will analyse respiratory contacts to three healthcare services that capture more of the community disease burden than acute data sources, such as hospitalisations. The objective is to explore associations between contacts to these services and the patient's age, gender and deprivation. Results will be compared between healthcare services, and with non-respiratory contacts to explore how contacts differ by service and illness. It is crucial to investigate the sociodemographic patterns in healthcare-seeking behaviour to enable targeted public health interventions.

DESIGN

Ecological study.

SETTING

Surveillance of respiratory contacts to three healthcare services in England: telehealth helpline (NHS111); general practitioner in-hours (GPIH); and general practitioner out of hours unscheduled care (GPOOH).

PARTICIPANTS

13 million respiratory contacts to NHS111, GPIH and GPOOH.

OUTCOME MEASURES

Respiratory contacts to NHS111, GPIH and GPOOH, and non-respiratory contacts to NHS111 and GPOOH.

RESULTS

More respiratory contacts were observed for females, with 1.59, 1.73, and 1.95 times the rate of contacts to NHS111, GPOOH and GPIH, respectively. When compared with 15-44 year olds, there were 37.32, 18.66 and 6.21 times the rate of respiratory contacts to NHS111, GPOOH and GPIH in children <1 year. There were 1.75 and 2.70 times the rate of respiratory contacts in the most deprived areas compared with the least deprived to NHS111 and GPOOH. Elevated respiratory contacts were observed for males <5 years compared with females <5 years. Healthcare-seeking behaviours between respiratory and non-respiratory contacts were similar.

CONCLUSION

When contacts to services that capture more of the disease burden are explored, the demographic patterns are similar to those described in the literature for acute systems. Comparable results were observed between respiratory and non-respiratory contacts suggesting that when a wider spectrum of disease is explored, sociodemographic factors may be the strongest influencers of healthcare-seeking behaviour.

The COVID-19 pandemic: a new challenge for syndromic surveillance

The COVID-19 pandemic is exerting major pressures on society, health and social care services and science. Understanding the progression and current impact of the pandemic is fundamental to planning, management and mitigation of future impact on the population. Surveillance is the core function of any public health system, and a multi-component surveillance system for COVID-19 is essential to understand the burden across the different strata of any health system and the population. Many countries and public health bodies utilise ‘syndromic surveillance’ (using real-time, often non-specific symptom/preliminary diagnosis information collected during routine healthcare provision) to supplement public health surveillance programmes. The current COVID-19 pandemic has revealed a series of unprecedented challenges to syndromic surveillance including: the impact of media reporting during early stages of the pandemic; changes in healthcare-seeking behaviour resulting from government guidance on social distancing and accessing healthcare services; and changes in clinical coding and patient management systems. These have impacted on the presentation of syndromic outputs, with changes in denominators creating challenges for the interpretation of surveillance data. Monitoring changes in healthcare utilisation is key to interpreting COVID-19 surveillance data, which can then be used to better understand the impact of the pandemic on the population. Syndromic surveillance systems have had to adapt to encompass these changes, whilst also innovating by taking opportunities to work with data providers to establish new data feeds and develop new COVID-19 indicators. These developments are supporting the current public health response to COVID-19, and will also be instrumental in the continued and future fight against the disease.

Can syndromic surveillance help forecast winter hospital bed pressures in England?

Background

Health care planners need to predict demand for hospital beds to avoid deterioration in health care. Seasonal demand can be affected by respiratory illnesses which in England are monitored using syndromic surveillance systems. Therefore, we investigated the relationship between syndromic data and daily emergency hospital admissions.

Methods

We compared the timing of peaks in syndromic respiratory indicators and emergency hospital admissions, between 2013 and 2018. Furthermore, we created forecasts for daily admissions and investigated their accuracy when real-time syndromic data were included.

Results

We found that syndromic indicators were sensitive to changes in the timing of peaks in seasonal disease, especially influenza. However, each year, peak demand for hospital beds occurred on either 29^th or 30^th December, irrespective of the timing of syndromic peaks. Most forecast models using syndromic indicators explained over 70% of the seasonal variation in admissions (adjusted R square value). Forecast errors were reduced when syndromic data were included. For example, peak admissions for December 2014 and 2017 were underestimated when syndromic data were not used in models.

Conclusion

Due to the lack of variability in the timing of the highest seasonal peak in hospital admissions, syndromic surveillance data do not provide additional early warning of timing. However, during atypical seasons syndromic data did improve the accuracy of forecast intensity.

[Flu-like disease in summer - what do we know about it?]

Durchsucht man die deutschsprachige medizinische Literatur nach dem Begriff „Sommergrippe“, scheitert man kläglich. Jeder glaubt zu wissen, was damit gemeint ist, doch keiner schreibt darüber. Ist das überhaupt ein seriöses Thema?

Telephone announcements encouraging common cold self-management reduce demand for general practice appointments

Background

Patients consulting with the common cold contribute to seasonal demand for general practice appointments. Seeing a community pharmacist or using self-management may have been more appropriate options. The study aimed to measure if the use of telephone announcements signposting appropriate patients with the common cold in the direction of community pharmacy or self-management reduced demand for general practice consultations.

Methods

Patients telephoning a UK general practice to request an appointment between December 2017 and March 2018 heard announcements regarding management of the common cold. The percentage of callers choosing to continue to speak to a receptionist was compared with baseline data prior to the intervention. The mean waiting time to the third available routine general practice appointment during the intervention was compared with the previous year.

Results

Routine calls continuing to reception reduced by 5.5 % (p<0.001) when the incidence of the common cold is at its highest and by 3.9% (p<0.001) throughout the intervention. The mean waiting time to the third available routine appointment reduced by 21%.

Conclusion

This study has demonstrated that the use of telephone announcements signposting appropriate patients with the common cold in the direction of community pharmacy or self-management reduces calls to reception. This strongly infers that the telephone announcements reduce demand for general practice appointments and is supported by the reduced mean waiting time to the third available routine appointment. Implementation of this intervention could help general practitioners reduce seasonal demand in their own practices.

Developing influenza and respiratory syncytial virus activity thresholds for syndromic surveillance in England

Influenza and respiratory syncytial virus (RSV) are common causes of respiratory tract infections and place a burden on health services each winter. Systems to describe the timing and intensity of such activity will improve the public health response and deployment of interventions to these pressures. Here we develop early warning and activity intensity thresholds for monitoring influenza and RSV using two novel data sources: general practitioner out-of-hours consultations (GP OOH) and telehealth calls (NHS 111). Moving Epidemic Method (MEM) thresholds were developed for winter 2017-2018. The NHS 111 cold/flu threshold was breached several weeks in advance of other systems. The NHS 111 RSV epidemic threshold was breached in week 41, in advance of RSV laboratory reporting. Combining the use of MEM thresholds with daily monitoring of NHS 111 and GP OOH syndromic surveillance systems provides the potential to alert to threshold breaches in real-time. An advantage of using thresholds across different health systems is the ability to capture a range of healthcare-seeking behaviour, which may reflect differences in disease severity. This study also provides a quantifiable measure of seasonal RSV activity, which contributes to our understanding of RSV activity in advance of the potential introduction of new RSV vaccines.

Long-lasting cough in an adult German population: incidence, symptoms, and related pathogens

Studies of the incidence of pertussis in adults have shown that it accounts for only 5–15% cases of prolonged coughing. We assessed the burden of suffering related to prolonged coughing and tried to identify further causative agents. Based on a sentinel study with 35 general practitioners in two German cities (Krefeld, Rostock), with 3,946 patients fulfilling the inclusion criteria, we estimated the incidence of prolonged coughing in adults. In 975 of these outpatients, PCR and/or serology for adenovirus, Bordetella pertussis and B. parapertussis, human metapneumovirus, influenza virus A and rhinovirus, parainfluenza virus, Mycoplasma pneumonia, and respiratory syncytial virus (RSV) were performed. Treatment data were extracted for a subgroup of 138 patients. Descriptive statistics, including Kaplan–Maier curves were generated. Yearly incidence ranged between 1.4 and 2.1% per population in the two cities. Adult patients sought medical attention only after a median of 3 weeks of coughing. Irrespective of smoking and unrelated to the identified pathogens, the median duration of coughing was 6 weeks, with an interquartile range of 4–11 weeks. In 48.3% of patients, possible pathogens were identified, among which adenovirus (15.1%), RSV (7.5%), B. pertussis (5.6%), and influenza viruses (4.0%) were most often found. Symptoms were not indicative of a specific agent and a total of 64% of patients received antibiotics. Prolonged adult coughing requiring medical attention prompts substantial healthcare use. Apart from B. pertussis, a broad range of pathogens was associated with the symptoms. However, patients sought medical attention too late to guide efficacious therapeutic interventions using the diagnostic tests.