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Biundo E, Dronova M, Chicoye A, Cookson R, Devlin N, Doherty TM, Garcia S, Garcia-Ruiz AJ, Garrison LP, Nolan T, Postma M, Salisbury D, Shah H, Sheikh S, Smith R, Toumi M, Wasem J, Beck E. Capturing the Value of Vaccination within Health Technology Assessment and Health Economics-Practical Considerations for Expanding Valuation by Including Key Concepts. Vaccines (Basel) 2024; 12:773. [PMID: 39066411 PMCID: PMC11281546 DOI: 10.3390/vaccines12070773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 06/25/2024] [Accepted: 06/26/2024] [Indexed: 07/28/2024] Open
Abstract
Following the development of a value of vaccination (VoV) framework for health technology assessment/cost-effectiveness analysis (HTA/CEA), and identification of three vaccination benefits for near-term inclusion in HTA/CEA, this final paper provides decision makers with methods and examples to consider benefits of health systems strengthening (HSS), equity, and macroeconomic gains. Expert working groups, targeted literature reviews, and case studies were used. Opportunity cost methods were applied for HSS benefits of rotavirus vaccination. Vaccination, with HSS benefits included, reduced the incremental cost-effectiveness ratio (ICER) by 1.4-50.5% (to GBP 11,552-GBP 23,016) depending on alternative conditions considered. Distributional CEA was applied for health equity benefits of meningococcal vaccination. Nearly 80% of prevented cases were among the three most deprived groups. Vaccination, with equity benefits included, reduced the ICER by 22-56% (to GBP 7014-GBP 12,460), depending on equity parameters. Macroeconomic models may inform HTA deliberative processes (e.g., disease impact on the labour force and the wider economy), or macroeconomic outcomes may be assessed for individuals in CEAs (e.g., impact on non-health consumption, leisure time, and income). These case studies show how to assess broader vaccination benefits in current HTA/CEA, providing decision makers with more accurate and complete VoV assessments. More work is needed to refine inputs and methods, especially for macroeconomic gains.
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Affiliation(s)
- Eliana Biundo
- GSK, Building W23, 20 Avenue Fleming, 1300 Wavre, Belgium (S.G.); (H.S.); (S.S.)
| | | | - Annie Chicoye
- AC Health Consulting, Sciences Po, 75007 Paris, France;
| | - Richard Cookson
- Centre for Health Economics, University of York, York YO10 5DD, UK;
| | - Nancy Devlin
- Health Economics Unit, Centre for Health Policy, University of Melbourne, Melbourne 3010, Australia; (N.D.); (T.N.)
| | - T. Mark Doherty
- GSK, Building W23, 20 Avenue Fleming, 1300 Wavre, Belgium (S.G.); (H.S.); (S.S.)
| | - Stephanie Garcia
- GSK, Building W23, 20 Avenue Fleming, 1300 Wavre, Belgium (S.G.); (H.S.); (S.S.)
| | - Antonio J. Garcia-Ruiz
- Department of Pharmacology and Clinical Therapeutics, Faculty of Medicine, University of Malaga, 29071 Malaga, Spain;
| | - Louis P. Garrison
- School of Pharmacy, University of Washington, Seattle, WA 98195, USA;
| | - Terry Nolan
- Health Economics Unit, Centre for Health Policy, University of Melbourne, Melbourne 3010, Australia; (N.D.); (T.N.)
| | - Maarten Postma
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, 9700 AB Groningen, The Netherlands;
- Department of Economics, Econometrics & Finance, Faculty of Economics & Business, University of Groningen, 9713 AB Groningen, The Netherlands
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung 40132, Indonesia
| | - David Salisbury
- Programme for Global Health, Royal Institute of International Affairs, Chatham House, London SW1Y 4LE, UK;
| | - Hiral Shah
- GSK, Building W23, 20 Avenue Fleming, 1300 Wavre, Belgium (S.G.); (H.S.); (S.S.)
| | - Shazia Sheikh
- GSK, Building W23, 20 Avenue Fleming, 1300 Wavre, Belgium (S.G.); (H.S.); (S.S.)
| | - Richard Smith
- College of Medicine and Health, University of Exeter, Exeter EX1 2HZ, UK;
| | | | - Jurgen Wasem
- Institute for Health Care Management and Research, University of Duisburg-Essen, 45127 Essen, Germany;
| | - Ekkehard Beck
- GSK, Building W23, 20 Avenue Fleming, 1300 Wavre, Belgium (S.G.); (H.S.); (S.S.)
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2
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Neri M, Brassel S, Schirrmacher H, Mendes D, Vyse A, Steuten L, Hamson E. Vaccine-Preventable Hospitalisations from Seasonal Respiratory Diseases: What Is Their True Value? Vaccines (Basel) 2023; 11:vaccines11050945. [PMID: 37243048 DOI: 10.3390/vaccines11050945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 05/28/2023] Open
Abstract
Hospitals in England experience extremely high levels of bed occupancy in the winter. In these circumstances, vaccine-preventable hospitalisations due to seasonal respiratory infections have a high cost because of the missed opportunity to treat other patients on the waiting list. This paper estimates the number of hospitalisations that current vaccines against influenza, pneumococcal disease (PD), COVID-19, and a hypothetical Respiratory Syncytial Virus (RSV) vaccine, could prevent in the winter among older adults in England. Their costs were quantified using a conventional reference costing method and a novel opportunity costing approach considering the net monetary benefit (NMB) obtained from alternative uses of the hospital beds freed-up by vaccines. The influenza, PD and RSV vaccines could collectively prevent 72,813 bed days and save over £45 million in hospitalisation costs. The COVID-19 vaccine could prevent over 2 million bed days and save £1.3 billion. However, the value of hospital beds freed up by vaccination is likely to be 1.1-2 times larger (£48-93 million for flu, PD and RSV; £1.4-2.8 billion for COVID-19) when quantified in opportunity cost terms. Considering opportunity costs is key to ensuring maximum value is obtained from preventative budgets, as reference costing may significantly underestimate the true value of vaccines.
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3
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Svendsen AT, Nielsen HL, Bytzer P, Coia JE, Engberg J, Holt HM, Lemming L, Lomborg S, Marmolin ES, Olesen BS, Andersen LP, Ethelberg S, Engsbro AL. The incidence of laboratory-confirmed cases of enteric pathogens in Denmark 2018: a national observational study. Infect Dis (Lond) 2023; 55:340-350. [PMID: 36868794 DOI: 10.1080/23744235.2023.2183253] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND Only a subset of enteric pathogens is under surveillance in Denmark, and knowledge on the remaining pathogens detected in acute gastroenteritis is limited. Here, we present the one-year incidence of all enteric pathogens diagnosed in Denmark, a high-income country, in 2018 and an overview of diagnostic methods used for detection. METHODS All 10 departments of clinical microbiology completed a questionnaire on test methods and provided 2018-data of persons with positive stool samples with Salmonella species, Campylobacter jejuni/coli, Yersinia enterocolitica, Aeromonas species, diarrheagenic Escherichia coli (Enteroinvasive (EIEC), Shiga toxin-producing (STEC), Enterotoxigenic (ETEC), Enteropathogenic (EPEC), and intimin-producing/attaching and effacing (AEEC)), Shigella species., Vibrio cholerae, norovirus, rotavirus, sapovirus, adenovirus, Giardia intestinalis, Cryptosporidium species, and Entamoeba histolytica. RESULTS Enteric bacterial infections were diagnosed with an incidence of 229.9 cases/100,000 inhabitants, virus had an incidence of 86/100,000 and enteropathogenic parasites of 12.5/100,000. Viruses constituted more than half of diagnosed enteropathogens for children below 2 years and elderly above 80 years. Diagnostic methods and algorithms differed across the country and in general PCR testing resulted in higher incidences compared to culture (bacteria), antigen-test (viruses), or microscopy (parasites) for most pathogens. CONCLUSIONS In Denmark, the majority of detected infections are bacterial with viral agents primarily detected in the extremes of ages and with few intestinal protozoal infections. Incidence rates were affected by age, clinical setting and local test methods with PCR leading to increased detection rates. The latter needs to be taken into account when interpreting epidemiological data across the country.
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Affiliation(s)
- Anna Tølbøll Svendsen
- Department of Medicine, Zealand University Hospital, Køge, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark
| | - Hans Linde Nielsen
- Department of Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Peter Bytzer
- Department of Medicine, Zealand University Hospital, Køge, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - John Eugenio Coia
- Department of Clinical Microbiology, Sydvestjysk Sygehus, Esbjerg, Denmark.,Department of Regional Health Research, University of Southern, Odense, Denmark
| | - Jørgen Engberg
- Department of Clinical Microbiology, Zealand University Hospital, Slagelse, Denmark
| | - Hanne Marie Holt
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | - Lars Lemming
- Department of Clinical Microbiology, Aarhus University Hospital, Denmark
| | - Steen Lomborg
- Department of Clinical Microbiology, Sygehus Sønderjylland, Aabenraa, Denmark
| | - Ea Sofie Marmolin
- Department of Clinical Microbiology, Sygehus Lillebælt, Vejle, Denmark
| | - Bente Scharvik Olesen
- Department of Clinical Microbiology, Copenhagen University Hospital Herlev, Copenhagen, Denmark
| | - Leif Percival Andersen
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Steen Ethelberg
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark.,Department of Public Health, Global Health Section, University of Copenhagen, Copenhagen, Denmark
| | - Anne Line Engsbro
- Department of Clinical Microbiology, Zealand University Hospital, Slagelse, Denmark.,Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
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4
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Chadwick PR, Trainor E, Marsden GL, Mills S, Chadwick C, O'Brien SJ, Evans CM, Mullender C, Strazds P, Turner S, Weston V, Toleman MS, de Barros C, Kontkowski G, Bak A. Guidelines for the management of norovirus outbreaks in acute and community health and social care settings. J Hosp Infect 2023:S0195-6701(23)00043-9. [PMID: 36796728 DOI: 10.1016/j.jhin.2023.01.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/19/2023] [Accepted: 01/22/2023] [Indexed: 02/17/2023]
Affiliation(s)
| | - Eamonn Trainor
- Northern Care Alliance NHS Foundation Trust, Greater Manchester, UK.
| | - Gemma L Marsden
- Healthcare Infection Society, London, UK; Royal College of General Practitioners, London, UK
| | - Samuel Mills
- British Infection Association, Seafield, West Lothian, UK; Oxford University NHS Foundation Trust, Oxford, UK
| | | | | | - Cariad M Evans
- Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | | | - Pixy Strazds
- Infection Prevention Society, London, UK; St Andrew's Healthcare, Northampton, UK
| | - Sarah Turner
- Infection Prevention Society, London, UK; Stockport Council, Stockport, UK
| | - Valya Weston
- Healthcare Infection Society, London, UK; Infection Prevention Society, London, UK; NHS England, London, UK
| | - Michelle S Toleman
- Healthcare Infection Society, London, UK; Cambridge University Hospitals NHS Trust, Cambridge, UK
| | | | | | - Aggie Bak
- Healthcare Infection Society, London, UK
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5
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Winder N, Gohar S, Muthana M. Norovirus: An Overview of Virology and Preventative Measures. Viruses 2022; 14:v14122811. [PMID: 36560815 PMCID: PMC9781483 DOI: 10.3390/v14122811] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 12/05/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
Norovirus (NoV) is an enteric non-enveloped virus which is the leading cause of gastroenteritis across all age groups. It is responsible for around 200,000 deaths annually and outbreaks are common in small communities such as educational and care facilities. 40% of all NoV outbreaks occur in long-term and acute-care facilities, forming the majority of outbreaks. Nosocomial settings set ideal environments for ease of transmission, especially due to the presence of immunocompromised groups. It is estimated to cost global economies around £48 billion a year, making it a global issue. NoV is transmitted via the faecal-oral route and infection with it results in asymptomatic cases or gastrointestinal disease. It has high mutational rates and this allows for new variants to emerge and be more resistant. The classification system available divides NoV into 10 genogroups and 49 genotypes based on whole amino acid sequencing of VP1 capsid protein and partial sequencing of RdRp, respectively. The most predominant genotypes which cause gastroenteritis in humans include GI.1 and GII.4, where GII.4 is responsible for more extreme clinical implications such as hospitalisation. In addition, GII.4 has been responsible for 6 pandemic strains, the last of which is the GII.4 Sydney (2012) variant. In recent years, the successful cultivation of HuNoV was reported in stem cell-derived human intestinal enteroids (HIEs), which promises to assist in giving a deeper understanding of its underlying mechanisms of infection and the development of more personalized control measures. There are no specific control measures against NoV, therefore common practices are used against it such as hand washing. No vaccine is available, but the HIL-214 candidate passed clinical phase 2b and shows promise.
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6
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Lindesmith LC, Boshier FAT, Brewer-Jensen PD, Roy S, Costantini V, Mallory ML, Zweigart M, May SR, Conrad H, O’Reilly KM, Kelly D, Celma CC, Beard S, Williams R, Tutill HJ, Becker Dreps S, Bucardo F, Allen DJ, Vinjé J, Goldstein RA, Breuer J, Baric RS. Immune Imprinting Drives Human Norovirus Potential for Global Spread. mBio 2022; 13:e0186122. [PMID: 36102514 PMCID: PMC9600701 DOI: 10.1128/mbio.01861-22] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 08/25/2022] [Indexed: 01/11/2023] Open
Abstract
Understanding the complex interactions between virus and host that drive new strain evolution is key to predicting the emergence potential of variants and informing vaccine development. Under our hypothesis, future dominant human norovirus GII.4 variants with critical antigenic properties that allow them to spread are currently circulating undetected, having diverged years earlier. Through large-scale sequencing of GII.4 surveillance samples, we identified two variants with extensive divergence within domains that mediate neutralizing antibody binding. Subsequent serological characterization of these strains using temporally resolved adult and child sera suggests that neither candidate could spread globally in adults with multiple GII.4 exposures, yet young children with minimal GII.4 exposure appear susceptible. Antigenic cartography of surveillance and outbreak sera indicates that continued population exposure to GII.4 Sydney 2012 and antigenically related variants over a 6-year period resulted in a broadening of immunity to heterogeneous GII.4 variants, including those identified here. We show that the strongest antibody responses in adults exposed to GII.4 Sydney 2012 are directed to previously circulating GII.4 viruses. Our data suggest that the broadening of antibody responses compromises establishment of strong GII.4 Sydney 2012 immunity, thereby allowing the continued persistence of GII.4 Sydney 2012 and modulating the cycle of norovirus GII.4 variant replacement. Our results indicate a cycle of norovirus GII.4 variant replacement dependent upon population immunity. Young children are susceptible to divergent variants; therefore, emergence of these strains worldwide is driven proximally by changes in adult serological immunity and distally by viral evolution that confers fitness in the context of immunity. IMPORTANCE In our model, preepidemic human norovirus variants harbor genetic diversification that translates into novel antigenic features without compromising viral fitness. Through surveillance, we identified two viruses fitting this profile, forming long branches on a phylogenetic tree. Neither evades current adult immunity, yet young children are likely susceptible. By comparing serological responses, we demonstrate that population immunity varies by age/exposure, impacting predicted susceptibility to variants. Repeat exposure to antigenically similar variants broadens antibody responses, providing immunological coverage of diverse variants but compromising response to the infecting variant, allowing continued circulation. These data indicate norovirus GII.4 variant replacement is driven distally by virus evolution and proximally by immunity in adults.
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Affiliation(s)
- Lisa C. Lindesmith
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Florencia A. T. Boshier
- Department of Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Paul D. Brewer-Jensen
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sunando Roy
- Department of Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Veronica Costantini
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Michael L. Mallory
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Mark Zweigart
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Samantha R. May
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Helen Conrad
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Kathleen M. O’Reilly
- Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Daniel Kelly
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Cristina C. Celma
- Enteric Virus Unit, The Virus Reference Department, UK Health Security Agency, London, United Kingdom
| | - Stuart Beard
- Enteric Virus Unit, The Virus Reference Department, UK Health Security Agency, London, United Kingdom
| | - Rachel Williams
- Department of Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
- Department of Genetics & Genomic Medicine, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Helena J. Tutill
- Department of Genetics & Genomic Medicine, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Sylvia Becker Dreps
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Filemón Bucardo
- Department of Microbiology, National Autonomous University of Nicaragua, León, León, Nicaragua
| | - David J. Allen
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jan Vinjé
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Richard A. Goldstein
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - Judith Breuer
- Department of Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
- Department of Microbiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Ralph S. Baric
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
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7
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Mendes D, Averin A, Atwood M, Sato R, Vyse A, Campling J, Weycker D, Slack M, Ellsbury G, Mugwagwa T. Cost-effectiveness of using a 20-valent pneumococcal conjugate vaccine to directly protect adults in England at elevated risk of pneumococcal disease. Expert Rev Pharmacoecon Outcomes Res 2022; 22:1285-1295. [PMID: 36225103 DOI: 10.1080/14737167.2022.2134120] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Despite the current pneumococcal vaccination program in England for older adults and adults with underlying conditions, disease burden remains high. We evaluated cost-effectiveness of 20-valent pneumococcal conjugate vaccine (PCV20) compared to current pneumococcal recommendations for adults in England. METHODS Lifetime outcomes/costs of invasive pneumococcal disease (IPD) and community-acquired pneumonia (CAP) among adults aged 65-99 years and adults aged 18-64 years with underlying conditions in England were projected using a probabilistic cohort model. Vaccination with PCV20 was compared with 23-valent pneumococcal polysaccharide vaccine (PPV23) from the National Health Service perspective. RESULTS PCV20 was cost saving compared with PPV23 in base case and most sensitivity analyses. In the base case, replacing PPV23 with PCV20 prevented 7,789 and 140,046 cases of IPD and hospitalized CAP, respectively, and 22,199 associated deaths, resulting in incremental gain of 91,375 quality-adjusted life-years (QALYs) and incremental savings of £160M. In probabilistic sensitivity analyses, PCV20 (vs. PPV23) was cost saving in 85% of simulations; incremental cost per QALY was below £30,000 in 99% of simulations. CONCLUSIONS PCV20 vaccination in adults aged 65-99 years and those aged 18-64 years with underlying comorbidities in England is expected to prevent more hospitalizations, save more lives, and yield lower overall costs than current recommendations for PPV23.
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Affiliation(s)
| | | | - Mark Atwood
- Policy Analysis Inc. (PAI), Chestnut Hill, MA
| | | | | | | | | | - Mary Slack
- School of Medicine & Dentistry, Griffith University, Gold Coast Campus, Queensland 4222, Australia
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8
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Brassel S, Neri M, Schirrmacher H, Steuten L. The Value of Vaccines in Maintaining Health System Capacity in England. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022:S1098-3015(22)02096-4. [PMID: 35973927 DOI: 10.1016/j.jval.2022.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 05/04/2022] [Accepted: 06/30/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES In situations of excess demand for healthcare, treating one patient means losing the opportunity to treat another. Therefore, each decision bears an opportunity cost. Nevertheless, when assessing the value of health technologies, these opportunity costs are not always fully considered. We present a pragmatic approach for conceptualizing vaccines' health system capacity value when considering opportunity costs. METHODS Our approach proxies opportunity costs through the net monetary benefit forgone as scarce healthcare resources are used to treat a vaccine-preventable disease instead of a patient from the waiting list. We apply this approach to cost the resource "hospital beds" for 3 different scenarios of excess demand. Empirically, we estimate the opportunity costs saved for 4 selected vaccination programs from the national schedule in England during a hypothetical scenario of long-lasting excess demand induced by the pandemic. RESULTS The opportunity cost avoided through vaccination rises with excess demand for treatment. When treating an acute vaccine-preventable outcome is a suboptimal choice compared with treating elective patients, preventing a vaccine-preventable disease from blocking a hospital bed generates opportunity cost savings of approximately twice the direct costs saved by avoiding vaccine-preventable hospitalizations. CONCLUSIONS Policy makers should be aware that, in addition to preventing the outcome of interest, vaccines and other preventative health technologies deliver value in maintaining regular healthcare services and clearing the pent-up demand from the pandemic. Therefore, health system capacity value should be a key-value element in health technology assessment. Existing and potential future vaccination programs deliver more value than hitherto quantified.
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9
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O'Reilly KM, Sandman F, Allen D, Jarvis CI, Gimma A, Douglas A, Larkin L, Wong KLM, Baguelin M, Baric RS, Lindesmith LC, Goldstein RA, Breuer J, Edmunds WJ. Predicted norovirus resurgence in 2021-2022 due to the relaxation of nonpharmaceutical interventions associated with COVID-19 restrictions in England: a mathematical modeling study. BMC Med 2021; 19:299. [PMID: 34753508 PMCID: PMC8577179 DOI: 10.1186/s12916-021-02153-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/04/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND To reduce the coronavirus disease burden in England, along with many other countries, the government implemented a package of non-pharmaceutical interventions (NPIs) that have also impacted other transmissible infectious diseases such as norovirus. It is unclear what future norovirus disease incidence is likely to look like upon lifting these restrictions. METHODS Here we use a mathematical model of norovirus fitted to community incidence data in England to project forward expected incidence based on contact surveys that have been collected throughout 2020-2021. RESULTS We report that susceptibility to norovirus infection has likely increased between March 2020 and mid-2021. Depending upon assumptions of future contact patterns incidence of norovirus that is similar to pre-pandemic levels or an increase beyond what has been previously reported is likely to occur once restrictions are lifted. Should adult contact patterns return to 80% of pre-pandemic levels, the incidence of norovirus will be similar to previous years. If contact patterns return to pre-pandemic levels, there is a potential for the expected annual incidence to be up to 2-fold larger than in a typical year. The age-specific incidence is similar across all ages. CONCLUSIONS Continued national surveillance for endemic diseases such as norovirus will be essential after NPIs are lifted to allow healthcare services to adequately prepare for a potential increase in cases and hospital pressures beyond what is typically experienced.
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Affiliation(s)
- Kathleen M O'Reilly
- Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Frank Sandman
- Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.,Statistics, Modelling and Economics Department, National Infection Service, Public Health England, London, UK.,NIHR Health Protection Research Unit in Modelling and Health Economics, London School of Hygiene and Tropical Medicine, London, UK
| | - David Allen
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Christopher I Jarvis
- Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Amy Gimma
- Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Amy Douglas
- Gastrointestinal Pathogens Unit, National Infection Service, Public Health England, London, UK
| | - Lesley Larkin
- Gastrointestinal Pathogens Unit, National Infection Service, Public Health England, London, UK
| | - Kerry L M Wong
- Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Marc Baguelin
- Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.,MRC Centre for Global Infectious Disease Analysis, J-IDEA, Department of Infectious Disease Epidemiology, Imperial College London, St Mary's Campus, London, UK
| | - Ralph S Baric
- Department of Epidemiology, University of North Carolina, Chapel Hill, USA
| | - Lisa C Lindesmith
- Department of Epidemiology, University of North Carolina, Chapel Hill, USA
| | | | - Judith Breuer
- Division of Infection and Immunity, University College London, London, UK.,Department of Microbiology, Virology and Infection Control, Great Ormond Street Hospital for Children, London, UK
| | - W John Edmunds
- Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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10
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Yasmin F, Ali SH, Ullah I. Norovirus outbreak amid COVID-19 in the United Kingdom; priorities for achieving control. J Med Virol 2021; 94:1232-1235. [PMID: 34713915 PMCID: PMC8662166 DOI: 10.1002/jmv.27426] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 10/23/2021] [Accepted: 10/27/2021] [Indexed: 12/20/2022]
Abstract
Norovirus, an enteric virus primarily responsible for gastroenteritis outbreaks worldwide, is currently causing outbreaks around the United Kingdom during the COVID-19 pandemic. With an already exhausted health care system, the significant burden norovirus can have on the National Health Service, including economic and social burdens, is immense and cannot be tolerated. Primary challenges and priorities to be focused on due to the increase in norovirus outbreaks include a further depletion of health care services, increase cases in schools, nurseries, and care facilities, underreporting of the cases, and no effective vaccine being available. Therefore, it is essential to increase awareness about norovirus and its transmission in public, take necessary precautions, and increase reporting of cases. This article discusses the impact norovirus has during the COVID-19 pandemic, and the challenges, and recommendations to achieve control before it reaches epidemic levels.
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Affiliation(s)
- Farah Yasmin
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Syed Hasan Ali
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Irfan Ullah
- Department of Community Medicine, Kabir Medical College, Gandhara University, Peshawar, Pakistan
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11
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Qian W, Huang J, Wang X, Wang T, Li Y. CRISPR-Cas12a combined with reverse transcription recombinase polymerase amplification for sensitive and specific detection of human norovirus genotype GII.4. Virology 2021; 564:26-32. [PMID: 34601182 DOI: 10.1016/j.virol.2021.09.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/24/2021] [Accepted: 09/24/2021] [Indexed: 11/16/2022]
Abstract
Human norovirus (NOV) is a common and serious virus that accounts for sporadic cases and outbreaks of gastroenteritis. This study aimed to develop rapid, reliable and portable detection systems by coupling reverse transcription recombinase polymerase amplification (RT-RPA) with CRISPR-Cas12a (RT-RPA-Cas12a) for NOV genotype GII.4. Here, three primers for RNA-dependent RNA polymerase gene of NOV were designed and screened. Then, RT-RPA products were detected using CRISPR-Cas12a system by combing with fluorescence or lateral flow (LF). RT-RPA-Cas12a-based fluorescence or LF assay can be completed within 40 min, with the detection limit of up to 9.65 × 102copies/mL and no cross-reactivity with metapneumovirus, bocavirus, seoul virus, and respiratory syncytial virus. Furthermore, the detection coincidence rates of RT-RPA-Cas12a-based fluorescence and LF with qRT-PCR were 98.3%. Therefore, the present study suggests that both RT-RPA-Cas12a-based fluorescence and LF are promising sensitive, specific and alternative method for diagnosis of NOV genotype GII.4 without ancillary equipment.
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Affiliation(s)
- Weidong Qian
- School of Food and Biological Engineering, Shaanxi University of Science and Technology, Xi'an, 710021, PR China.
| | - Jie Huang
- School of Food and Biological Engineering, Shaanxi University of Science and Technology, Xi'an, 710021, PR China
| | - Xuefei Wang
- School of Food and Biological Engineering, Shaanxi University of Science and Technology, Xi'an, 710021, PR China
| | - Ting Wang
- School of Food and Biological Engineering, Shaanxi University of Science and Technology, Xi'an, 710021, PR China
| | - Yongdong Li
- Ningbo Municipal Center for Disease Control and Prevention, Ningbo, 315010, PR China.
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12
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Fraenkel CJ, Böttiger B, Söderlund-Strand A, Inghammar M. Risk of environmental transmission of norovirus infection from prior room occupants. J Hosp Infect 2021; 117:74-80. [PMID: 34547321 DOI: 10.1016/j.jhin.2021.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 08/24/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Environmental contamination of norovirus (NoV) is believed to be a significant source for further transmission in hospitals. AIM To investigate the risk of acquiring NoV in a cleaned room previously occupied by a patient with NoV infection. The risk of having a roommate with recent NoV infection was also assessed. METHODS In a retrospective cohort, comprising 33,788 room stays at five infectious Disease wards in southern Sweden from 2013 to 2018, the risk of acquiring NoV infection after admission to an exposed or non-exposed room was analysed with uni- and multivariable statistical analysis, controlling for age, colonization pressure and any roommate. RNA sequencing of the NoV strains involved in suspected room transmission was also performed. RESULTS Five of the 1106 patients exposed to a room with a prior occupant with NoV infection and 49 in the non-exposed group acquired NoV infection. An association between NoV acquisition was found in the univariable analysis (odds ratio (OR) 3.3, P=0.01), but not when adjusting for potential confounders (OR 1.9, P=0.2). Sequencing of the NoV samples showed that only two of the five exposed patients with acquired NoV infection were infected by identical strains to the prior room occupant, inferring a room transmission risk of 0.2% (95% confidence interval 0.05-0.78%). None of the 52 patients who shared room with a roommate with NoV symptoms resolved for ≥48 h acquired NoV infection. CONCLUSIONS In absolute terms, the risk of room transmission of NoV is low. Discontinuation of isolation ≥48 h after resolution of symptoms seems adequate.
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Affiliation(s)
- C-J Fraenkel
- Department of Infection Control, Region Skåne, Lund, Sweden; Division of Infection Medicine, Department of Clinical Sciences, Lund University, Sweden.
| | - B Böttiger
- Department of Clinical Microbiology, University and Regional Laboratories, Lund, Sweden
| | - A Söderlund-Strand
- Department of Clinical Microbiology, University and Regional Laboratories, Lund, Sweden
| | - M Inghammar
- Division of Infection Medicine, Department of Clinical Sciences, Lund University, Sweden
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O'Reilly KM, Sandman F, Allen D, Jarvis CI, Gimma A, Douglas A, Larkin L, Wong KL, Baguelin M, Baric RS, Lindesmith LC, Goldstein RA, Breuer J, Edmunds WJ. Predicted Norovirus Resurgence in 2021-2022 Due to the Relaxation of Nonpharmaceutical Interventions Associated with COVID-19 Restrictions in England: A Mathematical Modelling Study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2021:2021.07.09.21260277. [PMID: 34282423 PMCID: PMC8288156 DOI: 10.1101/2021.07.09.21260277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND To reduce the coronavirus disease burden in England, along with many other countries, the Government implemented a package of non-pharmaceutical interventions (NPIs) that have also impacted other transmissible infectious diseases such as norovirus. It is unclear what future norovirus disease incidence is likely to look like upon lifting these restrictions. METHODS Here we use a mathematical model of norovirus fitted to community incidence data in England to project forward expected incidence based on contact surveys that have been collected throughout 2020-2021. RESULTS We report that susceptibility to norovirus infection has likely increased between March 2020 to mid-2021. Depending upon assumptions of future contact patterns incidence of norovirus that is similar to pre-pandemic levels or an increase beyond what has been previously reported is likely to occur once restrictions are lifted. Should adult contact patterns return to 80% of pre-pandemic levels the incidence of norovirus will be similar to previous years. If contact patterns return to pre-pandemic levels there is a potential for the expected annual incidence to be up to 2-fold larger than in a typical year. The age-specific incidence is similar across all ages. CONCLUSIONS Continued national surveillance for endemic diseases such as norovirus will be essential after NPIs are lifted to allow healthcare services to adequately prepare for a potential increase in cases and hospital pressures beyond what is typically experienced.
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Affiliation(s)
- Kathleen M O'Reilly
- Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Frank Sandman
- Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
- Statistics, Modelling and Economics Department, National Infection Service, Public Health England, London, UK
- NIHR Health Protection Research Unit in Modelling and Health Economics, London School of Hygiene and Tropical Medicine, London, UK
| | - David Allen
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Christopher I Jarvis
- Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Amy Gimma
- Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Amy Douglas
- Gastrointestinal Pathogens Unit, National Infection Service, Public Health England, London, UK
| | - Lesley Larkin
- Gastrointestinal Pathogens Unit, National Infection Service, Public Health England, London, UK
| | - Kerry Lm Wong
- Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Marc Baguelin
- Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
- MRC Centre for Global Infectious Disease Analysis, J-IDEA, Department of Infectious Disease Epidemiology, Imperial College London, St Mary's Campus, London, UK
| | - Ralph S Baric
- Department of Epidemiology, University of North Carolina, Chapel Hill, USA
| | - Lisa C Lindesmith
- Department of Epidemiology, University of North Carolina, Chapel Hill, USA
| | | | - Judith Breuer
- Division of Infection and Immunity, University College London, London, UK
- Department of Microbiology, Virology and Infection Control, Great Ormond Street Hospital for Children, London, UK
| | - W John Edmunds
- Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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Wilson AM, King M, López‐García M, Clifton IJ, Proctor J, Reynolds KA, Noakes CJ. Effects of patient room layout on viral accruement on healthcare professionals' hands. INDOOR AIR 2021; 31:1657-1672. [PMID: 33913202 PMCID: PMC8242823 DOI: 10.1111/ina.12834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/25/2021] [Accepted: 03/23/2021] [Indexed: 05/16/2023]
Abstract
Healthcare professionals (HCPs) are exposed to highly infectious viruses, such as norovirus, through multiple exposure routes. Understanding exposure mechanisms will inform exposure mitigation interventions. The study objective was to evaluate the influences of hospital patient room layout on differences in HCPs' predicted hand contamination from deposited norovirus particles. Computational fluid dynamic (CFD) simulations of a hospital patient room were investigated to find differences in spatial deposition patterns of bioaerosols for right-facing and left-facing bed layouts under different ventilation conditions. A microbial transfer model underpinned by observed mock care for three care types (intravenous therapy (IV) care, observational care, and doctors' rounds) was applied to estimate HCP hand contamination. Viral accruement was contrasted between room orientation, care type, and by assumptions about whether bioaerosol deposition was the same or variable by room orientation. Differences in sequences of surface contacts were observed for care type and room orientation. Simulated viral accruement differences between room types were influenced by mostly by differences in bioaerosol deposition and by behavior sequences when deposition patterns for the room orientations were similar. Differences between care types were likely driven by differences in hand-to-patient contact frequency, with doctors' rounds resulting in the greatest predicted viral accruement on hands.
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Affiliation(s)
- Amanda M. Wilson
- Rocky Mountain Center for Occupational and Environmental HealthUniversity of UtahSalt Lake CityUTUSA
- Department of Family and Preventive MedicineSchool of MedicineUniversity of UtahSalt Lake CityUTUSA
- Department of Community, Environment, & PolicyMel and Enid Zuckerman College of Public HealthUniversity of ArizonaTucsonAZUSA
| | | | | | - Ian J. Clifton
- The Leeds Regional Adult Cystic Fibrosis CentreSt. James's University HospitalLeeds Teaching Hospital NHS TrustLeedsUK
| | | | - Kelly A. Reynolds
- Department of Community, Environment, & PolicyMel and Enid Zuckerman College of Public HealthUniversity of ArizonaTucsonAZUSA
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15
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Ondrikova N, Clough HE, Douglas A, Iturriza-Gomara M, Larkin L, Vivancos R, Harris JP, Cunliffe NA. Differential impact of the COVID-19 pandemic on laboratory reporting of norovirus and Campylobacter in England: A modelling approach. PLoS One 2021; 16:e0256638. [PMID: 34432849 PMCID: PMC8386829 DOI: 10.1371/journal.pone.0256638] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 08/11/2021] [Indexed: 12/15/2022] Open
Abstract
Background The COVID-19 pandemic has impacted surveillance activities for multiple pathogens. Since March 2020, there was a decline in the number of reports of norovirus and Campylobacter recorded by England’s national laboratory surveillance system. The aim is to estimate and compare the impact of the COVID-19 pandemic on norovirus and Campylobacter surveillance data in England. Methods We utilised two quasi-experimental approaches based on a generalised linear model for sequential count data. The first approach estimates overall impact and the second approach focuses on the impact of specific elements of the pandemic response (COVID-19 diagnostic testing and control measures). The following time series (27, 2015–43, 2020) were used: weekly laboratory-confirmed norovirus and Campylobacter reports, air temperature, conducted Sars-CoV-2 tests and Index of COVID-19 control measures stringency. Results The period of Sars-CoV-2 emergence and subsequent sustained transmission was associated with persistent reductions in norovirus laboratory reports (p = 0.001), whereas the reductions were more pronounced during pandemic emergence and later recovered for Campylobacter (p = 0.075). The total estimated reduction was 47% - 79% for norovirus (12–43, 2020). The total reduction varied by time for Campylobacter, e.g. 19% - 33% in April, 1% - 7% in August. Conclusion Laboratory reporting of norovirus was more adversely impacted than Campylobacter by the COVID-19 pandemic. This may be partially explained by a comparatively stronger effect of behavioural interventions on norovirus transmission and a relatively greater reduction in norovirus testing capacity. Our study underlines the differential impact a pandemic may have on surveillance of gastrointestinal infectious diseases.
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Affiliation(s)
- Nikola Ondrikova
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- Institute for Risk & Uncertainty, University of Liverpool, Liverpool, United Kingdom
- NIHR Health Protection Research Unit in Gastrointestinal Infections, University of Liverpool, Liverpool, United Kingdom
- * E-mail:
| | - Helen E. Clough
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- NIHR Health Protection Research Unit in Gastrointestinal Infections, University of Liverpool, Liverpool, United Kingdom
| | - Amy Douglas
- Gastrointestinal Pathogens Unit, National Infection Service, Public Health England, London, United Kingdom
| | | | - Lesley Larkin
- Gastrointestinal Pathogens Unit, National Infection Service, Public Health England, London, United Kingdom
| | - Roberto Vivancos
- NIHR Health Protection Research Unit in Gastrointestinal Infections, University of Liverpool, Liverpool, United Kingdom
- Field Service, National Infection Service, Public Health England, Liverpool, United Kingdom
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, United Kingdom
| | - John P. Harris
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- North West Health Protection Team, Public Health England, Liverpool, United Kingdom
| | - Nigel A. Cunliffe
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- NIHR Health Protection Research Unit in Gastrointestinal Infections, University of Liverpool, Liverpool, United Kingdom
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16
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Salah I, Parkin IP, Allan E. Copper as an antimicrobial agent: recent advances. RSC Adv 2021; 11:18179-18186. [PMID: 35480904 PMCID: PMC9033467 DOI: 10.1039/d1ra02149d] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/11/2021] [Indexed: 12/13/2022] Open
Abstract
From its uses in ancient civilisations, copper has an established history as an antimicrobial agent. Extensive research has determined the efficacy and mechanism of copper's antimicrobial activity against microorganisms. The process is multifaceted with the main mechanism of bactericidal activity being the generation of reactive oxygen species (ROS), which irreversibly damages membranes. Copper ions released from surfaces lead to RNA degradation and membrane disruption of enveloped viruses. For fungi, the mechanism involves the physical deterioration of the membrane and copper ion influx. Due to variations in the experimental parameters, it is difficult to compare studies directly. In this review article, we outline the importance of the experimental conditions currently employed and how they bear little resemblance to real-world conditions. We endorse previous recommendations calling for an update to industrial standard tests.
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Affiliation(s)
- Intisar Salah
- Materials Chemistry Research Centre, Department of Chemistry, University College London 20 Gordon Street London UK
| | - Ivan P Parkin
- Materials Chemistry Research Centre, Department of Chemistry, University College London 20 Gordon Street London UK
| | - Elaine Allan
- Department of Microbial Diseases, Eastman Dental Institute, University College London Royal Free Campus, Rowland Hill Street London UK
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17
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Bartsch SM, O'Shea KJ, Lee BY. The Clinical and Economic Burden of Norovirus Gastroenteritis in the United States. J Infect Dis 2021; 222:1910-1919. [PMID: 32671397 DOI: 10.1093/infdis/jiaa292] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/28/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Although norovirus outbreaks periodically make headlines, it is unclear how much attention norovirus may receive otherwise. A better understanding of the burden could help determine how to prioritize norovirus prevention and control. METHODS We developed a computational simulation model to quantify the clinical and economic burden of norovirus in the United States. RESULTS A symptomatic case generated $48 in direct medical costs, $416 in productivity losses ($464 total). The median yearly cost of outbreaks was $7.6 million (range across years, $7.5-$8.2 million) in direct medical costs, and $165.3 million ($161.1-$176.4 million) in productivity losses ($173.5 million total). Sporadic illnesses in the community (incidence, 10-150/1000 population) resulted in 14 118-211 705 hospitalizations, 8.2-122.9 million missed school/work days, $0.2-$2.3 billion in direct medical costs, and $1.4-$20.7 billion in productivity losses ($1.5-$23.1 billion total). The total cost was $10.6 billion based on the current incidence estimate (68.9/1000). CONCLUSION Our study quantified norovirus' burden. Of the total burden, sporadic cases constituted >90% (thus, annual burden may vary depending on incidence) and productivity losses represented 89%. More than half the economic burden is in adults ≥45, more than half occurs in winter months, and >90% of outbreak costs are due to person-to-person transmission, offering insights into where and when prevention/control efforts may yield returns.
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Affiliation(s)
- Sarah M Bartsch
- Public Health Informatics, Computational, and Operations Research, City University of New York, New York City, New York, USA
| | - Kelly J O'Shea
- Public Health Informatics, Computational, and Operations Research, City University of New York, New York City, New York, USA
| | - Bruce Y Lee
- Public Health Informatics, Computational, and Operations Research, City University of New York, New York City, New York, USA
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18
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Alsved M, Fraenkel CJ, Bohgard M, Widell A, Söderlund-Strand A, Lanbeck P, Holmdahl T, Isaxon C, Gudmundsson A, Medstrand P, Böttiger B, Löndahl J. Sources of Airborne Norovirus in Hospital Outbreaks. Clin Infect Dis 2021; 70:2023-2028. [PMID: 31257413 PMCID: PMC7201413 DOI: 10.1093/cid/ciz584] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 06/27/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Noroviruses are the major cause of viral gastroenteritis. Disease transmission is difficult to prevent and outbreaks in health-care facilities commonly occur. Contact with infected persons and contaminated environments are believed to be the main routes of transmission. However, noroviruses have recently been found in aerosols and airborne transmission has been suggested. The aim of our study was to investigate associations between symptoms of gastroenteritis and the presence of airborne norovirus, and to investigate the size of norovirus-carrying particles. METHODS Air sampling was repeatedly performed close to 26 patients with norovirus infections. Samples were analyzed for norovirus RNA by reverse transcription quantitative polymerase chain reaction. The times since each patient's last episodes of vomiting and diarrhea were recorded. Size-separating aerosol particle collection was performed. RESULTS Norovirus RNA was found in 21 (24%) of 86 air samples from 10 different patients. Only air samples during outbreaks, or before a succeeding outbreak, tested positive for norovirus RNA. Airborne norovirus RNA was also strongly associated with a shorter time period since the last vomiting episode (odds ratio 8.1; P = .04 within 3 hours since the last vomiting episode). The concentrations of airborne norovirus ranged from 5-215 copies/m3, and detectable amounts of norovirus RNA were found in particles <0.95 µm and >4.51 µm. CONCLUSIONS The results suggest that recent vomiting is the major source of airborne norovirus and imply a connection between airborne norovirus and outbreaks. The presence of norovirus RNA in submicrometre particles indicates that airborne transmission can be an important transmission route.
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Affiliation(s)
- Malin Alsved
- Division of Ergonomics and Aerosol Technology, Department of Design Sciences, Lund University
| | - Carl-Johan Fraenkel
- Department of Infection Control, Region Skåne.,Division of Infection Medicine, Department of Clinical Sciences, Lund University.,Department of Infectious Diseases, Skåne University Hospital
| | - Mats Bohgard
- Division of Ergonomics and Aerosol Technology, Department of Design Sciences, Lund University
| | - Anders Widell
- Department of Translational Medicine, Lund University, Lund, Sweden
| | - Anna Söderlund-Strand
- Department of Clinical Microbiology, University and Regional Laboratories, Lund, Sweden
| | - Peter Lanbeck
- Department of Infectious Diseases, Skåne University Hospital
| | | | - Christina Isaxon
- Division of Ergonomics and Aerosol Technology, Department of Design Sciences, Lund University
| | - Anders Gudmundsson
- Division of Ergonomics and Aerosol Technology, Department of Design Sciences, Lund University
| | - Patrik Medstrand
- Department of Translational Medicine, Lund University, Lund, Sweden
| | - Blenda Böttiger
- Department of Clinical Microbiology, University and Regional Laboratories, Lund, Sweden
| | - Jakob Löndahl
- Division of Ergonomics and Aerosol Technology, Department of Design Sciences, Lund University
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Morgan M, Watts V, Allen D, Curtis D, Kirolos A, Macdonald N, Maslen E, Morgan D, Saei A, Sedgwick J, Stevenson J, Turbitt D, Vivancos R, Waugh C, Williams C, Decraene V. Challenges of investigating a large food-borne norovirus outbreak across all branches of a restaurant group in the United Kingdom, October 2016. ACTA ACUST UNITED AC 2020; 24. [PMID: 31064638 PMCID: PMC6505182 DOI: 10.2807/1560-7917.es.2019.24.18.1800511] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
During October and November 2016, over 1,000 customers and staff reported gastroenteritis after eating at all 23 branches of a restaurant group in the United Kingdom. The outbreak coincided with a new menu launch and norovirus was identified as the causative agent. We conducted four retrospective cohort studies; one among all restaurant staff and three in customers at four branches. We investigated the dishes consumed, reviewed recipes, interviewed chefs and inspected restaurants to identify common ingredients and preparation methods for implicated dishes. Investigations were complicated by three public health agencies concurrently conducting multiple analytical studies, the complex menu with many shared constituent ingredients and the high media attention. The likely source was a contaminated batch of a nationally distributed ingredient, but analytical studies were unable to implicate a single ingredient. The most likely vehicle was a new chipotle chilli product imported from outside the European Union, that was used uncooked in the implicated dishes. This outbreak exemplifies the possibility of rapid spread of infectious agents within a restaurant supply chain, following introduction of a contaminated ingredient. It underlines the importance of appropriate risk assessments and control measures being in place, particularly for new ingredients and ready-to-eat foods.
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Affiliation(s)
- Mari Morgan
- These authors share first authorship.,European Programme for Intervention Epidemiology Training, Stockholm, Sweden.,Health Protection, Public Health Wales NHS Trust, Cardiff, United Kingdom
| | - Vicky Watts
- Field Service - Epidemiology, National Infection Service, Public Health England, Liverpool, United Kingdom.,United Kingdom Field Epidemiology Training Programme, Public Health England, London, United Kingdom.,These authors share first authorship
| | - David Allen
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom.,National Institute for Health Research Health Protection Research Unit in Gastrointestinal Infections, United Kingdom.,Virus Reference Department, National Infection Service, Colindale, Public Health England, London, United Kingdom
| | - Daniele Curtis
- Field Service - Epidemiology, National Infection Service, Public Health England, London, United Kingdom
| | - Amir Kirolos
- Department of Public Health and Health Policy, NHS Lothian, Edinburgh, Scotland
| | - Neil Macdonald
- Field Service - Epidemiology, National Infection Service, Public Health England, London, United Kingdom
| | - Ellie Maslen
- North East North Central London Health Protection Team, Public Health England, London, United Kingdom
| | - Deb Morgan
- Incidents & Resilience Team, Food Standards Agency, London, United Kingdom
| | - Ayoub Saei
- Statistics, Modelling & Economics Department, National Infection Service - Data & Analytical Sciences, Public Health England, London, United Kingdom
| | - James Sedgwick
- Field Service - Epidemiology, National Infection Service, Public Health England, London, United Kingdom
| | - Janet Stevenson
- Department of Public Health and Health Policy, NHS Lothian, Edinburgh, Scotland
| | - Deborah Turbitt
- Public Health England London, Public Health England, London, United Kingdom
| | - Roberto Vivancos
- Field Service - Epidemiology, National Infection Service, Public Health England, Liverpool, United Kingdom
| | - Catriona Waugh
- Department of Public Health and Health Policy, NHS Lothian, Edinburgh, Scotland
| | - Chris Williams
- Health Protection, Public Health Wales NHS Trust, Cardiff, United Kingdom
| | - Valerie Decraene
- Field Service - Epidemiology, National Infection Service, Public Health England, Liverpool, United Kingdom
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A phase 2 study of the bivalent VLP norovirus vaccine candidate in older adults; impact of MPL adjuvant or a second dose. Vaccine 2020; 38:5842-5850. [PMID: 32563606 DOI: 10.1016/j.vaccine.2020.06.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/16/2020] [Accepted: 06/04/2020] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Acute norovirus gastroenteritis causes significant morbidity and in uncommon cases fatality in older adults. We investigated the safety and immunogenicity of bivalent virus-like particle (VLP) vaccine candidate formulations with and without monophosphoryl lipid A (adjuvant MPL) in this population. METHODS In this phase II, double-blind, controlled trial 294 healthy adults, ≥ 60 years of age, were randomized (1:1:1:1) to four groups to receive one or two intramuscular immunizations 28 days apart, with 26 18-49 year-old controls who received one MPL-free dose. One-dose groups received placebo on Day 1. Vaccine formulations contained 15 μg GI.1 and 50 μg GII.4c VLP antigens and 500 μg Al(OH)3, with or without 15 μg MPL. We measured histo-blood group antigen blocking (HBGA) antibodies and ELISA Ig at Days 1, 8, 29, 57, 211 and 393, and avidity indices and cell-mediated immunity (CMI). Solicited local and systemic adverse events (AE) were assessed for 7 days and unsolicited AEs for 28 days after each injection. RESULTS After one dose HBGA antibodies to both VLP antigens increased with similar kinetics and magnitude in all groups; geometric mean titres (GMTs) persisted above baseline through Day 393. GMTs were similar across age strata (18-49, 60-74, 75-84 and ≥ 85 years of age) and unaffected by a second vaccination or MPL. Total Ig showed similar responses. No clinically relevant differences or changes in avidity or CMI were observed between formulations. Both formulations were well tolerated with no vaccine-related SAEs, the most frequent AEs being mild injection site pain and fatigue. CONCLUSIONS Adults over 60 years of age displayed no safety concerns and had similar immune responses to the norovirus VLP vaccine candidate as younger adults, unaffected by increasing age, a second dose or inclusion of MPL. This data supports the further development of the MPL-free vaccine candidate for older adults.
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Haigh J, Cutino-Moguel MT, Wilks M, Welch C, Melzer M. A service evaluation of simultaneous near-patient testing for influenza, respiratory syncytial virus, Clostridium difficile and norovirus in a UK district general hospital. J Hosp Infect 2019; 103:441-446. [DOI: 10.1016/j.jhin.2019.08.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 08/29/2019] [Indexed: 10/26/2022]
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22
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Smith CM, Allen DJ, Nawaz S, Kozlakidis Z, Nastouli E, Hayward A, Ward KN. An interactive data visualisation application to investigate nosocomial transmission of infections. Wellcome Open Res 2019; 4:100. [PMID: 31372504 DOI: 10.12688/wellcomeopenres.15240.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2019] [Indexed: 01/08/2023] Open
Abstract
Background: Healthcare-associated infections represent a major threat to patient, staff and visitor safety. Identification of episodes that are likely to have resulted from nosocomial transmission has important implications for infection control. Routinely collected data on ward admissions and sample dates, combined with pathogen genomic information could provide useful insights. We describe a novel, open-source, application for visualising these data, and demonstrate its utility for investigating nosocomial transmission using a case study of a large outbreak of norovirus infection. Methods: We developed the application using Shiny, a web application framework for R. For the norovirus case study, cases were defined as patients who had a faecal sample collected at the hospital in a winter season that tested positive for norovirus. Patient demographics and ward admission dates were extracted from hospital systems. Detected norovirus strains were genotyped and further characterised through sequencing of the hypervariable P2 domain. The most commonly detected sub-strain was visualised using the interactive application. Results: There were 156 norovirus-positive specimens collected from 107 patients. The most commonly detected sub-strain affected 30 patients in five wards. We used the interactive application to produce three visualisations: a bar chart, a timeline, and a schematic ward plan highlighting plausible transmission links. Visualisations showed credible links between cases on the elderly care ward. Conclusions: Use of the interactive application provided insights into transmission in this large nosocomial outbreak of norovirus, highlighting where infection control practices worked well or could be improved. This is a flexible tool that could be used for investigation of any infection in any hospital by interactively changing parameters. Challenges include integration with hospital systems for extracting data. Prospective use of this application could inform better infection control in real time.
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Affiliation(s)
- Catherine M Smith
- Institute of Health Informatics, University College London, London, NW1 2DA, UK
| | - David J Allen
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK.,Virus Reference Department, Public Health England, London, NW9 5HT, UK.,NIHR Health Protection Unit in Gastrointestinal Infections, London, UK
| | - Sameena Nawaz
- Virus Reference Department, Public Health England, London, NW9 5HT, UK
| | - Zisis Kozlakidis
- Institute of Health Informatics, University College London, London, NW1 2DA, UK.,World Health Organization, International Agency for Research on Cancer, Lyon, France
| | - Eleni Nastouli
- Clinical Virology, University College London Hospitals NHS Foundation Trust, London, NW1 2BU, UK.,Department of Population, Policy and Practice, UCL GOS Institute of Child Health, University College London, London, UK
| | - Andrew Hayward
- Institute of Epidemiology and Health Care, University College London, London, WC1E 6BT, UK
| | - Katherine N Ward
- Division of Infection and Immunity, University College London, London, WC1E 6BT, UK
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23
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Smith CM, Allen DJ, Nawaz S, Kozlakidis Z, Nastouli E, Hayward A, Ward KN. An interactive data visualisation application to investigate nosocomial transmission of infections. Wellcome Open Res 2019; 4:100. [PMID: 31372504 PMCID: PMC6668043 DOI: 10.12688/wellcomeopenres.15240.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2019] [Indexed: 12/04/2022] Open
Abstract
Background: Healthcare-associated infections represent a major threat to patient, staff and visitor safety. Identification of episodes that are likely to have resulted from nosocomial transmission has important implications for infection control. Routinely collected data on ward admissions and sample dates, combined with pathogen genomic information could provide useful insights. We describe a novel, open-source, application for visualising these data, and demonstrate its utility for investigating nosocomial transmission using a case study of a large outbreak of norovirus infection. Methods: We developed the application using Shiny, a web application framework for R. For the norovirus case study, cases were defined as patients who had a faecal sample collected at the hospital in a winter season that tested positive for norovirus. Patient demographics and ward admission dates were extracted from hospital systems. Detected norovirus strains were genotyped and further characterised through sequencing of the hypervariable P2 domain. The most commonly detected sub-strain was visualised using the interactive application. Results: There were 156 norovirus-positive specimens collected from 107 patients. The most commonly detected sub-strain affected 30 patients in five wards. We used the interactive application to produce three visualisations: a bar chart, a timeline, and a schematic ward plan highlighting plausible transmission links. Visualisations showed credible links between cases on the elderly care ward. Conclusions: Use of the interactive application provided insights into transmission in this large nosocomial outbreak of norovirus, highlighting where infection control practices worked well or could be improved. This is a flexible tool that could be used for investigation of any infection in any hospital by interactively changing parameters. Challenges include integration with hospital systems for extracting data. Prospective use of this application could inform better infection control in real time.
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Affiliation(s)
- Catherine M Smith
- Institute of Health Informatics, University College London, London, NW1 2DA, UK
| | - David J Allen
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK.,Virus Reference Department, Public Health England, London, NW9 5HT, UK.,NIHR Health Protection Unit in Gastrointestinal Infections, London, UK
| | - Sameena Nawaz
- Virus Reference Department, Public Health England, London, NW9 5HT, UK
| | - Zisis Kozlakidis
- Institute of Health Informatics, University College London, London, NW1 2DA, UK.,World Health Organization, International Agency for Research on Cancer, Lyon, France
| | - Eleni Nastouli
- Clinical Virology, University College London Hospitals NHS Foundation Trust, London, NW1 2BU, UK.,Department of Population, Policy and Practice, UCL GOS Institute of Child Health, University College London, London, UK
| | - Andrew Hayward
- Institute of Epidemiology and Health Care, University College London, London, WC1E 6BT, UK
| | - Katherine N Ward
- Division of Infection and Immunity, University College London, London, WC1E 6BT, UK
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24
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Rogers BR, Holmes CW, Hull M, Westmoreland D, Celma C, Beard S, Dunning J, Tang JW. Persistent norovirus outbreaks in a hospital setting - The role of environmental contamination. J Infect 2019; 79:277-287. [PMID: 31201820 DOI: 10.1016/j.jinf.2019.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 06/08/2019] [Indexed: 01/24/2023]
Affiliation(s)
- Benedict Rs Rogers
- Clinical Microbiology, University Hospitals of Leicester NHS Trust, Level 5 Sandringham Building, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK
| | - Christopher W Holmes
- Clinical Microbiology, University Hospitals of Leicester NHS Trust, Level 5 Sandringham Building, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK
| | - Matthew Hull
- Infection Prevention and Control, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Dawn Westmoreland
- Infection Prevention and Control, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Cristina Celma
- Enteric Virus Unit, National Infection Service, Public Health England, London, UK
| | - Stuart Beard
- Enteric Virus Unit, National Infection Service, Public Health England, London, UK
| | - Jake Dunning
- Enteric Virus Unit, National Infection Service, Public Health England, London, UK
| | - Julian W Tang
- Clinical Microbiology, University Hospitals of Leicester NHS Trust, Level 5 Sandringham Building, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK; Respiratory Sciences, University of Leicester, Leicester, UK.
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25
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Inns T, Clough HE, Harris JP, Vivancos R, Adams N, O'Brien SJ. Estimating the burden of care home gastroenteritis outbreaks in England, 2014-2016. BMC Infect Dis 2019; 19:12. [PMID: 30611217 PMCID: PMC6321657 DOI: 10.1186/s12879-018-3642-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 12/20/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Outbreaks of infectious gastroenteritis in care homes are common, with norovirus a frequent cause. In England there is no co-ordinated national surveillance system. We aimed to estimate the burden of these outbreaks. METHODS Using a generalised linear mixed effects regression model we described the relationship between the observed number of care home outbreaks and covariates. Estimated model parameters were used to infer uplift in the number of outbreaks expected if all areas were subjected to enhanced surveillance. From this we then estimated the total burden of care home gastroenteritis outbreaks in this period. RESULTS We estimated a total of 14,146 care home gastroenteritis outbreaks in England during 2014-2016; this is 47% higher than the reported total and a rate of 32.4 outbreaks per 100 care homes per year. The median number of outbreaks from the model estimates was 31 (IQR 20-46) compared to 19 (IQR 12-34) reported from routine surveillance. CONCLUSIONS This estimated care home gastroenteritis burden in England indicates that current surveillance substantially underestimates the number of outbreaks, by almost half. Improving this surveillance could provide better epidemiological knowledge of the burden of norovirus to inform public health policy, particularly with the advent of norovirus vaccines.
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Affiliation(s)
- Thomas Inns
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK. .,NIHR Health Protection Research Unit in Gastrointestinal Infections, University of Liverpool, Liverpool, UK. .,National Infection Service, Public Health England, London, UK.
| | - Helen E Clough
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - John P Harris
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK.,NIHR Health Protection Research Unit in Gastrointestinal Infections, University of Liverpool, Liverpool, UK
| | - Roberto Vivancos
- NIHR Health Protection Research Unit in Gastrointestinal Infections, University of Liverpool, Liverpool, UK.,National Infection Service, Public Health England, London, UK.,NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK
| | - Natalie Adams
- National Infection Service, Public Health England, London, UK
| | - Sarah J O'Brien
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK.,NIHR Health Protection Research Unit in Gastrointestinal Infections, University of Liverpool, Liverpool, UK
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26
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Sandmann FG, Jit M, Robotham JV, Deeny SR. Revisiting the winter burden of acute gastroenteritis on hospital beds in England: change in data collection supports analytical method for previously missing values. J Hosp Infect 2018; 100:115-117. [PMID: 29908252 DOI: 10.1016/j.jhin.2018.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 06/07/2018] [Indexed: 10/14/2022]
Affiliation(s)
- F G Sandmann
- Statistics, Modelling and Economics Department, Public Health England, London, UK; Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
| | - M Jit
- Statistics, Modelling and Economics Department, Public Health England, London, UK; Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - J V Robotham
- Statistics, Modelling and Economics Department, Public Health England, London, UK
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