Using a novel 'difference-in-differences' method and syndromic surveillance to estimate the change in local healthcare utilisation during periods of media reporting in the early stages of the COVID-19 pandemic in England

OBJECTIVES

Syndromic surveillance supplements traditional laboratory reporting for infectious diseases monitoring. Prior to widespread COVID-19 community surveillance, syndromic surveillance was one of several systems providing real-time information on changes in healthcare-seeking behaviour. The study objective was to identify changes in healthcare utilisation during periods of high local media reporting in England using 'difference-in-differences' (DiD).

STUDY DESIGN

A retrospective observational study was conducted using five media events in January-February 2020 in England on four routinely monitored syndromic surveillance indicators.

METHODS

Dates 'exposed' to a media event were estimated using Google Trends internet search intensity data (terms = 'coronavirus' and local authority [LA]). We constructed a negative-binomial regression model for each indicator and event time period to estimate a direct effect.

RESULTS

We estimated a four-fold increase in telehealth 'cough' calls and a 1.4-fold increase in emergency department (ED) attendances for acute respiratory illness in Brighton and Hove, when a so-called 'superspreading event' in this location was reported in local and national media. Significant decreases were observed in the Buxton (telehealth and ED attendance) and Wirral (ED attendance) areas during media reports of a returnee from an outbreak abroad and a quarantine site opening in the area respectively.

CONCLUSIONS

We used a novel approach to directly estimate changes in syndromic surveillance reporting during the early phase of the COVID-19 pandemic in England, providing contextual information on the interpretation of changes in health indicators. With careful consideration of event timings, DiD is useful in producing real-time estimates on specific indicators for informing public health action.

Machine learning to refine decision making within a syndromic surveillance service

Background

Worldwide, syndromic surveillance is increasingly used for improved and timely situational awareness and early identification of public health threats. Syndromic data streams are fed into detection algorithms, which produce statistical alarms highlighting potential activity of public health importance. All alarms must be assessed to confirm whether they are of public health importance. In England, approximately 100 alarms are generated daily and, although their analysis is formalised through a risk assessment process, the process requires notable time, training, and maintenance of an expertise base to determine which alarms are of public health importance. The process is made more complicated by the observation that only 0.1% of statistical alarms are deemed to be of public health importance. Therefore, the aims of this study were to evaluate machine learning as a tool for computer-assisted human decision-making when assessing statistical alarms.

Methods

A record of the risk assessment process was obtained from Public Health England for all 67,505 statistical alarms between August 2013 and October 2015. This record contained information on the characteristics of the alarm (e.g. size, location). We used three Bayesian classifiers- naïve Bayes, tree-augmented naïve Bayes and Multinets - to examine the risk assessment record in England with respect to the final ‘Decision’ outcome made by an epidemiologist of ‘Alert’, ‘Monitor’ or ‘No-action’. Two further classifications based upon tree-augmented naïve Bayes and Multinets were implemented to account for the predominance of ‘No-action’ outcomes.

Results

The attributes of each individual risk assessment were linked to the final decision made by an epidemiologist, providing confidence in the current process. The naïve Bayesian classifier performed best, correctly classifying 51.5% of ‘Alert’ outcomes. If the ‘Alert’ and ‘Monitor’ actions are combined then performance increases to 82.6% correctly classified. We demonstrate how a decision support system based upon a naïve Bayes classifier could be operationalised within an operational syndromic surveillance system.

Conclusions

Within syndromic surveillance systems, machine learning techniques have the potential to make risk assessment following statistical alarms more automated, robust, and rigorous. However, our results also highlight the importance of specialist human input to the process.

Association between glycaemic control and common infections in people with Type 2 diabetes: a cohort study

AIM

To investigate the impact of glycaemic control on infection incidence in people with Type 2 diabetes.

METHODS

We compared infection rates during 2014 in people with Type 2 diabetes and people without diabetes in a large primary care cohort in the UK (the Royal College of General Practitioners Research and Surveillance Centre database). We performed multilevel logistic regression to investigate the impact of Type 2 diabetes on presentation with infection, and the effect of glycaemic control on presentation with upper respiratory tract infections, bronchitis, influenza-like illness, pneumonia, intestinal infectious diseases, herpes simplex, skin and soft tissue infections, urinary tract infections, and genital and perineal infections. People with Type 2 diabetes were stratified by good [HbA_1c < 53 mmol/mol (< 7%)], moderate [HbA_1c 53-69 mmol/mol (7-8.5%)] and poor [HbA_1c > 69 mmol/mol (> 8.5%)] glycaemic control using their most recent HbA_1c concentration. Infection incidence was adjusted for important sociodemographic factors and patient comorbidities.

RESULTS

We identified 34 278 people with Type 2 diabetes and 613 052 people without diabetes for comparison. The incidence of infections was higher in people with Type 2 diabetes for all infections except herpes simplex. Worsening glycaemic control was associated with increased incidence of bronchitis, pneumonia, skin and soft tissue infections, urinary tract infections, and genital and perineal infections, but not with upper respiratory tract infections, influenza-like illness, intestinal infectious diseases or herpes simplex.

CONCLUSIONS

Almost all infections analysed were more common in people with Type 2 diabetes. Infections that are most commonly of bacterial, fungal or yeast origin were more frequent in people with worse glycaemic control.

Developing and validating a new national remote health advice syndromic surveillance system in England

Background

Public Health England (PHE) coordinates a suite of real-time national syndromic surveillance systems monitoring general practice, emergency department and remote health advice data. We describe the development and informal evaluation of a new syndromic surveillance system using NHS 111 remote health advice data.

Methods

NHS 111 syndromic indicators were monitored daily at national and local level. Statistical models were applied to daily data to identify significant exceedances; statistical baselines were developed for each syndrome and area using a multi-level hierarchical mixed effects model.

Results

Between November 2013 and October 2014, there were on average 19 095 NHS 111 calls each weekday and 43 084 each weekend day in the PHE dataset. There was a predominance of females using the service (57%); highest percentage of calls received was in the age group 1-4 years (14%). This system was used to monitor respiratory and gastrointestinal infections over the winter of 2013-14, the potential public health impact of severe flooding across parts of southern England and poor air quality episodes across England in April 2014.

Conclusions

This new system complements and supplements the existing PHE syndromic surveillance systems and is now integrated into the routine daily processes that form this national syndromic surveillance service.

Achievement Goals and Intrinsic Motivation: A Meta-Analytic Review

This article presents a meta-analysis of the experimental literature that has examined the effect of performance and mastery achievement goals on intrinsic motivation. Summary analyses provided supportfor the hypothesis that the pursuit ofperformance goals has an undermining effect on intrinsic motivation relative to the pursuit of mastery goals. Moderator analyses were conducted in an attempt to explain significant variation in the magnitude and direction of this effect across studies. Results indicated that the undermining effect ofperformance goals relative to mastery goals was contingent on whether participants received confirming or nonconfirming competence feedback, and on whether the experimental procedures induced a performance-approach or performance-avoidance orientation. These findings provide conceptual clarity to the literature on achievement goals and intrinsic motivation and suggest numerous avenues for subsequent empirical work.

Self-sampling for community respiratory illness: a new tool for national virological surveillance

This report aims to evaluate the usefulness of self-sampling as an approach for future national surveillance of emerging respiratory infections by comparing virological data from two parallel surveillance schemes in England. Nasal swabs were obtained via self-administered sampling from consenting adults (≥ 16 years-old) with influenza symptoms who had contacted the National Pandemic Flu Service (NPFS) health line during the 2009 influenza pandemic. Equivalent samples submitted by sentinel general practitioners participating in the national influenza surveillance scheme run jointly by the Royal College of General Practitioners (RCGP) and Health Protection Agency were also obtained. When comparable samples were analysed there was no significant difference in results obtained from self-sampling and clinician-led sampling schemes. These results demonstrate that self-sampling can be applied in a responsive and flexible manner, to supplement sentinel clinician-based sampling, to achieve a wide spread and geographically representative way of assessing community transmission of a known organism.

The Cold Weather Plan evaluation: an example of pragmatic evidence-based policy making?

OBJECTIVES

An evaluation of the Cold Weather Plan (CWP) for England 2011-2012 was undertaken in April 2012 to generate the basis for further revisions. It is widely considered good practice to formulate and revise policy on the basis of the best available evidence. This paper examines whether the evaluation is an example of pragmatic evidence-based policy-making.

STUDY DESIGN

A process evaluation with a formative multimethods approach.

METHODS

An electronic survey and national workshop were conducted alongside the production of a number of summary reports from the Health Protection Agency surveillance systems and Met Office meteorological data. The Department of Health and the Met Office were consulted on how the evaluation recommendations shaped the revised CWP and Met Office Cold Weather Alerting System respectively.

RESULTS

The Cold Weather Plan survey had 442 responses, a majority from Local Authorities, and from all regions of England. Thematic analysis generated qualitative data, which along with feedback from the workshop were synthesized into six main recommendations. Reviewing the new CWP and the Met Office Cold Weather Alerting System revealed significant modifications on the basis of the evaluation.

CONCLUSIONS

The evaluation sets the context for cold weather and health during the 2011-2012 winter. This study shows that the CWP 2012-2013 was revised on the basis of the national evaluation recommendations and is an example of pragmatic evidence-based policy-making.

Detection of varying influenza circulation within England in 2012/13: informing antiviral prescription and public health response

BACKGROUND

Subnational variation of 2009 pandemic influenza activity in England has been reported; however, little work has been published on this topic for seasonal influenza. If variation is present, this knowledge may assist with both identifying the onset of influenza epidemics, informing community antiviral prescription and local health planning.

METHODS

An end-of-season analysis of influenza surveillance systems (acute respiratory outbreaks, primary care consultations, virological testing, influenza-confirmed secondary care admissions and excess all-cause mortality) was undertaken at national and subnational levels for 2012/13 when influenza B and A(H3N2) dominated.

RESULTS

National community antiviral prescription was recommended in Week 51 following national threshold exceedance. However, this was preceded up to 2 weeks by subnational influenza activity in 2/9 regions in England. Regional variation in circulation of influenza subtypes was observed and severe influenza surveillance data sources were able to monitor the subnational impact.

CONCLUSIONS

Evidence of virological activity in two or more regions above a threshold indicated the onset of the 2012/13 season. Subnational thresholds should be determined and evaluated in order to improve timeliness of the national antiviral alert. During the season, outputs should be reported at levels that can inform local public health responses and variation considered when retrospectively evaluating the impact of interventions.

Using an Emergency Department Syndromic Surveillance System to investigate the impact of extreme cold weather events

This report describes the development of novel syndromic cold weather public health surveillance indicators for use in monitoring the impact of extreme cold weather on attendances at EDs, using data from the 2010-11 and 2011-12 winters. A number of new surveillance indicators were created specifically for the identification and monitoring of cold weather related ED attendances, using the diagnosis codes provided for each attendance in the Emergency Department Syndromic Surveillance System (EDSSS), the first national syndromic surveillance system of its kind in the UK. Using daily weather data for the local area, a time series analysis to test the sensitivity of each indicator to cold weather was undertaken. Diagnosis codes relating to a health outcome with a potential direct link to cold weather were identified and assigned to a number of 'cold weather surveillance indicators'. The time series analyses indicated strong correlations between low temperatures and cold indicators in nearly every case. The strongest fit with temperature was cold related fractures in females, and that of snowfall was cold related fractures in both sexes. Though currently limited to a small number of sentinel EDs, the EDSSS has the ability to give near real-time detail on the magnitude of the impact of weather events. EDSSS cold weather surveillance fits well with the aims of the Cold Weather Plan for England, providing information on those particularly vulnerable to cold related health outcomes severe enough to require emergency care. This timely information aids those responding to and managing the effects on human health, both within the EDs themselves and in the community as a whole.

Uptake and impact of a new live attenuated influenza vaccine programme in England: early results of a pilot in primary school-age children, 2013/14 influenza season

Binary file ES_Abstracts_Final_ECDC.txt matches

Uptake and impact of a new live attenuated influenza vaccine programme in England: early results of a pilot in primary school-age children, 2013/14 influenza season

As part of the introduction and roll-out of a universal childhood live-attenuated influenza vaccination programme, 4–11 year-olds were vaccinated in seven pilot areas in England in the 2013/14 influenza season. This paper presents the uptake and impact of the programme for a range of disease indicators. End-of-season uptake was defined as the number of children in the target population who received at least one dose of influenza vaccine. Between week 40 2013 and week 15 2014, cumulative disease incidence per 100,000 population (general practitioner consultations for influenza-like illness and laboratory-confirmed influenza hospitalisations), cumulative influenza swab positivity in primary and secondary care and cumulative proportion of emergency department respiratory attendances were calculated. Indicators were compared overall and by age group between pilot and non-pilot areas. Direct impact was defined as reduction in cumulative incidence based on residence in pilot relative to non-pilot areas in 4–11 year-olds. Indirect impact was reduction between pilot and non-pilot areas in <4 year-olds and >11 year-olds. Overall vaccine uptake of 52.5% (104,792/199,475) was achieved. Although influenza activity was low, a consistent, though not statistically significant, decrease in cumulative disease incidence and influenza positivity across different indicators was seen in pilot relative to non-pilot areas in both targeted and non-targeted age groups, except in older age groups, where no difference was observed for secondary care indicators.

The impact of thunderstorm asthma on emergency department attendances across London during July 2013

BACKGROUND

This study illustrates the potential of using emergency department attendance data, routinely accessed as part of a national syndromic surveillance system, to monitor the impact of thunderstorm asthma.

METHODS

The Emergency Department Syndromic Surveillance System (EDSSS) routinely monitors anonymised attendance data on a daily basis across a sentinel network of 35 emergency departments. Attendance data for asthma, wheeze and difficulty breathing are analysed on a daily basis.

RESULTS

A statistically significant spike in asthma attendances in two EDSSS emergency departments in London was detected on 23 July 2013, coinciding with a series of large violent thunderstorms across southern England. There was also an increase in the reported severity of these attendances.

CONCLUSIONS

This preliminary report illustrates the potential of the EDSSS to monitor the impact of thunderstorms on emergency department asthma attendances. Further work will focus on how this system can be used to quantify the impact on emergency departments, thus potentially improving resource planning and also adding to the thunderstorm asthma evidence-base.

Developing a new syndromic surveillance system for the London 2012 Olympic and Paralympic Games

Syndromic surveillance is vital for monitoring public health during mass gatherings. The London 2012 Olympic and Paralympic Games represents a major challenge to health protection services and community surveillance. In response to this challenge the Health Protection Agency has developed a new syndromic surveillance system that monitors daily general practitioner out-of-hours and unscheduled care attendances. This new national system will fill a gap identified in the existing general practice-based syndromic surveillance systems by providing surveillance capability of general practice activity during evenings/nights, over weekends and public holidays. The system will complement and supplement the existing tele-health phone line, general practitioner and emergency department syndromic surveillance systems. This new national system will contribute to improving public health reassurance, especially to meet the challenges of the London 2012 Olympic and Paralympic Games.

Early spread of the 2009 influenza A(H1N1) pandemic in the United Kingdom – use of local syndromic data, May–August 2009

Following the confirmation of the first two cases of pandemic influenza on 27 April 2009 in the United Kingdom (UK), syndromic surveillance data from the Health Protection Agency (HPA)/QSurveillance and HPA/NHS Direct systems were used to monitor the possible spread of pandemic influenza at local level during the first phase of the outbreak. During the early weeks, syndromic indicators sensitive to influenza activity monitored through the two schemes remained low and the majority of cases were travel-related. The first evidence of community spread was seen in the West Midlands region following a school-based outbreak in central Birmingham. During the first phase several Primary Care Trusts had periods of exceptional influenza activity two to three weeks ahead of the rest of the region. Community transmission in London began slightly later than in the West Midlands but the rates of influenza-like illness recorded by general practitioners (GPs) were ultimately higher. Influenza activity in the West Midlands and London regions peaked a week before the remainder of the UK. Data from the HPA/NHS Direct and HPA/QSurveillance systems were mapped at local level and used alongside laboratory data and local intelligence to assist in the identification of hotspots, to direct limited public health resources and to monitor the progression of the outbreak. This work has demonstrated the utility of local syndromic surveillance data in the detection of increased transmission and in the epidemiological investigation of the pandemic and has prompted future spatio-temporal work.

Early spread of the 2009 influenza A(H1N1) pandemic in the United Kingdom--use of local syndromic data, May-August 2009

Following the confirmation of the first two cases of pandemic influenza on 27 April 2009 in the United Kingdom (UK), syndromic surveillance data from the Health Protection Agency (HPA)/QSurveillance and HPA/NHS Direct systems were used to monitor the possible spread of pandemic influenza at local level during the first phase of the outbreak. During the early weeks, syndromic indicators sensitive to influenza activity monitored through the two schemes remained low and the majority of cases were travel-related. The first evidence of community spread was seen in the West Midlands region following a school-based outbreak in central Birmingham. During the first phase several Primary Care Trusts had periods of exceptional influenza activity two to three weeks ahead of the rest of the region. Community transmission in London began slightly later than in the West Midlands but the rates of influenza-like illness recorded by general practitioners (GPs) were ultimately higher. Influenza activity in the West Midlands and London regions peaked a week before the remainder of the UK. Data from the HPA/NHS Direct and HPA/QSurveillance systems were mapped at local level and used alongside laboratory data and local intelligence to assist in the identification of hotspots, to direct limited public health resources and to monitor the progression of the outbreak. This work has demonstrated the utility of local syndromic surveillance data in the detection of increased transmission and in the epidemiological investigation of the pandemic and has prompted future spatio-temporal work.

Value of syndromic surveillance in monitoring a focal waterborne outbreak due to an unusual Cryptosporidium genotype in Northamptonshire, United Kingdom, June – July 2008

The United Kingdom (UK) has several national syndromic surveillance systems. The Health Protection Agency (HPA)/NHS Direct syndromic surveillance system uses pre-diagnostic syndromic data from a national telephone helpline, while the HPA/QSurveillance national surveillance system uses clinical diagnosis data extracted from general practitioner (GP)-based clinical information systems. Data from both of these systems were used to monitor a local outbreak of cryptosporidiosis that occurred following Cryptosporidium oocyst contamination of drinking water supplied from the Pitsford Reservoir in Northamptonshire, United Kingdom, in June 2008. There was a peak in the number of calls to NHS Direct concerning diarrhoea that coincided with the incident. QSurveillance data for the local areas affected by the outbreak showed a significant increase in GP consultations for diarrhoea and gastroenteritis in the week of the incident but there was no increase in consultations for vomiting. A total of 33 clinical cases of cryptosporidiosis were identified in the outbreak investigation, of which 23 were confirmed as infected with the outbreak strain. However, QSurveillance data suggest that there were an estimated 422 excess diarrhoea cases during the outbreak, an increase of about 25% over baseline weekly levels. To our knowledge, this is the first time that data from a syndromic surveillance system, the HPA/QSurveillance national surveillance system, have been able to show the extent of such a small outbreak at a local level. QSurveillance, which covers about 38% of the UK population, is currently the only GP database that is able to provide data at local health district (primary care trust) level. The Cryptosporidium contamination incident described demonstrates the potential usefulness of this information, as it is unusual for syndromic surveillance systems to be able to help monitor such a small-scale outbreak.

Syndromic surveillance to assess the potential public health impact of the Icelandic volcanic ash plume across the United Kingdom, April 2010

The Health Protection Agency and Health Protection Scotland used existing syndromic surveillance systems to monitor community health in the UK following the volcanic eruption in Iceland in April 2010.

Syndromic surveillance to assess the potential public health impact of the Icelandic volcanic ash plume across the United Kingdom, April 2010

Binary file ES_Abstracts_Final_ECDC.txt matches

Vomiting calls to NHS Direct provide an early warning of norovirus outbreaks in hospitals

A wintertime peak of norovirus activity occurs each year, affecting institutions including schools and hospitals. Traditional laboratory and outbreak surveillance systems for norovirus are too vulnerable to reporting delay to act as a timely signal of activity in the community. Calls to the National Health Service (NHS) telephone service NHS Direct have the potential to be an early warning tool for public health purposes. We investigated whether NHS Direct vomiting calls can be used as a reliable indicator of norovirus activity and, if so, whether the increase in calls precedes the epidemic of hospital outbreaks. Laboratory reports were used as the reference standard to define the norovirus season. From 2004 to 2008, four series of NHS Direct call data were compared with laboratory data held at the Health Protection Agency Centre for Infections in order to identify the best predictor of the season start. The four series included: (1) modelled and extracted the proportion of calls likely to be for 'non-rotavirus' gastroenteritis; (2) the mean proportion of weekly vomiting calls in children aged <5 years; (3) the mean proportion of weekly vomiting calls for all ages; (4) the slope of the vomiting call data. Issuing an alert when 4% or more of NHS Direct vomiting calls in all age groups for two weeks in a row should provide up to four weeks' advance warning of forthcoming norovirus pressures on the health service.

Estimating influenza vaccine effectiveness using routinely collected laboratory data

BACKGROUND

Estimation of influenza vaccine effectiveness (V/E) is needed early during influenza outbreaks in order to optimise management of influenza--a need which will be even greater in a pandemic situation.

OBJECTIVE

Examine the potential of routinely collected virological surveillance data to generate estimates of V/E in real-time during winter seasons.

METHODS

Integrated clinical and virological community influenza surveillance data collected over three winters 2004/5-2006/7 were used. We calculated the odds of vaccination in persons that were influenza-virus-positive and the odds in those that were negative and provided a crude estimate of V/E. Logistic regression was used to obtain V/E estimates adjusted for confounding variables such as age.

RESULTS

Multivariable analysis suggested that adjustments to the crude V/E estimate were necessary for patient age and month of sampling. The annual adjusted V/E was 2005/6, 67% (95% CI 41% to 82%); 2006/7 55% (26% to 73%) and 2007/8 67% (41% to 82%). The adjusted V/E in persons <65 years was 70% (57% to 78%) and 65 years and over 46% (-17% to 75%). Estimates differed by small insignificant amounts when calculated separately for influenza A and B; by interval between illness onset and swab sample; by analysis for the period November to January in each year compared with February to April and according to viral load.

CONCLUSION

We have demonstrated the potential of using routine virological and clinical surveillance data to provide estimates of V/E early in season and conclude that it is feasible to introduce this approach to V/E measurement into evaluation of national influenza vaccination programs.

Seasonality and trends in the incidence and prevalence of gout in England and Wales 1994-2007

OBJECTIVES

To examine seasonality and long-term trends in the incidence and prevalence of gout.

METHODS

A retrospective study (1994-2007) using routinely collected surveillance data from the Royal College of General Practitioners Weekly Returns Service sentinel general practice network in England and Wales. New cases and acute attacks of gout per 10,000 population were calculated for age groups 0-44, 45-64, 65-74 and > or =75 years. Long-term trends of annual incidence were assessed by regression analysis. Seasonality indices were calculated using 4-weekly data, and the relative risk of gout incidence during the summer was estimated. Annual prevalence was estimated from the consulting patient population (2001-7) and from prescribing data on defined daily doses (DDD) of allopurinol (2003-7).

RESULTS

The annual incidence rate of new gout cases was stable over the period 1998-2007; acute attacks decreased on average 4% per annum. New gout cases and acute attacks combined into 4-weekly incidence rates peaked during the "summer" period of each year. There was an increased risk of gout diagnosis during summer months (late April to mid-September; odds ratio 1.22, 95% CI 1.18 to 1.26). The annual prevalence of gout in 2001-7 was 0.46%, with highest rates in men > or =75 years (2.57%). Estimated prevalence based on a DDD of 400 mg allopurinol was 0.37%.

CONCLUSION

The incidence of gout is seasonal. This has implications for the management of patients who currently have gout, and for those who are at risk of future attacks. The decreasing trend in the incidence of acute attacks suggests that patient management is improving.

Lessons from 40 years' surveillance of influenza in England and Wales

The influenza virus continues to pose a significant threat to public health throughout the world. Current avian influenza outbreaks in humans have heightened the need for improved surveillance and planning. Despite recent advances in the development of vaccines and antiviral drugs, seasonal epidemics of influenza continue to contribute significantly to general practitioner workloads, emergency hospital admissions, and deaths. In this paper we review data produced by the Royal College of General Practitioners Weekly Returns Service, a sentinel general practice surveillance network that has been in operation for over 40 years in England and Wales. We show a gradually decreasing trend in the incidence of respiratory illness associated with influenza virus infection (influenza-like illness; ILI) over the 40 years and speculate that there are limits to how far an existing virus can drift and yet produce substantial new epidemics. The burden of disease caused by influenza presented to general practitioners varies considerably by age in each winter. In the pandemic winter of 1969/70 persons of working age were most severely affected; in the serious influenza epidemic of 1989/90 children were particularly affected; in the millennium winter (in which the NHS was severely stretched) ILI was almost confined to adults, especially the elderly. Serious confounders from infections due to respiratory syncytial virus are discussed, especially in relation to assessing influenza vaccine effectiveness. Increasing pressure on hospitals during epidemic periods are shown and are attributed to changing patterns of health-care delivery.

Can syndromic thresholds provide early warning of national influenza outbreaks?

BACKGROUND

Influenza incidence thresholds are used to help predict the likely impact of influenza and inform health professionals and the public of current activity. We evaluate the potential of syndromic data (calls to a UK health helpline NHS Direct) to provide early warning of national influenza outbreaks.

METHODS

Time series of NHS Direct calls concerning 'cold/flu' and fever syndromes for England and Wales were compared against influenza-like-illness clinical incidence data and laboratory reports of influenza. Poisson regression models were used to derive NHS Direct thresholds. The early warning potential of thresholds was evaluated retrospectively for 2002-06 and prospectively for winter 2006-07.

RESULTS

NHS Direct 'cold/flu' and fever calls generally rose and peaked at the same time as clinical and laboratory influenza data. We derived a national 'cold/flu' threshold of 1.2% of total calls and a fever (5-14 years) threshold of 9%. An initial lower fever threshold of 7.7% was discarded as it produced false alarms. Thresholds provided 2 weeks advanced warning of seasonal influenza activity during three of the four winters studied retrospectively, and 6 days advance warning during prospective evaluation.

CONCLUSION

Syndromic thresholds based on NHS Direct data provide advance warning of influenza circulating in the community. We recommend that age-group specific thresholds be developed for other clinical influenza surveillance systems in the UK and elsewhere.

Morbidity profiles of patients consulting during influenza and respiratory syncytial virus active periods

We compared the burden of illness due to a spectrum of respiratory diagnostic categories among persons presenting in a sentinel general practice network in England and Wales during periods of influenza and of respiratory syncytial virus (RSV) activity. During all periods of viral activity, incidence rates of influenza-like illness, bronchitis and common cold were elevated compared to those in baseline periods. Excess rates per 100,000 of acute bronchitis were greater in children aged <1 year (median difference 2702, 95% CI 929-4867) and in children aged 1-4 years (994, 95% CI 338-1747) during RSV active periods rather than influenza; estimates for the two viruses were similar in other age groups. Excess rates of influenza-like illness in all age groups were clearly associated with influenza virus activity. For common cold the estimates of median excess rates were significantly higher in RSV active periods for the age groups <1 year (3728, 95% CI 632-5867) and 5-14 years (339, 95% CI 59-768); estimates were similar in other age groups for the two viruses. The clinical burden of disease associated with RSV is as great if not greater than influenza in patients of all ages presenting to general practitioners.

Surveillance of influenza-like illness in England and Wales during 1966-2006

We report surveillance data collected since 1966 from a general practice database in England and Wales. Incidence rates of influenza-like illness (ILI) peaked during the winter of 1969/70, and were then followed by a decade of heightened activity. There has since been a gradual downward trend of ILI, interspersed with winters of heightened activity; since 1999/2000, the incidence of ILI has been at its lowest for 40 years. We argue that the decade following the herald waves of the pandemic could be equally important for the planning of healthcare services in the community.

Surveillance of influenza-like illness in England and Wales during 1966-2006

We report surveillance data collected since 1966 from a general practice database in England and Wales. Incidence rates of influenza-like illness (ILI) peaked during the winter of 1969/70, and were then followed by a decade of heightened activity. There has since been a gradual downward trend of ILI, interspersed with winters of heightened activity; since 1999/2000, the incidence of ILI has been at its lowest for 40 years. We argue that the decade following the herald waves of the pandemic could be equally important for the planning of healthcare services in the community.

Respiratory illness associated with influenza and respiratory syncytial virus infection

AIMS

To estimate excess morbidity during periods of influenza and respiratory syncytial virus (RSV) activity.

METHODS

Retrospective analysis of a sentinel practice network database in active and non-active virus periods.

MAIN OUTCOME MEASURES

clinical diagnoses of new episodes of influenza-like illness (ILI), acute bronchitis, asthma, and otitis media.

RESULTS

The clinical diagnosis of ILI was consistent with influenza virus activity and acute bronchitis with RSV. During periods of virus activity, estimates of excess morbidity in children aged 1-4 and 5-14 years diagnosed as having acute otitis media exceeded those diagnosed with each of the other three conditions; in children <1 year estimates for acute bronchitis were highest. Using a broad definition of virus activity and summarising the data for all children diagnosed with ILI, 60% was attributable to influenza (40% RSV) as were 37% of episodes diagnosed as acute bronchitis, 9% of those with asthma and 48% of those with otitis media. Using a narrow definition, corresponding proportions were: for ILI diagnoses 77% (23% RSV), acute bronchitis 32%, asthma zero, and otitis media 45%. Acute bronchitis was diagnosed twice as frequently in association with RSV as with influenza in all age groups: excess asthma episodes were only evident in RSV active periods.

CONCLUSIONS

Except in relation to ILI, RSV caused more illness than the influenza virus in the respiratory diagnoses examined, emphasising the need for RSV prevention and treatment. Influenza was not associated with excess asthma episodes.

Functional chimeras of human immunodeficiency virus type 1 Gp120 and influenza A virus (H3) hemagglutinin

In an attempt to produce a protein that will allow determination of the native human immunodeficiency virus type 1 (HIV-1) gp120 (Env) structure in its trimeric state, we fused the globular head of gp120 to the stalk region of influenza virus A (X31) hemagglutinin (HA). The chimeric protein (EnvHA) has been expressed by using a recombinant vaccinia virus system, and its functional characteristics were determined. EnvHA is expressed as a 120- to 150-kDa protein that can oligomerize to form dimers and trimers. It retains the low-pH (5.2 to 5.4) requirement of X31-HA to trigger membrane fusion but, unlike X31-HA, it is not absolutely dependent on exogenously added trypsin for protein processing to release the HA2 fusion peptide. In terms of receptor binding the chimeric protein retains specificity for human CD4 but, in relation to the membrane fusion event, it appears to lose the Env coreceptor specificity of the parental HIV-1 strains: NL43 for CXCR4 and JRFL for CCR5. These properties suggest that stable, functional EnvHAs are being produced and that they may be exploited in terms of structural studies. Further, the potential of introducing the envHA genes into influenza viruses, by use of reverse genetics, and their use as a therapeutic vaccine for HIV are discussed.

A cross-cultural analysis of avoidance (relative to approach) personal goals

The results from this research supported our primary hypothesis that the adoption of avoidance (relative to approach) personal goals varies as a function of individualism-collectivism (across representations of this distinction). Interdependent self-construals were positively related and independent self-construals were negatively related to adoption of avoidance goals (Study 1), Asian Americans adopted more avoidance goals than non-Asian Americans (Study 2), andpersonsfrom South Korea and Russia adopted more avoidance goals than those in the United States (Studies 3 and 4, respectively). Studies 3 and 4 investigated andfound supportfor our secondary hypothesis that avoidance personal goals are a negative predictor of subjective well-being in individualistic (the United States), but not collectivistic (South Korea and Russia), countries. The findings are discussed in terms of other approach-avoidance constructs and motivational processes.

A 2 X 2 achievement goal framework

A 2 x 2 achievement goal framework comprising mastery-approach, mastery-avoidance, performance-approach, and performance-avoidance goals was proposed and tested in 3 studies. Factor analytic results supported the independence of the 4 achievement goal constructs. The goals were examined with respect to several important antecedents (e.g., motive dispositions, implicit theories, socialization histories) and consequences (e.g., anticipatory test anxiety, exam performance, health center visits), with particular attention allocated to the new mastery-avoidance goal construct. The results revealed distinct empirical profiles for each of the achievement goals; the pattern for mastery-avoidance goals was, as anticipated, more negative than that for mastery-approach goals and more positive than that for performance-avoidance goals. Implications of the present work for future theoretical development in the achievement goal literature are discussed.

What is satisfying about satisfying events? Testing 10 candidate psychological needs

Three studies compared 10 candidate psychological needs in an attempt to determine which are truly most fundamental for humans. Participants described "most satisfying events" within their lives and then rated the salience of each of the 10 candidate needs within these events. Supporting self-determination theory postulates (Ryan & Deci, 2000)--autonomy, competence, and relatedness, were consistently among the top 4 needs, in terms of both their salience and their association with event-related affect. Self-esteem was also important, whereas self-actualization or meaning, physical thriving, popularity or influence, and money-luxury were less important. This basic pattern emerged within three different time frames and within both U.S. and South Korean samples and also within a final study that asked, "What's unsatisfying about unsatisfying events?" Implications for hierarchical theories of needs are discussed.

Behavioral activation and inhibition in everyday life

Joint effects of daily events and dispositional sensitivities to cues of reward and punishment on daily positive affect (PA) and negative affect (NA) were examined in 3 diary studies. Study 1 showed that positive events were strongly related to PA but not NA, whereas negative events were strongly related to NA but not PA. Studies 2 and 3 examined how the dispositional sensitivities of independent appetitive and aversive motivational systems, the Behavioral Activation System (BAS) and the Behavioral Inhibition System (BIS), moderated these relationships. Participants in Study 2 with higher BAS sensitivity reported more PA on average; those with more sensitive BIS reported more NA. Also, BIS moderated reactions to negative events, such that higher BIS sensitivity magnified reactions to negative events. Study 3 replicated these findings and showed that BAS predisposed people to experience more positive events. Results demonstrate the value of distinguishing within-person and between-person effects to clarify the functionally independent processes by which dispositional sensitivities influence affect.

Behavioral activation and inhibition in everyday life

Joint effects of daily events and dispositional sensitivities to cues of reward and punishment on daily positive affect (PA) and negative affect (NA) were examined in 3 diary studies. Study 1 showed that positive events were strongly related to PA but not NA, whereas negative events were strongly related to NA but not PA. Studies 2 and 3 examined how the dispositional sensitivities of independent appetitive and aversive motivational systems, the Behavioral Activation System (BAS) and the Behavioral Inhibition System (BIS), moderated these relationships. Participants in Study 2 with higher BAS sensitivity reported more PA on average; those with more sensitive BIS reported more NA. Also, BIS moderated reactions to negative events, such that higher BIS sensitivity magnified reactions to negative events. Study 3 replicated these findings and showed that BAS predisposed people to experience more positive events. Results demonstrate the value of distinguishing within-person and between-person effects to clarify the functionally independent processes by which dispositional sensitivities influence affect.

Among friends? An examination of friendship and the self-serving bias

Do friends bound each other's self-enhancement tendencies? Do friends display the self-serving bias (SSB; i.e. taking individual credit for success but blaming a partner for failure)? Dyads consisting of either friends or strangers engaged in an interdependent-outcomes creativity test, received bogus success or failure feedback at the dyadic level, and made responsibility attributions for the joint test performance. Strangers displayed the SSB. Friends, in contrast, refrained from the SSB: they shared responsibility for both successful and unsuccessful test outcomes. Friendship does place boundaries on self-enhancement.

Personal goals in social roles: divergences and convergences across roles and levels of analysis

Most contemporary personal goal research aggregates across goals, perhaps masking important differences between goals. We assessed this risk by examining both similarities and differences between the goals that participants pursued in five important social roles. Previous relevant findings (Cantor, Norem, Niedenthal, Langston, & Brower, 1987) and self-determination theory (Deci & Ryan, 1985) were used to predict between-role differences in goal appraisal dimensions. Although theoretically meaningful differences were found across child, employee, romantic, friendship, and student goals, and also across within- and between-subject levels of analysis, all goals were essentially the same in one important way: Making longitudinal progress in them predicted positive change in accompanying role-circumstances and role-satisfaction (excepting friendship goals). This indicates that researchers do not necessarily lose information by aggregating, and affirms that goal-attainment is generally desirable.

Goal striving, need satisfaction, and longitudinal well-being: the self-concordance model

An integrative model of the conative process, which has important ramifications for psychological need satisfaction and hence for individuals' well-being, is presented. The self-concordance of goals (i.e., their consistency with the person's developing interests and core values) plays a dual role in the model. First, those pursuing self-concordant goals put more sustained effort into achieving those goals and thus are more likely to attain them. Second, those who attain self-concordant goals reap greater well-being benefits from their attainment. Attainment-to-well-being effects are mediated by need satisfaction, i.e., daily activity-based experiences of autonomy, competence, and relatedness that accumulate during the period of striving. The model is shown to provide a satisfactory fit to 3 longitudinal data sets and to be independent of the effects of self-efficacy, implementation intentions, avoidance framing, and life skills.

Test anxiety and the hierarchical model of approach and avoidance achievement motivation

This research was designed to incorporate the test anxiety (TA) construct into the hierarchical model of approach and avoidance achievement motivation. Hypotheses regarding state and trait TA were tested in 2 studies, and the results provided strong support for the predictions. State TA (specifically, worry) was documented as a mediator of the negative relationship between performance-avoidance goals and exam performance. The positive relationship between performance-approach goals and exam performance was shown to be independent of TA processes. A series of analyses documented the conceptual and functional convergence of trait TA and fear of failure (FOF), and further validation of the proposed integration was obtained by testing trait TA/FOF and state TA together in the same model. Mastery goals were positively and performance-avoidance goals negatively related to long-term retention.

Test anxiety and the hierarchical model of approach and avoidance achievement motivation

This research was designed to incorporate the test anxiety (TA) construct into the hierarchical model of approach and avoidance achievement motivation. Hypotheses regarding state and trait TA were tested in 2 studies, and the results provided strong support for the predictions. State TA (specifically, worry) was documented as a mediator of the negative relationship between performance-avoidance goals and exam performance. The positive relationship between performance-approach goals and exam performance was shown to be independent of TA processes. A series of analyses documented the conceptual and functional convergence of trait TA and fear of failure (FOF), and further validation of the proposed integration was obtained by testing trait TA/FOF and state TA together in the same model. Mastery goals were positively and performance-avoidance goals negatively related to long-term retention.

Goal striving, need satisfaction, and longitudinal well-being: the self-concordance model

An integrative model of the conative process, which has important ramifications for psychological need satisfaction and hence for individuals' well-being, is presented. The self-concordance of goals (i.e., their consistency with the person's developing interests and core values) plays a dual role in the model. First, those pursuing self-concordant goals put more sustained effort into achieving those goals and thus are more likely to attain them. Second, those who attain self-concordant goals reap greater well-being benefits from their attainment. Attainment-to-well-being effects are mediated by need satisfaction, i.e., daily activity-based experiences of autonomy, competence, and relatedness that accumulate during the period of striving. The model is shown to provide a satisfactory fit to 3 longitudinal data sets and to be independent of the effects of self-efficacy, implementation intentions, avoidance framing, and life skills.

Avoidance personal goals and the personality-illness relationship

Three studies demonstrated that avoidance personal goals are positively related to physical symptom reports. These results were obtained (a) using both longitudinal and retrospective methodologies and (b) controlling for neuroticism and other alternative predictor variables. In 2 of the studies, a process model was validated in which perceived competence and perceived controlledness were shown to mediate the observed relationship between avoidance goals and symptomatology. Specifically, avoidance goals predicted perceived competence and perceived controlledness, and these variables in turn predicted longitudinal and retrospective symptom reports. Ancillary results help clarify the unique roles of neuroticism and avoidance goals as predictors of physical symptomatology.

Avoidance personal goals and the personality-illness relationship

Three studies demonstrated that avoidance personal goals are positively related to physical symptom reports. These results were obtained (a) using both longitudinal and retrospective methodologies and (b) controlling for neuroticism and other alternative predictor variables. In 2 of the studies, a process model was validated in which perceived competence and perceived controlledness were shown to mediate the observed relationship between avoidance goals and symptomatology. Specifically, avoidance goals predicted perceived competence and perceived controlledness, and these variables in turn predicted longitudinal and retrospective symptom reports. Ancillary results help clarify the unique roles of neuroticism and avoidance goals as predictors of physical symptomatology.