Hassan Burhan

Effect of Live Attenuated Influenza Vaccine on Pneumococcal Carriage

The widely used nasally-administered Live Attenuated Influenza Vaccine (LAIV) alters the dynamics of naturally occurring nasopharyngeal carriage of Streptococcus pneumoniae in animal models. Using a human experimental model (serotype 6B) we tested two hypotheses: 1) LAIV increased the density of S. pneumoniae in those already colonised; 2) LAIV administration promoted colonisation. Randomised, blinded administration of LAIV or nasal placebo either preceded bacterial inoculation or followed it, separated by a 3-day interval. The presence and density of S. pneumoniae was determined from nasal washes by bacterial culture and PCR. Overall acquisition for bacterial carriage were not altered by prior LAIV administration vs. controls (25/55 [45.5%] vs 24/62 [38.7%] respectively, p=0.46). Transient increase in acquisition was detected in LAIV recipients at day 2 (33/55 [60.0%] vs 25/62 [40.3%] in controls, p=0.03). Bacterial carriage densities were increased approximately 10-fold by day 9 in the LAIV recipients (2.82 vs 1.81 log10 titers, p=0.03). When immunisation followed bacterial acquisition (n=163), LAIV did not change area under the bacterial density-time curve (AUC) at day 14 by conventional microbiology (primary endpoint), but significantly reduced AUC to day 27 by PCR (p=0.03). These studies suggest that LAIV may transiently increase nasopharyngeal density of S. pneumoniae. Transmission effects should therefore be considered in the timing design of vaccine schedules. Trial registration The study was registered on EudraCT (2014-004634-26) Funding The study was funded by the Bill and Melinda Gates Foundation and the UK Medical Research Council.

Hands are vehicles for transmission of Streptococcus pneumoniae in novel controlled human infection study

Streptococcus pneumoniae (pneumococcus) is a major cause of acute otitis media, sinusitis, pneumonia and meningitis worldwide [1]. More than 1.2 million infant deaths are attributed to S. pneumoniae annually [2]. Hands can be vehicles for of transmission of pneumococcus leading to nasopharyngeal colonisation, even after drying http://ow.ly/svlu30liKqP

Screening Heroin Smokers attending Community Drug Services for COPD

BACKGROUND: Heroin smoking is associated with deprivation, early onset severe emphysema, premature morbidity and mortality, and high use of health care, but individuals engage poorly with traditional health services. METHODS: In this cross‐sectional study, we screened a population of heroin smokers, prescribed opiate substitution therapy by community drug services, for airway disease. We assessed drug exposure, respiratory symptoms, health status, and COPD prevalence. Subjects completed spirometry, completed Medical Research Council (MRC) Dyspnea Scale, COPD Assessment Tool (CAT) questionnaire, recorded drug exposure, and provided feedback. RESULTS: A total of 753 people (73% of those approached) completed screening, with 260 participants (35%) having COPD using FEV1/FVC < 0.7 and 293 (39%) participants having COPD using the lower limit of normal. A further 112 participants (15%) had asthma‐COPD overlap (ACO) with features of COPD and asthma. Compared with those with normal spirometry, participants with COPD were more breathless (MRC score 3.1 vs 1.9; P < .001) and had worse health status (CAT score 22.9 vs 13.4; P < .001), respectively. Individuals with COPD had smoked cigarettes (P < .001), heroin (P < .001), and crack (P = .03) for longer and were more likely to still be smoking heroin (P < .01). Feedback was strongly positive, with 92% of respondents happy for other health‐care appointments to be colocated with drug key worker appointments. CONCLUSIONS: Most heroin smokers had COPD or ACO, most commonly mild to moderate disease. In high‐risk areas, screening this population provides an opportunity to reduce symptoms and risk. Anchoring respiratory health screening to drug center appointments delivers high completion and satisfaction and is an appropriate model for screening other hard‐to‐reach populations.

P119 Picking up a bug by picking your nose hand to nose transmission of streptococcus pneumoniae in healthy participants – pilot study

Introduction and Objectives Streptococcus pneumoniae (pneumococcus) is a leading cause of morbidity and mortality worldwide, causing community acquired pneumonia (CAP), otitis media, bacterial meningitis and septicemia. Respiratory illnesses are reduced by handwashing, but for pneumococcus, the importance of non-aerosolised modes of spread is unknown. Our objective was to investigate the modes of transmission of S.pneumoniae from the hands to nose that are able to cause colonisation. Methods This study examines “hand-to-nose” transmission using a modification of our established controlled human infection model: healthy volunteers were administered pneumococcus (serotype 6B) onto their fingertip or back of their hands in a wet or dry dot, and asked to either sniff the bacterial residue, or make direct contact with the nasal mucosal surface (pick/poke their nose). Colonisation was defined as pneumococcal culture at any time point between day 2 and 9 post exposure. Results Colonisation rates were highest in those participants who poked their nose with wet pneumococcus (‘wet poke group’ 4/10, 40%), and who sniffed the wet bacteria from the back of the hand (‘wet sniff group’ 3/10, 30%). Drying of the bacteria on the skin before “sniff” or “poke” was associated with low colonisation rates (1/10 and 0/10 respectively). The ‘wet sniff’ technique was further investigated to improve precision of rates, extending the group to 33 participants, of which 6 were positive (18%). Conclusion We have shown that hands can be vehicles for transmission of Streptococcus pneumoniae and that wet particles increased transmission. This reinforces the imperative for good hand hygiene especially in populations at risk of invasive pneumococcal disease or pneumonia such as young children, elderly and immunosuppressed people

M22 Does telephoning patients before the difficult-to-treat asthma clinic improve attendance?

Aims To assess the use of telephone reminders in a difficult-to-treat asthma service on: 1) clinic attendance rates 2) the prevalence of poor concordance Background Non attendance at clinics leads to increased pressure on NHS resources and cost the NHS £3225 million in 2012–2013. Our trust has an opt-in appointment text message reminder service – despite which, the did-not-attend (DNA) rate at our tertiary asthma clinic was ≥20% in 2016. It is known that up to 30% of patients attending tertiary asthma services have poor adherence with their asthma medication.1 We were interested in establishing whether directly telephoning patients prior to review would allow us to impact DNA rate and simultaneously identify non-concordant individuals that might be redirected to specialist pharmacy input prior to clinical review. Methods During a 3 month period [Feb-Apr 2017] we telephoned patients≥1 week prior to their scheduled appointment – in total 3 attempts were made to contact an individual. During successful contacts express permission was sought to access electronic prescription fulfilment data. Results Successful contact was made with 53.4% [66/126] patients – 41 did not answer, 19 had no valid contact details. The majority of those contacted [54/66] agreed to an adherence check but only n=37 had been registered on the electronic prescription fulfilment system, of these 51% [19/37] had an asthma medication pick-up rate <80%. Of those successfully contacted n=64/66 attended their appointment which compared favourably to the overall DNA rate during the same period in 2016 [3.0% vs 17.5%; p=<0.05]. Although we managed to perform a compliance check on less than a third of the total cohort [37/122], our telephone system allowed ≥1 in 6 patients [19/122]to be directed to a dedicated specialist pharmacist led clinics (focussing on optimising concordance/education) thus creating additional capacity in our difficult-to-treat asthma service. Conclusion Telephoning patients prior to clinic was associated with a substantial reduction in DNAs, and identified individuals that could benefit from a targeted intervention around concordance. The health economics of the intervention need further evaluation. Reference . Robinsonet al. Systematic assessment of difficult-to-treat asthma. ERJ2003, September;22(3):478–83.

P198 Anchoring copd screening to drug services in heroin and crack smokers to improve diagnosis

COPD is associated with social deprivation which can reinforce health inequality, especially in difficult to access groups. Heroin and crack smoking is associated with early onset severe COPD but this population engages poorly with non-emergency medical services although they engage effectively with specialist drug services. As such, despite an expansion in community spirometry provision, different models of care may be needed to optimise COPD diagnosis and management. In order to access this group Liverpool Clinical Commissioning Group (CCG) funded a COPD screening programme where all current and former heroin and crack smokers using local drug services were offered spirometry at drug key worker appointments where they collected their opiate substitute prescription. If willing they also completed MRC, CAT, a record of cigarette and drug exposure and had oxygen saturations measured. They also provided feedback about the programme Eight hundred and seven (807) out of the population of 1100 participated which represents 73% of the client group. Airflow obstruction consistent with COPD was present in 379 (47%) with a further 50 (6%) having reversible airflow obstruction consistent with asthma. Of those with COPD, 154 (41%) had mild, 144 (38%) moderate and 81 (21%) severe or very severe COPD. Mean FEV1 was 2.93L (0.93), mean CAT was 19.5 (10.5) and mean MRC was 2.64 (1.29). Of the 379 with COPD, only a minority (41%) were diagnosed, a third of people were prescribed no inhaler therapy and, when prescribed, treatment was typically sub-optimal. Amongst those with COPD, 337 (90%) were current cigarette smokers while 93 (25%) and 105 (28%) still smoked crack and heroin respectively. When asked to feedback 96% of respondents were happy with the process and 93% would be willing to attend future COPD appointments at drug centres. Anchoring spirometry to key worker appointments in heroin and crack smokers was popular amongst service users and a majority completed spirometry. Airway disease was present in a majority with 47% having mostly undiagnosed but symptomatic COPD with significant scope to improve treatment. This model of screening and treatment improved healthcare access and could be used in other hard to reach groups, such as the homeless.

Ascertaining baseline knowledge of oxygen therapy and respiratory failure

Introduction: COPD mortality secondary to respiratory failure in the UK is double the European average (NHS England, 2015¹). Following this report, the BTS recommend the need to improve emergency oxygen (O 2 ) administration and respiratory failure management. This management need was highlighted by the findings of our hospital O2 Audit where only 33% of patients received formally prescribed oxygen. Aim and Methods: To establish the extent of staff knowledge of O 2 prescribing in respiratory failure, a cross-sectional survey of 100 healthcare professionals within our acute Trust was undertaken. Results: Healthcare staff (Nursing - 36%, medical - 50%, allied professions - 14%) completed a questionnaire survey. 49% reported receiving no respiratory failure training and 46% lacked education on O 2 therapy. 92% considered O 2 to be a drug, however 49% failed to identify a venturi valve as a controlled O 2 device with 40% not knowing how or when to use it. ABGs showing Type I Respiratory Failure were correctly interpreted by 75% of participants, however only 38% recognised Type II Respiratory Failure with compensation. Participants: (80%) recognised the need for education though not via e-Learning provision. Study days, ward based learning or a combination were the preferred option (43%). Conclusion: Education is essential to improve O 2 management and the diagnosis and treatment of respiratory failure. A trust-wide staff education programme to improve patient management and safety has now been developed and will be audited post implementation. ¹ NHS England (2015) Respiratory. .

A comparison of general and respiratory physicans' follow up arrangements post discharge after asthma exacerbations

Introduction: BTS guidelines recommend that patients admitted to hospital with acute asthma exacerbations receive a secondary care follow-up appointment about a month post discharge and that, as well as oral corticosteroid (OCS), inhaled corticosteroids (ICS) are started or continued at discharge. We postulated that, compared with those managed by general/acute physicians, patients admitted with acute asthma under respiratory specialists were more likely to receive timely follow up appointments and to be discharged on OCS/ICS. Method: We reviewed electronic records of all patients admitted to our trust with acute asthma in 2015, comparing those discharged by respiratory specialists with those discharged by general physicians with regards to outpatient follow-up and discharge on ICS/OCS. Results: We reviewed 141 admissions. 30 patients discharged from the Emergency Observation Ward were excluded. Complete records were available for 85 patients. 24 of the 53 non-respiratory admissions (45%) were followed up compared with 28 of the 32 respiratory admissions (87.5%). No patients managed by generalists and only 12(37.5%) of those managed by respiratory specialists were reviewed within 4 weeks. Mean (SD) time to follow up for non-respiratory was 11.7 (2.9) v 7.0 (4.8) weeks for respiratory. Only 4 (5%) patients did not attend appointments. All resp patients were discharged on ICS/OCS compared as were all but one (98%) non-respiratory admission. Conclusion: ICS prescription rates on discharge was near ubiquitous. Follow up appointments were more commonly organised by specialists and than those discharged under the care of general physicians, but few patients were seen within a month.

P210 Community Acquired Pneumonia- Severity and Mortality

Background Community acquired pneumonia (CAP) is a common cause of hospital admissions and carries a high mortality rate. Risk stratification through clinical assessment, underlying chronic lung disease, SIRS and CURB65 helps identify patients at moderate to high risk of mortality. Despite prompt and appropriate management, a significant number of patients (18.3%) die in hospital (BTS Adult CAP audit 2009/10). Aims and objectives We wished to determine our hospital’s CAP mortality rate and ascertain the proportion of patients with a high likelihood of death, as predicted by high CURB-65 scores, markers of severe infection (SIRS criteria) and underlying chronic respiratory disease. Methods Case notes of all patients admitted with CAP over a 3 month period were requested and 175 were obtained. Information was gathered on the presence of underlying chronic lung conditions, CAP severity/mortality markers (SIRS and CURB65 scores) and mortality. Results At least one underlying chronic pulmonary condition was found in 45.1% (n = 79), the commonest being COPD (n = 56). CURB65 score was 0 to 1 in 39.4% (low risk), 2 in 27.4% (moderate risk), 3–5 in 17.2% (high risk) and not done in 16% (n = 28). SIRS criteria were met in just under half of the cases (48.5% n = 85). An in-patient mortality review during this study period showed that 8% (n = 14) CAP patients died in hospital within 30 days. An association of these patients with background lung condition, CURB65 and SIRS is shown in Table 1.Abstract P210 Table 1 Characteristics of CAP patients who died in hospital within 30 days (n = 14) Mortality Chronic lung disease CURB65 SIRS SIRS and/or CURB65 2–5 Yes No 0–1 2–5 Yes No Yes No Numbers 10 4 1 7 5 9 8 6 % 12.6% 4.2% 1.4% 9% 5.9% 10% 9% 7% Conclusion We showed an improvement in mortality figures compared with the BTS National CAP adult audit 5 years ago (8% vs 18.3%). A significant number of these patients have an underlying chronic lung disease which predisposed them to developing CAP. The highest mortality was seen in patients with a high CURB65 score with SIRS response.

Community acquired pneumonia – Coding and advancing quality

Background: Community acquired pneumonia (CAP) is a key clinical focus area of Advancing Quality (AQ), a programme which has shown to decrease mortality with significant financial gain for North West Hospitals (ref: N Engl J Med 2012; 367:1821-8, Health Econ. (2013)DOI: 10.1002/hec). A dedicated AQ pneumonia lead nurse relies on coding system for case identification but current codes fail to differentiate CAP from other causes of pneumonia. Aims and Objectives: To find out the number of patients who had CAP amongst cases coded as Pneumonia specified (organism known) and non-specified (organism unknown). Methods: A prospective data was collected for patients coded as pneumonia specified and non-specified over 3 months period (n=250). A thorough review of medical notes, discharge summaries and investigation results for the admission episode was undertaken to identify actual number of CAP cases. Results: Out of the 250 cases reviewed only 70% had CAP, while 12.4% had pneumonia due to other cause. Moreover, 17.6% (44) were miscoded as pneumonia, the most common being sepsis with other or unknown source followed by exacerbation of COPD. Conclusion: Though majority of the patients coded as pneumonia had CAP, a significant proportion had other diagnosis. Current coding system categorises pneumonia based on isolation of a causative organism but fail to specifically differentiate between its clinical forms. Also, it is not infrequent to find other conditions being miscoded as pneumonia. We suggest a revised coding for different pneumonias to reflect clinical rather than theoretically significant differences between diseases.