Roger Morbey

Trends in antibiotic prescribing in primary care for clinical syndromes subject to national recommendations to reduce antibiotic resistance, UK 1995–2011: analysis of a large database of primary care consultations

OBJECTIVES To measure trends in antibiotic prescribing in UK primary care in relation to nationally recommended best practice. PATIENTS AND METHODS A descriptive study linking individual patient data on diagnosis and prescription in a large primary care database, covering 537 UK general practices during 1995-2011. RESULTS The proportion of cough/cold episodes for which antibiotics were prescribed decreased from 47% in 1995 to 36% in 1999, before increasing to 51% in 2011. There was marked variation by primary care practice in 2011 [10th-90th percentile range (TNPR) 32%-65%]. Antibiotic prescribing for sore throats fell from 77% in 1995 to 62% in 1999 and then stayed broadly stable (TNPR 45%-78%). Where antibiotics were prescribed for sore throat, recommended antibiotics were used in 69% of cases in 2011 (64% in 1995). The use of recommended short-course trimethoprim for urinary tract infection (UTI) in women aged 16-74 years increased from 8% in 1995 to 50% in 2011; however, a quarter of practices prescribed short courses in ≤16% of episodes in 2011. For otitis media, 85% of prescriptions were for recommended antibiotics in 2011, increasing from 77% in 1995. All these changes in annual prescribing were highly statistically significant (P < 0.001). CONCLUSIONS The implementation of national guidelines in UK primary care has had mixed success, with prescribing for coughs/colds, both in total and as a proportion of consultations, now being greater than before recommendations were made to reduce it. Extensive variation by practice suggests that there is significant scope to improve prescribing, particularly for coughs/colds and for UTIs.

Using real-time syndromic surveillance to assess the health impact of the 2013 heatwave in England.

Heatwaves are a seasonal threat to public health. During July 2013 England experienced a heatwave; we used a suite of syndromic surveillance systems to monitor the impact of the heatwave. Significant increases in heatstroke and sunstroke were observed during 7-10 July 2013. Syndromic surveillance provided an innovative and effective service, supporting heatwave planning and providing early warning of the impact of extreme heat thereby improving the public health response to heatwaves.

Assessing the Likely Impact of a Rotavirus Vaccination Program in England: The Contribution of Syndromic Surveillance

BACKGROUND In July 2013, a rotavirus vaccination program for 2- to 3-month-olds was introduced in the United Kingdom. We present an initial impact analysis of this new vaccine program using national syndromic surveillance systems. METHODS General practitioner (GP) in-hours, GP out-of-hours, and emergency department (ED) syndromic surveillance systems were used to monitor GP consultations and ED visits for gastroenteritis, diarrhea, and vomiting. Data were stratified by age group and compared between pre- and postvaccine-year rotavirus seasons. Incidence rate ratios (IRRs) and percentage ratios were calculated for GP in-hours consultations and GP out-of-hours and ED data, respectively. RESULTS There was a significant reduction in gastroenteritis, diarrhea, and vomiting GP in-hours consultations in children aged 0-4 years when comparing the rotavirus season in the pre- and postvaccine years (P < .001 for all indicators). IRRs illustrated a 26%-33% and 23%-31% decrease in gastroenteritis incidence in the <1 and 1-4 years age groups, respectively, across the syndromic surveillance systems. There was also an 8% decrease recorded in the 5-14 years age group in the GP in-hours and ED systems. CONCLUSIONS Syndromic surveillance revealed a marked decline in gastroenteritis, coinciding with the introduction of the new rotavirus vaccine program in England. The largest reduction in disease was observed in infants, although some impact was also demonstrated in children aged 1-4 and 5-14 years, suggesting possible herd protection in older age groups. This study was limited to the first postvaccine year, and further analysis is required to assess the longer-term impact of the vaccine.

Using real-time syndromic surveillance systems to help explore the acute impact of the air pollution incident of March/April 2014 in England.

During March and early April 2014 there was widespread poor air quality across the United Kingdom. Public Health England used existing syndromic surveillance systems to monitor community health during the period. Short lived statistically significant rises in a variety of respiratory conditions, including asthma and wheeze, were detected. This incident has demonstrated the value of real-time syndromic surveillance systems, during an air pollution episode, for helping to explore the impact of poor air quality on community health in real-time.

Development and refinement of new statistical methods for enhanced syndromic surveillance during the 2012 Olympic and Paralympic Games

Prior to the 2012 London Olympic and Paralympic Games, new statistical methods had to be developed for the enhanced syndromic surveillance during the Games. Different methods were developed depending on whether or not historical data were available. Practical solutions were needed to cope with the required daily reporting and data quality issues. During the Games, nearly 4800 signals were tested on average each day, generating statistical alarms that were assessed to provide information on areas of potential public health concern and reassurance that no major adverse incident had occurred. Graphical abstract

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.

The use of syndromic surveillance to monitor the incidence of arthropod bites requiring healthcare in England, 2000-2013: a retrospective ecological study.

Climate change experts predict the number of nuisance-biting arthropods in England will increase but there is currently no known surveillance system in place to monitor or assess the public health impact of arthropod bites. This retrospective ecological study utilized arthropod bites requiring healthcare from five national real-time syndromic surveillance systems monitoring general practitioner (GP) consultations (in-hours and out-of-hours), emergency department (ED) attendances and telephone calls to remote advice services to determine baseline incidence in England between 2000 and 2013 and to assess the association between arthropod bites and temperature. During summer months (weeks 20-40) we estimated that arthropod bites contribute a weekly median of ~4000 GP consultations, 750 calls to remote advice services, 700 ED and 1300 GP out-of-hours attendances. In all systems, incidence was highest during summer months compared to the rest of the year. Arthropod bites were positively associated with temperature with incidence rate ratios (IRRs) that ranged between systems from 1·03 [95% confidence interval (CI) 1·01-1·06] to 1·14 (95% CI 1·11-1·16). Using syndromic surveillance systems we have established and described baseline incidence of arthropod bites and this can now be monitored routinely in real time to assess the impact of extreme weather events and climate change.

Emergency department syndromic surveillance providing early warning of seasonal respiratory activity in England

Seasonal respiratory infections place an increased burden on health services annually. We used a sentinel emergency department syndromic surveillance system to understand the factors driving respiratory attendances at emergency departments (EDs) in England. Trends in different respiratory indicators were observed to peak at different points during winter, with further variation observed in the distribution of attendances by age. Multiple linear regression analysis revealed acute respiratory infection and bronchitis/bronchiolitis ED attendances in patients aged 1-4 years were particularly sensitive indicators for increasing respiratory syncytial virus activity. Using near real-time surveillance of respiratory ED attendances may provide early warning of increased winter pressures in EDs, particularly driven by seasonal pathogens. This surveillance may provide additional intelligence about different categories of attendance, highlighting pressures in particular age groups, thereby aiding planning and preparation to respond to acute changes in EDs, and thus the health service in general.

Novel public health risk assessment process developed to support syndromic surveillance for the 2012 Olympic and Paralympic Games

Background Syndromic surveillance aims to provide early warning and real time estimates of the extent of incidents; and reassurance about lack of impact of mass gatherings. We describe a novel public health risk assessment process to ensure those leading the response to the 2012 Olympic Games were alerted to unusual activity that was of potential public health importance, and not inundated with multiple statistical ‘alarms’. Methods Statistical alarms were assessed to identify those which needed to result in ‘alerts’ as reliably as possible. There was no previously developed method for this. We identified factors that increased our concern about an alarm suggesting that an ‘alert’ should be made. Results Between 2 July and 12 September 2012, 350 674 signals were analysed resulting in 4118 statistical alarms. Using the risk assessment process, 122 ‘alerts’ were communicated to Olympic incident directors. Conclusions Use of a novel risk assessment process enabled the interpretation of large number of statistical alarms in a manageable way for the period of a sustained mass gathering. This risk assessment process guided the prioritization and could be readily adapted to other surveillance systems. The process, which is novel to our knowledge, continues as a legacy of the Games.

Estimating primary care attendance rates for fever in infants after meningococcal B vaccination in England using national syndromic surveillance data

BACKGROUND In September 2015, the United Kingdom became the first country to introduce the multicomponent group B meningococcal vaccine (4CMenB) into a national infant immunisation programme. In early clinical trials 51-61% of infants developed a fever when 4CMenB was administered with other routine vaccines. Whilst administration of prophylactic paracetamol is advised, up to 3% of parents may seek medical advice for fever following vaccination. We used research-level general practitioner consultations to identify any increase in attendances for all-cause fever in vaccine-eligible infants following 4CMenB introduction in England. METHODS Consultations for infant all-cause fever in the year following the vaccine introduction were identified from The Phoenix Partnership (TPP) ResearchOne general practice database using Read (CTV3) codes. Average daily consultation rates and incidence rate ratios (IRRs) were calculated for vaccine-eligible age groups and compared to the two years preceding vaccine introduction. The difference between pre- and post-vaccine all-cause fever consultations was estimated. RESULTS All-cause fever consultations in vaccine-eligible 7-10 week olds were 1.6-fold higher (IRR, 1.58; 95% CI, 1.22-2.05) compared to the two previous years and 1.5-fold higher (IRR 1.47; 95% CI, 1.17-1.86) in 15-18 week-olds. There were no significant differences in 0-6 or 11-14 week-olds. Applying the difference between pre- and post-vaccine consultation rates to the 4CMenB vaccine-eligible age groups across England estimated 1825 additional fever consultations in the year following 4CMenB introduction. CONCLUSIONS We found a small but significant difference in all-cause fever consultation rates in vaccine-eligible infants who would have received 4CMenB with other vaccines.