Thomas Waite

Excess Winter Deaths in Europe: a multi-country descriptive analysis

BACKGROUND Winter deaths are a known health and social care challenge for many countries. A previous international comparison showed significant differences in excess winter deaths across Europe in the 1990s, with the northern countries having lower excess winter mortality than those in southern Europe. METHODS The Excess Winter Deaths Index (EWDI) is the ratio of deaths in the winter period (December to March) compared with deaths in the non-winter period. Data from the Eurostat database and national registries were used to calculate the EWDI for 31 countries in Europe across the time period 2002/2003 to 2010/2011. RESULTS National EWDI values show heterogeneity, with a broad pattern of increasing EWDI values from northern to southern Europe and increasing mean winter temperature (r(2) = 0.50, P > 0.0001). Malta, Portugal, Spain, Cyprus and Belgium all had an EWDI that was statistically significantly higher than the average EWDI for the other 30 European countries. There was no clear association between country-level EWDI and the level of inter-annual variability in winter temperature across Europe. DISCUSSION This article demonstrates the differences in EWDI that exist between European countries with implications for both research and policy. Many deaths may be avoidable as environmental, social and personal factors are known to contribute to winter mortality. We now need to work to better understand the causes of inter-country differences.

The English national cohort study of flooding and health: cross-sectional analysis of mental health outcomes at year one.

BackgroundIn winter 2013/14 there was widespread flooding in England. Previous studies have described an increased prevalence of psychological morbidity six months after flooding. Disruption to essential services may increase morbidity however there have been no studies examining whether those experiencing disruption but not directly flooded are affected.The National Study of Flooding and Health was established in order to investigate the longer-term impact of flooding and related disruptions on mental health and wellbeing.MethodsIn year one we conducted a cross sectional analysis of people living in neighbourhoods affected by flooding between 1 December 2013 and 31 March 2014. 8761 households were invited to participate. Participants were categorised according to exposure as flooded, disrupted by flooding or unaffected.We used validated instruments to screen for probable psychological morbidity, the Patient Health Questionnaire (PHQ 2), Generalised Anxiety Disorder scale (GAD-2) and Post Traumatic Stress Disorder (PTSD) checklist (PCL-6).We calculated prevalence and odds ratios for each outcome by exposure group relative to unaffected participants, adjusting for confounders.Results2126 people (23%) responded. The prevalence of psychological morbidity was elevated amongst flooded participants ([n = 622] depression 20.1%, anxiety 28.3%, PTSD 36.2%) and disrupted participants ([n = 1099] depression 9.6%, anxiety 10.7% PTSD 15.2%).Flooding was associated with higher odds of all outcomes (adjusted odds ratios (aORs), 95% CIs for depression 5.91 (3.91–10.99), anxiety 6.50 (3.77–11.24), PTSD 7.19 (4.33–11.93)).Flooded participants who reported domestic utilities disruption had higher odds of all outcomes than other flooded participants, (aORs, depression 6.19 (3.30–11.59), anxiety 6.64 (3.84–11.48), PTSD 7.27 (4.39–12.03) aORs without such disruption, depression, 3.14 (1.17–8.39), anxiety 3.45 (1.45–8.22), PTSD 2.90 (1.25–6.73)). Increased floodwater depth was significantly associated with higher odds of each outcome.Disruption without flooding was associated with borderline higher odds of anxiety (aOR 1.61 (0.94–2.77)) and higher odds of PTSD 2.06 (1.27–3.35)) compared with unaffected participants. Disruption to health/social care and work/education was also associated with higher odds of psychological morbidity.ConclusionsThis study provides an insight into the impact of flooding on mental health, suggesting that the impacts of flooding are large, prolonged and extend beyond just those whose homes are flooded.

Effect of evacuation and displacement on the association between flooding and mental health outcomes: a cross-sectional analysis of UK survey data

Summary Background Extensive flooding occurred during the winter of 2013–14 in England. Previous studies have shown that flooding affects mental health. Using data from the 2013–14 Public Health England National Study of Flooding and Health, we compared the prevalence of symptoms of depression, anxiety, and post-traumatic stress disorder between participants displaced by flooding and those flooded, but not displaced, 1 year after flooding. Methods In this multivariable ordinal regression analysis, we collected data from a cross-sectional survey collected 1 year after the flooding event from flood-affected postcodes in five counties in England. The analysis was restricted to individuals whose homes were flooded (n=622) to analyse displacement due to flooding. The primary outcome measures were depression (measured by the PHQ-2 depression scale) and anxiety (measured by the two-item Generalised Anxiety Disorder [GAD]-2 anxiety scale), and post-traumatic stress disorder (measured by the Post-Traumatic Stress Disorder Checklist [PCL]-6 scale). We adjusted analyses for recorded potential confounders. We also analysed duration of displacement and amount of warning received. Findings People who were displaced from their homes were significantly more likely to have higher scores on each scale; odds ratio (OR) for depression 1·95 (95% CI 1·30–2·93), for anxiety 1·66 (1·12–2·46), and for post-traumatic stress disorder 1·70 (1·17–2·48) than people who were not displaced. The increased risk of depression was significant even after adjustment for severity of flooding. Scores for depression and post-traumatic stress disorder were higher in people who were displaced and reported receiving no warning than those who had received a warning more than 12 h in advance of flooding (p=0·04 for depression, p=0·01 for post-traumatic stress disorder), although the difference in anxiety scores was not significant. Interpretation Displacement after flooding was associated with higher reported symptoms of depression, anxiety, and post-traumatic stress disorder 1 year after flooding. The amount of warning received showed evidence of being protective against symptoms of the three mental illnesses studied, and the severity of flooding might be the reason for some, but not all, of the differences between the groups. Funding National Institute for Health Research Health Protection Research Units (HPRU) in Emergency Preparedness and Response at Kings College London, Environmental Change and Health at the London School of Hygiene and Tropical Medicine, and Evaluation of Interventions at the University of Bristol, Public Health England.

Pseudo-outbreaks of Stenotrophomonas maltophilia on an intensive care unit in England.

BACKGROUND In June 2014, a cluster of identical S. maltophilia isolates was reported in an adult intensive care unit (ICU) at a district general hospital. An outbreak control team was convened to investigate the cluster and inform control measures. AIM To identify potential risk factors for isolation of S. maltophilia in this setting. METHODS We conducted a cohort study of ICU patients for whom a bronchoalveolar lavage (BAL) specimen was submitted between October 2013 and October 2014. Cases were patients with S. maltophilia-positive BAL. We calculated the association between isolation of S. maltophilia and patient characteristics using risk ratios (RRs) with 95% confidence intervals (95% CIs) and univariate logistic regression. Chi-squared or Fishers exact tests were used. BAL specimens were microbiologically typed using pulse-field gel electrophoresis (PFGE). FINDINGS Eighteen patients met the case definition. Two patients had clinical presentations that warranted antibiotic treatment for S. maltophilia. All cases were exposed to bronchoscopy. PFGE typing revealed clusters of two strain types. We found statistically significant elevated risks of isolating BRISPOSM-4 in patients exposed to bronchoscope A (RR: 13.56; 95% CI: 1.82-100; P < 0.001) and BRISPOSM-3 in patients exposed to bronchoscope B (RR: 16.89; 95% CI: 2.14-133; P < 0.001). S. maltophilia type BRISPOSM-4 was isolated in water used to flush bronchoscope A after decontamination. CONCLUSION Two pseudo-outbreaks occurred in which BAL specimens had been contaminated by reusable bronchoscopes. We cannot exclude the potential for colonization of the lower respiratory tract of exposed patients. Introduction of single-use bronchoscopes was an effective control measure.

Carbon monoxide poisoning and flooding: changes in risk before, during and after flooding require appropriate public health interventions.

Introduction While many of the acute risks posed by flooding and other disasters are well characterised, the burden of carbon monoxide (CO) poisoning and the wide range of ways in which this avoidable poisoning can occur around flooding episodes is poorly understood, particularly in Europe. The risk to health from CO may continue over extended periods of time after flooding and different stages of disaster impact and recovery are associated with different hazards. Methods A review of the literature was undertaken to describe the changing risk of CO poisoning throughout flooding/disaster situations. The key objectives were to identify published reports of flood-related carbon monoxide incidents that have resulted in a public health impact and to categorise these according to Noji’s Framework of Disaster Phases (Noji 1997); to summarise and review carbon monoxide incidents in Europe associated with flooding in order to understand the burden of CO poisoning associated with flooding and power outages; and to summarise those strategies in Europe which aim to prevent CO poisoning that have been published and/or evaluated. The review identified 23 papers which met its criteria. The team also reviewed and discussed relevant government and non-government guidance documents. This paper presents a summary of the outcomes and recommendations from this review of the literature. Results Papers describing poisonings can be considered in terms of the appliance/source of CO or the circumstances leading to poisoning.The specific circumstances identified which lead to CO poisoning during flooding and other disasters vary according to disaster phase. Three key situations were identified in which flooding can lead to CO poisoning; pre-disaster, emergency/recovery phase and post-recovery/delayed phase. These circumstances are described in detail with case studies. This classification of situations is important as different public health messages are more appropriate at different phases of a disaster. The burden of disease from poisoning caused by each potential source and at each phase of a disaster is different. CO poisoning is not compulsory and deaths associated with a flood but delayed for a period of months, for example due to a damaged boiler, may never be attributed to the flood as surveillance often ends once the floodwaters recede. The problem of under–reporting is crucial to our understanding of flooding-related poisoning. The indoor use of portable generators, cooking and heating appliances designed for use outdoors during periods of loss of mains power or gas is a particular problem. In the recovery phase, equipment for pumping, dehumidifying and drying out of properties poses a new risk. In the long term, mortality and morbidity associated with the renewed use of boilers which may have suffered covert damage in flooding is recognised but very difficult to quantify. Papers evaluating interventions were not found and where literature exists on prevention of CO poisoning in disaster situations, it is from the USA. Conclusions This paper for the first time describes the different risks of CO poisoning posed by the different phases of a disaster. There is a specific need to recognise that any room in a building can harbour a CO emitting appliance in flooding; wood burners and rarely used chimney flues may become particularly problematic following a flood. Recommendations 1) Public health workers and policy makers should consider establishing toolkits using the CDC toolkit approach; the acceptability of any intervention must be evaluated further to guide informed policy. 2) CO poisoning must form part of syndromic and event based surveillance systems for flooding and should be included in measures of the health impact of flooding. 3) CO monitors in the domestic environment should be sited not only in proximity to known CO emitters but also in locations where mobile or short term CO emitting appliances may be placed, including woodburners and infrequently used fireplaces.

Chemoprophylaxis and vaccination in preventing subsequent cases of meningococcal disease in household contacts of a case of meningococcal disease: a systematic review

Household contacts of an index case of invasive meningococcal disease (IMD) are at increased risk of acquiring disease. In revising WHO guidance on IMD in sub-Saharan Africa, a systematic review was undertaken to assess the effect of chemoprophylaxis and of vaccination in preventing subsequent cases of IMD in household contacts following an index case. A literature search for systematic reviews identified a single suitable review on chemoprophylaxis in 2004 (three studies meta-analysed). A search for primary research papers published since 2004 on chemoprophylaxis and without a date limit on vaccination was therefore undertaken. There were 2381 studies identified of which two additional studies met the inclusion criteria. The summary risk ratio for chemoprophylaxis vs. no chemoprophylaxis (four studies) in the 30-day period after a case was 0·16 [95% confidence interval (CI) 0·04-0·64, P = 0·008]; the number needed to treat to prevent one subsequent case was 200 (95% CI 111-1000). A single quasi-randomized trial assessed the role of vaccination. The risk ratio for vaccination vs. no vaccination at 30 days was 0·11 (95% CI 0·01-2·07, P = 0·14). The results support the use of chemoprophylaxis to prevent subsequent cases of IMD in household contacts of a case. Conclusions about the use of vaccination could not be drawn.

The case for systems thinking about climate change and mental health

It is increasingly necessary to quantify the impacts of climate change on populations, and to quantify the effectiveness of mitigation and adaptation strategies. Despite growing interest in the health effects of climate change, the relationship between mental health and climate change has received little attention in research or policy. Here, we outline current thinking about climate change and mental health, and discuss crucial limitations in modern epidemiology for examining this issue. A systems approach, complemented by a new style of research thinking and leadership, can help align the needs of this emerging field with existing and research policy agendas.This Perspective reviews the literature on climate change and mental health, and advocates for a systems approach, which considers the complex set of interacting distal, intermediate and proximate factors that influence mental health risk, in future research.

Chapter 18:Buncefield Fire

The Buncefield depot is one of the largest oil storage and transfer sites in the UK, handling refined petroleum products and additives before distribution to other facilities. On Sunday 11 December 2005, over-filling of tank 912 with unleaded car fuel resulted in spillage of 300 tonnes of petrol around the tank and formation of a vapour cloud. This ignited at 06:01 hours, producing an explosion and fire that burned for five days, by which time 23 tanks of diesel, kerosene and aviation fuel had been destroyed. The fire plume was dispersed widely above a temperature inversion layer, limiting the ground level plume deposition and resulting health hazards. This chapter describes the circumstances of the event and the Health Protection Agency public health response. Aspects covered include estimation of emissions and pollutants, public health response, environmental impact findings (including atmospheric and plume dispersion modelling, air quality monitoring and international impact) and health impact findings (including emergency department case note review, an occupational health surveillance register, and the Buncefield follow up population survey). The significance of the findings and public health lessons identified are discussed, including consideration of potential health outcomes for different meteorological scenarios that had occurred on other days during 2005.