Abstract Air pollution, including particulate matter and nitrogen oxides, with their adverse impact on respiratory, cardiovascular, and neurological disease, has been associated with changes in traffic density and other increases in pollutants. Background information on typical pollutants and air quality measurements is based on World Health Organization (WHO) criteria. Multidisciplinary input to such investigations is important, involving specialists in toxicology and environmental science, as well as health protection specialist staff, plus the local authority public health team. Mapping air pollution levels through geographical information systems to identify localities where guideline values are exceeded is important, together with health impact assessments to monitor public health outcomes. There are complex local, social, and political aspects to be considered, and so there is a vital need to ensure engagement with local communities and communication with different interest groups. The usual air quality parameters may deteriorate significantly during local emergencies such as wildfires, that are likely to increase in frequency with climate change and associated global heating. There are several unanswered questions; ways they should be considered and managed are suggested.

This chapter describes the importance of evidence-based decisions in health protection practice. It describes the hierarchy of evidence, from systematic reviews of randomized controlled trials to case reports and opinion. The chapter emphasizes the importance of assessing methodological quality, the quality of the evidence, and the risks of different types of bias. For policy to be as robust as possible it should be based on the best available evidence, and much evidence is useful even when it isn’t used in policy. Therefore, in this chapter, tools are described for reaching evidence-based recommendations, including the Evidence to Decision Framework. Factors that may influence policy development are reviewed, including social and political pressures that may impede evidence-based policy. Finally, the chapter considers critical appraisal of policy using the AGREE II tool.

Abstract Clusters of disease are often reported to health protection, and a finger is pointed at a nearby environmental hazard that is thought to be the cause. There is an expectation that the causal linkage will be clarified, and action taken to alleviate the resulting anxiety and stop further ill health. Most reported clusters are not real, but all are worth some level of investigation to alleviate anxiety and rule out any potential environmental link. However, investigating such clusters is not easy. Neither is investigating causal linkages to environmental issues. Using an example of childhood cancer and contaminated land, this chapter takes a stepwise, structured approach to the investigation, defining realistic outcomes and clear criteria to stop such an investigation. The vital role of a multi-agency incident team to integrate health studies and environmental investigations is explored. Readers will be able to undertake such investigations for themselves across a wide range of putative clusters of chronic diseases.

Abstract This chapter explores the definition of screening in the context of health protection practice. Screening is clearly defined with appropriate examples, and its application explored within the framework of day-to-day health protection practice. In the United Kingdom (UK), screening as a public health action is the process of identifying healthy people who may be at increased risk of a disease. The chapter outlines the ten key screening criteria and different health protection interventions that do not meet screening criteria such as post-exposure registers, surveillance, diagnostic testing, monitoring of health outcomes, and health checks. Not all ‘screening’ activity adheres to these criteria, since screening is more than a test—it is a programme. The UK screening programme and screening in health protection are described in detail. One of the difficulties is that the word ‘screening’ is used in daily language with different meanings. These can include environmental screening for a microorganism or a specific chemical, asking patients questions about exposure or symptoms, testing people for a disease biomarker, or examining healthy workers before or during exposure. Relevant references and sources are provided, so that interested readers may explore the subject in more depth in relation to their specific practice and setting.

Communicable disease outbreak investigation is one of the key health protection functions. The investigation of environmental situations and incidents is also a developing area in the field. This chapter takes an all-hazard approach to cover the general principles and practice of incident and outbreak investigation and management in all three domains of health protection (communicable disease control, emergency response, and environmental public health). It includes: the key definitions and steps in investigation of incidents and outbreaks; the practical approaches to managing incidents and outbreaks; the steps and processes in the investigation and control of emergency response and environmental public health incidents; and the overall approach to public health risk assessment in all three domains.

This chapter describes the strategies for business continuity when a significant challenging event affects a hospital or other healthcare provider: the scenario is a norovirus outbreak affecting several wards and staff. The strategy includes business impact analysis and a disaster recovery plan. The importance of developing a generic response plan, rather than a response for each type of incident, is emphasized. The early involvement of the infection control team, isolating or cohorting patients, and liaison with the community are essential components of the response. The chapter describes how a ‘less serious event’ (a few reported cases) may rapidly escalate into a major incident. The business continuity plan should be implemented early, and should identify which services can be stopped, and which must continue. Finally, the importance of holding a multi-agency and multi-professional debrief meeting as soon as the incident is declared over is emphasized, with revision of the plan accordingly.

Abstract The concepts of ‘sustainability’ (the set of conditions where we meet current needs without compromising the ability of future generations to meet their own needs) and ‘sustainable development’ (the plan of actions required to achieve this) are increasingly gaining attention in the field of health protection. This chapter outlines how public health and health protection are intricately interlinked with all three pillars of sustainability (economic development, the environment, social equity). The health co-benefits of sustainable development, which is more than just responding to climate change, are described, as well as practical suggestions as to how health protection and health protection practitioners can act to improve sustainability from national and international to individual levels.

Psychosis can affect a person's functioning, quality of life and physical health. Early intervention for service users presenting with psychosis has been implemented via early intervention teams, but there are inconsistencies in assessment and treatment. The aim of this study was to examine time to treatment (defined as the commencement of antipsychotic medication) for service users experiencing first-episode psychosis, the impact of this and engagement with teams. The authors explored the effect of patient characteristics (eg gender, deprivation, ethnicity, age) and early intervention teams on time to treatment for psychosis. A retrospective cohort study was undertaken using routine data of service users accessing three early intervention teams from 2018–19. The care records of 457 service users were examined, including patient characteristics, assessments, time to first contact, treatment and time to discharge. Data were analysed using the Statistical Package for Social Sciences. Use of the Positive and Negative Syndrome Scale assessment tool differed across the three early intervention teams. Engagement with all teams varied by gender. Men were particularly slow to access treatment in one team (118 of 163 service users, 72.4%). Increased emphasis on engaging male patients may improve service delivery. Improved communication between early intervention teams could increase standardisation of assessment and treatment.

OBJECTIVE:To examine the effectiveness of one dose of the COVID-19 vaccine on care-home residents. STUDY DESIGN:Natural experiment. METHODS:We compared the effectiveness of single doses of Pfizer/BioNTech BNT162b2 (effective at 10 days) and AstraZeneca ChAdOx1 (effective at 14 days) vaccines in vaccinated and control (unvaccinated) homes. Using routine data, all care-homes reporting COVID-19 outbreaks between 11/12/2020 and 12/3/2021 in a sub-region of North West England were included. RESULTS:Of 126 care-homes (4042 residents), with outbreaks, 55 (44%, 1686 residents) reported onset dates before vaccination commenced; 38 (30%, 1304 residents) reported onset < 10 (BNT162b2) and < 14 days (ChAdOx1) after vaccine administration; and 33 (26%, 1052 residents) reported onset > 10 (BNT162b2) and > 14 (ChAdOx1) days after vaccination. Eighty-nine (71%) homes used ChAdOx1 vaccine. A single dose of vaccine before the outbreak onset significantly lowered the risk of symptoms (reduced by 48%), positivity (by 65%), hospitalisation (by 68%), and death (by 81%). Some vaccine effectiveness was also noted in care-homes that received one dose of vaccine within 10-14 days of outbreak onset. The number needed to vaccinate to prevent one resident from COVID-19-related hospitalisation was 34, and death was 17. CONCLUSIONS:This real-world, natural experiment adds to the evidence of COVID-19 vaccine effectiveness from different studies using varying designs. In the context of lockdown's impact on infection rates and on-going care-home outbreaks, a single dose of either ChAdOx1 or BNT162b2 vaccine had a significant impact on reducing COVID-19 related hospitalisation and death in care-home residents. Natural experiments should be used more in public health.

Purpose The purpose of the study was to examine whether there were differences in the provision of non-pharmacological interventions based on the level of intellectual disability and the presence or absence of autism. Mental health conditions are often underdiagnosed in adults with intellectual disability and do not always receive psychological interventions as recommended by the National Institute for Health and Care Excellent guidelines. To realise the national UK programme's aim of stopping the overuse of medications in people with intellectual disability, it is important that these individuals have access to appropriate non-pharmacological interventions. The authors examined the relationship between an individual's level of intellectual disability and the presence or absence of autism with access to relevant non-pharmacological interventions from specialist community intellectual disability services.Design/methodology/approach A cross-sectional study of adults accessing four specialist intellectual disability services in North West England in 2019.Findings There was a high prevalence of mental health comorbidity, even higher for autistic adults. However, a relatively small percentage of the study population was receiving psychological interventions. The most frequent non-pharmacological intervention was a positive behaviour support plan, irrespective of comorbid mental illnesses.Research limitations/implications Not having access to psychological interventions for the treatment of mental illness could result in poor health outcomes and increasing health inequalities. The study highlights the need for developing psychological interventions, particularly for those with moderate to severe intellectual disability and for those with associated autism.Originality/value This large sample study examined the relationship between intellectual disability level and the presence of autism with accessing psychological interventions.

Background Autism has been linked to higher rates of self-harm. Research is yet to establish the reason for the association between autism and self-harm as a distress response. Methods Using the ‘thinking patterns profiling model’, this study explored characteristics associated with self-harm risk in 100 autistic young people. Secondary analysis of routinely collected clinical data was conducted using odds ratios and t-tests. Results We found the prevalence of reported self-harm risk was 48%. Young people with reported self-harm risks had significantly lower regulation skills (p ≤ 0.01) and lower social flexibility skills (p ≤ 0.01) compared to those without reported self-harm risk. For those described as impulsive, mean scores on the following skills were significantly lower: perspective-taking skills (p ≤ 0.01), flexible thinking for creative problem-solving (p ≤ 0.05) and sensory tolerating (p ≤ 0.05). There was no relationship between reported self-harm risk and adverse childhood experiences. Conclusions These findings suggest that profiling tools such as ‘Thinking Patterns Profiling Model’ can be used to explore unique patterns of vulnerability and resilience related to self-harm risk in autism. The findings suggest that autistic thinking patterns might interplay with other factors (e.g. impulsivity). Patterns are based on each person’s profile across four core skill-sets: regulation, flexible thinking, sensory coherence, and social perspective-taking. These findings motivate a person-centred and profile-informed approach to planning support and adjustments. Further studies are needed to confirm the ways in which mechanisms typically involved in self-harm risk, may interact with core cognitive and affective differences found in autism.

Bias against left-handers is well-documented and seen in the etymology of "left" and "right" in most languages. The subject of this study, Ehud, lived between the exodus of the Hebrew slaves from Egypt and the establishment of the Israelite kingdom (c1200-1000 BC), at the transition between the Late Bronze Age and Iron Age 1. His left-handedness was crucial to his deliverance of the proto-nation from tyranny, recorded in Judges in the Hebrew Bible. The description of Ehud as left-handed ('iṭṭēr yaḏ-yεmînô) is used once more in the Hebrew Bible, also in Judges, to describe the artillery of Ehud's tribe. The words apparently mean "bound/restricted in the right hand", sometimes interpreted as "ambidextrous". This is unlikely: ambidexterity is uncommon. The artillery used the sling with either hand, but Ehud used his left (śεm'ōl) hand to draw his sword. śεm'ōl, used throughout the Hebrew Bible, means left, without bias or derogatory implications. We suggest that 'iṭṭēr yaḏ-yεmînô was a right-handed bias towards left-handed people, but Ehud's left-handed victory was recognized as significant. Significant enough that (a) the language changed and the biased description was dropped in favour of simple description, and (b) the army changed with the development of left-handed slingers (artillery).

Background Mental, neurological, and substance-use disorders cause medium to long term disability in all countries. They are amenable to treatment but often treatment is only available in hospitals, as few staff feel competent to give treatment. The WHO developed the “Mental Health GAP” (mhGAP) course to train non-specialist clinical staff in basic diagnosis and treatment. At Bwindi Community Hospital, in south-west Uganda, mental health care was initially only provided at the hospital. It was extended outside the hospital in two implementation phases, initially by establishing 17 clinics in the community, run by qualified mental health staff from the hospital. In the second implementation phase staff in 12 health centers were trained using mhGAP and ran their own clinics under supervision. Methods Using routine data the defined data variables for the individuals attending the clinics was extracted. Results A total of 2,617 people attended a mental health care clinic in the study period between January 2016 and March 2020. Of these 1,051 people attended more than once. The number of patients attending clinics increased from 288 during the baseline to 693 in the first implementation phase then to 839 patients in the second implementation phase. After mhGAP training, about 30% of patients were seen locally by mhGAP trained healthcare personnel. The average number of mental health patients seen each month increased from 12 to 65 over the time of the study. The number of patients living >20 km from the hospital increased from 69 in the baseline to 693 in the second implementation phase. The proportion of patients seen at the hospital clinic dropped from 100% to 27%. Conclusions Providing mental health care in the community at a distance from the hospital substantially increased the number of people accessing mental health care. Training health center-based staff in mhGAP contributed to this. Not all patients could appropriately be managed by non-specialist clinical staff, who only had the five-day training in mhGAP. Supplies of basic medicines were not always adequate, which probably contributed to patients being lost to follow-up. About 50% of patients only attend the clinic once. Further work is required to understand the reasons.

Objectives: We reviewed environmental public health practice at a local level (roles, responsibilities, interaction with partner agencies) to establish what and how an integrated approach to the service, as found in Cheshire and Merseyside, North West England, should be delivered, if at all, and at what footprint. Study design: Mixed methods approach. Methods: We triangulated: qualitative interviews with relevant professionals to gain an in-depth understanding of their interest and vision for any health protection input to health risks and outcomes from environmental issues; an electronic questionnaire assessing experience, interest, vision and comfort zones of a wider range of professionals involved in environmental health issues; a half-day workshop to review study findings and agree ways forward. Results: Stakeholders value their local health protection team's input, but environmental public-health knowledge and skills also exist in local authority teams. Regional health protection teams can provide environmental public-health expertise to local partners and agencies. They harness national input and evidence with local frontline professionals practice, enabling locally grounded approaches, integrating science into local contexts, to answer difficult, often incorrigible, problems. Conclusions: Specialist leadership by experienced Consultants in Health Protection is of value to local authority public health and environmental teams and should be based on a footprint that is appropriate to enhance local relationships without compromising available expert knowledge and skills. Crown Copyright & COPY; 2023 Published by Elsevier Ltd on behalf of The Royal Society for Public Health. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4. 0/).

Atmospheric particulate matter (PM) causes 3.7 million annual deaths worldwide and potentially damages every organ in the body. The cancer-causing potential of fine particulates (PM2.5) highlights the inextricable link between air quality and human health. With over half of the world's population living in cities, PM2.5 emissions are a major concern, however, our understanding of exposure to urban PM is restricted to relatively recent (post-1990) air quality monitoring programmes. To investigate how the composition and toxicity of PM has varied within an urban region, over timescales encompassing changing patterns of industrialisation and urbanisation, we reconstructed air pollution records spanning 200 years from the sediments of urban ponds in Merseyside (NW England), a heartland of urbanisation since the Industrial Revolution. These archives of urban environmental change across the region demonstrate a key shift in PM emissions from coarse carbonaceous 'soot' that peaked during the mid-twentieth century, to finer combustion-derived PM2.5 post-1980, mirroring changes in urban infrastructure. The evolution of urban pollution to a recent enhanced PM2.5 signal has important implications for understanding lifetime pollution exposures for urban populations over generational timescales.

Human health and wellbeing are intimately linked to the state of the environment [...]

If research is to have an impact and change health outcomes for the better, the findings of the research should be translated into recommendations and actions that can influence policy and/or practice [...]

Purpose This study aims to evaluate the quality of transition from child and adolescent services to adult intellectual disability services, using the relevant National Institute for Health and Care Excellence (NICE) standard (QS140). In addition, this study also identifies any differences in transition quality between those young people with intellectual disability with and without autism. Design/methodology/approach Using routinely collected clinical data, this study identifies demographic and clinical characteristics of, and contextual complexities experienced by, young people in transition between 2017 and 2020. Compliance with the quality standard was assessed by applying dedicated search terms to the records. Findings The study highlighted poor recording of data with only 22% of 306 eligible cases having sufficient data recorded to determine compliance with the NICE quality standard. Available data indicated poor compliance with the standard. Child and adolescent mental health services, generally, did not record mental health co-morbidities. Compliance with three out of the five quality statements was higher for autistic young people, but this only reached statistical significance for one of those statements (i.e. having a named worker, p = 0.02). Research limitations/implications Missing data included basic clinical characteristics such as the level of intellectual disability and the presence of autism. This required adult services to duplicate assessment procedures that potentially delayed clinical outcomes. This study highlights that poor compliance may reflect inaccurate recording that needs addressing through training and introduction of shared protocols. Originality/value To the best of the authors’ knowledge, this is the first study to examine the transition process between children’s and adults’ intellectual disability health services using NICE quality standard 140.

Natural cycles underpin the very stuff of life. In this commentary we consider unnatural cycles: that is, anthropogenic activities which have a circularity, but whose nature is to have a detrimental effect on human health, exacerbating existing problems. Natural cycles have feedback loops, some of which have recently come to light, with an understanding that everything is connected in some way. In health, feedback loops are imperative in homeostatic mechanisms. However, in the unnatural cycle the feedback loops serve to reinforce (and in some cases amplify) negative problems. We offer a commentary on an unnatural cycle moving from air quality to lung function and back to air quality; we call this the lung disease unnatural cycle. We suggest where links occur, and where wider consideration of interactions between various disciplines can lead to breaking this unnatural (or vicious) cycle, changing it to a healthy cycle where individual health can be improved, along with better global scale outcomes. We suggest that many activities within this unnatural cycle occur within silos. However, the improved cycle incorporates joint activities at geological, health, and financial levels, to the mutual benefit of all, breaking the unnatural cycle, and improving health, life and financial costs.

SETTING: Nobel Medical College and Teaching Hospital, Biratnagar, Nepal. OBJECTIVE: To determine the pattern of antimicrobial resistance and hospital exit outcomes in neonates with suspected sepsis in a tertiary neonatal intensive care unit (NICU). DESIGN: This hospital-based cohort study was conducted to follow patients from January to December 2019. All identified cases of suspected sepsis were enlisted from hospital records. RESULTS: Sepsis was suspected in 177 (88%) of the 200 cases admitted in the NICU; 52 (29%) were culture-positive. Pseudomonas was the predominant organism isolated ( n = 40; 78%), followed by coagulase negative staphylococcus ( n = 12, 23%). Nine (17%) of the 52 isolates were resistant to the Access and Watch group of antibiotics, including some resistance to Reserve group drugs such as imipenem and linezolid. Most treated cases ( n = 170, 96%) improved, although 7 (4%) left against medical advice. CONCLUSION: Most of the pathogens were resistant to WHO Access and Watch antibiotics and occasional resistance was observed to Reserve group drugs. Most sepsis was caused by Gram-negative bacilli. Improving turnaround times for antibiotic sensitivity testing using point-of-care testing, and a greater yield of culture-positive results are needed to enhance the management of neonatal sepsis.