OBJECTIVES:To provide overview and understanding of the current challenges in assessing the cost-effectiveness of antimicrobial resistance (AMR) campaigns and highlight the main considerations for policy makers when evaluating existing and future evidence to inform decision making. STUDY DESIGN:Policy commentary. METHODS:A rapid review of cost-effectiveness analyses evaluating public AMR campaigns highlighted significant challenges with existing methodologies which were reviewed extensively in further literature searches to inform overview and commentary. RESULTS:Longstanding challenges in measuring clinical outcomes for use in economic evaluations and the methodologies available to health economists to evaluate public health campaigns were identified: Identifying and measuring appropriate outcomes, including broader societal impacts, capturing relevant outcomes which result over longer timescales, and accounting for the costs of AMR. These remain significant obstacles in assessing the true cost-effectiveness of interventions. CONCLUSIONS:Little methodological progress has been made in this area over the past 20 years, leaving policy makers in a difficult conundrum when justifying future investment in public campaigns to combat AMR. Evidence of high societal value placed on such interventions suggests future work to establish the cost-effectiveness of public AMR campaigns and support policy making are essential.

Hand, foot and mouth disease (HFMD) is a contagious communicable disease, with a high incidence in children aged under 10 years. It is a mainly self-limiting disease but can also cause serious neurological or cardiopulmonary complications in some cases, which can lead to death. Little is known about the burden of HMFD on primary care health care services in the UK. The aim of this work was to describe trends in general practitioner (GP) consultations for HFMD in England from January 2017 to December 2022 using a syndromic surveillance network of GPs. Daily GP consultations for HFMD in England were extracted from 1 January 2017 to 31 December 2022. Mean weekly consultation rates per 100,000 population and 95% confidence intervals (CI) were calculated. Consultation rates and rate ratios (RR) were calculated by age group and sex. During the study period, the mean weekly consultation rate for HFMD (per 100,000 registered GP patients) was 1.53 (range of 0.27 to 2.47). In England, children aged 1-4 years old accounted for the largest affected population followed by children <1 years old. We observed a seasonal pattern of HFMD incidence during the non-COVID years, with a seasonal peak of mean weekly rates between months of September and December. HFMD is typically diagnosed clinically rather than through laboratory sampling. Therefore, the ability to look at the daily HFMD consultation rates provides an excellent epidemiological overview on disease trends. The use of a novel GP-in-hours surveillance system allowed a unique epidemiological insight into the recent trends of general practitioner consultations for HFMD. We demonstrate a male predominance of cases, the impact of the non-pharmaceutical interventions during the COVID-19 pandemic, and a change in the week in which the peak number of cases happens post-pandemic.

Background: This review assessed the clinical-and cost-effectiveness of point-of-care tests to guide the initial management of people presenting with suspected acute respiratory infection. Methods: Searches for systematic reviews, randomised controlled trials and cost-utility studies were conducted in May 2023. Sources included MEDLINE, Epistemonikos, EMBASE, Cochrane Central Register of Controlled Trials, the Costeffectiveness Analysis Registry and reference checking. Eligible studies included people (>= 16 years) making initial contact with the health system with symptoms suggestive of acute respiratory infection. Risk of bias in randomised controlled trials was assessed using the Cochrane risk-of-bias tool. The Drummond checklist was used for cost-utility studies. Meta-analyses of clinical outcomes were conducted to estimate summary risk ratios with 95% confidence intervals. Study characteristics and main results were summarised narratively and tabulated. Results: Clinical effectiveness: Fourteen randomised controlled trials were included; all had a high risk of bias. Ten randomised controlled trials analysed point-of-care tests for C-reactive protein. Compared with usual care, the effects on hospital admissions and mortality were highly uncertain due to sparse data. Three randomised controlled trials had heterogeneous findings on the resolution of symptoms/time to full recovery. The risk of re-consultations increased in patients receiving C-reactive protein point-of-care tests (pooled risk ratio 1.61, 95% confidence interval 1.07 to 2.41; four studies). There was a reduction in antibiotics initially prescribed (C-reactive protein point-of-care tests vs. usual care: pooled risk ratio 0.75, 95% confidence interval 0.68 to 0.84; nine studies). The effects of procalcitonin point-of-care tests compared with usual care on hospital admission, escalation of care, and duration of symptoms were very uncertain as only one randomised controlled trial was included. The study found a large reduction in antibiotic prescriptions within 7 days. Two studies revealed a large reduction in initial antibiotic prescriptions for Group A streptococcus point-of-care tests versus usual care. Only one study compared an influenza point-of-care test with usual care. The effect of the antibiotics prescribed was very uncertain. No deaths occurred in either treatment group. Cost-effectiveness: Six of the 17 included cost-utility studies were judged to be directly applicable to our review, 4 of which focused on the C-reactive protein point-of-care test. The results suggested that the C-reactive protein point-of-care test is potentially cost-effective; these studies were generally limited to capturing only short-term costs and consequences. One study evaluated 14 different point-of-care tests for Group A streptococcus; none were cost-effective compared with usual care. A further study evaluated two rapid tests (Quidel for influenza [Quidel Corp, San Diego, CA, USA], and BinaxNOW [Binax, Inc., Portland, ME, USA]) for the pneumococcal antigen) compared to culture/serology and found that they were not cost-effective. Limitations: Rapid synthesis methods were used, so relevant studies may have been missed. No evidence was identified for several review questions. Conclusion: C-reactive protein point-of-care test may reduce the number of patients given an antibiotic prescription but could increase the rate of re-consultations. C-reactive protein point-of-care test may potentially be cost-effective but existing estimates were based on very small and uncertain gains in quality-adjusted life-years and only accounted for short-term costs and consequences. There was very limited or an absence of evidence for other point-of-care tests.

Syndromic surveillance now forms an integral part of the surveillance for a wide range of hazards in many countries. Establishing syndromic surveillance systems can be difficult due to the many different sources of data that can be used, cost pressures, the importance of data security, and the presence of different (and rapidly evolving) technologies. Here we describe major points in the development of the UK Health Security Agency English real-time syndromic surveillance service over its first 2 decades (1998 to 2018). We identify the key wider themes that we believe are important in ensuring a sustainable and useful syndromic surveillance service. We conducted semistructured interviews with current members of the UK Health Security Agency syndromic surveillance team who were involved from the earliest stages and previous senior colleagues who were supportive of the syndromic surveillance work during the early phases. For this viewpoint, we partitioned the development of syndromic surveillance in England into 3 time periods: 1998 to 2005 ("the beginnings"); 2006 to 2011 ("the growth phase"); and 2012 to 2018 ("mainstream"). We asked the interviewees for their views about the development of syndromic surveillance, and in particular the main drivers and events, the team and system, and outputs and uses. The results from the interviews highlighted some key themes including the integration of syndromic surveillance into the public health system, creativity, good collaboration and teamwork, leadership and determination to persevere, and agility and the ability to adapt to new threats. Using the results of the discussions and our personal experience of running the syndromic surveillance service from inception and over decades, we constructed a set of recommendations for establishing and running sustainable syndromic surveillance systems. In this age of increased automation, with the ability to transfer data in real-time and to use machine learning and artificial intelligence, we are approaching a "new age of syndromic surveillance." We consider that the focus on the public health questions, relationships, collaboration, leadership, and true teamwork should not be underestimated in the success of and usefulness of real-time syndromic surveillance systems.

INTRODUCTION:Asthma epidemics linked to thunderstorms (thunderstorm asthma; TSA) have been reported internationally for several decades. TSA can have severe impact on an individuals' health, resulting in severe outcomes, including death. TSA events can also put intense pressures on local health care services. OBJECTIVE:To describe changes in healthcare seeking behavior associated with a period of thunderstorm activity in England, June 2023, using routinely available health surveillance data. METHODS:Asthma and difficulty breathing-type presentations were analyzed from telehealth advice calls and emergency department attendances. RESULTS:This was the largest TSA event documented in England since the English syndromic surveillance programme was established over 25 years ago. The scale of the increase in asthma-type activity was above previously reported TSA events in England and activity coincided with forecasted storm alerts, both temporally and geographically. However, increases in asthma-type patient contacts were only observed around storm alerts occurring during periods of high pollen activity. Additionally, increases in asthma-type patient contacts during the TSA episode were not observed in young children (under 5 years) or older adults (65 years and over). CONCLUSION:This work supports the evidence of the health impact of TSA in England. It also particularly adds to the evidence base that pollen is a leading causal factor in TSA episodes in England. Further investigations into the spatiotemporal relationships between TSA, storm and pollen activity would help in the identification of drivers affecting different age groups, as well as to inform messaging to both healthcare professionals and the public regarding the timing of events and mitigation steps that may be taken.

BACKGROUND:During 2022, a new public health threat emerged when cases of paediatric acute hepatitis of unknown aetiology (HUA) were identified in children aged under 16 years old in the United Kingdom (UK). At the time, the epidemiology and extent of cases was based upon limited and non-standardised reporting from hospitals and liver units. We aimed to adapt existing real-time syndromic surveillance systems to support the epidemiological investigation of cases of HUA presenting to emergency departments (EDs) in England. METHODS:Syndromic surveillance is generally based on the collection of patient symptoms or chief complaints, which are collected using automated routines in near real-time. Here, we used an existing ED syndromic surveillance system monitoring daily patient attendances across a network of approximately 150 EDs in England. Clinical diagnosis codes related to the potential symptoms associated with the HUA incident were selected and attendance data monitored retrospectively and prospectively during the incident. RESULTS:From 2 April 2018 to 31 December 2021, there were small sporadic numbers of daily ED attendances for 'liver conditions' in children with no observed secular trends or seasonality across the 1 to 4 and 5 to 14 years age groups. The period 2 April to 29 July was compared across each year included in the analysis. Mean daily HUA attendances during 2018 to 2021 was 0.05 and 0.22 for 1 to 4 and 5 to 14 years respectively, however in 2022 there were 0.26 and 0.42 mean daily attendances. This represented an increase of 377% and 94% in the 1 to 4 and 5 to 14 years age groups, respectively. From June 2022, daily syndromic 'liver condition' attendances appeared to decrease and the rate of increase in cumulative attendances slowed. CONCLUSIONS:We demonstrate how syndromic surveillance provided support to the HUA outbreak using an existing syndromic surveillance framework to develop new indicators based on the newly emerging clinical symptoms. The outputs from the syndromic tool matched clinical and epidemiological findings with respect to trends in other HUA-related data, including clinical and laboratory reports, over time. This work demonstrates the potential for syndromic surveillance supporting the epidemiological surveillance of hepatitis and providing a valuable tool for the real-time management of future unknown health threats.

Background:This review assessed the clinical- and cost-effectiveness of point-of-care tests to guide the initial management of people presenting with suspected acute respiratory infection. Methods:Searches for systematic reviews, randomised controlled trials and cost-utility studies were conducted in May 2023. Sources included MEDLINE, Epistemonikos, EMBASE, Cochrane Central Register of Controlled Trials, the Cost-effectiveness Analysis Registry and reference checking. Eligible studies included people (≥ 16 years) making initial contact with the health system with symptoms suggestive of acute respiratory infection. Risk of bias in randomised controlled trials was assessed using the Cochrane risk-of-bias tool. The Drummond checklist was used for cost-utility studies. Meta-analyses of clinical outcomes were conducted to estimate summary risk ratios with 95% confidence intervals. Study characteristics and main results were summarised narratively and tabulated. Results:Fourteen randomised controlled trials were included; all had a high risk of bias. Ten randomised controlled trials analysed point-of-care tests for C-reactive protein. Compared with usual care, the effects on hospital admissions and mortality were highly uncertain due to sparse data. Three randomised controlled trials had heterogeneous findings on the resolution of symptoms/time to full recovery. The risk of re-consultations increased in patients receiving C-reactive protein point-of-care tests (pooled risk ratio 1.61, 95% confidence interval 1.07 to 2.41; four studies). There was a reduction in antibiotics initially prescribed (C-reactive protein point-of-care tests vs. usual care: pooled risk ratio 0.75, 95% confidence interval 0.68 to 0.84; nine studies). The effects of procalcitonin point-of-care tests compared with usual care on hospital admission, escalation of care, and duration of symptoms were very uncertain as only one randomised controlled trial was included. The study found a large reduction in antibiotic prescriptions within 7 days. Two studies revealed a large reduction in initial antibiotic prescriptions for Group A streptococcus point-of-care tests versus usual care. Only one study compared an influenza point-of-care test with usual care. The effect of the antibiotics prescribed was very uncertain. No deaths occurred in either treatment group. Cost-effectiveness:Six of the 17 included cost-utility studies were judged to be directly applicable to our review, 4 of which focused on the C-reactive protein point-of-care test. The results suggested that the C-reactive protein point-of-care test is potentially cost-effective; these studies were generally limited to capturing only short-term costs and consequences. One study evaluated 14 different point-of-care tests for Group A streptococcus; none were cost-effective compared with usual care. A further study evaluated two rapid tests (Quidel for influenza [Quidel Corp, San Diego, CA, USA], and BinaxNOW [Binax, Inc., Portland, ME, USA]) for the pneumococcal antigen) compared to culture/serology and found that they were not cost-effective. Limitations:Rapid synthesis methods were used, so relevant studies may have been missed. No evidence was identified for several review questions. Conclusion:C-reactive protein point-of-care test may reduce the number of patients given an antibiotic prescription but could increase the rate of re-consultations. C-reactive protein point-of-care test may potentially be cost-effective but existing estimates were based on very small and uncertain gains in quality-adjusted life-years and only accounted for short-term costs and consequences. There was very limited or an absence of evidence for other point-of-care tests. Future work:Research is needed to explore the impact of point-of-care tests on triaging decisions across different clinical settings and to quantify the longer-term health and cost consequences. Study registration:This study is registered as PROSPERO CRD42023429515. Funding:This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR159946) and is published in full in Health Technology Assessment; Vol. 29, No. 13. See the NIHR Funding and Awards website for further award information.

The purpose of syndromic surveillance is to provide early warning of public health incidents, real-time situational awareness during incidents and emergencies, and reassurance of the lack of impact on the population, particularly during mass gatherings. The United Kingdom Health Security Agency (UKHSA) currently coordinates a real-time syndromic surveillance service that encompasses 6 national syndromic surveillance systems reporting on daily health care usage across England. Each working day, UKHSA analyzes syndromic data from over 200,000 daily patient encounters with the National Health Service, monitoring over 140 unique syndromic indicators, risk assessing over 50 daily statistical exceedances, and taking and recommending public health action on these daily. This English syndromic surveillance service had its origins as a small exploratory pilot in a single region of England in 1999 involving a new pilot telehealth service, initially reporting only on “cold or flu” calls. This pilot showed the value of syndromic surveillance in England, providing advanced warning of the start of seasonal influenza activity over existing laboratory-based surveillance systems. Since this initial pilot, a program of real-time syndromic surveillance has evolved from the single-system, -region, -indicator pilot (using manual data transfer methods) to an all-hazard, multisystem, automated national service. The suite of systems now monitors a wide range of syndromes, from acute respiratory illness to diarrhea to cardiac conditions, and is widely used in routine public health surveillance and for monitoring seasonal respiratory disease and incidents such as the COVID-19 pandemic. Here, we describe the 25-year evolution of the English syndromic surveillance system, focusing on the expansion and improvements in data sources and data management, the technological and digital enablers, and novel methods of data analytics and visualization.

OBJECTIVES:To examine the accuracy and impact of artificial intelligence (AI) software assistance in lung cancer screening using CT. METHODS:A systematic review of CE-marked, AI-based software for automated detection and analysis of nodules in CT lung cancer screening was conducted. Multiple databases including Medline, Embase and Cochrane CENTRAL were searched from 2012 to March 2023. Primary research reporting test accuracy or impact on reading time or clinical management was included. QUADAS-2 and QUADAS-C were used to assess risk of bias. We undertook narrative synthesis. RESULTS:Eleven studies evaluating six different AI-based software and reporting on 19 770 patients were eligible. All were at high risk of bias with multiple applicability concerns. Compared with unaided reading, AI-assisted reading was faster and generally improved sensitivity (+5% to +20% for detecting/categorising actionable nodules; +3% to +15% for detecting/categorising malignant nodules), with lower specificity (-7% to -3% for correctly detecting/categorising people without actionable nodules; -8% to -6% for correctly detecting/categorising people without malignant nodules). AI assistance tended to increase the proportion of nodules allocated to higher risk categories. Assuming 0.5% cancer prevalence, these results would translate into additional 150-750 cancers detected per million people attending screening but lead to an additional 59 700 to 79 600 people attending screening without cancer receiving unnecessary CT surveillance. CONCLUSIONS:AI assistance in lung cancer screening may improve sensitivity but increases the number of false-positive results and unnecessary surveillance. Future research needs to increase the specificity of AI-assisted reading and minimise risk of bias and applicability concerns through improved study design. PROSPERO REGISTRATION NUMBER:CRD42021298449.

Since November 2023, the absolute number of attendances at emergency departments for pneumonia among children aged 5-14 years in England have been above expected levels for the time of year. This increased signal peaked during March 2024 but then persisted into early summer 2024 despite decreases in prevalence of seasonal respiratory pathogens. Record linkage between emergency department and laboratory databases points to this unusual activity being driven largely by Mycoplasma pneumoniae.

Background Prepandemic sentinel surveillance focused on improved management of winter pressures, with influenza-like illness (ILI) being the key clinical indicator. The World Health Organization (WHO) global standards for influenza surveillance include monitoring acute respiratory infection (ARI) and ILI. The WHO’s mosaic framework recommends that the surveillance strategies of countries include the virological monitoring of respiratory viruses with pandemic potential such as influenza. The Oxford-Royal College of General Practitioner Research and Surveillance Centre (RSC) in collaboration with the UK Health Security Agency (UKHSA) has provided sentinel surveillance since 1967, including virology since 1993. Objective We aim to describe the RSC’s plans for sentinel surveillance in the 2023-2024 season and evaluate these plans against the WHO mosaic framework. Methods Our approach, which includes patient and public involvement, contributes to surveillance objectives across all 3 domains of the mosaic framework. We will generate an ARI phenotype to enable reporting of this indicator in addition to ILI. These data will support UKHSA’s sentinel surveillance, including vaccine effectiveness and burden of disease studies. The panel of virology tests analyzed in UKHSA’s reference laboratory will remain unchanged, with additional plans for point-of-care testing, pneumococcus testing, and asymptomatic screening. Our sampling framework for serological surveillance will provide greater representativeness and more samples from younger people. We will create a biomedical resource that enables linkage between clinical data held in the RSC and virology data, including sequencing data, held by the UKHSA. We describe the governance framework for the RSC. Results We are co-designing our communication about data sharing and sampling, contextualized by the mosaic framework, with national and general practice patient and public involvement groups. We present our ARI digital phenotype and the key data RSC network members are requested to include in computerized medical records. We will share data with the UKHSA to report vaccine effectiveness for COVID-19 and influenza, assess the disease burden of respiratory syncytial virus, and perform syndromic surveillance. Virological surveillance will include COVID-19, influenza, respiratory syncytial virus, and other common respiratory viruses. We plan to pilot point-of-care testing for group A streptococcus, urine tests for pneumococcus, and asymptomatic testing. We will integrate test requests and results with the laboratory-computerized medical record system. A biomedical resource will enable research linking clinical data to virology data. The legal basis for the RSC’s pseudonymized data extract is The Health Service (Control of Patient Information) Regulations 2002, and all nonsurveillance uses require research ethics approval. Conclusions The RSC extended its surveillance activities to meet more but not all of the mosaic framework’s objectives. We have introduced an ARI indicator. We seek to expand our surveillance scope and could do more around transmissibility and the benefits and risks of nonvaccine therapies.

IntroductionAntimicrobial resistance (AMR) is a major public health threat. With the growing emphasis on patient-centred care/ shared decision making, it is important for healthcare professionals’ (HCPs) who prescribe, dispense, administer and/or monitor antimicrobials to be adequately equipped to facilitate appropriate antimicrobial use. We systematically identified existing interventions which aim to improve HCPs interaction with patients and examined barriers and facilitators of appropriate the use of such interventions and appropriate antimicrobial use among both HCPs and patientsantimicrobial use while using these interventions.MethodsWe searched MEDLINE, EMBASE, Web of Science, Google Scholar, and internet (via Google search engine). We included primary studies, published in English from 2010 to 2023 [PROSPERO (CRD42023395642)]. The protocol was preregistered with PROSPERO (CRD42023395642). We performed quality assessment using mixed methods appraisal tool. We applied narrative synthesis and used the COM-B (Capability, Opportunity, Motivation -Behaviour) as a theoretical framework for barriers and facilitators at HCP and patient levels.ResultsOf 9,172 citations retrieved from database searches, From 4,979 citations remained after removal of duplicates. We included 59 studies spanning over 13 countries. Interventions often involved multiple components beyond HCPs’ interaction with patients. From 24 studies reporting barriers and facilitators, we identified issues relating to capability (such as, knowledge/understanding about AMR, diagnostic uncertainties, awareness of interventions and forgetfulness); opportunity (such as, time constraint and intervention accessibility) and motivation (such as, patient’s desire for antibiotics and fear of litigation).ConclusionThe findings of this review should be considered by intervention designers/adopters and policy makers to improve utilisation and effectiveness.

BACKGROUND:Tackling the public health challenge of antimicrobial resistance (AMR) requires promotion of appropriate antimicrobial use by health-care professionals. The objective of this review was to identify interventions that facilitate appropriate antimicrobial behaviours when health-care professionals interact with patients and any considerations for factors associated with health inequalities. METHODS:For this systematic review, we searched electronic databases (MEDLINE, EMBASE, Web of Science and Google Scholar) from Jan 31, 2023, to Feb 8, 2023. We included search terms such as antimicrobial use/prescribing, health-care professionals, and AMR programmes. We included any relevant primary study published from year 2010 and in English. We conducted forward and backward citation searching from included studies on March 27, 2023. We extracted information on the interventions following the Template for Intervention Description and Replication (TIDieR) guideline and examined reports on how the interventions might impact on inequalities. We performed quality assessment using the Mixed Methods Appraisal Tool (MMAT). We conducted descriptive synthesis. The protocol is registered with PROSPERO (CRD42023395642). FINDINGS:After screening 4979 records, we included 59 studies. Most studies were randomised trials (n=25) and qualitative/mixed methods studies (n=16). Included studies covered 16 countries, particularly the UK (n=16) and the USA (n=13). Most studies (n=34) fulfilled at least 80% of the relevant quality criteria, but 12 studies fulfilled less than 50%. Many interventions were established strategies (eg, TARGET: Treat Antibiotics Responsibly, Guidance, Education and Tools). Patient interaction elements of the interventions often involved using education materials (eg, digital/paper leaflets, and videos) and point-of-care testing. While many studies (n=49) included participants from disadvantaged groups, only three examined how outcomes differ between groups. In those studies, antimicrobial prescription was not associated with age, sex, and level of learning disability. Some other studies reported issues with language barriers and potential digital exclusion, especially for older people. INTERPRETATION:We might have missed some relevant studies due to publication year and language restrictions. Notwithstanding, this review showed that the potential impact of factors associated with health inequalities are not routinely considered during the implementation and evaluation of interventions to improve health-care professionals' interaction with patients. Future work should routinely consider this to help mitigate potential inequalities. FUNDING:UK Health Security Agency.

OBJECTIVE:Countries routinely offering acellular pertussis vaccine, where long-term protection is not sustained, have the challenge of selecting an optimal schedule to minimise disease among young infants. We conducted a narrative systematic review and synthesis of information to evaluate different pertussis immunisation strategies at controlling pertussis disease, hospitalisation, deaths, and vaccine effectiveness among young infants.METHODS:We conducted a review of the literature on studies about the primary, booster, and/or maternal vaccination series and synthesised findings narratively. Countries offering the first three doses of vaccine within six-months of life and a booster on or before the second year or life were defined as accelerated primary and booster schedules, respectively. Countries offering primary and booster doses later were defined as extended primary and booster schedules. All search results were screened, and articles reviewed and reconciled, by two authors. The Risk of Bias in Non-randomised Studies of Intervention tool was used to evaluate the risk of bias.FINDINGS:A total of 98 studies were included in the analyses and the following recurring themes were described: timing of vaccination, vaccine coverage, waning immunity/vaccine effectiveness, direct and indirect effectiveness, switching from an accelerated to extended schedule, impact of changes in testing. The risk of bias was generally low to moderate for most studies.CONCLUSION:Comparing schedules is challenging and there was insufficient evidence to that one schedule was superior to another. Countries must select a schedule that maintains high vaccine coverage and reduced the risk of delaying the delivery vaccines to protect infants.

Seasonal peaks in infectious disease incidence put pressures on health services. Therefore, early warning of the timing and magnitude of peak activity during seasonal epidemics can provide information for public health practitioners to take appropriate action. Whilst many infectious diseases have predictable seasonality, newly emerging diseases and the impact of public health interventions can result in unprecedented seasonal activity. We propose a Machine Learning process for generating short-term forecasts, where models are selected based on their ability to correctly forecast peaks in activity, and can be useful during atypical seasons. We have validated our forecasts using typical and atypical seasonal activity, using respiratory syncytial virus (RSV) activity during 2019-2021 as an example. During the winter of 2020/21 the usual winter peak in RSV activity in England did not occur but was 'deferred' until the Spring of 2021. We compare a range of Machine Learning regression models, with alternate models including different independent variables, e.g. with or without seasonality or trend variables. We show that the best-fitting model which minimises daily forecast errors is not the best model for forecasting peaks when the selection criterion is based on peak timing and magnitude. Furthermore, we show that best-fitting models for typical seasons contain different variables to those for atypical seasons. Specifically, including seasonality in models improves performance during typical seasons but worsens it for the atypical seasons.

Chickenpox is a common childhood disease caused by varicella-zoster virus (VZV). VZV vaccination is not part of the UK childhood immunisation programme, but its potential inclusion is regularly assessed. It is therefore important to understand the ongoing burden of VZV in the community to inform vaccine policy decisions. General practitioner (GP) chickenpox consultations were studied from 1 September 2016 to 9 December 2022. Over the study period, the mean weekly chickenpox consultation rate per 100,000 population in England was 3.4, with a regular peak occurring between weeks 13 and 15. Overall, rates decreased over time, from a mean weekly rate of 5.5 in 2017 to 4.2 in 2019. The highest mean weekly rates were among children aged 1–4 years. There was no typical epidemic peak during the COVID-19 pandemic, but in 2022, rates were proportionally higher among children aged < 1 year old compared to pre-pandemic years. Chickenpox GP consultation rates decreased in England, continuing a longer-term decline in the community. The COVID-19 pandemic impacted rates, likely caused by the introduction of non-pharmaceutical interventions to prevent SARS-CoV-2 transmission. The lasting impact of the interruption of typical disease transmission remains to be seen, but it is important to monitor the chickenpox burden to inform decisions on vaccine programmes.

Thunderstorm asthma is often characterised by a sudden surge in patients presenting with exacerbated symptoms of asthma linked to thunderstorm activity. Here, we describe a large spike in asthma and difficulty breathing symptoms observed across parts of England on 17 June 2021. The number of healthcare presentations during the asthma event was compared to expected levels for the overall population and across specific regions. Across affected geographical areas, emergency department attendances for asthma increased by 560% on 17 June compared to the average number of weekday daily attendances during the previous 4 weeks. General practitioner out of hours contacts increased by 349%, National Health Service (NHS) 111 calls 193%, NHS 111 online assessments 581% and ambulance call outs 54%. Increases were particularly noted in patient age groups 5–14 and 15–44 years. In non-affected regions, increases were small (<10%) or decreased, except for NHS 111 online assessments where there was an increase of 39%. A review of the meteorological conditions showed several localised, weak, or moderate thunderstorms specifically across parts of Southeast England on the night of June 16. In this unprecedented episode of asthma, the links to meteorologically defined thunderstorm activity were not as clear as previous episodes, with less evidence of ‘severe’ thunderstorm activity in those areas affected, prompting further discussion about the causes of these events and implications for public health management of the risk.

OBJECTIVE To examine the accuracy of artificial intelligence (AI) for the detection of breast cancer in mammography screening practice. DESIGN Systematic review of test accuracy studies. DATA SOURCES Medline, Embase, Web of Science, and Cochrane Database of Systematic Reviews from 1 January 2010 to 17 May 2021. ELIGIBILITY CRITERIA Studies reporting test accuracy of AI algorithms, alone or in combination with radiologists, to detect cancer in women's digital mammograms in screening practice, or in test sets. Reference standard was biopsy with histology or follow-up (for screen negative women). Outcomes included test accuracy and cancer type detected. STUDY SELECTION AND SYNTHESIS Two reviewers independently assessed articles for inclusion and assessed the methodological quality of included studies using the QUality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. A single reviewer extracted data, which were checked by a second reviewer. Narrative data synthesis was performed. RESULTS Twelve studies totalling 131 822 screened women were included. No prospective studies measuring test accuracy of AI in screening practice were found. Studies were of poor methodological quality. Three retrospective studies compared AI systems with the clinical decisions of the original radiologist, including 79 910 women, of whom 1878 had screen detected cancer or interval cancer within 12 months of screening. Thirty four (94%) of 36 AI systems evaluated in these studies were less accurate than a single radiologist, and all were less accurate than consensus of two or more radiologists. Five smaller studies (1086 women, 520 cancers) at high risk of bias and low generalisability to the clinical context reported that all five evaluated AI systems (as standalone to replace radiologist or as a reader aid) were more accurate than a single radiologist reading a test set in the laboratory. In three studies, AI used for triage screened out 53%, 45%, and 50% of women at low risk but also 10%, 4%, and 0% of cancers detected by radiologists. CONCLUSIONS Current evidence for AI does not yet allow judgement of its accuracy in breast cancer screening programmes, and it is unclear where on the clinical pathway AI might be of most benefit. AI systems are not sufficiently specific to replace radiologist double reading in screening programmes. Promising results in smaller studies are not replicated in larger studies. Prospective studies are required to measure the effect of AI in clinical practice. Such studies will require clear stopping rules to ensure that AI does not reduce programme specificity. STUDY REGISTRATION Protocol registered as PROSPERO CRD42020213590.

BACKGROUND:Benzodiazepines and Z-drugs (such as zopiclone) are widely prescribed in primary care. Given their association with addiction and dependence, understanding where and for whom these medications are being prescribed is a necessary step in addressing potentially harmful prescribing.OBJECTIVE:To determine whether there is an association between primary care practice benzodiazepine and Z-drug prescribing and practice population socioeconomic status in England.METHODS:This was a cross-sectional study. An aggregated data set was created to include primary care prescribing data for 2017, practice age and sex profiles and practice Index of Multiple Deprivation (IMD) scores-a marker of socioeconomic status. Drug doses were converted to their milligram-equivalent of diazepam to allow comparison. Multiple linear regression was used to examine the association between IMD and prescribing (for all benzodiazepines and Z-drugs in total, and individually), adjusting for practice sex (% male) and older age (>65 years) distribution (%).RESULTS:Benzodiazepine and Z-drug prescribing overall was positively associated with practice-level IMD score, with more prescribing in practices with more underserved patients, after adjusting for age and sex (P < 0.001), although the strength of the association varied by individual drug. Overall, however, IMD score, age and sex only explained a small proportion of the overall variation in prescribing across GP practices.CONCLUSION:Our findings may, in part, be a reflection of an underlying association between the indications for benzodiazepine and Z-drug prescribing and socioeconomic status. Further work is required to more accurately define the major contributors of prescribing variation.

In January 2015, Public Health England and the United Kingdom (UK) Ministry of Defence investigated cases of diarrhoea and fever in military personnel recently returned to the UK after supporting the response to the Ebola epidemic in Sierra Leone. Tests for Ebola virus infection were negative. PCR tests detected the ipaH gene in 10/12 faecal specimens, and Shigella boydii serotype 20 was isolated from 7 patients. A case control study was undertaken and analysed using multivariable logistic regression. Consumption of a coronation chicken lunch at the transit camp in Sierra Leone (SL) 24-48 h prior to departure for the UK was significantly associated with disease [adjusted odds ratio (OR) 28.15, 95% CI: 1.87-422.65]. In the context of heightened concern during the Ebola epidemic, this outbreak highlights the importance of rapid and effective microbiological and epidemiological investigations to identify the aetiological agent in patients presenting with fever and diarrhoea.