Abstract Background Group A Streptococcus (GAS) outbreaks in care homes lead to significant morbidity among residents. In 2025, 36 iGAS care home outbreaks were reported in England, throat swabs for culture were collected in 56% of these. Lateral flow devices (LFDs) offer rapid GAS detection for prompt initiation of control measures. LFD sensitivity and specificity for detecting asymptomatic carriage is unknown. Objectives We aimed to test feasibility and methodology to evaluate the diagnostic accuracy and acceptability of LFDs in GAS care home outbreaks. Methods We took throat swabs for LFD and culture from staff and residents, as directed by the incident management team for an iGAS outbreak in a care home. We compared the diagnostic accuracy of LFDs (index test) to culture (reference standard). We asked staff about acceptability and recorded result turn-around time and operational feasibility. LFD results weren’t shared outside the study team. Results We recruited 80 residents and staff. Amongst those approached, the uptake rate was 97.5% overall, 98% for staff (60/61) and 95% for residents (20/21). Individual results were available within 5 minutes for LFDs and between 2-4 days (median 3) for culture. All LFD and culture results were concordant and negative. Based on 80 culture negative participants, specificity is estimated at 100% (95.4%-100%) in this setting. Amongst healthcare staff, 96% (46/48) would hypothetically be willing to perform an LFD self-test and 85% (41/48)​ on residents; 98% (47/48) would feel confident hypothetically reading the result of an LFD. Conclusions GAS LFDs are likely to be highly specific; we report an estimate with a relatively few non-infected participants and cannot estimate sensitivity. GAS LFDs provide results substantially quicker than culture and are highly acceptable to staff within a care home setting. A full prospective evaluation of LFD use in care homes is needed to inform management of GAS outbreaks in care homes.

An unusually large outbreak of invasive meningococcal disease affecting young adults occurred in South East England between 13 and 18 March 2026, with 21 confirmed cases including two fatalities. Thirteen cases were university students and 19 had attended the same nightclub over a 3-day period. The outbreak strain was a distinct genome within the previously seen type B: P1.12-1,16-183: F1-5: ST-485 (cc41/44). Over 13,000 chemoprophylaxis doses and 11,000 meningococcal B vaccinations were provided to possible contacts.

Umbrella protocols have recently come to be widely used in clinical trial designs. However, the value of this approach in public health is less well recognized. The coronavirus disease 2019 (COVID-19) pandemic highlighted the need for rapid, reliable and scalable evaluation of diagnostic technologies. In the United Kingdom of Great Britain and Northern Ireland, this need prompted the development of an umbrella research protocol enabling multiple clinical evaluation studies of similar designs to be undertaken under a single overarching preapproved ethics and governance framework. We describe the development, implementation and evolution of this protocol, which was designed to support timely assessment of the performance of in vitro diagnostic devices and associated testing approaches in various settings. The umbrella protocol allowed studies to be started quickly during the pandemic, reduced administrative burdens, supported regulatory submissions and enabled prospective collection of samples for surveillance. While the system described reflects British governance structures, the principles underpinning this approach, including proportionality (ensuring oversight requirements are appropriate to the risk level), standardization and preapproved flexibility, are applicable to many settings. The protocol now forms part of the United Kingdom's wider pandemic preparedness structure and illustrates how preapproved, adaptable research frameworks can accelerate evidence generation during outbreaks. The world is now assessing lessons from the COVID-19 pandemic and it is timely to consider how research systems can support innovative designs such as umbrella protocols. We therefore summarize lessons learnt and practical considerations to support other countries seeking to adopt similar approaches within their own ethical and regulatory systems.

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.

We aimed to estimate the secondary attack rate of mpox among UK household contacts and determine factors associated with transmission to inform public health management of contacts, during the global outbreak in 2022. Information was collected via NHS and public health services and included age, gender, place of residence, setting, and type of contact. Aggregate information was summarized for the UK. Record level data was combined for England, Wales and Northern Ireland, and multivariable logistic regression was used to determine factors associated with transmission. The secondary attack rate among UK household mpox contacts was 4% (60/1 526). Sexual contact with the index case was associated with a 11-fold increase in adjusted odds of becoming a case in England, Wales, and Northern Ireland (95% CI 5.5-22, p < 0.001). Household contacts outside of London had increased odds compared to London residents (adjusted OR 2.9, 95%CI 1.6-5.4, p < 0.001), while female contacts had reduced odds of becoming a case (aOR: 0.41, 95% CI: 0.15-0.95). We found a low overall secondary attack rate among household mpox contacts with strong evidence of increased transmission risk associated with sexual contact. This evidence will inform the risk assessment of contacts and support prioritization of those with close intimate contact for follow up.

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.

Contact tracing was used globally to prevent onwards transmission of COVID-19. Tracing contacts alone is unlikely to be sufficient in controlling community transmission, due to the pre-symptomatic, overdispersed and airborne nature of COVID-19 transmission. We describe and demonstrate the validity of a national enhanced contact tracing programme for COVID-19 cluster surveillance in England. Data on cases occurring between October 2020 and September 2021 were extracted from the national contact tracing system. Exposure clusters were identified algorithmically by matching ≥2 cases attending the same event, identified by matching postcode and event category within a 7-day rolling window. Genetic validity was defined as exposure clusters with ≥2 cases from different households with identical viral sequences. Exposure clusters were fuzzy matched to the national incident management system (HPZone) by postcode and setting description. Multivariable logistic regression modelling was used to determine cluster characteristics associated with genetic validity. Over a quarter of a million (269,470) exposure clusters were identified. Of the eligible clusters, 25% (3,306/13,008) were genetically valid. 81% (2684/3306) of these were not recorded on HPZone and were identified on average of one day earlier than incidents recorded on HPZone. Multivariable analysis demonstrated that exposure clusters occurring in workplaces (aOR = 5·10, 95% CI 4·23-6·17) and education (aOR = 3·72, 95% CI 3·08-4·49) settings were those most strongly associated with genetic validity. Cluster surveillance using enhanced contact tracing in England was a timely, comprehensive and systematic approach to the detection of transmission events occurring in community settings. Cluster surveillance can provide intelligence to stakeholders to support the assessment and management of clusters of COVID-19 at a local, regional, and national level. Future systems should include predictive modelling and network analysis to support risk assessment of exposure clusters to improve the effectiveness of enhanced contract tracing for outbreak detection.

Background It is not yet fully understood to what extent in-flight transmission contributed to the spread of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). This study aimed to determine the occurrence and extent of SARS-CoV-2 transmission in-flight and assess factors associated with transmission risk to inform future control strategies. Methods Retrospective cohort study using data obtained from contact tracing of international flights arriving in England between 02/08/2021–15/10/2021. Transmission risk was estimated by calculating the secondary attack rate (SAR). Univariable and multivariable analyses of the SAR by specific risk factors was undertaken, including: number of in-flight index cases; number of symptomatic index cases; contact vaccination status; flight duration; proximity to the index case(s); contact age. Results 11,307 index cases linked to 667,849 contacts with 5,289 secondary cases reported. In-flight SAR was 0.79% (95% CI: 0.77–0.81). Increasing numbers of symptomatic cases (when > 4 index cases compared to one index case aOR 1.85; 95% CI: 1.40–2.44) and seating proximity to an index case (seated within compared to outside of two rows OR 1.82; 95% CI: 1.50–2.22) were associated with increased risk of secondary cases. Full vaccination history was protective (aOR 0.52; 95% CI: 0.47–0.57). Conclusions This study confirms that in-flight transmission of SARS-CoV-2 occurred. There are factors associated with increased risk of infection. Contact tracing identified exposed persons who subsequently developed infection. A targeted approach to contact tracing passengers with the highest exposure risk could be an effective use of limited public health resources.

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Abstract Background Following removal of non-pharmaceutical interventions (NPI) to restrict SARS-CoV-2 transmission in England, large increases above seasonally expected levels of group A streptococcal (GAS) infections and associated deaths were seen, particularly in children, during 2022. Methods Nationwide data from UK Health Security Agency surveillance databases were extracted, including statutory clinical notifications of scarlet fever and laboratory-confirmed invasive GAS infections (iGAS; sterile-site specimens). Analyses compared infection and mortality rates in England for the pre-COVID-19 pandemic (2017-2019), pandemic-NPI (2020-2021), and post removal of COVID-19 NPI (post-NPI; 2022-2023) periods. Results Pre-pandemic, a mean of 2481 iGAS cases (range 2138-2921; 13%-14% < 15y; Figure) per-year were recorded in England (4.4/100,000 population; 95% confidence interval (CI):4.3-4.6). Case numbers fell markedly during the pandemic-NPI period, 1462 iGAS cases in 2020 (2.6/100,000; 7% aged < 15y) and 829 in 2021 (1.5/100,000; 6% < 15y; Figure). Post-NPI cessation, iGAS cases increased to 2892 (5.1/10,000; 24% < 15y) in 2022, remaining high into Jan-Mar 2023 (1361; 21% < 15y). Scarlet fever diagnoses similarly increased, with 54,630 (91.6/100,000; CI: 90.8-92.4) notified in 2022 (England & Wales), the highest number since 1953. In 2022, 339 deaths (< 7d iGAS diagnosis) were reported (case-fatality rate (CFR) 11.7%; CI:10.6-13.0%; 16% deaths were aged < 15y), compared to 214-335 per-year pre-pandemic (8%-10% in < 15y) and 88 in 2021 (6%< 15y). Respiratory virus co-infections were identified in 19% iGAS aged < 15y during 2022, CFR: 19.8%. Post-NPI cessation, strain typing identified increasing dominance of emm1 and emm12 (all ages: 35% and 18%) in 2022, compared with 3% and 2% in pandemic-NPI and 23% and 6% pre-pandemic (all-ages). Conclusion iGAS presentations showed a marked rebound in 2022, most notably in children, with re-emergence of emm1. The rapid, steep increase in morbidity was possibly driven by increased opportunities for exposure and sub-optimal immunity following COVID-19 NPI. Disclosures All Authors: No reported disclosures

Objective In September 2020, 15 861 SARS-CoV-2 case records failed to upload from the Second Generation Surveillance System (SGSS) to the Contact Tracing Advisory Service (CTAS) tool, delaying the contact tracing of these cases. This study used CTAS data to determine the impact of this delay on population health outcomes: transmission events, hospitalisations and mortality. Previously, a modelling study suggested a substantial impact.Design Observational study.Setting England.Population Individuals testing positive for SARS-CoV-2 and their reported contacts.Main outcome measures Secondary attack rates (SARs), hospitalisations and deaths among primary and secondary contacts were calculated, compared with all other concurrent, unaffected cases. Affected SGSS records were matched to CTAS records. Successive contacts and cases were identified and matched to hospital episode and mortality outcomes.Results Initiation of contact tracing was delayed by 3 days on average in the primary cases in the delay group (6 days) compared with the control group (3 days). This was associated with lower completion of contact tracing: 80% (95% CI: 79% to 81%) in delay group and 83% (95% CI: 83% to 84%) in control group. There was some evidence to suggest increased transmission to non-household contacts among those affected by the delay. The SAR for non-household contacts was higher among secondary contacts in the delay group than the control group (delay group: 7.9%, 95% CI: 6.5% to 9.2%; control group: 5.9%, 95% CI: 5.3% to 6.6%). There did not appear to be a significant difference between the delay and control groups in the odds of hospitalisation (crude OR: 1.1 (95% CI: 0.9 to 1.2)) or death (crude OR: 0.7 (95% CI: 0.1 to 4.0)) among secondary contacts.Conclusions Our analysis suggests that the delay in contact tracing had a limited impact on population health outcomes; however, contact tracing was not completed for all individuals, so some transmission events might not be captured.

BackgroundHouseholds appear to be the highest risk setting for COVID-19 transmission. Large household transmission studies in the early stages of the pandemic in Asia reported secondary attack rates ranging from 5 to 30%.AimWe aimed to investigate the transmission dynamics of COVID-19 in household and community settings in the UK.MethodsA prospective case-ascertained study design based on the World Health Organization FFX protocol was undertaken in the UK following the detection of the first case in late January 2020. Household contacts of cases were followed using enhanced surveillance forms to establish whether they developed symptoms of COVID-19, became confirmed cases and their outcomes. We estimated household secondary attack rates (SAR), serial intervals and individual and household basic reproduction numbers. The incubation period was estimated using known point source exposures that resulted in secondary cases.ResultsWe included 233 households with two or more people with 472 contacts. The overall household SAR was 37% (95% CI: 31-43%) with a mean serial interval of 4.67 days, an R0 of 1.85 and a household reproduction number of 2.33. SAR were lower in larger households and highest when the primary case was younger than 18 years. We estimated a mean incubation period of around 4.5 days.ConclusionsRates of COVID-19 household transmission were high in the UK for ages above and under 18 years, emphasising the need for preventative measures in this setting. This study highlights the importance of the FFX protocol in providing early insights on transmission dynamics.

Objective In September 2020, records of 15,861 SARS-CoV-2 cases failed to upload from the Second Generation Laboratory Surveillance System (SGSS) to the Contact Tracing Advisory Service (CTAS) tool, resulting in a delay in the contact tracing of these cases. This study used CTAS data to determine the impact of this delay on health outcomes: transmission events, hospitalisations, and mortality. Previously, a modelling study had suggested a substantial impact.Design Observational studySetting England.Population Individuals testing positive for SARS-CoV-2 and their reported contacts.Main outcome measures Secondary attack rates (SARs), hospitalisations, and deaths amongst primary and secondary contacts were calculated, compared to all other concurrent, unaffected cases. SGSS records affected by the event were matched to CTAS records and successive contacts and cases were identified.Results The initiation of contact tracing was delayed by 3 days on average in the primary cases in the delay group (6 days) compared to the control group (3 days). This was associated with lower completion of contact tracing of primary cases in the delay group: 80% (95%CI: 79-81%) in the delay group and 83% (95%CI: 83-84%) in the control group. There was some evidence to suggest an increase in transmission to non-household contacts amongst those affected by the delay. The SAR for non-household contacts was higher amongst secondary contacts in the delay group than the control group (delay group: 7.9%, 95%CI:6.4% to 9.2%; control group: 5.9%, 95%CI: 5.3% to 6.6%). There was no evidence of a difference between the delay and control groups in the odds of hospitalisation (crude odds ratio: 1.1 (95%CI: 0.9 to 1.2) or death (crude odds ratio: 0.7 (0.1 to 4.0)) amongst secondary contacts.Conclusions The delay in contact tracing had a limited impact on population health outcomes.Strengths and limitations of the study ### Competing Interest StatementThe authors have declared no competing interest.### Funding StatementThe authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. LF, LP, AC, MH, and IO acknowledge support from the NIHR Health Protection Research Unit in Behavioural Science and Evaluation at University of Bristol. PS was funded by the NIHR Programme Grants for Applied Research programme (grant RP-PG-0616-20008). SS was funded by UKRI (grant MC\_UU\_00002/10) and UKHSA. For the purpose of open access, the author has applied a Creative Commons Attribution (CC BY) licence to any Author Accepted Manuscript version arising.### Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:The Research Ethics and Governance Group (REGG) of Public Health England (PHE) (now UK Health Security Agency (UKHSA)) gave ethical approval for this work. R&D reference: R&D 431.I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesThe data that support this study were collected as part of a public health response and are considered sensitive and not made publicly available. Reasonable requests for access to anonymised data and data dictionary will be considered by the authors on request.

Between 7 and 25 May, 86 monkeypox cases were confirmed in the United Kingdom (UK). Only one case is known to have travelled to a monkeypox virus (MPXV) endemic country. Seventy-nine cases with information were male and 66 reported being gay, bisexual, or other men who have sex with men. This is the first reported sustained MPXV transmission in the UK, with human-to-human transmission through close contacts, including in sexual networks. Improving case ascertainment and onward-transmission preventive measures are ongoing.

After community transmission of monkeypox virus was identified in Europe, interviews of 45 case-patients from England indicated transmission in international sexual networks of gay and bisexual men since April 2022. Interventions targeting sex-on-premises venues, geospatial dating applications, and sexual health services are likely to be critical for outbreak control.

Background: Identifying areas that pose the greatest risk for community transmission of COVID-19 is essential to direct public health action and allow safe re-opening of society. Spread of B.1.1.7 (alpha) lineage provided a unique opportunity to quantify COVID-19 transmission risk associated with community settings in England 2020/21. Methods: All cases of COVID-19 occurring between 11/2020 and 01/2021 reported through the English national contact tracing system included. Recruitment occurred when B.1.1.7 regional prevalence was between 20-80%. Case groups were defined as: >2 cases reporting the same, location and attendance date 7-3 days before onset. Genetic concordance, presence/absence of S-gene target failure (SGTF) in grouped cases, was determined. Odds ratios for concordance and 95% confidence intervals were calculated. Sensitivity analysis compared concordance in single to 2-3 day case groups. Findings: There were 41,325 case groups with SGTF data containing 115,410 exposure events. Odds ratios ranged from 1.87 (95% CI:1.76-1.98) for shops, 29.9 (95% CI:23.1-38.7), nursery/preschool and 35.6 (95% CI:19.7-64.2) for visiting friends/relatives. Odds ratios of concordance increased with larger cluster sizes in educational settings. Concordance estimates were reduced when case grouping time period was increased from 1 to 2-3 days. Interpretation: Transmission risk varies across community settings, likely due to different behavioural or environmental factors. Risk does not capture number of users which also affects impact of settings on transmission. Limited data for certain settings due to non-pharmaceutical interventions in place. We recommend data are used to guide policy and prioritise action when assessing and managing COVID-19 community case clusters. Funding: EB funded by EMBL. No additional funding.Declaration of Interest: None to declare

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.