Changes in children’s contact patterns between termtime and school holidays affect the transmission of several respiratory-spread infections. Transmission of varicella zoster virus (VZV), the causative agent of chickenpox, has also been linked to the school calendar in several settings, but temporal changes in the proportion of young children attending childcare centres may have influenced this relationship.
We used two modelling methods (a simple difference equations model and a Time series Susceptible Infectious Recovered (TSIR) model) to estimate fortnightly values of a contact parameter (the per capita rate of effective contact between two specific individuals), using GP consultation data for chickenpox in England and Wales from 1967–2008.
The estimated contact parameters were 22–31% lower during the summer holiday than during termtime. The relationship between the contact parameter and the school calendar did not change markedly over the years analysed.
In England and Wales, reductions in contact between children during the school summer holiday lead to a reduction in the transmission of VZV. These estimates are relevant for predicting how closing schools and nurseries may affect an outbreak of an emerging respiratory-spread pathogen.
School closure is a potential intervention during an influenza pandemic and has been investigated in many modelling studies.
To systematically review the effects of school closure on influenza outbreaks as predicted by simulation studies.
We searched Medline and Embase for relevant modelling studies published by the end of October 2012, and handsearched key journals. We summarised the predicted effects of school closure on the peak and cumulative attack rates and the duration of the epidemic. We investigated how these predictions depended on the basic reproduction number, the timing and duration of closure and the assumed effects of school closures on contact patterns.
School closures were usually predicted to be most effective if they caused large reductions in contact, if transmissibility was low (e.g. a basic reproduction number <2), and if attack rates were higher in children than in adults. The cumulative attack rate was expected to change less than the peak, but quantitative predictions varied (e.g. reductions in the peak were frequently 20–60% but some studies predicted >90% reductions or even increases under certain assumptions). This partly reflected differences in model assumptions, such as those regarding population contact patterns.
Simulation studies suggest that school closure can be a useful control measure during an influenza pandemic, particularly for reducing peak demand on health services. However, it is difficult to accurately quantify the likely benefits. Further studies of the effects of reactive school closures on contact patterns are needed to improve the accuracy of model predictions.
Estimates of the effectiveness of influenza vaccines in older adults may be biased because of difficulties identifying and adjusting for confounders of the vaccine-outcome association. We estimated vaccine effectiveness for prevention of serious influenza complications among older persons by using methods to account for underlying differences in risk for these complications.
We conducted a retrospective cohort study among Ontario residents aged ≥65 years from September 1993 through September 2008. We linked weekly vaccination, hospitalization, and death records for 1.4 million community-dwelling persons aged ≥65 years. Vaccine effectiveness was estimated by comparing ratios of outcome rates during weeks of high versus low influenza activity (defined by viral surveillance data) among vaccinated and unvaccinated subjects by using log-linear regression models that accounted for temperature and time trends with natural spline functions. Effectiveness was estimated for three influenza-associated outcomes: all-cause deaths, deaths occurring within 30 days of pneumonia/influenza hospitalizations, and pneumonia/influenza hospitalizations.
During weeks when 5% of respiratory specimens tested positive for influenza A, vaccine effectiveness among persons aged ≥65 years was 22% (95% confidence interval [CI], −6%–42%) for all influenza-associated deaths, 25% (95% CI, 13%–37%) for deaths occurring within 30 days after an influenza-associated pneumonia/influenza hospitalization, and 19% (95% CI, 4%–31%) for influenza-associated pneumonia/influenza hospitalizations. Because small proportions of deaths, deaths after pneumonia/influenza hospitalizations, and pneumonia/influenza hospitalizations were associated with influenza virus circulation, we estimated that vaccination prevented 1.6%, 4.8%, and 4.1% of these outcomes, respectively.
By using confounding-reducing techniques with 15 years of provincial-level data including vaccination and health outcomes, we estimated that influenza vaccination prevented ∼4% of influenza-associated hospitalizations and deaths occurring after hospitalizations among older adults in Ontario.
To investigate the impact on mortality due to pneumonia or influenza of the change from risk-based to age group-based targeting of the elderly for yearly influenza vaccination in England and Wales.
Excess mortality estimated using time series of deaths registered to pneumonia or influenza, accounting for seasonality, trend and artefacts. Non-excess mortality plotted as proxy for long-term trend in mortality.
England and Wales.
Persons aged 65–74 and 75+ years whose deaths were registered to underlying pneumonia or influenza between 1975/1976 and 2004/2005.
Multiplicative effect on average excess pneumonia and influenza deaths each winter in the 4–6 winters since age group-based targeting of vaccination was introduced (in persons aged 75+ years from 1998/1999; in persons aged 65+ years from 2000/2001), estimated using multivariable regression adjusted for temperature, antigenic drift and vaccine mismatch, and stratified by dominant circulating influenza subtype. Trend in baseline weekly pneumonia and influenza death rates.
There is a suggestion of lower average excess mortality in the six winters after age group-based targeting began compared to before, but the CI for the 65–74 years age group includes no difference. Trend in baseline pneumonia and influenza mortality shows an apparent downward turning point around 2000 for the 65–74 years age group and from the mid-1990s in the 75+ years age group.
There is weakly supportive evidence that the marked increases in vaccine coverage accompanying the switch from risk-based to age group-based targeting of the elderly for yearly influenza vaccination in England and Wales were associated with lower levels of pneumonia and influenza mortality in older people in the first 6 years after age group-based targeting began. The possible impact of these policy changes is observed as weak evidence for lower average excess mortality as well as a turning point in baseline mortality coincident with the changes.
Influenza; Mortality; Mass Vaccination; Aged; Trends
To review the effects of school closures on pandemic and seasonal influenza outbreaks.
MEDLINE and EMBASE, reference lists of identified articles, hand searches of key journals and additional papers from the authors' collections.
Studies were included if they reported on a seasonal or pandemic influenza outbreak coinciding with a planned or unplanned school closure.
Of 2579 papers identified through MEDLINE and EMBASE, 65 were eligible for inclusion in the review along with 14 identified from other sources. Influenza incidence frequently declined after school closure. The effect was sometimes reversed when schools reopened, supporting a causal role for school closure in reducing incidence. Any benefits associated with school closure appeared to be greatest among school-aged children. However, as schools often closed late in the outbreak or other interventions were used concurrently, it was sometimes unclear how much school closure contributed to the reductions in incidence.
School closures appear to have the potential to reduce influenza transmission, but the heterogeneity in the data available means that the optimum strategy (eg, the ideal length and timing of closure) remains unclear.
Epidemiology; Public Health; Systematic Reviews
Assess the current BCG vaccination policies and delivery pathways for immunisation in Primary Care Trusts (PCTs) in England since the 2005 change in recommendations.
A survey of key informants across PCTs using a standardised, structured questionnaire.
152 PCTs in England.
Complete questionnaires were returned from 127 (84%) PCTs. Sixteen (27%) PCTs reported universal infant vaccination and 111 (73%) had selective infant vaccination. Selective vaccination outside infancy was also reported from 94 (74%) PCTs. PCTs with selective infant policy most frequently vaccinated on postnatal wards (51/102, 50%), whereas PCTs with universal infant vaccination most frequently vaccinated in community clinics (9/13, 69%; p=0.011). To identify and flag up eligible infants in PCTs with targeted infant immunisation, those who mostly vaccinate on postnatal wards depend on midwives and maternity records, whereas those who vaccinate primarily in the community rely more often on various healthcare professionals.
Targeted infant vaccination has been implemented in most PCTs across the UK. PCTs with selective infant vaccination provide BCG vaccine via a greater variety of healthcare professionals than those with universal infant vaccination policies. Data on vaccine coverage would help evaluate the effectiveness of delivery. Interruptions of delivery noted here emphasise the importance of not just an agreed, standardised, local pathway, but also a named person in charge.
Wet markets are common in many parts of the world and may promote the emergence, spread and maintenance of livestock pathogens, including zoonoses. A survey was conducted in order to assess the potential of Vietnamese and Cambodian live bird markets (LBMs) to sustain circulation of highly pathogenic avian influenza virus subtype H5N1 (HPAIV H5N1). Thirty Vietnamese and 8 Cambodian LBMs were visited, and structured interviews were conducted with the market managers and 561 Vietnamese and 84 Cambodian traders. Multivariate and cluster analysis were used to construct a typology of traders based on their poultry management practices. As a result of those practices and large poultry surplus (unsold poultry reoffered for sale the following day), some poultry traders were shown to promote conditions favorable for perpetuating HPAIV H5N1 in LBMs. More than 80% of these traders operated in LBMs located in the most densely populated areas, Ha Noi and Phnom Penh. The profiles of sellers operating at a given LBM could be reliably predicted using basic information about the location and type of market. Consequently, LBMs with the largest combination of risk factors for becoming virus reservoirs could be easily identified, potentially allowing control strategies to be appropriately targeted. These findings are of particular relevance to resource-scarce settings with extensively developed LBM systems, commonly found in South-East Asia.
To determine how school closure for pandemic (H1N1) 2009 affected students’ contact patterns, we conducted a retrospective questionnaire survey at a UK school 2 weeks after the school reopened. School closure was associated with a 65% reduction in the mean total number of contacts for each student.
Disease outbreaks; influenza; human; social behavior; schools; Great Britain; school closures; viruses; expedite; dispatch
The transmissibility of the strain of influenza virus which caused the 1968 influenza pandemic is poorly understood. Increases in outbreak size between the first and second waves suggest that it may even have increased between successive waves. The authors estimated basic and effective reproduction numbers for both waves of the 1968 influenza pandemic. Epidemic curves and overall attack rates for the 1968 pandemic, based on clinical and serologic data, were retrieved from published literature. The basic and effective reproduction numbers were estimated from 46 and 17 data sets for the first and second waves, respectively, based on the growth rate and/or final size of the epidemic. Estimates of the basic reproduction number (R0) were in the range of 1.06–2.06 for the first wave and, assuming cross-protection, 1.21–3.58 in the second. Within each wave, there was little geographic variation in transmissibility. In the 10 settings for which data were available for both waves, R0 was estimated to be higher during the second wave than during the first. This might partly explain the larger outbreaks in the second wave as compared with the first. This potential for change in viral behavior may have consequences for future pandemic mitigation strategies.
basic reproduction number; disease outbreaks; influenza, human; models, theoretical; Orthomyxoviridae
Interventions to increase hand washing in schools have been advocated as a means to reduce the transmission of pandemic influenza and other infections. However, the feasibility and acceptability of effective school-based hygiene interventions is not clear.
A pilot study in four primary schools in East London was conducted to establish the current need for enhanced hand hygiene interventions, identify barriers to their implementation and to test their acceptability and feasibility. The pilot study included key informant interviews with teachers and school nurses, interviews, group discussions and essay questions with the children, and testing of organised classroom hand hygiene activities.
In all schools, basic issues of personal hygiene were taught especially in the younger age groups. However, we identified many barriers to implementing intensive hygiene interventions, in particular time constraints and competing health issues. Teachers' motivation to teach hygiene and enforce hygienic behaviour was primarily educational rather than immediate infection control. Children of all age groups had good knowledge of hygiene practices and germ transmission.
The pilot study showed that intensive hand hygiene interventions are feasible and acceptable but only temporarily during a period of a particular health threat such as an influenza pandemic, and only if rinse-free hand sanitisers are used. However, in many settings there may be logistical issues in providing all schools with an adequate supply. In the absence of evidence on effectiveness, the scope for enhanced hygiene interventions in schools in high income countries aiming at infection control appears to be limited in the absence of a severe public health threat.
Since 2004, 21 highly pathogenic avian influenza H5N1 outbreaks in domestic poultry and eight human cases have been confirmed in Cambodia. As a result, a large number of avian influenza education campaigns have been ongoing in provinces in which H5N1outbreaks have occurred in humans and/or domestic poultry.
Data were collected from 1,252 adults >15 years old living in two southern provinces in Cambodia where H5N1 has been confirmed in domestic poultry and human populations using two cross-sectional surveys conducted in January 2006 and in November/December 2007. Poultry handling behaviors, poultry mortality occurrence and self-reported notification of suspect H5N1 poultry cases to animal health officials in these two surveys were evaluated. Our results demonstrate that although some at risk practices have declined since the first study, risky contact with poultry is still frequent. Improved rates of reporting poultry mortality were observed overall, but reporting to trained village animal health workers decreased by approximately 50%.
Although some improvements in human behavior have occurred, there are still areas—particularly with respect to the handling of poultry among children and the proper treatment of poultry and the surrounding household environment—that need to be addressed in public health campaigns. Though there were some differences in the sampling methods of the 2006 and 2007 surveys, our results illustrate the potential to induce considerable, potentially very relevant, behavioral changes over a short period of time.
Background Since 2004, H5N1 outbreaks have been recurrent in domestic poultry and humans in Cambodia. To date, seven human cases (100% CFR) and 22 outbreaks in poultry have been confirmed. Household ownership of backyard poultry (FAO Sector 4 poultry production) in rural Cambodia is high. An understanding of the extent and frequency of poultry handing behaviors in these settings is necessary to assess the risk associated with different practices and to formulate sensible recommendations to mitigate this risk. We collected new data from six geographic regions to examine patterns of human contact with poultry among rural farmers in Cambodia and identify populations with the highest potential exposure to H5N1.
Methods and Findings A cross‐sectional survey was undertaken in which 3,600 backyard poultry owners from 115 randomly selected villages in six provinces throughout Cambodia were interviewed. Using risk assessment methods, patterns of contact with poultry as surrogate measures of exposure to H5N1 were used to generate risk indices of potential H5N1 transmission to different populations in contact with poultry. Estimates of human exposure risk for each study participant (n = 3600) were obtained by multiplying each reported practice with a transmission risk‐weighting factor and summing these over all practices reported by each individual. Exposure risk estimates were then examined stratified by age and gender. Subjects reported high contact with domestic poultry (chickens and ducks) through the daily care and food preparation practices, however contact patterns varied by gender and age. Males between the ages of 26‐40 reported practices of contact with poultry that give rise to the highest H5N1 transmission risk potential, followed closely by males between the ages of 16‐25. Overall, males had a higher exposure risk potential than females across all age groups (p < 0·001).
Conclusions Our results demonstrate that most of the population in rural Cambodia is in frequent contact with domestic poultry. About half of the population in this study carried out on a regular basis at least one of the practices considered to be high risk for the effective transmission if the bird is infected. There was however substantial variation in the frequency of different practices and thus the potential risk of transmission of H5N1 from poultry to humans is not uniform across age and gender even amongst populations living in close proximity to poultry.
Animal–human interface; Cambodia; H5N1; risk analysis; semi‐quantitative risk assessment; transmission risk
The population's views concerning influenza vaccine are important in maintaining high uptake of a vaccine that is required yearly to be effective. Little is also known about the views of the more vulnerable older population over the age of 74 years.
A cross-sectional survey of community dwelling people aged 75 years and over wh, previous participant was conducted using a postal questionnaire. Responses were analysed by vaccine uptake records and by socio-demographic and medical factors.
85% of men and 75% of women were vaccinated against influenza in the previous year. Over 80% reported being influenced by a recommendation by a health care worker. The most common reason reported for non uptake was good health (44%), or illness considered to be due to the vaccine (25%). An exploration of the crude associations with socio-economic status suggested there may be some differences in the population with these two main reasons. 81% of people reporting good health lived in owner occupied housing with central heating vs. 63% who did not state this as a reason (p = 0.04), whereas people reporting ill health due to the vaccine was associated with poorer social circumstances. 11% lived in the least deprived neighbourhood compared to 36% who did not state this as a reason (p = 0.05) and were less likely to be currently married than those who did not state this as a reason (25% vs 48% p = 0.05).
Vaccine uptake was high, but non uptake was still noted in 1 in 4 women and 1 in 7 men aged over 74 years. Around 70% reported they would not have the vaccine in the following year. The divergent reasons for non-uptake, and the positive influence from a health care worker, suggests further uptake will require education and encouragement from a health care worker tailored towards the different views for not having influenza vaccination. Non-uptake of influenza vaccine because people viewed themselves as in good health may explain the modest socio-economic differentials in influenza vaccine uptake in elderly people noted elsewhere. Reporting of ill-health due to the vaccine may be associated with a different, poorer background.
Objective To estimate the protection against death provided by vaccination against influenza.
Design Prospective cohort follow up supplemented by weekly national counts of influenza confirmed in the community.
Setting Primary care.
Participants 24 535 patients aged over 75 years from 73 general practices in Great Britain.
Main outcome measure Death.
Results In unvaccinated members of the cohort daily all cause mortality was strongly associated with an index of influenza circulating in the population (mortality ratio 1.16, 95% confidence interval 1.04 to 1.29 at 90th centile of circulating influenza). The association was strongest for respiratory deaths but was also present for cardiovascular deaths. In contrast, in vaccinated people mortality from any cause was not associated with circulating influenza. The difference in patterns between vaccinated and unvaccinated people could not easily be due to chance (P = 0.02, all causes).
Conclusions This study, using a novel and robust approach to control for confounding, provides robust evidence of a protective effect on mortality of vaccination against influenza.
Objective To examine the determinants of vulnerability to winter mortality in elderly British people.
Design Population based cohort study (119 389 person years of follow up).
Setting 106 general practices from the Medical Research Council trial of assessment and management of older people in Britain.
Participants People aged ≥ 75 years.
Main outcome measures Mortality (10 123 deaths) determined by follow up through the Office for National Statistics.
Results Month to month variation accounted for 17% of annual all cause mortality, but only 7.8% after adjustment for temperature. The overall winter:non-winter rate ratio was 1.31 (95% confidence interval 1.26 to 1.36). There was little evidence that this ratio varied by geographical region, age, or any of the personal, socioeconomic, or clinical factors examined, with two exceptions: after adjustment for all major covariates the winter:non-winter ratio in women compared with men was 1.11 (1.00 to 1.23), and those with a self reported history of respiratory illness had a winter:non-winter ratio of 1.20 (1.08 to 1.34) times that of people without a history of respiratory illness. There was no evidence that socioeconomic deprivation or self reported financial worries were predictive of winter death.
Conclusion Except for female sex and pre-existing respiratory illness, there was little evidence for vulnerability to winter death associated with factors thought to lead to vulnerability. The lack of socioeconomic gradient suggests that policies aimed at relief of fuel poverty may need to be supplemented by additional measures to tackle the burden of excess winter deaths in elderly people.
Influenza vaccination policy for elderly people in Britain has changed twice since 1997 to increase protection against influenza but there is no information available on how this has affected vaccine uptake, and socioeconomic variation therein, among people aged over 74 years.
Vaccination information for 1997–2000 was collected directly from general practices taking part in a MRC-funded Trial of the Assessment and Management of Older People in the Community. This was linked to information collected during assessments carried out as part of the Trial. Regression modelling was used to assess relative probabilities (as relative risks, RR) of having vaccination according to year, gender, age, area and individual socioeconomic characteristics.
Out of 106 potential practices, 73 provided sufficient information to be included in the analysis. Uptake was 48% (95% CI 45%, 55%) in 1997 and did not increase substantially until 2000 when the uptake was a third higher at 63% (50%, 66%). Vaccination uptake was lower among women than men (RR 0.9), people aged 85 or more compared to people aged under 80 (RR 0.9), those in the most deprived areas (RR 0.8) compared to the least deprived, and was relatively high for those in owner-occupied homes with central heating compared to other non-supported housing (RR for remainder = 0.9). This pattern did not change over the years studied.
Increased uptake in 2000 may have resulted from the additional financial resources given to practices; it was not at the expense of more disadvantaged socioeconomic groups but nor did they benefit disproportionately.