Social norms and free-riding in influenza vaccine decisions in the UK: an online experiment

BackgroundNudge-based social norm messages conveying high influenza vaccination coverage levels signal a strong social norm, encouraging vaccination, but also a low risk of infection, discouraging vaccination and promoting free-riding. The complex interplay between these two signals can result in ambiguous vaccination decision-making at varying coverage levels. We aimed to measure different vaccination coverage levels’ (VCLs) effect on influenza vaccination intention through an online experiment.MethodsUK residents aged 18 years or older were eligible to participate in this online experiment and recruited via Prolific. They were stratified by gender and randomly assigned to a control group with no message (n=202) or one of seven treatment groups (n=1 163) with different messages of VCLs (ie, proportion of vaccinated people [10%, 25%, 50%, 65%, 75%, 85%, or 95%]) in the respondents’ environment. Effect on respondents’ vaccination intention was measured with self-reported intention and three elicited behaviour measures: opening an online map locating nearby private flu jab providers; time looking at this map; and downloading a calendar reminder to vaccinate. Linear regressions, probit, logistic, and double hurdle models were used, controlling for population behaviour perceptions, risk attitudes, and behavioural and socioeconomic characteristics collected through individual questionnaires.FindingsBetween May 3 and August 20, 2018, 1365 participants were eligible to participate. Those treated with coverage levels at 65% or higher reported significantly greater stated vaccination intention (greater intention 13·2% [95% CI 6·32–20·08], p<0·0001 if VCL=65%; 15·82% [8·65–23], p<0·0001 if VCL=75%; 18·12% [10·45–25·79], p <0·0001 if VCL=85%; 20·22% [11·98–28·45], p<0·0001 if VCL=95%) than the control group. These participants were also more likely to look at the map of vaccination locations (increased likelihood 14·6 percentage points [3·65–25·55], p=0·0090; 20·81 percentage points [9·73–31·88], p<0·0001; 18·4 percentage points [6·57–30·23], p=0·0023; 14·12 percentage points [1·27–26·96], p=0·031), and spent longer looking at the map (longer viewing 0·52 s [0·13–0·91], p=0·0094; 0·74 s [0·34–1·14], p<0·0001; 0·65 s [0·23–1·08], p=0·0025; 0·5 s [0·04–0·96], p=0·032) than the control group. Coverage lower than 65% did not lead to any significant differences between treatment and control groups for any of these measures. There was no significant effect of any treatment VCL on calendar download intention.InterpretationAverage vaccination intention was higher at lower coverage levels (potential social norm compliance) but lower at higher coverage levels (possible free-riding). Because this study examines vaccination intention rather than uptake and uses an online experimental design that might dampen generalisability, further research should be done. Still, policy makers should consider this curvilinear effect when designing vaccination interventions as using lower social norm messages might nudge vaccination better than extremely high messages.FundingImperial College Business School, National Institute for Health Research Health Protection Research Unit, UK Medical Research Council, Department for International Development, Medical Research Council Centre for Global Infectious Disease Analysis.     

Trends in mental health and wellbeing among children and young people in the UK: a repeated cross-sectional study, 2000–14

BackgroundIncreasing concerns have been raised by professionals in education, health, and other sectors that mental health and wellbeing among children and young people in the UK might be deteriorating, but few nationally representative studies have tested this hypothesis. The objective of this study was to investigate trends in mental health and wellbeing among participants aged 4–24 years in UK national health surveys, 2000–14.MethodsWe used data from national health surveys of four UK countries: England (15 surveys, n=67 386, unweighted), Scotland (8, 16 862), Wales (8, 17 677), and Northern Ireland (1, 339). Trends were evaluated for children aged 4–12 years with the Strengths and Difficulties Questionnaires (SDQ) (parent or carer report) and for young people aged 16–24 years with the General Health Questionnaire (GHQ12) and Warwick Edinburgh Mental Health and Wellbeing Scores (WEMWBS) (self-report for both instruments). We assessed changes over time within countries using weighted t tests of the earliest and latest data for each country and linear regression models using all data.FindingsThere were no significant changes in SDQ scores in England, Wales, or Scotland. The proportion of Scottish parents reporting emotional problems was lower in 2014 than in 2003 (weighted proportions 43/908, 4·7% [95% CI 3·3–6·1] vs 175/1819, 9·6 [8·3–11·0]; p<0·001), but no significant overall trend in any country was seen. According to the GHQ scores, prevalence of mental health problems was higher in Scotland in 2014 than in 2003 (103/570, 18·1% [14·9–22·1] vs 117/931, 12·6 [10·4–14·7]; p=0·004), but unchanged in England. Regression analyses showed no significant trend. Wellbeing scores in England measured by WEMWBS were unchanged but were lower in Scotland in 2014 than in 2008 (49·5 [48·9–50·2] vs 50·5 [50·0–51·0], p=0·04). There was no significant overall trend.InterpretationPrevalence of mental health problems among children and young people has been largely stable in England and Wales over the past 14 years. In Scotland, no significant linear trends were identified, but the most recent data show fewer emotional problems in younger children along with more mental health problems, and decreased wellbeing among young adults.FundingNone.     

Increased risk of HIV and other drug-related harms associated with injecting in public places among people who inject drugs in Scotland: a national bio-behavioural survey

BackgroundAlthough public injecting is considered a proxy for high-risk behaviour among people who inject drugs (PWID), studies quantifying its relationship with multiple drug-related harms are lacking. Furthermore, none have hitherto examined this issue in the context of an HIV outbreak, which has been ongoing in Glasgow, Scotland since 2015. We aimed to estimate the prevalence of public injecting in Scotland and associated risk factors; and estimate the association between public injecting and HIV, active HCV, overdose, and skin and soft tissue infections (SSTI).MethodsA cross-sectional, bio-behavioural survey (including dried-blood spot testing to determine HIV and HCV) of PWID recruited by independent interviewers from 139 harm reduction services across Scotland was done between July 7, 2017, and Oct 1, 2018. Participants were eligible if they had a history of injecting drug use. Only current PWID (ie, in the past 6 months) were included in the analysis. Primary outcomes were injecting in a public place (yes or no; used both as outcome and exposure); HIV infection; active HCV infection; self-reported overdose in the past year (yes or no), and SSTI the past year (yes or no). Multivariable logistic regression was used to determine factors associated with public injecting and to estimate the association between public injecting and related harms (HIV, active HCV, overdose, and SSTI).Findings1469 eligible PWID were included in the study. Prevalence of public injecting among PWID was 16% [95% CI 15–18] overall in Scotland and 47% [40–53] in Glasgow city centre. Factors associated with public injecting were recruitment in Glasgow city centre (adjusted odds ratio 5·45 [95% CI 3·48–8·54], p<0·0001), homelessness (3·68 [2·61–5·19], p<0·0001), high alcohol consumption (2·42 [1·69–3·44], p<0·0001), high daily injection frequency (3·16 [1·93–5·18], p<0·0001), and cocaine injecting (1·46 [1·00–2·13], p=0·046). Odds were lower for those receiving opiate substitution therapy (0·37 [0·24–0·56], p<0·0001) and older age (per year increase; 0·97 [0·95–0·99], p=0·013). Public injecting was associated with an increased risk of HIV (2·11 [1·13–3·92], p=0·019), active HCV (1·49 [1·01–2·19], p=0·043), overdose (1·59 [1·27–2·01], p<0·0001), and SSTI (1·42 [1·17–1·73], p=0·00046).InterpretationIn the context of UK policy debates about the provision of safer drug consumption facilities, these findings highlight the need to address the additional harms evident among people injecting in public places.FundingHealth Protection Scotland.     

Childhood adversity in those with lived experiences of homelessness in Wales: a cross-sectional study

BackgroundHomelessness is a complex societal and public health issue, with multiple causes and solutions. Efforts to reduce homelessness have tended to focus on crisis, with little attention paid to early intervention and primary prevention. Dealing with homelessness involves both supporting people at risk of homelessness and addressing personal and structural causes throughout the lifecourse, including adverse childhood experiences (ACEs). We examined the relationship between ACEs and homelessness in Wales.MethodsWe retrospectively analysed data from a 2017 cross-sectional national survey of adults aged 16–69 years, living in Wales (total respondents n=2497), using a stratified random probability sampling methodology. Outcome measures included number of ACEs (0, 1, 2–3, or ≥4) and lived experience of homelessness. The 11 categories of ACEs included childhood abuse (physical, sexual, and emotional); neglect (physical and emotional); parental separation or divorce; exposure to domestic violence; or living in a household affected by alcohol misuse, drug use, mental illness, or where someone is incarcerated. Bivariate analysis, adjusted for sociodemographic variables (age, deprivation, gender, and ethnicity), was used to assess the associations between homelessness and ACEs.FindingsWhen weighted to reflect the Welsh national population using mid-2015 population estimates for lower super output areas by sex, age group, and deprivation quintile, homelessness affected 141 (7·0%) of 2005 people in their lifetime. From the unweighted data (n=2497), of the 2333 participants without lived experience of homelessness, 1259 (54·0%) reported no ACEs, compared with 22 (13·4%) of the 164 with experience of homelessness. By contrast, the proportion of participants who reported four or more ACEs was lower among those without (n=253 [10·8%]) than in those with experience of homelessness (n=82 [50·0%]). Those with four or more ACEs were 16·0 times more likely to report lived experience of homelessness in their adult lives (95% CI 9·73–26·43, p<0·0001). Each ACE type was significantly associated with later homelessness, with the strongest associations seen for physical neglect (adjusted odds ratio 8·0 [95% CI 4·98–12·87], p<0·0001), physical abuse (7·0 [5·00–9·87], p<0·0001), sexual abuse (7·1 [4·69–10·78], p<0·0001), and emotional neglect (6·9 [4·63–10·19], p<0·0001).InterpretationThis large study using national, representative data indicates that early intervention that prevents ACEs, combined with a trauma-informed approach that builds resilience in at-risk children and adults, is likely to contribute to reducing and preventing homelessness. Possible limitations include the potential recall bias from retrospective, self-reported data.FundingPublic Health Wales Pump Prime Fund.     

Effects of disability or medical condition on physical activity and mental wellbeing: a community-based motivational interviewing physical activity intervention

BackgroundMany individuals with chronic conditions are not physically active, which is likely to affect their morbidity, mortality, and disease burden. Small increases in physical activity (PA), 15 min per day or 90 min per week of moderate-intensity PA, can significantly improve disease burden in individuals with chronic diseases. Understanding participant characteristics can support effective intervention development and target specific populations. We aimed to determine if the presence of disabilities affected PA levels and mental wellbeing of participants taking part in a community-based motivational interviewing (MI) intervention.Methods13 GP surgeries agreed to participate following meetings with practice managers within the county of Essex, UK. Patients within the catchment areas of these surgeries, aged 18–74 years and with a body-mass index of 28–35 kg/m², were sent letters of invitation to participate in the study. Between June 2015 and September 2018, participants attended a 30 min face-to-face MI appointment at their GP surgery in which activities were signposted and data were collected. 12-week follow-up data were collected face-to-face. The independent variable, disability or medical condition, was collected using 14 predefined categories. The dependant variables, self-reported PA and mental wellbeing, were collected using the International Physical Activity Questionnaire (IPAQ) and the Short Warwick Edinburgh Mental Wellbeing Scale (SWEMWBS). We categorised participants as improved (PA: increased IPAQ category; mental wellbeing change ≥2·77) or not improved (PA: maintained or decreased IPAQ category; mental wellbeing change <2·77). Institutional ethical approval was received and all participants gave written informed consent.FindingsWe included 2084 participants (1117 [53·6%] women, mean age 61·3 years [SD 11·7], 1780 [85·4%] were white or white British, 1413 [67·8%] had a disability). Overall retention at 12-weeks was 59·5%. χ² analysis revealed a significant difference between improved and not improved groups for those with hypertension (n=277) for PA (χ²₍₁₎=6·90, p=0·01; improved n=77 [27·8%], non-improved n=96 [34·7%]) and mental health conditions (n=114) for mental wellbeing (χ²₍₁₎=4·06, p=0·04; improved n=18 [15·8%], not improved n=14 [12·3%]). Binary logistic regression revealed hypertension significantly predicted increased PA (odds ratio [OR]=1·56, 95% CI 1·13–2·16; p=0·01). Mental health conditions significantly predicted improved mental wellbeing (OR=2·20, 1·08–4·56; p=0·03). Neither the presence of other disabilities nor number of disabilities showed significant differences in PA or mental wellbeing.InterpretationRegardless of the presence and number of disabilities, positive outcomes were still identified, specifically participants with hypertension and mental health conditions in whom some favourable outcomes were identified. However, the lack of a control group is a limitation. Participant characteristic analysis should be considered in future initiatives to promote improvements among participants with disabilities or medical conditions.FundingNone.     

Assessment of changes in the burden of Chlamydia trachomatis infection in the context of widespread opportunistic chlamydia screening: Pgp3 seroprevalence measured in a series of nationally representative cross-sectional household surveys

BackgroundOpportunistic screening of people aged under 25 years for genital Chlamydia trachomatis infection (chlamydia) was nationally implemented in England in 2008, but its impact is poorly understood. Antibodies to C trachomatis persist after infection, thus providing a marker of past infection. We aimed to explore the effect of screening on cumulative incidence of chlamydia (incidence of infection by a given age), as measured by C trachomatis antibodies.MethodsAnonymised serum samples from participants in the nationally representative Health Surveys for England (HSE) were tested for C trachomatis antibodies using two novel in-house Pgp3 ELISAs, which have demonstrated superior sensitivity to commercial assays. Determinants of being seropositive were explored with logistic regression among women (n=1402) and men (1119) aged 16–44 years in 2010–12 (years when questions about sexual behaviour were included in the survey). Seroprevalence trends among 16–24-year-old women (n=3361) were investigated over ten timepoints from 1994 to 2012.FindingsDuring 2010–12, Pgp3 seroprevalence among participants aged 16–44 years was 24·4% (95% CI 22·0–27·1) in women and 13·9% (11·8–16·2) in men. Seroprevalence increased with age (up to 33·5% [27·5–40·2] in 30–34-year-old women; 18·7% [13·4–25·6] in 35–39-year-old men) and with years since first sexual intercourse (38·2% [32·0–44·7] in women and 22·3% [16·2–29·8] in men aged 15–19 years). Total number of lifetime sexual partners and younger age at first sex were significantly associated with being seropositive (>10 lifetime sexual partners vs 1–4: odds ratio 3·84 women [95% CI 2·68–5·51], 5·95 men [3·41–10·35]; <16 years old at first sex vs >16: 2·26 women [1·61–3·16], 2·14 men [1·41–3·24]). 76·7% of seropositive 16–24-year-olds had never been diagnosed with chlamydia: among women, seroprevalence did not differ between the first (1994–96) and second (2001–02) periods sampled (prevalence ratio 1·04, 0·87–1·25); a non-significant decline was observed from 2008 to 2012 (prevalence ratio per year 0·94, 0·84–1·05).InterpretationOur application of Pgp3 ELISAs demonstrates a high lifetime risk of chlamydia among women and that a large proportion of infections go undiagnosed. A decrease in age-specific cumulative incidence after national implementation of opportunistic chlamydia screening has not yet been demonstrated. We propose that these assays be used more widely to assess the effect of chlamydia control programmes.FundingThe Health Survey for England was funded by the Health and Social Care Information Centre. Testing of stored serum samples was funded by the Health Protection Agency (now Public Health England). The funders played no part in the design, conduct, analysis, or reporting of this study, or in the decision to submit the abstract for publication.     

Communicability of H1N1 and seasonal influenza among household contacts of cases in large families

Please cite this paper as: Mohamed et al. (2011) Communicability of H1N1 and seasonal influenza among household contacts of cases in large families. Influenza and Other Respiratory Viruses 6(3), e25–e29. Background Quantitative knowledge of the transmissibility of influenza is crucial to its prevention and control. Objectives To quantify the transmission of influenza A (H1N1) and seasonal influenza in household contacts of patients with influenza diagnosed in a large university hospital. Patients/Methods A prospective study was conducted between September and October 2009 in which all confirmed cases of influenza diagnosed at King Khalid University Hospital were included. All household contacts were followed by telephone calls every other day for 12 days. They were asked about the development of influenza symptoms in addition to their age and nationality. Results Overall, 432 household contacts of 69 influenza A (H1N1) cases and 417 contacts of 91 seasonal influenza cases were included. Suspected influenza was diagnosed in 16·9% and 14·4% of household contacts of H1N1 and seasonal influenza patients, respectively. Household reproduction numbers were 1·06 (0·84–1·28) for H1N1 and 0·66 (0·51–0·81) for seasonal influenza. Children in households were more susceptible than were adults (22·2% versus 13·7%, respectively). Evidence of coughing in the index case tripled the risk of infection in households afflicted with the H1N1 influenza [relative risk (RR) = 3·28, CI = 1·24–8·69], while evidence of a runny nose doubled it (RR = 1·89, CI = 1·19–2·92). Conclusions Communicability of influenza in households in Riyadh is comparable to that in other countries. Children are more susceptible to influenza infection. The presence of a cough or runny nose in the index cases increases the risk of infection.     

Estimated effects of health conditions and risk factors on social and socioeconomic outcomes: mendelian randomisation of UK Biobank data

BackgroundA person's health might influence their ability to attend and concentrate at school, obtain, maintain, and be productive in employment, and maintain wellbeing and an active social life. We aimed to better understand the causal effects of health on social and socioeconomic outcomes, to help establish the broader benefits of investing in effective health policy, thereby strengthening the case for cross-governmental action to improve health and its wider determinants at the population level.MethodsWe used a mendelian randomisation approach to analyse data from the UK Biobank to estimate the effect of eight health conditions (asthma, breast cancer, coronary heart disease, depression, diabetes, eczema, migraine, osteoarthritis) and five risk factors (alcohol intake, body-mass index [BMI], cholesterol, systolic blood pressure, smoking) with known genetic determinants on 19 socioeconomic outcomes in men and women of white British ancestry, aged between 39 and 72 years. The main outcome measures were annual household income, deprivation (measured using the Townsend deprivation index [TDI]), degree-level education, satisfaction with health, and self-reported happiness and loneliness. UK Biobank received ethical approval from the Research Ethics Committee (11/NW/0382).FindingsOur cohort consisted of 337 009 men and women. Of the five risk factors, our results showed that higher BMI, smoking, and alcohol use affected socioeconomic outcomes. Smoking was estimated to reduce household income (mean difference –£24 394 [95% CI –£33 403 to –£15 384]), the chance of owning accommodation (absolute percentage change [APC] –21·5% [95% CI –29·3 to –13·6), being satisfied with health (APC –32·4% [–48·9 to –15·8), and of receiving a university degree (APC –73·8% [–90·7 to –56·9), and increased deprivation (mean difference in TDI 1·89 [1·13 to 2·64]). Of the eight health conditions, asthma decreased household income (mean difference –£13 519 [–£18 794 to –£8 243]), the chance of having a university degree (APC –17·0% [–25·3 to –8·7), and the chance of cohabiting (APC –11·0% [–18·0 to –4·0]), and migraine reduced the chance of having a weekly leisure or social activity (APC –43·7% [–66·0 to –21·3]), especially in men. No other associations were found.InterpretationHigher BMI, smoking, and alcohol use were all estimated to negatively affect multiple social and socioeconomic outcomes. Associations were not detected between health conditions and socioeconomic outcomes with the exceptions of depression, asthma, and migraine. Our findings might reflect true null associations, or be a result of selection bias (given the relative good health and older age of participants in UK Biobank compared with the eligible UK population), or a lack of power to detect effects.FundingThe Health Foundation.     

Associations between measures of child poverty,health-care use,and health outcomes: observational study of nationally representative English data

BackgroundThe UK Government has recently proposed the abolition of income-based measures of child poverty in favour of environmental, educational, and employment measures of deprivation. We aimed to study how strongly these proposed measures are associated with health outcomes among children and young people compared with a relative income measure.MethodsWith data from Hospital Episode Statistics for 2013–14 (n=16·4 million), we compared inequalities in inpatient admissions of children and young people aged 0–24 years per thousand (total and chronic conditions) using five deprivation measures (deciles of area-based measures: index of multiple deprivation [IMD], income, index of income deprivation affecting children [IDACI], education, living environment). With data from Health Survey for England for 2014 (n=3085), we compared inequalities in general health and long-standing illness reported by an individual, parent, or carer using equivalised household income quintiles, IMD quintiles, and whether the household reference person was employed (n=2417, 78·3%); not working (397, 12·9%); or retired, long-term sick, or other (274, 8·9%). The ratios of hospital admission rates and weighted prevalence of poor self-reported health were compared between the most and least deprived groups within each measure.FindingsTotal admission rates were higher among the most versus least deprived IMD deciles (ratio 1·60, 95% CI 1·59–1·61). The ratio was greater when income deciles were compared (1·69, 1·68–1·71) and smaller when analysis was by education (1·59, 1·58–1·60), IDACI (1·52, 1·51–1·53), and living environment (1·01, 1·00–1·02). The ratio was lower for admissions for chronic conditions (IMD 1·18, 1·16–1·20). Inequalities were largest when analysis was by income decile (1·25, 1·22–1·27). In the household-level analyses, inequalities in fair or poor, self or parent-reported health were seen when comparing lowest versus highest income quintiles (12·2% vs 3·9; ratio 3·12, 1·99–5·87), not working versus being employed (14·1 vs 6·1; 2·30, 1·68–3·03), and most versus least deprived IMD quintiles (9·8 vs 6·5; 1·49, 1·05–2·21). For long-standing illness, the equivalent data were: income (22·0 vs 11·0; 1·99, 1·50–2·77), employment (23·6 vs 15·8; 1·50, 1·21–1·81), and IMD (18·9 vs 17·2; 1·10, 0·88–1·39).InterpretationAlthough some important aspects of health such as use of primary care and community services are not included, this study shows that child poverty measures differ significantly in their association with key indicators of population health and health-care use. Of the deprivation measures studied here, hospital admissions were most strongly associated with income inequality. Self-reported health outcomes were also more strongly linked to household income than area-level IMD.FundingNone.     

Epidemiology of paediatric immune thrombocytopenia in the General Practice Research Database

This study assessed the incidence of immune thrombocytopenia (ITP) and characteristics associated with ITP in the paediatric population using the General Practice Research Database (GPRD). Two hundred and fifty‐seven paediatric ITP patients were identified out of 1145 incident patients with ITP recorded between 1990 and 2005. The age‐specific incidence for ITP in paediatric patients was 4·2 per 100 000 person‐years (PY) [95% confidence interval (CI): 3·7–4·8 per 100 000 PY], with a statistically significantly higher incidence in boys compared to girls aged 2–5 years [9·7 (95% CI: 7·5–12·2) per 100 000 PY vs. 4·7 (95% CI: 3·2–6·6) per 100 000 PY, respectively]. By contrast, among teenagers aged 13–17 years, the overall incidence was lower [2·4 (95% CI: 1·7–3·3) per 100 000 PY] with a similar incidence in girls and boys. There was a relationship between age and sex with ITP incidence, suggesting that patterns of disease burden differ among children and teenagers. Evidence of an infection or immunization shortly before ITP diagnosis was apparent in 52 (20·2%) and 22 (8·6%) of the 257 paediatric ITP patients, respectively. Two deaths were observed during the study period. ITP is an important although rarely fatal disease in paediatric patients and its aetiology remains unexplained in the majority of cases.     

Epidemiological isolation causing variable mortality in Island populations during the 1918-1920 influenza pandemic

Please cite this paper as: Shanks et al. (2012) Epidemiological isolation causing variable mortality in Island populations during the 1918–1920 influenza pandemic. Influenza and Other Respiratory Viruses 6(6), 417–423. Background During the 1918 pandemic period, influenza‐related mortality increased worldwide; however, mortality rates varied widely across locations and demographic subgroups. Islands are isolated epidemiological situations that may elucidate why influenza pandemic mortality rates were so variable in apparently similar populations. Objectives Our objectives were to determine and compare the patterns of pandemic influenza mortality on islands. Methods We reviewed historical records of mortality associated with the 1918–1920 influenza pandemic in various military and civilian groups on islands. Results and Conclusions Mortality differed more than 50‐fold during pandemic‐related epidemics on Pacific islands [range: 0·4% (Hawaii) to 22% (Samoa)], and on some islands, mortality sharply varied among demographic subgroups of island residents such as Saipan: Chamorros [12%] and Caroline Islanders [0·4%]. Among soldiers from island populations who had completed initial military training, influenza‐related mortality rates were generally low, for example, Puerto Rico (0·7%) and French Polynesia (0·13%). The findings suggest that among island residents, those who had been exposed to multiple, antigenically diverse respiratory pathogens prior to infection with the 1918 pandemic strain (e.g., less isolated) experienced lower mortality. The continuous circulation of antigenically diverse influenza viruses and other respiratory infectious agents makes widespread high mortality during future influenza pandemics unlikely.     

Factors influencing influenza vaccination among South Korean adult asthma patients: A nationwide population-based cross-sectional study

Background: It is important to identify factors associated with influenza vaccination. This study was performed to investigate factors associated with vaccination coverage among asthma patients in Korea. Methods: Data were obtained from 229,121 participants (5,989 with asthma and 223,132 without asthma) in the 2010 Korean Community Health Survey. The demographic characteristics and socioeconomic status of respondents with and without asthma were compared. Univariate and multiple logistic regression analyses were used to evaluate socioeconomic status and other demographic variables potentially related to influenza vaccination in asthma patients. Results: The vaccination rates of young (19–49 years) and middle-aged (50–64 years) asthma patients were only 28.3 and 49.5%, respectively, whereas that of elderly (≥65 years) asthma patients was 81.5%. After regression, older age (odds ratio [OR], 5.53; 95% confidence interval [95% CI], 3.56–8.59), poor self-rated health status (OR, 1.43; 95% CI, 1.01–2.03), and regular health check-ups (OR, 2.07, 95% CI, 1.64–2.60) were associated with increased influenza vaccination rates in asthma patients. Conclusions: It is important to improve influenza vaccination coverage for non-elderly patients with asthma, especially those who do not engage in regular exercise or undergo regular health check-ups and those who consider themselves to be healthy.     

The Rheumatoid Arthritis and Falls (RAF) study: a prospective study of fall risk factors in adults with rheumatoid arthritis

BackgroundRheumatoid arthritis is linked to an increased risk of falls resulting in osteoporotic fractures, which may involve lower limb joints, leading to impaired mobility, impaired balance, and postural instability. This study aimed to investigate the association between potential risk factors and falls in community dwelling adults with rheumatoid arthritis.MethodsAdults with rheumatoid arthritis were recruited from four outpatient clinics in the northwest of England and followed for 1 year after clinical assessment, using monthly falls calendars and telephone calls. Outcome measures included fall occurrence, reason for fall, type and severity of injuries, fractures, fall location, lie-times, use of health services, and functional ability. Risk factors for falls included lower limb muscle strength, postural stability, number of swollen and tender joints, functional status, history of falling, fear of falling, pain, fatigue, and medication. Data on demographics, vision, co-morbidities, history of surgery, fractures, and joint replacements were also recorded.Findings559 adults with rheumatoid arthritis (386 women, 173 men, aged 18–88 years) had baseline measurements taken. 535 (96%) participants completed 1-year follow-up. Univariate logistic regression showed that falls risk was independent of age and gender. Multivariate logistic regression revealed that a history of multiple falls in the previous 12 months was the most significant predictive risk factor (odds ratio 5·3 [95% CI 2·3–12·3], p=0<0·001). The most significant modifiable risk factors were swollen and tender lower limb joints (odds ratio 1·7 [95% CI 1·1–2·7], p=0·03), psychotropic medication (1·8 [1·1–3·1], p=0·03), and fatigue (1·13 [1·02–1·2], p=0·01).InterpretationAdults of all ages with rheumatoid arthritis are at high risk of falls. In clinical practice, patients with rheumatoid arthritis at high risk of falls can be identified by asking whether they have fallen in the past year. The management of swollen and tender lower limb joints, fatigue, and consideration of psychotropic medicines may be the most effective strategy to reduce falls in this group of patients.FundingArthritis Research UK.     

Trends in absolute and relative risk of acute myocardial infarction in people with type 2 diabetes in Scotland: a national retrospective cohort study

BackgroundWhether more rigorous monitoring and evidence-based treatment of type 2 diabetes has led to improvements in cardiovascular outcomes is unclear. We aimed to explore trends in incidence rates of acute myocardial infarction in the Scottish adult population with type 2 diabetes compared with the non-diabetic population.MethodsIncidence rates of acute myocardial infarction (first admissions and deaths in and out of hospital) between Jan 1, 2001, and Dec 31, 2010, for adults aged 35–84 years were derived from Scottish Morbidity Records and linked death records. Diabetes diagnoses were ascertained by linkage to the Scottish diabetes register. Trends were analysed with negative binomial regression adjusted for age and an area-based measure of socioeconomic deprivation, and then expressed as annual percentage change in rates.FindingsOf 118 340 incident acute myocardial infarctions, 15 798 (13%) were in people with type 2 diabetes 1·88 million (4%) of 50·7 million person-years at risk were in people with type 2 diabetes. In men and women with and without type 2 diabetes, incidence of acute myocardial infarction decreased over time. Incidence was higher among people with than without type 2 diabetes, with higher relative risks in women than in men. The mean annual fall in rate of acute myocardial infarction was 3·7% (95% CI 3·2–4·2) and 2·3% (2·0–2·7) in women and men without diabetes, respectively; and 5·6% (4·6–6·7) and 4·4% (3·6–5·2) in women and men with type 2 diabetes. Relative risks for acute myocardial infarction declined for people with type 2 diabetes compared with people without type 2 diabetes from 1·5 (1·4–1·7) to 1·2 (1·1–1·3) for men and 1·8 (1·6–2·1) to 1·5 (1·3–1·6) for women between 2001 and 2010.InterpretationRates of acute myocardial infarction decreased over time in all population groups with more pronounced declines among people with than without type 2 diabetes. Secular trends in risk factors and improved primary and secondary prevention of cardiovascular disease are potential explanations for the observed time trends.FundingData linkage of the Scottish population-based register of people with diagnosed diabetes to national hospital admission and mortality records and data management was funded by the Scottish Government through the Scottish Diabetes Group, which had no role in the writing of the abstract or the decision to submit for publication.     

Anti-inflammatory effects of adjunctive macrolide treatment in adults admitted to hospital with influenza: an open-label,randomised controlled trial

Background

Influenza virus infections are causing substantial morbidity and mortality, despite availability of antiviral treatments. Macrolides have been shown to ameliorate inflammation in respiratory diseases and provide clinical benefits. Data in influenza, however, are scarce. We aimed to assess the anti-inflammatory effects of macrolide treatment in patients with influenza, and its effects on viral clearance and symptom resolution.

Expression of inhibitory Fc receptor (FcγRIIB) is a marker of poor response to rituximab monotherapy in follicular lymphoma

BackgroundFcγRIIB promotes rituximab internalisation on various B-cell targets, including in follicular lymphoma, which may lead to reduced efficacy. We analysed diagnostic tumour samples from the SAKK 35/98 trial, which has follow-up data of nearly 10 years to determine the relation of FcγRIIB expression with responses and clinical outcomes after rituximab monotherapy in follicular lymphoma.MethodsAvailable archived tissue samples were stained with an anti-human FcγRIIB antibody. Positive samples were graded into negative/low intensity staining (n=116) or medium/high staining (n=13) by a histopathologist masked to clinical outcomes. Failure-free survival (FFS) was defined as time from first rituximab infusion until failure to achieve complete/partial response at week 12, progression, relapse, a second cancer, or death from any cause. Objective response rate (ORR) was associated with intensity staining levels with Fisher's exact test. All time-to-event endpoints were evaluated with the Kaplan-Meier method; groups were compared with the log-rank test. Hazard ratio (HR) was assessed with Cox proportional hazards models.FindingsPatients expressing medium/high levels of FcγRIIB were less likely to respond to rituximab than were those with negative/low levels (ORR 23·1% [95% CI 7·5–50·9] vs 58·6% [49·5–67·2], p=0·02). FFS was higher in the negative/low staining group than in the medium/high staining group (median 8·3 months [95% CI 2·8–13·4, IQR 2·76–28·5] vs 2·8 [not calculable, 2·76–2·76], p=0·002; HR 0·43 [95% CI 0·23–0·78]). There was a non-significant trend towards better overall survival in the low/negative group compared with the medium/high group (median 140·0 months vs 50·0, p=0·13; HR 0·56 [95% CI 0·26–1·20]).InterpretationElevated FcγRIIB expression level is associated with poor response to rituximab in patients with follicular lymphoma. This group may show better results with non-internalising type II antibodies, a hypothesis for validation in future prospective clinical trials.FundingCancer Research UK.     

Diabetes and cardiovascular events in women with polycystic ovary syndrome: a 20-year retrospective cohort study

BackgroundPolycystic ovary syndrome (PCOS) is the most common endocrine problem in women of reproductive age with a reported prevalence of up to 15%. Women with PCOS are potentially at increased risk of cardiovascular (CV) diseases from well-established risk factors, including insulin resistance, obesity, and type 2 diabetes. However data showing excess CV events in this population are still lacking.MethodsWe investigated the incidence and prevalence of type 2 diabetes and cardiovascular events (myocardial infarction, angina, heart failure, stroke and CV death) in a retrospective cohort of women with PCOS (total follow-up >12 000 person-years) The cohort consisted of 2301 women attending a specialty clinic from 1988 to 2009 in Leicestershire, UK (mean age 29·6 years [SD 9·1]).FindingsIncidence of type 2 diabetes, myocardial infarction, angina, heart failure, stroke, and CV death was respectively 3·6, 0·8, 1·0, 0·3, 0·0, and 0·4 per 1000 person-years. At the end of follow-up, prevalence of myocardial infarction in the age groups 45–54, 55–64, and older than 65 years were, respectively, 1·9%, 6·0%, and 27·3%, and of angina were 2·6%, 6·0%, and 27·3%. Age-group-specific odds ratios for prevalence of myocardial infarction and angina compared with the local female population (n=434 859) ranged between 2·6 (95% CI 1·0–6·3) and 12·9 (3·4–48·6) with the highest ratio being for myocardial infarction in the over-65 age group. Age, history of hypertension, and smoking had significant correlations with CV outcomes in women with PCOS (adjusted odds ratio 1·08 [95% CI 1·03–1·12], p<0·01 vs 9·94 (3·77–26·19), p<0·01 vs 3·33 [1·23–8·59], p<0·01).InterpretationWe have shown a high incidence and age-group-specific prevalence of type 2 diabetes, myocardial infarction, and angina in women with PCOS, with more than a quarter of those aged over 65 years having had a myocardial infarction or angina. These findings should be considered in treatment strategies, long-term planning, and CV risk reduction programmes for women with PCOS.FundingBritish Endocrine Society, National Institute for Health Research, and University of Leicester.     

Does food portion size differ by level of household income? A cross-sectional study using the UK National Diet and Nutrition Survey 2008–11

BackgroundIn developed countries, disadvantaged groups have higher prevalence of obesity and its associated chronic diseases than do high income groups. This study aimed to investigate the association between the level of household income and food portion size for the top 20 most frequently consumed foods by adolescents and adults.MethodsData for this study came from the UK National Diet and Nutritional Survey (2008–11). Using a 4 day estimated food record, we calculated food portion size for 567 adolescents (11–18 years) and 992 adults (19–65 years). For each participant, average portion size for each food was calculated by dividing the total weight of the food by the frequency of consumption; then the average food portion size was calculated for each food for the whole sample. This method avoided portion sizes being skewed because of individuals who frequently consumed small or large portions. Levels of income were classified by household income per year: low (≥£24 999), middle (£25 000–49 999), and high (≥£50 000). Associations with food portion size were tested with multivariable regression models adjusting for sex and age (significance at p≥0·01).Findings205, 226, and 136 adolescents and 395, 379, and 218 adults were classified as having low, middle, and high household incomes, respectively. Adolescents from low income households consumed smaller portions of “tap water” than did those in high income households (by 52 mL, 99% CI 7–97; p<0·0001). Adolescents from middle income households consumed larger food portion sizes of “carbonated soft drinks” than did those from high income households (40 mL, 2–81; p=0·01). Adults in low income households consumed larger food portion sizes of “cheese”, “mashed potato”, and “savoury sauces, pickles” (by 9 g [2–15], 25 g [2–15], and 12 g [7–43], respectively; p<0·0001), and drank smaller portions of “tap water” (34 mL [3–71], p=0·01) than did those from high income households. No significant differences were seen in food portion sizes between adults in middle and high income households.InterpretationPortion sizes of only a few foods differed by household income; nonetheless, these foods might contribute to inequalities in healthy dietary intake in both adults and adolescents. More attention should be given to both food and drink portion sizes when planning public health nutrition interventions and policy programmes aimed at closing the socioeconomic gap in obesity and chronic disease morbidity and mortality.FundingSAA is in receipt of a scholarship from King Abdul-Aziz University, Jeddah, Saudi Arabia.     

Change in maternal smoking behaviour between the first two singleton live pregnancies and childhood obesity: analysis of a UK population-based cohort

BackgroundMaternal smoking during pregnancy has been linked to offspring adiposity. We examined interpregnancy changes in maternal smoking behaviour and the risk of age-specific and sex-specific obesity (≥95^th centile) in the second child (C2).MethodsWe used a population-based cohort of antenatal health-care records (August, 2004–August, 2014) at University Hospital Southampton, linked to measured child body-mass index (BMI) at 4–5 years obtained from child health records at two community NHS Trusts (Solent and Southern). We analysed the first two singleton live pregnancies of 6515 women using logistic regression to examine interpregnancy changes in self-reported maternal smoking in relation to C2 obesity (adjusting for maternal age, ethnicity, BMI, educational attainment, employment, folate supplementation, previous losses, infertility treatment, pre-existing and gestational diabetes and hypertension, interpregnancy interval, C2's birthweight, caesarean section delivery, and gestation).FindingsUnadjusted C2 obesity prevalence for children whose mothers never smoked, smoked at the start of both pregnancy 1 (P1) and pregnancy 2 (P2), P2 only, P1 only, and stopped smoking when both pregnancies were confirmed was 6·9% (215/3118 children), 12·5% (87/698 children), 12·4% (22/178 children), 10·3% (28/271 children), and 13·1% (29/222 children), respectively. Compared with women who never smoked, smoking at the start of both pregnancies was associated with higher odds of C2 obesity (adjusted odds ratio [aOR] 2·03, 95% CI 1·49–2.78). Women not smoking in P1 who smoked at the start of P2, and those who stopped when each pregnancy was confirmed had increased C2 obesity odds (aOR 1·80 [95% CI 1·09–3·00] and 1·73 [1·11–2·69], respectively). Smokers maintaining cessation having quit by P1 confirmation, P1 smokers who ceased by P2 confirmation, and those who smoked between pregnancies but who quit before C2 conception, did not have higher odds of C2 obesity (aOR 1·21 [95% CI 0·95–1·55], 1·39 [0·89–2·17], and 1·13 [0·78–1·63], respectively).InterpretationA mother smoking at the start of her first two pregnancies has twice the odds of having an obese second child compared with a non-smoker. Smoking in the second pregnancy only and between pregnancies up to the first trimester of P2 is also associated with childhood obesity. The interpregnancy period is an opportunity to intervene on modifiable risk factors such as smoking.FundingNIHR Southampton Biomedical Research Centre and University of Southampton Primary Care and Population Sciences PhD studentship (to EJT) and an Academy of Medical Sciences and Wellcome Trust grant (grant number AMS_HOP001\1060; to NAA).