NIHR HPRU in Evaluation of Interventions Blog

Vaccinating children - why peace of mind should not be forgotten when it comes to funding

Tue, 11 Feb 2020 11:20:00 +0000

Vaccinating children – why peace of mind should not be forgotten when it comes to funding

Gemma Lasseter, Research Fellow and Programme Manager, National Institute for Health Research Health Protection Research Unit in Evaluation of Interventions at the University of Bristol

Vaccinating children against serious diseases is a complicated process. Even after all the scientific discoveries and developments, there are important decisions to be made by parents and politicians.

In the UK, government policy on whether to fund new vaccines, or modify their availability, is based on advice from an independent scientific advisory group. This involves weighing up the benefits and costs, and then deciding whether a vaccine is value for money.

The idea is to find a balance between the cost of doing something (such as routinely vaccinating all children against a particular disease) and how much benefit you get from doing it (such as health gains by preventing disease and the associated economic savings).

Yet the current approach does not take into account many of the benefits that vaccinations offer and which set them apart from other health interventions. The fact that vaccinations are preventative rather than curative, for example, or that they offer long-term protection and increased peace of mind. This, in turn, could mean that vaccines are at a disadvantage compared with other health interventions when it comes to making decisions about funding.

Vaccination factors

Previous research suggests that parents make decisions about childhood vaccinations according to a mixture of social and personal factors. Social factors include societal norms and moral beliefs. Personal factors include perceived effectiveness, the risk of infection, side effects, and ease of access.

The peace of mind – a sense of wellbeing and reassurance – that comes from getting a child vaccinated could be another important personal factor. But little research has been done in this area, so the potential benefit is not currently considered by decision makers.

Our research investigated “vaccine associated peace of mind” by discussing the topic with members of the public to see whether it was a factor in their experiences of vaccination.

We found that peace of mind was dependent on an individual’s knowledge about the benefits of having a specific jab. Feelings of reassurance were linked to knowing that once vaccinated, their child was protected against a disease. But for those few who considered vaccinations a routine health intervention, peace of mind was not mentioned.

Participants in one focus group said that the longer a vaccine had been available, the safer it felt to them. They spoke of being reassured by knowing a vaccination had been used for many years.

There were some exceptions. For example, although the MenB vaccine (given to offer protection from life-threatening infections including meningitis and blood poisoning caused by meningococcal group B bacteria) was considered relatively “new” by many participants (it was introduced in 2015), it brought increased peace of mind because of the severity of the diseases it prevented.

Parental concerns

Peace of mind was also found to vary over time. Although it was linked to knowledge about health benefits, or to reassurance received from healthcare providers, it could all be diminished by short-term concerns relating to the pain or distress their child might suffer when receiving an injection.

Also, certain vaccines offered less peace of mind if a parent had only experienced a mild form of the disease as a child, or had no personal experience at all.

Many of the parents we spoke to said that making vaccination decisions was a complex process, with each person choosing to vaccinate (or not) by balancing their beliefs about the benefits versus the potential risks. Some mentioned feelings of anxiety about making the wrong decision.

For most, the amount of peace of mind they reported was linked to their opinions about the severity of a disease and possible susceptibility. But concerns about vaccine-associated side effects were also found to reduce peace of mind.

Overall, the research found that vaccine associated peace of mind – although it varied in magnitude and duration – was a valued benefit for some people when making vaccination decisions for their children. This suggests that the current economic approach used to make funding decisions may not be enough. When it comes to improving public health, peace of mind should be considered in the future.

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Reducing hepatitis C in Georgia - how a little country tackled a big problem

Tue, 04 Feb 2020 15:47:00 +0000

Reducing hepatitis C in Georgia - how a little country tackled a big problem

Dr Josephine Walker, Senior Research Associate in Mathematical Modelling and Health Economics, NIHR Health Protection Research Unit in Evaluation of Interventions at the University of Bristol

The country of Georgia (population 3.7 million) has one of the highest burdens of chronic hepatitis C in the world, with more than 5% of adults infected with the virus in 2015. Hepatitis C is a blood-borne virus which causes slowly progressing liver disease, with cirrhosis and end stage liver disease occurring 20-30 years after infection. In the 1990s in Georgia, an epidemic of injecting drug use and unsafe healthcare practices led to the spread of this disease, and the long-term health effects are now materialising, particularly in middle-aged men, more than 15% of whom are chronically infected.

In 2015, following the national survey that revealed the extent of infection in the country, Georgia launched a national Hepatitis C elimination programme, aiming to treat the estimated 150,000 infected individuals in the country to reduce prevalence by 90% by the end of 2020. This would be accomplished through working with international partners such as the US Centers for Disease Control and Prevention, the drug company Gilead Sciences, and a range of academic and industry partners that advise the programme.

In 2014, Gilead had developed the first of a range of new effective treatments for chronic Hepatitis C and they agreed to donate all of the drugs needed to cure Hepatitis C patients in Georgia. The treatment programme got underway in April 2015, and as of February 2019 the programme had treated more than 54,000 people. In addition, after Georgia’s treatment programme started, the World Health Organization (WHO) declared global targets to reduce the rate of new infections (by 90%) and deaths due to viral hepatitis (by 65%) by 2030.

Evaluating the intervention

This level of scale-up of treatment is an amazing accomplishment. We set out to measure the impact of the 54,000 treatments and how close Georgia is to meeting their target by 2020 and WHO’s targets by 2030.

To do this, we first had to develop a mathematical model which represented the whole population of Georgia, including their risks of acquiring and transmitting Hepatitis C due to either injecting drug use or exposure to unsafe healthcare, and how these risks change over time. We used data from surveys of people who inject drugs, and a national survey of Hepatitis C from 2015 to calibrate the model. The resulting model has a large peak in injecting-related risk in the 1990s, and includes the impact of harm reduction measures such as needle and syringe provision and opioid substitution therapy on reducing transmission, as well as a reduced general population risk after the introduction of blood-safety measures.

Our results show that the programme has already reduced both incidence and prevalence by 37%, and mortality by 14%, with 250 Hepatitis C-related deaths and >3,500 new infections prevented. If we continue to track the benefits of those 54,000 treatments to 2030, we capture more prevented deaths (>3,100) and infections averted (>20,000).

However, the current rate that people are started on treatment is not fast enough to reduce prevalence by 90% by the end of 2020. To accomplish this, the treatment rate would have to be quadrupled from 1,000 to 4,000 treatments per month. If the current rate continues, 50% reductions in prevalence and incidence will be achieved in 2020 and 90% in 2026, with a 65% reduction in mortality in 2028.

Implications

Georgia’s Hepatitis C programme demonstrates that through a strong commitment from the government and engagement with international partners, in just a few years, an incredible impact can be made to reduce the impact of Hepatitis C. By integrating modelling work within the guidance for the elimination programme, we have helped demonstrate that, to reach Georgia’s initial targets, more work needs to be done to identify bottlenecks and improve case-finding and linkage to care, so that treatment rates increase as much as possible.

Our next steps will be to evaluate the cost-effectiveness of different strategies used within the programme in order to understand how treatment numbers can be optimally scaled up. We look forward to considering not only how this massive intervention can be improved in Georgia, but what lessons can be learned for other countries in earlier stages of scaling up access to Hepatitis C treatment.

Papers

Original paper: Interim effect evaluation of the hepatitis C elimination programme in Georgia: a modelling study by Josephine G. Walker, Tinatin Kuchuloria, David Sergeenko, Hannah Fraser, Aaron Lim, Shaun Shadaker et al. Published in The Lancet Global Health. 18 December 2019.

Commentary: Evaluating the impact of Georgia's hepatitis C elimination plan: lessons learned for the global initiative by Yvan Hutin, Niklas Luhmann and Philippa Easterbrook. Published in The Lancet Global Health 18 December 2019.

Are social media and dating apps a good way of getting sexual health information to men who have sex with men?

Tue, 24 Sep 2019 13:50:00 +0000

Are social media and dating apps a good way of getting sexual health information to men who have sex with men?

Dr Joanna Kesten, NIHR Health Protection Research Unit in Evaluation of Interventions at the University of Bristol

Sexually transmitted infections (STIs) among gay, bisexual and other men who have sex with men are on the rise in the UK. Tackling this is a public health priority.

Knowledge of STIs is variable and often poor among men who have sex with men, despite it being known that they are at high risk of infection. Rates of testing for STIs are low among those with poor knowledge of STIs – especially among those who are HIV-negative or who don’t know their HIV status.

Research has shown that the use of dating apps and social media to meet sexual partners influences the spread of STI epidemic: by increasing social networks, enabling rapid partner change and therefore reducing the time for infections to spread.

But social media and dating app platforms could also offer opportunities to promote access to sexual health information and encourage reduced sexual risk taking.

Together with colleagues at the National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Blood Borne and Sexually Transmitted Infections, we asked men who have sex with men – recruited through dating apps SCRUFF and Growlr and social media - their views on how acceptable receiving sexual health information in this way might be.

We found that, overall, men who have sex with men were happy to receive sexual health information through social media platforms and dating apps, with some important observations and caveats:

Most men were happy to receive sexual health messages while browsing social media, as there is time to absorb the information. At the same time, there were concerns that sharing or commenting on sexual health information on social media might lead to judgements and discrimination.
While social media reaches a high proportion of the population, dating apps can easily target men who have sex with men. However, there are tensions between the ability to provide information at an opportune time through dating apps, when users are connecting with new sexual partners, with the potential to adversely affect the app user’s experience.
The use and impact of sexual health information delivered through social media and dating apps varied, ranging from no impact to reading information, sharing with peers, and increased awareness, to influencing healthcare-seeking, decision-making and risk-taking behaviours.
Ensuring that information is engaging, positive in tone, not too clinical, focused on building social norms and delivered by trusted organisations were viewed as important for supporting its use.

This research supports the development of new interventions that use dating apps and social media for sexual health promotion. We hope that it will be useful to public health professionals and individuals in other organisations concerned with promoting sexual health and reducing the spread of STIs, as well as to men who have sex with men themselves.

Public Health England’s Health Improvement Directorate are now working on translating these findings into sexual health promotion messaging.

The research is part of a wider programme of research led by the NIHR Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections, which aims to gather evidence on the behaviours, attitudes and factors that influence the risk of STI and blood borne virus acquisition and transmission to inform the development of novel interventions.

Read the full paper about the study published in the journal BMC Public Health.

Acknowledgements

This study is a collaboration between the NIHR HPRU in Evaluation of Interventions at the University of Bristol and the NIHR HPRU in Blood Borne and Sexually Transmitted Infections at UCL in partnership with Public Health England and in collaboration with the London School of Hygiene & Tropical Medicine.

The study is supported by the NIHR HPRU in Evaluation of Interventions at the University of Bristol, in partnership with Public Health England.

Disclaimer

The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR, the Department of Health and Social Care or Public Health England.

Making global tuberculosis data more accessible: a new R package

Tue, 28 May 2019 16:40:00 +0000

Making global tuberculosis data more accessible: a new R package

Author: Sam Abbott, PhD student, National Institute for Health Research (NIHR) Health Protection Research Unit in Evaluation of Interventions at the University of Bristol

Global and regional tuberculosis (TB) incidence rates, as well as trends in the annual percentage change of TB incidence rates. Generated using getTBinR.

The problem to solve

Tuberculosis (TB) is one of the oldest human diseases, with recorded cases in ancient Egypt, renaissance Europe, and in the modern day across the globe. It is thought to infect over 1.7 billion people globally, of which 5-15% will develop symptomatic TB in their lifetime (World Health Organization 2018). Of this number around 10% are likely to die from TB or TB related causes and globally TB remains the leading cause of death from infectious disease. TB is preventable and curable, but the majority of cases occur in less economically developed countries and are never diagnosed. Whilst global incidence rates have decreased year on year since the early 2000’s, global TB incidence remains above 134 per 100,000 people.

The World Health Organization (WHO) makes country-level TB data publicly available in an annual report. These data can be downloaded from the WHO website in a series of raw .csv (spreadsheet) data files and are a fantastic tool for understanding global trends in TB. Unfortunately, exploring the data requires several repetitive steps that need to be repeated for each .csv file. Once these have been completed more work is needed to generate usable summary statistics, data visualisations and maps. This overhead may be too much for many users.

The package: getTBinR

getTBinR (Abbott 2019) is an open-source R package (R Core Team 2019) that facilitates working with data collected by the WHO on the epidemiology of TB. All data is freely available from the WHO. The aim of getTBinR is to allow researchers, analysts, and other interested individuals, to quickly and easily gain access to a detailed TB data set and to start using it to derive key insights. It provides a consistent set of tools that can be used to rapidly evaluate hypotheses on a widely used data set before they are explored further using more complex methods or more detailed data.

The functions provided in the package were developed to have sensible defaults to allow those new to the field to quickly gain key insights but also allow sufficient customisation so that experienced users can rapidly prototype new ideas. The package code is archived on Zenodo (Abbott 2019) and Github.

What data is available?

The data sourced by getBTinR is collected by the WHO from national governments and used to compile the yearly global TB report. These data include TB notifications, mortality rates, the proportion of drug resistant cases, case detection rates, treatment rates, interventions, outcomes, and planned intervention budgets. The WHO has a complete description of the data and data collection process. These data are used by the WHO, governmental organisations and researchers to summarise country-level TB epidemiology, as well as the wider global and regional picture.

What does the package do?

The package automates downloading, cleaning, and joining the various TB-related datasets compiled by the WHO. On top of this, it supplies a data dictionary search tool that makes exploring the data easier. For experienced R users it provides a set of functions to be used within an R session. For those new to R, or new to analysing public health data, it also provides an interactive dashboard and automated country-level report.

getTBinR provides a range of mapping and visualisation tools. The figures at the top of this post were produced using a small subset of that functionality and are a good example of the kind of information that the package helps to extract. They show the global and regional trends in TB incidence rates and the annual change of those rates. They highlight the fact that TB reductions are no longer increasing annually and that regional trends differ (see here for the code to generate these figures).

Another example of a use of the package, to explore estimates of the TB case fatality ratio, can be seen here. See here for further examples and the package documentation.

Why is this package needed?

Developing tools for accessing and exploring data sets benefits the public health research community by enabling multiple data sets to be combined in a consistent manner, increasing their visibility, and providing a framework for exploring key questions. Tooling also reduces barriers to entry, allowing non-specialists to explore data sets that would otherwise be inaccessible. This widening of access may lead to new insights and wider interest for key public health issues.

References

Abbott, Sam. 2019. “GetTBinR: An R Package for Accessing and Summarising the World Health Organisation Tuberculosis Data.” Journal of Open Source Software 4 (34): 1260.

Abbott, Sam. 2019. “Seabbs/getTBinR 0.6.0.” Zenodo.

R Core Team. 2019. “R: A Language and Environment for Statistical Computing.” Vienna, Austria. .

World Health Organization. 2018. “Global Tuberculosis Report.” .

Zoonotic TB affects humans and needs to be taken seriously

Sun, 24 Mar 2019 09:14:00 +0000

Zoonotic TB affects humans and needs to be taken seriously

Author: Dr Ellen Brooks-Pollock, Lecturer in Veterinary Public Health and Lecturer in Infectious Disease Mathematical Modelling, NIHR Health Protection Research Unit in Evaluation of Interventions, University of Bristol

With 40 new cases of zoonotic tuberculosis (TB) in the UK in 2017, and incidence globally likely to be underestimated, Dr Ellen Brooks-Pollock argues it’s time that this preventable disease was taken seriously.

24 March is World Tuberculosis Day. On this date in 1882, Robert Koch announced his discovery of the TB bacterium. Before that it was widely believed that tuberculosis, or TB, was an inherited disease, and Koch’s discovery demonstrated that TB was in fact an infectious disease that could be prevented.

Despite this advance, there were still many things unknown about TB at the beginning of the 20th century. One was the conundrum of TB in different species of animals. It was known that all sorts of mammals could develop TB. But were they caused by the same type of bacteria? Of particular concern was tuberculosis in cattle and whether drinking milk from a TB-infected cow, or eating meat with tuberculous lesions could lead to human infection.

A history of bovine TB

In 1901, the British Royal Commission on Tuberculosis was set up to investigate:

whether the disease in animals and man is one and the same.
whether animals and man can be reciprocally infected with it.
under what conditions, if at all, the transmission of the disease from animals to man takes place, and what are the circumstances favourable or unfavourable to such transmission.

In 1901, at the British Congress on Tuberculosis, the eminent Robert Koch presented results of his experiments. In his experiments, he took two groups of TB-free cattle and infected one group with bovine tuberculosis (TB derived from a cow) and the other with human TB. He found that the first group developed TB lesions, whereas the second group did not. From this, he concluded that human and bovine TB were caused by different species and therefore that humans were not susceptible to bovine TB. Koch is quoted:

“Though the important question whether man is susceptible to bovine tuberculosis at all is not yet absolutely decided, one is nevertheless already at liberty to say that, if such a susceptibility really existing, the infection of human beings is but a very rare occurrence. […] I therefore do not deem it advisable to take any measures against it.”

His conclusion that no public health measures against bovine TB were required could have had disastrous consequences, as we know now that bovine TB can and does cause TB in humans via drinking TB-contaminated milk and via direct aerosol transmission.

Zoonotic TB today

Bovine TB disease in humans is called zoonotic TB. In 2018, it is estimated that there were 150,000 new cases of zoonotic TB worldwide, although this is almost certainly an underestimate because zoonotic TB is clinically indistinguishable from other forms of TB and the majority of cases occur in rural populations with limited access to healthcare.

Zoonotic TB has been neglected because of its relatively small contribution to the global TB burden. However, zoonotic TB is now receiving attention because of the 2035 target for global TB elimination and was explicitly included for the first time in the Global Plan to End TB.

In 2017, a collaboration between the World Health Organization, the World Organisation for Animal Health and the Food and Agriculture Organization of the United Nations published ‘The Roadmap for Zoonotic Tuberculosis’. The roadmap detailed 10 priority areas for advancing the fight against zoonotic TB. Number 1 is a call for more accurate data.

A serious health risk

In the UK, we have sporadic cases of zoonotic TB. In 2017, 40 people were diagnosed with zoonotic TB in the UK: although this might seem like a low number, the number of cases has doubled since 2004, and 1 in 8 farmers in southwest England may have latent TB. Half of zoonotic TB cases in the UK report occupational contact with cattle, like a Gloucestershire veterinarian who lost 7.5kg in weight, and two thirds of cases report consuming unpasteurised milk.

It is no longer acceptable to condemn zoonotic TB as a minority concern that is unrelated to TB in cattle. Zoonotic TB must be taken as seriously as all other cases of TB and persons at high risk of exposure and disease must be treated as a legitimate risk group.

Celebrating 10 years of the e-Bug project

Thu, 14 Mar 2019 10:26:00 +0000

Celebrating 10 years of the e-Bug project

Author: Catherine Hayes, Research Assistant, National Infection Service, Public Health England

Antimicrobial resistance (AMR) is a public health issue of global importance. As an issue exacerbated by the publics’ overuse and misuse of antimicrobials, interventions that improve understanding are vital to targeting AMR. The UK five-year action plan for antimicrobial resistance (2019–2024) outlines the aims of the UK Department of Health in targeting this issue, including the need for all children to leave school with an understanding of AMR.

e-Bug is an international programme that seeks to educate young people about the correct use of antibiotics and encourage good hygiene practices to shape future attitudes and behaviours. Children often have the highest rates of infection and are the most common users of antibiotics, so by encouraging targeted hygienic behaviour from a young age we can reduce infection rates and consequently the need for antibiotic use.

Operated by Public Health England, e-Bug was launched in 2009 following an EU-wide needs assessment which outlined the necessity for educational resources for young people and schools covering the topics of hygiene and antibiotics.

The resources aim to teach 4–18-year olds, are fully evidence-based, and have been evaluated across Europe. They have been shown to significantly improve knowledge in children and young people in and outside of the school setting. This has led to international recognition and endorsement by Ministries of Health and Education across Europe; in the UK e-Bug has been endorsed by the National Institute for Health and Care Excellence (NICE) and included in the 5 year action plan mentioned above.

e-Bug around the world

The implementation of e-Bug is aided by international stakeholders around the world who specialise in public health, microbiology and education. Over the last decade e-Bug has been recognised across the globe as a trusted and effective resource to reduce infection rates in children and instil appropriate attitudes towards the use of antibiotics. e-Bug resources have been translated into 24 different languages and partners in over 30 countries work with schools and governments to implement the resources and improve understanding of AMR.

e-Bug 10-year anniversary

To celebrate a decade of e-Bug teaching, and to share practice with international partners and stakeholders, Public Health England, supported by the Microbiology Society, held a two-day event in January 2019. Presentations and workshops showcased current and emerging trends and technologies in infection prevention and AMR education and ranged from educational games and a school musical on the discovery of antibiotics to engagement of children via Scouts and Girl Guiding.

The event was opened with a keynote presentation from Dr Cliodna McNulty, e-Bug lead, who reviewed a decade of e-Bug achievements and the meeting was closed by Andrea Nilsson from the European Centre for Disease Prevention and Control (ECDC) on the impact of the European Antibiotic Awareness Day (EAAD) campaign. The event was attended by 90 individuals representing 20 countries, including the USA, Philippines and Saudi Arabia.

“It's been a privilege to be invited to the 10-year anniversary - it's been inspiring and given me a boost to take our work nationally." Ryan Hamilton, Antimicrobial Pharmacist

"The level of collaboration and shared vision was really inspiring – so many focused and creative projects and from all across Europe. It was also exciting to see the materials and concepts beginning to be used globally. A really informative and enjoyable two days." Viv Todd, retired Teacher

The future of e-Bug

As rates of resistance increase, the need for resources such as e-Bug will continue to grow. e-Bug has increased its reach through training of teachers and STEM ambassadors to provide the knowledge, confidence and skills to educate children about AMR and infection prevention.

The training has been implemented via local authorities and universities who have the resources to engage schools. These local authority pilots offer a great opportunity to evaluate the effect of e-Bug education on behaviour change, which includes increased hand-washing, and reduction in school absenteeism, from reduced number of common infections.

A redevelopment of the website and development of new resources around food hygiene and the microbiome will ensure e-Bug stays current and relevant. e-Bug continues to expand internationally, recently new partners have piloted e-Bug education across the Thanjavur region in India, focusing on primary school aged children. There are further exciting plans to expand the reach of e-Bug education to Malaysia, the Maldives and the Netherlands.

Visit the e-Bug website to view the resources and find out more or email the team to get in touch.

This British Science Week, promote e-Bug to teachers and schools or use the materials in outreach or science events with young people.

What stops adolescents self-consenting for vaccinations?

Tue, 29 Jan 2019 10:23:00 +0000

What stops adolescents self-consenting for vaccinations?

Author: Dr Harri Fisher, Senior Research Associate, Population Health Sciences, Bristol Medical School, University of Bristol

Vaccination programmes have the potential to stop young people getting life-threatening infectious diseases, such as human papilloma virus (HPV), tetanus, diphtheria and whooping cough. A growing number of schools-based vaccination programmes are offered to adolescents. Who should give consent for these older children to be vaccinated? Should it be parents or should young people be allowed to decide for themselves?

The challenge

The United Nations Convention on the Rights of the Child recognises that children and young people have the right to take part in decision-making processes about their own health and any treatment they need.

In a clinical setting, consent is often part of the decision-making process before treatment is given. It can broadly be defined as ‘giving permission for something to happen’.

We carried out a systematic review of qualitative and quantitative studies looking at consent for adolescent vaccination programmes and found there were a number of challenges which prevent adolescent self-consent for vaccination.

Barriers to consent

Policy and legal framework

Countries have different policies about whether young people can consent for vaccinations. For example, in the USA young people can only consent for vaccinations if it is for a sexually transmitted infection (e.g. HPV).

However, in the UK and Sweden young people can consent to medical interventions, including vaccinations, if they are considered ‘Gillick competent’. Despite this, some studies show that local guidance and misunderstandings of the law stop young people being able to consent for vaccinations.

Protection

Some adults and young people thought that adolescents should be able to self-consent for vaccination because it protects their health. More often though, health workers seemed to be more concerned about protecting their reputation as professionals, and also relationships with parents. This is illustrated with the following quote from a professional who was interviewed shortly after the HPV vaccination programme was introduced in Wales:

“Because if you were to immunise a Gillick competent girl and her parents were dead against the vaccination, the ripples that that would cause in the school, you know ‘the nurse immunised my daughter even though we were against it’. It doesn’t really matter what the law would say, you’ve undermined confidence in the service. There are consequences”

Young people’s independence

Some of the studies included in the review suggested there was support for the idea that young people should be able to act independently from their parents, and consent themselves for vaccinations. This is illustrated by a quote from a parent who took part in a study from the USA.

“If they are old enough, regardless if you say no as parents, they have the right to go.”

However, there was a stronger preference for parents to have responsibility for providing consent. Vaccine eligible young people were often felt by healthcare professionals to be ‘too young’ in terms of their maturity, in addition to their physical size.

Implications for adolescent self-consent and future research

Through this systematic review, we found that there were a number of structural challenges which are currently preventing young people being able to consent for vaccinations. In particular, inconsistent interpretations of the law and an emphasis on parent’s responsibility to provide consent can prevent young people’s access to recommended vaccinations.

Despite these challenges, self-consent could be used as an intervention to increase coverage of adolescent vaccination programmes.

Next steps

We are now undertaking an evaluation to see whether procedures allowing young women to self-consent to the HPV vaccination programme are acceptable and whether it can increase uptake in areas that are not meeting the government targets.

Building on our previous research, we will also find out whether these new consent procedures can help young women who may be less likely to receive the HPV vaccine, such as those from some minority ethnic groups.

Further information

For further information about the ‘Consent for HPV vaccine’ study, contact the Principal Investigator Dr Suzanne Audrey a Senior Research Fellow at the University of Bristol, or the Study Manager, Dr Harri Fisher.

What's normal in children's respiratory infections? Bristol parents helped us find out.

Wed, 23 Jan 2019 08:12:00 +0000

What's normal in children's respiratory infections? Bristol parents helped us find out.

Author: Dr Emma Anderson, Senior Research Associate, Centre for Academic Primary Care, University of Bristol

As any parent knows, children get coughs, colds and ear infections all the time. Symptoms of these respiratory infections – including runny nose, cough and sore throat – can seem never-ending.

In the EEPRIS Study, led by Professor Alastair Hay from the University of Bristol’s Centre for Academic Primary Care, we recruited parents across Bristol to tell us about their children’s respiratory symptoms as they became ill. Gathering information in the community means we are able to find out more about common respiratory illnesses than when we study those who have decided to consult their GP. It also gives us a more accurate picture of how likely parents are to consult for these common illnesses, something which has been surprisingly unclear.

Two of our main findings were that:

it takes up to three weeks for most children’s respiratory infections to resolve
about one in twelve children who develop a respiratory infection see their GP

What we did – novel community research

Most research in this area has looked at respiratory infections in children who see their GP. Our study was novel in that we followed children out in the community, tracking them from their first noticeable respiratory symptom. We achieved this because of the willingness of Bristol parents to record their children’s symptoms online as they developed.

In total, 331 parents with 485 children took part in the study, reporting symptoms of 346 new respiratory infections that developed between February and July 2016 via (email prompted) online surveys. We were initially unsure of how this project would be received, and so we were delighted to find local parents and children were so willing to get involved. We are very grateful to all the families that made this possible.

Duration of symptoms – younger children have longer illnesses

The data showed us that it took 23 days for 90 per cent of children to recover from all symptoms. Overall, the average (median) duration of symptoms for any respiratory infection was nine days. The youngest children (aged up to 3 years old) had longer illnesses, with an average (median) symptom duration of 11 days compared to 7 days for the older children (aged 4+). It is important to be aware of this difference as parents and clinicians tend to worry more about illnesses in very young children, and lengthy symptoms can be a cause for worry.

Type of symptoms makes a difference

We also found that when a parent reported any chesty symptoms, such as a wet cough and wheeze, the illness lasted longer (an average of 12 days) than those with only upper respiratory infection symptoms, such as a runny nose and sore throat (average 8 days). Among upper respiratory symptoms, runny nose was the most persistent and earache was the fastest to resolve.

Why is this important?

Our findings will be useful for parents to know what to expect in these common illnesses in their children, which could help them know whether to consult their GP or not. This knowledge can also help GPs and public health professionals give general advice to parents about the normal course of respiratory infections, including when to consult. It may also have a role in helping reduce unnecessary antibiotic prescribing.

The study was published in Annals of Family Medicine and was funded by the National Institute for Health Research (NIHR) Health Protection Research Unit in Evaluation of Interventions.

Paper: Respiratory tract infections in children in the community: prospective online inception cohort study. Alastair D Hay et al. Annals of Family Medicine.

Further information

About the Centre for Academic Primary Care

The Centre for Academic Primary Care (CAPC) at the University of Bristol is a leading centre for primary care research in the UK, one of nine forming the NIHR School for Primary Care Research. It sits within Bristol Medical School, an internationally recognised centre of excellence for population health research and teaching. Follow us on Twitter: @capcbristol.

About the NIHR Health Protection Research Unit in Evaluation of Interventions

The Health Protection Research Unit (HPRU) in Evaluation of Interventions, based in Population Health Sciences at the University of Bristol, is part of the National Institute for Health Research and a partnership between University of Bristol and Public Health England (PHE), in collaboration with University College London, Cambridge MRC Biostatistics Unit and University of the West of England. We are a multidisciplinary team undertaking applied research on the development and evaluation of interventions to protect the public’s health. Our aim is to support PHE in delivering its objectives and functions. Our focus is on the PHE priority area of infection. Follow us on Twitter: @HPRU_EI.

About the National Institute for Health Research

The National Institute for Health Research (NIHR) is the nation's largest funder of health and care research. The NIHR:

funds, supports and delivers high quality research that benefits the NHS, public health and social care
engages and involves patients, carers and the public in order to improve the reach, quality and impact of research
attracts, trains and supports the best researchers to tackle the complex health and care challenges of the future
invests in world-class infrastructure and a skilled delivery workforce to translate discoveries into improved treatments and services
partners with other public funders, charities and industry to maximise the value of research to patients and the economy.

The NIHR was established in 2006 to improve the health and wealth of the nation through research, and is funded by the Department of Health and Social Care. In addition to its national role, the NIHR commissions applied health research to benefit the poorest people in low- and middle-income countries, using Official Development Assistance funding.

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Can we eliminate human papilloma virus?

Wed, 12 Sep 2018 06:51:00 +0000

Can we eliminate human papilloma virus?

Authors: Dr Sam Merriel, GP and Honorary Lecturer, Centre for Academic Primary Care, University of Bristol and Dr Joanna Kesten, Senior Research Associate, NIHR Health Protection Research Unit in Evaluation of Interventions, University of Bristol

Researchers from the Centre for Academic Primary Care and Population Health Sciences, Bristol Medical School, with colleagues from Queens University Belfast, Ulster University, and Southampton University, have published an editorial in the British Journal of General Practice (BJGP) in response to Public Health England’s (PHE) recommendation to roll out a targeted Human papillomavirus (HPV) vaccination programme for men who have sex with men (MSM) through genitourinary medicine (GUM) and HIV clinics across England.

The editorial argues that although this announcement is a positive step, it would be more effective to follow more recent recommendations to introduce gender neutral HPV vaccination to achieve total elimination of HPV, rather than a reduction. The PHE proposal means MSM who do not attend sexual health clinics, unvaccinated women and heterosexual men who have sex abroad would continue to suffer from HPV-related genital warts and cancers.

HPV is one of the mostly common sexually transmitted infections globally. Most people who contract HPV have no symptoms. Certain HPV subtypes are associated with anogenital and oral cancers in men and women, and many strains of the virus cause genital warts.

The incidence of HPV-related cancers, particularly oropharyngeal cancers, has risen in recent decades. Preventive measures to reduce the burden of HPV-related diseases include safe sex practices, regular cervical smears for women, and HPV vaccination programmes. However, the optimal approach for the reduction and prevention of HPV-related diseases is yet to be determined.

HPV vaccination

The HPV vaccine was introduced in 2006 and has been adopted in a number of countries worldwide. There are three types of HPV vaccine; the bivalent vaccine (covering HPV sub types 16 and 18); the quadrivalent vaccine (covering HPV sub-types 6, 11, 16 and 18); and the 9-valent vaccine (covering HPV sub-types 6, 11, 16, 18, 31, 33, 45, 52, and 58). The current recommendation in the UK is for two doses to be given, based on evidence that the effectiveness is comparable to a three dose schedule.

Optimal coverage for HPV vaccination programmes targeting adolescent females is at least 70%, which is being achieved in the UK and Australia, but not in other high-income countries such as France, Italy, Germany, The Netherlands, and the USA.

Female-only HPV vaccination programmes theoretically protect heterosexual males if optimal coverage is reached. However, this herd immunity does not extend to men who have sex with men (MSM) and heterosexual males who are sexually active overseas, exacerbating health inequities, particularly for MSM who are at increased risk of HPV-related diseases.

Extending HPV vaccination to men who have sex with men

Currently, the four nations of the UK have HPV vaccination programmes only for adolescent females based on the original recommendations of the UK Joint Committee on Vaccination and Immunisation (JCVI). Public Health England recently endorsed adding a targeted HPV vaccination programme for MSM after running a pilot programme for MSM through sexual health clinics in 2016/17.

Before the PHE recommendation could be implemented, the JCVI re-evaluated the available evidence for HPV vaccination and recommended that current UK vaccination programmes be extended to adolescent males as well. All four nations have accepted the recommendation. However, there has been no timeline or details about implementation, and no discussion about catch-up programmes for young adult males.

Testing through cervical screening

Cervical screening (formally known as pap smears or cervical smears) aims to detect abnormal cells in the cervix. Recently HPV testing has been added to cervical screening programmes, as most cervical cancers are caused by HPV infection. Women with abnormal cervical cells detected on screening need to undergo further diagnostic testing to determine if the changes are pre-cancerous or if cervical cancer is present and, if necessary, to receive appropriate treatment.

Optimal cervical screening coverage to reduce cervical cancer rates is at least 80% of all eligible women. As of 31 March 2017, 72.0% of women in England had been screened adequately, and coverage in England and other UK nations has been falling in recent years.

No single approach

It is likely that no single approach will achieve the aims of the International Papillomavirus Society to ‘move towards eliminating HPV as a public health problem’. Cervical screening coverage is sub-optimal in the UK and trending downwards, and public health teams will have to work hard to maintain current HPV vaccination coverage.

HPV vaccination also does not protect against all cervical cancer in women, so the extent of the anticipated reduction in cervical cancer rates will be interesting to follow in the coming years. A robust gender-neutral HPV vaccination programme, in combination with cervical screening and safe sex campaigns might help in reducing the burden of HPV-related disease.

Read the BJGP editorial by Merriel S. et al “’Jabs for the boys’:time to deliver on HPV vaccination recommendations.