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Health Protection (Adults)

Introduction

Health Protection involves planning, surveillance and response to incidence and outbreaks; it prevents and reduces the harm caused by communicable diseases and minimises the health impact from environmental hazards such as chemicals and radiation. It also includes delivery of major programmes such as national immunisation programmes and the provision of health services to diagnose and treat infectious diseases.

 

The Local Authorities Regulations 2013 with section 6C of the NHS Act 2006 insert; and section 12 of Health and social care Act 2012 defines the new health protection duty of local authorities that includes:

      i.        Public Health team on behalf of Director of Public Health is responsible for LA's contribution to health protection matters including response to incidents and emergencies.  PHE provide will provide specialist support and have a complementary role to play.  Both PHE and LA PH will work as single unit; and

    ii.        NHS organisations including NHS England and our local CCG have a legal responsibility under NHS ACT 2006 to mobilise resources to manage incidents and emergencies.  They also have legal duty to co-operate with Local Authority Public Health in delivering health protection national and local priorities.

 

Role of Health Protection involves:

      i.                Planning and response to incidents and emergencies

    ii.                surveillance of communicable and notifiable diseases

   iii.                Reduction of detriment due to communicable and non-communicable diseases and prevention of infection and infectious diseases

   iv.                minimising health impact of environmental hazards

    v.                Reducing premature mortality and morbidity by improving environmental sustainability

 

The role of Health Protection begins from the day life is conceived till the end stage of life. Most of the Health protection issues involve:

      i.                vaccine preventable diseases (measles, mumps, rubella and human papillomavirus);

    ii.                gastrointestinal diseases (food poisoning notifications, food hygiene standards);

   iii.                respiratory diseases (tuberculosis, pneumococcal disease, seasonal flu, asthma);

   iv.                hepatitis;

    v.                sexually transmitted infections (Chlamydia, HIV); and

   vi.                Environmental hazards (radon, skin cancer, air pollution, water quality).

 

Since 1st April 2013, NHSE have been responsible for the local commissioning of screening and immunisation services through public health commissioning teams in each of its 27 Area Teams. Bedford Borough Council is part of the South Midlands & Hertfordshire (SMH) NHSE Area Team. Public Health England (PHE) is responsible for providing expert quality assurance of the screening and immunisation services through the specialist national screening teams and staff who previously worked for the Health Protection Agency. Bedford Borough Council is part of the PHE Midlands and East of England region and the East of England Centre.

Locally, the DPH has a duty to ensure plans are in place to protect their population including protection through screening and immunisation. Public Health provides independent scrutiny and challenge of the plans of NHSE, PHE and providers. PHE supports the DPH to hold NHSE to account through the provision of data and information on performance against standards. Directors of Public Health (DsPH) need to assure themselves that the combined plans from all these organisations and are delivering effective screening and immunisation programmes to their local populations.

 

This chapter covers Health Protection as it relates to Adults.  For the Health Protection chapter on pregnant mothers, children and young people, please follow this link

 

Seasonal Influenza

Influenza (often referred to as flu) is an acute viral infection of the respiratory tract (nose, mouth, throat, bronchial tubes and lungs) characterised by a fever, chills, headache, muscle and joint pain, and fatigue. For otherwise healthy individuals, flu is an unpleasant but usually self-limiting disease with recovery within two to seven days. Flu is easily transmitted and even people with mild or no symptoms can still infect others. The risk of serious illness from influenza is higher among children under six months of age, older people and those with underlying health conditions such as respiratory disease, cardiac disease or immunosuppression, as well as pregnant women. These groups are at greater risk of complications from flu such as bronchitis or pneumonia or in some rare cases, cardiac problems, meningitis and/or encephalitis.

 

The influenza virus was first identified in 1933. There are two main types that cause infection: influenza A and influenza B. Influenza A usually causes a more severe illness than influenza B. The influenza virus is unstable and new strains and variants are constantly emerging, which is one of the reasons why the flu vaccine should be given each year.

 

The aim of the national flu immunisation programme is to offer protection against the effects of flu to as many eligible people as possible, particularly those most at risk. As much vaccination as possible should take place before the flu virus circulates. Protection can be achieved directly through individual immunisation, or indirectly through herd immunity, which is one of the major benefits of the childhood flu immunisation programme. Improving and extending the child flu immunisation programme is a key focus in protecting the population from flu.

 

PHE carries out laboratory tests to identify which strains of flu are in circulation, coordinates information at the UK level and communicates this information to other health professionals and to the public. The Department of Health (DH) annually circulates annual flu letters detailing its plans for the year’s influenza immunisation programme to public health and healthcare professionals in the NHS and other health authorities in England.

 

NHS Trust chief executives, directors of public health and general practitioners are asked to continue to plan their immunisation programmes based on the previously established long-term, three-year trajectory of achieving the following aspirational targets by 2015/16: to reach or exceed 75% vaccine uptake among those aged 65 years and over; and to reach or exceed 55% uptake among those under 65 years in clinical risk groups, including pregnant women.

 

Eligibility:

Flu vaccinations are currently offered free of charge to the following at-risk groups:

  1. People aged 65 years or over (including those becoming age 65 years by 31 march)
  2. Pregnant women (including those women who become pregnant during the flu season)
  3. People with a serious medical conditions such as:

 

  • chronic (long-term) respiratory disease, such as severe obstructive pulmonary disease (COPD) or bronchitis
  • chronic heart disease, such as heart failure
  • chronic kidney disease at stage 3, 4 or 5;
  • chronic liver disease
  • chronic neurological disease, such as Parkinson's disease, motor  neurone disease or learning disability;
  • diabetes;
  • splenic dysfunction; or
  • A weakened immune system due to disease (such as HIV/AIDS) or treatment (such as cancer treatment).

 

4.  People living in long-stay residential care homes or other long stay care facilities where rapid spread is likely to follow introduction of infection and cause high morbidity and mortality. This does not include, for instance, prisons, young offender institutions, or university halls of residence.

5.  People who are in receipt of a carer’s allowance, or those who are the main care of an older or disabled person whose welfare may be at risk if the carer falls ill.

6.  Healthcare workers with direct patient contact and social care workers. Immunisation given to healthcare staff directly involved in patient care and social care workers who are employed to provide personal care, acts as an adjunct to good infection prevention and control procedures. In particular, the flu vaccine reduces the risk of infection to the patient/client, infection amongst staff, and staff absenteeism.

 

Seasonal Influenza Immunisation uptake

Seasonal influenza vaccination uptake for patients aged under 65 years in an ‘at risk category’ however has consistently remained below the target for last three years with an uptake of 43.4% in 2015/16, comparing to 45.1% nationally.(fig 11)

 

The uptake of vaccination in pregnant women has dropped to 47.2% in comparison to its own performance previous year (53.8%); however it remains significantly better than the England and NHE midland and East averages (42.3;and 42.4% respectively). (Fig 11).

 

There has been a drop in performance for people aged under 65 years old at risk with a reduction of 2.5% in <65 at risk category (43.4% in 2015/16). Within the ‘At risk’ categories, 49.4% of people with Chronic Heart disease showing an improvement of 2% from its own previous year performance; 69.1% of the people with Diabetes were vaccinated maintaining its last year’s uptake; an uptake of 55.5% for people with Chronic Kidney disease with an improvement of 3%; people with Chronic Neurological disease show an improvement by 2.7% with an uptake of 51%. All these categories have uptakes better than England averages.  Remaining long-term conditions although have improved its own previous year’s performances but their averages are lower than England averages for those conditions. People with liver diseases have improved by 4.7% with an uptake of 38.4%; similarly people with immunosuppression have improved by 2.2% with an uptake of 48%., and people with chronic respiratory conditions have improved by 1.5% with an uptake of 44.6% (fig 12). 34.1% of people with Asplenia have been vaccinated with an improvement of 1.3%.  Despite a reduction in overall uptake of vaccination in those in the ‘Under 65 at risk’ group, there were improvements in all of the categories. The new eligible category ‘morbid Obesity’ brought the overall total proportion of people vaccinated down. Reaching out to people with long term conditions and influencing them to receive vaccination remains a huge challenge. 46.8% of Carers (informal carers) registered with GP practices in Bedford Borough have been vaccinated with an improvement of 2.0%.

 

Figure 1:  Flu Immunisation uptake of Eligible groups within Bedford Borough

Health protection

 

Source: Immform Data set 2015-16; DPH report of NHSE Midland and East and national comparator from flu plan 2016/17

Figure 2: Seasonal flu immunisation uptake in people below age 65 and with a long term condition

 

Health protection

Source: Immform Data set 2015-16; DPH report of NHSE Midland and East and national comparator from flu plan 2016/17

The association between deprivation and uptake is not evident as uptake in the category 65+, people below 65 ‘at risk’ is better in 20% most deprived practices and uptake in pregnant women is very similar. Conversely, uptake in carers, children age 2 and 3 were better in 20% least deprived (affluent) practices than 20% most deprived. This has followed a similar trend over previous years. Variation in the uptake of seasonal flu vaccination by general practice for all three main risk categories including over 65 years and patients below 65 years at risk and pregnant women have been noticed between GP practices.  This indicates inequality in the provision of an effective health protection measure for vulnerable patients at a practice level.

 

Impact of Seasonal Flu on population and health economy:

Mortality – Deaths contributed to or caused by seasonal influenza:

The seasonal influenza virus does not necessarily cause high mortality, but for people who are over 65 years of age who are already sick it may speed up their death. For some people with long term conditions, under the age of 65 years, the risk of mortality from seasonal influenza can be far higher than the average population.

 

Between the years 2013/14 and 2014/15 there were 127 (2 years rolling) residents who died with Influenza as the primary cause of death (Source: Mede-analytics accessed through Public Health Intelligence). There were 63 deaths where Influenza and Influenza related illnesses (ICD 10: J10-J18) were recorded as underlying cause of death in Bedford Borough residents, a decrease of 6 deaths from previous (69).  Directly standardised rate of deaths die to Influenza shows some decline to 4.2/100,000 in 2015/16 from 4.8/100,000 in 2014/15(fig14) .

Fig 3 showing DSR of Influenza related deaths in 2015/16

Health Protection

Source: ONS death file 2015/16

 

In each year and season over 90% of pneumonia deaths occur in people aged 65 years or more. Out of the 63 deaths 61 were diagnosed to have pneumonia as their primary diagnosis. Bedford Borough has seen an increase in the proportion of the population aged over 65 years with an expected 16% rise, and an expected rise amongst people aged over 85 years by 32% between 2014 and 2021. This trend is expected to continue into the foreseeable future. As a result, an increasing proportion of the population will be vulnerable to severe disease from influenza.

 

Future seasonal vaccination campaigns will need to provide for an increasing number of people eligible for vaccination in order to mitigate the potential burden of disease from future seasonal influenza epidemics. In addition to the ageing population is the increasing burdens of obesity and alcohol in the Bedfordshire population; this can be anticipated to increase the proportion of people aged below 65 at high risk from seasonal influenza due to chronic long term conditions such as chronic heart disease, chronic liver disease, chronic kidney disease and diabetes.

Hospital Admissions:

There have been 807 hospital admissions of people registered in the practices within BBC where Influenza and its associated complications were the primary diagnoses in 2015-16(crude number)(fig 15); out of which 256 admissions were in Jan-March (Quarter 4). Out of which there were 226 people with age 85 and above who were hospitalised as an emergency. 70% of the total admissions were from people age 65 and above (Fig 16) .  The trend of emergency admission shows slight increase with crude admission rate of 4.1/1000 population (2014/15) to 4.4/1000 population in 2015/16.

These admissions incurred an inpatient cost of £2.23million to the local health economy for the year 2015-16.

Fig 4 showing number of flu related emergency admissions in 2015-16.

Health Protection

Source: Mede-analytics accessed through Public Health Intelligence: codes searched (J10-J18)

 

Fig 5 showing proportion of emergency admissions due to Influenza related illnesses in various age groups(2015/15)

Health protection

Source: Mede-analytics accessed through Public Health Intelligence: codes searched (J101 - Influenza with other respiratory manifestations, other influenza virus identified, J108 - Influenza with other manifestations, other influenza virus identified, J111 - Influenza with other)

Fig 6 showing trend of emergency admissions since 2012 where Influenza and Influenza related admissions were the primary diagnosis

Health protection

 

Source: Mede-analytics accessed through Public Health Intelligence: codes searched (J101 - Influenza with other respiratory manifestations, other influenza virus identified, J108 - Influenza with other manifestations, other influenza virus identified, J111 - Influenza with other)

 

National and Local Strategies

Best practice guidelines used:

      i.        “The flu immunisation programme 2015/16”. Letter from the Chief Medical Officer, the director of nursing and the chief pharmaceutical officer for England, 27 March 2015. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/418428/Annual_flu_letter_24_03_15__FINALv3_para9.pdf 

    ii.        Department of Health: seasonal flu plan 2015-2016. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/418038/Flu_Plan_Winter_2015_to_2016.pdf

   iii.        NICE 2009. Amantadine, oseltamivir and zanamivir for the treatment of influenza. Available at: www.nice.org.uk/TA168

 

Each year the chief medical officer (CMO), along with the chief nursing officer and chief pharmaceutical officer, sends a letter detailing the next seasonal flu immunisation programme. The letter from the CMO is a letter for the action of many key health providers and commissioners including:

      i.        GPs

    ii.        Chief executives of Primary Care Trusts ( Now Clinical commissioning group), NHS Trusts and Foundation Trusts

   iii.        Directors of Public Health, Immunisation and flu coordinators

   iv.        Medical Directors of NHS Trusts

    v.        Directors of Nursing, Directors of Maternity Services, Lead Nurses, Midwives, Practice Nurses, Health visitors

 

A number of changes to the national immunisation programme are being made during 2015-16 to reflect the planned and phased implementation of a series of recommendations by the Joint Committee on Vaccination and Immunisation (JCVI), improving the overall level of protection against preventable diseases. The existing flu immunisation programme for children will be extended over a number of years to include all children aged two to 16 inclusive.

Recommendations for seasonal influenza immunisation are further detailed in the green book, which is updated regularly online.

 

What are the unmet service needs/gaps?

Seasonal Influenza vaccination:

 

  1. Flu vaccine uptake is particularly poor in some GP practices. This variation is independent of practice level deprivation, and indicates inequality in the protection of groups of vulnerable patients against seasonal influenza. In this variation of influenza vaccine uptake what is not clear is how much of this variation is due to resistance of the different GP practice populations and how much is due to variation in service provision. 
  2. Specific patient groups aged below 65 years of age such as those with Chronic Liver disease, Chronic Respiratory disease and Asplenia appear to have poor uptake. Although uptake of vaccination in pregnant women has improved again this year, it still remains below the national target of 55%. .
  3. Gap in awareness: Seasonal influenza presents a varied picture due to the occurrence of a variety of other viral infections that can cause flu like symptoms. This can mask the threat that influenza presents to vulnerable people with a much greater risk of complications and undermines people’s sense of urgency in accessing seasonal flu vaccination which is a safe and effective method to protect people at high risk from flu; freely available to them from their GPs. The population needs influencing and accepting the benefit of vaccination. 

 

Recommendations

The Local authority does not have direct responsibility of delivering seasonal Influenza immunisation; the responsibility now lies with NHS England area team of Central Midland and East. The Immunisation programme is delivered through general practitioners and community pharmacies in primary care.  The Public health team in the local authority will be ensuring and supporting the agencies responsible for the delivery of the seasonal influenza (flu) immunisation programme. Public health supports commissioners in localising national plans and supports providers in addressing the gaps and providing recommendations in the local plans.

Recommendations identified through last year’s evaluation:Recommendations identified through last year’s evaluation:

  1. A coordinated Bedfordshire wide campaign to raise awareness of the importance of flu and need for vaccination for individuals at risk from influenza, for Health Care Workers (HCW);  and Social Care Workers including those in the private sector who are making number of visits to vulnerable people in their own homes and are the potential carriers. This campaign must start ahead of the seasonal flu vaccination season, and should include targeted messaging for patient groups with low flu vaccine uptake, for example pregnant women, patients with Respiratory disease, liver disease, kidney disease and neurological conditions. A more coordinated campaign has the advantage of increasing the reach of the message, whilst maintaining consistency.
  2. A focussed campaign to educate NHS staff dealing with pregnant women on the importance of the flu vaccination. This needs to be targeted at key staff groups such as midwives and GP practice staff (both clinical and non-clinical) to ensure that a consistent and accurate message is provided to pregnant women.
  3. NHS organisations, including GP practices, community services and hospitals must continue to improve uptake of the seasonal flu vaccine by frontline health care workers as a measure to protect the health of vulnerable patients.
  4. The commissioning organisations for NHS and social care in Bedford Borough need to identify ways to ensure providers of NHS care and providers of residential care in Bedfordshire actively promote and provide free flu vaccination for frontline social care and care support workers.
  5. Local barriers to flu vaccine uptake needs to be identified, particularly in groups with low uptake, specifically groups of people below the age 65 who have long term conditions. This could involve surveys of patient experience or focus group work.
  6. Bedford Borough occupational health department should ensure the provision of flu vaccination to its local authority staff in regular contact with vulnerable people. Monitoring and evaluation of use of flu clinics / voucher schemes would help to determine uptake and identify groups with low uptake.

 

Tuberculosis

TB is a curable infectious disease caused by a type of bacterium called Mycobacterium tuberculosis or other bacterium in the M. tuberculosis complex). It is spread by droplets containing the bacteria being coughed out by someone with infectious TB, and then being inhaled by other people.  The initial infection clears in over 80% of people but, in a few cases, a defensive barrier is built round the infection and the TB bacteria lie dormant. This is called latent TB; the person is not ill and is not infectious. If the immune system fails to build the defensive barrier, or the barrier fails later, latent TB can spread in the lung.

 

Not all forms of tuberculosis are infectious. Those with TB in organs other than the lungs are not infectious to others, nor are people with just latent tuberculosis. Some people with pulmonary tuberculosis are infectious, particularly those with bacteria which can be seen on simple microscope examination of the sputum, who are termed ‘smear positive’. The risk is greatest in those with prolonged, close household exposure to a person with infectious TB.

 

TB incidence in the UK has increased since the early 1990s, but has remained relatively stable since 2005. Public Health England’s (2015) Reports of cases of tuberculosis highlighted that in 2014; there were 6,520 new cases of TB recorded in England. The Collaborative TB Strategy for England, 2015-2020 reports that nearly three quarters (73%) of all TB cases in England occur in those born abroad, mainly in high TB burden countries, and most of these cases (85%) occur among settled migrants who have been in the country for more than two years, rather than in new entrants. Majority of cases were young adults age 15-44 years It also suggests that although there has been a small decline in incidence in the past two years, it is too early to say whether this is the start of a downward trend. Despite this, it remains high compared with many other western European countries.

 

Facts, Figures and Trends

Incidence of Tuberculosis

In 2014, there were 27 tuberculosis (TB) case reported to the Public Health England Enhanced Tuberculosis Surveillance System (ETS) of new TB patients resident from Bedford Borough council geography. This equates to a rate of 15.2 per 100,000(95% CI 9.9-22.5), which is significantly higher than the EOE rate of 7.0 (95% confidence intervals (CI) 6.3-7.7) cases per 100,000 population. Bedford has experienced upward trend since 2000 when 18 cases were reported rising to 27 case reports 2014(fig17). In 2014, around 70% of all TB cases were in people born outside the UK, and largely shows the higher incidence of TB in the communities from which migrants have originated. EoE report stated that about one in 10 (8.6%) of cases were reported as having one or more of the social risk factors of: high alcohol use, substance use, homelessness; and past or current imprisonment. The majority of cases in the EOE were in the unemployed (41.2) suggesting deprivation and lifestyle behaviour do influence TB infection

Fig 7  showing three year rolling average  of TB cases reported (Bedford Borough Council)

Health protection

Source: Tuberculosis in the East of England Public Health England Centre; Annual review (2014 data)

Fig 8 below demonstartes that crude rate of cases/100,000 population of Bedford did show decline 38.7/100,000 in  2013 from 52.5/100,000 in 2012. However, it has again gone up to 41/100,000 in 2014. This is significantly higher than both England and East of England average.

Fig 8 showing annual TB rate/100,000 population by local authotity ( 2000-2014)

Health Protection

 

Source: Tuberculosis in the East of England Public Health England Centre; Annual review (2014 data)

To address the gaps recommended in NICE 2016 and National TB startegy. Five practices out of the 9 high risk practices identied with BBC have implemented Latent TB screening test for their new registrants and eligible high risks patients on their register not tested for LTBI. Project will be evaluated and local TB service will be informed with the recoomendations from the findings.

 

National and Local Strategies

Best practice based on:

      i.        Tuberculosis: Quality standard [QS141] Published date, January 2017accssed through https://www.nice.org.uk/guidance/qs141

    ii.        NICE guideline [NG33]; Published January 2016  ,updated: May 2016 NICE 

   iii.        Pathway Tuberculosis accessed throughhttps://www.nice.org.uk/guidance/ng33

   iv.        National Institute of Health and Clinical Excellence (NICE, 2012) Identifying and managing tuberculosis among hard-to-reach groups Public Health Guidance 37

    v.        Collaborative Tuberculosis Strategy for England (2015-2020)

   vi.        Department of Health (2009) Supply of TB drugs to patients – changes to regulations and advice on implementation

 

England has a higher rate of TB than most other western countries as well as being four times as high as the USA. In response to this concern, PHE released the ‘Collaborative tuberculosis strategy for England 2014 to 2019’ in January 2015. 

 

The strategy aims to commit to tackling TB through the following areas of focus:

•           Improving access to services and ensure early diagnosis;

•           Provide universal access to high quality diagnostics;

•           Improve treatment and care services;

•           Ensure comprehensive contact tracing;

•           Improve BCG vaccination uptake;

•           Reduce drug resistant TB;

•           Tackle TB in underserved populations;

•           Systematically implement new entrant latent TB screening;

•           Strengthen surveillance and monitoring and

•           Ensure an appropriate workforce to deliver TB control.

 

The strategy recommends screening recent entrants to the UK (last 5 years) for latent TB at priority practices. The process for screening for latent TB, in line with the recommendations for best practice outlined by NICE (2011) involves the use of Interferon Gamma Release Assays (IGRA). An economic evaluation of the use of such screening processes for latent TB has demonstrated cost-effectiveness (Gray & Ormerod, 2007). TB Services commissioned by Bedfordshire Clinical Commissioning Group incorporate the routine use of IGRA testing (T-Spot).

 

Effective screening and treatment of 1000 cases of latent TB, at a cost of £550,000, could prevent 150 active cases of TB, which would cost an estimated £900,000 to treat. The effective management of each active case of TB, through a local TB service, is essential in preventing the progression of the infection to a drug resistant or multi-drug resistant strain, which average a cost of £50-70,000 per case to treat.

 

Evidence exists to support the structure of the BCG immunisation programme to prevent against TB infection, and also to support the delivery of local services to prevent, diagnose and manage TB. Following a review of BCG vaccination by the JCVI, a national policy change was implemented in 2005 and is still relevant to refer

 

What are the unmet service needs/gaps?

Unlike England as a whole, data shows that Bedford Borough hasn’t shown a sustained decrease in incidence of TB each year with fluctuations since 2009 (Table 3). There are a number of key actions which may be taken to reduce TB incidence and improve the health outcomes for those with TB in Bedford Borough.

 

  i.    Screening for latent and active TB within the new entrant population to meet the recommendations of the national strategy. It is likely that doing so will have a significant impact upon the capacity of the TB Service; however, the cost-effectiveness of screening for TB has been demonstrated.  Local processes for identifying new entrants likely to be at high risk of TB are currently inadequate and are not effective in identifying all those who would require screening to meet current best practice guidance.

 

ii.         Local TB Service provision should be commissioned in line with best practice guidance for hard-to-reach groups, which incorporates elements to improve service provision such as:

•           Access to emergency accommodation

•           Rapid access clinics

•           Referral pathways to supportive services

•           Improved access to screening

 

ii.    A review of local surge capacity is required, to ensure adequate TB service     capacity and support in place in the event of a local TB outbreak. 

 

  iii. The local BCG immunisation programme switched from a school based national programme, to a targeted programme in 2005. It is apparent that a cohort of young people will have fallen between the two programmes, and some of these children will be considered at high risk of TB infection. Work should be undertaken locally to ensure that appropriate and sufficient measures are being taken to identify young people at risk of TB in order to offer then screening and /or immunisation.

 

  iv. Local priorities are focused on improving services for the prevention, detection and treatment of latent and active TB, in line with latest best practice guidance (NICE 2016).

 

Recommendations

Unlike England as a whole, data shows that Bedford Borough hasn’t shown a sustained decrease in incidence of TB each year with fluctuations since 2009 (Table 3). There are a number of key actions which may be taken to reduce TB incidence and improve the health outcomes for those with TB in Bedford Borough.

 

  i.    Screening for latent and active TB within the new entrant population to meet the recommendations of the national strategy. It is likely that doing so will have a significant impact upon the capacity of the TB Service; however, the cost-effectiveness of screening for TB has been demonstrated.  Local processes for identifying new entrants likely to be at high risk of TB are currently inadequate and are not effective in identifying all those who would require screening to meet current best practice guidance.

ii.         Local TB Service provision should be commissioned in line with best practice guidance for hard-to-reach groups, which incorporates elements to improve service provision such as:

•           Access to emergency accommodation

•           Rapid access clinics

•           Referral pathways to supportive services

•           Improved access to screening

 

ii.    A review of local surge capacity is required, to ensure adequate TB service     capacity and support in place in the event of a local TB outbreak. 

  iii. The local BCG immunisation programme switched from a school based national programme, to a targeted programme in 2005. It is apparent that a cohort of young people will have fallen between the two programmes, and some of these children will be considered at high risk of TB infection. Work should be undertaken locally to ensure that appropriate and sufficient measures are being taken to identify young people at risk of TB in order to offer then screening and /or immunisation.

  iv. Local priorities are focused on improving services for the prevention, detection and treatment of latent and active TB, in line with latest best practice guidance (NICE 2011).

 

Hepatitis B & C

Hepatitis B and Hepatitis C are blood borne viral infections that can lead to Chronic Liver disease and Liver Cancer resulting in potentially preventable serious ill health and death.

The virus may be transmitted by contact with infected blood or body fluids such as through household or sexual contact with an infected person. The virus can be transmitted by the following routes:

 

      i.        Vertical transmission (mother to baby) from an infectious mother to her unborn child;

    ii.        Sexual transmission through unprotected vaginal and anal sex;

   iii.        Sharing or use of contaminated equipment during injecting drug use;

   iv.        Medical or dental treatment in medium to high prevalence countries;

    v.        Receipt of infectious blood or infectious blood products from medium to high prevalence countries;

   vi.        Needle stick or other sharps injuries (in particular those sustained by hospital personnel);

  vii.        Tattooing and body piercing.

 

Hepatitis B is a vaccine preventable disease, which means infection can be prevented in high risk groups through the provision of immunisation.

 

Facts, Figures and Trends

Hepatitis B

Public Health England (PHE) has had significant issues with geographical assignment of the Hepatitis data. There has been no clear change in the incidence of Hepatitis B in the East of England since 2009 with an incidence of 0.85/100,000 in 2009 and 0.89/100,000 in 2014.

 

Nationally, there seems to have been an overall trend of a reduction in cases since 2009 with 1.15 cases per 100,000 however rates have fluctuated. The PHE Health Protection report, August 2012 (Vol 6 no 34) gives an incidence of Hepatitis B in various age groups of England. The 25–34 age group have the highest incidence at 2.26 per 100,000 population followed by 35-44 age group with 1.94 per 100,000per population. The above data is not available in local form.

 

The incidence of Hepatitis B in 2012 (Bedford borough) was 13.6 /100,000. The population vaccination coverage for Hepatitis B at one year old (for eligible children) and at 2 years old, uptake is 100% (2015/16).

 

Hospital admission rate( 3 year-2012-2014)  for Hepatitis B related end stage liver disease or Hepatocellular carcinoma was less than England average of 1.14/100,000 population and East of England average of 0.49/100,000. The value cannot be displayed due to low number of cases. There were no deaths recorded due to end stage hepatitis liver disease in people age below 75.

7.3% of eligible people entering substance misuse treatment received a complete course of Hepatitis B vaccination is higher than the EoE average of 6.3%, and similar to England average of 8.7.

 

Hepatitis C

Count of lab confirmed Hepatitis C increased, 3 cases reported for Bedford; with a rate of 1.3/100,000.Public Health England (PHE) has had significant issues with geographical assignment of the Hepatitis data.

78.9% of people in substance misuse treatment who inject drugs received Hepatitis C testing in in between (2012-14); this is similar to England and East of England averages of 81.5% and 80.3% respectively.

Hospital admission rate for Hepatitis C related end stage liver disease and hepatocellular cancer was recorded 3.9/100,000(3-year pooled 2012-14) , which is higher than England of  2.3/100,000 and EoE average of 2.0/100,000. Premature mortality due to end stage liver disease in people with Hepatitis C was reported as 0.45/100,000 population and is similar to England average of 0.65 and EoE average of 0.47.

 

National and Local Strategies

Hepatitis B and C:

 The Best practice guidelines and evidence used to deliver Hepatitis services are:

      i.        The green book https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/179349/green_book_complete.pdf.pdf 

    ii.        BASSH UK National guidelines on the management of the viral Hepatitis A,B and C 2008

   iii.        Hepatitis B and C: ways to promote and offer testing to all people at increased risk of infection. NICE public health guidance 43. Dec 2012

   iv.        UK national guidelines on safer sex advice July 2012

    v.        Joint Report on Hepatitis C in the East of England 2006 August 2007; NHS East of England, Health Protection Agency Regional Epidemiology Unit, Eastern Cancer Registry and Information Centre (ECRIC), Eastern Region Public Health Observatory (ERPHO). http://www.erpho.org.uk/Download/Public/18413/1/HepC%20in%20the%20EoE%20Joint%20Report%20Aug%202007.pdf 

 

The above best practice guidance and evidence base recommends to provide antenatal screening and new-born immunisation programme and vaccinate all in high risk groups as identified in the green book. Post exposure vaccination and testing should be available for accidental inoculation, contamination and sexual partners.  Testing for Hepatitis B should be available in primary care, prisons and youth offender institutions, immigration removal centres, drugs services and in genitourinary medicine and sexual health clinics, Mental health and Learning Disability assessment and treatment unites for disturbed/challenging service users; and all prisoners, youth offenders and immigration detainees should be offered access to confidential testing for Hep B and C during their detention.

 

Best practice also suggests to raise awareness and provide services to test and early diagnose Hepatitis B and C especially for those at high risk (such as migrants from high prevalence countries, people who inject or have injected drugs, men who have sex with men, those who change sexual partners frequently, those in receipt of infectious blood or infectious intervention and persons with tattoos and skin piercings).  General population should be educated about the importance of early diagnosis and management of Hepatitis B and C and safer sex should always be promoted.

 

There should be regular updates to Health care workers to follow standard infection control precautions at all times; provision of needle exchange and harm reduction programs in drug services, accident and emergency services and some pharmacies.  Health care professionals should have knowledge and skills to identify and appropriately address the needs of high risk groups.  Primary care practitioners should promote the importance of Hepatitis C testing for children who may have been exposed to Hepatitis C at birth or during childbirth

 

Local skin piercing businesses should adhere to health and safety measures and national regulations while offering their services. 

 

To address the gap in data storage there should be a system for collection and collation of robust service level data on testing and treatment

 

What are the unmet needs/ service gaps?

Hepatitis B and Hepatitis C

  1. Develop the knowledge and skills of healthcare professionals and others providing services for people at increased risk of Hepatitis B and C
  2. Foster and adoptive families need to be made aware of the need for Hepatitis vaccine;
  3. Prison: the procedure for screening for BBV’s could be improved with point of care testing;
  4. Immigration detainees – Routine testing not supported by UK Boarder agency/Dept. of health (DOH), however will do serology testing if requested or perceived high risk
  5. Primary care – Hepatitis B and C awareness raising, and testing needs to increase
  6. Skin piercing businesses are regulated by Bedford Borough and should be using sterile procedures and equipment, however a number of freelance practitioners remain unregulated therefore there may be a risk of infection. 
  7. Lack of robust data for immunization, testing and treatment of Hepatitis B and C disaggregated at the LA level.

 

Recommendations

  1. Raise awareness of Hepatitis B vaccination at foster carers training (BCCG and SEPT)
  2. Explore the uptake of Hepatitis Vaccination in people with learning difficulties in residential homes (Local Authority Public Health)
  3. Increase testing  for Hepatitis B and C in: Primary care; HMP Bedford; Youth offending Service; Yarlswood Immigration removal centre; Brook and Terrence Higgins Trust Sexual health Clinics and Bedford and Luton and Dunstable Hospital Trust Genito-urinary Medicine Clinics (BCCG-responsible organisation)
  4. Wider use of Point of Care Tests (POCT) for both Hepatitis B and C in HMP Bedford; Yarlswood Immigration removal centre; and Primary care (SEPT, SIRCO and BCCG-responsible organisations)
  5. Increase range of needle exchange and harm reduction programs in BHT and LDHT Accident and Emergency departments (BCCG)
  6. Raising awareness of the risks of tattoos and body piercings to the skin piercers and the general population (Local Authority Public Health and environmental health)
  7.  Hepatitis B and C data collection of vaccinations, screening and treatment, needs strengthening by using formal contracting / commissioning in: Bedford hospital trust; Luton and Dunstable hospital trust; Brook and Terrence Higgins trust Sexual Health services; Primary care; Learning disabilities; Foster carers; HMP Bedford; Yarlswood Immigration removal centre and CAN partnership ( BCCG –responsible organisation)

 

Health Care Acquired Infection (HCAI)

HCAI are infections that are acquired as a result of healthcare interventions. There are a number of factors that can increase the risk of acquiring an infection, but high standards of infection control practice minimise the risk of occurrence. PHE assists infection control and the control of antimicrobial resistance in the healthcare setting by monitoring these infections with mandatory and voluntary surveillance schemes covering bacteraemia (blood stream infections). Bacteraemia caused by Staphylococcus aureus - both methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive Staphylococcus aureus (MSSA), E.Coli and glycopeptide-resistant enterococcus (GRE), Clostridium difficile infection (C. diff/CDI) and surgical site infections (of which some orthopaedic categories are mandatory) via the surgical site infection surveillance scheme (SSISS) are all monitored. Other healthcare associated infections, including antimicrobial (antibiotic) resistant micro-organisms are also monitored via a voluntary microbiology laboratory reporting system.

The HPA (now part of Public Health England, as of 1 April 2013) coordinated England's participation in the European Centre for Disease Controls (ECDC) Fourth National Prevalence Survey on Healthcare Associated Infections & First National Prevalence Survey on Antimicrobial Use and Quality Indicators in England. Hospitals in England participated in data collection between September and November 2011. Key results from the survey have shown that

  • The prevalence of HCAI was 6.4%. A total of 3,360 patients were diagnosed with an active HCAI with 135 patients having more than one.
  • When comparing ward specialties, HCAI prevalence was highest in patients in intensive care units (ICUs) at 23.4 per cent followed by surgical wards at eight per cent.
  • The most common types of HCAI were respiratory (including pneumonia and infections of the lower respiratory tract) (22.8 per cent), urinary tract infections (UTI) (17.2 per cent), and surgical site infections (15.7 per cent). Since the last PPS in 2006 there has been a eighteen fold reduction overall in MRSA bloodstream infections - from 1.3 per cent to less than 0.1 per cent in patients; and a fivefold reduction in C. difficile infections (from two per cent to 0.4 per cent).
  • The prevalence of antimicrobial use was 34.7%.
  • Most antibiotic use (53 per cent) in hospitals was in patients receiving treatment for infections which commenced in the community. Thirty percent of surgical prophylaxis was prescribed for greater than one day.

 

Surveillance of Healthcare Associated Infection (HCAI)

 

The Department of Health (DH) began mandatory surveillance of MRSA bloodstream infections (bacteraemia) in 2001. Data is reported via the Health Protection Agency monthly and quarterly. This includes all MRSA bloodstream infections, whether acquired in the hospital or in the community and whether considered to be contaminants or not.

 

From January 1st 2011 it became mandatory for English NHS Acute Trusts to report Methicillin Sensitive Staphylococcus aureus (MSSA) and from 1st June 2011 to report Escherichia. Coli bacteraemia surveillance data to Public Health England (PHE).

 

Depending on the time and location of testing bacteraemia are either apportioned to the acute trust or non-acute settings. When an in-patient, if identified on day 1 or 2 of admission (with day 1 being admission day) the case is considered non-acute apportioned and if identified on day 3 or later the case is considered hospital apportioned. However, if apportioned to the community setting any recent inpatient activity would be investigated as a component of the Post Infection Review (PIR) or Root Cause Analysis (RCA).

 

Facts, Figures, Trends

The profile of Infection prevention and control (IPC) has been raised significantly over the last few years due to increased public awareness and the publication of the Health and Social Care Act (2008) Code of Practice for the Prevention and Control of Healthcare Associated Infections (updated 2011). This legislative Act means everyone involved in healthcare provision must demonstrate acceptable standards of infection prevention and control.

 

Clostridium Difficile: 

Since 2004 the reporting of Clostridium difficile infection has been mandatory. All NHS Trusts are required to test all diarrhoeal stool samples submitted to the microbiology laboratory for examination in accordance with the Department of Health (DOH 2012) guidelines. All episodes of infection are reported via the Public Health England (PHE) mandatory enhanced surveillance system. An episode consists of one or more GDH EIA and C-diff toxin positive stool during a 28 day period. Targets have been set for all NHS organisations, including Clinical Commissioning Groups (CCG). CCG targets are based on cases amongst the population, for which the CCG is responsible, whether acquired in acute hospitals or within the community.

The number of CDI cases within BCCG reached 87 for patients aged 2 years and over against an annual ceiling of 73, which are 14 cases over the ceiling. Of these 38 were apportioned to the acute trusts and remaining 49 were apportioned to non-acute trusts diagnosed from samples taken within 48 hours of admission to the hospital or taken in the community. There are now more non-acute trust cases over the year than acute trust apportioned which may reflect earlier patient discharge and patient management within the non-acute setting.

 

Figure 9 showing C.Diff infection cases apportioned to Bedfordshire clinical commissioning group

 

Health Protection

Source: BCCG Health Protection Committee report, September 2016

Figure 10 howing Trend of C diff infection apportioned to BCCG since 2008

 

Health Protection

 

Figures below showing BCCG C.Diff cases apportioned to our local acute trusts fig 11a and 11b (BGH)

Health Protection                                          

Health Protection

 

Bedford Hospital NHS Trust finished the year with 23 cases against a year end ceiling of 10 cases (Fig 11b)Full reviews have been carried out for all cases. The following themes have been identified as on-going issues

  • Timeliness of specimen collection – many of the patients had symptoms several days before a specimen was collected
  • Timeliness of isolation of affected patient – usually due to lack of recognition that the patient may have an infection and so delay in specimen collection leading to delay in isolation.
  • Antimicrobial stewardship was not optimal in a few cases. The antimicrobial pharmacist is involved in all patient reviews and again timely feedback is given to the appropriate team caring for the patients.

Luton and Dunstable foundation trust finished the year with 11 cases against a year end ceiling of 6(fig 11a)Full reviews of all cases have been carried out. The following have been identified from RCA this year:

  • Appropriateness and timeliness of specimen collection and testing – there have been delays at ward level in collection of samples
  • Isolation delays due to delayed identification of the issue

 

Benchmarking within the East of England shows that despite being over the year end ceiling, BCCG is sixth lowest with 20.43 cases of infection per 100,000 of population. This is lower than the East of England and the England total for the year.

Benchmarking within the East of England shows Bedford Hospital NHS Trust has an infection rate of 19.07 cases per 100,000 occupied bed days for April 2015 – March 2016. This is sixteenth within the East of England.  Luton and Dunstable Foundation trust has 5.70 infections per 100,000 occupied bed days which is the lowest within the East of England.

There were a total of 51 non-acute apportioned cases of CDI for the year. 25 (49%) of the non-acute cases had their specimen taken at admission to hospital (within 48 hours) and 26 (51%) had their specimen sent by the GP.

Local NHS and non NHS partners agreed following System-wide Actions:

  • Full review of all cases of CDI with feedback to all relevant parties including clinicians, GPs and other provider services highlighting any issues, lessons learnt and good practice. In this way it helps to keep infections high on the profile of all provider organisations.
  • Antimicrobial stewardship groups in progress for all providers to include surveillance of antimicrobial usage, guidance/policy updates and prescribing issues. Medicines management continue to monitor GP antibiotic prescribing
  • In-patient stay areas are monitoring time to isolation with an emphasis on rapid isolation and testing for all patients with diarrhoea
  • Communication among all providers and ways to improve this.

 

Acute provider action plans to be discussed at the system-wide meetings as part of the on-going actions plan.                                              

 

Methicillin Resistant Staphylococcus Aureus (MRSA)

Staphylococcus aureus is a common coloniser of human skin and mucosa, but can cause disease, particularly if there is an opportunity for the bacteria to enter the body. Methicillin-resistant Staphylococcus aureus (MRSA) are a subset of Staphylococcus aureus resistant to most β-lactam antibiotics such as flucloxacillin that are normally used to treat Staphylococcus aureus infections. Most patients who are colonised with MRSA do not go on to develop an infection, but colonisation is a known risk factor. Reporting of MRSA bacteraemia has been mandatory in England since April 2001 when the Department of Health (DH) began mandatory surveillance. Reduction targets have been set year on year since then with the goal of no avoidable infections and since April 2013 there has been a zero tolerance objective nationwide.

 

The final number of cases of MRSA bacteraemia for BCCG was 3 against a zero tolerance ceiling nationally for the year. 1 case was identified as hospital apportioned to Bedford Hospital NHS Trust and 2 cases were non acute apportioned. A full review was carried out for each case with all providers involved in the process. Luton and Dunstable hospital Foundation trust finished the year with 4 cases of MRSA bacteraemia but all cases were non-BCCG patients

 

Fig 12  showing MRSA bacteraemia cases apportioned to BCCG patient population

Methicillin sensitive bacteraemia cases 2015-16

   

 

Bedford Hospital Assigned

L&D Hospital Assigned

Assigned to other acute trusts

Non acute trust

Non NHS Trusts

Total reported

MRSA Bacteraemia

1

1

1

1

3

77

Source: Patient Safety and Quality Committee report, September 2016

 

Fig  13 Trend of MRSA Bacteraemia from 1st April 2009 till 31st march 2016.

Health ProtectionBCCG has had 1.64 cases per 100,000 population and is fifteenth within the East of England from April 2015 to March 2016. This is comparable to the England total of 1.52 cases per 100,000 populations for the year.

 

From the Post Infection Review the following were identified and System-wide actions were taken to strengthen MRSA bacteraemia prevention by strengthening the clinical input at the post infection review meetings so that lessons learnt are given a priority and immediate actions can be taken; dissemination and discussion of findings across the whole health economy via the system wide group were carried out to share practice and learning.  Antimicrobial stewardship and policy reviews were also carried out by provider organisations.

 

Methicillin Sensitive Staphylococcus aureus (MSSA) Bacteraemia

Figure 14   allocation of MSSA bacteraemia to BCCG

Health Protection

 

Mandatory surveillance for MSSA bacteraemia began in January 2011. Presently no trajectories have been set however all cases must be reported. Root cause analysis must be undertaken for acute trust apportioned cases to determine trends.

 

58 cases were identified  in between April 2015- march 2016; out of which 10 cases were apportioned to acute trusts and remaining were from non-acute trust (fig 23). Reviews of all cases were carried out to determine if there was any connection between cases or links to healthcare. Two cases were linked to healthcare but not to each other, all other cases were found to be sporadic with no link to healthcare.

 

Escherichia coli (E. coli) Bacteraemia

 

Enhanced mandatory surveillance for E. coli bacteraemia was commenced in June 2011 and all cases must be reported and an investigation carried out to determine if the case may be healthcare related. Presently no targets have been set.

 

There were 261 cases of E-Coli bacteraemia reported between April 2015 and March 2016; out of which only 13.4% of the cases (35) were health care related; another 55% (144) of the cases were non health care related where source of infection were known. Remaining 31% (82) of the cases where source of infection could not be identified(unknown).

 

Figure 14 showing E.Coli Bacteraemia apportioned to BCCG 2015/16

Health Protection

 

 

National and Local Strategies

i.        Healthcare associated infection: http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publichealth/Healthprotection/Healthcareassociatedinfection/index.htm

ii.        Mandatory surveillance of orthopaedic surgical site infection and C. difficile associated diarrhoea; accessed through http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Bulletins/theweek/Chiefexecutivebulletin/DH_4080306

iii.        NICE infection Prevention and Control Clinical standard 61

Mandatory surveillance of Clostridium difficile associated disease (CDAD) in people aged 65 years and over has been included in the healthcare-associated infection surveillance system for acute trusts in England since January 2004. This scheme is operated by the HPA (now PHE) on behalf of the DH. Data are collected quarterly from each of the 169 acute NHS trusts in England that treat adult patients.

Acute NHS trusts in England are required to report all cases of CDAD in patients aged 65 years and over. This applies whether C. difficile is considered to have been acquired in that trust, in another hospital or in the community. Cases are defined as all diarrhoeal specimens that test positive for C. difficile toxin where the patient has not been diagnosed with CDAD in the preceding four weeks. The criteria for testing for infection and reporting cases were defined by the National Clostridium difficile Standards Group. All acute trusts are also required to participate in a random sampling scheme to enable strain characterisation. This began in January 2005. New ambitions have been set for the NHS which builds on the progress made on infections last year. The NHS is being asked to collectively reduce the numbers of infections on MRSA by a further 29% and Clostridium difficile (C. difficile) by 17%.

National Institute for Health and Clinical Excellence (NICE)

NICE have published infection Prevention and Control Clinical standard 61 (April 2014).  Available at:   www.nice.org.uk/guidance/qs61#close

 

The care standard covers the prevention and control of infection for people receiving health care in primary, community and secondary care settings. It is expected to contribute to improvements in infection rates and avoidable death from healthcare associated infections and has 6 quality statements:

National Institute for Health and Clinical Excellence (NICE)

NICE have published infection Prevention and Control Clinical standard 61 (April 2014). 

  1. People are prescribed antibiotics in accordance with local antibiotic formularies as part of antimicrobial stewardship.
  2. Organisations that provide healthcare have a strategy for continuous improvement in infection prevention and control, including accountable leadership, multi-agency working and the use of surveillance systems.
  3. People receive healthcare from healthcare workers who decontaminate their hands immediately before and after every episode of direct contact or care.
  4. People who need a urinary catheter have their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed.
  5. People who need a vascular access device have their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the device and its removal as soon as it is no longer needed.
  6. People with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate), are educated about the safe management of the device or equipment, including techniques to prevent infection.

 

The quality measure accompanying the quality statements aim to improve the structure, process and outcomes of care in areas identified as needing quality improvement.

This document has been circulated to the infection prevention and control teams at each provider organisation.

 

What are the unmet service needs/gaps?

BCCG continues to work closely with all providers to ensure a continued reduction of Health care acquired infections with review and feedback of all cases, regular system-wide meetings to discuss issues, learning and innovations and focus on good antibiotic stewardship. However, the objectives for the current financial year are once again challenging and will require continued vigilance in this area:

      i.        Robust process to challenge excessive and inappropriate prescribing of Antibiotics and further GP ownership of all cases (does not mean GPs are responsible for infection);

    ii.        Patient education about the treatment compliance and importance of adherence to the prescribed dose and course;

   iii.        Sharpening Root cause analysis for all HCAIs.

   iv.        Ensure local policy on Infection Control is implemented at the practice and apply Infection Control measures (hand washing, use of PPE, handling sharps, decontamination, sterilisation, disinfection and patient isolation) in managing patients.

 

Recommendations 

      i.        Support and adopt Zero tolerance approach for all avoidable HCAI

    ii.        Significant engagement with partner agencies, increased discussion with all acute providers and further GP ownership of all cases. Ensure commissioners, providers and other partner agencies involved in performance management comprehensively comply with mandatory surveillance process.

   iii.        Year-end review of data, with sharpened regular root cause analysis (RCA) for better understanding the causes of these infections and, where appropriate, use in making improvements in infection prevention and control practices. The availability of a more comprehensive picture of the scale of HCAI, nationally and locally, will support clinicians and patients in making meaningful choices about providing and receiving healthcare.

   iv.        Identify and address risk reduction: Apply infection control measures at all levels, implement infection control policies. Maintain infection control capacity. Educate clinicians to comply with antibiotic policy and patients to adhere with the antibiotic treatment.

    v.        Consider reduction plan for E-coli and MSSA bacteraemia: In line with the requirement stated in the NHS Operating Framework 2011/12, that organisations should plan to make “sufficient progress in collecting and analysing data on MSSA and E. coli bacteraemia", it may also be possible to reduce rates of the subset (around 30%) of E. coli bacteraemia occurring in hospital inpatients through the same mechanism. Additionally a proportion of cases are likely to relate to healthcare in the community and by focussing on this as well, it may also be possible to reduce rates of E-coli infection. Bedfordshire is not yet required to set reduction plans at this stage. It should comprehensively comply with mandatory data reporting to support establishing robust base line of HCA E.coli infection. Bedfordshire in discussion with its participating agencies may consider what additional interventions could be introduced to minimise E.Coli infections.

   vi.        NICE have published infection Prevention and Control Clinical standard 61 (April 2014). The care standard covers the prevention and control of infection for people receiving health care in primary, community and secondary care settings. This document has been circulated to the infection prevention and control teams at each provider organisation. Providers should ensure that the quality measure accompanying the quality statements aim to improve the structure, process and outcomes of care in areas identified as needing quality improvement.

 

Current Services

Tuberculosis:

Patients living in Bedford Borough will predominantly access TB services commissioned by NHS Bedfordshire CCG and provided by Cambridgeshire Community Services, based at the Luton and Dunstable Hospital.

 

The following services provided as part of the wider service delivery:

 

  1. Screening and diagnosing:  active and latent TB. Screening is undertaken on a range of patient groups including new entrants, high risk groups and contacts of diagnosed TB cases.
  2. Treatment: Patients diagnosed with latent TB will be started on the appropriate medication regimen and are managed within the TB service as long as they remain non-complex. Patients with active TB will commence an appropriate treatment regimen, guided by a Chest Physician at the Luton & Dunstable Hospital, supported by the TB Service. 
  3. BCG immunisation is delivered as part of a targeted immunisation programme for those screened as being at high risk of contracting TB.  

 

Seasonal Influenza Vaccination:

NHS England through its local NHS providers will deliver the programme. GP practices are the main source of free influenza vaccinations for people in an identified risk category. Community pharmacies are also commissioned by NHSE to deliver flu vaccination service. This is available during the national flu vaccination campaign, which usually runs from October to January each year.  For pregnant women there is an argument for having midwives provide seasonal flu vaccination in order to facilitate vaccination. The setting for this is likely to remain the GP practice in most cases, and such a service development will require development of a service specification and contractual arrangements.

Each year influenza immunisation uptake is monitored for all of the risk categories and PHE will continue to be responsible for coordinating and monitoring the data collection for influenza vaccine uptake and reporting of national data on influenza immunisation of eligible patient groups and frontline healthcare workers.

It is the employers' responsibility regarding arrangements for vaccination of healthcare workers in direct contact with patients and in social care settings and should make vaccines available free of charge to employees if a risk assessment indicates that they are needed. Public Health in the local authority is responsible for providing support to NHS agencies and ensuring the successful delivery of the flu vaccination programme.

 

Hepatitis B and C:

The following providers are involved in supplying services for Hepatitis B and C:

South Essex Partnership Trust (SEPT) provides the following services at HMP Bedford:

-       Day 1 – All prisoners given information on BBV on reception

-       Day 2 – All offered blood tests for BBV at ‘well man’s screening’

-       All prisoners have to make appointment for blood test at the next available clinic on a Monday

Results are sent to the prison doctor electronically and prisoners are referred to GUM if positive

 

Yarlswood Immigration removal centre provides the following services at Milton Ernest and Bedford:

-       Offer serology tests for all BBV’s if requested or are high risks.

-       Referral to Hepatology and / or GUM if required

 

Bedford GUM Service offers tests for all BBV’s at Bedford Hospital Trust.

 

Luton and Dunstable GUM Service offers tests for all BBVs at the Luton and Dunstable Hospital Trust

 

Brook Sexual Health Service in Bedford offers tests for all BBVs.

 

The following Sphere clinics offer tests for all BBVs

 

-       Asplands Surgery; Woburn Sands;

-       Cranfield Surgery;

-       12, Goldington Rd Surgery Bedford;

-       Great Barford Surgery;

-       Houghton Close Surgery, Ampthill;

-       Kirby Road Surgery,  Dunstable;

-       Leighton Road Surgery,  Leighton Buzzard;

-       Linden Road Surgery,  Bedford;

-       Pemberley Ave Surgery, Bedford;

-       Putnoe Medical Centre Bedford;

-       Wootton Healthy Living Centre

 

Health Care Acquired Infection:

As of April 2007 all acute NHS Trusts in England are required to report all cases of CDI in patients aged 2 years and over. All NHS trusts are responsible for uploading their surveillance data each month and PHE (formerly the Health Protection Agency) produces tables of counts of CDI on a monthly and annual basis. Every quarter the data collected in the enhanced surveillance is used to produce epidemiological commentaries

 

What are the main findings for health protection?

Key Findings:

      i.        Uptake of Seasonal Influenza vaccine in carers and in persons with serious medical conditions needs improvement and flu immunisation for carers working at care homes/residential homes commissioned by local authorities needs attention as uptake is not as expected.

    ii.        Preschool boosters, especially MMR coverage although better than England and EOE, needs further improvement as it has not met its target of 95%.

   iii.        To make our current Tuberculosis aligned to National TB strategy and NICE compliant; processes for identifying high risk new entrant pateints should be in place and screening should be offered to all high risk patients at the time of the registration. Five practices within Bedfordshire are offering Latent TB infection screening to its eligible high risk people.

   iv.        Bedfordshire Clinical commissioning Group (BCCG) has seen an overall reduction in C.diff cases. Between April 2015 and March 2016 there were a total of 87 cases of CDI in patients aged 2 years and over and it has exceeded its trajectory by 11 cases.

    v.        There is a zero tolerance for MRSA bacteraemia; in the year 2015/16. Any of the providers could not maintain and incidence rate of MRSA/100,000 has exceeded its trajectory of zero tolerance by 7 cases being reported.  

   vi.        High level of uptake for Antenatal screening at both the local hospitals. However we are unable to analyse screening outcome data beyond the level of acute Hospital Trust. This inhibits the compilation of trend data relating to HIV, Syphilis, and Hepatitis B.

 

Key Inequalities

     i. When GP practice level performance is considered against the Indices of Multiple Deprivation (IMD) Index score, no clear relationship is observed for any of the 6 immunisations delivered between birth and 5 years of age. This suggests that across Bedford Borough, level of deprivation does not influence level of immunisation uptake. Further work is required locally to understand the factors that might be adversely affecting immunisation uptake.

   ii. Uptake Influenza vaccination by the population in Bedford Borough Council is below the national targets especially in people with long term conditions and pregnant women. We still have to reach out to 15% of the eligible vulnerable population to have a positive impact on reducing premature mortality.  Part of this picture is wide inequality in uptake of seasonal influenza vaccination between GP practice registered populations, with some practices not able to influence over half of patients in some risk categories.

  iii. Lack of full immunisation history as a part of the routine health screening when prisoners are sentenced into the prison and vaccinations records update are not available as per the DOH(2012) requirement.

 

  iv. There is no reliable national data related to the prevalence of communicable disease in our local prison, beyond HIV, Hepatitis B and C. 

 

   v. POCT (Point of care and testing) not available at the detention centre. All the detainees are not offered Hepatitis B vaccination when entering the centre.

 

  vi. Gap in services for homeless migrants in promoting and facilitating screening and treatment. More needs to be done to facilitate screening in this population especially for infectious diseases, particularly HIV, Hepatitis B, C and TB, and where appropriate haemoglobin electrophoresis and full antenatal screening.

 

Key recommendations

  1. Agencies involved in delivering services should plan a targeted approach to improve our immunisation uptake (Flu in at risk groups and preschool boosters) with multi agency involvement.
  2. Joint campaign in conjunction with partner agencies to raise awareness about Infectious and non-infectious disease screening uptake especially cervical cancer screening in young women.
  3. Jointly agreed communication strategy and pathway between local authorities and all the partner agencies involved.   One responsible agency for safe cascading and disseminating consistent information to all relevant partner agencies and external agencies.
  4. Annual infection control training to all carers and primary care professionals, also annual Immunisation update for primary care professionals (GPs and nurses) should be arranged.  Community infection prevention is now a responsibility of Local authority under the leadership of DPH. .
  5. Increase screening and diagnosis for Tuberculosis; review patient pathways as appropriate and advise the commissioning of surveillance, detection and provision of services for TB to make our current service NICE complaint and to fit national TB strategy.
  6. Developing a locally agreed, multiagency protocol to govern the management of infants born to Hepatitis B positive mothers.
  7. Improving early access time of 10 weeks required for maintaining uptake of antenatal and newborn screening indicators

 

This chapter links to the following chapters in the JSNA:

 

References

              I.                BASSH UK National guidelines on the management of the viral Hepatitis A,B and C 2008

             II.                Collaborative Tuberculosis Strategy for England (2015-2020)

            III.                Department of Health (2006) Immunisation against infectious disease London: TSO

           IV.                Department of Health (2009) Supply of TB drugs to patients – changes to regulations and advice on implementation

            V.                Department of Health (2009a) Healthy Child Programme: Pregnancy and the first five years of life London: DH

           VI.                Department of Health (2009b) Healthy Child Programme: From 5-19 years old London

         VII.                Department of Health (2011) Hepatitis B antenatal screening and new-born immunisation programme: Best practice guidance  London : DH

        VIII.                Department of Health (DoH) ‘Hepatitis B antenatal screening and new-born immunisation programme - Best practice guidance’ makes clear recommendations to improve the uptake rate of existing Hepatitis B immunisation programmes for new-borns who are at risk of Hepatitis B infection (DH, 2011).

           IX.                Department of Health: seasonal flu plan 2015-2016. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/418038/Flu_Plan_Winter_2015_to_2016.pdf

            X.                Healthcare associated infection: http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publichealth/Healthprotection/Healthcareassociatedinfection/index.htm

           XI.                Hepatitis B and C: ways to promote and offer testing to all people at increased risk of infection. NICE public health guidance 43. Dec 2012

         XII.                Joint Report on Hepatitis C in the East of England 2006 August 2007; NHS East of England, Health Protection Agency Regional Epidemiology Unit, Eastern Cancer Registry and Information Centre (ECRIC), Eastern Region Public Health Observatory (ERPHO). http://www.erpho.org.uk/Download/Public/18413/1/HepC%20in%20the%20EoE%20Joint%20Report%20Aug%202007.pdf 

        XIII.                Mandatory surveillance of orthopaedic surgical site infection and C. difficile associated diarrhoea; accessed through http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Bulletins/theweek/Chiefexecutivebulletin/DH_4080306

       XIV.                National Childhood Influenza Vaccination Programme, 2015 to 2016 (Seasonal influenza vaccine uptake for children of primary school age) accessed through https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/544542/Childhood_Influenza_Vaccination_Programme_Report_2015_2016.pdf

        XV.                National Institute of Health and Clinical Excellence (NICE, 2012) Identifying and managing tuberculosis among hard-to-reach groups Public Health Guidance 37

       XVI.                Neonatal hepatitis B immunisation programme, 2013-accessed through https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/256463/1_neonatal_hepatitis_b.pdf

      XVII.                Neonatal hepatitis B immunisation programme, 2013-accessed through https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/256463/1_neonatal_hepatitis_b.pdf

    XVIII.                NHS Infectious Diseases in Pregnancy Screening Programme Standards 2016 to 2017 accessed through: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/529070/IDPS_Programme_Standards_2016_to_2017.pdf

       XIX.                NHS Infectious Diseases in Pregnancy Screening Programme: Laboratory Handbook 2016 to 2017 accessed through: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/539828/NHS_Infectious_Diseases_in_Pregnancy_Screening_Programme_Laboratory_Handbook_2016_2017_with_gateway_number.pdf

        XX.                NICE 2009. Amantadine, oseltamivir and zanamivir for the treatment of influenza. Available at: www.nice.org.uk/TA168

       XXI.                NICE guideline [NG33]; Published January 2016  ,updated: May 2016 NICE 

      XXII.                NICE infection Prevention and Control Clinical standard 61 Available at:   http://publications.nice.org.uk/infection-prevention-and-control-qs61#close

    XXIII.                Pathway Tuberculosis accessed throughhttps://www.nice.org.uk/guidance/ng33

   XXIV.                The flu immunisation programme 2015/16. Letter from the Chief Medical Officer, the director of nursing and the chief pharmaceutical officer for England, 27 March 2015. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/418428/Annual_flu_letter_24_03_15__FINALv3_para9.pdf 

     XXV.                The green book https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/179349/green_book_complete.pdf.pdf 

   XXVI.                The National Institute for Health and Clinical Excellence (NICE) (2009)Reducing differences in the uptake of immunisations (including targeted vaccines) among children and young people aged under 19 years  London : NICE

  XXVII.                Tuberculosis: Quality standard [QS141] Published date, January 2017accessed through https://www.nice.org.uk/guidance/qs141

 XXVIII.                UK national guidelines on safer sex advice July 2012

 

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