Paediatric respiratory tract infection surveillance: a...

14 March 2017

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Paediatric respiratory tract infection surveillance: a

community-based feasibility inception cohort study

Emma C. Anderson 1, 2, Suzanne M. Ingle 1, 2, Peter Muir 1, 3, Charles R. Beck 1, 2, 4,

John P. Leeming 5, Christie Cabral 1, 2, Joanna M. Kesten 1, 6, and Alastair D. Hay 1, 2

bristol.ac.uk/eepris

1 NIHR Health Protection Research Unit in Evaluation of Interventions, University of Bristol 2 School of Social and Community Medicine, University of Bristol 3 Public Health England, Specialist Virology Centre, Bristol 4 Field Epidemiology Service, Public Health England, Bristol 5 North Bristol NHS Trust, Bristol Centre for Antimicrobial Research and Evaluation (BCARE) 6 NIHR Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at

University Hospitals Bristol NHS Foundation Trust, Bristol, UK

Background

• Burden of infectious diseases + children + RTIs

• Antimicrobial resistance

• Most research conducted at presentation

• Research needed to better understand: - who acquires infections (and why),

- natural history of infections among non-consulters,

- who consults (and why) and

- how to develop self care interventions

• Feasibility of recruitment & retention to community cohort study

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Aims

1. Establish feasibility of (predominately online) recruitment and retention to a

paediatric RTI community surveillance study

- with collection of syndromic and microbiological data

2. Estimate for community RTIs in children:

- symptom duration

- primary care consultation rates

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virus data

Methods

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Participants: Immunocompetent children ≥3 months to ≤14 years +parents/carers

Recruitment: (mainly) letters from GP surgeries in the Bristol area - Also: reminder letter, text, posters and cards in GP surgeries, UoB website, ‘snowball’ recruitment

Timeline: Enrolment end Feb–early June 2016 (staggered); no new RTIs after July

Enrolment: • Parent returns paper consent form in post to study team • Tel call (admin) to check eligibility and explain study process • Eligible parent emailed a link to complete baseline data online

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Data collection (1)

1. Parents provided baseline data online for eligible child/ren = Recruited - child characteristics, household demographics, health anxiety

2. Parents replied to weekly email (link). Yes = New study RTI

- confirm absence/presence of “new RTI” symptoms

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Data collection (2)

3. Once symptomatic:

- Parents - daily data online (symptoms severity)

- RN home visit - swabs (nasal & saliva) -> take to lab on ice (ideal)

- Parents took swabs (intended no help from RN) -> post to lab (pragmatic)

4. On recovery (parent-reported 2 days symptom free):

- Parents took (asymptomatic) swabs -> post to lab, final questions

5. Primary care medical notes review

- Medical history and consultation details for children with RTI

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Results - recruitment

• 10 GP surgeries took part, 5 sent mailout

• Parent/carer of 10,310 children invited (94% no response)

- reminder letter sent from 4 surgeries to 8,401

- reminder text sent from 2 surgeries to 1543

• 485 children enrolled (4.7% of invited) from 331 families

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Results - recruitment

Sample characteristics

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Invited, not enrolled (N = 9,853) Enrolled (N = 485) Chi-squared p-value

Age, years median (IQR) 6 (3-10) 4 (2-8) <0.001*

Female, N (%) 4,831 (49.0%) 245 (50.3%) 0.52

IMD decile, N (%):

<0.001

1 (most deprived) 2,278 (23.1) 41 (8.7)

2 878 (8.9) 44 (9.3)

3 1,315 (13.3) 41 (8.7)

4 1,140 (11.6) 58 (12.3)

5 342 (3.5) 15 (3.2)

6 350 (3.6) 45 (9.6)

7 970 (9.9) 63 (13.4)

8 1,668 (16.9) 105 (22.3)

9 414 (4.2) 25 (5.3)

10 (least deprived) 494 (5.0) 34 (7.2)

*Wilcoxon rank-sum p value

Results Parent-level Characteristic N (%)

Gender

Missing 3 (0.91)

Female 301 (90.9)

Male 27 (8.16)

Age, years* (median, IQR) 39 (35-45)

Missing 13 (3.93)

Ethnicity

Missing 13 (3.93)

Asian 7 (2.11)

Black 10 (3.02)

Mixed 8 (2.42)

White 291 (87.92)

Other 2 (0.60)

Employment

Missing 13 (3.93)

Full time parent/care-giver 45 (13.60)

In full time education 3 (0.91)

Not currently employed 13 (3.93)

Working full time 77 (23.26)

Working part-time 180 (54.38)

Education

Missing 13 (3.93)

'A' Levels / NVQs / GNVQs or equivalent 19 (5.74)

First degree / diploma / HNC / HND or equivalent 165 (49.85)

Higher degree (eg MSc, PhD) or equivalent 117 (35.35)

No official qualification 3 (0.91)

Up to GCSEs/ GCEs / 'O' Levels or equivalent 14 (4.23)

Do you have any medical training?

Missing 13 (3.93)

No 252 (76.13)

Yes 66 (19.94)

• Parents = highly educated mothers

• Children = less deprived and younger than those

invited not participating

Results – data collection

From cohort of 485 children (331 families):

• New onset RTIs recorded: 346 in 259 (53.4%) children from 206 (62%) families

- 122 (25%) children from 113 (34%) families ill with RTI at baseline

• RN visit complete for 57% of RTIs

- 199 (57%) of 346 RTIs had RN visit (169 [65%] children, 139 [42%] families)

• Retention to symptoms resolution = 87%

- 305 (88%) of 346 RTIs in 225 (87%) children from 180 (87%) families

• Swab sets received by laboratory = over 90% of all possible sets:

- 195 (98% of 199) = symptomatic (in 165 [98%] children from 136 [98%] families)

- 282 (92% of 305) = asymptomatic (in 215 [96%] children from 172 [96%] families)

• Primary care notes review complete: 100% (of 259)

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Consultation rates (notes review)

Restricting to first RTI in family with symptoms reported, N=197:

• 16 (8.1% of 197 [95% CI 4.7% to 12.8%]) resulted in ≥1 NHS consultation

- 14 GP, 2 Emergency Department attendances

• 19 NHS contacts in total - equivalent to 9.6 consultations per 100 RTI episodes

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04 April 2017 Results

Symptoms duration (parent-reported)

RTI duration (days) by percentile

All 10th 25th 50th 75th 90th p-valuea

All (first RTIs per family) children 197 4 7 9 14 23 -

Consultingb and non-consultingb children

Consultingb 16 6 9 13 18 37 0.06

Non-consultingb 181 4 6 9 13 21

Upper and lower respiratory tract infection

Exclusively upperd RTI symptoms 86c 3 5 8 11 15 <0.001

Any lowerd RTI symptoms 104c 6 8 12 18 29.5

Constitutional symptom severity (mean maximum) scoree by upperd and lowerd RTI

Upperd RTI Lowerd RTI

Fever 0.55 1.07

Fatigue 0.83 1.71

Disruption to sleep 1.15 2.19

Disruption to other activities 0.67 1.43

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a Log-rank test for difference between consulting and non-consulting episodes b Any NHS (primary and secondary care) attendance according to medical notes

Restricting to first RTI in family with symptoms reported, N=197:

Results

• Median RTI duration = 9 days (IQR 7-14 days) • 23 days for resolution of symptoms in 90% children (95% CI 85%-94%)

• Weak evidence: consulting children longer duration than non-consulting

Conclusion

• Community infection surveillance is feasible

- Low response rates

- Less deprived families with younger children more likely to respond

- Excellent retention - Symptom data, Microbial data

• Novel evidence of consultation rate per community illness:

- Parents seek primary care support in around 1 in 12 RTI episodes

• Community RTI duration similar to duration gained from consulting populations (previous research)

• Parent-reported LRTI symptoms are prognostically significant

- longer duration, more severe symptoms

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Questions?

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Acknowledgements

This research was partly funded by the NIHR Health Protection Research Unit

in Evaluation of Interventions at University of Bristol.

The views expressed are those of the author(s) and not necessarily those of the

NHS, the NIHR, the Department of Health or Public Health England.



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URTI

LRTI

systemic

Results – LRTI vs URTI

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0.0

00

.25

0.5

00

.75

1.0

0

0 20 40 60 80analysis time

cluster = Exclusively URTI cluster = Mix

cluster = Exclusively LRTI cluster = Neither URTI or LRTI

Kaplan-Meier survival estimates

LRTI longer duration

median = 8 vs 12 days*

*P<0.001


Severity of systemic symptoms

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Upper and lower respiratory tract infection

Exclusively upperd RTI symptoms 86c 3 5 8 11 15 <0.001

Any lowerd RTI symptoms 104c 6 8 12 18 29.5

Constitutional symptom severity (mean maximum) scoree by upperd and lowerd RTI

Upperd RTI Lowerd RTI

Fever 0.55 1.07

Fatigue 0.83 1.71

Disruption to sleep 1.15 2.19

Disruption to other activities 0.67 1.43

Restricting to first RTI in family with symptoms reported, N=197

c 7 RTI episodes which did not report any URTI or LRTI-defining symptoms d Parent reported upper RTI symptoms: earache, sore throat, runny/blocked nose, ear discharge, dry cough or barking/croupy cough.

Parent reported lower RTI symptoms: wet/productive cough, breathing faster/shortness of breath, or wheeze/whistling chest e Maximum of daily scores in first 21 days, based on Likert scale zero (‘normal, no problem’) to six (‘as bad as it could be’)

The EEPRIS Study Team

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31 October 2016

Professor Alastair Hay – Chief Investigator

Emma Anderson – Study Manager

and clinician interview lead

Anna Gilbertson – Research Nurse

Penny Seume – Administrator

Co-investigators Dr Suzanne Ingle – statistician, University of Bristol (UoB)

Dr Peter Muir – microbiology lead, Public Health England (PHE)

Dr Charles Beck – (PHE) – infection surveillance/ PHE advice

Dr John Leeming (UoB) – microbiology advice

Professor Adam Finn (UoB) – HPRU microbiology advice

Dr Jo Kesten (UoB) – qualitative lead for parent/child interviews

Collaborators Dr Christie Cabral (UoB) – qualitative advisor

Dr Isabel Lane (UoB) – clinician interviews, intervention development

Dr Katy Turner (UoB) – RTI modelling implications advice

Dr Jennifer Oliver (UoB) – HPRU microbiology advice

Professor William Hollingworth (UoB) – health economics advice

Dr Hannah Thornton (UoB) – microbiological methodology advice

Dr Isabel Oliver (PHE) – PHE perspective

Dr Richard Puleston (PHE) – epidemiology advice

Dr Paul Cleary (PHE) – epidemiology advice

Dr Tim Moss – Qualitative research/ health psychology advice,

Doctoral supervisor for Emma Anderson

Sue Milner – Research Nurse

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