Patrick Nguipdop-Djomo

Objective: Government guidance to reduce COVID-19 transmission was rapidly implemented by headteachers in primary and secondary schools in England. This study investigated the main challenges and opportunities faced by headteachers during the pandemic recovery period (starting in March 2021 when schools reopened indefinitely). Findings are intended to inform education policy to support schools and for future outbreaks. Design: Qualitative study involving semi-structured interviews. Setting: Primary and secondary schools in England from April to September 2022. Method: We undertook remote interviews using Zoom with 10 headteachers and senior leaders from six primary and four secondary schools. A thematic analysis was conducted to identify challenges and opportunities faced by schools when implementing COVID-19 preventive measures. Results: Participants continued to implement some preventive measures (ventilation, optional face masks, handwashing) into the recovery period. Hybrid learning was a large burden on schools, even more so than remote learning. Many schools felt confident in their ability to scale preventive measures up or down if needed in the future. Due to the increased utilisation of resources dedicated to the COVID-19 response, school budgets were felt to be at risk for the forthcoming school years. Conclusion: Implementation measures advised by the Government were perceived as helpful but came at a large human resource and financial cost. Schools should be provided with flexible guidance to allow leadership to tailor preventive measures to their own context. This would require technical advisory support to be available. Further research is needed to understand the impact of the COVID-19 recovery period on a wider scale for both teachers and students.

Bovine tuberculosis (bTB), a neglected zoonotic disease, is endemic in cattle in many Sub-saharan African countries, yet its contribution to tuberculosis (TB) burden is understudied. Rapid urbanisation and increase in demand for animal proteins, including dairy products, increases the risk of spill over. This study compared the latent tuberculosis infection (LTBI) risk in children, a proxy-measure for recent TB infection, in children living in high cattle density areas to children from the general population in Cameroon. Cross-sectional study in the Centre Region of Cameroon in 2021, recruiting 160 children aged 2–15 years, stratified by exposure to livestock, people treated for pulmonary TB (PTB) and the general community. Veinous blood was tested for LTBI using QuantiFERON–TB Gold-Plus. Prevalence were calculated and the association to exposure and other risk factors investigated using logistic regression models. The crude LTBI prevalence were 8.2% in the general population, 7.3% in those exposed to cattle and 61% in pulmonary TB household contacts. After adjusting for confounding and sampling design, exposure to cattle and exposure to pulmonary TB were associated with higher risk of LTBI than the general population (respectively odds ratio (OR): 3.56, 95%CI: 0.34 to 37.03; and OR: 10.36, 95%CI: 3.13 to 34.21). Children frequently consuming cow milk had higher risk of LTBI (OR: 3.35; 95%CI 0.18 to 60.94). Despite limited statistical power, this study suggests that children exposed to cattle in a setting endemic for bTB had higher risk of LTBI, providing indirect evidence that Mycobacterium bovis may contribute to TB burden.

Background: Bovine tuberculosis (bTB), a neglected zoonotic disease, is endemic in cattle in many Sub-saharan African countries, yet its contribution to tuberculosis (TB) burden is understudied. Rapid urbanisation and increase in demand for animal proteins, including dairy products, increases the risk of spill over. This study compared the latent tuberculosis infection (LTBI) risk in children, a proxy-measure for recent TB infection, in children living in high cattle density areas to children from the general population in Cameroon. Method: Cross-sectional study in the Centre Region of Cameroon in 2021, recruiting 160 children aged 2-15 years, stratified by exposure to livestock, people treated for pulmonary TB (PTB) and the general community. Veinous blood was tested for LTBI using QuantiFERON–TB Gold-Plus. Prevalences were calculated and the association to exposure and other risk factors investigated using logistic regression models. Results: The crude LTBI prevalence were 8.2% in the general population, 7.3% in those exposed to cattle and 61% in pulmonary TB household contacts. After adjusting for confounding and sampling design, exposure to cattle and exposure to pulmonary TB were associated with higher risk of LTBI than the general population (respectively odds ratio (OR): 3.56, 95%CI: 0.34 to 37.03; and OR: 10.36, 95%CI: 3.13 to 34.21). Children frequently consuming cow milk had higher risk of LTBI (OR: 3.35; 95%CI 0.18 to 60.94). Conclusion: Despite limited statistical power, this study suggests that children exposed to cattle in a setting endemic for bTB had higher risk of LTBI, providing indirect evidence that Mycobacterium bovis may contribute to TB burden. Author Summary: Tuberculosis (TB) is the top infectious disease killer worldwide. Mycobacterium bovis ( M. bovis ) is the most common zoonotic and second most common cause of TB in humans. The pathogen is naturally resistant to pyrazinamide, a key component of standard anti-tuberculosis treatment, thus can hamper TB control and elimination efforts. M. bovis is endemic in cattle in this setting, but there is limited information on its contribution to TB burden. We used a specific test, the Interferon Gamma Released Assay, to compare latent TB infection (LTBI) rates in a random sample of children with high exposure to cattle, to that of children from the general community and from households with known pulmonary TB patient in and around a major urban centre in Cameroon; LTBI in children provide insight on recent infection, thus transmission. After adjusting for background differences, we found that exposure to cattle was associated with over three times higher risk of LTBI compared to the general population (and household exposure associated with over 10 times higher risk of infection). Our results suggest that exposure to cattle (therefore M. bovis ) contributes significantly to TB burden, and should be investigated thoroughly to support control efforts.

Background: The role of children and staff in SARS-CoV-2 transmission outside and within households is still not fully understood when large numbers are in regular, frequent contact in schools. Methods: We used the self-controlled case-series method during the alpha- and delta-dominant periods to explore the incidence of infection in periods around a household member infection, relative to periods without household infection, in a cohort of primary and secondary English school children and staff from November 2020 to July 2021. Results: We found the relative incidence of infection in students and staff was highest in the 1-7 days following household infection, remaining high up to 14 days after, with risk also elevated in the 6-12 days before household infection. Younger students had a higher relative incidence following household infection, suggesting household transmission may play a more prominent role compared with older students. The relative incidence was also higher amongst students in the alpha variant dominant period. Conclusions: This analysis suggests SARS-CoV2 infection in children, young people and staff at English schools were more likely to be associated with within-household transmission than from outside the household, but that a small increased risk of seeding from outside is observed. Key messages: Question : With respect to incidence of SARS-CoV-2 infection before and after household member infection, is within-household transmission more likely than community transmission amongst school children and staff? Findings : In this self-controlled case-series analysis, the relative incidence of infection in students and staff was highest in the 1-7 days following household infection, remaining high up to 14 days after, with the highest relative incidence found in younger, primary school-aged children. Importance : Within-household transmission is more likely than from outside the household, but a small increased risk of seeding from outside the household is observed as well as variation by age and variant dominant period.

BACKGROUND: We examined fidelity and feasibility of implementation of COVID‐19 preventive measures in schools, and explored associations between adherence to these measures and staff well‐being, to inform policy on sustainable implementation and staff wellbeing.METHODS: Surveys were conducted across 128 schools in England with 107 headteachers and 2698 staff‐members with reference to autumn term 2020, examining school‐level implementation of preventive measures, adherence, and teacher burnout (response rates for headteacher and staff surveys were 84% and 59%, respectively).RESULTS: The median number of measures implemented in primary and secondary schools was 33 (range 23‐41), and 32 (range 22‐40), respectively; most measures presented challenges. No differences were found regarding number of measures implemented by school‐level socio‐economic disadvantage. High adherence was reported for staff wearing face‐coverings, staff regularly washing their hands, (secondary only) desks facing forwards, and (primary only) increased cleaning of surfaces and student hand‐washing. Adherence to most measures was reported as higher in primary than secondary schools. Over half of school leaders and 42% (517/1234) of other teaching staff suffered from high emotional exhaustion. Higher teacher‐reported school‐wide adherence with measures was consistently associated with lower burnout for leaders and other teaching staff.CONCLUSIONS: Findings indicate a tremendous effort in implementing preventive measures and an urgent need to support investments in improving teacher wellbeing.

Tuberculosis (TB) rates in England are among the highest in high-income countries. Poverty and historic and current immigration from high TB incidence parts of the world are two major drivers of tuberculosis in England. However, little has been done in recent years to examine socio-economic trends in TB rates in England, and to disentangle the role of deprivation from that of place of birth in the current TB epidemiology. To assess the association between England’s 2008–2012 TB notification rates and small area-level deprivation, together and separately in the UK-born and foreign-born populations. Ecological analysis of the association between quintiles of England’s 2010 Index of Multiple Deprivation (IMD) and TB rates at the Lower-layer Super Output Area (LSOA; average population ~1500) level, using negative binomial and zero-inflated negative binomial regression models, adjusting for age, sex, urban/rural area classification, and area-level percentage of non-White residents. There was a log-linear gradient between area-deprivation levels and TB rates, with overall TB rates in the most deprived quintile areas three times higher than the least deprived quintile after adjustment for age and sex (IRR = 3.35; 95%CI: 3.16 to 3.55). The association and gradient were stronger in the UK-born than the foreign-born population, with UK-born TB rates in the most deprived quintiles about two-and-a-half times higher than the least deprived quintile (IRR = 2.39; 95%CI: 2.19 to 2.61) after controlling for age, sex, urban/rural classification and percentage of non-White residents; whereas the comparable figure for foreign-born persons was 80% higher (IRR = 1.78; 95%CI: 1.66 to 1.91). Socio-economic deprivation continues to play a substantial role in sustaining the TB epidemic in England, especially in the UK-born population. This supports the case for further investigations of the underlying social- determinants of TB.

Addressing social determinants of tuberculosis (TB) is essential to achieve elimination, including in low-incidence settings. We measured the association between socio-economic status and intermediate social determinants of health (SDHs, including drug misuse, tobacco smoking and alcohol), and TB, taking into account their clustering in individuals. We conducted a case-control study in 23–38 years old UK-born White adults with first tuberculosis episode, and randomly selected age and sex frequency-matched community controls. Data was collected on education, household overcrowding, tobacco smoking, alcohol and drugs use, and history of homelessness and prison. Analyses were done using logistic regression models, informed by a formal theoretical causal framework (Directed Acyclic Graph). 681 TB cases and 1183 controls were recruited. Tuberculosis odds were four times higher in subjects with education below GCSE O-levels, compared to higher education (OR = 3.94; 95%CI: 2.74, 5.67), after adjusting for other TB risk factors (age, sex, BCG-vaccination and stays ≥3 months in Africa/Asia). When simultaneously accounting for respective SDHs, higher tuberculosis risk was independently associated with tobacco smoking, drugs use (especially injectable drugs OR = 5.67; 95%CI: 2.68, 11.98), homelessness and area-level deprivation. Population Attributable Fraction estimates suggested that tobacco and class-A drug use were, respectively, responsible for 18% and 15% of TB cases in this group. Our findings suggest that socio-economic deprivation remains a driver of tuberculosis in England, including through drugs misuse, tobacco smoking, and homelessness. These findings further support the integration of health and social services in high-risk young adults to improve TB control efforts.