Elizabeth Button

Background: Influenza and respiratory syncytial virus (RSV) predominantly circulate during the winter season and cause acute respiratory illness (ARI). Deploying molecular point-of-care testing (POCT) in primary care can inform whether a patient presenting with an ARI has influenza or RSV. An early virological diagnosis could facilitate appropriate use of antivirals and enable better antimicrobial stewardship. Objective: This study aimed to report the impact of POCT for influenza and RSV on antimicrobial prescribing, including antiviral therapy in primary care. Methods: The impact of POCT for influenza on antimicrobial stewardship (PIAMS) in UK primary care was a nested cohort study undertaken from January 20 to May 31, 2023, after the period of peak virus circulation, within practices that contribute data to the English sentinel network. People presenting with ARI had a nasopharyngeal swab performed and were tested for influenza and RSV with a molecular POCT analyzer located within the practice. Data on antimicrobial prescribing and other study outcomes were collected by linking information from the analyzer to coded data from the patient’s computerized medical record. Results: In total, 323 swabs were collected from 10 PIAMS study practices. In total, 59.7% (197/323) of swabbed patients were female, and the mean age was 37.28 (SD 25.05) years. Furthermore, 2.9% (9/323) of all swabs were positive, with 0.3% (1/323) positive for influenza A, 1.6% (5/323) positive for influenza B, and 0.9% (3/323) positive for RSV. In total, 80 patients were prescribed antibiotics 7 days following POCT testing. There were no instances of antiviral prescribing in the 7 days post testing. A statistically significant difference in antibiotic prescribing given a positive POCT result compared with a negative test was not found with an unadjusted odds ratio (OR) of 7 days post testing. A statistically significant difference in antibiotic prescribing given a positive POCT result compared with a negative test was not found with an unadjusted OR of 1.54 (95% CI 0.38‐6.30; P=.55) and adjusted OR of 1.21 (95% CI 0.00‐1.78). Conclusions: This study illustrates the risk of having a narrow study window; our observation period was not aligned with when influenza was circulating. The peak of weekly incidence of influenza in the sentinel network was in the last week of 2022, and RSV was circulating before this. Further evidence is needed to assess the impact of POCT on antimicrobial prescribing. The viruses tested for using POCT could be aligned with the circulating viruses identified by the sentinel network.

Data quality in primary care is important for surveillance and research projects based on routinely collected computerised medical records data. We present the results of a targeted intervention of incentives and tools to record specific data about acute respiratory infectious disease. As part of an epidemiological study, practices received a template to code this information, which could also act as a consultation template. Use of the template was not restricted to patients taking part in the epidemiological study. We saw significant increases in coded data for patients in the study in the four areas that we examined; oxygen saturation, body temperature, respiratory rate and history of fever. For patients not included in the study we saw only small differences between study practices and non-study practices. There was an increased frequency of recording of measured body temperature in study practices but the effect was small (1.1%) 95% CI [0.56%,1.66%]. Primary care data quality can be improved with targeted interventions and support, but the effect does not transfer out of the specific patients for which it has been incentivised.

BACKGROUND Influenza and respiratory syncytial virus (RSV) predominantly circulate during the winter season and cause acute respiratory infections (ARI). Deploying molecular point-of-care testing (POCT) in primary care at can inform whether a patient presenting with an ARI has influenza or RSV. An early virological diagnosis, could facilitate appropriate use of antivirals and enable better antimicrobial stewardship. OBJECTIVE To report the impact of POCT for influenza and RSV on antimicrobial prescribing including antiviral therapy in primary care. METHODS The impact of POCT for influenza on antimicrobial stewardship (PIAMS) in UK primary care was an observational study undertaken 20th Jan–31st May 2023, in practices that contribute data to the English sentinel network. People presenting with ARI had nasopharyngeal swab performed and were tested for Influenza and RSV with a molecular POCT analyser located within the practice. Data on antimicrobial prescribing and other study outcomes were collected by linking information from the analyser to coded data from the patient’s computerised medical record (CMR). RESULTS In total 323 swabs were collected from ten PIAMS study practices. 59.7% (197/323) of swabbed patients were female, and the mean age was 37 years. 2.79% (9/323) of all swabs were positive, with 0.31% (1/323) positive for influenza A, 1.55% (5/323) postivie for influenza B and 0.93% (3/323) positive for RSV. In total 80 patients were prescribed antibiotics seven days following POCT testing. There were no instances of antiviral prescribing in the seven days post-testing. The odds ratio for antibiotic prescribing given a positive POCT result was 1.54 (95% CI: 0.38–6.30; P =0.55) compared with a negative test. CONCLUSIONS This study illustrates the risk of having a narrow study window, our observation period was not aligned with when influenza was circulating. The peak of weekly incidence of influenza in the sentinel network was in the last week of 2022, and RSV circulating prior to this. Further evidence is needed to assess the impact of POCT on antibimicrobial prescribing. The viruses tested for using POCT could be aligned with the circulating viruses identified by the sentinel network. CLINICALTRIAL Not applicable INTERNATIONAL REGISTERED REPORT RR2-10.2196/46938

Background: There are gaps in our understanding of the clinical characteristics and disease burden of the respiratory syncytial virus (RSV) among community-dwelling adults. This is in part due to a lack of routine testing at the point of care. More data would enhance our assessment of the need for an RSV vaccination program for adults in the United Kingdom. Objective: This study aimed to implement point-of-care-testing (POCT) in primary care to describe the incidence, clinical presentation, risk factors, and economic burden of RSV among adults presenting with acute respiratory infection. Methods: We are recruiting up to 3600 patients from at least 21 practices across England to participate in the Royal College of General Practitioners Research Surveillance Centre. Practices are selected if they undertake reference virology sampling for the Royal College of General Practitioners Research Surveillance Centre and had previous experience with respiratory illness studies. Any adult, ≥40 years old, presenting with acute respiratory infection with onset ≤10 days, but without RSV within the past 28 days, will be eligible to participate. We will estimate the incidence proportion of RSV, describe the clinical features, and risk factors of patients with RSV infection, and measure the economic burden of RSV infection. Results: A total of 25 practices across different English health administrative regions expressed interest and were recruited to participate. We have created and tested an educational program to deploy POCT for RSV in primary care. In addition to using the POCT device, we provide suggestions about how to integrate POCT into primary care workflow and templates for high-quality data recording of diagnosis, symptoms, and signs. In the 2023-2024 winter RSV detection in the sentinel network grew between October and late November. According to data from the UK Health Security Agency, the peak RSV swab positivity was in International Standards Organization week 48, 2023. Data collection remains ongoing, and results from the subset of practices participating in this study are not yet available. Conclusions: This study will provide data on the RSV incidence in the community as well as rapid information to inform sentinel surveillance and vaccination programs. This information could potentially improve clinical decision-making. International Registered Report Identifier (IRRID): DERR1-10.2196/60669

Infectious intestinal disease (IID) is a syndrome consisting of diarrhoea and vomiting symptoms linked to a causative pathogen. The Third Study of IID (IID3) will report its incidence in the community within the UK and assess how it has changed since the second IID study (IID2) in 2012. We implemented an automated, online patient recruitment process within a national sentinel surveillance network and compared its performance versus IID2 in terms of: Patient recruitment rates and demographic characteristics of recruited participants. We utilised a text messaging system (TMS) running off a computerised medical record systems (CMR) application programme interface (API). Demographic analysis showed that the majority of those recruited to IID3/IID2 studies were >65 years and female. However, the recruitment of participants of non-white ethnicity was statistically significantly different between IID3/IID2. Further work is required to improve recruitment in the younger patient demographic and in ethnic minority populations.

Background: Influenza contributes to the surge in winter infections and the consequent winter pressures on the health service. Molecular point-of-care testing (POCT) for influenza may improve patient management by providing rapid and accurate clinical diagnosis to inform the timely initiation of antiviral therapy and reduce unnecessary admissions and antibiotics use. Aim: To explore factors that influence the adoption or non-adoption of POCT in English general practices and provide insights to enable its integration into routine practice workflows. Design & setting: A qualitative implementation evaluation was conducted in 10 general practices within the English national sentinel network (Oxford RCGP Research and Surveillance Centre), from April–July 2023. Method: Using the Non-adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework, data collection and analysis were conducted across 10 practices. We made ethnographic observations of the POCT workflow and surveyed the practice staff for their perspectives on POCT implementation. Data were analysed using a mix of descriptive statistics, graphical modelling techniques, and framework analysis. Results: Ethnographic observations identified the following two modes of POCT integration into practice workflow: (1) clinician POCT workflow, which typically involved batch testing owing to time constraints; and (2) research nurse or healthcare assistant POCT workflow, which was characterised by immediate testing of individual patients. Survey data indicated that most primary care staff considered the POCT training offered was sufficient and these practices were ready for change. Some participants agreed that there was the capacity and resources to integrate POCT into workflows. It was uncertain as to whether POCT required changes to organisational routines and processes. Conclusion: General practices should demonstrate flexibility in the workflow and workforce they deploy to integrate POCT into routine clinical workflow.

Background: Prepandemic sentinel surveillance focused on improved management of winter pressures, with influenza-like illness (ILI) being the key clinical indicator. The World Health Organization (WHO) global standards for influenza surveillance include monitoring acute respiratory infection (ARI) and ILI. The WHO’s mosaic framework recommends that the surveillance strategies of countries include the virological monitoring of respiratory viruses with pandemic potential such as influenza. The Oxford-Royal College of General Practitioner Research and Surveillance Centre (RSC) in collaboration with the UK Health Security Agency (UKHSA) has provided sentinel surveillance since 1967, including virology since 1993. Objective: We aim to describe the RSC’s plans for sentinel surveillance in the 2023-2024 season and evaluate these plans against the WHO mosaic framework. Methods: Our approach, which includes patient and public involvement, contributes to surveillance objectives across all 3 domains of the mosaic framework. We will generate an ARI phenotype to enable reporting of this indicator in addition to ILI. These data will support UKHSA’s sentinel surveillance, including vaccine effectiveness and burden of disease studies. The panel of virology tests analyzed in UKHSA’s reference laboratory will remain unchanged, with additional plans for point-of-care testing, pneumococcus testing, and asymptomatic screening. Our sampling framework for serological surveillance will provide greater representativeness and more samples from younger people. We will create a biomedical resource that enables linkage between clinical data held in the RSC and virology data, including sequencing data, held by the UKHSA. We describe the governance framework for the RSC. Results: We are co-designing our communication about data sharing and sampling, contextualized by the mosaic framework, with national and general practice patient and public involvement groups. We present our ARI digital phenotype and the key data RSC network members are requested to include in computerized medical records. We will share data with the UKHSA to report vaccine effectiveness for COVID-19 and influenza, assess the disease burden of respiratory syncytial virus, and perform syndromic surveillance. Virological surveillance will include COVID-19, influenza, respiratory syncytial virus, and other common respiratory viruses. We plan to pilot point-of-care testing for group A streptococcus, urine tests for pneumococcus, and asymptomatic testing. We will integrate test requests and results with the laboratory-computerized medical record system. A biomedical resource will enable research linking clinical data to virology data. The legal basis for the RSC’s pseudonymized data extract is The Health Service (Control of Patient Information) Regulations 2002, and all nonsurveillance uses require research ethics approval. Conclusions: The RSC extended its surveillance activities to meet more but not all of the mosaic framework’s objectives. We have introduced an ARI indicator. We seek to expand our surveillance scope and could do more around transmissibility and the benefits and risks of nonvaccine therapies.