Publications by authors named "Dan Lewer"

33 Publications

Social and structural determinants of injecting-related bacterial and fungal infections among people who inject drugs: protocol for a mixed studies systematic review.

BMJ Open 2021 08 9;11(8):e049924. Epub 2021 Aug 9.

Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, UK.

Introduction: Injecting-related bacterial and fungal infections are a common complication among people who inject drugs (PWID), associated with significant morbidity and mortality. Invasive infections, including infective endocarditis, appear to be increasing in incidence. To date, preventive efforts have focused on modifying individual-level risk behaviours (eg, hand-washing and skin-cleaning) without much success in reducing the population-level impact of these infections. Learning from successes in HIV prevention, there may be great value in looking beyond individual-level risk behaviours to the social determinants of health. Specifically, the risk environment conceptual framework identifies how social, physical, economic and political environmental factors facilitate and constrain individual behaviour, and therefore influence health outcomes. Understanding the social and structural determinants of injecting-related bacterial and fungal infections could help to identify new targets for prevention efforts in the face of increasing incidence of severe disease.

Methods And Analysis: This is a protocol for a systematic review. We will review studies of PWID and investigate associations between risk factors (both individual-level and social/structural-level) and the incidence of hospitalisation or death due to injecting-related bacterial infections (skin and soft-tissue infections, bacteraemia, infective endocarditis, osteomyelitis, septic arthritis, epidural abscess and others). We will include quantitative, qualitative and mixed methods studies. Using directed content analysis, we will code risk factors for these infection-related outcomes according to their contributions to the risk environment in type (social, physical, economic or political) and level (microenvironmental or macroenvironmental). We will also code and present risk factors at each stage in the process of drug acquisition, preparation, injection, superficial infection care, severe infection care or hospitalisation, and outcomes after infection or hospital discharge.

Ethics And Dissemination: As an analysis of the published literature, no ethics approval is required. The findings will inform a research agenda to develop and implement social/structural interventions aimed at reducing the burden of disease.

Prospero Registration Number: CRD42021231411.
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http://dx.doi.org/10.1136/bmjopen-2021-049924DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8354281PMC
August 2021

Role of community drug and alcohol services in physical healthcare for people who use illicit opioids: a qualitative study of clinical staff in the UK.

BMJ Open 2021 07 26;11(7):e046577. Epub 2021 Jul 26.

Institute of Epidemiology and Healthcare, University College London, London, UK

Objectives: To understand how clinicians working in addiction services perceive their responsibilities for physical healthcare of clients who use opioids, and how physical healthcare could be improved for this group.

Design: Qualitative study comprising semistructured interviews.

Participants: 16 clinicians, including nurses and nurse practitioners, nurse consultants, addiction psychiatrists, specialist general practitioners and psychiatry specialty registrars.

Setting: Community-based drug and alcohol treatment services in the UK, with services including outpatient opioid agonist therapy.

Results: We identified three overarching themes. First, clients have unmet physical health needs that are often first identified in community drug and alcohol services. Participants reported attempts to improve their clients' access to healthcare by liaising directly with health services and undertaking other forms of health advocacy, but report limited success, with many referrals ending in non-attendance. Second, most participants saw their role as supporting access to mainstream health services rather than providing physical healthcare directly, though sometimes reported frustration at being unable to provide certain treatments such as antibiotics for a respiratory infection. A minority of participants felt that people who use illicit opioids would be best served by an integrated 'one-stop-shop' model, but felt this model is currently unlikely to receive funding. Third, participants felt isolated from other health services, in part due to commissioning arrangements in which funding is provided through local government rather than the National Health Service.

Conclusions: Clinicians participating in this study serve a patient group with unmet physical health needs, but lack the resources to respond effectively to these needs.
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http://dx.doi.org/10.1136/bmjopen-2020-046577DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8314719PMC
July 2021

Cuts to local government funding and stalling life expectancy.

Authors:
Dan Lewer Jo Bibby

Lancet Public Health 2021 09 12;6(9):e623-e624. Epub 2021 Jul 12.

The Health Foundation, London, UK.

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http://dx.doi.org/10.1016/S2468-2667(21)00136-5DOI Listing
September 2021

Healthcare use by people who use illicit opioids (HUPIO): development of a cohort based on electronic primary care records in England.

Wellcome Open Res 2020 5;5:282. Epub 2021 May 5.

Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1UD, UK.

People who use illicit opioids such as heroin have substantial health needs, but there are few longitudinal studies of general health and healthcare in this population. Most research to date has focused on a narrow set of outcomes, including overdoses and HIV or hepatitis infections. We developed and validated a cohort using UK primary care electronic health records (Clinical Practice Research Datalink GOLD and AURUM databases) to facilitate research into healthcare use by people who use illicit opioid use (HUPIO). Participants are patients in England with primary care records indicating a history of illicit opioid use. We identified codes including prescriptions of opioid agonist therapies (methadone and buprenorphine) and clinical observations such as 'heroin dependence'. We constructed a cohort of patients with at least one of these codes and aged 18-64 at cohort entry, with follow-up between January 1997 and March 2020. We validated the cohort by comparing patient characteristics and mortality rates to other cohorts of people who use illicit opioids, with different recruitment methods. Up to March 2020, the HUPIO cohort included 138,761 patients with a history of illicit opioid use. Demographic characteristics and all-cause mortality were similar to existing cohorts: 69% were male; the median age at index for patients in CPRD AURUM (the database with more included participants) was 35.3 (interquartile range 29.1-42.6); the average age of new cohort entrants increased over time; 76% had records indicating current tobacco smoking; patients disproportionately lived in deprived neighbourhoods; and all-cause mortality risk was 6.6 (95% CI 6.5-6.7) times the general population of England. Primary care data offer new opportunities to study holistic health outcomes and healthcare of this population. The large sample enables investigation of rare outcomes, whilst the availability of linkage to external datasets allows investigation of hospital use, cancer treatment, and mortality.
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http://dx.doi.org/10.12688/wellcomeopenres.16431.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901498.2PMC
May 2021

Health of people experiencing co-occurring homelessness, imprisonment, substance use, sex work and/or severe mental illness in high-income countries: a systematic review and meta-analysis.

J Epidemiol Community Health 2021 Oct 23;75(10):1010-1018. Epub 2021 Apr 23.

MRC/CSO Social and Public Health Sciences Unit, University of Glasgow Institute of Health and Wellbeing, Glasgow, UK.

Background: People affected by homelessness, imprisonment, substance use, sex work or severe mental illness experience substantial excess ill health and premature death. Though these experiences often co-occur, health outcomes associated with their overlap have not previously been reviewed. We synthesised existing evidence on mortality, morbidity, self-rated health and quality of life among people affected by more than one of these experiences.

Methods: In this systematic review and meta-analysis, we searched Medline, Embase, and PsycINFO for peer-reviewed English-language observational studies from high-income countries published between 1 January 1998 and 11 June 2018. Two authors undertook independent screening, with risk of bias assessed using a modified Newcastle-Ottawa Scale. Findings were summarised by narrative synthesis and random-effect meta-analysis.

Results: From 15 976 citations, 2517 studies underwent full-text screening, and 444 were included. The most common exposure combinations were imprisonment/substance use (31% of data points) and severe mental illness/substance use (27%); only 1% reported outcomes associated with more than two exposures. Infections were the most common outcomes studied, with blood-borne viruses accounting for 31% of all data points. Multiple exposures were associated with poorer outcomes in 80% of data points included (sign test for effect direction, p<0.001). Meta-analysis suggested increased all-cause mortality among people with multiple versus fewer exposures (HR: 1.57 and 95% CI: 1.38 to 1.77), though heterogeneity was high.

Conclusion: People affected by multiple exclusionary processes experience profound health inequalities, though there are important gaps in the research landscape. Addressing the health needs of these populations is likely to require co-ordinated action across multiple sectors, such as healthcare, criminal justice, drug treatment, housing and social security.

Prospero Registration Number: CRD42018097189.
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http://dx.doi.org/10.1136/jech-2020-215975DOI Listing
October 2021

High COVID-19 death rates in prisons in England and Wales, and the need for early vaccination.

Lancet Respir Med 2021 06 16;9(6):569-570. Epub 2021 Mar 16.

Royal College of General Practitioners Secure Environments Group, London, UK.

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http://dx.doi.org/10.1016/S2213-2600(21)00137-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7963444PMC
June 2021

Linking opioid use disorder treatment from hospital to community.

Addiction 2021 08 18;116(8):2244-2245. Epub 2021 Mar 18.

Division of Addiction Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

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http://dx.doi.org/10.1111/add.15460DOI Listing
August 2021

Household transmission of seasonal coronavirus infections: Results from the Flu Watch cohort study.

Wellcome Open Res 2020 19;5:145. Epub 2020 Jun 19.

UCL Public Health Data Science Research Group, UCL Institute of Health Informatics, University College London, London, NW1 2DA, UK.

In the context of the current coronavirus disease 2019 (COVID-19) pandemic, understanding household transmission of seasonal coronaviruses may inform pandemic control. We aimed to investigate what proportion of seasonal coronavirus transmission occurred within households, measure the risk of transmission in households, and describe the impact of household-related factors of risk of transmission. Using data from three winter seasons of the UK Flu Watch cohort study, we measured the proportion of symptomatic infections acquired outside and within the home, the household transmission risk and the household secondary attack risk for PCR-confirmed seasonal coronaviruses. We present transmission risk stratified by demographic features of households. We estimated that the proportion of cases acquired outside the home, weighted by age and region, was 90.7% (95% CI 84.6- 94.5, =173/195) and within the home was 9.3% (5.5-15.4, 22/195). Following a symptomatic coronavirus index case, 14.9% (9.8 - 22.1, 20/134) of households experienced symptomatic transmission to at least one other household member. Onward transmission risk ranged from 11.90% (4.84-26.36, 5/42) to 19.44% (9.21-36.49, 7/36) by strain. The overall household secondary attack risk for symptomatic cases was 8.00% (5.31-11.88, 22/275), ranging across strains from 5.10 (2.11-11.84, 5/98) to 10.14 (4.82- 20.11, 7/69). Median clinical onset serial interval was 7 days (IQR= 6-9.5). Households including older adults, 3+ children, current smokers, contacts with chronic health conditions, and those in relatively deprived areas had the highest transmission risks. Child index cases and male index cases demonstrated the highest transmission risks. Most seasonal coronaviruses appear to be acquired outside the household, with relatively modest risk of onward transmission within households. Transmission risk following an index case appears to vary by demographic household features, with potential overlap between those demonstrating the highest point estimates for seasonal coronavirus transmission risk and COVID-19 susceptibility and poor illness outcomes.
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http://dx.doi.org/10.12688/wellcomeopenres.16055.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7848853PMC
June 2020

Seasonality and immunity to laboratory-confirmed seasonal coronaviruses (HCoV-NL63, HCoV-OC43, and HCoV-229E): results from the Flu Watch cohort study.

Wellcome Open Res 2020 10;5:52. Epub 2020 Dec 10.

UCL Public Health Data Science Research Group, Institute of Health Informatics, UCL, London, NW1 2DA, UK.

There is currently a pandemic caused by the novel coronavirus SARS-CoV-2. The intensity and duration of this first and second waves in the UK may be dependent on whether SARS-CoV-2 transmits more effectively in the winter than the summer and the UK Government response is partially built upon the assumption that those infected will develop immunity to reinfection in the short term. In this paper we examine evidence for seasonality and immunity to laboratory-confirmed seasonal coronavirus (HCoV) from a prospective cohort study in England. In this analysis of the Flu Watch cohort, we examine seasonal trends for PCR-confirmed coronavirus infections (HCoV-NL63, HCoV-OC43, and HCoV-229E) in all participants during winter seasons (2006-2007, 2007-2008, 2008-2009) and during the first wave of the 2009 H1N1 influenza pandemic (May-Sep 2009). We also included data from the pandemic and 'post-pandemic' winter seasons (2009-2010 and 2010-2011) to identify individuals with two confirmed HCoV infections and examine evidence for immunity against homologous reinfection. We tested 1,104 swabs taken during respiratory illness and detected HCoV in 199 during the first four seasons. The rate of confirmed HCoV infection across all seasons was 390 (95% CI 338-448) per 100,000 person-weeks; highest in the Nov-Mar 2008/9 season at 674 (95%CI 537-835) per 100,000 person-weeks. The highest rate was in February at 759 (95% CI 580-975) per 100,000 person-weeks. Data collected during May-Sep 2009 showed there was small amounts of ongoing transmission, with four cases detected during this period. Eight participants had two confirmed infections, of which none had the same strain twice. Our results provide evidence that HCoV infection in England is most intense in winter, but that there is a small amount of ongoing transmission during summer periods. We found some evidence of immunity against homologous reinfection.
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http://dx.doi.org/10.12688/wellcomeopenres.15812.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786426.2PMC
December 2020

Hospital readmission among people experiencing homelessness in England: a cohort study of 2772 matched homeless and housed inpatients.

J Epidemiol Community Health 2021 Jan 5. Epub 2021 Jan 5.

Institute of Health Informatics, University College London, London, UK.

Background: Inpatients experiencing homelessness are often discharged to unstable accommodation or the street, which may increase the risk of readmission.

Methods: We conducted a cohort study of 2772 homeless patients discharged after an emergency admission at 78 hospitals across England between November 2013 and November 2016. For each individual, we selected a housed patient who lived in a socioeconomically deprived area, matched on age, sex, hospital, and year of discharge. Counts of emergency readmissions, planned readmissions, and Accident and Emergency (A&E) visits post-discharge were derived from national hospital databases, with a median of 2.8 years of follow-up. We estimated the cumulative incidence of readmission over 12 months, and used negative binomial regression to estimate rate ratios.

Results: After adjusting for health measured at the index admission, homeless patients had 2.49 (95% CI 2.29 to 2.70) times the rate of emergency readmission, 0.60 (95% CI 0.53 to 0.68) times the rate of planned readmission and 2.57 (95% CI 2.41 to 2.73) times the rate of A&E visits compared with housed patients. The 12-month risk of emergency readmission was higher for homeless patients (61%, 95% CI 59% to 64%) than housed patients (33%, 95% CI 30% to 36%); and the risk of planned readmission was lower for homeless patients (17%, 95% CI 14% to 19%) than for housed patients (30%, 95% CI 28% to 32%). While the risk of emergency readmission varied with the reason for admission for housed patients, for example being higher for admissions due to cancers than for those due to accidents, the risk was high across all causes for homeless patients.

Conclusions: Hospital patients experiencing homelessness have high rates of emergency readmission that are not explained by health. This highlights the need for discharge arrangements that address their health, housing and social care needs.
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http://dx.doi.org/10.1136/jech-2020-215204DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8223662PMC
January 2021

Risk of discharge against medical advice among hospital inpatients with a history of opioid agonist therapy in New South Wales, Australia: A cohort study and nested crossover-cohort analysis.

Drug Alcohol Depend 2020 12 12;217:108343. Epub 2020 Oct 12.

National Drug and Alcohol Research Centre, 22-32 King St, Randwick NSW 2031, Australia.

Background: People who use illicit opioids have high rates of hospital admission. We aimed to measure the risk of discharge against medical advice among inpatients with a history of opioid agonist therapy (OAT), and test whether OAT is associated with lower risk of discharge against medical advice.

Methods: We conducted a cohort study of patients admitted to hospital in an emergency between 1 August 2001 and 30 April 2018 in New South Wales, Australia. All patients had a previous episode of OAT in the community. The main outcome was discharge against medical advice, and the main exposure was whether patients had an active OAT permit at the time of admission.

Results: 14,035/116,957 admissions (12 %) ended in discharge against medical advice. Admissions during periods of OAT had 0.79 (0.76-0.83; p < 0.001) times the risk of discharge against medical advice, corresponding to an absolute risk reduction of 3.0 percentage points. Risk of discharge against medical advice was higher among patients who were younger, male, identified as Aboriginal and/or Torres Strait Islander, and those admitted for accidents, drug-related reasons, or injecting-related injuries (such as cutaneous abscesses). In a subsample of 7793 patients included in a crossover-cohort analysis, OAT was associated with 0.84 (95 % CI 0.76-0.93; p < 0.001) times the risk of discharge against medical advice.

Conclusions: Among patients with a history of OAT, one in eight emergency hospital admissions ends in discharge against medical advice. OAT enrolment at the time of admission is associated with a reduction of this risk.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108343DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7736124PMC
December 2020

COVID-19 among people experiencing homelessness in England: a modelling study.

Lancet Respir Med 2020 12 23;8(12):1181-1191. Epub 2020 Sep 23.

UCL Collaborative Centre for Inclusion Health, University College London, London, UK.

Background: People experiencing homelessness are vulnerable to COVID-19 due to the risk of transmission in shared accommodation and the high prevalence of comorbidities. In England, as in some other countries, preventive policies have been implemented to protect this population. We aimed to estimate the avoided deaths and health-care use among people experiencing homelessness during the so-called first wave of COVID-19 in England-ie, the peak of infections occurring between February and May, 2020-and the potential impact of COVID-19 on this population in the future.

Methods: We used a discrete-time Markov chain model of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection that included compartments for susceptible, exposed, infectious, and removed individuals, to explore the impact of the pandemic on 46 565 individuals experiencing homelessness: 35 817 living in 1065 hostels for homeless people, 3616 sleeping in 143 night shelters, and 7132 sleeping outside. We ran the model under scenarios varying the incidence of infection in the general population and the availability of prevention measures: specialist hotel accommodation, infection control in homeless settings, and mixing with the general population. We divided our scenarios into first wave scenarios (covering Feb 1-May 31, 2020) and future scenarios (covering June 1, 2020-Jan 31, 2021). For each scenario, we ran the model 200 times and reported the median and 95% prediction interval (2·5% and 97·5% quantiles) of the total number of cases, the number of deaths, the number hospital admissions, and the number of intensive care unit (ICU) admissions.

Findings: Up to May 31, 2020, we calibrated the model to 4% of the homeless population acquiring SARS-CoV-2, and estimated that 24 deaths (95% prediction interval 16-34) occurred. In this first wave of SARS-CoV-2 infections in England, we estimated that the preventive measures imposed might have avoided 21 092 infections (19 777-22 147), 266 deaths (226-301), 1164 hospital admissions (1079-1254), and 338 ICU admissions (305-374) among the homeless population. If preventive measures are continued, we projected a small number of additional cases between June 1, 2020, and Jan 31, 2021, with 1754 infections (1543-1960), 31 deaths (21-45), 122 hospital admissions (100-148), and 35 ICU admissions (23-47) with a second wave in the general population. However, if preventive measures are lifted, outbreaks in homeless settings might lead to larger numbers of infections and deaths, even with low incidence in the general population. In a scenario with no second wave and relaxed measures in homeless settings in England, we projected 12 151 infections (10 718-13 349), 184 deaths (151-217), 733 hospital admissions (635-822), and 213 ICU admissions (178-251) between June 1, 2020, and Jan 31, 2021.

Interpretation: Outbreaks of SARS-CoV-2 in homeless settings can lead to a high attack rate among people experiencing homelessness, even if incidence remains low in the general population. Avoidance of deaths depends on prevention of transmission within settings such as hostels and night shelters.

Funding: National Institute for Health Research, Wellcome, and Medical Research Council.
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http://dx.doi.org/10.1016/S2213-2600(20)30396-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7511167PMC
December 2020

Protocol for a systematic review of treatment adherence for HIV, hepatitis C and tuberculosis among homeless populations.

Syst Rev 2020 09 13;9(1):211. Epub 2020 Sep 13.

Collaborative Centre for Inclusion Health, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 7HT, UK.

Background: Homelessness is a global issue and HIV, hepatitis C and tuberculosis are known to be prevalent in this group. Homeless populations face significant barriers to care. We aim to summarise evidence of treatment initiation and completion for homeless populations with these infections, and their associated factors, through a systematic review and meta-analysis.

Methods: We will search MEDLINE, Embase and CINAHL for all study types and conference abstracts looking at either (1) treatment initiation in a cohort experiencing homelessness with at least one of HIV, hepatitis C, active tuberculosis and/or latent tuberculosis infection (LTBI); (2) treatment completion for those who initiated treatment. We will perform a meta-analysis of the proportion of those with each infection who initiate and complete treatment, as well as analysis of individual and health system factors that may affect adherence levels. We will evaluate the quality of research papers using the Newcastle-Ottawa scale.

Discussion: Given the political emphasis on global elimination of these diseases, and the current lack of understanding of effective and equitable treatment adherence strategies in homeless populations, this review will provide insight to policy-makers and service providers aiming to improve homeless healthcare.

Systematic Review Registration: PROSPERO CRD42019153150.
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http://dx.doi.org/10.1186/s13643-020-01470-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7488663PMC
September 2020

Life expectancy of people who are dependent on opioids: A cohort study in New South Wales, Australia.

J Psychiatr Res 2020 11 23;130:435-440. Epub 2020 Aug 23.

National Drug and Alcohol Research Centre, 22-32 King St, Randwick, NSW, 2031, Australia.

Background: People who are dependent on opioids have increased risk of premature death, but there are few estimates of life expectancy.

Methods: We calculated age-specific mortality rates in a cohort of people who had at least one prescription of an opioid agonist (methadone or buprenorphine) between 2001 and 2018 in New South Wales, Australia. We used life tables to estimate life expectancy at age 18. We also estimated the potential years of life lost before age 75, decomposed by cause of death.

Results: The cohort included 47,197 people, with a median of 9.8 years of follow-up. 5097 participants died, and the standardised mortality ratio (compared to the general population of New South Wales) was 6.06 (95% CI 5.90-6.23). Life expectancy at age 18 was an additional 47.5 years (95% CI 42.9-50.5) for men and 50.7 years (95% CI 45.4-54.8) for women; deficits of 14.7 and 15.8 years respectively when compared to the general population. The largest cause of death was non-communicable physical diseases, which accounted for 47% of deaths in life tables for men and 42% for women. Drug-related deaths accounted for 16% of deaths for men and 19% for women, but due to the young age at which these deaths occur, they contributed approximately one third of potential years of life lost.

Conclusion: In common with people with serious mental illnesses, people who are dependent on opioids have substantially reduced life expectancy. In both populations most excess deaths relate to non-communicable physical diseases.
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http://dx.doi.org/10.1016/j.jpsychires.2020.08.013DOI Listing
November 2020

Prevalence and severity of abscesses and cellulitis, and their associations with other health outcomes, in a community-based study of people who inject drugs in London, UK.

PLoS One 2020 14;15(7):e0235350. Epub 2020 Jul 14.

Department of Public Health, Environments & Society, London School of Hygiene & Tropical Medicine, London, United Kingdom.

Background: Skin and soft tissue infections (SSTI) are a common but preventable cause of morbidity and mortality among people who inject drugs (PWID). They can be severe, and hospitalisations of PWID with SSTI are rising. The most common SSTI presentations are abscesses and cellulitis.

Methods: We used data from Care & Prevent, a cross-sectional community survey of PWID in London. We reported the lifetime prevalence of SSTI, severity of infections, key risk factors, and associated sequelae. Pictorial questions were used to assess SSTI severity.

Results: We recruited 455 PWID. SSTI lifetime prevalence was high: 64% reported an abscess and/or cellulitis. Over one-third (37%) reported a severe infection, 137 (47%) reported hospitalisation. SSTIrisk factors were: aged 35+ years, injecting once or more times a day, subcutaneous or intra-muscular injections, and making four or more attempts to achieve an injection. Those who reported having other health conditions were at higher odds of having an abscess or cellulitis, with risk tending to increase with number of reported conditions. Half (46%) employed self-care for their worst SSTI, and 43% waited for ten or more days before seeking medical care or not seeking medical care at all.

Conclusions: Abscess and cellulitis are very common among PWID in London. We corroborate findings indicating SSTIs are associated with risks, e.g. venous access problems, as well as other co-morbid conditions: septicaemia, endocarditis, DVT, and kidney disease. These co-morbidities may impact SSTIs severity and outcomes. Delayed healthcare seeking potentially exacerbates infection severity, which in turn increases poorer health outcomes and complications.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0235350PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7360031PMC
September 2020

Pandemic peak SARS-CoV-2 infection and seroconversion rates in London frontline health-care workers.

Lancet 2020 07 9;396(10246):e6-e7. Epub 2020 Jul 9.

Department of Clinical Virology, University College London Hospitals, London W1T 4EU, UK; Advanced Pathogen Diagnostics Unit, University College London Hospitals, London W1T 4EU, UK; Great Ormond Street Institute of Child Health, University College London, London, UK. Electronic address:

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http://dx.doi.org/10.1016/S0140-6736(20)31484-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7347344PMC
July 2020

Black, Asian and Minority Ethnic groups in England are at increased risk of death from COVID-19: indirect standardisation of NHS mortality data.

Wellcome Open Res 2020 24;5:88. Epub 2020 Jun 24.

UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, UCL, London, WC1E 7HB, UK.

: International and UK data suggest that Black, Asian and Minority Ethnic (BAME) groups are at increased risk of infection and death from COVID-19. We aimed to explore the risk of death in minority ethnic groups in England using data reported by NHS England. : We used NHS data on patients with a positive COVID-19 test who died in hospitals in England published on 28th April, with deaths by ethnicity available from 1st March 2020 up to 5pm on 21 April 2020. We undertook indirect standardisation of these data (using the whole population of England as the reference) to produce ethnic specific standardised mortality ratios (SMRs) adjusted for age and geographical region. : The largest total number of deaths in minority ethnic groups were Indian (492 deaths) and Black Caribbean (460 deaths) groups. Adjusting for region we found a lower risk of death for White Irish (SMR 0.52; 95%CIs 0.45-0.60) and White British ethnic groups (0.88; 95%CIs 0.86-0.0.89), but increased risk of death for Black African (3.24; 95%CIs 2.90-3.62), Black Caribbean (2.21; 95%CIs 2.02-2.41), Pakistani (3.29; 95%CIs 2.96-3.64), Bangladeshi (2.41; 95%CIs 1.98-2.91) and Indian (1.70; 95%CIs 1.56-1.85) minority ethnic groups. Our analysis adds to the evidence that BAME people are at increased risk of death from COVID-19 even after adjusting for geographical region, but was limited by the lack of data on deaths outside of NHS settings and ethnicity denominator data being based on the 2011 census. Despite these limitations, we believe there is an urgent need to take action to reduce the risk of death for BAME groups and better understand why some ethnic groups experience greater risk. Actions that are likely to reduce these inequities include ensuring adequate income protection, reducing occupational risks, reducing barriers in accessing healthcare and providing culturally and linguistically appropriate public health communications.
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http://dx.doi.org/10.12688/wellcomeopenres.15922.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7317462PMC
June 2020

Incidence and treatment costs of severe bacterial infections among people who inject heroin: A cohort study in South London, England.

Drug Alcohol Depend 2020 07 6;212:108057. Epub 2020 May 6.

National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, 4 Windsor Walk, Camberwell, London SE5 8AF, UK; South London and Maudsley NHS Foundation Trust, Monks Orchard Road Beckenham, London BR3 3BX, UK; Centre for Epidemiology and Biostatistics, Melbourne School of Global and Population Health, Level 3, 207 Bouverie Street, The University of Melbourne Victoria 3010 Australia; RAND Europe, Westbrook Centre, Milton Road, Cambridge CB4 1YG, UK.

Background: People who inject drugs often get bacterial infections. Few longitudinal studies have reported the incidence and treatment costs of these infections.

Methods: For a cohort of 2335 people who inject heroin entering treatment for drug dependence between 2006 and 2017 in London, England, we reported the rates of hospitalisation or death with primary causes of cutaneous abscess, cellulitis, phlebitis, septicaemia, osteomyelitis, septic arthritis, endocarditis, or necrotising fasciitis. We compared these rates to the general population. We also used NHS reference costs to calculate the cost of admissions.

Results: During a median of 8.0 years of follow-up, 24 % of patients (570/2335) had a severe bacterial infection, most commonly presenting with cutaneous abscesses or cellulitis. Bacterial infections accounted for 13 % of all hospital admissions. The rate was 73 per 1000 person-years (95 % CI 69-77); 50 times the general population, and the rate remained high throughout follow-up. The rate of severe bacterial infections for women was 1.50 (95 % CI 1.32-1.69) times the rate for men. The mean cost per admission was £4980, and we estimate that the annual cost of hospital treatment for people who inject heroin in London is £4.5 million.

Conclusions: People who inject heroin have extreme and long-term risk of severe bacterial infections.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301433PMC
July 2020

Associations between interrelated dimensions of socio-economic status, higher risk drinking and mental health in South East London: A cross-sectional study.

PLoS One 2020 14;15(2):e0229093. Epub 2020 Feb 14.

Department of Psychological Sciences, University of Liverpool, Liverpool, United Kingdom.

Aim: To examine patterns of hazardous, harmful and dependent drinking across different socio-economic groups, and how this relationship may be explained by common mental disorder.

Methods And Findings: Between 2011-2013, 1,052 participants (age range 17-91, 53% female) were interviewed for Phase 2 of the South East London Community Health study. Latent class analysis was used to define six groups based on multiple indicators of socio-economic status in three domains. Alcohol use (low risk, hazardous, harmful/dependent) was measured using the Alcohol Use Disorders Identification Test and the presence of common mental disorder was measured using the revised Clinical Interview Schedule. Multinomial regression was used to explore associations with hazardous, harmful and dependent alcohol use, including after adjustment for common mental disorder. Harmful and dependent drinking was more common among people in Class 2 'economically inactive renters' (relative risk ratio (RRR) 3.05, 95% confidence interval (CI) 1.07-8.71), Class 3 'economically inactive homeowners' (RRR 4.11, 95% CI 1.19-14.20) and Class 6 'professional renters' (RRR 3.51, 95% CI 1.14-10.78) than in Class 1 'professional homeowners'. Prevalent common mental disorder explained some of the increased risk of harmful or dependent drinking in Class 2, but not Class 3 or 6.

Conclusions: Across distinct socio-economic groups in a large inner-city sample, we found important differences in harmful and dependent drinking, only some of which were explained by common mental disorder. The increased risk of harmful or dependent drinking across classes which are very distinct from each other suggests differing underlying drivers of drinking across these groups. A nuanced understanding of alcohol use and problems is necessary to understand the inequalities in alcohol harms.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0229093PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7021306PMC
May 2020

The ACE Index: mapping childhood adversity in England.

J Public Health (Oxf) 2020 11;42(4):e487-e495

UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care UCL, 1-19 Torrington Place, London, WC1E 7HB, UK.

Background: Studies of adults show that adverse childhood experiences (ACEs) are associated with health and social problems and are more common among people living in deprived areas. However, there is limited information about the geographical pattern of contemporary ACEs.

Methods: We used data from the police, social services, schools and vital statistics in England to calculate population rates of events that represent childhood adversity. We constructed an 'ACE Index' that summarizes the relative frequency of ACEs at local authority level, informed by the methods of the Index of Multiple Deprivation. We explored associations between the ACE Index and local characteristics in cross-sectional ecological analysis.

Results: The ACE Index was strongly associated with the proportion of children that live in income-deprived households (child poverty). In addition, the ACE Index was independently associated with higher population density and was higher in certain regions, particularly the north-east.

Conclusions: The association between ACEs and child poverty provides evidence of a process in which deprivation increases the risk of adverse experiences in childhood. The ACE Index can inform allocation of resources for prevention and mitigation of ACEs.
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http://dx.doi.org/10.1093/pubmed/fdz158DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7685852PMC
November 2020

Premature mortality attributable to socioeconomic inequality in England between 2003 and 2018: an observational study.

Lancet Public Health 2020 01 5;5(1):e33-e41. Epub 2019 Dec 5.

UCL Collaborative Centre for Inclusion Health, University College London, London, UK; Institute of Epidemiology and Health Care, University College London, London, UK.

Background: Low socioeconomic position is consistently associated with increased risk of premature death. The aim of this study is to measure the aggregate scale of inequality in premature mortality for the whole population of England.

Methods: We used mortality records from the UK Office for National Statistics to study all 2 465 285 premature deaths (defined as those before age 75 years) in England between Jan 1, 2003, and Dec 31, 2018. Socioeconomic position was defined using deciles of the Index of Multiple Deprivation: a measure of neighbourhood income, employment, education levels, crime, health, availability of services, and local environment. We calculated the number of expected deaths by applying mortality in the least deprived decile to other deciles, within the strata of age, sex, and time. The mortality attributable to socioeconomic inequality was defined as the difference between the observed and expected deaths. We also used life table modelling to estimate years-of-life lost attributable to socioeconomic inequality.

Findings: 35·6% (95% CI 35·3-35·9) of premature deaths were attributable to socioeconomic inequality, equating to 877 082 deaths, or one every 10 min. The biggest contributors were ischaemic heart disease (152 171 excess deaths), respiratory cancers (111 083) and chronic obstructive pulmonary disease (83 593). The most unequal causes of death were tuberculosis, opioid use, HIV, psychoactive drugs use, viral hepatitis, and obesity, each with more than two-thirds attributable to inequality. Inequality was greater among men and peaked in early childhood and at age 40-49 years. The proportion of deaths attributable to inequality increased during the study period, particularly for women, because mortality rates among the most deprived women (excluding cardiovascular diseases) plateaued, and for some diseases increased. A mean of 14·4 months of life before age 75 years are lost due to socioeconomic inequality.

Interpretation: One in three premature deaths are attributable to socioeconomic inequality, making this our most important public health challenge. Interventions that address upstream determinants of health should be prioritised.

Funding: National Institute of Health Research; Wellcome Trust.
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http://dx.doi.org/10.1016/S2468-2667(19)30219-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7098478PMC
January 2020

Health and social care costs at the end of life: a matched analysis of linked patient records in East London.

Age Ageing 2019 12;49(1):82-87

Institute of Health Informatics, University College London, London NW1 2DA, UK.

Background: care in the final year of life accounts for 10% of inpatient hospital costs in UK. However, there has been little analysis of costs in other care settings. We investigated the publicly funded costs associated with the end of life across different health and social care settings.

Method: we performed cross-sectional analysis of linked electronic health records of residents aged over 50 in a locality in East London, UK, between 2011 and 2017. Those who died during the study period were matched to survivors on age group, sex, deprivation, number of long-term conditions and time period. Mean costs were calculated by care setting, age and months to death.

Results: across 8,720 matched patients, the final year of life was associated with £7,450 (95% confidence interval £7,086-£7,842, P < 0.001) of additional health and care costs, 57% of which related to unplanned hospital care. Whilst costs increased sharply over the final few months of life in emergency and inpatient hospital care, in non-acute settings costs were less concentrated in this period. Patients who died at older ages had higher social care costs and lower healthcare costs than younger patients in their final year of life.

Conclusions: the large proportion of costs relating to unplanned hospital care suggests that end-of-life planning could direct care towards more appropriate settings and lead to system efficiencies. Death at older ages results in an increasing proportion of care costs relating to social care than to healthcare, which has implications for an ageing society.
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http://dx.doi.org/10.1093/ageing/afz137DOI Listing
December 2019

Frequency of health-care utilization by adults who use illicit drugs: a systematic review and meta-analysis.

Addiction 2020 06 10;115(6):1011-1023. Epub 2020 Feb 10.

National Addictions Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Aims: To summarize evidence on the frequency and predictors of health-care utilization among people who use illicit drugs.

Design: Systematic search of MEDLINE, EMBASE and PsychINFO for observational studies reporting health-care utilization published between 1 January 2000 and 3 December 2018. We conducted narrative synthesis and meta-analysis following a registered protocol (identifier: CRD42017076525).

Setting And Participants: People who use heroin, powder cocaine, crack cocaine, methamphetamine, amphetamine, ecstasy/3,4-methyl​enedioxy​methamphetamine (MDMA), cannabis, hallucinogens or novel psychoactive substances; have a diagnosis of 'substance use disorder'; or use drug treatment services.

Measurements: Primary outcomes were the cumulative incidence (risk) and rate of care episodes in three settings: primary care, hospital admissions (in-patient) and emergency department (ED).

Findings: Ninety-two studies were included, 84% from North America and Australia. Most studies focused on people using heroin, methamphetamine or crack cocaine, or who had a diagnosis of drug dependence. We were able to conduct a meta-analysis of rates across 25 studies reporting ED episodes and 25 reporting hospital admissions, finding pooled rates of 151 [95% confidence interval (CI) = 114-201] and 41 (95% CI = 30-57) per 100 person-years, respectively; on average 4.8 and 7.1 times more often than the general population. Heterogeneity was very high and was not explained by drugs used, country of study, recruitment setting or demographic characteristics. Predictors of health-care utilization were consistent across studies and included unstable housing, drug injection and mental health problems. Opioid substitution therapy was consistently associated with reduced ED presentation and hospital admission. There was minimal research on health-care utilization by people using ecstasy/MDMA, powder cocaine, hallucinogens or novel psychoactive substances.

Conclusions: People who use illicit drugs are admitted to emergency department or hospital several times more often than the general population.
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http://dx.doi.org/10.1111/add.14892DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7210080PMC
June 2020

Causes of hospital admission and mortality among 6683 people who use heroin: A cohort study comparing relative and absolute risks.

Drug Alcohol Depend 2019 11 3;204:107525. Epub 2019 Sep 3.

National Addictions Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, 4 Windsor Walk, Camberwell, London SE5 8AF, UK; South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham BR3 3BX, UK; RAND Europe, Westbrook Centre, Milton Road, Cambridge, CB4 1YG, UK.

Background: Mortality in high-risk groups such as people who use illicit drugs is often expressed in relative terms such as standardised ratios. These measures are highest for diseases that are rare in the general population, such as hepatitis C, and may understate the importance of common long-term conditions.

Population: 6683 people in community-based treatment for heroin dependence between 2006 and 2017 in London, England, linked to national hospital and mortality databases with 55,683 years of follow-up.

Method: Age- and sex-specific mortality and hospital admission rates in the general population of London were used to calculate the number of expected events. We compared standardised ratios (relative risk) to excess deaths and admissions (absolute risk) across ICD-10 chapters and subcategories.

Results: Drug-related diseases had the highest relative risks, with a standardised mortality ratio (SMR) of 48 (95% CI 42-54) and standardised admission ratio (SAR) of 293 (95% CI 282-304). By contrast, other diseases had an SMR of 4.4 (95% CI 4.0-4.9) and an SAR of 3.15 (95% CI 3.11-3.19). However, the majority of the 621 excess deaths (95% CI 569-676) were not drug-related (361; 58%). The largest groups were liver disease (75 excess deaths) and COPD (45). Similarly, 80% (11,790) of the 14,668 excess admissions (95% CI 14,382-14,957) were not drug-related. The largest groups were skin infections (1073 excess admissions), alcohol (1060), COPD (812) and head injury (612).

Conclusions: Although relative risks of drug-related diseases are very high, most excess morbidity and mortality in this cohort was caused by common long-term conditions.
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http://dx.doi.org/10.1016/j.drugalcdep.2019.06.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6891224PMC
November 2019

Health-related quality of life and prevalence of six chronic diseases in homeless and housed people: a cross-sectional study in London and Birmingham, England.

BMJ Open 2019 04 24;9(4):e025192. Epub 2019 Apr 24.

Collaborative Centre for Inclusion Health, University College London, London, UK.

Objectives: To compare health-related quality of life and prevalence of chronic diseases in housed and homeless populations.

Design: Cross-sectional survey with an age-matched and sex-matched housed comparison group.

Setting: Hostels, day centres and soup runs in London and Birmingham, England.

Participants: Homeless participants were either sleeping rough or living in hostels and had a history of sleeping rough. The comparison group was drawn from the Health Survey for England. The study included 1336 homeless and 13 360 housed participants.

Outcome Measures: Chronic diseases were self-reported asthma, chronic obstructive pulmonary disease (COPD), epilepsy, heart problems, stroke and diabetes. Health-related quality of life was measured using EQ-5D-3L.

Results: Housed participants in more deprived neighbourhoods were more likely to report disease. Homeless participants were substantially more likely than housed participants in the most deprived quintile to report all diseases except diabetes (which had similar prevalence in homeless participants and the most deprived housed group). For example, the prevalence of chronic obstructive pulmonary disease was 1.1% (95% CI 0.7% to 1.6%) in the least deprived housed quintile; 2.0% (95% CI 1.5% to 2.6%) in the most deprived housed quintile; and 14.0% (95% CI 12.2% to 16.0%) in the homeless group. Social gradients were also seen for problems in each EQ-5D-3L domain in the housed population, but homeless participants had similar likelihood of reporting problems as the most deprived housed group. The exception was problems related to anxiety, which were substantially more common in homeless people than any of the housed groups.

Conclusions: While differences in health between housed socioeconomic groups can be described as a 'slope', differences in health between housed and homeless people are better understood as a 'cliff'.
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http://dx.doi.org/10.1136/bmjopen-2018-025192DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6501971PMC
April 2019

Causes of death among homeless people: a population-based cross-sectional study of linked hospitalisation and mortality data in England.

Wellcome Open Res 2019 11;4:49. Epub 2019 Mar 11.

Collaborative Centre for Inclusion Health, Institute of Epidemiology & Health Care, University College London, London, NW1 2DA, UK.

: Homelessness has increased by 165% since 2010 in England, with evidence from many settings that those affected experience high levels of mortality. In this paper we examine the contribution of different causes of death to overall mortality in homeless people recently admitted to hospitals in England with specialist integrated homeless health and care (SIHHC) schemes.  : We undertook an analysis of linked hospital admission records and mortality data for people attending any one of 17 SIHHC schemes between 1st November 2013 and 30th November 2016. Our primary outcome was death, which we analysed in subgroups of 10th version international classification of disease (ICD-10) specific deaths; and deaths from amenable causes. We compared our results to a sample of people living in areas of high social deprivation (IMD5 group). : We collected data on 3,882 individual homeless hospital admissions that were linked to 600 deaths. The median age of death was 51.6 years (interquartile range 42.7-60.2) for SIHHC and 71.5 for the IMD5 (60.67-79.0).  The top three underlying causes of death by ICD-10 chapter in the SIHHC group were external causes of death (21.7%; 130/600), cancer (19.0%; 114/600) and digestive disease (19.0%; 114/600).  The percentage of deaths due to an amenable cause after age and sex weighting was 30.2% in the homeless SIHHC group (181/600) compared to 23.0% in the IMD5 group (578/2,512). : Nearly one in three homeless deaths were due to causes amenable to timely and effective health care. The high burden of amenable deaths highlights the extreme health harms of homelessness and the need for greater emphasis on prevention of homelessness and early healthcare interventions.
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http://dx.doi.org/10.12688/wellcomeopenres.15151.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6449792PMC
March 2019

Outcomes of specialist discharge coordination and intermediate care schemes for patients who are homeless: analysis protocol for a population-based historical cohort.

BMJ Open 2017 Dec 14;7(12):e019282. Epub 2017 Dec 14.

Institute of Health Informatics, University College London, London, UK.

Introduction: People who are homeless often experience poor hospital discharge arrangements, reflecting ongoing care and housing needs. Specialist integrated homeless health and care provision (SIHHC) schemes have been developed and implemented to facilitate the safe and timely discharge of homeless patients from hospital. Our study aims to investigate the health outcomes of patients who were homeless and seen by a selection of SIHHC services.

Methods And Analysis: Our study will employ a historical population-based cohort in England. We will examine health outcomes among three groups of adults: (1) homeless patients seen by specialist discharge schemes during their hospital admission; (2) homeless patients not seen by a specialist scheme and (3) admitted patients who live in deprived neighbourhoods and were not recorded as being homeless. Primary outcomes will be: time from discharge to next hospital inpatient admission; time from discharge to next accident and emergency attendance and 28-day emergency readmission. Outcome data will be generated through linkage to hospital admissions data (Hospital Episode Statistics) and mortality data for November 2013 to November 2016. Multivariable regression will be used to model the relationship between the study comparison groups and each of the outcomes.

Ethics And Dissemination: Approval has been obtained from the National Health Service (NHS) Confidentiality Advisory Group (reference 16/CAG/0021) to undertake this work using unconsented identifiable data. Health Research Authority Research Ethics approval (REC 16/EE/0018) has been obtained in addition to local research and development approvals for data collection at NHS sites. We will feedback the results of our study to our advisory group of people who have lived experience of homelessness and seek their suggestions on ways to improve or take this work further for their benefit. We will disseminate our findings to SIHHC schemes through a series of regional workshops.
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http://dx.doi.org/10.1136/bmjopen-2017-019282DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5736042PMC
December 2017

Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis.

Lancet 2018 01 12;391(10117):241-250. Epub 2017 Nov 12.

Centre for Public Health Data Science, Institute of Health Informatics, University College London, London, UK; The Farr Institute of Health Informatics Research, University College London, London, UK; Institute of Epidemiology and Health Care, University College London, London, UK.

Background: Inclusion health focuses on people in extremely poor health due to poverty, marginalisation, and multimorbidity. We aimed to review morbidity and mortality data on four overlapping populations who experience considerable social exclusion: homeless populations, individuals with substance use disorders, sex workers, and imprisoned individuals.

Methods: For this systematic review and meta-analysis, we searched MEDLINE, Embase, and the Cochrane Library for studies published between Jan 1, 2005, and Oct 1, 2015. We included only systematic reviews, meta-analyses, interventional studies, and observational studies that had morbidity and mortality outcomes, were published in English, from high-income countries, and were done in populations with a history of homelessness, imprisonment, sex work, or substance use disorder (excluding cannabis and alcohol use). Studies with only perinatal outcomes and studies of individuals with a specific health condition or those recruited from intensive care or high dependency hospital units were excluded. We screened studies using systematic review software and extracted data from published reports. Primary outcomes were measures of morbidity (prevalence or incidence) and mortality (standardised mortality ratios [SMRs] and mortality rates). Summary estimates were calculated using a random effects model.

Findings: Our search identified 7946 articles, of which 337 studies were included for analysis. All-cause standardised mortality ratios were significantly increased in 91 (99%) of 92 extracted datapoints and were 11·86 (95% CI 10·42-13·30; I=94·1%) in female individuals and 7·88 (7·03-8·74; I=99·1%) in men. Summary SMR estimates for the International Classification of Diseases disease categories with two or more included datapoints were highest for deaths due to injury, poisoning, and other external causes, in both men (7·89; 95% CI 6·40-9·37; I=98·1%) and women (18·72; 13·73-23·71; I=91·5%). Disease prevalence was consistently raised across the following categories: infections (eg, highest reported was 90% for hepatitis C, 67 [65%] of 103 individuals for hepatitis B, and 133 [51%] of 263 individuals for latent tuberculosis infection), mental health (eg, highest reported was 9 [4%] of 227 individuals for schizophrenia), cardiovascular conditions (eg, highest reported was 32 [13%] of 247 individuals for coronary heart disease), and respiratory conditions (eg, highest reported was 9 [26%] of 35 individuals for asthma).

Interpretation: Our study shows that homeless populations, individuals with substance use disorders, sex workers, and imprisoned individuals experience extreme health inequities across a wide range of health conditions, with the relative effect of exclusion being greater in female individuals than male individuals. The high heterogeneity between studies should be explored further using improved data collection in population subgroups. The extreme health inequity identified demands intensive cross-sectoral policy and service action to prevent exclusion and improve health outcomes in individuals who are already marginalised.

Funding: Wellcome Trust, National Institute for Health Research, NHS England, NHS Research Scotland Scottish Senior Clinical Fellowship, Medical Research Council, Chief Scientist Office, and the Central and North West London NHS Trust.
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http://dx.doi.org/10.1016/S0140-6736(17)31869-XDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5803132PMC
January 2018

Opiate Injection-Associated Skin, Soft Tissue, and Vascular Infections, England, UK, 1997-2016.

Emerg Infect Dis 2017 08;23(8):1400-1403

In England, UK, hospital admissions caused by bacterial infections associated with opioid use have increased annually since 2012, after 9 years of decline, mirroring trends in overdose deaths. The increase occurred among persons of both sexes and in all age groups and suggests preventive measures need reviewing.
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http://dx.doi.org/10.3201/eid2308.170439DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5547794PMC
August 2017
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