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Use of cancer e-referral data to monitor health-seeking behaviours during the COVID-19 pandemic

Abstract   At the outset of the pandemic, concern arose that people with concerning symptoms would not attend their GP and delayed presentations would impact cancer survival. Ireland lacks a national database of GP attendances from which to observe this. Ireland has rapid access clinics in designated cancer centres, providing a streamlined pathway for the diagnosis of certain common cancers. Referral to these clinics can be made electronically from primary care, using a national messaging system Healthlink. Healthlink agreed to report on the volume of referrals at weekly intervals, given the concern regarding non-presentation. Rolling descriptive analytics included the comparison of referral numbers to pre-pandemic weeks in 2020 (Weeks 2-11) and to corresponding time periods in 2019. A marked reduction was observed in wave 1 of the pandemic. Weekly e-referrals dropped by more than 60% in weeks 12-14 (breast 62.5%; lung 57.9%; prostate 61.1%). This was not replicated in subsequent waves. By end-2020, the volume of referrals equated to 112.4% of total referrals in 2019. The objective demonstration of a fall in cancer referrals prompted a media campaign to highlight the importance of early diagnosis and to reassure that cancer diagnostic and treatment services continued to operate. It also prompted national communication in relation to other essential health services. Challenges identified included occasional misinterpretation of referral data as reflective of attendance and investigation at clinics and the potential influence of increased uptake of e-referral systems. While caveats exist in relation to interpretation, e-referral data from primary care to cancer centres is a useful tool to monitor trends in patient presentations with suspected cancer. Automated collection of cancer e-referral data at a national level provides real-time information, compared to manual data collection systems within hospitals which were challenged through redeployment of staff to the Covid response. Key messages Monitoring of e-referral rates provided a useful and timely proxy measure of health-seeking behaviour during the Covid pandemic. The significant drop in referrals during the first wave of the pandemic was not repeated, suggesting an improved understanding among the public of the need to investigate symptoms of possible cancer.

We are living in an era of fast and fundamental changes with an uneven impact on geographies and generations. The pace of the social transformations and technology innovations is accelerating and outpacing policies and responses in place. Also, the European drug situation and drug markets are becoming more complex and dynamic, with important implications for the EU drug monitoring system and research. Therefore the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) conducted the first 'futures exercise' to inform the agency's strategic reflection on how to improve the response of the EU monitoring system in the context of rapid changes in the information environment and new information needs. The EMCDDA piloted the usefulness of the foresight approach for transforming the agency and its monitoring activities into a more sensitive and agile system, which could, in turn, help increase Europe's preparedness for future challenges in health and security areas. The 'futures exercise' applied the horizon-scanning method to study events, issues, and trends affecting the drug area and went far beyond the drugs or the addiction field and the European region. It analysed global drivers of change that may have in the future implications for the drugs situation, drug monitoring and related responses. The methods applied ranged from literature review, thematic analysis, workshops and expert panels. It had a robust participatory component to enable stakeholders representing different disciplines and countries to contribute to and benefit from the process. Out of 14 Megatrends, five were selected as most significant for the drugs field, and the future EMCDDA work: technological change, climate change and environmental degradation, diversified inequalities, shifts in health challenges and population. Moreover, four categories of emerging changes in the drugs field were identified: shifts in drug policy, the discourse of addictions, drug markets and drug services. Key messages: Foresight is a valuable tool for analysis going beyond specific areas of expertise and recognising that a single-issue focus is often insufficient in dealing with emerging threats and opportunities. A participatory approach contributes to building a shared vision of the major drivers of change impacting the drugs field, information needs and future developments in the EU drug monitoring system. Background: Formaldehyde (FA) is an environmental pollutant widely used in several occupational settings. Beyond its carcinogenic effect, FA can trigger inflammation by promoting reactive oxygen species formation in exposed subjects. The current study aims to investigate the association between air-FA exposure and systemic oxidative stress induction in specific working environments.

Methods:
We accounted for three different scenarios of air-FA exposure by including a sample of pathologists and nurses from operating theatres (n = 185), traffic police officers (n = 154) and wood-workers (n = 127), who participated as volunteers. Exposure to air-FA was assessed by passive air-samplers (Radiello Õ ) and oxidative stress was quantified by 15-F2t-IsoP urinary biomarker (ELISA). A piecewise linear regression model was performed to analyse oxidative stress variation in response to air-FA exposure.

Conclusions:
Currently, the most precautionary regulatory limit of air-FA exposure in occupational settings is 0.1 ppm (TLW-TVA, i.e. 120 mg/m3). This limit is recommended to protect for eyes and upper respiratory tract irritation. However, our results highlighted that slightly lower exposures can induce a biological effect, which should deserve consideration from Primary Prevention perspective. Since oxidative stress may evolve in future diseases, it would be advisable considering to tailor the regulatory limits to such a pre-pathological condition rather symptoms onset.

Key messages:
Occupational exposure to air-FA is able to induce systemic oxidative stress even below the regulatory limit, independently from age and sex. Future updates of the regulatory limits in force may consider pre-pathological conditions, such as oxidative stress, rather symptoms onset.
Use of cancer e-referral data to monitor healthseeking behaviours during the COVID-19 pandemic this. Ireland has rapid access clinics in designated cancer centres, providing a streamlined pathway for the diagnosis of certain common cancers. Referral to these clinics can be made electronically from primary care, using a national messaging system Healthlink. Healthlink agreed to report on the volume of referrals at weekly intervals, given the concern regarding nonpresentation. Rolling descriptive analytics included the comparison of referral numbers to pre-pandemic weeks in 2020 (Weeks 2-11) and to corresponding time periods in 2019. A marked reduction was observed in wave 1 of the pandemic. Weekly ereferrals dropped by more than 60% in weeks 12-14 (breast 62.5%; lung 57.9%; prostate 61.1%). This was not replicated in subsequent waves. By end-2020, the volume of referrals equated to 112.4% of total referrals in 2019. The objective demonstration of a fall in cancer referrals prompted a media campaign to highlight the importance of early diagnosis and to reassure that cancer diagnostic and treatment services continued to operate. It also prompted national communication in relation to other essential health services. Challenges identified included occasional misinterpretation of referral data as reflective of attendance and investigation at clinics and the potential influence of increased uptake of e-referral systems. While caveats exist in relation to interpretation, e-referral data from primary care to cancer centres is a useful tool to monitor trends in patient presentations with suspected cancer. Automated collection of cancer e-referral data at a national level provides real-time information, compared to manual data collection systems within hospitals which were challenged through redeployment of staff to the Covid response.

Key messages:
Monitoring of e-referral rates provided a useful and timely proxy measure of health-seeking behaviour during the Covid pandemic. The significant drop in referrals during the first wave of the pandemic was not repeated, suggesting an improved understanding among the public of the need to investigate symptoms of possible cancer.

Background:
Surgical site infections (SSIs) are among the most common healthcare-associated infections (HAIs). Our objective was to describe incidence of SSI and adequacy of surgical antibiotic prophylaxis (SAP) in abdominal hysterectomy (HYST) interventions in our center.

Methods:
A prospective study was carried out in Hospital General Universitario Reina Sofia, Murcia. Patients subjected to HYST between May 1st and November 30th of 2020 were included. No exclusion criteria were established. SSI surveillance was done following CDC -NNIS guidelines. Data were obtained from clinical documents and electronic records, evaluated following local antimicrobial stewardship program (ASP) guidelines and classified as adequate or inadequate. Inadequate SAP was divided into five categories: ''Length of administration'', ''Antibiotic election'', ''Inadequate Timing'', ''Antibiotic indication'' and ''Other''.

Results:
A total of 57 interventions were recorded. Mean age was 52,7 y (sd = 11,4y). 3 SSI were found: 1 superficial and 2 deep. Total cumulative incidence was 5,3%. Grouping by NNIS risk score, cumulative incidence in NNIS 2-3 patients was 33,3%, while in NNIS 0 and NNIS 1 was 2,6% and 6,2%. Median hospitalization length was 3 days (IQR = 1). Median time from surgery to infection was 5 days (IQR =0.5). SAP was found to be adequate in 71% of interventions. Main causes of inadequacy were inadequate timing (77,7%), indication (11,1%), election (5,5%) and length of administration (5,5%). Conclusions: SSI incidence in HYST in our center was found to be slightly higher than other studies found in the literature. Issue/problem: At the time of arrival of the COVID-19 pandemic to Portugal, the Public Health Department of Lisbon and Tagus Valley Regional Health Administration was confronted with its obsolete information system, which could not provide the information that Public Health Authorities needed to bring the pandemic under control. In order to tackle this issue, our goal was to aggregate all the relevant epidemiological data for the region in an accessible and user-friendly dashboard.

Methods:
Starting from March 2020 we created a dashboard, which compiled and analyzed COVID-19 data, such as: confirmed and active cases, deaths, hospitalizations (including ICU beds), high/low risk contacts, mandatory confinements, tests, and clusters. This dashboard had anonymized data and was updated daily as well as constantly upgraded by taking into consideration new incoming data and feedback provided by users, serving its purpose as an advisory tool for policy.

Results:
The dashboard was available to Local, Regional, and National Public Health Authorities and made possible to monitor trends and predict epidemiological changes that, prior to its existence, were dispersed in several datasets. Most importantly, it allowed for a better allocation of human resources for contact tracing and case management activities, to easily identify basic social needs for the most vulnerable citizens. It also provided for policy measures adjusted to the smallest administrative division in Portugal, the parish, that ultimately allowed for a better epidemiological control in Lisbon Metropolitan Area in 2020. Lessons: The regional dashboard is far from perfect, but it highlights the constant need for robust information and epidemiological surveillance systems, serving both National, Regional and Local Public Health Authorities. It appeared out of necessity during a pandemic and it proved once more the importance of data analytics for guiding public health action based on evidence. Key messages: Data analytics can serve both as an advisory tool for policy as well as to guide public health interventions. The COVID-19 Dashboard for the Lisbon Region aggregates relevant epidemiological data that helped Public Health authorities better understand and control the Pandemic in the region.