Weekly Returns Service Research Articles

Skin conditions are the commonest new reason people present to general practitioners in England and Wales

Knowledge of the prevalence and incidence of skin conditions is a prerequisite for designing clinical services and providing appropriate training for primary health care professionals. In the U.K. the general practitioner and practice nurse are the first point of medical contact for persons with skin conditions. We aimed to obtain contemporary data in age-, gender- and diagnosis-specific detail on persons presenting to primary care with skin problems. Comparisons were made with similar data for other major disease groups and with similar data from other recent years. We used surveillance data collected in the Weekly Returns Service (WRS) of the Royal College of General Practitioners during 2006 and trend data for subsequent years. The WRS sentinel practices monitor all consultations by clinical diagnosis in a representative population of 950,000 in England and Wales. For conditions included in chapter XII of the International Classification of Diseases Ninth Revision (ICD9), 15% of the population consulted; a further 9% presented with skin problems classified elsewhere in the ICD9, making a total of 24%. There was no evidence of increasing or decreasing trend since 2006. Skin infections were the commonest diagnostic group, while 20% of children < 12 months were diagnosed with atopic eczema. Considered collectively, the incidence of new episodes of skin disorders (including diagnoses outside chapter XII) exceeded incidences for all other major disease groupings. Compared with other major disease groups, skin conditions are the most frequent reason for consultation in general practice. This result emphasizes the need for appropriate education and training for all medical students and particularly for continuing education in dermatology for all primary health care professionals.

The representativeness of sentinel practice networks

The representativeness of practice networks is important when using the information obtained to guide health policy. To develop a model for examining the representativeness of practice networks. Comparison of surveyed population, practice structure and prescribing characteristics with the national data using the Weekly Returns Service (WRS) for 2006 as an example of practice network. The population monitored was compared with the national PCT population. The practice postcode was linked to the Index of Multiple Deprivation and the distribution compared with the national equivalents. Doctor and practice-specific structural data (obtained by questionnaire) and practice-prescribing data were compared with the national equivalents. The significance of differences was evaluated using non-parametric tests. The WRS population was closely matched with the national data by age, gender and deprivation index. Compared with the national equivalents, WRS practices, included more younger GPs, had a larger average list per GP and fewer practices with a list of less than 1499 per GP. Prescribing patterns were similar to their PCT equivalents excepting for small reductions of antibacterial prescribing (items 7% and cost 5%). We demonstrate a low-cost model methodology for examining the representativeness of practice networks using independent data with minimum practice input.

Seasonality and trends in the incidence and prevalence of gout in England and Wales 1994–2007

Objectives:To examine seasonality and long-term trends in the incidence and prevalence of gout.Methods:A retrospective study (1994–2007) using routinely collected surveillance data from the Royal College of General Practitioners Weekly Returns...

Lessons from 40 years' surveillance of influenza in England and Wales.

The influenza virus continues to pose a significant threat to public health throughout the world. Current avian influenza outbreaks in humans have heightened the need for improved surveillance and planning. Despite recent advances in the development of vaccines and antiviral drugs, seasonal epidemics of influenza continue to contribute significantly to general practitioner workloads, emergency hospital admissions, and deaths. In this paper we review data produced by the Royal College of General Practitioners Weekly Returns Service, a sentinel general practice surveillance network that has been in operation for over 40 years in England and Wales. We show a gradually decreasing trend in the incidence of respiratory illness associated with influenza virus infection (influenza-like illness; ILI) over the 40 years and speculate that there are limits to how far an existing virus can drift and yet produce substantial new epidemics. The burden of disease caused by influenza presented to general practitioners varies considerably by age in each winter. In the pandemic winter of 1969/70 persons of working age were most severely affected; in the serious influenza epidemic of 1989/90 children were particularly affected; in the millennium winter (in which the NHS was severely stretched) ILI was almost confined to adults, especially the elderly. Serious confounders from infections due to respiratory syncytial virus are discussed, especially in relation to assessing influenza vaccine effectiveness. Increasing pressure on hospitals during epidemic periods are shown and are attributed to changing patterns of health-care delivery.

Surveillance of sexually transmitted diseases in general practice: a description of trends in the Royal College of General Practitioners Weekly Returns Service between 1994 and 2001

This paper describes the incidence of sexually transmitted infections (STIs) recorded in the Weekly Returns Service (WRS) between 1994 and 2001. There were approximately 76,500 new diagnoses of STIs (7500 males, 71,000 females) and associated syndromes. Candidiasis was the commonest condition reported in males and females followed by pelvic inflammatory disease. The ratio of males to females was 7.1 for non-specific urethritis, and 9.1 and 2.1 for Reiter's syndrome and pediculosis pubis, respectively. The incidence of anogenital warts and genital herpes changed little over time. New diagnoses of genital herpes were higher in females than in males (ratio 2.8:1), whereas the mean annual incidence of genital warts was similar in males and females. The WRS provides an insight into the burden of STI diagnoses, and diagnoses related to STIs that are managed in general practice, and as such has the potential to make a substantial contribution to STI surveillance in England.

The incidence of molluscum contagiosum, scabies and lichen planus

We aimed to describe the incidence of new episodes of molluscum contagiosum, scabies and lichen planus presenting to general practitioners in England and Wales. We examined data collected in a sentinel practice network (the Weekly Returns Service of the Royal College of General Practitioners) in which about half a million persons were observed each year over the period 1994-2003. The incidence of molluscum contagiosum in males was 243/100,000 person-years and in females 231; of scabies, males 351, females 437; of lichen planus, males 32, females 37. Incidence varied by year and age. Ninety per cent of molluscum contagiosum episodes were reported in children aged 0-14 years, where incidence in 2000 (midpoint of a 6-year period of stable incidence) was 1265/100,000 (95% CI 1240-1290). Scabies affected all ages and annual incidence ranged between 233 (95% CI 220-246) in 2003 and 470 (95% CI 452-488) in 2000. Lichen planus occurred chiefly in persons aged over 45 years: incidence (all ages) ranged between 27 (95% CI 23-31) in 2003 and 43 (95% CI 37-49) in 1998. The relative risk of female to male incidence (all ages) of molluscum contagiosum was 0.95 (95% CI 0.91-0.99); of scabies 1.25 (95% CI 1.21-1.28); and of lichen planus 1.19 (95% CI 1.08-1.13).

Eye Anomalies

Eye anomalies, including anophthalmos and microphthalmos (absent eye and small eye), are common features in congenital infection syndromes such as rubella. Influenza, Coxsackie virus, and Parvovirus are less well-established teratogens. We report an ecologic analysis of anophthalmia/microphthalmia prevalence in England in relation to temporal variation in these infections using routine infection data. The national (England) anophthalmos/microphthalmos register holds details of 406 babies (excluding chromosomal anomalies) born 1988-1994. Weekly infection data were obtained from the U.K. Public Health Laboratory Service and Royal College of General Practitioners Weekly Returns Service. We assigned cases and births an estimated exposure based on the population infection counts in the gestational weeks known to be critical for ocular development. We calculated the rate ratio of anophthalmos/microphthalmos prevalence for infection in the 90th percentile compared with the 10th percentile by Poisson regression. There was a positive association between severe anophthalmos/microphthalmos prevalence and Parvovirus B19 (rate ratio = 1.26; 95% confidence interval = 1.00-1.58) and for influenza (1.41; 1.08-1.84). Coxsackie virus showed a negative association with any anophthalmos/microphthalmos (0.75; 0.58-0.98) and with severe cases (0.66; 0.46-0.95). This analysis provides suggestive evidence for a teratogenic role of influenza and Parvovirus in anophthalmos/microphthalmos. The role of maternal infections in congenital anomaly etiology is worthy of further investigation.

The consistency of shingles and its significance for health monitoring

Accurate estimation of monitored populations is essential for epidemiological study. Many countries do not have systems of patient registration and routine disease surveillance is thereby hindered. We studied the incidence of shingles over time and investigated the hypothesis that the incidence is consistent and could be used as a proxy for estimating the monitored population. Annual incidence rates of shingles reported in the Weekly Returns Service (WRS) since 1970 and in the Dutch Sentinel Network (DSN) over the period 1998--2001 were studied. Gender specific annual rates (1998--2001) were compared after standardising for age. The population in the DSN was estimated by applying the WRS incidence rates to the numbers of DSN incident cases. The incidence of shingles was annually and seasonally consistent. Incidence in males was similar in both networks and in females approximately 18% greater in the WRS: in age groups 15-64 years, incidence was similar in both networks, but in children 0-14 years and in persons 65 years and over, it was higher in the WRS. The total populations in the DSN estimated from average age/gender specific rates in the WRS were within 12% of the observed in each of the 4 years surveyed. The incidence of shingles in the two countries was sufficiently close to estimate the surveyed population aged 15-64 years from knowledge of incident cases in the community. Routine monitoring of shingles in sentinel practice networks is commended as a method of assuring recording quality and as a means of estimating the survey population where the registered population is not known.

Influenza and its relationship to circulatory disorders

Three sources of data (general practice episode data from the Weekly Returns Service of the Royal College of General Practitioners, national hospital admission data for England and national mortality data by date of death) were examined separately in each winter (1994/1995 to 1999/2000) to investigate the impact of influenza on circulatory disease. Weekly data on incidence (clinical new episodes) hospital emergency admissions and deaths certified to circulatory disorders and to respiratory diseases (chapters VII and VIII of ICD9) during influenza epidemic periods (defined from combined clinical/virological surveillance) were examined in age groups 45-64, 65-74 and > or =75 years. Data collected in the four winters in which there were substantial influenza A epidemics were consolidated for the period 6 weeks before to 6 weeks after each peak of the epidemic, and associations between the variables at different time lags examined by calculating cross-correlation coefficients. We also examined deaths due to ischaemic heart disease (IHD) as a proportion of all circulatory deaths and deaths due to influenza/pneumonia as a proportion of all respiratory deaths. There were no increases of GP episodes nor of emergency admissions for circulatory disorders in any of the three age groups during epidemic periods. Increased circulatory deaths occurred in all age groups and particularly in the oldest group. The large cross-correlation coefficients of deaths (circulatory and respiratory) with GP respiratory episodes at weekly lags of 0, -1 and 1 were evidence that the deaths and episode distributions were contemporaneous. The ratios of excess circulatory deaths relative to excess respiratory deaths during epidemic periods were 0.74 (age 45-64), 0.72 (65-74) and 0.57 (> or =75 years). Increased circulatory deaths contemporary with new incident cases of respiratory episodes but with no concomitant increase in admissions suggests rapid death during the acute phase of illness. Influenza contingency planning needs to take account of these deaths in determining policy for prophylaxis and in providing facilities for cardio-respiratory resuscitation.

Declining incidence of episodes of asthma: a study of trends in new episodes presenting to general practitioners in the period 1989–98

BACKGROUNDA study was undertaken to determine trends in the incidence of new episodes of asthma presented to general practitioners participating in the Weekly Returns Service of the Royal College of...

Comparison of the seasonal patterns of asthma identified in general practitioner episodes, hospital admissions, and deaths

BACKGROUNDSeasonal variations in asthma are widely recognised. This study was undertaken to investigate the relative differences in seasonal patterns by age as they impact on episodes of care in general...

Incidence of allergic rhinitis in general practice, 1981-92.

To determine the epidemiology of hay fever and to consider the role of pollution. Examination of data on weekly incidence of allergic rhinitis and hay fever by age, sex, region, and location. Royal College of General Practitioners Weekly Returns Service. Practice data were based on registered populations of 220,000 in 1981, rising to 700,000 in 1992 from England and Wales. Numbers of new cases of hay fever and allergic rhinitis. Data on pollen counts for Darlington, Derby, and London. The incidence of allergic rhinitis fluctuated greatly from year to year but showed no trend. Peaks in hay fever coincided with peak pollen counts. No important differences were found between urban and rural locations or different parts of the country with respect to both size and timing of the peaks. Incidence was highest in children (5-14 years). The similarity of the results throughout England and Wales does not support an important role for local pollutants in hay fever. However, the possibility that levels of pollutants are high enough to act as an adjuvant in hay fever across the whole study area has not been excluded.

Morbidity registration and the fourth general practice morbidity survey in England and Wales.

The fourth morbidity survey in England and Wales is based on a population of 473,000 persons registered in 60 practices and cared for by 241 general practitioners. This presentation traces the evolution of morbidity surveys in England and Wales. That evolution has taken place against a background of advancing computer technology and the drift towards a paperless record. It is motivated by an increasing recognition of the need for data from primary health care an a realisation that a structured record is capable of servicing information needs without intermediary data sheets and coding procedures. The primary objectives of the study include assessment of disease prevalence by region, age-sex and social group; and to study trends over time. Morbidity and social data are collected in the practices and all relevant information stored on practice computers. At the end of the recording year, the computerised record for each patient is copied on to disks in an anonymized but uniquely identified form and transferred to the national Office of Population Censuses & Surveys for analysis. During the year, weekly extracts are taken of new episodes of illness in age and sex groupings which provide the basis of the Weekly Returns Service of the Royal College of General Practitioners.