Public acceptability of a technology-mediated stool sample collection platform to inform community-based surveillance of infectious intestinal disease: a pilot study

Background In the UK approximately a quarter of the population experience infectious intestinal disease (IID) each year. However, only 2% present to primary care, preventing a true determination of community burden and pathogen aetiology. The aim of this pilot study was to gauge public acceptability of a technology-mediated platform for reporting episodes of IID and for providing stool samples. Methods This study employed a cross-sectional online survey design, targeting individuals 16+ years old within Liverpool City Region, UK. Information sought included demographics, comfortability of reporting illness and IID symptoms, willingness to provide stool, and favoured stool-provision method. Univariable logistic regression was used to examine associations between demographic variables and providing a stool sample. Odds ratios (OR) and associated 95% confidence intervals (CIs) were produced. Results A total of 174 eligible participants completed the survey, with 69% female. The sample was skewed towards younger populations, with 2.9% aged 65+ years. Nearly a third (29%) had a household income of less than £30,000 per annum and 70% had attained a degree or higher. The majority identified as White British (81%) and 11% identified as ethnicities typically grouped Black, Asian and minority ethnic (BAME). Three quarters of participants were either ‘Comfortable’ or ‘Very Comfortable’ with reporting illness (75%) and with answering symptom-related questions (79%); 78% reported that they would provide a stool sample. Upon univariable analysis, increasing age – being 55+ (OR 6.28, 95% CI 1.15-117.48), and lower income (OR 2.5, 95% CI 1.02-6.60), was associated with providing a stool sample. Additionally, respondents identifying as BAME ethnicities and men may be less inclined to provide a stool sample. Conclusions This study assessed the acceptability of technology-mediated platforms for reporting IID and provision of stool samples in the community. Respondents were biased towards younger, technologically inclined, more affluent and educated populations. Acceptability for reporting illness and providing a stool sample through technology-mediated platforms was high. While older populations were under-represented, they were more likely to provide a stool sample. Qualitative research is required to better reach older and more deprived populations, and to understand potential age, gender and ethnic differences in compliance with stool sampling.

Whipple’s Disease

Whipple’s disease is a rare infectious intestinal disease with lipid deposition and multiple macrophages that contain argyrophilic rod-shaped formations found in the intestines and lymph nodes. This disease is difficult to diagnose and it is only after several years of treatment of other diseases that the correct diagnosis is established. The advent of antibiotics has improved the disease outcome – tetracycline antibiotics are used in most cases.

Foodborne Disease Estimates for the United Kingdom in 2018

In February 2020 the FSA published two reports which produced new estimates of foodborne norovirus cases. These were the ‘Norovirus Attribution Study’ (NoVAS study) (O’Brien et al., 2020) and the accompanying internal FSA technical review ‘Technical Report: Review of Quantitative Risk Assessment of foodborne norovirus transmission’ (NoVAS model review), (Food Standards Agency, 2020). The NoVAS study produced a Quantitative Microbiological Risk Assessment model (QMRA) to estimate foodborne norovirus. The NoVAS model review considered the impact of using alternative assumptions and other data sources on these estimates. From these two pieces of work, a revised estimate of foodborne norovirus was produced. The FSA has therefore updated its estimates of annual foodborne disease to include these new results and also to take account of more recent data related to other pathogens. The estimates produced include: •Estimates of GP presentations and hospital admissions for foodbornenorovirus based on the new estimates of cases. The NoVAS study onlyproduced estimates for cases. •Estimates of foodborne cases, GP presentations and hospital admissions for12 other pathogens •Estimates of unattributed cases of foodborne disease •Estimates of total foodborne disease from all pathogens Previous estimates An FSA funded research project ‘The second study of infectious intestinal disease in the community’, published in 2012 and referred to as the IID2 study (Tam et al., 2012), estimated that there were 17 million cases of infectious intestinal disease (IID) in 2009. These include illness caused by all sources, not just food. Of these 17 million cases, around 40% (around 7 million) could be attributed to 13 known pathogens. These pathogens included norovirus. The remaining 60% of cases (equivalent to 10 million cases) were unattributed cases. These are cases where the causal pathogen is unknown. Reasons for this include the causal pathogen was not tested for, the test was not sensitive enough to detect the causal pathogen or the pathogen is unknown to science. A second project ‘Costed extension to the second study of infectious intestinal disease in the community’, published in 2014 and known as IID2 extension (Tam, Larose and O’Brien, 2014), estimated that there were 566,000 cases of foodborne disease per year caused by the same 13 known pathogens. Although a proportion of the unattributed cases would also be due to food, no estimate was provided for this in the IID2 extension. New estimates We estimate that there were 2.4 million cases of foodborne disease in the UK in 2018 (95% credible intervals 1.8 million to 3.1 million), with 222,000 GP presentations (95% Cred. Int. 150,000 to 322,000) and 16,400 hospital admissions (95% Cred. Int. 11,200 to 26,000). Of the estimated 2.4 million cases, 0.9 million (95% Cred. Int. 0.7 million to 1.2 million) were from the 13 known pathogens included in the IID2 extension and 1.4 million1 (95% Cred. Int. 1.0 million to 2.0 million) for unattributed cases. Norovirus was the pathogen with the largest estimate with 383,000 cases a year. However, this estimate is within the 95% credible interval for Campylobacter of 127,000 to 571,000. The pathogen with the next highest number of cases was Clostridium perfringens with 85,000 (95% Cred. Int. 32,000 to 225,000). While the methodology used in the NoVAS study does not lend itself to producing credible intervals for cases of norovirus, this does not mean that there is no uncertainty in these estimates. There were a number of parameters used in the NoVAS study which, while based on the best science currently available, were acknowledged to have uncertain values. Sensitivity analysis undertaken as part of the study showed that changes to the values of these parameters could make big differences to the overall estimates. Campylobacter was estimated to have the most GP presentations with 43,000 (95% Cred. Int. 19,000 to 76,000) followed by norovirus with 17,000 (95% Cred. Int. 11,000 to 26,000) and Clostridium perfringens with 13,000 (95% Cred. Int. 6,000 to 29,000). For hospital admissions Campylobacter was estimated to have 3,500 (95% Cred. Int. 1,400 to 7,600), followed by norovirus 2,200 (95% Cred. Int. 1,500 to 3,100) and Salmonella with 2,100 admissions (95% Cred. Int. 400 to 9,900). As many of these credible intervals overlap, any ranking needs to be undertaken with caution. While the estimates provided in this report are for 2018 the methodology described can be applied to future years.