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Papers by Joanna Garstang

In- depth interview guides. Parental in-depth interview guide. This is the interview guide used w... more In- depth interview guides. Parental in-depth interview guide. This is the interview guide used with all bereaved families during the first or only interview. Parental in-depth follow-up guide. This is the interview guide used with bereaved families who had a follow-up interview. Professional in-depth interview guide. This is the interview guide used with professionals. (DOCX 24 kb)

Microbiology Spectrum, 2022

We report on the first large-scale assessment of the suitability of oral fluids for detection of ... more We report on the first large-scale assessment of the suitability of oral fluids for detection of SARS-CoV-2 antibody obtained from healthy children attending school. The sample type (gingiva-crevicular fluid, which is a transudate of blood but is not saliva) can be self collected.

SSRN Electronic Journal, 2021

Background : Little is known about the views of adolescents returning to secondary school during ... more Background : Little is known about the views of adolescents returning to secondary school during the current COVID-19 pandemic. Methods: In September 2020, Public Health England (PHE) recruited staff and students in secondary schools to provide nasal swabs, oral fluid and blood samples for SARS-CoV-2 infection and antibody testing. Students aged 11-18 years in five London schools completed a short questionnaire about their perception of the pandemic, returning to school, risk to themselves and to others and infection control measures, and participating in school testing. Results: A questionnaire was completed by 64% (297/462) participants. Students were generally not anxious at all (19.7%; 58/294) or not really anxious (40.0%, 114/295) about returning to school, although 5.4% (n=16/295) were extremely nervous. Most students were very worried about transmitting the virus to their family (60.2%; 177/294) rather than other students (22.0%; 65/296) or school staff (19.3%; 57/296), or catching the infection themselves (12.5%; 37/296). Students better maintained physical distancing in the presence of school staff (84.6%; 247/292) and in public places (79.5%; 233/293) but not when with other students (46.8%; 137/293) or friends (40.8%; 120/294). A greater proportion of younger students (school years 7-9) reported not being anxious at all than 16-18 year olds (47/174 [27.0%] vs 3/63 [4.8%]; p=0.001). They were also less likely to adhere to physical distancing and wearing face masks. Most students reported positive experiences with testing in schools, with 92.3% (262/284) agreeing to have another blood test in future visits. Conclusions: Younger students were less concerned about catching and transmitting SARS-CoV-2 and were less likely to adhere to protective measures. Greater awareness of the potential risks of COVID-19 transmission between secondary school students potentially leading to increased risk of infection in their teachers and their household members may increase adherence to infection control measures within and outside schools.

ABSTRACTBackgroundThe role of educational settings on SARS-CoV-2 infection and transmission remai... more ABSTRACTBackgroundThe role of educational settings on SARS-CoV-2 infection and transmission remains controversial. We investigated SARS-CoV-2 infection, seroprevalence and seroconversions rates in secondary schools during the 2020/21 academic year, which included the emergence of the more transmissible Alpha and Delta variants, in England.MethodsThe UK Health Security Agency (UKHSA) initiated prospective surveillance in 18 urban English secondary schools. Participants had nasal swabs for SARS-CoV-2 RT-PCR and blood sampling for SARS-CoV-2 Nucleoprotein and Spike protein antibodies at the start (Round 1: September-October 2020) and end (Round 2: December 2021) of the autumn term, when schools reopened after national lockdown was imposed in January 2021 (Round 3: March-April) and end of the academic year (Round 4: May-July).FindingsWe enrolled 2,314 participants (1277 students, 1037 staff). In-school testing identified 31 PCR-positive participants (20 students, 11 staff). Another 247 ...

BMJ Paediatrics Open, 2021

ObjectiveTo determine difference in frequency of referral for child protection medical examinatio... more ObjectiveTo determine difference in frequency of referral for child protection medical examination (CPME) in children subject to special guardianship order (SGO), subject to child protection plan (CPP) or neither.DesignService evaluation analysing data from CPME reports.SettingAcute and community healthcare providers in Birmingham UK, during 2018.PatientsAll children aged 0–18 years requiring CPME.Main outcome measuresDetails were obtained from CPME reports on: age, SGO status, CPP status, reason for CPME, injuries sustained, presence of non-accidental injury.Population data were obtained from the local children’s safeguarding board and national statistics.ResultsReports were available for 292/298 (98%) CPME, relating to 288 children. 5 children were subject to SGO, 39 were subject to CPP, none subject to both. Non-accidental injury was substantiated in 189/288 (66%). The child population was 288 000. 1665 children were subject to CPP and approximately 750 subject to SGO. The relati...

Aims: Since 2008, in England, all sudden unexpected deaths in infancy (SUDI) must be investigated... more Aims: Since 2008, in England, all sudden unexpected deaths in infancy (SUDI) must be investigated jointly by police, health and social care. This thesis aims to learn of parents’ and professionals’ experiences of this joint agency approach (JAA) and use this knowledge to improve these investigations. Methods: 1. Systematic literature review of bereaved parents’ experiences. 2. Systematic literature review of different models of SUDI investigation. 3. A mixed methods study of JAA investigation of SUDI cases; involving case note analysis, questionnaires and in-depth interviews with parents and professionals. 4. A descriptive study of outcomes of JAA SUDI investigation using Child Death Overview Panel (CDOP) data. Results: In the mixed methods study, 23/111 families were recruited giving theoretical saturation; the median time between death and parental study participation was 33 weeks. Parents felt that the JAA provided information about the death but offered minimal emotional support...

Child: Care, Health and Development, 2021

This paper reports part of a wider systematic review commissioned by the English National Safegua... more This paper reports part of a wider systematic review commissioned by the English National Safeguarding Panel on Sudden Unexpected Death in Infancy (SUDI). The wider review covered three areas: interventions to improve safer sleep practices in high-risk families, interventions to improve engagement with services and decision making by parents at high risk of SUDI about infant sleep environments. Here, we report the qualitative and quantitative studies reviewed under the engagement strand. Parental engagement is understood to be a multidimensional task for health and social care professionals comprising attitudinal, relational and behavioural components. Following a PROSPERO registered systematic review synthesizing the three strands outlined, 28 papers were found to be relevant in the review of interventions to improve engagement with services in families with children at risk of significant harm through abuse or neglect. No studies were found that specifically focused on engagement of families at high risk for SUDI, so these wider engagement studies were included. The different types of intervention reported in the included studies are described under two broad themes: Enablers (including parental motivation and working with families) and Barriers. Given the focus in the studies on interventions that support parental engagement, the Enablers theme is more extensive than the Barriers reported although all studies noted well-understood barriers. The evidence underpinning these interventions and approaches are reviewed in this paper. We conclude that effective engagement is facilitated by experienced professionals given time to develop supportive non-judgemental relationships with families in their homes, working long-term, linking with communities and other services. While these conclusions have been drawn from wider studies aimed at reducing child maltreatment, we emphasize lessons to be drawn for SUDI prevention work with families with children at risk of significant harm.

SIDS Sudden infant and early childhood death: The past, the present and the future, 2018

Paediatrics and Child Health, 2021

The COVID-19 pandemic led to huge changes to children’s daily lives including school closures, lo... more The COVID-19 pandemic led to huge changes to children’s daily lives including school closures, loss of contact with family and friends, and financial difficulties which impacted on the wellbeing of all children. The Social Determinants of Health model gives us a framework to consider the impact of lockdown directly on children, and indirectly through the impact on parents, families, community and government policy as children cannot be considered in isolation to families or society. Children have suffered directly with lack of access to healthcare, and a decline in their mental health. Infant bonding may have been affected due to maternal stress, anxiety or depression, compounded by limited Health Visitor support. Poverty, food insecurity and lack of exercise contributed to increased obesity. Many children will have been exposed to domestic violence, parental mental illness and child abuse without being able to tell teachers or other adults outside of the home, these Adverse Childhood Experiences (ACE) increase the risk for subsequent health and behaviour problems. Children have spent many hours online for school learning and socialising with friends but faced risks of criminal exploitation and grooming. The long-term financial implications of COVID-19 will continue to impact on society for many years to come and further increase social inequalities.

SARS-CoV-2 infection is generally mild or asymptomatic in children but the biological basis for t... more SARS-CoV-2 infection is generally mild or asymptomatic in children but the biological basis for this is unclear. We studied the profile of antibody and cellular immunity in children aged 3-11 years in comparison with adults. Antibody responses against spike and receptor binding domain (RBD) were high in children and seroconversion boosted antibody responses against seasonal Beta-coronaviruses through cross-recognition of the S2 domain. Seroneutralisation assays against alpha, beta and delta SARS-CoV-2 variants demonstrated comparable neutralising activity between children and adults. T cell responses against spike were >2-fold higher in children compared to adults and displayed a TH1 cytokine profile. SARS-CoV-2 spike-specific T cells were also detected in many seronegative children, revealing pre-existing responses that were cross-reactive with seasonal Alpha and Beta-coronaviruses. Importantly, all children retained high antibody titres and cellular responses at 6 months after ...

eClinicalMedicine, 2021

Background: Prospective, longitudinal SARS-CoV-2 sero-surveillance in schools across England was ... more Background: Prospective, longitudinal SARS-CoV-2 sero-surveillance in schools across England was initiated after the first national lockdown, allowing comparison of child and adult antibody responses over time. Methods: Prospective active serological surveillance in 46 primary schools in England tested for SARS-CoV-2 antibodies during June, July and December 2020. Samples were tested for nucleocapsid (N) and receptor binding domain (RBD) antibodies, to estimate antibody persistence at least 6 months after infection, and for the correlation of N, RBD and live virus neutralising activity. Findings: In June 2020, 1,344 staff and 835 students were tested. Overall, 11.5% (95%CI: 9.4À13.9) and 11.3% (95%CI: 9.2À13.6; p = 0.88) of students had nucleoprotein and RBD antibodies, compared to 15.6% (95%CI: 13.7À17.6) and 15.3% (95%CI: 13.4À17.3; p = 0.83) of staff. Live virus neutralising activity was detected in 79.8% (n = 71/89) of nucleocapsid and 85.5% (71/83) of RBD antibody positive children. RBD antibodies correlated more strongly with neutralising antibodies (rs=0.7527; p<0.0001) than nucleocapsid antibodies (rs=0.3698; p<0.0001). A median of 24.4 weeks later, 58.2% (107/184) participants had nucleocapsid antibody seroreversion, compared to 20.9% (33/158) for RBD (p<0.001). Similar seroreversion rates were observed between staff and students for nucleocapsid (p = 0.26) and RBD-antibodies (p = 0.43). Nucleocapsid and RBD antibody quantitative results were significantly lower in staff compared to students (p = 0.028 and <0.0001 respectively) at baseline, but not at 24 weeks (p = 0.16 and p = 0.37, respectively). Interpretation: The immune response in children following SARS-CoV-2 infection was robust and sustained (>6 months) but further work is required to understand the extent to which this protects against reinfection.

The Lancet Child & Adolescent Health, 2021

Background Little is known about the risk of SARS-CoV-2 infection and transmission in educational... more Background Little is known about the risk of SARS-CoV-2 infection and transmission in educational settings. Public Health England initiated a study, COVID-19 Surveillance in School KIDs (sKIDs), in primary schools when they partially reopened from June 1, 2020, after the first national lockdown in England to estimate the incidence of symptomatic and asymptomatic SARS-CoV-2 infection, seroprevalence, and seroconversion in staff and students. Methods sKIDs, an active, prospective, surveillance study, included two groups: the weekly swabbing group and the blood sampling group. The swabbing group underwent weekly nasal swabs for at least 4 weeks after partial school reopening during the summer half-term (June to mid-July, 2020). The blood sampling group additionally underwent blood sampling for serum SARS-CoV-2 antibodies to measure previous infection at the beginning (June 1-19, 2020) and end (July 3-23, 2020) of the summer half-term, and, after full reopening in September, 2020, and at the end of the autumn term (Nov 23-Dec 18, 2020). We tested for predictors of SARS-CoV-2 antibody positivity using logistic regression. We calculated antibody seroconversion rates for participants who were seronegative in the first round and were tested in at least two rounds. Findings During the summer half-term, 11 966 participants (6727 students, 4628 staff, and 611 with unknown staff or student status) in 131 schools had 40 501 swabs taken. Weekly SARS-CoV-2 infection rates were 4•1 (one of 24 463; 95% CI 0•1-21•8) per 100 000 students and 12•5 (two of 16 038; 1•5-45•0) per 100 000 staff. At recruitment, in 45 schools, 91 (11•2%; 95% CI 7•9-15•1) of 816 students and 209 (15•1%; 11•9-18•9) of 1381 staff members were positive for SARS-CoV-2 antibodies, similar to local community seroprevalence. Seropositivity was not associated with school attendance during lockdown (p=0•13 for students and p=0•20 for staff) or staff contact with students (p=0•37). At the end of the summer half-term, 603 (73•9%) of 816 students and 1015 (73•5%) of 1381 staff members were still participating in the surveillance, and five (four students, one staff member) seroconverted. By December, 2020, 55 (5•1%; 95% CI 3•8-6•5) of 1085 participants who were seronegative at recruitment (in June, 2020) had seroconverted, including 19 (5•6%; 3•4-8•6) of 340 students and 36 (4•8%; 3•4-6•6) of 745 staff members (p=0•60). Interpretation In England, SARS-CoV-2 infection rates were low in primary schools following their partial and full reopening in June and September, 2020.

Health Education Research, 2021

We examined the feasibility of implementing preventive measures to prevent SARS-CoV-2 transmissio... more We examined the feasibility of implementing preventive measures to prevent SARS-CoV-2 transmission across 105 English primary schools in summer 2020 via a survey and interviews with headteachers. High rates of implementation of most recommended measures were noted with the exception of requiring 2 m distance for students, fitting hand sanitizers in classrooms and introducing one-way systems in school corridors. Measures such as regular handwashing and stopping assemblies were considered easy to implement. Majorly challenging measures included distancing between individuals (for students: 51%, N = 99; for staff: 34%; N = 98; for parents: 26%, N = 100), spacing out desks (34%, N = 99), keeping same staff assigned to each student group (33%, N = 97) and staggering break times (25%, N = 99). Rapid implementation was facilitated by staff commitment and communication among stakeholders, but hampered by limitations with guidance received, physical environments, resources, parental adherenc...

eClinicalMedicine, 2021

Background: Older children have higher SARS-CoV-2 infection rates than younger children. We inves... more Background: Older children have higher SARS-CoV-2 infection rates than younger children. We investigated SARS-CoV-2 infection, seroprevalence and seroconversion rates in staff and students following the full reopening of all secondary schools in England. Methods: Public Health England (PHE) invited secondary schools in six regions (East and West London, Hertfordshire, Derbyshire, Manchester and Birmingham) to participate in SARS-CoV-2 surveillance during the 2020/21 academic year. Participants had nasal swabs for RT-PCR and blood samples for SARS-CoV-2 antibodies at the beginning (September 2020) and end (December 2020) of the autumn term. Multivariable logistic regression was used to assess independent risk factors for seropositivity and seroconversion. Findings: Eighteen schools in six regions enrolled 2,209 participants, including 1,189 (53.8%) students and 1,020 (46.2%) staff. SARS-CoV-2 infection rates were not significantly different between students and staff in round one (5/948; [0.53%] vs. 2/876 [0.23%]; p = 0.46) or round two (10/948 [1.05%] vs. 7/886 [0.79%]; p = 0.63), and similar to national prevalence. None of four and 7/15 (47%) sequenced strains in rounds 1 and 2 were the highly transmissible SARS-CoV-2 B.1.1.7 variant. In round 1, antibody seropositivity was higher in students than staff (114/893 [12.8%] vs. 79/861 [9.2%]; p = 0.016), but similar in round 2 (117/893 [13.1%] vs.117/872 [13.3%]; p = 0.85), comparable to local community seroprevalence. Between the two rounds, 8.7% (57/652) staff and 6.6% (36/549) students seroconverted (p = 0.16). Interpretation: In secondary schools, SARS-CoV-2 infection, seropositivity and seroconversion rates were similar in staff and students, and comparable to local community rates. Ongoing surveillance will be important for monitoring the impact of new variants in educational settings.

PLOS ONE, 2021

Background The reopening of schools during the COVID-19 pandemic has raised concerns about widesp... more Background The reopening of schools during the COVID-19 pandemic has raised concerns about widespread infection and transmission of SARS-CoV-2 in educational settings. In June 2020, Public Health England (PHE) initiated prospective national surveillance of SARS-CoV-2 in primary schools across England (sKIDs). We used this opportunity to assess the feasibility and agreeability of large-scale surveillance and testing for SARS-CoV-2 infections in school among staff, parents and students. Methods Staff and students in 131 primary schools were asked to complete a questionnaire at recruitment and provide weekly nasal swabs for SARS-CoV-2 RT-PCR testing (n = 86) or swabs with blood samples for antibody testing (n = 45) at the beginning and end the summer half-term. In six blood sampling schools, students were asked to complete a pictorial questionnaire before and after their investigations. Results In total, 135 children aged 4–7 years (n = 40) or 8–11 years (n = 95) completed the pictoria...

Trauma, Violence, & Abuse, 2021

Kinship care is a global phenomenon with a long history, which in high-income countries (HICs) at... more Kinship care is a global phenomenon with a long history, which in high-income countries (HICs) at least, is being increasingly formalized through legislation and policy. There are many benefits to kinship care, including improved child mental health and well-being when compared to other types of out-of-home care. Despite this, kinship care is not without its risks with a lack of support and training for kinship carers putting children at an increased risk of abuse and neglect. This scoping review was conducted across 11 databases to explore the breadth and depth of the literature about abuse and neglect within kinship care in HICs and to provide initial indications about the relationship between kinship care and abuse. Of the 2,308 studies initially identified, 26 met the inclusion criteria. A majority of studies were from the United States, and most used case review methods. From the included studies, rates of re-abuse, and particularly rates of physical and sexual abuse, appear to...

Paediatrics and Child Health, 2020

Abstract Serious Case Reviews (SCRs) provide an important opportunity for professional learning w... more Abstract Serious Case Reviews (SCRs) provide an important opportunity for professional learning when children have died or suffered serious harm from abuse or neglect. The triennial SCR analysis seeks to identify themes across SCRs to inform practice and guide the development of new strategies in order to prevent future harm to children. Neglect is a key feature of most serious case reviews; it is a complex issue with multiple contributory factors accumulating over time. Neglect is linked with unfavourable outcomes at individual and societal levels. Many of the families concerned are living in poverty and difficulties are exacerbated by the limitation of resources with which to support them. This article considers key messages for paediatric practice from the 2014–17 triennial review, particularly with respect to neglect and adolescent safeguarding concerns.

Acta Paediatrica, 2020

To identify how British Child Death Overview Panels (CDOP) and paediatric pathologists classify c... more To identify how British Child Death Overview Panels (CDOP) and paediatric pathologists classify cause of death for sleep-related Sudden Unexpected Death in Infancy (SUDI). To determine compliance with national requirements for SUDI investigation. Methods Electronic survey of CDOPs and pathologists using three vignettes of SUDI cases illustrating: accidental asphyxia, typical Sudden Infant Death Syndrome (SIDS) and SIDS with co-sleeping. Results 38(41%) of 92 CDOPs returned questionnaires, 32 were complete. 13(14%) of 90 pathologists returned complete questionnaires. 31(97%) CDOPs and 7(53%) pathologists agreed with the cause of death in the accidental asphyxia case; 24(75%) CDOPs and 9(69%) pathologists in the typical SIDS case; and 11(34%) CDOPs and 1(8%) pathologist in the co-sleeping SIDS case. Pathologists used the terms SUDI or unascertained as the cause of death for the accidental asphyxia case (46%) and the co-sleeping SIDS case (77%). These terms were used by CDOPs for the typical SIDS case (25%) and the co-sleeping SIDS case (41%). 17(46%) CDOPs reported compliance with guidelines for investigation in more than 75% of cases. Conclusion There is wide variation in classification of deaths, with only limited agreement between CDOPs and pathologists. The terms SIDS and accidental asphyxia are underused, even in typical cases. (199 words) CDOP Child Death Overview Panels SIDS Sudden Infant Death Syndrome SUDI Sudden Unexpected Death in Infancy Key Notes Child Death Overview Panels and paediatric pathologists differ widely in their classification of causes of death in Sudden Unexpected Death in Infancy. Child Death Overview Panels are more likely to classify deaths are due to accidental asphyxia than paediatric pathologists. Less than half of Child Death Overview Panels reported that local investigation of unexpected infant deaths was compliant with national guidance.

Archives of Disease in Childhood, 2018

The UK has a higher mortality for children from birth to 5 years old compared with most other cou... more The UK has a higher mortality for children from birth to 5 years old compared with most other countries in Western Europe,1 and this has been recognised as a national priority by the Royal College of Paediatrics and Child Health. Learning from child deaths is one part of the process by which we could start to address this issue. The paper by Firth et al highlights how data from child death overview panels (CDOPs) can be used to provide fresh understanding of why so many children in the UK die prematurely. Their analysis of CDOP data has shown the excess infant mortality in Bradford associated with congenital anomalies in babies born to consanguineous parents of Pakistani origin. This conclusion would have been considerably more difficult without the detailed information available from CDOP analysis of individual cases. Death certification can only give the medical cause for death, whereas CDOP considers broader factors and vulnerabilities including those directly relating to the child themselves, and social, familial and environmental considerations and the provision of services. Accurate identification of high-risk populations can therefore allow appropriate targeting of interventions, whether these are public health initiatives or safety campaigns. Firth et al 2 have shown one use of CDOP data from a local project. CDOP data have huge potential nationally to increase our understanding of why children die …

Child Abuse Review, 2018

Please refer to published version for the most recent bibliographic citation information. If a pu... more Please refer to published version for the most recent bibliographic citation information. If a published version is known of, the repository item page linked to above, will contain details on accessing it.

In- depth interview guides. Parental in-depth interview guide. This is the interview guide used w... more In- depth interview guides. Parental in-depth interview guide. This is the interview guide used with all bereaved families during the first or only interview. Parental in-depth follow-up guide. This is the interview guide used with bereaved families who had a follow-up interview. Professional in-depth interview guide. This is the interview guide used with professionals. (DOCX 24 kb)

Microbiology Spectrum, 2022

We report on the first large-scale assessment of the suitability of oral fluids for detection of ... more We report on the first large-scale assessment of the suitability of oral fluids for detection of SARS-CoV-2 antibody obtained from healthy children attending school. The sample type (gingiva-crevicular fluid, which is a transudate of blood but is not saliva) can be self collected.

SSRN Electronic Journal, 2021

Background : Little is known about the views of adolescents returning to secondary school during ... more Background : Little is known about the views of adolescents returning to secondary school during the current COVID-19 pandemic. Methods: In September 2020, Public Health England (PHE) recruited staff and students in secondary schools to provide nasal swabs, oral fluid and blood samples for SARS-CoV-2 infection and antibody testing. Students aged 11-18 years in five London schools completed a short questionnaire about their perception of the pandemic, returning to school, risk to themselves and to others and infection control measures, and participating in school testing. Results: A questionnaire was completed by 64% (297/462) participants. Students were generally not anxious at all (19.7%; 58/294) or not really anxious (40.0%, 114/295) about returning to school, although 5.4% (n=16/295) were extremely nervous. Most students were very worried about transmitting the virus to their family (60.2%; 177/294) rather than other students (22.0%; 65/296) or school staff (19.3%; 57/296), or catching the infection themselves (12.5%; 37/296). Students better maintained physical distancing in the presence of school staff (84.6%; 247/292) and in public places (79.5%; 233/293) but not when with other students (46.8%; 137/293) or friends (40.8%; 120/294). A greater proportion of younger students (school years 7-9) reported not being anxious at all than 16-18 year olds (47/174 [27.0%] vs 3/63 [4.8%]; p=0.001). They were also less likely to adhere to physical distancing and wearing face masks. Most students reported positive experiences with testing in schools, with 92.3% (262/284) agreeing to have another blood test in future visits. Conclusions: Younger students were less concerned about catching and transmitting SARS-CoV-2 and were less likely to adhere to protective measures. Greater awareness of the potential risks of COVID-19 transmission between secondary school students potentially leading to increased risk of infection in their teachers and their household members may increase adherence to infection control measures within and outside schools.

ABSTRACTBackgroundThe role of educational settings on SARS-CoV-2 infection and transmission remai... more ABSTRACTBackgroundThe role of educational settings on SARS-CoV-2 infection and transmission remains controversial. We investigated SARS-CoV-2 infection, seroprevalence and seroconversions rates in secondary schools during the 2020/21 academic year, which included the emergence of the more transmissible Alpha and Delta variants, in England.MethodsThe UK Health Security Agency (UKHSA) initiated prospective surveillance in 18 urban English secondary schools. Participants had nasal swabs for SARS-CoV-2 RT-PCR and blood sampling for SARS-CoV-2 Nucleoprotein and Spike protein antibodies at the start (Round 1: September-October 2020) and end (Round 2: December 2021) of the autumn term, when schools reopened after national lockdown was imposed in January 2021 (Round 3: March-April) and end of the academic year (Round 4: May-July).FindingsWe enrolled 2,314 participants (1277 students, 1037 staff). In-school testing identified 31 PCR-positive participants (20 students, 11 staff). Another 247 ...

BMJ Paediatrics Open, 2021

ObjectiveTo determine difference in frequency of referral for child protection medical examinatio... more ObjectiveTo determine difference in frequency of referral for child protection medical examination (CPME) in children subject to special guardianship order (SGO), subject to child protection plan (CPP) or neither.DesignService evaluation analysing data from CPME reports.SettingAcute and community healthcare providers in Birmingham UK, during 2018.PatientsAll children aged 0–18 years requiring CPME.Main outcome measuresDetails were obtained from CPME reports on: age, SGO status, CPP status, reason for CPME, injuries sustained, presence of non-accidental injury.Population data were obtained from the local children’s safeguarding board and national statistics.ResultsReports were available for 292/298 (98%) CPME, relating to 288 children. 5 children were subject to SGO, 39 were subject to CPP, none subject to both. Non-accidental injury was substantiated in 189/288 (66%). The child population was 288 000. 1665 children were subject to CPP and approximately 750 subject to SGO. The relati...

Aims: Since 2008, in England, all sudden unexpected deaths in infancy (SUDI) must be investigated... more Aims: Since 2008, in England, all sudden unexpected deaths in infancy (SUDI) must be investigated jointly by police, health and social care. This thesis aims to learn of parents’ and professionals’ experiences of this joint agency approach (JAA) and use this knowledge to improve these investigations. Methods: 1. Systematic literature review of bereaved parents’ experiences. 2. Systematic literature review of different models of SUDI investigation. 3. A mixed methods study of JAA investigation of SUDI cases; involving case note analysis, questionnaires and in-depth interviews with parents and professionals. 4. A descriptive study of outcomes of JAA SUDI investigation using Child Death Overview Panel (CDOP) data. Results: In the mixed methods study, 23/111 families were recruited giving theoretical saturation; the median time between death and parental study participation was 33 weeks. Parents felt that the JAA provided information about the death but offered minimal emotional support...

Child: Care, Health and Development, 2021

This paper reports part of a wider systematic review commissioned by the English National Safegua... more This paper reports part of a wider systematic review commissioned by the English National Safeguarding Panel on Sudden Unexpected Death in Infancy (SUDI). The wider review covered three areas: interventions to improve safer sleep practices in high-risk families, interventions to improve engagement with services and decision making by parents at high risk of SUDI about infant sleep environments. Here, we report the qualitative and quantitative studies reviewed under the engagement strand. Parental engagement is understood to be a multidimensional task for health and social care professionals comprising attitudinal, relational and behavioural components. Following a PROSPERO registered systematic review synthesizing the three strands outlined, 28 papers were found to be relevant in the review of interventions to improve engagement with services in families with children at risk of significant harm through abuse or neglect. No studies were found that specifically focused on engagement of families at high risk for SUDI, so these wider engagement studies were included. The different types of intervention reported in the included studies are described under two broad themes: Enablers (including parental motivation and working with families) and Barriers. Given the focus in the studies on interventions that support parental engagement, the Enablers theme is more extensive than the Barriers reported although all studies noted well-understood barriers. The evidence underpinning these interventions and approaches are reviewed in this paper. We conclude that effective engagement is facilitated by experienced professionals given time to develop supportive non-judgemental relationships with families in their homes, working long-term, linking with communities and other services. While these conclusions have been drawn from wider studies aimed at reducing child maltreatment, we emphasize lessons to be drawn for SUDI prevention work with families with children at risk of significant harm.

SIDS Sudden infant and early childhood death: The past, the present and the future, 2018

Paediatrics and Child Health, 2021

The COVID-19 pandemic led to huge changes to children’s daily lives including school closures, lo... more The COVID-19 pandemic led to huge changes to children’s daily lives including school closures, loss of contact with family and friends, and financial difficulties which impacted on the wellbeing of all children. The Social Determinants of Health model gives us a framework to consider the impact of lockdown directly on children, and indirectly through the impact on parents, families, community and government policy as children cannot be considered in isolation to families or society. Children have suffered directly with lack of access to healthcare, and a decline in their mental health. Infant bonding may have been affected due to maternal stress, anxiety or depression, compounded by limited Health Visitor support. Poverty, food insecurity and lack of exercise contributed to increased obesity. Many children will have been exposed to domestic violence, parental mental illness and child abuse without being able to tell teachers or other adults outside of the home, these Adverse Childhood Experiences (ACE) increase the risk for subsequent health and behaviour problems. Children have spent many hours online for school learning and socialising with friends but faced risks of criminal exploitation and grooming. The long-term financial implications of COVID-19 will continue to impact on society for many years to come and further increase social inequalities.

SARS-CoV-2 infection is generally mild or asymptomatic in children but the biological basis for t... more SARS-CoV-2 infection is generally mild or asymptomatic in children but the biological basis for this is unclear. We studied the profile of antibody and cellular immunity in children aged 3-11 years in comparison with adults. Antibody responses against spike and receptor binding domain (RBD) were high in children and seroconversion boosted antibody responses against seasonal Beta-coronaviruses through cross-recognition of the S2 domain. Seroneutralisation assays against alpha, beta and delta SARS-CoV-2 variants demonstrated comparable neutralising activity between children and adults. T cell responses against spike were >2-fold higher in children compared to adults and displayed a TH1 cytokine profile. SARS-CoV-2 spike-specific T cells were also detected in many seronegative children, revealing pre-existing responses that were cross-reactive with seasonal Alpha and Beta-coronaviruses. Importantly, all children retained high antibody titres and cellular responses at 6 months after ...

eClinicalMedicine, 2021

Background: Prospective, longitudinal SARS-CoV-2 sero-surveillance in schools across England was ... more Background: Prospective, longitudinal SARS-CoV-2 sero-surveillance in schools across England was initiated after the first national lockdown, allowing comparison of child and adult antibody responses over time. Methods: Prospective active serological surveillance in 46 primary schools in England tested for SARS-CoV-2 antibodies during June, July and December 2020. Samples were tested for nucleocapsid (N) and receptor binding domain (RBD) antibodies, to estimate antibody persistence at least 6 months after infection, and for the correlation of N, RBD and live virus neutralising activity. Findings: In June 2020, 1,344 staff and 835 students were tested. Overall, 11.5% (95%CI: 9.4À13.9) and 11.3% (95%CI: 9.2À13.6; p = 0.88) of students had nucleoprotein and RBD antibodies, compared to 15.6% (95%CI: 13.7À17.6) and 15.3% (95%CI: 13.4À17.3; p = 0.83) of staff. Live virus neutralising activity was detected in 79.8% (n = 71/89) of nucleocapsid and 85.5% (71/83) of RBD antibody positive children. RBD antibodies correlated more strongly with neutralising antibodies (rs=0.7527; p<0.0001) than nucleocapsid antibodies (rs=0.3698; p<0.0001). A median of 24.4 weeks later, 58.2% (107/184) participants had nucleocapsid antibody seroreversion, compared to 20.9% (33/158) for RBD (p<0.001). Similar seroreversion rates were observed between staff and students for nucleocapsid (p = 0.26) and RBD-antibodies (p = 0.43). Nucleocapsid and RBD antibody quantitative results were significantly lower in staff compared to students (p = 0.028 and <0.0001 respectively) at baseline, but not at 24 weeks (p = 0.16 and p = 0.37, respectively). Interpretation: The immune response in children following SARS-CoV-2 infection was robust and sustained (>6 months) but further work is required to understand the extent to which this protects against reinfection.

The Lancet Child & Adolescent Health, 2021

Background Little is known about the risk of SARS-CoV-2 infection and transmission in educational... more Background Little is known about the risk of SARS-CoV-2 infection and transmission in educational settings. Public Health England initiated a study, COVID-19 Surveillance in School KIDs (sKIDs), in primary schools when they partially reopened from June 1, 2020, after the first national lockdown in England to estimate the incidence of symptomatic and asymptomatic SARS-CoV-2 infection, seroprevalence, and seroconversion in staff and students. Methods sKIDs, an active, prospective, surveillance study, included two groups: the weekly swabbing group and the blood sampling group. The swabbing group underwent weekly nasal swabs for at least 4 weeks after partial school reopening during the summer half-term (June to mid-July, 2020). The blood sampling group additionally underwent blood sampling for serum SARS-CoV-2 antibodies to measure previous infection at the beginning (June 1-19, 2020) and end (July 3-23, 2020) of the summer half-term, and, after full reopening in September, 2020, and at the end of the autumn term (Nov 23-Dec 18, 2020). We tested for predictors of SARS-CoV-2 antibody positivity using logistic regression. We calculated antibody seroconversion rates for participants who were seronegative in the first round and were tested in at least two rounds. Findings During the summer half-term, 11 966 participants (6727 students, 4628 staff, and 611 with unknown staff or student status) in 131 schools had 40 501 swabs taken. Weekly SARS-CoV-2 infection rates were 4•1 (one of 24 463; 95% CI 0•1-21•8) per 100 000 students and 12•5 (two of 16 038; 1•5-45•0) per 100 000 staff. At recruitment, in 45 schools, 91 (11•2%; 95% CI 7•9-15•1) of 816 students and 209 (15•1%; 11•9-18•9) of 1381 staff members were positive for SARS-CoV-2 antibodies, similar to local community seroprevalence. Seropositivity was not associated with school attendance during lockdown (p=0•13 for students and p=0•20 for staff) or staff contact with students (p=0•37). At the end of the summer half-term, 603 (73•9%) of 816 students and 1015 (73•5%) of 1381 staff members were still participating in the surveillance, and five (four students, one staff member) seroconverted. By December, 2020, 55 (5•1%; 95% CI 3•8-6•5) of 1085 participants who were seronegative at recruitment (in June, 2020) had seroconverted, including 19 (5•6%; 3•4-8•6) of 340 students and 36 (4•8%; 3•4-6•6) of 745 staff members (p=0•60). Interpretation In England, SARS-CoV-2 infection rates were low in primary schools following their partial and full reopening in June and September, 2020.

Health Education Research, 2021

We examined the feasibility of implementing preventive measures to prevent SARS-CoV-2 transmissio... more We examined the feasibility of implementing preventive measures to prevent SARS-CoV-2 transmission across 105 English primary schools in summer 2020 via a survey and interviews with headteachers. High rates of implementation of most recommended measures were noted with the exception of requiring 2 m distance for students, fitting hand sanitizers in classrooms and introducing one-way systems in school corridors. Measures such as regular handwashing and stopping assemblies were considered easy to implement. Majorly challenging measures included distancing between individuals (for students: 51%, N = 99; for staff: 34%; N = 98; for parents: 26%, N = 100), spacing out desks (34%, N = 99), keeping same staff assigned to each student group (33%, N = 97) and staggering break times (25%, N = 99). Rapid implementation was facilitated by staff commitment and communication among stakeholders, but hampered by limitations with guidance received, physical environments, resources, parental adherenc...

eClinicalMedicine, 2021

Background: Older children have higher SARS-CoV-2 infection rates than younger children. We inves... more Background: Older children have higher SARS-CoV-2 infection rates than younger children. We investigated SARS-CoV-2 infection, seroprevalence and seroconversion rates in staff and students following the full reopening of all secondary schools in England. Methods: Public Health England (PHE) invited secondary schools in six regions (East and West London, Hertfordshire, Derbyshire, Manchester and Birmingham) to participate in SARS-CoV-2 surveillance during the 2020/21 academic year. Participants had nasal swabs for RT-PCR and blood samples for SARS-CoV-2 antibodies at the beginning (September 2020) and end (December 2020) of the autumn term. Multivariable logistic regression was used to assess independent risk factors for seropositivity and seroconversion. Findings: Eighteen schools in six regions enrolled 2,209 participants, including 1,189 (53.8%) students and 1,020 (46.2%) staff. SARS-CoV-2 infection rates were not significantly different between students and staff in round one (5/948; [0.53%] vs. 2/876 [0.23%]; p = 0.46) or round two (10/948 [1.05%] vs. 7/886 [0.79%]; p = 0.63), and similar to national prevalence. None of four and 7/15 (47%) sequenced strains in rounds 1 and 2 were the highly transmissible SARS-CoV-2 B.1.1.7 variant. In round 1, antibody seropositivity was higher in students than staff (114/893 [12.8%] vs. 79/861 [9.2%]; p = 0.016), but similar in round 2 (117/893 [13.1%] vs.117/872 [13.3%]; p = 0.85), comparable to local community seroprevalence. Between the two rounds, 8.7% (57/652) staff and 6.6% (36/549) students seroconverted (p = 0.16). Interpretation: In secondary schools, SARS-CoV-2 infection, seropositivity and seroconversion rates were similar in staff and students, and comparable to local community rates. Ongoing surveillance will be important for monitoring the impact of new variants in educational settings.

PLOS ONE, 2021

Background The reopening of schools during the COVID-19 pandemic has raised concerns about widesp... more Background The reopening of schools during the COVID-19 pandemic has raised concerns about widespread infection and transmission of SARS-CoV-2 in educational settings. In June 2020, Public Health England (PHE) initiated prospective national surveillance of SARS-CoV-2 in primary schools across England (sKIDs). We used this opportunity to assess the feasibility and agreeability of large-scale surveillance and testing for SARS-CoV-2 infections in school among staff, parents and students. Methods Staff and students in 131 primary schools were asked to complete a questionnaire at recruitment and provide weekly nasal swabs for SARS-CoV-2 RT-PCR testing (n = 86) or swabs with blood samples for antibody testing (n = 45) at the beginning and end the summer half-term. In six blood sampling schools, students were asked to complete a pictorial questionnaire before and after their investigations. Results In total, 135 children aged 4–7 years (n = 40) or 8–11 years (n = 95) completed the pictoria...

Trauma, Violence, & Abuse, 2021

Kinship care is a global phenomenon with a long history, which in high-income countries (HICs) at... more Kinship care is a global phenomenon with a long history, which in high-income countries (HICs) at least, is being increasingly formalized through legislation and policy. There are many benefits to kinship care, including improved child mental health and well-being when compared to other types of out-of-home care. Despite this, kinship care is not without its risks with a lack of support and training for kinship carers putting children at an increased risk of abuse and neglect. This scoping review was conducted across 11 databases to explore the breadth and depth of the literature about abuse and neglect within kinship care in HICs and to provide initial indications about the relationship between kinship care and abuse. Of the 2,308 studies initially identified, 26 met the inclusion criteria. A majority of studies were from the United States, and most used case review methods. From the included studies, rates of re-abuse, and particularly rates of physical and sexual abuse, appear to...

Paediatrics and Child Health, 2020

Abstract Serious Case Reviews (SCRs) provide an important opportunity for professional learning w... more Abstract Serious Case Reviews (SCRs) provide an important opportunity for professional learning when children have died or suffered serious harm from abuse or neglect. The triennial SCR analysis seeks to identify themes across SCRs to inform practice and guide the development of new strategies in order to prevent future harm to children. Neglect is a key feature of most serious case reviews; it is a complex issue with multiple contributory factors accumulating over time. Neglect is linked with unfavourable outcomes at individual and societal levels. Many of the families concerned are living in poverty and difficulties are exacerbated by the limitation of resources with which to support them. This article considers key messages for paediatric practice from the 2014–17 triennial review, particularly with respect to neglect and adolescent safeguarding concerns.

Acta Paediatrica, 2020

To identify how British Child Death Overview Panels (CDOP) and paediatric pathologists classify c... more To identify how British Child Death Overview Panels (CDOP) and paediatric pathologists classify cause of death for sleep-related Sudden Unexpected Death in Infancy (SUDI). To determine compliance with national requirements for SUDI investigation. Methods Electronic survey of CDOPs and pathologists using three vignettes of SUDI cases illustrating: accidental asphyxia, typical Sudden Infant Death Syndrome (SIDS) and SIDS with co-sleeping. Results 38(41%) of 92 CDOPs returned questionnaires, 32 were complete. 13(14%) of 90 pathologists returned complete questionnaires. 31(97%) CDOPs and 7(53%) pathologists agreed with the cause of death in the accidental asphyxia case; 24(75%) CDOPs and 9(69%) pathologists in the typical SIDS case; and 11(34%) CDOPs and 1(8%) pathologist in the co-sleeping SIDS case. Pathologists used the terms SUDI or unascertained as the cause of death for the accidental asphyxia case (46%) and the co-sleeping SIDS case (77%). These terms were used by CDOPs for the typical SIDS case (25%) and the co-sleeping SIDS case (41%). 17(46%) CDOPs reported compliance with guidelines for investigation in more than 75% of cases. Conclusion There is wide variation in classification of deaths, with only limited agreement between CDOPs and pathologists. The terms SIDS and accidental asphyxia are underused, even in typical cases. (199 words) CDOP Child Death Overview Panels SIDS Sudden Infant Death Syndrome SUDI Sudden Unexpected Death in Infancy Key Notes Child Death Overview Panels and paediatric pathologists differ widely in their classification of causes of death in Sudden Unexpected Death in Infancy. Child Death Overview Panels are more likely to classify deaths are due to accidental asphyxia than paediatric pathologists. Less than half of Child Death Overview Panels reported that local investigation of unexpected infant deaths was compliant with national guidance.

Archives of Disease in Childhood, 2018

The UK has a higher mortality for children from birth to 5 years old compared with most other cou... more The UK has a higher mortality for children from birth to 5 years old compared with most other countries in Western Europe,1 and this has been recognised as a national priority by the Royal College of Paediatrics and Child Health. Learning from child deaths is one part of the process by which we could start to address this issue. The paper by Firth et al highlights how data from child death overview panels (CDOPs) can be used to provide fresh understanding of why so many children in the UK die prematurely. Their analysis of CDOP data has shown the excess infant mortality in Bradford associated with congenital anomalies in babies born to consanguineous parents of Pakistani origin. This conclusion would have been considerably more difficult without the detailed information available from CDOP analysis of individual cases. Death certification can only give the medical cause for death, whereas CDOP considers broader factors and vulnerabilities including those directly relating to the child themselves, and social, familial and environmental considerations and the provision of services. Accurate identification of high-risk populations can therefore allow appropriate targeting of interventions, whether these are public health initiatives or safety campaigns. Firth et al 2 have shown one use of CDOP data from a local project. CDOP data have huge potential nationally to increase our understanding of why children die …

Child Abuse Review, 2018

Please refer to published version for the most recent bibliographic citation information. If a pu... more Please refer to published version for the most recent bibliographic citation information. If a published version is known of, the repository item page linked to above, will contain details on accessing it.