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University of Nottingham

UOA 6 - Epidemiology and Public Health

RA5a: Research environment and esteem

OVERVIEW

 

The Epidemiology and Public Health (EPH) group is part of the School of Community Health Sciences in the Faculty of Medicine and Health Sciences, and collaborates with a wide range of clinical, public health and policy researchers within and outside the University of Nottingham. Since the 2001 RAE the EPH group has undergone radical strategic restructuring to:

 

  • Concentrate resources in areas of existing research strength in chronic and infectious disease epidemiology
  • develop new research and policy groups in tobacco control and social epidemiology
  • establish and consolidate a strong medical statistics group to underpin our research
  • build expertise and infrastructure in the application of routine primary care (GPRD, THIN) and other major data sources in epidemiology
  • develop expertise in systematic review and meta-analysis to support strategic research planning
  • establish infrastructure and capacity to carry out clinical trials to test hypotheses arising from our observational epidemiology and systematic review work
  • invest in new public health academic capacity, particularly in health protection.

 

This has been achieved by redeployment of academic posts and sustained investment in training and development of new researchers to establish the critical mass necessary to allow us to recruit more senior academics from outside Nottingham. Of the 25 category A staff returned in UoA6, 20 have joined the EPH group since January 2001. Several of these have been recruited and/or retained through successful competition for external training or higher Fellowships (and one personal Chair) during this RAE period, including:

 

 Richard Hubbard: British Lung Foundation Chair in Respiratory Epidemiology 2005 (value £425,000, for studies using routine databases to investigate respiratory disease); formerly Wellcome Trust Advanced Fellow, 2000-3

Joe West: Department of Health Clinician Scientist Fellowship in Applied Clinical Research 2006-2011 for work in liver disease epidemiology; formerly Wellcome Clinical Epidemiology Research Training Fellow, 2001-2004)

Tim Card: HEFCE Clinical Senior Lectureship Award 2006-2011, Wellcome Training Fellowship in clinical epidemiology (gastrointestinal disease epidemiology) 2000-2003

Tricia McKeever: Wellcome Epidemiology Training Fellowship (dietary effects in asthma and COPD), 2002-6

Carsten Flohr: John Radcliffe Travel Fellowship (clinical trials of the effects of hookworm eradication on allergic disease in Vietnam) 2004-6

Nina Lewis: Coeliac UK Clinical Research Training Fellowship (morbidity and mortality in coeliac disease and dermatitis herpetiformis), 2005-2008 

Jo Feary: Wellcome Clinical Training Fellowship (Epidemiology MSc training linked to Wellcome project grant funding, for hookworm trials in asthma), 2007-8

Sinéad Langan: BUPA training fellowship, to study flares in atopic eczema 2005-7

Rachael Murray: Cancer Research UK Research Training Fellowship, to develop methods to support spontaneous smoking cessation, 2007-10

 

Since 2001 we have attracted new research income of over £14.65 million and published over 790 papers in peer-review journals, including 16 in Nature, Nature Genetics, The New England Journal of Medicine and The Lancet. We have also secured the necessary funding to relocate the entire EPH research and teaching activity into a new, £4.5 million purpose-built Institute of Population Health building at the Nottingham City Hospital campus (commencing 2008).

 

 

Postgraduate students

 

Including our international students and MD students (we inherited a legacy of MD degrees for clinical researchers), 22 of our PhD or MD students have been awarded their degrees since 2001, and we have enrolled 31 new doctoral students (five of whom have completed) since 2001. We have reformed our Masters teaching programmes to attract new researchers in epidemiology and public health. Our postgraduate research training is strongly supported by the Graduate School, and by an active research meeting programme (see http://www.nottingham.ac.uk/chs/research/eph-seminars.php).

 

 

Research structure and strategy

 

Our strategy in researching chronic and infectious disease is based on 3 components: 

i)        Original epidemiological research to define occurrence and determinants of disease 

ii)       Use of (i) and of systematic review and meta-analysis methods to identify potentially reversible or avoidable risk factors

iii)     Test the effectiveness of exposure modification in randomised controlled trials (RCTs)

 

We have also invested strongly in developing key resources to support this approach:

i)        Skills in the management and analysis of large databases 

ii)       Systematic reviews and meta-analysis (including the editorial base of the Cochrane Skin Group)

iii)     Phase III / IV clinical trials (underpinned by the Nottingham Clinical Trials Support Unit)

iv)     Establishment of a strong medical statistics group. 

 

Consistent with the above we have also developed a substantial interest in tobacco control, stimulated by the crucial role of smoking in the aetiology of many of the diseases of interest to us. 

 

The main areas of work, and the people in the research teams involved, are as follow. 

 

Respiratory disease, allergic skin disease and allergy: 

John Britton (JB), Tricia McKeever (TM), Sarah Lewis (SL), Andrew Fogarty (AF), Richard Hubbard (RH), Laila Tata (LT), Andrea Venn (AV), Jo Leonardi-Bee (JL-B), Carsten Flohr (CF), Hywel Williams (HW), Kim Thomas (KT), Sinead Langan (SL)

 

Gastro-intestinal disease (including gastrointestinal infection): 

Richard Logan (RL), Keith Neal (KN), Joe West JW), Tim Card (TC), Masoud Solaymani-Dodaran (MS), Matthew Grainge (MG), LT

 

Cancer epidemiology: 

Ken Muir (KM), RL, MG, MS, TC, JW

 

Social Epidemiology: Richard Wilkinson (RW), Shona Kelly (SK)

 

Tobacco control: 

Ann McNeill (AM), Stacey Anderson (SA), Tim Coleman (TC), JB, SL, RH, JL-B

 

Population Health, Health Protection and Infectious Disease Epidemiology

Jonathan Van-Tam (JVT), Peter Marks (PM), KN

 

 

1.         Respiratory disease, allergic skin disease and allergy

 

1.1       Effects of diet

 

We have an established interest in the effects of nutrients, including magnesium, vitamin C, vitamin E, sodium, individual fatty acids, and some whole foods on the risk of asthma, allergy, and chronic airflow obstruction, arising from continuing study of a cohort of over 2500 adults established in Nottingham in 1991. Through Training Fellowship funding for Tricia McKeever we have confirmed several of these effects in independent cohorts in the Netherlands and USA. We have tested the effects of modification of vitamin C, vitamin E, magnesium and whole fruit intakes on asthma in clinical trials. We continue to explore potential modifiable dietary effects, including a randomised trial of sodium restriction in asthma, and the effects of diet in early life. We are in the process of a further follow-up of the Nottingham cohort to assess impacts of diet on longer term morbidity and mortality. 

 

1.2       Allergic disease in the developing world

 

Through collaborative work in Ethiopia and Vietnam we have made substantive contributions to the epidemiological evidence demonstrating that adoption of an urbanised lifestyle is associated with a substantial increase in the risk of allergic disease. In particular we have confirmed an inverse, intensity-related association between infection with helminth (particularly hookworm) parasites and the risk of asthma and eczema. This work has underpinned successful funding applications for clinical trials investigating the importance of the effect of helminth infection in clinical terms, including an RCT of hookworm eradication in children living in an area of endemic infection in Vietnam, showing an increase in the prevalence of allergic sensitisation after eradication (data submitted for publication). John Britton is PI for a series of Wellcome-funded randomised controlled trials (dose-ranging, safety and intervention) of experimental hookworm infection in asthma (work in collaboration David Pritchard’s group in the School of Pharmacy).

 

1.3       Effects of indoor and outdoor pollution 

 

There is considerable public, as well as scientific, interest in the effects of outdoor and indoor pollution on respiratory disease, particularly asthma and allergy. Our studies have quantified the relation between living near a main road and the risk of asthma, showing that risk increases substantially with proximity within about 150m of a road, and defined the independent effects of indoor volatile organic compounds, formaldehyde, nitrogen dioxide and dampness on asthma risk and severity in children. In Ethiopia we have identified indoor pollution from fossil fuels, and particularly kerosene, as an important determinant of risk of asthma, allergic sensitisation, eczema and hayfever, thus identifying a further factor that may contribute to the effect of urbanisation and affluence on allergic disease. We have quantified the independent effects of passive smoke exposure on asthma symptoms in schoolchildren, and on biomarkers of cardiovascular disease risk. 

Pollution effects interact with aeroallergen exposure, and our work with Diane Gold (Harvard) and Tom Platts-Mills (University of Virginia) has illustrated the impact of indoor allergen exposure on asthma morbidity in sensitised individuals. We also helped to establish and conduct a definitive multicentre trial of reducing domestic mite allergen exposure through allergen avoidance measures in asthma. 

 

1.4       Early life effects on asthma and allergy

 

Allergic disease risk decreases with increasing birth order, and this effect is thought to be mediated by exposure to infection. To obtain a new independent dataset with the power to test this hypothesis and explore potential explanations, we linked the electronic records of family members in a subset of the UK General Practice Research Database to establish a new birth cohort of nearly 30,000 children. Analysis confirmed a strong protective effect of birth order on the risk of incident eczema, hayfever and asthma after 1 year of age, but found no evidence that the frequency of infection or exposure to antibiotics or vaccinations were responsible. Hence other mechanisms must be involved in the birth order effect. We have since applied the same data linkage methods to The Health Improvement Network (THIN) national primary care database, this time creating a birth cohort of nearly 300,000 pregnancies to explore this hypothesis further. We are also examining the impact of maternal asthma and allergy, and of use of asthma therapies, on pregnancy outcomes. 

 

1.5       Paracetamol and asthma

 

Our Ethiopian studies have demonstrated clear evidence of a dose-response relation between paracetamol use and allergic disease. Although previously reported in developed countries, this association is potentially confounded in the latter context by the relative contraindication of aspirin in asthma. Since our Ethiopian populations are largely untreated and unaware of the contraindication, our work provides independent evidence that the association is likely to be causal. This is supported by our analyses of the risk of asthma, COPD and lung function in the NHANES III dataset. We were awarded funding for a clinical trial of paracetamol withdrawal in patients with asthma in Ethiopia, but have had to defer this work following a personal tragedy affecting one of our Ethiopian co-applicants. 

 

1.6       Adverse effects of drug therapy 

 

Since inhaled corticosteroids are widely used, rare side effects could generate a significant burden of disease. We have investigated the effect of inhaled steroids on the risk of bone fracture, by taking data from 6000 participants in the MRC Elderly study and linking these to computerised general practice records. We demonstrated a clear dose-response relationship between use of inhaled corticosteroids and fracture risk, independent of frailty and physicial activity. We have confirmed these findings in an independent analysis using THIN. 

 

 

2.         Gastrointestinal disease (including gastrointestinal infection)

 

2.1       Inflammatory bowel disease (IBD) and coeliac disease. 

 

We have quantified the mortality risk for people with inflammatory bowel diseases, demonstrating a major impact in those with onset in youth. In coeliac disease we have confirmed low mortality in adult disease but found a relative increase for childhood-diagnosed cases. We have also shown that the increased risk of hip fracture associated with these diseases is substantially lower than previous estimates, and for IBD estimated the contribution of corticosteroid use to this. This work has made an important contribution to the reappraisal and downgrading of screening interventions for osteoporosis in these conditions.

 

We have also studied the effect of prolonged aminosalicyclate use on colorectal cancer risk, demonstrating a reduction, and on renal disease, which we found was less common than previously thought. This work has contributed to the continuing debate surrounding the balance of risk and benefits from 5-ASA use. We also found that azathioprine had a similarly beneficial effect on colorectal cancer risk in IBD. This and a subsequent study showing no increase the risk of malignancy with Azathioprine in IBD (the use of which has been curtailed by concerns about this risk) has potential to expand the use of this highly beneficial drug to improve care of IBD.

 

We have defined the frequency of coeliac disease in the UK, demonstrating 1% prevalence but that most cases remain undiagnosed. We have also shown that malignancy risk in coeliac disease is far lower than previously thought, and particularly that coeliac disease is associated with a 50-60% reduction in breast cancer risk. This finding has since been independently confirmed. We have identified possible reductions in risk of vascular disease in people with coeliac disease, findings that are being further investigated in a clinical research training fellowship. This work is of importance to the debate on screening and case finding for asymptomatic coeliac disease. 

 

2.2       Liver disease 

 

Mortality from liver disease in the UK has increased more than three-fold in the past 30 years, and has overtaken peptic ulcer as the main cause of digestive disease mortality. We have begun a 5-year project (DOH Clinician Scientist Award for Joe West) to investigate the causes of this increase, and early results indicate that factors other than alcohol abuse are probably contributing. Related projects have documented the prevalence and incidence of autoimmune liver diseases (PSC and PBC), the mortality risk associated with them, and have examined whether an unproven but commonly used therapy (Ursodeoxy cholic acid) is efficacious. This work has also examined the risk of cardiovascular disease in people with PBC, which surprisingly, (since hypercholesterolaemia is a feature of this condition), is not raised.

 

2.3       Infections

 

With the Trent Hepatitis C study group we have been involved in studies identifying the major risk factors for disease progression and mortality in Hepatitis C (HCV) disease. Our recent publications have described a 3-fold increased mortality associated with HCV in the East Midlands and that this increase is due equally to liver disease and drug misuse. In collaboration with the MRC biostatistics unit we have modelled progression rates of HCV infection to assist service planning, building on work on predictors of progression of mild disease and the prognosis of severe liver fibrosis.

 

We have been involved in all three UK national epidemiological studies of food poisoning in the last 6 years, showing the utility of case-case comparisons for the epidemiology of food poisoning. The work has also identified importance of eating in restaurants, and proton pump inhibitor therapy as key risk factors on a population level. We have also shown that post infection bowel disturbance persists for 6 years in over 50% of cases. 

 

 

3.         Skin disease

 

The Centre of Evidence Based Dermatology (CEBD) has an international reputation for skin research and evidence-based practice. It is the editorial base for the Cochrane Skin Group; the co-ordinating centre for the UK Dermatology Clinical Trials Network; and the base for the National Library for Health Skin Disorders Specialist Library.

 

3.1 Epidemiology and measurement of atopic eczema

 

Our work has explored potential causes of eczema occurrence and exacerbation, starting by developing a working definition of atopic eczema for epidemiological studies (The UK Working Party criteria) that is now globally the most widely used epidemiological definition. We have also developed a new valid and quick method for measuring eczema severity using patient-derived factors – the Patient Oriented Eczema Scale (POEM). We conducted the HTA systematic review on eczema treatments, which informed the current NICE guidelines and international guidance on eczema. 

 

We represent eczema interests on the Steering Group of the International Study of Asthma and Allergies in Childhood (ISAAC) - a global collaboration that resulted in the first world map of eczema and the first documentation of prevalence trends over the last 10 years. Our finding of increased eczema occurrence in hard water areas has led to a national RCT on the value of water softeners for eczema sufferers. 

 

3.2 Reducing uncertainties through systematic reviews, clinical trials and knowledge management 

 

The CEBD houses the editorial base of the Cochrane Skin Group, which produces and maintains high quality systematic reviews on interventions for skin diseases. Research priorities identified through this process are then explored by the UK Dermatology Clinical Trials Network, which co-ordinates externally funded RCTs (five externally funded, NIHR approved RCTs are currently running, and 2 have been completed). The National Library for Health Skin Disorders Specialist Library provides a dissemination vehicle for RCT and Cochrane review results, completing the cycle of generation, production and dissemination of research that directly addresses healthcare decision making in the NHS and beyond. 

 

The CEBD will continue to expand its activity on RCTs through the UK Dermatology Clinical Trials Network into Europe and globally, to tackle less common skin diseases with significant morbidity and/or mortality. The Centre has recently been short listed for an NIHR Programme grant. The success of the centre relies on close collaborations in Nottingham and with the MRC Clinical Trials Unit in Oxford, the National Library for Health, the European Dermato-Epidemiology Network and the Cochrane Collaboration. 

 

4.         Cancer

 

Our cancer work has included a range of large-scale collaborative, multicentre case-control studies to identify environmental and genetic aetiological factors for selected cancers, and large community-based randomised evaluations aimed at reducing disease burden. 

 

4.1       Colon cancer 

 

We are working on a range of studies of gastrointestinal malignancies, and in particular have completed a multi-centre randomised clinical trial of intervention with aspirin (300 mg/day) and/or folic acid supplements in preventing the recurrence of adenomas of the large bowel (ukCAP trial). This has demonstrated a 37% reduction in advanced adenoma recurrence  with aspirin. Ken Muir and the group have also coordinated studies of genetic polymorphism effects on the risk of colorectal adenoma development and recurrence, in particular identifying the MTHFR C677T polymorphism as a low penetrance CRC susceptibility allele. Richard Logan has recently been appointed Director of the Bowel Cancer Screening Programme Eastern hub, responsible for screening the one million 60-70 year olds in Eastern England, enabling us to continue our programme of work in cancer chemoprevention.

 

4.2       Barrett's oesophagus and oesophageal cancer

 

Barrett's oesophagus is a premalignant condition estimated to affect 5% of people. Screening and/or surveillance have been proposed to prevent cancer in these individuals. We have shown that while there is a 10-fold risk of oesophageal cancer, and a 30-fold risk of oesophageal adenocarcinoma, the risk is not increased in uncomplicated acid reflux or oesophagitis as had been previously suggested. These findings are of obvious importantance to the debate on the likely effectiveness of surveillance systems for this condition.  

 

4.3       Brain, Breast and Prostate Cancer

 

Ken Muir is joint PI in the largest ever aetiological study of brain tumours, which has provided robust evidence of a lack of association between mobile phone use and brain tumour risk, and of increased risks of glioma and meningioma in subjects with allergic and other immune conditions. Genome scans from the >2000 participants are being used to investigate polygenic or low-penetrance allele effects on these tumours, and have identified two new predisposition genes. 

 

In breast cancer, Ken Muir is PI in the UK-SE Asia Cancer Epidemiology Programme, a series of aetiological studies of cancer incidence between East and West, including a large-scale case-control collection in China, Thailand, Vietnam and Malaysia. The work is part of a wider Nottingham-China Complementary and Alternative Medicines Group established to investigate the molecular mechanisms of action of dietary and herbal compounds.  One objective is to identify key items of diet that have potential anti-cancer properties, and to date we have identified two that are currently being characterised for patenting. The group is looking at new products from China/Asia for application in rheumatologic, respiratory and dermatological diseases. 

 

In prostate cancer, Ken Muir’s group has demonstrated strong familial effects on prostate cancer risk, of up to five-fold, in men whose father or siblings have had prostate cancer. We are part of an international collaboration undertaking whole genome scans to elucidate the structure, location and actions of the gene or genes responsible. 

 

4.4       HPV infection and cervical cancer

 

We have used archived cervical smears to demonstrate that 20% of women aged over 50 can develop detectable HPV over a three year period, and therefore that women with a normal smear history should not be withdrawn from screening programmes. We have also confirmed the importance of HPV-16 infection 10 years earlier in the development of cervical cancer, particularly in older women.

 

 

5.         Social epidemiology

 

The work of the Social Epidemiology group, led by Richard Wilkinson, centres on understanding how social structure translates into individual risks for illness and premature death, and identifying the biological pathways. Our work on understanding why smaller income differentials in a society are related to better population health has shown that the same pattern applies to many other social problems associated with relative deprivation, including obesity, teenage births, mental health, violence and the educational performance of school children. These issues are of crucial importance because they affect the prevalence of so many health and social problems among the vast majority of the population. As well as working on these macrosocial issues, we have continued to work on the social determinants of chronic stress through which inequality is likely to affect health and other outcomes. 

 

The group’s work also involves the integration of broader research findings on the psychosocial determinants of health. Active collaborations in clued the Peers and Levels of Stress (PaLS) project and the West of Scotland Twenty-07 Cohort Study at the MRC Social & Public Health Unit in Glasgow, the ESRC network on Social Capital and Mental Health (chaired by Prof Schneider, Nottingham), an MRC funded project at York on ethnic group density effects on physical health, the ESRC Priority network on Capability and Resilience, and with a group based at UCL which brings together academic epidemiologists and insurance industry actuaries to investigate the rapid decline in death rates among the elderly.

 

 

6.         Tobacco Control 

 

Smoking is the largest known cause of premature mortality and social inequality in health in the UK, and is a particularly powerful cause of morbidity and mortality from respiratory and other diseases of interest to our group. We have therefore prioritised investment in developing research in tobacco control, through internal staff development and training; through external recruitment (Professor Ann McNeill, appointed September 2006; Stacey Anderson (from UCSF) appointed October 2007); and through special appointments to leading figures in tobacco control currently working outside academia (Martin Raw, Luk Joossens, Jacques Le Houzec).  Our work focusses on the design and delivery of cessation services for existing smokers and the effectiveness of population strategies to reduce the prevalence of smoking, and a proposed five-year programme of work is currently shortlised for funding in the UKCRC Public Health Centres of Excellence competition (decision due December 2007). 

 

6.1       Smoking cessation 

Smoking cessation is typically the most effective means of improving individual health, but efficacy and uptake of current treatments and services is poor. We have carried out a range of RCTs and complex intervention evaluations in smoking cessation, studying the effectiveness of brief interventions, of routine provision of nicotine replacement therapy in hospital inpatients, the implementation, reach and effectiveness of the NHS stop smoking services, of therapeutic agents such as varenicline, qualitative design studies and cluster randomised trials of cessation services foryoung people, socially disadvantaged groups and people with mental health problems, and the effect of proactive case-finding of smokers in primary care and referral into cessation services on uptake and cessation. Our work contributed directly to the first NICE public health guidance on smoking cessation, and the current NICE programme on provision of cessation services. We lead a multicentre study of the effectiveness and safety of nicotine replacement therapy in pregnancy, and Tim Coleman is part of a UK team investigating the effectiveness of English NHS stop smoking services. We are also leading an investigation into the effectiveness and cost effectiveness of relapse prevention interventions with a view to assessing which would be most feasible for trialling within the NHS. 

We have used the THIN primary care dataset to investigate rare adverse effects of bupropion and nicotine replacement therapy (NRT), producing evidence countering adverse media reports on bupropion safety and countering the relative contraindication on use of NRT in cardiovascular disease, leading the MHRA to relax this contraindication. We have shown that the new GP contract, which requires recording of smoking status, has led to a marked increase in ascertainment of smoking status, but has not influenced prescribing of NRT or, by implication, cessation intervention uptake. We are currently examining the impact of the English ban on public smoking on uptake of cessation services. 

 

6.2       Tobacco control policy and harm reduction strategies

 

We are involved in developing and driving tobacco control policy through a combination of original research, evidence synthesis and policy advocacy. Through the RCP tobacco advisory group we were responsible for reviewing evidence on smoke-free policy (Going smoke-free: The medical case for clean air in the home, at work and in public places, RCP 2005) which played a pivotal role in informing the work of the Commons Health Committee inquiry into smoking in public places (2005), and the subsequent design and implementation of smoke-free legislation in England. We also made major contributions to the European Respiratory Society ASPECT and Lifting the Smokescreen reports, which have been similarly influential in informing the recent EU green paper on smoke-free policy. We have engaged in a range of studies of avoidable risk factors for smoking initiation, of measuring and comparing the design, toxin content and exposure across a range of smoked and oral tobacco products from the UK and other countries, and of the effectiveness of international tobacco control policies such as health warnings, reimbursement strategies and smoke-free legislation on cessation.

 

We are also actively engaged in researching and promoting harm reduction policies in tobacco consumption, through the development of international policies to regulate content and delivery of cigarettes, the development of effective medicinal substitutes for tobacco smoking, and in the potential use of low-nitrosamine smokeless tobacco. We are part of an international collaboration planning to test the acceptability and effectiveness of alternative nicotine products in randomised trials. We led the production of the recent RCP Harm reduction in nicotine addiction report in October 2007, presenting the evidence for radical reform of nicotine product regulation to enable the delivery of effective harm reduction strategies for smokers. 

 

 

7.         Population Health, Health Protection, Infectious disease

 

Through active succession planning with NHS support we have created three new posts in population health, two of which have been appointed in 2007 (Peter Marks, Jonathan Van-Tam) and the third (joint academic post with the new Nottingham Veterinary School) for appointment in 2008. Jonathan Van-Tam took up the new Chair in Health Protection in October 2007, bringing expertise in the prevention of and provision of services for major disease epidemics, particularly avian and pandemic influenza. Over the past 3 years he has been heavily involved in national and international pandemic preparedness activities, including work with most major UK Government Departments, the Cabinet Office Civil Contingencies Secretariat, the European Centre for Disease Control and Prevention, the World Health Organisation and various vaccine and antiviral drug manufacturers. Through him the population health group now has extensive links in pandemic preparedness research, and is well placed to exploit funding streams for pandemic influenza research expected over the next 5 years. 

 

We have maintained an interest in meningococcal carriage and transmission, being one of the main centres in a national study of meningococcal carriage after introduction of the Meningococcal C vaccine demonstrating that carriage of group C meningococci (the cause of 40% of invasive meningococcal disease) was markedly reduced, and remained so for 2 years after vaccination, and identifying risk factors for transmission of disease in teenagers. Our work on large outbreaks has demonstrated that a population based approach had long term beneficial effects on the types of meningococci that re-colonised treated individuals, suggesting a herd effect of these campaigns, thus identifying future opportunities for more effective interventions to prevent transmission and spread of meningococcal disease.

 

 

Structures that support our research

 

 

1          Statistics

 

We have radically restructured our statistics research and support by investing in young statisticians closely integrated into our research teams and thus equipped to develop their own research themes. The group has developed particular skills in multilevel modelling, systematic review and meta-analysis, and with Professor Paddy Farrington at the Open University has developed the case-series method for application to chronic disease epidemiology in the analysis of primary care datasets. The statistics group is led and mentored by Professor Sarah Lewis and now includes five statisticians, all of whom now lead their own work as well as providing vital support to others the EPH research group. The quality of Sarah Lewis’ writing (and leadership by example) was recognised recently in a lead editorial published with one of her papers in the American Journal of Epidemiology, entitled ‘Please read the following paper and write this way.’ (Friedman G, American Journal of Epidemiology 2005;161:405). 

 

2          Large database support

 

Since 2001 we have substantially expanded our use of large datasets, and particularly The Health Improvement Network (THIN) general practice database. THIN currently includes reliable computerised data since 1990 from more than 2.5 million people in 300 general practices. We house this dataset in Nottingham and have had a central role in its development – particularly in linking census-derived variables such as socioeconomic status, and of within-family records to generate the largest available birth cohort dataset (see above). We have used the primary care datasets in a range of studies and collaborations, generating over 40 original published papers since 1.1.01 and four PhD theses. We also work closely with the QResearch group in Primary Care on shared methodological and analysis issues. 

 

3.         Clinical Trials Support Unit

 

Consistent with our strategy of testing the validity of observational epidemiological findings and research priorities identified in systematic reviews in clinical trials, we have established (with others) a Clinical Trials Support Unit, directed by Hywel Williams, to develop an extensive infrastructure and expertise in clinical trial design and management within the UKCRN. The Unit is currently engaged in over 40 trials addressing a range of questions, from formal placebo-controlled trials of drugs or nutrients to cluster randomised studies of complex interventions in primary care. We have established strong local community and primary care links to recruit for our trials, and with NHS pharmacy services to allow us to meet the new regulatory conditions for administration of medications in clinical trials. 

 

 

Interactions with the nhs, industry and commerce

 

Eleven of the senior academics in EPH hold honorary senior clinical contracts, and deliver at least 5 programmed activities per week (50% WTE) to service in gastroenterology, respiratory medicine, acute medicine, dermatology, primary care and public health. This exposure promotes identification of new areas of research and is a strong source of recruitment of junior researchers. We work closely with local PCTs and Regional and SHA staff in developing and assessing services, for example in the assessment of the impact of the national schools fruit scheme on dietary fruit intake in children, and run the Bowel Cancer Screening Programme Eastern hub. 

 

Hywel Williams is Chair of Research for Patient Benefit for Trent, a member of the HTA commissioning board and directs the Nottingham hub of the Mutildisciplinary Assessment of Technology Centre for Health http://www.match.ac.uk/, jointly funded by EPSRC and medical device industry partners with the aim of developing better methods for assessing the value of healthcare technology products. 

 

Through his honorary contract with the Health Protection Agency, Jonathan Van-Tam has continuing commitments to national and international pandemic preparedness work, which in turn identifies new areas of research.

 

Members of the Division are involved in a wide range of consultancy and industrial collaborations, particularly in large database development and analysis, smoking cessation product development, H5N1 vaccine development, influenza drugs, and elsewhere. Ann McNeill has provided several substantive evidence reviews relating to smoking cessation services for NICE; John Britton is currently a member of the NICE programme development group for smoking cessation. 

 

 

Sustainability and growth

 

The research group has established itself over the past 7 years through strategic investment and particularly by creating a strong culture of encouraging and rewarding successful competition for external training fellowship funding by ensuring that all successful intermediate and senior fellowship applicants are granted tenured contracts after successful completion. All junior researchers receive support and mentoring, and are expected to develop their own research interests with the support of senior colleagues. The establishment of this culture has been the key to the successful development of our respiratory, gastroenterology, dermatology and statistics groups and has in turn attracted external investment from NHS partners for further expansion in population health and health protection. We will continue this approach, enhanced by the now steady supply of promising new researchers from our MPH programme, a growing PhD programme, and are confident that the group will continue to grow and thrive through the next 5-10 years. 

 

 

Research strategy

 

Over the next five years our research strategy will be

 

1.         To relocate the entire group into the new Institute of Population Health building, scheduled for completion in 2008/9, to integrate current research and postgraduate teaching into a single site 

 

2.         Develop our MPH course by adding alternative routes for Masters in Epidemiology and International Health, and thereby train, develop and identify more potential new researchers to expand the research group by 2008/9.

 

3.         Establish a stronger research portfolio in Health Protection and Infectious Disease Epidemiology.

 

4.         Continue to expand our public health research into other priority areas, particularly obesity, alcohol and dietary change 

 

5.         Expand our large primary care database work to capitalise on opportunities arising from the new availability of primary care data from other EU countries and the introduction of electronic patient records in the NHS

 

6.         Continue to support and invest in research work in current areas of strength through UKCRN structures (outlined above)

 

7.         Use the above developments to expand our PhD programme with the objective of retaining promising researchers for the medium to long term future

 

 

Esteem indicators

 

Members of the EPH group are widely engaged in a range of activities reflecting esteem and reputation outside Nottingham. Several members serve or have served on research funding boards for organisations including the MRC, Asthma UK, British Lung Foundation, CRUK, and others. Particular indicators for individuals comprise: 

 

Stacey Anderson: Top 10 Research Paper of the Year, Tobacco Control, 2005; Invited presentation on countering cigarette marketing to Office on Smoking and Health, Centers for Disease Control, Atlanta, 2007.

 

John Britton:  Bisset Hawkins Trust Medal for “work done in the preceding 10 years in advancing sanitary science or in promoting public health”, RCP 2007; Milroy Lecturer, RCP 2006; Chair RCP Tobacco Advisory Group 1996-present; Chair ERS Tobacco Control Committee 2005-8; Special Advisor to Commons Health Committee inquiry into smoking in public places, 2005; Member, EC Scientific Committee on Emerging and Newly Identified Health Risks Working Group on Smokeless Tobacco, 2006-present; Member, NICE Programme Development Group on Smoking Cessation, 2006-present; Member, Board of Directors, Action on Smoking and Health 2000-present; Joint Executive Editor, Thorax 1996-2002; Editorial Consultant The Lancet 2005-present. Several keynote/plenary lectures at international conferences.  

Tim Card: Member, National Association of Colitis and Crohn’s disease Medical Awards Panel 2006-present

Tim Coleman: Assitant editor Addiction, editorial advisor BMJ 2001-present and Thorax 1999-2002, Member, Population and Behavioural Science Board and Tobacco Advisory Group at Cancer Research UK 2005-date, RCGP representative to RCP Tobacco Advisory Group 1999-date,  Chair, NPRI-funded PRE-EMPT trial steering group, member DMEC for MRC-funded ZORN trial, and TSCs for 2 further NPRI funded trials. 

 

Carsten Flohr: World Allergy Organization Fellowship for Junior Scientists, 2003; Hugh Wallace Publication Prize, Royal Society of Medicine 2005; International Symposium of Atopic Dermatitis Young Investigator Award 2005; Secretary of the British Epidermo-Epidemiology Society 2007-present; International Study of Asthma and Allergies in Childhood (ISAAC) Phase Two Steering Group member 2007-present; Barry Kay Award, British Society for Allergy and Clinical Immunology for best clinical scientific research 2007.

 

Matthew Grainge: Acting Statistics Editor, Cochrane Skin Group; Plenary lecture, Society for Social Medicine, 2006

 

Richard Hubbard: Awarded British Lung Foundation Chair in Respiratory Epidemiology 2005; Associate editor Thorax 2006-present; External examiner, pharmacoepidemiology module, LSHTM; Member, British Thoracic Society interstitial lung disease management guidelines group.

 

Shona Kelly: Survey Advisor, West of Scotland Twenty-07 Study, Peers and Levels of Stress Survey, MRC Youth and Health Programme, Canadian Health Measures Survey, Statistics Canada. 

 

Sinéad Langan: Secretary of the European Dermato-Epidemiology Network

 

Jo Leonardi-Bee: Statistics Editor, Cochrane Skin Group 2003-present

 

Sarah Lewis: Statistics Editor Thorax 1996-2007; Statistical Editor International Journal of Obesity 2006-present; Asthma UK Grants Committee Statistician. 

 

Richard Logan: BUPA Foundation Epidemiology Prize 2004 (with Joe West) for work on celiac disease; Visiting Professor, Karolinska Institute; Editor, Journalscan section Gut;  Member CR-UK Population and Behavioural Sciences Committee (research awards)   2003-7, CORE Research Awards Committee  2002-present. 

 

Tricia McKeever: Statistical Editor, Thorax, 2004-present.

 

Ann McNeill: Deputy Editor, Nicotine and Tobacco Research 2006-present; European Editor Tobacco Control 2003-present; Senior Editor, Tobacco Control 2001-3; Chair, MRC TSC for ZORN trial (nicotine or bupropion in smoking cessation); Scientific coordinator for Analysis of Science and Policy in Europe for the Control of Tobacco aproject (ASPECT) 2004; Chair, WHO Scientific Advisory Committee on Tobacco Product Regulation 2000-1; Chair, WHO Europe Partnership Project to reduce tobacco dependence 1999-2001;

 

Ken Muir: Member of WATCH government expert advisory group on exposure limits for chemicals, 2004-6; Expert advisor to Food Standards Agency (FSA) panel overseeing the case for folate supplementation of foods, 2006; Invited expert for FSA panels on phytoaestrogens, colorectal cancer and genetics 2006.

 

Keith Neal: Associate Editor Journal of Infection 2005-present; CCDC representative on the United Kingdom Advisory Panel for infected health care workers (Department of Health); Appointed member, Epidemiology of Foodborne infections Group (FSA); Member of the British Infection Society Scientific Committee (1998 - 2004). 

 

Laila Tata: Young Epidemiologist’s Prize: 3rd. Royal Society of Medicine - Epidemiology and  Public Health section, 2005.

 

Kim Thomas: Adviser to the National Institute for Clinical Excellence (March 2005 – present); Member, Medicines for Children Research Network (MCRN) Clinical Studies Group for general paediatrics (Nov 2006 to present); Affiliate member, Health Technology Assessment (HTA) commissioning board (April 2006 to present).

 

Jonathan Van Tam: Member, Order of the British Empire (military division), 1998; UK Health Protection Agency (HPA) Influenza and Respiratory Viruses Programme Board, 2004-present; Secretary of State for Health’s Joint Committee on Vaccination and Immunisation, RSV sub-group, 2004-present; Secretary of State for Health’s Specialist Advisory Committee on Antimicrobial Resistance (SACAR), 2000-04; European Federation of Pharmaceutical Industry Associations (EFPIA), Influenza Vaccine Supply Task Force, 2002-2004; Temporary Adviser, World Health Organisation (Influenza Branch), 2004-5; Expert Advisor, EU Commission (DG Sanco), 2005; European Centre for Disease Prevention and Control (ECDC) Expert Advisory Committee on Avian Influenza, 2006; European Centre for Disease Prevention and Control (ECDC) Chairman, Expert Advisory Committee on Human H5N1 vaccines, 2007. Editorial Board Member: Influenza and other Respiratory Viruses, 2007; Elected Board Member: International Society for Influenza and Respiratory Viruses, 2007.

 

Joe West: BUPA Foundation Epidemiology Prize 2004 (with Richard Logan) for work on coeliac disease. Member, medical advisory committee to Coeliac UK 2005-present. 

 

Richard Wilkinson: BMA best book in public health award for Social Determinants of Health.  Several keynote addresses at international conferences. Single authored books and papers published in 9 languages. WHO's The Solid Facts (of which he is first editor) translated into 24 languages and is WHO European Region's most frequently downloaded publication.

 

Hywel Williams: Chair, National RDSU network 2004-2006; Member, HTA commissioning board (2005-present); Chair, Trent Research for Patient Benefit Programme (2006 to present); Member, American Academy of Dermatology Epidemiology Expert Resource Group; Member, Trent Comprehensive Research Network; Executive member, STROBE working group; External advisor to NICE guidelines on atopic eczema and expert committee on guidelines for referral to dermatology specialist services; Co-ordinating editor of Cochrane Skin Group; Clinical Lead for NLH Skin Disorders Specialist Library; Clinical Trials Editor to Journal of Investigative Dermatology and Section Editor to Archives of Dermatology; six named lectures and 18 plenary talks at major international dermatology meetings. Chair European Dermato-Epidemiology Network (2005 to 2008).