Provisional 1 monthly topic of interest: Victorian diseases 2 This topic examines recent hospital admissions data due to a range of diseases that were widespread during the 19th and early 2th centuries. This report focuses on five diseases: gout, tuberculosis (TB), malnutrition, whooping cough and measles. Whilst these diseases were common in the 19th and early 2th centuries, the fact that the way in which diseases are described, classified and reported has changed significantly since the 18's means that it is difficult to obtain official data on the prevalence of these diseases during this time. Mortality data shows a dramatic decline in deaths due to infectious diseases during the 2th century (e.g. mortality rates for TB peaked in 1918, with a rate of 263 per for males and 132 per for females) including measles, mumps, diphtheria and whooping cough, in part due to the introduction of the childhood vaccination programme 3. This topic looks at recent hospital admissions data due to these diseases and is intended to inform and highlight statistics to health professionals, journalists and researchers. NHS Choices 4 states: Gout - "A type of arthritis where crystals of sodium urate form inside and around joints. The most common symptom is sudden and severe pain in the joint, along with swelling and redness." " Factors that increase your risk of gout include: age and gender gout is more common when you get older and is three to four times more likely in men, being overweight or obese, having high blood pressure or diabetes, having close relatives with gout (gout often runs in families), having long-term kidney problems that reduce the elimination of uric acid, a diet rich in purines and drinking too much beer or spirits". TB - "A bacterial infection spread through inhaling tiny droplets from the coughs or sneezes of an infected person. TB mainly affects the lungs. However, it can affect any part of the body, including the bones and nervous system." "Before antibiotics were introduced, TB was a major health problem in the UK. Nowadays, the condition is much less common. However, in the last 2 years TB cases have gradually increased, particularly among ethnic minority communities who are originally from places where TB is more common". Malnutrition - "A serious condition that occurs when a person s diet does not contain the right amount of nutrients." " Malnutrition is caused by either an inadequate diet or a problem absorbing nutrients from food. There are many reasons why this might happen, including having reduced mobility, a long-term health condition or a low income". Whooping Cough - "A highly contagious bacterial infection of the lungs and airways." "Due to the success of the NHS vaccination scheme, whooping cough is now uncommon in young children. Most cases occur in adults whose immunity has faded and in these cases symptoms tend to be less serious. Babies are affected most severely by whooping cough, and are most at risk of developing complications. For this reason, babies under 12 months who contract whooping cough will often need treatment in hospital. Whooping cough is a cyclical disease with the number of cases peaking every three to four years". Measles - "A highly infectious viral illness that can be very unpleasant and can sometimes lead to serious complications. However, it's now uncommon in the UK because of the effectiveness of the MMR vaccination. However, the number of cases has risen in recent years and there have been some high-profile outbreaks". Additional current data are also provided for seven other diagnoses that were prevalent in the 19th and early 2th centuries in Table 1, although there are generally low numbers of hospital admissions. Scarlet fever - "A bacterial illness that causes a distinctive pink-red rash. Scarlet fever used to be a very serious disease, but most cases today are mild. This is because scarlet fever can easily be treated with antibiotic tablets". Diphtheria - "A contagious bacterial infection that mainly affects the nose and throat. Before a vaccination programme was introduced in 194, diphtheria was a very common condition and one of the leading causes of death in children". Scurvy - "A rare condition that can develop if you don't have enough vitamin C in your diet. People tend to think that scurvy is a disease of the past because our diet and standard of living has improved over the years". Mumps - "A contagious viral infection that used to be common in children. Before the introduction of the MMR vaccine in 1988, mumps was a common infection in school-aged children. It is much less common now". Rickets - "A condition that affects bone development in children. It causes the bones to become soft and weak, which can lead to bone deformities. Rickets was common in the past, but it mostly disappeared in the Western world during the early twentieth century thanks to the fortification with vitamin D of foods". Cholera - "A bacterial infection caused by drinking contaminated water or eating food that has been in contact with contaminated water. There have been no cases of cholera originating in England and Wales for over 1 years, although travellers do occasionally bring the infection back with them". Typhoid fever - "A bacterial infection that can spread throughout the body, affecting many organs. Because of the way the infection is spread, typhoid fever is most common in parts of the world that have poor levels of sanitation and limited access to clean water". Key facts Data are grouped in years, covering a five year period from August 21-July 211 to August 214-July 215 (provisional data from April 214 onwards), and shows: Over the 5 year period, admissions with a primary diagnosis of measles increased from 231 admissions in August 21 to July 211 until they reached a peak of 587 in August 212 to July 213. This was around the time of a reported outbreak of the disease 5. Since then, admissions have dropped significantly; levels are now 78.8 per cent lower than 5 years ago, with 49 admissions recorded in August 214 to July 215. The number of admissions with a primary diagnosis of whooping cough followed a similar trend to measles, with admission numbers peaking in August 212 to July 213 at 697. This number decreased to 287 in August 214 to July 215. In terms of the most recent period, children aged -9 accounted for most whooping cough admissions. TB admissions show a steady year-on-year decrease. There were 4,581 admissions in August 21 to July 211 compared with 2,856 in August 214 to July 215. London Area Team accounted for 39.5 per cent of the decrease, where admissions reduced by 681 across the 5 year period. In the last year the highest number of admissions by age was in the 3-39 age group with 481 admissions for males and 286 for females. TB rates showed some regional variation, with the highest rates in South Yorkshire & Bassetlaw (12.1 per population) and the lowest in North Yorkshire and Humber (1.4 per ). Rates of admission for TB also showed variation between indices of multiple deprivation decile; rates were highest for the 1 per cent most areas (1.7 per ) and lowest in the in the 1 per cent least areas (1.5 per ). Admissions with a primary diagnosis of malnutrition increased by 34.2 per cent, from 544 in August 21 to July 211 to 73 in August 214 to July 215. The increase in admissions where malnutrition was either a primary or secondary diagnosis is even more pronounced at 5.8 per cent over the 5 year period. In the last year, the number of admissions for malnutrition were greatest in the 6-69 group for males (78 admissions) and the 5-59 group for females (91 admissions). Admissions with a primary diagnosis of gout continued to increase each year; in August 21 to July 211 there were 4,825 admissions, which increased 27.3 per cent to 6,14 in the most recent year. This could be in part due to an ageing population, as age is known to be a risk factor of gout. In August 214 to July 215, gout admissions were significantly higher in males than females across all ages, representing 73.7 per cent of admissions. For both sexes the number of admissions was highest in the 8+ age group, with 1,98 admissions for males and 869 admissions for females. In terms of regional variation, the highest rates were in Cumbria, Northumberland, Tyne & Wear (17.2 admissions per population) and lowest in Hertfordshire & South Midlands (7.7 admissions per population).
Finished Admission Episodes Finished Admission Episodes Table 1 of Finished Admission Episodes 6 with i) a primary diagnosis 7 and ii) a primary or secondary diagnosis 8 of selected diseases, August 21 - July 211 to August 214 - July 215 9 Diagnosis Aug 1 - Jul 11 Primary Diagnosis Aug 11 - Aug 12 - Jul 12 Jul 13 Aug 13 - Jul 14 Aug 14 - Jul 15 Aug 1 - Jul 11 Primary or Secondary Diagnosis Aug 11 - Aug 12 - Jul 12 Jul 13 Aug 13 - Jul 14 Aug 14 - Jul 15 Gout 4,825 5,22 5,547 6,18 6,14 65,387 69,49 77,883 92,59 14,972 TB 4,581 4,2 4,171 3,194 2,856 7,528 7,315 7,16 6,77 5,457 Measles 231 356 587 86 49 274 441 646 97 58 Malnutrition 544 693 655 659 73 4,883 5,49 5,81 7,145 7,366 Whooping Cough 238 669 697 256 287 272 742 821 32 369 Scurvy 6 1 22 15 14 82 82 18 94 113 Mumps 248 227 315 36 196 298 257 365 37 242 Rickets 62 72 5 46 49 629 797 68 521 533 Scarlet Fever 46 459 632 824 952 466 57 74 962 1,99 Cholera 7 4 11 7 12 9 8 29 25 36 Diphtheria 5 7 7 3 9 92 116 11 76 89 Typhoid 348 234 173 29 196 37 251 21 221 27 Chart 1: of Finished Admission Episodes with a primary diagnosis of selected victorian diseases, August 21 - July 211, to August 214 - July 215 7 6 5 4 3 2 Gout TB Measles Malnutrition WhoopingCough 1 Aug 1 - Jul 11 Aug 11 - Jul 12 Aug 12 - Jul 13 Aug 13 - Jul 14 Aug 14 - Jul 15 Year Chart 2: of Finished Admission Episodes with a primary diagnosis of selected victorian diseases, August 21 - July 211, to August 214 - July 215 1 9 8 7 6 5 4 Measles Malnutrition WhoopingCough 3 2 1 Aug 1 - Jul 11 Aug 11 - Jul 12 Aug 12 - Jul 13 Aug 13 - Jul 14 Aug 14 - Jul 15 Year
Finished Admission Episodes Finished Admission Episodes Female Male The remainder of the report provides further breakdowns for the five main diseases, for the latest year only. Charts have been produced for gout and TB only due to low numbers for the other diseases. Table 2 of Finished Admission Episodes with a primary diagnosis of selected diseases, by age and gender, August 214 - July 215 Age Gout TB Measles Malnutrition Whooping Cough -9-47 23 11 137 1-19 2 77 2 4 4 2-29 38 312 3 13-3-39 246 481 1 13-4-49 55 257-4 2 5-59 774 215-55 1 6-69 815 121 1 78 1 7-79 988 96-57 1 8+ 1,98 58-65 - Unknown 15 46-5 2 Total 4,526 1,71 3 341 148-9 - 44 12 7 126 1-19 3 9 2 7 3 2-29 6 21 5 32 2 3-39 18 286-33 1 4-49 41 135-56 2 5-59 87 134-91 2 6-69 179 89-54 2 7-79 47 58-54 - 8+ 869 55-54 - Unknown 4 45-1 1 Total 1,614 1,146 19 389 139 Chart 3a & 3b Finished Admission Episodes with a primary diagnosis of gout and TB, by age and gender, August 214 - July 215 Chart 3a Gout 1,2 Chart 3b TB 6 1, Male 5 Male 8 Female 4 Female 6 3 4 2 2 1-9 1-19 2-29 3-39 4-49 5-59 6-69 7-79 8+ - -9 1-19 2-29 3-39 4-49 5-59 6-69 7-79 8+ Age Age
Table 3 and rate (per population 1 ) of Finished Admission Episodes with a primary diagnosis of selected diseases, by Area Team of Residence 11, August 214 - July 215 Area Team of Residence Gout TB Malnutrition Arden, Herefordshire and Worcestershire 163 1. 76 4.6 26 1.6 7.4 Bath, Gloucestershire, Swindon and Wiltshire 144 9.7 29 2. 9.6 9.6 Birmingham and the Black ry 292 11.9 16 6.5 29 1.2 27 1.1 Somerset, Somerset 161 11.1 139 9.6 33 2.3 5.3 Cheshire, Warrington and Wirral 13 1.6 28 2.3 18 1.5 5.4 Cumbria, Northumberland, Tyne and Wea 332 17.2 5 2.6 26 1.3 13.7 Derbyshire and Nottinghamshire 278 14. 48 2.4 26 1.3 7.4 Devon, Cornwall and Isles of Scilly 162 9.6 27 1.6 4 2.4 1.6 Durham, Darlington and Tees 192 16.3 22 1.9 18 1.5 12 1. East Anglia 236 9.6 56 2.3 38 1.5 4.2 Essex 184 1.5 45 2.6 13.7 1.6 Greater Manchester 428 15.6 175 6.4 48 1.7 2.7 Hertfordshire and the South Midlands 29 7.7 79 2.9 36 1.3 9.3 Kent and Medway 15 8.5 43 2.4 14.8 5.3 Lancashire 192 13.1 44 3. 21 1.4 18 1.2 Leicestershire and Lincolnshire 187 1.6 53 3. 18 1. 6.3 London 854 1.1 1,2 11.9 69.8 35.4 Merseyside 161 13.5 21 1.8 16 1.3 6.5 North Yorkshire and Humber 188 11.2 23 1.4 23 1.4 15.9 Shropshire and Staffordshire 173 1.9 43 2.7 11.7 8.5 South Yorkshire and Bassetlaw 153 1.4 178 12.1 33 2.2 9.6 Surrey and Sussex 292 1.7 89 3.3 36 1.3 9.3 Thames Valley 195 9.5 77 3.7 15.7 8.4 Wessex 283 1.4 85 3.1 54 2. 13.5 West Yorkshire 33 14.3 111 4.8 46 2. 8.3 Unknown/Other 71 153 14 9 England 6,74 11.3 2,715 5. 717 1.3 278.5 Note: England counts and rates include episodes where the Area Team of Residence is not known, but is known to be within England s and rates are not included for measles due to very low numbers by Area Team Chart 4a Rate (per population) of Finished Admission Episodes with a primary diagnosis of gout by Area Team of Residence, August 214 - July 215 18. Whooping Cough 16. 14. 12. 1. 8. 6. 4. 2.. England Rate Area Team of Residence Chart 4b Rate (per population) of Finished Admission Episodes with a primary diagnosis of TB by Area Team of Residence, August 214 - July 215 14. 12. 1. 8. 6. 4. 2.. England Rate Area Team of Residence
Table 4 Mean, median length of stay 12 and emergency admissions as a count and percentage of all admissions, with a primary diagnosis of selected diseases, August 214 - July 215 Mean Length of Stay (days) Median Length of Stay of emergency admissions Emergency admissions as % of total Diagnosis (days) Gout 6.3 3 5,93 82.9 TB 2. 9 1,621 56.8 Measles 1.2 48 98. Malnutrition 2.8 12 56 76.7 WhoopingCough 3.6 2 274 95.5 Table 5 and rate (per population) of Finished Admission Episodes with a primary diagnosis of selected diseases by Indices of Multiple Deprivation 21 decile 13, August 214 - July 215 IMD decile Gout TB Measles Malnutrition Whooping Cough 1 - Most 723 14.1 547 1.7 1.2 124 2.4 64 1.2 2 76 14.6 57 9.7 7.1 88 1.7 36.7 3 633 12.2 33 6.3 4.1 75 1.4 42.8 4 658 12.6 312 6. 3.1 79 1.5 24.5 5 617 11.7 387 7.4 4.1 65 1.2 23.4 6 559 1.7 189 3.6 4.1 64 1.2 15.3 7 569 1.9 156 3. 2. 67 1.3 17.3 8 582 11.1 18 2.1 4.1 68 1.3 28.5 9 479 9.1 87 1.7 7.1 47.9 13.2 1 - Least 489 9.3 8 1.5 3.1 39.7 16.3 Chart 5a & 5b Rate (per population) of Finished Admission Episodes with a primary diagnosis of gout & TB by Indices of Multiple Deprivation 21 decile, August 214 - July 215 Chart 5a Gout Chart 5b TB 16 12 14 1 12 1 8 8 6 6 4 4 2 2 1 - Most 2 3 4 5 6 7 8 9 1 - Least IMD 21 decile 1 - Most 2 3 4 5 6 7 8 9 1 - Least IMD 21 decile Footnotes 1. Provisional Data The data are provisional and may be incomplete or contain errors for which no adjustments have yet been made. s produced from provisional data are likely to be lower than those generated for the same period in the final dataset. This shortfall will be most pronounced in the final month of the latest period, i.e. November from the (month 9) April to November extract. It is also probable that clinical data are not complete, which may in particular affect the last two months of any given period. There may also be errors due to coding inconsistencies that have not yet been investigated and corrected. 2. ICD1 codes used - Victorian Diseases The following ICD1 codes were used to identify the conditions within the report: Gout M1 - Gout Tuberculosis A15.- Respiratory tuberculosis, bacteriologically and histologically confirmed A16.- Respiratory tuberculosis, not confirmed bacteriological or histologically A17.-D Tuberculosis of nervous system A18.- Tuberculosis of other organs A19.- Miliary tuberculosis J65.X Pneumoconiosis associated with tuberculosis O98. Tuberculosis complicating pregnancy, childbirth and the puerperium P37. Congenital tuberculosis
Malnutrition E4.X Kwashiorkor E41.X Nutritional marasmus E42.X Marasmic kwashiorkor E43.X Unspecified severe protein-energy malnutrition E44. Moderate protein-energy malnutrition E44.1 Mild protein-energy malnutrition E45.X Retarded development following protein-energy malnutrition E46.X Unspecified protein-energy malnutrition O25.X Malnutrition in pregnancy Please note that the presence of an ICD-1 code of malnutrition on the admission episode indicates that the patient was diagnosed with, and would therefore receive the appropriate treatment, for malnutrition during the episode of care. The cause of malnutrition is not presented here but may be due to dietary issues, an inability to absorb nutrients normally or another disease affecting the patient s ability to feed normally. Whooping Cough A37 Whooping cough Measles B5.- Measles Scurvy E54.X Ascorbic acid deficiency Typhoid Fever A1. Typhoid fever Scarlet Fever A38.X Scarlet fever Diphtheria A36 Diphtheria Mumps B26.- Mumps Rickets E55. Rickets, active Cholera A.- Cholera 3. Twentieth Century Mortality Trends Griffiths, C; Brock, A (23) Twentieth century mortality trends in England and Wales. Health Statistics Quarterly. 18. 5-17 www.ons.gov.uk/ons/rel/hsq/health-statistics-quarterly/no--18--summer-23/twentieth-century-mortality-trends-in-england-and-wales.pdf 4. NHS Choices http://www.nhs.uk/conditions/gout/pages/introduction.aspx http://www.nhs.uk/conditions/tuberculosis/pages/introduction.aspx http://www.nhs.uk/conditions/malnutrition/pages/introduction.aspx http://www.nhs.uk/conditions/whooping-cough/pages/introduction.aspx http://www.nhs.uk/conditions/measles/pages/introduction.aspx http://www.nhs.uk/conditions/scurvy/pages/introduction.aspx http://www.nhs.uk/conditions/typhoid-fever/pages/introduction.aspx http://www.nhs.uk/conditions/scarlet-fever/pages/introduction.aspx http://www.nhs.uk/conditions/diphtheria/pages/introduction.aspx http://www.nhs.uk/conditions/mumps/pages/introduction.aspx http://www.nhs.uk/conditions/rickets/pages/introduction.aspx http://www.nhs.uk/conditions/cholera/pages/definition.aspx 5. Measles outbreak http://www.nhs.uk/news/212/8august/pages/measles-cases-england-almost-double.aspx 6. Finished Admission Episodes A finished admission episode (FAE) is the first period of inpatient care under one consultant within one healthcare provider. are counted against the year in which the admission episode finishes. Admissions do not represent the number of inpatients, as a person may have more than one admission within the year. 7. Primary Diagnosis The primary diagnosis is the first of up to 2 (14 from 22-3 to 26-7 and 7 prior to 22-3) diagnosis fields in the Hospital Episode Statistics (HES) data set and provides the main reason why the patient was admitted to hospital. 8. Number of episodes in which the patient had a primary or secondary diagnosis The number of episodes where this diagnosis was recorded in any of the 2 (14 from 22-3 to 26-7 and 7 prior to 22-3) primary and secondary diagnosis fields in a Hospital Episode Statistics (HES) record. Each episode is only counted once, even if the diagnosis is recorded in more than one diagnosis field of the record. 9. Assessing growth through time (Admitted patient care) HES figures are available from 1989-9 onwards. Changes to the figures over time need to be interpreted in the context of improvements in data quality and coverage (particularly in earlier years), improvements in coverage of independent sector activity (particularly from 26-7) and changes in NHS practice. For example, changes in activity may be due to changes in the provision of care. 1. ONS Population Estimates Population estimates are only currently available for mid-213 from the Office of National Statistics and are therefore not concurrent with the period presented in this publication. has been calculated using the total population within the same category e.g. all persons aged -16 in London Area Team. Please see footnote 12 for details of population data used for calculating deprivation decile rates The estimated resident population of an area includes all people who usually live there, whatever their nationality. People arriving into an area from outside the UK are only included in the population estimates if their total stay in the UK is 12 months or more. Visitors and short term migrants (those who enter the UK for 3 to 12 months for certain purposes) are not included. Similarly, people who leave the UK are only excluded from the population estimates if they remain outside the UK for 12 months or more. This is consistent with the United Nations recommended definition of an international long-term migrant. Members of UK and non-uk armed forces stationed in the UK are included in the population and UK forces stationed outside the UK are excluded. Students are taken to be resident at their term time address. 11. Area Team / Clinical Commissioning Group of residence The Clinical Commissioning Group (CCG) or Area Team (AT) containing the patient s normal home address. This does not necessarily reflect where the patient was treated as they may have travelled to another CCG/AT for treatment. In April 213 changes to the structure of the NHS came into effect (http://www.nhs.uk/nhsengland/thenhs/about/pages/nhsstructure.aspx). Primary Care Trusts (PCTs) and Strategic Health Authorities (SHAs) were abolished and were replaced with organisations such as Clinical Commissioning Groups (CCGs) and NHS England Area Teams (ATs). In addition there are now four NHS England Regions above the Area Teams in the structural hierarchy. 12. Length of stay (duration of spell) The difference in days between the admission date and the episode end date (duration of episode) or discharge date (duration of spell), where both dates are given. Information relating to LOS is based only on the final episode of the hospital spell. 13. Indices of Multiple Deprivation
The Indices of Multiple Deprivation (IMD) are a measure of multiple deprivation which ranks the relative deprivation of each area of England in a number of domains (such as health and income) and then combines the individual scores to produce a composite score for each area. The patient's residential postcode is then mapped to one of these areas and summarised into 1 groups (deciles) for presentation. The analysis in this topic uses IMD 21 data. See https://www.gov.uk/government/publications/english-indices-of-deprivation-21 for further details. The population denominator is the population in each IMD decile. This was calculated by linking ONS population data to IMD 21 data via Lower Super Output Area (LSOA) and aggregating in to IMD deciles. Please note that population estimates for IMD deciles are linked to ONS population data from 21 as this is the latest data available within HES that can be mapped to the corresponding LSOAs. All other population estimates within this report are based on 212 population data. Source statement Source: Hospital Episode Statistics (HES), Health and Social Care Information Centre Source of population data: Office for National Statistics (ONS) The responsible statistician for this publication is Jane Winter, Section Head, Hospital Episode Statistics (enquiries@hscic.gov.uk, 3 33 5678). Copyright 215, Health and Social Care Information Centre. All rights reserved.