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Public Health England

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Illustration: ©sakkmesterke/iStock #59827296

Once upon a time, people used to go courting. Indeed, songs have been written upon the subject (see Seven Brides for Seven Brothers…). Things moved at a much slower pace in the ‘marital relationship’ department – to the extent that in essence, one had actually be married in order to even know what the term meant. Today, the requirement to woo has been largely replaced by the requirement that you have a mobile phone, an appropriate geosocial networking (GSN) app, and the willingness to get to know someone in the biblical sense in a very short space of time.

While this may represent cultural progress, and has undoubtedly enriched the lives of many, such apps (for example, Grind’r or Tinder), which largely allow quickly and easily arranged anonymous encounters, may be contributing to a rise in serious sexually transmitted infections (STIs).

A 2014 US study [1] of HIV negative men who have sex with men (MSM) and use GSN applications to meet sexual partners, showed that:

  • They were at greater risk for gonorrhoea and Chlamydia than those who meet in-person or on the internet
  • They were 25% more likely to be infected with gonorrhoea and 37% more likely to be infected with Chlamydia
  • There was no difference in their likelihood of infection with either HIV or syphilis

Participants were drawn from those using an STI clinic so of course, the results are not fully representative.

A similar trend was found in New Zealand in 2012 [2], particularly amongst young men, although numbers were far too small to identify a true trend. The Rhode Island Department of Health (HEALTH) report of 2014 also suggests high risk behaviours (including the use of social media to arrange meetings) are responsible for an increase in STIs [3].

It would appear that a similar trend is occurring in the UK in terms of STI rates. Public Health England’s 2014 STI report [4] for 2013-2014 showed:

  • The largest proportional increase in diagnoses were reported for syphilis (33%) and gonorrhoea (19%)
  • Chlamydia was the most common infection
  • Gay men accounted for 81% of syphilis and 63% of gonorrhoea cases – gonorrhoea diagnoses rose 26% in this group, nearly double the national rate
  • Large increases in STI diagnoses were seen in MSM, including a 46% increase in syphilis and a 32% increase in gonorrhoea
  • Among heterosexuals, young people (15 to 24 years) experienced the highest STI rates: 63% of Chlamydia cases, 54% of genital warts, 42% of genital herpes and 56% of gonorrhoea

However, is it disingenuous to blame a phone app? While these facilitate the sexual encounter, it is still up to the participants in that encounter to practice safe sex and not be complacent. In the early days of HIV in the UK, the safe sex message was taken very seriously, as evidenced by a fall in gonorrhoea rates. However, as treatments improved, post-exposure prophylaxis became available, and being HIV positive was no longer (for most) an immediate death sentence, behaviours again became risky, with a subsequent increase in gonorrhoea rates. The 1990 – 2010 European Surveillance Report [5] (ECDC 2012), found that gonorrhoea was reported three times more often in men than in women, with more than a quarter of all cases (26%) reported in MSM. Half of the syphilis cases were reported by MSM.

Clearly, the largest problem area is MSM, but young people the age of 25 are also at risk [4]. As ever, advice on safe sex is important. While some app owners are sending such messages and advice on their sites, a whole systems approach is required. In a bold move, new apps are being developed which include health information and forums for advice and support, along with the dating function.

Health care professionals need to be aware of the at risk groups and advise accordingly.

 

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

  1. Beymer MR, Weiss RE, Bolan RK, Rudy et, et al. Sex On-Demand: Geosocial Networking Phone Apps and Risk of Sexually Transmitted Infections among a Cross-Sectional Sample of Men who have Sex with Men in Los Angeles County. Sex Transm Infect. 2014. 90; 7:567–572 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4198579/ Accessed August 2015
  2. Stylianou G. Phone app link to gay syphilis epidemic. The Press. 25th Aug 2012. http://www.stuff.co.nz/the-press/news/7545452/Phone-app-link-to-gay-syphilis-epidemic Accessed August 2015
  3. Rhode Island Department of Health (HEALTH). HEALTH Releases New Data on Infectious Syphilis, Gonorrhea, and HIV. 22nd June 2015. http://www.ri.gov/press/view/24889 Accessed August 2015
  4. Public Health England. Infection report: HIV-STIs. 9; 22. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/437433/hpr2215_STI_NCSP_v6.pdf Accessed August 2015
  5. European Centre for Disease Prevention and Control. Sexually transmitted infections in Europe 1990–2010. EDCD. 2012. http://ecdc.europa.eu/en/publications/Publications/201206-Sexually-Transmitted-Infections-Europe-2010.pdf Accessed August 2015

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NHS England’s CEO outlines the implementation of the ‘Five Year Forward View’ at this year’s NHS Confederation conference

Image: ©Rick Partington/Shutterstock #274143101

On 23rd October 2014, NHS England published its Five Year Forward View, which began with the statement (1,2):

‘the NHS is at a crossroads and needs to change and improve as it moves forward.’

The NHS Five Year Forward View was developed by several organisations that oversee and deliver health care (2). These organisations include NHS England, Public Health England, Health Education England, Monitor, the NHS Trust Development Authority, and the Care Quality Commission, with input from patient groups, clinicians and independent experts (1,3,4,5,6,7). This collective document, the Five Year Forward View, was developed as a five-year plan of how the NHS should change if it is to close the widening gaps in the funding and quality of care of the NHS (2). It includes a description of various local and national models of care required to support healthcare delivery, disease prevention, new models of service delivery, and integration of services (2).

The NHS Five Year Forward View had three main recommendations (2):

  • Firstly, that we all take our health more seriously, to reduce the health burden due to alcohol, smoking and obesity.
  • Second, that changes should be made in the way that health services are provided, including by combining health and social care.
  • Third, that the government provides financial support to allow the delivery of high-quality NHS services. In the latter case, staged funding increases were proposed to close the £30-billion gap by 2020/21.

The NHS Five Year Forward View detailed the following new models for future health care provision (2):

  • GP practices to be allowed to combine into single organisations providing a wider range of services.
  • New organisations to be created that provide both GP and hospital services together with mental health, community and social care.
  • Creation of seven-day-a-week networks to patients needing urgent care.
  • Sustaining local hospitals, if clinically justified and supported by local commissioners.
  • Concentrating some services into specialist centres.
  • Allowing groups of midwives to set up NHS-funded midwifery services to give women the choice of having home births.
  • Provision of more health and rehabilitation health services in care homes and thus improving the quality of life and reduce hospital bed use.
  • Provision of more support for carers and encouraging volunteering.

On 3rd June 2015, the NHS Confederation held its annual conference in Liverpool (8,9). The conference was attended by more than 3,000 health-sector leaders. NHS England’s CEO, Simon Stevens delivered the keynote speech on the opening day and set out his plans for how the NHS could deliver the Five Year Forward View(2). The priorities include redesigning NHS emergency care, tackling poor performance and harnessing the health service’s purchasing power. Simon Stevens told the NHS Confederation conference audience (9):

“We, the National Health Service, have set out our stall before the British people and come together to charter our own destiny.”

Simon Stevens did acknowledge that previous strategies for improving NHS performance have not only failed but have been ‘tested to destruction.’ He added that he saw no likelihood of the NHS receiving additional cash this year but announced several specific improvement measures during his keynote speech (9).

Recommended Improvement Measures for the NHS, June 2015:

1) Poorly Performing NHS Regions

New measures are recommended to tackle poor performance in three regions: Essex, North Cumbria, and North-West Devon. These measures will include a ‘success regime’ for regulators working with NHS England in these regions (9).

2) Re-design of Emergency Care

The urgent redesign of emergency care in the NHS will be an attempt to address a current system that is confusing for patients who have conditions that could be treated by their GP or even pharmacist (9).

3) NHS Purchasing

The importance of harnessing the ‘purchasing power’ of the NHS is highlighted by recommendations that the NHS should review some of its biggest areas of spending. The high-cost areas that are targeted include the use of employment agencies, for medical and nursing staffing. Temporary staffing costs are the single largest cause of hospital deficits (9).

4) Learning Disability Care

New models for learning disability care are recommended, including a closure programme for some long-stay institutions, following a programme of transition (9).

5) Public Health

At the NHS Confederation conference, Simon Stevens reiterated some of the points about public health previously made by the Health Secretary, Jeremy Hunt (9). The public health issues that will take priority include smoking, lack of exercise, obesity and alcohol, all of which create health consequences that place an increasing burden on NHS resources (9).

It can sometimes be difficult to appreciate how much healthcare in the UK is improving and just how resilient the NHS has been during the financial storms of recent years. Protected NHS funding and dedicated NHS staff have been the key reasons for these improvements and resilience. Seventy years after its creation, despite its problems, it is important to find hope in the fact that millions of people are working for the same thing, to maintain and improve the National Health Service.

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

(1) NHS England website: http://www.england.nhs.uk Accessed June 24, 2015

(2) NHS England. Five Year Forward View. Published October 23, 2014. http://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf Accessed June 24, 2015

(3) Public Health England website: https://www.gov.uk/government/organisations/public-health-england Accessed June 24, 2015

(4) Health Education England website: https://hee.nhs.uk Accessed June 24, 2015

(5) Monitor website. https://www.gov.uk/government/organisations/monitor Accessed June 24, 2015

(6) NHS Trust Development Authority website: http://www.ntda.nhs.uk Accessed June 24, 2015

(7) Care Quality Commission website: http://www.cqc.org.uk Accessed June 24, 2015

(8) The NHS Confederation website: http://www.nhsconfed.org Accessed June 24, 2015

(9) NHS Confederation Conference, 2015. Stevens issues clarion call to NHS leaders to redesign care for patients. June 3, 2015. https://www.england.nhs.uk/2015/06/03/redesign-care/ Accessed June 24, 2015

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England and Scotland are first to implement a national vaccination programme: but who will follow?

Image: ©Komsan Loonprom/Shutterstock #236173498

On June 21st 2015, an announcement was made by the Department of Health and the UK Public Health Minister that the Meningococcal B (MenB) vaccine, will be offered to babies at 2, 4 and 12 months of age in England and Scotland, from September 1st, 2015 (1). All 17- and 18-year-olds will be offered a combined vaccine against meningococcal strains A, C, W and Y (1).

Meningococcal meningitis and septicaemia occur as a result of a systemic bacterial infection by Neisseria meningitidis. Although the MenB vaccine has been available for several years, this national childhood immunisation programme for meningococcal B infection is the first of its kind in the world.

There has been active campaigning for this vaccination programme by patient groups and by the Meningitis Research Foundation (2). As yet, no other country has implemented a national immunisation programme for Meningococcal B infection.

Babies born in England and Scotland on or after 1st July 2015 will be offered the MenB vaccine, Bexsero® along with their other routine immunisations, as described in the NHS Vaccination Schedule (3).

Meningococcal classification is done according to the characteristics of the bacterial polysaccharide capsule, or by the sequence type (ST). Of the 12 identified capsular groups, groups B, C, W and Y are the most common in the UK (3,4). Since the introduction of a routine Meningococcal C conjugate vaccination programme, cases of group C Meningococcal infections have reduced. Group B Meningococcal infections now account for more than 80% of cases in the UK (3,4).

Meningococci are Gram-negative bacteria (diplococci) and are common commensals of the human nasopharynx. Between 5% and 11% of adults and up to 25 % of adolescents carry the bacteria without any signs or symptoms. Transmission is by droplet or aerosol spread, or by direct contact (3,4).

Meningococcal meningitis and septicaemia are most common in babies and children under five, with a second peak in adolescence. The peak age for meningococcal disease is 5 months of age. In the year 2011 to 2012, there were 613 laboratory-confirmed cases of meningitis B infection and 33 deaths (4). One in ten patients who survive meningococcal meningitis will have major physical and/or neurological disability.

Teenagers are common carriers of these bacteria, so vaccinating teenagers is believed to have benefits for the whole population, as well as protecting those vaccinated (5). So, from 1st September 2015, all 17- and 18-year-olds will be offered a combined vaccine that protects them from the four strains of Meningococcus A, C, W and Y (MenACWY). The MenACWY vaccine will be offered to students starting university this year.

MenB vaccine, Bexsero®, was licensed for use in Europe in January 2013, despite the absence of data to support an assessment of its clinical effectiveness and cost-effectiveness (6). There have been extensive reviews of the health and cost benefits of MenB vaccine over several years, but these have not been convincing either in terms of clinical effectiveness or cost-effectiveness.

In the UK, the Joint Committee on Vaccination and Immunisation (JCVI) have a key role in advising the government regarding vaccination (7). Following the approval of Bexsero®, during 2013 and 2014 the JCVI continued to state that there was insufficient evidence that the protection offered by the vaccine would protect children enough to justify a routine vaccination programme (8,9,10). This decision by JCVI was made despite data from a randomised controlled clinical trial of MenB vaccine, published in the Lancet in 2013 (11). In support of this decision, it was also noted that the numbers of children infected with Meningococcus B and C were falling (4).

The MenB vaccine, Bexsero®, has previously been available privately in the UK and Ireland and is used worldwide during small outbreaks of meningitis B in schools and colleges, for example. The vaccine is already freely available to those with medical conditions that may increase the risk of Meningococcal infection, including asplenia, splenic dysfunction, complement deficiencies and those patients treated with the monoclonal antibody Eculizumab (Soliris®) (4). The MenB vaccine, Bexsero®, is offered to laboratory workers who may be at risk of exposure to Meningococcus B. Public Health England provides guidance regarding the use of the vaccine in those who have been in contact with Meningococcal B infection (5).

In March 2015, GlaxoSmithKline (GSK) acquired Novartis Vaccines and Diagnostics, and now market the MenB vaccine, Bexsero® (12). From March 2015, the Department of Health agreed a price with GSK for the vaccine; this was a key turning point in the decision to implement the immunisation programme this year and was widely reported by the general media (13). This decision was made and announced in advance of the UK General Election held in May 2015 (13).

It is still unclear how much this vaccination programme will cost the NHS, not just in terms of the cost of the vaccine, but also the cost of staffing and administration. Although England and Scotland will be implementing a Meningococcal B vaccination programme from September 1st, and Ireland and Wales may follow, it seems unlikely that Europe and the rest of the world will follow.

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

(1) Department of Health news. New programmes to protect against meningitis and septicaemia. Published June 21, 2015. https://www.gov.uk/government/news/new-programmes-to-protect-against-meningitis-and-septicaemia Accessed June 26, 2015

(2) Meningitis Research Foundation website. http://www.meningitis.org Accessed June 26, 2015

(3) NHS vaccination schedule website. http://www.nhs.uk/conditions/vaccinations/pages/vaccination-schedule-age-checklist.aspx Accessed June 26, 2015

(3) NHS Choices. Meningitis website. http://www.nhs.uk/conditions/Meningitis/Pages/Introduction.aspx Accessed June 26, 2015

(4) The Green Book. Chapter 22. Meningococcal Meningitis and Septicaemia. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/302904/Green_Book_Chapter_22_v2_5.pdf Accessed June 26, 2015

(5) Ladhani SN, Corderry R, Mandal S et al. Preventing secondary cases of invasive meningococcal capsular group B (MenB) disease: benefits of offering vaccination in addition to antibiotic chemoprophylaxis to close contacts of cases in the household, educational setting, clusters and the wider community. (Version 1.1, Dated 01 April 2014). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/328835/Invasive_meningococcus_secondary_case_prevention_April_2014.pdf Accessed June 26, 2015

(6) European Medicine Agency (EMA). Medicinal Product Information. Bexsero suspension for injection in pre-filled syringe Meningococcal group B Vaccine (rDNA, component, adsorbed). http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/002333/WC500137881.pdf Accessed June 26, 2015

(7) Joint Committee on Vaccination and Immunisation (JCVI) website. https://www.gov.uk/government/groups/joint-committee-on-vaccination-and-immunisation Accessed June 26, 2015

(8) JCVI interim position statement on use of Bexsero meningococcal B vaccine in the UK. July 2013. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/224896/JCVI_interim_statement_on_meningococcal_B_vaccination_for_web.pdf Accessed June 26, 2015

(9) Editorial. Meningitis Vaccine: Moral Maize. The Guardian. July 24, 2013, http://www.theguardian.com/commentisfree/2013/jul/24/meningitis-vaccine-moral-maze-editorial Accessed June 26, 2015

(10) Boseley S. Meningitris B Vaccine Rejected by UK. July 24, 2014. http://www.theguardian.com/society/2013/jul/24/meningitis-b-vaccine-rejected-uk Accessed June 26, 2015

(11) Vesikari T, Esposito S, Prymula R, et al. Immunogenicity and safety of an investigational multicomponent, recombinant, meningococcal serogroup B vaccine (4CMenB) administered concomitantly with routine infant and child vaccinations: results of two randomised trials. Lancet. 2013;381(9869): 825-835. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61961-8/fulltext Accessed June 26, 2015

(12) GlaxoSmithKline (GSK) Pre-Quarterly Results Communication Q1 2015. On 2 March 2015 GSK completed the major three-part transaction with Novartis. March 2015. https://www.gsk.com/media/628161/q1-2015-pre-announcement-aide-memoire.pdf Accessed June 26, 2015

(13) Little A. Every baby to be vaccinated against meningitis B in world first protection programme. The Express. March 29, 2015. http://www.express.co.uk/news/uk/567144/British-babies-vaccinated-against-meningitis-B Accessed June 26, 2015

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Microbiome data now being gathered may form the basis for a ‘personalised’ approach to improving individual microbial populations

Image: ©Pixelbliss/Shutterstock #280702511

In May 2015, a molecular microbiology study was published in the Proceedings of the National Academy of Sciences (1). This study showed that gut bacteria could be DNA ‘fingerprinted,’ as their DNA sequences were shown to represent a unique form of identification in more than 80% of individuals examined (1). This study has little to do with ‘CSI’-style forensic identification but does have implications for our health, diet, development and genetics and our ability to defend ourselves from true microbial pathogens (1).

That the human body is believed to contain ten times more microbial cells than human cells (trillions of them) can be an uncomfortable thought. Even more remarkable is that, in terms of numbers, the population of these microbes accounts for up to 90% of the total number of cells associated with our bodies. Our human microbial population weighs between 1% and 3% of our total body mass (1.5 kg); this is equivalent to the weight of the largest human internal organ, the liver (2).

The terminology of the body’s flora and fauna can be confusing. This could be why someone, probably working in advertising, came up with the phrase ‘friendly bacteria.’ The term ‘microbiota’ is the collective noun that refers to the viruses, fungi and bacteria that inhabit our bodies, mainly in our gut and on the surface of our skin. The microbiota has a commensal and a symbiotic relationship with us. The term, ‘microbiome’ is used to refer to the collection of the genomes of these microbes. These two names, ‘microbiota’ and ‘microbiome,’ are often used interchangeably.

Our view of our personal microbial health has changed during the past 20 years. Until the 1990’s there was the ‘germicidal view’ that all bacteria were harmful and that we should be doing all we could to sterilise our home environment, ourselves and our food. There are now increasing numbers of scientific and healthcare news stories, as well as television commercials, which advise us to encourage and nurture our own, resident, and very personal ‘friendly bacteria.’

As with the dietary anti-oxidant ‘industry’ that arose from cardiovascular research in the 1980’s, the food industry has been swift to promote the sales of dietary probiotic supplements. Global sales of probiotics have been reported as £13.6 billion ($21.6 billion USD) in 2010 and are expected to exceed £19.6 billion ($31.1 billion USD) during 2015 (3).

In February 2015, an editorial collaboration between the journals, Nature and Scientific American, resulted in the publication of a series of special reports entitled, Innovations in the Microbiome(4) These and other recent publications have helped to place the importance of the normal human microbial population further into the medical spotlight.

For almost a century, epidemiological studies have shown that diet has a profound effect on human health. Recently, the link has been made between diet and the gut microbiota, with emphasis on the effects that a ‘western’ diet of refined foods and high protein have on these organisms. In 2011, a study linked long-term dietary patterns to changing gut bacterial enterotypes in humans (5). In 2014, a study in wild mice clearly demonstrated that dietary change can induce gut bacterial ‘enterotype switches’ within hosts (6). ‘Biome reconstitution’ has been proposed as a treatment approach to immune disorders, including allergy and autoimmune disease and to preventing colonic cancer, obesity, diabetes, and metabolic disease (7, 8).

In the past ten years, sequencing technologies have allowed the development of a detailed reference database of the diverse microbes that inhabit our bodies. In 2007, in the US, the National Institutes of Health (NIH) Human Microbiome Project (HMP) Consortium was launched, consisting of more than 200 members, from nearly 80 universities and scientific institutions (9). In its 2012 report, the HMP listed the major ways in which knowledge of the human microbiome may change the future of science and medicine (10). The HMP has considered the potential privacy issues surrounding knowledge of the individual microbiome, the flow between human microbes and those found in nature (in water and soil) (10).

The microbiome data now being gathered may form the basis for a ‘personalised’ approach to improving individual microbial populations. Most importantly, solutions to microbial antibiotic resistance may be found through increasing knowledge of microbial interactions. At this same time comes the realisation that overuse of antibiotics, as part of our ‘war on germs’ mentality, has allowed true microbial pathogens to develop antibiotic resistance. The lack of a functioning and complete personal microbial population leaves us vulnerable to bacterial pathogens that we may be increasingly less able to fight.

In 2013, the Chief Medical Officer for England highlighted the increasing problem of antibiotic resistance. These concerns led to the Department of Health launching a five-year Antimicrobial Resistance (AMR) Strategy, which is supported by NHS England’s Antibiotic Awareness Campaign (11,12). In October 2014, Public Health England produced the first report on the English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) (13). These latest initiatives by the medical profession and healthcare regulators to reduce antibiotic prescribing is just one approach that has to be made.

The European Molecular Biology Laboratory (EMBL) annual conference, held in Heidelberg in June 2015, was devoted to the topic of the Human Microbiome (14). This meeting included discussions on the design of possible therapeutic or dietary interventions to prevent and treat disease. An announcement was made at the meeting of the first results from the Personalised Nutrition Project, run by research groups in Israel (15). The u-Biome Project is a crowdfunded ‘citizen science’ initiative that is set to analyse the microbiome in the context of individual health and is currently recruiting participants (16).

The rationale for learning more about the ‘normal’ or ‘optimal’ microbiome, and how to reconstitute or nurture it, is an important component of individual healthcare (17, 18). For the future development of interventions for resistant microbial pathogens, the human microbiota may play more than just a ‘friendly’ role, it may be life-saving.

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

(1) Franzosa EA, Huang K, Meadow JF, Gevers D, Lemon KP, Bohannan BJ, Huttenhower C. Identifying personal microbiomes using metagenomic codes. Proc Natl Acad Sci U S A. 2015;pii 201423854. http://www.pnas.org/content/early/2015/05/08/1423854112 Accessed June 10, 2015

(2) The Human Microbiome Project. Structure, function and diversity of the healthy human microbiome. Nature 2011;486:207-14. http://www.nature.com/nature/journal/v486/n7402/full/nature11234.html Accessed June 10, 2015

(3) Business Communications Company (BCC) market research data for sales of probiotic foods and supplements, 2010 and 2015. http://www.bccresearch.com/pressroom/fod/global-market-for-probiotics-reach-$36.7-billion-2018 Accessed June 10, 2015

(4) Special Report. Innovations in the Microbioma. Scientific American Vol 312, Feb 2015. http://www.scientificamerican.com/editorial/innovations-in-the-microbiome/ Accessed June 10, 2015

(5) Wu GD, Chen J, Hoffmann C, et al. Linking Long-Term Dietary Patterns with Gut Microbial Enterotypes. Science 2011;334(6052):105-108. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3368382/ Accessed June 10, 2015

(6) Wang J, Linnenbrink M, Kunzel S, et al. Dietary history contributes to enterotype-like clustering and functional metagenomic content in the intestinal microbiome of wild mice. Proc Natl Acad Sci USA 2014; 111:E2703-E2710. http://www.pnas.org/content/111/26/E2703.full Accessed June 10, 2015

(7) Parker W, Ollerton J. Evolutionary biology and anthropology suggest biome reconstitution as a necessary approach toward dealing with immune disorders. Evolution, Medicine, and Public Health 2013;2013(1):89-103. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3868394/ Accessed June 10, 2015

(8) Grice EA, Segre JA. The Human Microbiome: Our Second Genome. Annual Review of Genomics and Human Genetics 2012;13:151-170. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3518434/ Accessed June 10, 2015

(9) The National Instututes of Health (NIH) Human Microbiome Project website http://commonfund.nih.gov/hmp/index Accessed June 10, 2015

(10) National Institutes for Health (NIH). Human Microbiome Project defines normal bacterial makeup of the body. Genome sequencing creates first reference data for microbes living with healthy adults. June 13th 2012. http://www.nih.gov/news/health/jun2012/nhgri-13.htm Accessed June 10, 2015

(11) The Department of Health Antimicrobial Resistance (AMR) Strategy 2013 to 2018. First published September 10, 2013. https://www.gov.uk/government/publications/uk-5-year-antimicrobial-resistance-strategy-2013-to-2018 Accessed June 10, 2015

(12) NHS Antibiotic Awareness Campaign. Last revised 24th Sept 2014. http://www.nhs.uk/NHSEngland/ARC/Pages/AboutARC.aspx Accessed June 10, 2015

(13) Public Health England. English Surveillance Programme Antimicrobial Utilisation and Resistance (ESPAUR) Report. Published Oct 10, 2014. https://www.gov.uk/government/publications/english-surveillance-programme-antimicrobial-utilisation-and-resistance-espaur-report Accessed June 10, 2015

(14) European Molecular Biology Laboratory (EMBL) website. http://www.embl.de/aboutus/general_information/index.html Accessed June 10, 2015

(15) The Personalised Nutrition Project website. http://newsite.personalnutrition.org/WebSite/Home.aspx Accessed June 10, 2015

(16) u-Biome – Sequencing Your Microbiome website. https://www.indiegogo.com/projects/ubiome-sequencing-your-microbiome#/story Accessed June 10, 2015

(17) Grogan D. Microbes in the Gut Are Essential to Our Well-Being. Scientific American. Feb 17, 2015. http://www.scientificamerican.com/article/microbes-in-the-gut-are-essential-to-our-well-being/ Accessed June 10, 2015

(18) Parums D. ‘Indigenous’ Human Microbes – the Microbiota and the Microbiome. Thomson Reuters Life Sciences Connect. May 26, 2015. http://lsconnect.thomsonreuters.com/indigenous-human-microbes-the-microbiota-and-the-microbiome/ Accessed July 6, 2015

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