22 results found
Zhu J, Holmes A, 2022, Changing patterns of bloodstream infections in the community and acute care across two COVID-19 epidemic waves: a retrospective analysis using data linkage, Clinical Infectious Diseases, Vol: 75, Pages: e1082-e1091, ISSN: 1058-4838
BackgroundWe examined the epidemiology of community- and hospital-acquired bloodstream infections (BSIs) in COVID-19 and non-COVID-19 patients across two epidemic waves.MethodsWe analysed blood cultures of patients presenting and admitted to a London hospital group between January 2020 and February 2021. We reported BSI incidence, as well as changes in sampling, case mix, healthcare capacity, and COVID-19 variants.Results34,044 blood cultures were taken. We identified 1,047 BSIs; 653 (62.4%) community-acquired and 394 (37.6%) hospital-acquired. Important changes in patterns were seen. Among community-acquired BSIs, Escherichia coli BSIs remained lower than pre-pandemic level during COVID-19 waves, however peaked following lockdown easing in May 2020, deviating from the historical trend of peaking in August. The hospital-acquired BSI rate was 100.4 per 100,000 patient-days across the pandemic, increasing to 132.3 during the first wave and 190.9 during the second, with significant increase seen in elective inpatients. Patients who developed a hospital-acquired BSI, including those without COVID-19, experienced 20.2 excess days of hospital stay and 26.7% higher mortality, higher than reported in pre-pandemic literature. In intensive care, the BSI rate was 421.0 per 100,000 patient-ICU days during the second wave, compared to 101.3 pre-COVID. The BSI incidence in those infected with the SARS-CoV-2 Alpha variant was similar to that seen with earlier variants.ConclusionsThe pandemic and national responses have impacted the patterns of community- and hospital-acquired BSIs, in COVID-19 and non-COVID-19 patients. Factors driving the observed patterns are complex. Infection surveillance needs to consider key aspects of pandemic response and changes in healthcare access and practice.
Charani E, McKee M, Ahmad R, et al., 2021, Optimising antimicrobial use in humans-review of current evidence and an interdisciplinary consensus on key priorities for research, The Lancet Regional Health - Europe, Vol: 7, Pages: 1-10, ISSN: 2666-7762
Addressing the silent pandemic of antimicrobial resistance (AMR) is a focus of the 2021 G7 meeting. A major driver of AMR and poor clinical outcomes is suboptimal antimicrobial use. Current research in AMR is inequitably focused on new drug development. To achieve antimicrobial security we need to balance AMR research efforts between development of new agents and strategies to preserve the efficacy and maximise effectiveness of existing agents.Combining a review of current evidence and multistage engagement with diverse international stakeholders (including those in healthcare, public health, research, patient advocacy and policy) we identified research priorities for optimising antimicrobial use in humans across four broad themes: policy and strategic planning; medicines management and prescribing systems; technology to optimise prescribing; and context, culture and behaviours. Sustainable progress depends on: developing economic and contextually appropriate interventions; facilitating better use of data and prescribing systems across healthcare settings; supporting appropriate and scalable technological innovation. Implementing this strategy for AMR research on the optimisation of antimicrobial use in humans could contribute to equitable global health security.
Ahmad R, Atun R, Birgand G, et al., 2021, Macro level influences on strategic responses to the COVID-19 pandemic – an international survey and tool for national assessments, Journal of Global Health, Vol: 11, Pages: 1-11, ISSN: 2047-2978
Background Variation in the approaches taken to contain the SARS-CoV-2 (COVID-19) pandemic at country level has been shaped by economic and political considerations, technical capacity, and assumptions about public behaviours. To address the limited application of learning from previous pandemics, this study aimed to analyse perceived facilitators and inhibitors during the pandemic and to inform the development of an assessment tool for pandemic response planning.Methods A cross-sectional electronic survey of health and non-healthcare professionals (5 May - 5 June 2020) in six languages, with respondents recruited via email, social media and website posting. Participants were asked to score inhibitors (-10 to 0) or facilitators (0 to +10) impacting country response to COVID-19 from the following domains – Political, Economic, Sociological, Technological, Ecological, Legislative, and wider Industry (the PESTELI framework). Participants were then asked to explain their responses using free text. Descriptive and thematic analysis was followed by triangulation with the literature and expert validation to develop the assessment tool, which was then compared with four existing pandemic planning frameworks.Results 928 respondents from 66 countries (57% healthcare professionals) participated. Political and economic influences were consistently perceived as powerful negative forces and technology as a facilitator across high- and low-income countries. The 103-item tool developed for guiding rapid situational assessment for pandemic planning is comprehensive when compared to existing tools and highlights the interconnectedness of the 7 domains. Conclusions The tool developed and proposed addresses the problems associated with decision making in disciplinary silos and offers a means to refine future use of epidemic modelling.
Zhu J, Ferlie E, Castro-Sánchez E, et al., 2021, Macro level factors influencing strategic responses to emergent pandemics: a scoping review, Journal of Global Health, Vol: 11, Pages: 1-16, ISSN: 2047-2978
Background: Strategic planning is critical for successful pandemic management. This study aimed to identify and review the scope and analytic depth of situation analyses conducted to understand their utility, and capture the documented macro-level factors impacting4pandemic management. Methods: To synthesise this disparate body of literature, we adopted a two-step search and 6review process. A systematic search of the literature was conducted to identify all studies since 2000, that have 1) employed a situation analysis;and2) examined contextual factors influencing pandemic management. The included studies are analysed using a seven-domain systems approach rom the discipline of strategic management. Findings: Nineteen studies were included in the final review ranging from single country (6) to regional, multi-country studies (13). Fourteen studies had a single disease focus, with 5 studies evaluating responses to one or more of COVID-19, Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS),Influenza A (H1N1),Ebola virus disease, and Zika virus disease pandemics. Six studies examined a single domain from political, economic, sociological, technological, ecological or wider industry(PESTELI), 5 studies examined two to four domains, and8studies examined five or more domains. Methods employed were predominantly literature reviews. The recommendations focus predominantly on addressing inhibitors in the sociological and technological domains with few recommendations articulated in the political domain. Overall, the legislative domain is least represented. Conclusions: Ex-post analysis using the seven-domain strategic management framework provides further opportunities for a planned systematic response to pandemics which remains critical as the current COVID-19 pandemic evolves.
Zhu N, Aylin P, Rawson T, et al., 2021, Investigating the impact of COVID-19 on primary care antibiotic prescribing in North West London across two epidemic waves, Clinical Microbiology and Infection, Vol: 27, Pages: 762-768, ISSN: 1198-743X
ObjectivesWe investigated the impact of COVID-19 and national pandemic response on primary care antibiotic prescribing in London.MethodsIndividual prescribing records between 2015 and 2020 for 2 million residents in north west London were analysed. Prescribing records were linked to SARS-CoV-2 test results. Prescribing volumes, in total, and stratified by patient characteristics, antibiotic class and AWaRe classification, were investigated. Interrupted time series analysis was performed to detect measurable change in the trend of prescribing volume since the national lockdown in March 2020, immediately before the first COVID-19 peak in London.ResultsRecords covering 366 059 patients, 730 001 antibiotic items and 848 201 SARS-CoV-2 tests between January and November 2020 were analysed. Before March 2020, there was a background downward trend (decreasing by 584 items/month) in primary care antibiotic prescribing. This reduction rate accelerated to 3504 items/month from March 2020. This rate of decrease was sustained beyond the initial peak, continuing into winter and the second peak. Despite an overall reduction in prescribing volume, co-amoxiclav, a broad-spectrum “Access” antibiotic, prescribing rose by 70.1% in patients aged 50 and older from February to April. Commonly prescribed antibiotics within 14 days of a positive SARS-CoV-2 test were amoxicillin (863/2474, 34.9%) and doxycycline (678/2474, 27.4%). This aligned with national guidelines on management of community pneumonia of unclear cause. The proportion of “Watch” antibiotics used decreased during the peak in COVID-19.DiscussionA sustained reduction in community antibiotic prescribing has been observed since the first lockdown. Investigation of community-onset infectious diseases and potential unintended consequences of reduced prescribing is urgently needed.
Zhen X, Lundborg CS, Sun X, et al., 2021, Correction to: Economic burden of antibiotic resistance in China: a national level estimate for inpatients., Antimicrob Resist Infect Control, Vol: 10
Ahmad R, Atun R, Birgand G, et al., 2021, Macro Level Influences on Strategic Responses to the COVID-19 Pandemic - A Tool for National Assessments, Journal of Global Health, ISSN: 2047-2978
Zhen X, Stålsby Lundborg C, Sun X, et al., 2021, Economic burden of antibiotic resistance in China: a national level estimate for inpatients., Antimicrob Resist Infect Control, Vol: 10
BACKGROUND: Antibiotic resistance (AR) threats public health in China. National-level estimation of economic burden of AR is lacking. We aimed to quantify the economic costs of AR in inpatients in China. METHODS: We performed a multicentre and retrospective cohort study including 15,990 patient episodes at four tertiary hospitals in China from 2013 to 2015 to assess the impact of AR on hospital mortality, length of stay, and costs. We estimated the societal economic burden of AR using findings from the cohort study and secondary data from national surveillance hubs and statistical reports. RESULTS: Patients with multi-drug resistant (MDR) infection or colonisation caused by Staphylococcus aureus, Enterococcus faecalis, Enterococcus faecium, Escherichia coli, Klebsiella pneumonia, Pseudomonas aeruginosa, and Acinetobacter baumannii experienced higher individual patient cost ($3391, 95% uncertainty interval (UI) $3188-3594), longer hospital stay (5.48 days, 95% UI 5.10-5.87 days), and higher in-hospital mortality rates (1.50%, 95% UI 1.29-1.70%). In China, 27.45% of bacterial infection or colonisation that occurred in inpatients were resistant, of which 15.77% were MDR. A societal economic burden attributed to AR was estimated to be $77 billion in 2017, which is equivalent to 0.37% of China's yearly gross domestic product, with $57 billion associated with MDR. CONCLUSIONS: This is the first study to estimate national-level economic burden of AR in China. AR places a significant burden on patient health and healthcare systems. Estimation of economic costs of resistant infection or colonisation is the essential step towards building an economic case for global and national actions to combat AMR.
Zhu NJ, McLeod M, McNulty CAM, et al., 2021, Trends in Antibiotic Prescribing in Out-of-Hours Primary Care in England from January 2016 to June 2020 to Understand Behaviours during the First Wave of COVID-19, ANTIBIOTICS-BASEL, Vol: 10, ISSN: 2079-6382
- Author Web Link
- Citations: 13
Abbas M, Abbas M, Zhu NJ, et al., 2021, Hospital-onset COVID-19 infection surveillance systems: a systematic review, Journal of Hospital Infection
Zhu N, Sanchez EC, Zhen X, et al., 2020, Addressing antimicrobial resistance in China: progress and challenges in translating political commitment into national action, Publisher: ELSEVIER SCI LTD, Pages: 212-212, ISSN: 1201-9712
Jadeja N, Zhu NJ, Lebcir RM, et al., 2020, Optimising policy analysis for AMR: A review of the capability of system dynamics for economic evaluation, Publisher: ELSEVIER SCI LTD, Pages: 215-215, ISSN: 1201-9712
Zhu J, Ahmad R, Holmes A, et al., 2020, System dynamics modelling to formulate policy interventions to optimise antibiotic prescribing in hospitals, Journal of the Operational Research Society, Vol: 72, Pages: 2490-2502, ISSN: 0160-5682
Multiple strategies have been used in the National Health System (NHS) in England to reduce inappropriate antibiotic prescribing and consumption in order to tackle antimicrobial resistance. These strategies have included, among others, restricting dispensing, introduction of prescribing guidelines, use of clinical audit, and performance reviews as well as strategies aimed at changing the prescribing behaviour of clinicians. However, behavioural interventions have had limited effect in optimising doctors’ antibiotic prescribing practices. This study examines the determinants of decision-making for antibiotic prescribing in hospitals in the NHS. A system dynamics model was constructed to capture structural and behavioural influences to simulate doctors’ prescribing practices. Data from the literature, patient records, healthcare professional interviews and survey responses were used to parameterise the model. The scenario simulation shows maximum improvements in guideline compliance are achieved when compliance among senior staff is increased, combined with fast laboratory turnaround of blood cultures, and microbiologist review. Improving guideline compliance of junior staff alone has limited impact. This first use of system dynamics modelling to study antibiotic prescribing decision-making demonstrates the applicability of the methodology for design and evaluation of future policies and interventions.
Rawson TM, Moore L, Zhu N, et al., 2020, Bacterial and fungal co-infection in individuals with coronavirus: A rapid review to support COVID-19 antimicrobial prescribing, Clinical Infectious Diseases, Vol: 71, Pages: 2459-2468, ISSN: 1058-4838
BackgroundTo explore and describe the current literature surrounding bacterial/fungal co-infection in patients with coronavirus infection.MethodsMEDLINE, EMBASE, and Web of Science were searched using broad based search criteria relating to coronavirus and bacterial co-infection. Articles presenting clinical data for patients with coronavirus infection (defined as SARS-1, MERS, SARS-COV-2, and other coronavirus) and bacterial/fungal co-infection reported in English, Mandarin, or Italian were included. Data describing bacterial/fungal co-infections, treatments, and outcomes were extracted. Secondary analysis of studies reporting antimicrobial prescribing in SARS-COV-2 even in the absence of co-infection was performed.Results1007 abstracts were identified. Eighteen full texts reported bacterial/fungal co-infection were included. Most studies did not identify or report bacterial/fungal coinfection (85/140;61%). 9/18 (50%) studies reported on COVID-19, 5/18 (28%) SARS-1, 1/18 (6%) MERS, and 3/18 (17%) other coronavirus.For COVID-19, 62/806 (8%) patients were reported as experiencing bacterial/fungal co-infection during hospital admission. Secondary analysis demonstrated wide use of broad-spectrum antibacterials, despite a paucity of evidence for bacterial coinfection. On secondary analysis, 1450/2010 (72%) of patients reported received antimicrobial therapy. No antimicrobial stewardship interventions were described.For non-COVID-19 cases bacterial/fungal co-infection was reported in 89/815 (11%) of patients. Broad-spectrum antibiotic use was reported.ConclusionsDespite frequent prescription of broad-spectrum empirical antimicrobials in patients with coronavirus associated respiratory infections, there is a paucity of data to support the association with respiratory bacterial/fungal co-infection. Generation of prospective evidence to support development of antimicrobial policy and appropriate stewardship interventions specific for the COVID-19 pandemic are urgently requi
Ahmad R, Zhu NJ, Leather AJM, et al., 2019, Strengthening strategic management approaches to address antimicrobial resistance in global human health: a scoping review, BMJ Global Health, Vol: 4, ISSN: 2059-7908
Introduction: The development and implementation of national strategic plans is a critical component towards successfully addressing antimicrobial resistance (AMR). This study aimed to review the scope and analytical depth of situation analyses conducted to address AMR in human health to inform the development and implementation of national strategic plans. Methods: A systematic search of the literature was conducted to identify all studies since 2000, that have employed a situation analysis to address AMR. The included studies are analysed against frameworks for strategic analysis, primarily the PESTELI (Political, Economic, Sociological, Technological, Ecological, Legislative, Industry) framework, to understand the depth, scope and utility of current published approaches. Results: 10 studies were included in the final review ranging from single country (6) to regional-level multicountry studies (4). 8 studies carried out documentary review, and 3 of these also included stakeholder interviews. 2 studies were based on expert opinion with no data collection. No study employed the PESTELI framework. Most studies (9) included analysis of the political domain and 1 study included 6 domains of the framework. Technological and industry analyses is a notable gap. Facilitators and inhibitors within the political and legislative domains were the most frequently reported. No facilitators were reported in the economic or industry domains but featured inhibiting factors including: lack of ring-fenced funding for surveillance, perverse financial incentives, cost-shifting to patients; joint-stock drug company ownership complicating regulations. Conclusion: The PESTELI framework provides further opportunities to combat AMR using a systematic, strategic management approach, rather than a retrospective view. Future analysis of existing quantitative data with interviews of key strategic and operational stakeholders is needed to provide critical insights about where implementation eff
Ahmad R, Zhu J, Lebcir MR, et al., 2019, How the health-seeking behaviour of pregnant women affects neonatal outcomes: findings of System Dynamics modelling in Pakistan, BMJ Global Health, Vol: 4, ISSN: 2059-7908
Background: Limited studies have explored how health-seeking behaviour during pregnancy through to delivery affect neonatal outcomes. We modelled health-seeking behaviour across urban and rural settings in Pakistan, where poor neonatal outcomes persist with wide disparities. Methods and Findings: A System Dynamics model was developed and parameterised. Following validation tests, the model was used to determine neonatal mortality for pregnant women considering their decisions to access, refuse, and switch antenatal care services in four provider sectors: public, private, traditional, and charitable. Four health-seeking scenarios were tested across different pregnancy trimesters. Health-seeking behaviour in different sub-groups by geographic locations, and social network effect was modelled. The largest reduction in neonatal mortality was achieved with antenatal care provided by skilled providers in public, private or charitable sectors, combined with the use of institutional delivery. Women’s social networks had strong influences on if, when and where to seek care. Interventions by Lady Health Workers had a minimal impact on health-seeking behaviour and neonatal outcomes after Trimester 1. Optimal benefits were achieved for urban women when antenatal care was accessed within Trimester 2, but for rural women within Trimester 1. Antenatal care access delayed to Trimester 3 had no protective impact on neonatal mortality. Conclusions: System Dynamics modelling enables capturing complexity of health-seeking behaviours and impact on outcomes, informing: intervention design, implementation of targeted policies, and uptake of services specific to urban/rural settings considering structural enablers/barriers to access, cultural contexts, and strong social network influences.
Naylor NR, Atun R, Zhu N, et al., 2018, Estimating the burden of antimicrobial resistance: a systematic literature review, Antimicrobial Resistance and Infection Control, Vol: 7, ISSN: 2047-2994
Background: Accurate estimates of the burden of antimicrobial resistance (AMR) are needed to establish the magnitude of this global threat in terms of both health and cost, and to enable cost-effectiveness evaluations of interventions aiming to tackle the problem. This review aimed to establish the alternative methodologies used in estimating AMR burden in order to appraise the current evidence base. Methods: MEDLINE, EMBASE, Scopus, EconLit, PubMed and grey literature were searched. English language studies evaluating the impact of AMR (from any microbe) on patient, payer/provider and economic burden published between January 2013 and December 2015 were included. Independent screening of title/abstracts followed by full texts was performed using pre-specified criteria. A study quality score (from zero to one) was derived using Newcastle-Ottawa and Phillips checklists. Extracted study data were used to compare study method and resulting burden estimate, according to perspective. Monetary costs were converted into 2013 USD. Results: Out of 5,187 unique retrievals, 214 studies were included. 187 studies estimated patient health, 75 studies estimated payer/provider and 11 studies estimated economic burden. 64% of included studies were single centre. The majority of studies estimating patient or provider/payer burden used regression techniques. 48% of studies estimating mortality burden found a significant impact from resistance, excess healthcare system costs ranged from non-significance to $1 billion per year, whilst economic burden ranged from $21,832 per case to over $3 trillion in GDP loss. Median quality scores (interquartile range) for patient, payer/provider and economic burden studies were 0.67 (0.56-0.67), 0.56 (0.46-0.67) and 0.53 (0.44-0.60) respectively. Conclusions: This study highlights what methodological assumptions and biases can occur dependent on chosen outcome and perspective. Currently, there is considerable variability in burden estimates, whi
Naylor NR, Zhu N, Hulscher M, et al., 2017, Is antimicrobial stewardship cost-effective? A narrative review of the evidence, Clinical Microbiology and Infection, Vol: 23, Pages: 806-811, ISSN: 1198-743X
AIMS: This narrative review aimed to collate recent evidence on the cost-effectiveness and cost-benefit of antimicrobial stewardship (AMS) programmes, to address the question 'is AMS cost-effective?', while providing resources and guidance for future research in this area. SOURCES: PubMed was searched for studies assessing the cost-effectiveness, cost-utility or cost-benefit of AMS interventions in humans, published from January 2000 to March 2017, with no setting inclusion/exclusion criteria specified. Reference lists of retrieved reviews were searched for additional articles. CONTENT: Recent evidence on the cost-effectiveness and cost-benefit of AMS is described, studies suggest persuasive and structural AMS interventions may provide health economic benefits to the hospital setting. However, overall, cost-effectiveness evidence for AMS is severely limited, especially for the community setting. Recommendations for future research in this area are therefore provided, including discussion of appropriate health economic methodological choice. IMPLICATIONS: Health systems have a finite and decreasing resource, decision makers currently do not have necessary evidence to assess whether AMS programmes provide sufficient benefits. Although the evidence-base of the cost-effectiveness of AMS is increasing, it remains inadequate for investment decision-making. Robust health economics research needs to be completed to enhance the generalizability and usability of cost-effectiveness results.
Naylor NR, Silva S, Kulasabanathan K, et al., 2016, Methods for estimating the burden of antimicrobial resistance: a systematic literature review protocol, Systematic Reviews, Vol: 5, ISSN: 2046-4053
Background:Estimates of the burden of antimicrobial resistance (AMR) are needed to ascertain AMR impact, evaluate interventions and to allocate resources efficiently. Recent studies have estimated health, cost and economic burden relating to AMR, with outcomes of interest ranging from drug-bug resistance impact on mortality in a hospital setting to total economic impact of AMR on the global economy. However, recent collation of this information has been largely informal, with no formal quality assessment of the current evidence base (e.g. with predefined checklists). This review therefore aims to establish what perspectives and resulting methodologies have been used in establishing the burden of AMR, whilst also ascertaining the quality of these studies. Methods:The literature review will identify relevant literature using a systematic review methodology. MEDLINE, EMBASE, Scopus and EconLit will be searched utilising a predefined search string. Grey literature will be identified by searching within a predefined list of organisational websites. Independent screening of retrievals resultswill be performed in a two-stage process (abstracts and full texts), utilising a pre-defined inclusion and exclusion criteria. Data will be extracted into a data extraction table and descriptive examination will be performed. Study quality will be assessed using the Newcastle-Ottawa scales and the Philips checklists where appropriate. A narrative synthesis of the results will be presented. Discussion:This review will provide an overview of previous health, cost and economic definitions of burden and the resultant impact of these different definitions on the burden of AMR estimated. The review will also explore the methods that have been used to calculate this burden and discuss resulting study quality. This review can therefore act as a guide to methods for future research in this area.Trial Registration:This review has been registered with the PROSPERO International Prospective Regis
de Jongh TE, Gurol-Urganci I, Allen E, et al., 2016, Integration of antenatal care services with health programmes in low- and middle-income countries: systematic review, Journal of Global Health, Vol: 6, ISSN: 2047-2978
BackgroundAntenatal care (ANC) presents a potentially valuable platform for integrated delivery of additional health services for pregnant women–services that are vital to reduce the persistently high rates of maternal and neonatal mortality in low– and middle–income countries (LMICs). However, there is limited evidence on the impact of integrating health services with ANC to guide policy. This review assesses the impact of integration of postnatal and other health services with ANC on health services uptake and utilisation, health outcomes and user experience of care in LMICs.MethodsCochrane Library, MEDLINE, Embase, CINAHL Plus, POPLINE and Global Health were searched for studies that compared integrated models for delivery of postnatal and other health services with ANC to non–integrated models. Risk of bias of included studies was assessed using the Cochrane Effective Practice and Organisation of Care (EPOC) criteria and the Newcastle–Ottawa Scale, depending on the study design. Due to high heterogeneity no meta–analysis could be conducted. Results are presented narratively.Findings12 studies were included in the review. Limited evidence, with moderate– to high–risk of bias, suggests that integrated service delivery results in improved uptake of essential health services for women, earlier initiation of treatment, and better health outcomes. Women also reported improved satisfaction with integrated services.ConclusionsThe reported evidence is largely based on non–randomised studies with poor generalizability, and therefore offers very limited policy guidance. More rigorously conducted and geographically diverse studies are needed to better ascertain and quantify the health and economic benefits of integrating health services with ANC.
de Jongh TE, Gurol-Urganci I, Allen E, et al., 2016, Barriers and enablers to integrating maternal and child health services to antenatal care in low and middle income countries, BJOG-AN INTERNATIONAL JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Vol: 123, Pages: 549-557, ISSN: 1470-0328
- Author Web Link
- Citations: 36
Zhu J, Allen E, Kearns A, et al., 2014, Lady health workers in Pakistan: improving access to health care for rural women and families, Lady health workers in Pakistan: improving access to health care for rural women and families, Boston, MA, USA, Publisher: Maternal Health Task Force
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