February 2017
Welcome to the ebulletin Welcome to the February e-bulletin which focuses on heart health. In this edition we have Advisory Group member Joanne Oliver talking to us about her involvement with the British Heart Foundation and how research in Wales is leading to a greater understand of the processes behind inherited heart conditions. There is information about the ACTIVE Project which aims to tackle inactivity in young people and Laura Rich from Public Health Wales explains the risk of smoking to heart health. Public Health Network Cymru is arranging a number of events over the next few months including a Research in Wales Showcase event on 2 March, a conference on Adverse Childhood Experiences on 15 March and a Behaviour Change Seminar which is due to be held at the end of April. We are also in the middle of arranging our yearly roadshow events which will take place in May. Keep a lookout on the website and future e-bulletins for further information. If you would like to contribute to our e-bulletins and/or website please email us at publichealth.network@wales.nhs.uk
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Heart
t Murmurs Spotlight on Heart Health The spotlight for this month’s e-bulletin is Heart Health. Every 3 minutes, someone in the UK is struck by heart disease and a healthy heart is essential to help prevent and manage heart disease. An unhealthy diet, physical inactivity, stress, tobacco use and the harmful use of alcohol can all contribute to heart disease. There is also a greater understanding of the processes behind inherited heart conditions that cause disturbances in heart rhythm. (BHF, 2017)
The British Heart Foundation in Wales – What research is telling us about inherited heart conditions By Joanne Oliver, British Heart Foundation The British Heart Foundation (BHF) has pioneered life- saving research for over 50 years that continues to transform the lives of people living with heart and circulatory conditions. This month, BHF have launched a new campaign that raises awareness of the sudden devastation caused by heart disease. New estimates by BHF indicate that around 30,000 people in Wales are carrying a faulty gene that puts them at high risk of developing coronary heart disease or sudden death (1). Worryingly, the majority of people affected are undiagnosed and unaware that they may be at risk of a deadly heart attack or cardiac arrest. The figure is higher than previous estimates due to better understanding of the prevalence of inherited heart conditions. BHF Cymru warns the overall figure could be much higher due to underdiagnoses and undiscovered faulty genes which can increase a person’s risk of these potentially fatal conditions. Inherited heart conditions can affect people of any age and each child of someone with an inherited heart condition can have a 50 per cent chance of inheriting it. For many families, the first sign that there is a problem is when someone dies suddenly with no obvious cause or explanation. Did you know that each week in the UK around 12 seemingly healthy people aged 35 or under are victims of sudden cardiac death with no explanation, largely due to these devastating conditions?(2). Professor Alan Williams, Chair of BHF in Wales is a leading expert in researching aspects of heart rhythm conditions. He is currently working with his research team, now based at Swansea University Medical School, to greater understand the processes behind inherited heart conditions that cause disturbances in heart rhythm. Disturbances in heart rhythm (arrhythmias) are a major cause of death and current treatments are not very effective. Although some of the processes involved in arrhythmias are understood, many of the early causative events remain a mystery. Abnormalities in how cells within the heart handle calcium, a crucial cellular signal, are emerging as important drivers of arrhythmias. We don’t fully understand these mechanisms yet. It is vital to gain insight into these early events in order to be able to prevent the development of arrhythmias. Our work will provide the first detailed descriptions of these abnormalities that arise following mutation of key calcium release channels known as ryanodine receptors (RyR) which fundamentally underpin severe, early onset arrhythmias. Genetic alterations of RyR, found in many heart patients, are believed to cause some inherited heart conditions, conditions that produce irregular heartbeats that can lead to sudden cardiac death in infants and adults. Professor Williams and his team at Swansea aim to use new tools developed by the team to investigate these defects in unprecedented detail. This work will lead to a better understanding of these events and ultimately, improve the treatment of arrhythmias. BHF-funded research has helped to discover many of the faulty genes that cause inherited heart conditions, which has led to the development of structured genetic testing services for those at highest risk for some of these conditions. However, more research is urgently needed to better detect and treat these conditions to stop the devastation brought to loved ones, who could also be at risk themselves. Professor Sir Nilesh Samani, Medical Director at the British Heart Foundation, says: “The reality is that there are hundreds of thousands of people across the UK who are unaware that they could be at risk of sudden death. If undetected and untreated, inherited heart conditions can be deadly and they continue to devastate families, often by taking away loved ones without warning. Thanks to the public’s kind support BHF-funded researchers have discovered some of the genes responsible for these frightening conditions but there is still much to do. We urgently need to fund more research to better understand these heart conditions, make more discoveries, develop new treatments and save more lives.” 1) BHF analysis of PHG Foundation, Heart to Heart: inherited cardiovascular conditions services (2009); with revised prevalence estimates for familial hypercholesterolemia (FH) – Nordestgaard et al 2013 - and dilated cardiomyopathy (DCM) (Hershberger 2013) 2) Papadakis, Sharma et al. “The magnitude of sudden cardiac death in the young: a death certificate-based review in England and Wales.” Europace 2009 Vol.11, No.10, p1353-1358
CASE STUDY 1 Long QT syndrome (LQTS) is an inherited condition that can cause heart rhythm disturbances. It occurs in about 1 in 2,000 people. Lora D’Alesio, who lives in Cardiff, was 24 when she had a cardiac arrest at home. A veterinary nurse, Lora was accompanied home by a colleague that day who had been trained to administer CPR on dogs and cats. Her colleague used her skills and did CPR on Lora until the paramedics arrived. Lora was dead for around 5 minutes before being revived by the paramedics. Lora was then in an induced coma for three days, in hospital for 3 weeks and during this time was diagnosed with Long QT, an inherited heart condition. Two months prior to her cardiac arrest, Lora had mentioned to her GP that she had been experiencing heart palpitations, dizziness and chest pains but her GP had simply dismissed her as a fit, young and healthy young woman. Lora said: “I’m determined not to let it get in the way of my life. I still haven’t had my licence back from the DVLA so I still can’t drive which frustrates me. I still go running even though I’m not really supposed to. They ran tests on my parents, my two brothers and sisters but their tests all came back normal. There was no history of sudden infant deaths in my family. The doctors have not really spoken to me about what implications this will have on my own future and starting a family, which is something I would like to do”. CASE STUDY 2 ARVC (arrhythmogenic right ventricular cardiomyopathy) is an inherited heart condition that causes heart muscle to be replaced by fibrous tissue and fat so the ventricle becomes thin and stretched, meaning the heart does not pump blood around your body properly and there is an increased risk of sudden cardiac arrest. ARVC can also cause abnormal heart rhythms, because your heart’s normal electrical impulses are disrupted as they pass through areas of damaged and scarred muscle cells. Leigh Manley, from Maesteg, is still waiting for a formal diagnosis from doctors since suddenly collapsing unconscious on the treadmill at the gym one Saturday last October, but investigations now lean towards a diagnosis of ARVC. Leigh was initially told by paramedics that he had suffered a benign faint, and tests results gave no indication of anything wrong until he undertook a Bruce test and an abnormality was then picked up on the ECG. Leigh said: “Since October my life has been turned on its head. I read about the case of the England cricketer James Taylor before Christmas who is suffering from the exercise-induced heart condition, ARVC and tried to take some inspiration from this. My life has just been about adapting my lifestyle to this news, but it hasn’t been easy. It’s difficult at the moment because I’ve lost my confidence to even walk up the road and my independence has been removed because I’ve had to surrender my driver’s license for 6 months from the fitting of my defibrillator. I am confident I can adapt my lifestyle in spite of my previous active life. I just have to focus on the bigger picture, which is my family and my close friends. It’s a small sacrifice to make when you analyse it closely, it’s just not a position I expected to be thrust into”. For more information and advice about inherited heart conditions and to support the BHF to fund more research to end the devastation of heart disease visit www.bhf.org.uk/unexpected
Teenage Heart Health - The ACTIVE Project
By Michaela James, ACTIVE Trial Manager The ACTIVE Project is Swansea University’s new innovative project that aims to tackle the issue of inactivity amongst young people. Teenage physical activity levels are observing a notable decline. It appears that teens now opt to engage in more sedentary behaviours; a worrying notion given the increased risk of heart disease and other related cardiovascular conditions that are associated with inactivity. Consequently, something needs to be done to increase the activity levels of this population and this is where the ACTIVE Project comes into its own. ACTIVE is a British Heart Foundation funded project which aims to tackle inactivity by giving teenagers vouchers to spend on activities of their choice to reduce the time spent sedentary and lower the risk of heart disease. The project is designed to change the attitudes of young people, encouraging teenagers to embrace alternative activities - whether it is dancing, trampolining, swimming or skateboarding . By giving this group a choice, ACTIVE aims to empower teenagers to take ownership of their behaviours and tailor activity directly to what they individually enjoy. The project involves Year 9 pupils (aged 13-14) from 7 schools in Swansea (4 intervention and 3 control) to look into the growing problem of teenage inactivity. This work follows on from a previous study done by Swansea University which used just one school but showed improved attitudes towards physical activity and improved fitness and activity levels. With heart disease killing one in four people in the United Kingdom, it is vital that projects such as ACTIVE incorporate a preventative approach to the implications of sedentary behaviours. If we can instil positive, active behaviours from a young age, we can hope to increase the heart health of the population. Follow the ACTIVE project on Twitter @ActiveProject_
Smoking and Heart Health By Laura Rich, Public Health Practitioner, Public Health Wales Smoking is the biggest preventable cause of ill health and premature death, resulting in 1 in 2 lifelong smokers in Wales dying from their habit. Smokers are exposed to over 4,000 chemicals every time they smoke. These chemicals damage the lining of the coronary arteries, which in turn causes fatty materials to build up and block the arteries, restricting the circulation of blood. The chemicals make platelets in the blood stickier, causing the blood to form clots which can result in blocked arteries and cause heart attacks. Carbon monoxide which is inhaled during smoking reduces the amount of oxygen in a smoker’s blood, causing their heart to work harder to supply the body with oxygen. Nicotine absorbed through smoking also stimulates the body, producing adrenaline resulting in the heart beating faster and raising your blood pressure. British Heart Foundation reports that coronary heart disease is the UK’s single biggest killer, with about 14% of deaths from heart disease. Smokers under the age of 40 have a five times greater risk of a heart attack than non-smokers (ASH 2016). Stopping smoking is the single greatest health improvement that a smoker can make to their health with some benefits including: • Within 24 hours of stopping - carbon monoxide will be eliminated from the body • 1 year smokefree - the risk of heart attack falls to about half that of a smoker • 15 years of stopping smoking - the risk of heart attack falls to levels similar to that of a person who has never smoked. The best way to stop smoking successfully is with specialist support and using a medication. Stop Smoking Wales provides a free, friendly and flexible service. For more information on NHS Stop Smoking Services in Wales or to start your smokefree journey contact Stop Smoking Wales. Visit: stopsmokingwales.com Call: 0800 085 2219
On The Spot This month we have Public Health Network Cymru Advisory Group member Joanne Oliver on the spot. Joanne is the Health Service Engagement Lead for the British Heart Foundation in Wales.
What is your area of expertise?
I qualified in 1980 and am still a Registered General Nurse specialising in cardiac nursing, Cardiac Rehabilitation and Heart Failure. I successfully completed my Masters in Advanced Nurse Practice at Cardiff University and my dissertation focussed on education programmes to support best practice provision within Palliative Care for Heart Failure Patients. Since 2012 I have worked in a few different roles within BHF (Area manager for Wales, Regional Manager for Wales and West) and was appointed as BHF Health Service Engagement Lead for Wales in April 2016. The main focus of my current role is to lead high level engagement whilst influencing senior decision makers within NHS Wales health and social care to ensure that they understand the need for prioritising evidence based care for those people at risk of or who have CVD. It is my aim to use my knowledge and field intelligence to identify current and future opportunities for CVD innovative implementation, best practice development, spread and adoption, and the co-ordination of activities to capitalise on these opportunities.
Why did you join the PHNC Advisory Group?
Prevention for those who are at risk or support for those who have diagnosed CVD conditions with improved chances of survival is so important within Wales. I am keen to utilise every opportunity to ensure that the issues Wales faces from CVD remain high profile within Public Health. The PHNC allows me to share information and my knowledge as well as learning from its expert members and excellent resources that the Network provides.
What do you think are the main challenges facing us in preventing and managing heart disease in Wales? February 2017 sees the launch of a new campaign for the BHF to raise awareness of the hidden nature and potentially devastating consequences of inherited heart conditions. The challenges we face in preventing and managing these types of heart conditions are in the complexity of the conditions, and the lack of understanding around some of the processes that cause the rhythm disturbances.
We urgently need more research investment in this area of heart disease to identify better methods of diagnosis and screening, more effective treatments, quality support for patients and their families and better management of the conditions. We also need an increase in public awareness of the prevalence of those living with a faulty gene, meaning that they are at a higher risk of a heart condition and for those working alongside patients to listen and take action when symptoms of heart rhythm disturbance are reported or identified.
What tips would you give our members to actively promote Heart Month?
We have so many fantastic resources and support available for those working in the field of heart health. We would encourage all Public Health Network members, to take up the opportunity to utilise all of the information to promote improved Heart Health and to join our Health Care Professional membership programme: BHF Alliance – The More We Know, The Stronger We Grow. The BHF Alliance (which is free to join) seeks to grow and nurture a supportive and inspirational network of health care professionals who are involved with people at risk of developing or who are diagnosed with Cardiovascular Disease (CVD). A member can maximize their potential to make a difference, share experiences and support the development of others. Joining is simple, visit bhf.org.uk/alliance where you can learn more about the benefits, hear what our members have to say and complete the short online application form.
If you were granted 3 wishes what would they be?
• That we had unlimited resources to invest into life-saving research on heart disease • That we all take responsibility in developing a greater understanding of heart conditions and that all patients have prompt access to the services and support they need • That we all take proactive steps to look after our heart and prevent some forms of heart disease this way.
The Grapevine This section of the ebulletin is dedicated to news from the network members. You can submit news on the work being undertaken in your area, write us an article, showcase an upcoming project or show off your achievements! If you would like to submit an article for the Grapevine, please email publichealth.network@wales.nhs.uk The article should be no longer than 500 words and pictures are always welcome!
International Women’s Day By Dr Edna Asbury-Ward, Glyndwr University International Women’s Day (March 8) is a global day celebrating the social, economic, cultural and political achievements of women. The day also marks a call to action for gender parity. The earliest Women’s Day observance was held on February 28, 1909, in New York. It was organized by the Socialist Party of America in remembrance of the 1908 strike of the International Ladies Garment Workers Union. International Women’s Day is all about unity, celebration, reflection, advocacy and action - whatever that looks like globally or at a local level. International Women’s Day continues to be a powerful platform globally that unifies tenacity and drives action for gender parity, while celebrating the social, cultural, economic and political achievements of women. Through meaningful celebration and targeted bold action, we can all be responsive and responsible leaders in creating a more gender inclusive world. The theme of this year’s IWD is #beboldforchange. The day is an official holiday in some parts of the world. The ten International Women’s Day values are: Justice, Dignity, Hope, Equality, Collaboration, Tenacity, Appreciation, Respect, Empathy and Forgiveness. Full details of IWD can be found at www.internationalwomensday.com Cardiff is the only part of Wales that is holding an IWD event this year; details can be found at: Annual International Women’s Day celebration of Women Connect First at Cardiff City Hall, Facebook https://www.facebook.com/events/1158067837574664/ Email: admin@womenconnectfirst.org.uk Tel: 029 2034 3154. Women Connect First was started to improve the lives of disadvantaged BME women and communities in South Wales.
Shared Practice In last month’s e-bulletin we started a monthly update of the projects which can be viewed on the Shared Practice Directory. This month’s project is #walkandtalk. The project is delivered by Mind In You which has developed a series of innovative and unique programmes overseen by Mind In Sport Limited. #walkandtalk aims to provide a safe environment to promote overall wellbeing by providing low intensity exercise with opportunities to develop relationships and engage in informal therapy if need be. The key focus is that of empowering individuals to reach their full potential with a holistic and proactive approach to personal development which builds in key themes such as health promotion, lifestyle, good mental health and improving performance. If you would like to add your own project to the Shared Practice Directory there is an easy online form (only accessible to members) and once approved by one of the coordinators your project will then appear on the directory. There is also a Self Assessment Toolkit which can be printed off or completed online and allows coordinators to quality assure the development and delivery of new and existing projects. If you need help completing the toolkit or have any questions, please contact one of the coordinators at publichealth.network@wales.nhs.uk
The Health Disability Sport Partnership By Catherine Chin, Betsi Cadwaladr University Health Board The Health Disability Sport Partnership (HDSP) is a joint partnership between Betsi Cadwaladr University Health Board (BCUHB) and Disability Sport Wales (DSW), the first of its kind in the UK. Through a process of up-skilling health professionals and supporting them to signpost disabled people towards physical activity (including sport) opportunities via a Health Disability Sport Pathway, the aim of the HDSP is to improve the health and wellbeing of disabled people. In the first three years of the project over 550 disabled people have been signposted from health towards physical activity (including sport). In order to assess the impact this has had on disabled people, and to examine whether the HDSP is a cost effective intervention that should be rolled out across Wales, a health impact assessment (HIA) and a social return on investment analysis (SROI) were conducted. The HIA was a really valuable tool that enabled us to establish what outcomes disabled people and their family/friends have experienced from their involvement in the HDSP, as well as impacts on Health, Local Authorities and DSW. The SROI model was the next step that enabled us to present these outcomes in terms of monetary values, something that was important to demonstrate as we look to continue and roll out the partnership to other health boards. Participation in physical activity (including sport) has improved the physical and mental health and wellbeing of the disabled people who were involved. Benefits included feeling more confident, less socially isolated and a number of disabled children no longer being bullied. Positive impacts were also found for the health and wellbeing of some family members of disabled people. The results found that for every £1 invested in the HDSP, £124 of added social value was created. The SROI enabled us to demonstrate that the HDSP is a cost effective model for increasing levels of physical activity (including sport) amongst disabled populations, creating social value through improved health and well-being of disabled people, and that of their families. Health and (disability) sport working in partnership represents an effective intervention that improved the health and wellbeing of disabled people and can contribute to reducing the burden of physical inactivity. To find out more visit our online app www.hdspathway.co.uk Lee Parry-Williams from Wales Health Impact Assessment Support Unit added how pleased she was to see the application of HIA and SROI in the project evaluation. “This project illustrates the importance and value of evaluation alongside applying the appropriate tools and methodology. We all recognise the importance of evaluating projects to ensure we learn and use that learning to inform future developments. In the case of the HDSP the learning from the HIA was used to inform small changes in delivery concurrent to project delivery, therefore adding value and strengthening positive outcomes. In addition, the impacts identified were also used to inform the first part of the SROI process. The two methodologies complemented one another. Both sets of findings are now being used to enhance the case to achieve sustainability and further role out across Wales of the concept of the Disability Sports Pathway. If people wish to know more about applying HIA, WHIASU are here to provide advice and guidance”. Lots of information can be found on their website For those wanting insight into www.whiasu.wales.nhs.uk. Health Economics, a new concise guide produced by The Centre for Health Economics and Medicine at Bangor University on behalf of Public Health Wales entitled ‘A Guide to Health Economics for those Working in Public Health’ will be helpful.
Networks and Partnerships: Wales Collaborating for Global Health Annual Charter Celebration Conference 27 March 2017, Future Inns, Cardiff, Wales Public Health Wales and the International Health Coordination Centre (IHCC) are delighted to invite you to attend the second Charter for International Health Partnerships in Wales Celebration Conference Networks and Partnerships: Wales Collaborating for Global Health, to be held on the 27th of March 2017 in the Future Inns, Cardiff Bay, CF10 4AU. The conference will focus on how to maximise the benefits of national and international networks, building active and sustainable partnerships and collaborations as well as celebrating the progress made in the implementation of the Charter for International Health Partnerships in Wales (the Charter) and how it contributes to the global health and sustainable development agenda. Conference Objectives:
Share experiences and opportunities including the benefits and challenges from taking part in international networks and collaborations
Explore synergies and approaches in achieving health, wellbeing and reducing inequalities across various sectors and networks in Wales, the UK, Europe and globally
Show interrelation between implementing the Global Health agenda, Health 2020, the Well-being of Future Generations (Wales) Act2015, 2030 Agenda for Sustainable Development
Share progress towards implementing the Charter across the NHS through partnerships and links within Wales and across Europe and the world
Provide a forum for international exchange, discussion, networking and learning
Promoting and supporting international collaboration is at the heart of the work of the IHCC, which provides a focal point for health related international work across the NHS in Wales. For the last two year, the IHCC has been actively supporting the implementation of the Charter. With a set of values and principles that all NHS Health Boards and Trusts in Wales pledged to, the Charter is a key tool to continue to drive this agenda forward and is a good example of the NHS being globally responsible in keeping with the Well-being of Future Generations Act goals. We are very pleased to confirm that Vaughan Gething, AM, the Cabinet Secretary for Health, Well-being and Sport in Wales, will open this year’s conference and Dr. Christoph Hamelmann, Head of the WHO European Office for Investment for Health and Development, will address the event on behalf of the WHO Europe. We are very much looking forward to celebrating with you this special occasion. Please use EVENTBRITE to register your attendance.
News Round-Up Welcome to the News Round-Up. Click on the headings of the news items to take you to the full news story on the Public Health Network Cymru Website.
Smoking Public Health Wales issues updated advice on e-cigarettes Public Health Wales has published its updated position statement providing advice to the public about the potential impacts of e-cigarettes on health.
Alcohol Thousands of high risk drinkers die without accessing alcohol treatment service A report from Public Health Wales suggests that a substantial majority of almost 8,000 individuals who went on to die from alcohol related causes had no contact with alcohol treatment services, despite repeated hospital admission and A&E attendance.
Children and Young People Childhood obesity plan - case studies The Department of Health has published a series of case studies from local authorities and businesses on how they are working with families and schools to deliver the government’s childhood obesity plan.
Poverty Poverty biggest ‘threat’ to children’s health in Wales Poverty is the biggest threat to children’s health in Wales, a report by the Royal College of Paediatrics has claimed.
Natural Environment Federation of City Farms and Community Gardens The Federation of City Farms and Community Gardens is pleased to announce that they have secured funding to create an exciting new programme to support community growing in Wales.
Click Here for more news on the Public Health Network Cymru website
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Public Health Research, Policy and Practice: Working Together in Wales University of South Wales (ATRiuM Building), Cardiff Developing Making Every Contact Count in Wales: A National Network & Learning Event Novotel, Cardiff What Matters to Children & Young People Conversation? Conwy
International Women’s Day National Event
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Growing Better Together Cardiff Next Steps for the Health and Social Care Workforce in Wales: Recruitment, Training and Retention Cardiff An Introduction to Evaluation of Healthy Lifestyle Initiatives University of South Wales, Treforest
World Oral Health Day World Wide
Young LGBTQ People: Making Things Perfectly Queer Conwy
Improving the Physical Health of Adults with Severe Mental Illness London Young People and Substance Misuse: Why the Drugs Don’t Work? Cardiff
Networks and Partnerships: Wales Collaborating for Global Health Future Inns, Cardiff Understanding How to Safeguard the Welfare of Children and Young People - Accredited training through level 2 Agored Cymru Cardiff
Click Here for more events on the Public Health Network Cymru website
The Health Buzz World Walking
Devised by cardiac rehabilitation instructor Duncan Galbraith, the World Walking app is a constant pedometer, recording the number of steps taken each day. Users pick legendary global routes, such as Route 66 in the United States or Peru’s Machu Picchu Inca Trail, and try to take enough steps to complete it. The app encourages social interaction too and lets walkers form virtual clubs, working together to meet distance targets (available for iPhone and Android).
#TechniHealth Seminar to be live streamed Public Health Network Cymru will be hosting a seminar entitled #TechniHealth – Health Promotion in the Digital Era on 27 February 2017. This event is fully booked, however the event will be live streamed via Twitter so you won’t miss out! To join, please visit the PHNC twitter page and follow the conversations using #Technihealth. There will also be an opportunity to keep the conversations going after the event on the newly re-launched PHNC forum, Over to You.
Public Health Research, Policy and Practice The Policy, Research and International Development Directorate within Public Health Wales will be hosting a conference to showcase some of the latest public health research in Wales. The event, which will be taking place on 2 March in Cardiff (10am – 3pm), will be promoting and enhancing the understanding of research in Wales and strengthening collaborations between the public sector, universities and third sector organisations. For those who have not registered to attend there will be live tweeting and live streaming on the Research and Development Twitter account during the day. Please follow @PHRWales for updates, and if tweeting yourself, please include #RIW2017.
Contact Us Publichealth.network@wales.nhs.uk Capital Quarter 2 Floor 5 Tyndall Street Cardiff CF10 4BZ www.publichealthnetwork.cymru If you have any news or events to contribute to the next edition, please submit them to: publichealth.network@wales.nhs.uk Deadline for submission is the 3rd Friday of every month.
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