Search

Tuberculosis is a major public health problem in India with more than 2 million new cases every year. With the growing crisis of inadequate healthcare workforce, monitoring of drug treatment for Tuberculosis is an arduous task. mHealth services (healthcare using mobile communication technologies) are gaining support as an effective tool to handle the situation, especially where technological and human resources are limited. This paper illustrates the delivery of a mHealth service with insights into the feasibility and applicability of deploying a voice call based reminder system for drug adherence in a resource limited setting. more...

SUMMARYThis study determined the risk of respiratory infection associated with high-risk procedures (HRPs) performed by healthcare workers (HCWs) in high-risk settings. We prospectively studied 481 hospital HCWs in China, documented risk factors for infection, including performing HRPs, measured new infections, and analysed whether HRPs predicted infection. Infection outcomes were clinical respiratory infection (CRI), laboratory-confirmed viral or bacterial infection, and an influenza infection. About 12% (56/481) of the study participants performed at least one HRP, the most common being airway suctioning (7·7%, 37/481). HCWs who performed a HRP were at significantly higher risk of developing CRI and laboratory-confirmed infection [adjusted relative risk 2·9, 95% confidence interval (CI) 1·42–5·87 and 2·9, 95% CI 1·37–6·22, respectively]. Performing a HRP resulted in a threefold increase in the risk of respiratory infections. This is the first time the risk has been prospectively quantified in HCWs, providing data to inform occupational health and safety policies. more...

Measuring treatment outcome is important for successful tuberculosis (TB) control programmes. The purpose of this study was to examine the outcomes of various types of TB cases registered in Pakistan over a 2-year period and compare those outcomes among the different provinces and regions of the country. A retrospective, cohort study was conducted in which TB treatment outcome reports were reviewed. Of the 349 694 pulmonary TB cases registered in Pakistan during 2006 and 2007, 309154 (88.4%) were treated successfully. Treatment success was significantly higher in new smear-positive cases and lower in retreatment cases. Among the provinces and regions, treatment success was significantly higher in 4 out of 8 provinces. Treatment success needs to be improved, particularly in retreatment cases. The national TB control programme should review the provincial and regional programmes and learn lessons from well-performing programmes. Patient factors that may affect the treatment outcome should be also studied. more...

Introduction: Zika virus has been documented since 1952, but been associated with mild, self-limiting disease. Zika virus is classified as an arbovirus from a family of Flaviviridae and primarily spread by Aedes Aegypti mosquitos. However, in a large outbreak in Brazil in 2015, Zika virus has been associated with microcephaly. Methods: In this review we applied the Bradford-Hill viewpoints to investigate the association between Zika virus and microcephaly. We examined historical studies, available data and also compared historical rates of microcephaly prior to the Zika virus outbreak. The available evidence was reviewed against the Bradford Hill viewpoints. Results: All the nine criteria were met to varying degrees: strength of association, consistency of the association, specificity, temporality, plausibility, coherence, experimental evidence, biological gradient and analogy. Conclusion: Using the Bradford Hill Viewpoints as an evaluation framework for causation is highly suggestive that the association between Zika virus and microcephaly is causal. Further studies using animal models on the viewpoints which were not as strongly fulfilled would be helpful. more...

© 2016 Informa UK Limited, trading as Taylor & Francis Group. Introduction: Cholera’s impact is greatest in resource-limited countries. In the last decade several large epidemics have led to a global push to improve and implement the tools for cholera prevention and control. Areas covered: PubMed, Google Scholar and the WHO website were searched to review the literature and summarize the current status of cholera vaccines to make recommendations on improving immunization approaches to cholera. Oral cholera vaccines (OCVs) have demonstrated their effectiveness in endemic, outbreak response and emergency settings, highlighting their potential for wider adoption. While two doses of the currently available OCVs are recommended by manufacturers, a single dose would be easier to implement. Encouragingly, recent studies have shown that cold chain requirements may no longer be essential. The establishment of the global OCV stockpile in 2013 has been a major advance in cholera preparedness. New killed and live-attenuated vaccines are being actively explored as candidate vaccines for endemic settings and/or as a traveller’s vaccine. The recent advances in cholera vaccination approaches should be considered in the global cholera control strategy. Expert commentary: The development of affordable cholera vaccines is a major success to improve cholera control. New vaccines and country specific interventions will further reduce the burden of this disease globally. more...

Background: China has one of the highest incidence rates of oesophageal cancer in the world. The role of human papillomavirus (HPV) has been extensively researched in oesophageal squamous cell carcinoma (OSCC) with indeterminate results. The majority of these studies have been conducted in the Chinese population. Evidence for a definitive HPV-OSCC association could potentially support prophylactic vaccination in target populations, highlighting the need for ongoing investigation. The aim of this review is to summarise the findings of HPV DNA in OSCC tissue in Chinese subjects, with a view to informing further research in this area. Methods: A systematic literature search of the Chinese National Knowledge Infrastructure (CNKI) database, Medline, Embase and PubMed was conducted for all studies in English and Chinese language, examining OSCC tissue for HPV DNA in China. Reference lists of retrieved articles were reviewed and hand searches of relevant, key journals were conducted, to source articles which were not electronically indexed. Sixty-four studies met our selection criteria. Data from case-control and cross-sectional studies were analysed separately for any HPV-OSCC association, using the Epi InfoTM 3.5.3 software program. Results: From all studies conducted in the Chinese population, 2166/5953 (36%) of all OSCC tissue and 478/1684 (28%) of healthy control tissue, tested positive for HPV. We found that 11/16 case-control and cross-sectional studies had a statistically significant crude odds ratio, which supported a potential HPV-OSCC association. The largest study, carried out in the high incidence County of Anyang in Henan Province, reported 207/265 (78%) OSCC tissues testing positive for HPV DNA against 203/357 (57%) controls and had an unadjusted odds ratio of 2.71 (p-value < 0.0001). Conclusion: A rigorous meta-analysis would improve interpretation of the data and a well-designed large-scale case-control study is warranted. If a link is found between HPV and OSCC, prophylactic HPV vaccines could be of significant benefit in China. more...

The shifting global demography and ageing of populations worldwide brings with new challenges for the health care, and an imperative for healthy ageing and preventive health strategies for adults. Immunization is the low hanging fruit for healthy ageing, and yet under-utilized for various reasons, including waning immunity in the elderly, lack of RCT data in this age group, and lack of provider confidence in vaccines for the elderly. The elderly people have a higher incidence of infection and more severe and serious consequences of infection. Diseases such as influenza, pneumococcal disease and herpes zoster have long been recognized as causing a high burden in the elderly, but evidence is also emerging for other infections such as pertussis being a major cause of the morbidity in this age group. Now, there are several vaccines which can prevent major infectious diseases in the elderly. To improve uptake of these vaccines, elderly vaccination should be viewed through a different lens to pediatric vaccination, accepting that vaccines are less immunogenic in the elderly. The population health impact of vaccines in the elderly, despite of immunosenescence and lower immunogenicity, is still likely to be high given the increased disease incidence. Vaccination is an important and readily available means of prevention in the elderly. more...

Objective To determine if there was herd protection conferred to unprotected healthcare workers (HCWs) by N95 respirators worn by colleagues. Methods Data were analysed from a prospective cluster randomized clinical trial conducted in Beijing, China between 1 December 2008 and 15 January 2009. A minimum compliance level (MCL) of N95 respirators for prevention of clinical respiratory illness (CRI) was set based on various compliance cut-offs. The CRI rates were compared between compliant (≥MCL) and non-compliant (Results Data were analysed from 949 HCWs who wore N95 respirators and 125 HCWs who did not wear masks. At 50% MCL there were no significant differences in the CRI rates between compliant and non-compliant N95 wearers by ward. In multivariate analysis, the CRI rate in non-compliant HCWs was significantly lower compared with controls (relative risk 0.26; 95% confidence interval 0.08, 0.82). Conclusion This study suggests herd protection from use of N95 respirators by colleagues within a hospital ward. more...

SUMMARYWe compared the rates of fever in adult subjects with laboratory-confirmed influenza and other respiratory viruses and examined the factors that predict fever in adults. Symptom data on 158 healthcare workers (HCWs) with a laboratory-confirmed respiratory virus infection were collected using standardized data collection forms from three separate studies. Overall, the rate of fever in confirmed viral respiratory infections in adult HCWs was 23·4% (37/158). Rates varied by virus: human rhinovirus (25·3%, 19/75), influenza A virus (30%, 3/10), coronavirus (28·6%, 2/7), human metapneumovirus (28·6%, 2/7), respiratory syncytial virus (14·3%, 4/28) and parainfluenza virus (8·3%, 1/12). Smoking [relative risk (RR) 4·65, 95% confidence interval (CI) 1·33–16·25] and co-infection with two or more viruses (RR 4·19, 95% CI 1·21–14·52) were significant predictors of fever. Fever is less common in adults with confirmed viral respiratory infections, including influenza, than described in children. More than 75% of adults with a viral respiratory infection do not have fever, which is an important finding for clinical triage of adult patients with respiratory infections. The accepted definition of ‘influenza-like illness’ includes fever and may be insensitive for surveillance when high case-finding is required. A more sensitive case definition could be used to identify adult cases, particularly in event of an emerging viral infection. more...

Background With the increase in patient activity during the 2009 H1N1 pandemic, came an associated increase in occupational infections of healthcare workers (HCWs). Objectives The aim of this study was to examine factors associated with the transmission of pandemic (H1N1) 2009 among HCWs. Methods A 1:4 matched case–control study by hospital, ward, age, and gender was conducted in HCWs from hospitals in Beijing during February 2010. Cases were diagnosed with pandemic (H1N1) 2009, and controls had neither influenza-like illness nor diagnosis with pandemic (H1N1) 2009 during August 2009 to January 2010. Information during 7 days before symptom onset of case was collected, and controls were queried about the same period. Results A total of 51 cases identified via National Notifiable Infectious Disease Surveillance System participated in this study. Controls were matched to cases for a total of 255 individuals. About 19·6% (10/51) of cases and 26·0% (53/204) of controls recalled they had conducted a high-risk procedure on a patient with pandemic (H1N1) 2009. 72·5% (37/51) of cases and 71·6% (146/204) of controls stated they wore medical masks in ≥80% of working time. Only 5·9% (3/51) and 36·3% (74/204) of cases and controls, respectively, reported receiving pandemic vaccination. Participants receiving pandemic vaccination had a significantly lower risk of infection during the pandemic (OR = 0·150, 95% CI: 0·047–0·479, P = 0·001). The estimated vaccine effectiveness was 85·0%. Conclusions We showed a high vaccine effectiveness of the pandemic vaccine and that vaccination was the only factor significantly associated with risk of infection in HCWs. more...

Background The aim of this study was to examine the rate of transmission of influenza and other respiratory viruses from children attending an Emergency Department to their family members in the household using active surveillance. Methods A prospective hospital-based study was conducted over three consecutive winters (2006–2008) in children aged more...

ObjectivesThe aim of this survey was to investigate parental vaccination attitudes and responses to vaccine-related media messages from political and medical leaders.DesignThis was a cross-sectional study using a semiquantitative questionnaire. Data were analysed using descriptive statistics, X2tests and logistic regression.SettingData were collected from a web-based questionnaire distributed in Australia by a market research company in May of 2017.Participants411 participants with at least one child under 5 were included in this study. The sample was designed to be representative of Australia in terms of gender and state of residence.Primary and secondary outcome measuresThe primary outcome measures were parental attitudes towards childhood immunisation before and after viewing vaccine-related messages from political and medical leaders, including Donald Trump (USA), Pauline Hanson (Australia) and Michael Gannon (Australia). Parents were classified as having ‘susceptible’ (not fixed) or ‘fixed’ (positive or negative) views towards vaccination based on a series of questions.ResultsParents with fixed vaccination views constituted 23.8% (n=98) of the total sample; 21.7% (n=89) were pro-vaccination and 2.2% (n=9) were anti-vaccination. The remaining 76.2% of participants were classified as having susceptible views towards vaccination. Susceptible parents were more likely to report a change in their willingness to vaccinate after watching vaccine-related messages compared with fixed-view parents, regardless of whether the messaging was positive or negative (Trump OR 2.54, 95% CI (1.29 to 5.00); Hanson OR 2.64, 95% CI (1.26 to 5.52); Gannon OR 2.64, 95% CI (1.26 to 5.52)). Susceptible parents were more likely than fixed-view parents to report increased vaccine hesitancy after viewing negative vaccine messages (Trump OR 2.14, 95% CI (1.11 to 4.14), Hanson OR 2.34, 95% CI (1.21 to 4.50)).ConclusionsThe findings suggest that most parents including the vaccinating majorty are susceptible to vaccine messaging from political and medical leaders. Categorising parents as ‘fixed-view’ or ‘susceptible’ can be a useful strategy for designing and implementing future vaccine promotion interventions. more...

Due to the advent of the new influenza A (H1N1) strain in 2009, many countries introduced mass immunization programs. Healthcare workers (HCWs) were amongst the key groups targeted for the vaccine in these programs. However, experience with the seasonal influenza vaccine has shown that there are multiple barriers related to the attitudes and perceptions of the population which influence uptake. The aim of this study was to determine pandemic influenza A (H1N1) vaccination rate amongst a group of Chinese HCWs and the associated factors around acceptance. A cross-sectional investigation of HCWs (doctors, nurses and technicians) from 19 hospitals in Beijing, China was conducted in January 2010. The main outcome measures were awareness, risk perception of H1N1, preventive measures and uptake of H1N1 vaccination during the pandemic. A total of 1657 HCWs completed the survey. A quarter of the participants reported receiving the pandemic influenza A (H1N1) vaccine. Occupation (being a doctor), receiving seasonal flu vaccine and believing in the effectiveness of the vaccine were all strongly associated with accepting the pandemic influenza A (H1N1) vaccine. Over a thousand participants (61%, 1008/1657) agreed that they were 'concerned about the side effects of the swine flu vaccine', while 758 (46%) were 'concerned that the vaccine had not been tested adequately'. While studies reported high rates of willingness to receive the vaccine, in reality these did not transpire. Aside from promoting seasonal flu vaccination, authorities need to start educational campaigns much earlier in a pandemic. Programs that are simultaneously launched with the introduction of the vaccine will not be as successful, as those which have built momentum alongside the pandemic. more...

Please cite this paper as: MacIntyre et al. (2011) A cluster randomized clinical trial comparing fit-tested and non-fit-tested N95 respirators to medical masks to prevent respiratory virus infection in health care workers. Influenza and Other Respiratory Viruses DOI: 10.1111/j.1750-2659.2010.00198.x. Background We compared the efficacy of medical masks, N95 respirators (fit tested and non fit tested), in health care workers (HCWs). Methods A cluster randomized clinical trial (RCT) of 1441 HCWs in 15 Beijing hospitals was performed during the 2008/2009 winter. Participants wore masks or respirators during the entire work shift for 4 weeks. Outcomes included clinical respiratory illness (CRI), influenza-like illness (ILI), laboratory-confirmed respiratory virus infection and influenza. A convenience no-mask/respirator group of 481 health workers from nine hospitals was compared. Findings The rates of CRI (3·9% versus 6·7%), ILI (0·3% versus 0·6%), laboratory-confirmed respiratory virus (1·4% versus 2·6%) and influenza (0·3% versus 1%) infection were consistently lower for the N95 group compared to medical masks. By intention-to-treat analysis, when P values were adjusted for clustering, non-fit-tested N95 respirators were significantly more protective than medical masks against CRI, but no other outcomes were significant. The rates of all outcomes were higher in the convenience no-mask group compared to the intervention arms. There was no significant difference in outcomes between the N95 arms with and without fit testing. Rates of fit test failure were low. In a post hoc analysis adjusted for potential confounders, N95 masks and hospital level were significant, but medical masks, vaccination, handwashing and high-risk procedures were not. Interpretation Rates of infection in the medical mask group were double that in the N95 group. A benefit of respirators is suggested but would need to be confirmed by a larger trial, as this study may have been underpowered. The finding on fit testing is specific to the type of respirator used in the study and cannot be generalized to other respirators. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN: ACTRN12609000257268 (http://www.anzctr.org.au). more...

Objective: The objective of this study was to describe trends in hospital admissions by HIV-infected patients for cytomegalovirus (CMV) disease in Australia in the eight year period from 1993 (before highly active antiretroviral therapy) to 2001 (widespread use of highly active antiretroviral therapy). Study Design: Using data from the National Hospital Morbidity Database (NHMD) complied by the Australian Institute of Health and Welfare (AIHW), we examined the rates of hospital admissions for CMV in HIV-infected patients, by year, sex, age group, length of stay and number of diagnoses. Results: Between 1993 and 2001, 21,846 patients were admitted with both HIV infection and CMV disease. 30.2% (6610/21846) of the HIV infected patients admitted to hospital were principally diagnosed with CMV disease. By 2000- 2001, the rate of hospital admissions was only 45cases per 1000 HIV-infected population. Conclusion: Dramatic decreases in the number of hospitalizations for CMV disease in HIV-infected patients have oc- curred over the eight-year study period in Australia, which may be related to the introduction of highly active antiretrovi- ral therapy. more...

Australia has a history of migration, especially during the wars in Europe, but many have forgotten the difficulties underlying asylum and wars endured by their forefathers. Preventive, indefinite detention of asylum seekers, most of whom are found to be genuine refugees, impinges on their human rights. The mental and physical health consequences of detention in this already traumatised group are significant, particularly in children. There are abundant studies to support this but, even as these studies continue to be done, asylum seekers languish in detention centres. To be fully addressed, the health implications of detention cannot be considered in isolation, but must be considered frankly and openly by health professionals in the broader historical and political context within which they occur. If we do not do this, we risk turning a blind eye to, or even condoning, human rights abuses. more...

Cytomegalovirus (CMV) is a significant pathogen causing disease in renal transplant patients. The highest incidence of CMV disease occurs during the first 3 months post-transplant and is most problematic in CMV-naïve transplant recipients. In this study, we conducted a retrospective review of two databases, the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and the National Hospital Morbidity Database, from the Australian Institute of Health and Welfare (AIHW), to examine CMV in renal transplant recipients. The first source looked at CMV serostatus at the time of transplantation and the second recorded hospital admissions for recipients with invasive CMV disease.From the ANZDATA registry, we obtained information from 13,530 renal transplants recipients from 1980 to 2004. Of these recipients, 7808 had a known CMV serostatus, of which 65.7% (5134/7808) had a positive sero antibody status and 34.2% (2674/7808) had a negative sero antibody status. In univariate analysis, factors significantly associated with renal rejection were being male, recipient age Preventative strategies for CMV in renal transplant recipients should be a priority. New vaccines for CMV may soon be available and renal transplant recipients would be a suitable target group for vaccination. more...

Many developed countries, like Australia, maintain a high population level immunity against measles, however, there remains a risk of acquisition of measles in non-immune travellers and subsequent importation into Australia leading to localised outbreaks. In this study, we estimate the incidence of measles and describe characteristics including immunisation and pre-travel health seeking behaviour of notified cases of measles in New South Wales and Victoria, Australia between February 2013 and January 2014. Cases were followed up by telephone interview using a questionnaire to collect information of demographic and travel characteristics. In NSW, the incidence was highest in age group 0–9years (20/million population) whereas in Victoria the highest incidence was observed in 10–19 (23/million population) years group. Out of 44 cases interviewed, 25 (56.8%) had history of travel outside of Australia during or immediately prior to the onset of measles. Holiday (60%) was the main reason for travel with 44% (11/25) reporting visiting friends and relatives (VFR) during the trip. The major reason described for not seeking prior medical advice before travel were “no perceived risk of diseases” (41%) and “previous overseas travel without any problem” (41%). Of the 25 measles cases with recent overseas travel during the incubation period, one reported a measles vaccine prior to their recent trip. Four cases were children of parents who refused vaccination. Twenty out of 25 (80.0%) had attended mass gathering events. Young adults and VFR travellers should be a high priority for preventive strategies in order to maintain measles elimination status. more...

The efficacy of the conventional bacille Calmette-Guerin (BCG) vaccine is often questioned because of conflicting trial results [1]. In this context, a new BCG vaccine developed by Grode et al. [2] has been seen as a favourable development in tuberculosis (TB) control [3]. BCG vaccine development is a challenge for many reasons, not least of which is the complex immunology of mycobacterial infections. The pathogenesis of TB, and prevention of TB by BCG, is predominantly a function of cell-mediated immunity. Mycobacterium tuberculosis (MTB) and BCG are phagocytosed, but remain viable for some time within the phagosome. There, BCG antigens must be presented to major histocompatibility complex (MHC) class II molecules to activate CD4+ cells, and to MHC class I molecules to activate CD8+ cells [3]. However, both MTB and BCG fail to activate CD8+ cells sufficiently. The relative failure of activation of CD8+ cells is thought to be related to the enzyme urease, which keeps the intracellular pH high and thus inhibits presentation of antigens to T cells which would otherwise activate the CD8+ response. Grode et al. [2] have engineered a BCG strain which overcomes this problem and allows release of antigen into the cell and thereby stimulates a CD8+ cell response in addition to the CD4 response seen with conventional BCG. They did this first by engineering a strain of BCG which secretes listeriolysin (Hly), an enzyme from Listeria monocytogenes which perforates cell membranes. Second, they optimized the pH for Hly activity by making the BCG strain urease C-deficient. With the resultant lowering of intracellular pH, the BCG strain is able to better activate CD8 cells and antigen presentation. This new vaccine strain causes apoptosis of infected cells and release of BCG antigens, which are presented to CD8+ cells. The secretion of Hly and the engineered urease deficiency resulted in incrementally improved efficacy of the vaccine compared to conventional BCG, when tested in mice [2]. In severe combined immunodeficiency disease (SCID) mice tested, the modified BCG vaccine was less virulent than conventional vaccine, probably because of reduced intracellular persistence of the bacteria [2]. There are no published data yet on the use of this vaccine in humans, but phase 1 trials are being planned. Other approaches to modifying the BCG vaccine include a strain which secretes higher levels of MTB 30-kDa, a major secretory protein [4]. A combination of these approaches may result in even better efficacy, and may be the next step in vaccine development. more...

As vaccination programs continue to successfully control more and more infectious diseases, and the effects of these diseases become less visible, there has been increased focus on adverse events following immunization. Vaccines have been falsely implicated in the causation of a range of conditions, especially those which affect infants and young children, and whose aetiology is unknown, poorly understood or multifactorial. This paper explores some of the common immunization myths that clinicians may face. It is essential that health professionals have access to accurate information and are able to respond appropriately to parental concerns. This involves good communication; listening, empathy and tailoring advice to the specific concerns of the parent. Finally, health professionals need to provide consistent messages based on solid research evidence. more...

The aims of the study were to compare the burden of varicella and herpes zoster in Australia. No national surveillance exists for varicella or herpes zoster. We used hospital morbidity data from 1993–9 and pharmaceutical prescribing data from 1995–9.In the financial year 1998/99, there were 4718 hospitalizations for zoster compared to 1991 for varicella. For varicella the mean age of patients was 15 years compared to 69 years for zoster. The mean length of stay in hospital was 4·2 days for varicella and 12·7 days for zoster. Varicella accounted for 8396 (3726 with principal diagnosis varicella) bed days compared to 26266 (5382 with principal diagnosis of zoster) for zoster. The in-hospital case-fatality rate was 0·4% for varicella and 1% for zoster. In 1999, 59200 community-based cases of zoster were treated with antivirals. We estimate that 157266 cases of zoster occurred in the community in 1999, a rate of 830 per 100000 population.Herpes zoster has a higher burden of disease than varicella, and must be a component of disease surveillance in order to determine the full impact of vaccination on the epidemiology of varicella zoster virus (VZV). more...

SUMMARYWe analysed data from a prospective cohort of 255024 adults aged ⩾45 years recruited from 2006–2009 to identify characteristics associated with a zoster diagnosis. Diagnoses were identified by linkage to pharmaceutical treatment and hospitalization records specific for zoster and hazard ratios were estimated. Over 940583 person-years, 7771 participants had a zoster diagnosis; 253 (3·3%) were hospitalized. After adjusting for age and other factors, characteristics associated with zoster diagnoses included: having a recent immunosuppressive condition [adjusted hazard ratio (aHR) 1·58, 95% confidence interval (CI) 1·32–1·88], female sex (aHR 1·36, 95% CI 1·30–1·43), recent cancer diagnosis (aHR 1·35, 95% CI 1·24–1·46), and severe physical limitationvs.none (aHR 1·33, 95% CI 1·23–1·43). The relative risk of hospitalization for zoster was higher for those with an immunosuppressive condition (aHR 3·78, 95% CI 2·18–6·55), those with cancer (aHR 1·78, 95% CI 1·24–2·56) or with severe physical limitations (aHR 2·50, 95% CI 1·56–4·01). The novel finding of an increased risk of zoster diagnoses and hospitalizations in those with physical limitations should prompt evaluation of the use of zoster vaccine in this population. more...

SUMMARYIn Australia, varicella vaccine was universally funded in late 2005 as a single dose at 18 months. A school-based catch-up programme for children aged 10–13 years without a history of infection or vaccination was funded until 2015, when those eligible for universal infant vaccination would have reached the age of high school entry. This study projects the impact of discontinuing catch-up vaccination on varicella and zoster incidence and morbidity using a transmission dynamic model, in comparison with alternative policy options, including two-dose strategies. At current vaccine coverage (83% at 2 years and 90% at 5 years), ceasing the adolescent catch-up programme in 2015 was projected to increase varicella-associated morbidity between 2035 and 2050 by 39%. Although two-dose infant programmes had the lowest estimated varicella morbidity, the incremental benefit from the second dose fell by 70% if first dose coverage increased from 83% to 95% by age 24 months. Overall zoster morbidity was predicted to rise after vaccination, but differences between strategies were small. Our results suggest that feasibility of one-dose coverage approaching 95% is an important consideration in estimating incremental benefit from a second dose of varicella vaccine. more...

Background Currently there is an ongoing debate and limited evidence on the use of masks and respirators for the prevention of respiratory infections in health care workers (HCWs). This study aimed to examine available policies and guidelines around the use of masks and respirators in HCWs and to describe areas of consistency between guidelines, as well as gaps in the recommendations, with reference to the WHO and the CDC guidelines. Methods Policies and guidelines related to mask and respirator use for the prevention of influenza, SARS and TB were examined. Guidelines from the World Health Organization (WHO), the Center for Disease Control and Prevention (CDC), three high-income countries and six low/middle-income countries were selected. Results Uniform recommendations are made by the WHO and the CDC in regards to protecting HCWs against seasonal influenza (a mask for low risk situations and a respirator for high risk situations) and TB (use of a respirator). However, for pandemic influenza and SARS, the WHO recommends mask use in low risk and respirators in high risk situations, whereas, the CDC recommends respirators in both low and high risk situations. Amongst the nine countries reviewed, there are variations in the recommendations for all three diseases. While, some countries align with the WHO recommendations, others align with those made by the CDC. The choice of respirator and the level of filtering ability vary amongst the guidelines and the different diseases. Lastly, none of the policies discuss reuse, extended use or the use of cloth masks. Conclusion Currently, there are significant variations in the policies and recommendations around mask and respirator use for protection against influenza, SARS and TB. These differences may reflect the scarcity of level-one evidence available to inform policy development. The lack of any guidelines on the use of cloth masks, despite widespread use in many low and middle-income countries, remains a policy gap. Health organizations and countries should jointly evaluate the available evidence, prioritize research to inform evidence gaps, and develop consistent policy on masks and respirator use in the health care setting. more...

Phenomenological and mechanistic models are widely used to assist resource planning for pandemics and emerging infections. We conducted a systematic review, to compare methods and outputs of published phenomenological and mechanistic modelling studies pertaining to the 2013–2016 Ebola virus disease (EVD) epidemics in four West African countries – Sierra Leone, Liberia, Guinea and Nigeria. We searched Pubmed, Embase and Scopus databases for relevant English language publications up to December 2015. Of the 874 articles identified, 41 met our inclusion criteria. We evaluated these selected studies based on: the sources of the case data used, and modelling approaches, compartments used, population mixing assumptions, model fitting and calibration approaches, sensitivity analysis used and data bias considerations. We synthesised results of the estimated epidemiological parameters: basic reproductive number (R(0)), serial interval, latent period, infectious period and case fatality rate, and examined their relationships. The median of the estimated mean R(0) values were between 1·30 and 1·84 in Sierra Leone, Liberia and Guinea. Much higher R(0) value of 9·01 was described for Nigeria. We investigated several issues with uncertainty around EVD modes of transmission, and unknown observation biases from early reported case data. We found that epidemic models offered R(0) mean estimates which are country-specific, but these estimates are not associating with the use of several key disease parameters within the plausible ranges. We find simple models generally yielded similar estimates of R(0) compared with more complex models. Models that accounted for data uncertainty issues have offered a higher case forecast compared with actual case observation. Simple model which offers transparency to public health policy makers could play a critical role for advising rapid policy decisions under an epidemic emergency. more...

Serological data provide an important measure of past exposure and immunity to hepatitis A virus (HAV) infection in a population. National serosurveys from developed countries have typically indicated a decline in HAV seroprevalence over time as sanitation levels improve. We examined trends in the seroepidemiology of HAV antibodies in Victoria, Australia, drawing on cross-sectional samples taken at three time points over a 20-year period. Stored sera from 1988 (n=753), 1998 (n=1091), and 2008 (n=791) from persons aged 1-69 years were obtained from the state of Victoria, Australia. The within-year population adjusted results show a significant trend of increasing population HAV seroprevalence over time from 34.3% (95% CI 31.7-36.9) in 1988, to 40.0% (95% CI 37.1-42.8) in 1998 and 55.1% (95% CI 52.1-58.1) in 2008, P0.0001. A particularly noticeable rise in population seroprevalence was observed between 1998 and 2008 for those aged 5-39 years. The increase in HAV seropositivity over time is in contrast to the declining rates of disease notification in Australia. Based on comparisons with other Australian data, it appears the increase in population seroprevalence over the last two decades is unlikely to be due to endemic transmission of infection. Instead, other factors, including increases in travel to HAV endemic regions, migration to Australia from HAV endemic regions and vaccine uptake are more likely causes. Ongoing monitoring of serological HAV profiles in the population is required to determine future policy direction to prevent increased burden. more...

BACKGROUND Annual influenza vaccination is recommended for health care workers (HCWs) in many countries in order to reduce the morbidity associated with influenza in health care settings. However, compliance rates with influenza vaccination are commonly low. AIMS To evaluate the current vaccination status of HCWs in Beijing, China, and examine their attitudes towards the disease and the vaccine. METHODS In January 2009, a survey was completed by 1909 HCWs in emergency departments, infection fever clinics, respiratory ward/outpatient's clinics and pediatric medical departments of 24 hospitals in Beijing (99% response rate). RESULTS Respondents were categorized into three main groups by occupation: nursing (60%, n = 1143), medical (36%, n = 693) and other (4%, n = 73). When examining beliefs about the influenza vaccine, 57% (n = 1081) felt it was safe and 54% (n = 1028) thought it was effective. Less than 18% stated that they had been immunized in 2008; 40% (n = 765) or participants agreed with the statement 'the flu vaccine can cause flu in some people'. CONCLUSIONS A better understanding of the barriers to vaccination in this population should facilitate the development of programs to make health care facilities a safer environment for both HCWs and patients. more...

SUMMARYRespiratory outbreaks are common in aged-care facilities (ACFs), are both underreported and frequently identified late, and are often associated with considerable burden of illness and death. There is emerging evidence that active surveillance coupled with early and systematic intervention can reduce this burden. Active surveillance for influenza-like illness and rapid diagnosis of influenza were established in 16 ACFs in Sydney, Australia, prior to the winter of 2006. A point-of-care influenza test and laboratory direct immunofluorescence tests for common respiratory viruses were used for diagnosis. We achieved early identification of seven respiratory disease outbreaks, two of which were caused by influenza. For the influenza outbreaks, antiviral treatment and prophylaxis were initiated 4–6 days from symptom onset in the primary case. A simple active surveillance system for influenza was successfully implemented and resulted in early detection of influenza and other respiratory disease outbreaks. This enabled earlier implementation of prevention and control measures and increased the potential effectiveness of anti-influenza chemoprophylaxis. more...

There have been few surveys of Streptococcus pneumoniae and Neisseria meningitidis carriage in sick or frail elderly people who, with the very young, comprise the group who are at highest risk for pneumococcal disease. We studied pneumococcal carriage among participants in a pneumococcal immunisation study in the frail elderly.Subjects agedor=60 years were recruited from a large tertiary referral hospital in Sydney, Australia. Nose and throat swabs were collected at the time of enrolment and 12 months after immunisation.Before immunisation, only 1 of 315 participants was identified as a nasal carrier of S. pneumoniae; another was identified as throat carrier of N. meningitidis. None of the participants examined after immunisation was carrying either S. pneumoniae or N. meningitidis.The low rate of pneumococcal carriage in this population of hospitalised elderly patients was unexpected. The most likely reason is that long-term carriage is rare in this population and suggests that pneumococcal disease primarily follows recent acquisition of S. pneumoniae types not associated with carriage. more...

SUMMARYWe examined the impact of one-dose vs. two-dose vaccination strategies on the epidemiology of varicella zoster virus (VZV) in Australia, using a mathematical model. Strategies were assessed in terms of varicella (natural and breakthrough) and zoster incidence, morbidity, average age of infection and vaccine effectiveness (VE). Our modelling results suggest that compared to a one-dose vaccination strategy (Australia's current vaccination schedule), a two-dose strategy is expected to not only produce less natural varicella cases (5% vs. 13% of pre-vaccination state, respectively) but also considerably fewer breakthrough varicella cases (only 11·4% of one-dose strategy). Therefore a two-dose infant vaccination programme would be a better long-term strategy for Australia. more...

Limited information exists regarding optimal methods for the recruitment and retention of older people in clinical trials. The aim of this review is to identify common barriers to the recruitment of older people in clinical trials and to propose solutions to overcome these barriers. A review of literature was performed to identify common difficulties in recruiting older people. This in combination with our experience during recruitment for a randomized control trial, have highlighted numerous barriers. Population-specific recruitment strategies, simple informed-consent processes, and effective communication between the researcher and subject are effective strategies to overcome these barriers. more...

Pneumococcal vaccine is now recommended for all people aged 65 years and over in Australia, yet many in this age group remain unvaccinated, especially those from Non-English Speaking Backgrounds (NESB). Aim Our aim was to assess some of the perceived beliefs, benefits and barriers to pneumococcal immunisation in older people. Design and setting We conducted qualitative open-ended interviews among elderly hospital inpatients aged receiving care in the geriatric, cardiology, and orthopaedic departments of a large, 800-bed tertiary referral hospital. Methods 24 participants who had not received pneumococcal immunisation, and who were aged 60 years and over, were mentally competent and well enough to be interviewed were selected for our study. Results Three topics were addressed: patient attitudes towards vaccination, knowledge of vaccines and their purpose, and accessibility of patient education materials about vaccines and their purpose. Patients who accepted pneumococcal immunisation (acceptors) generally were unaware of the vaccine or did not know it was recommended for them. Patients who refused the pneumococcal vaccine (refusers) either would not consider it without the recommendation of their general practitioner or they maintained the belief that the vaccination would cause illness or symptoms. Knowledge about the availability and purpose of the pneumococcal vaccine was poor amongst our group. Conclusion Poor knowledge of the availability and purpose of pneumococcal immunisation was prevalent in our subjects. Appropriate education campaigns and trusting and positive relationships with the general practitioners are likely to improve immunisation uptake. more...

SUMMARYThe aim of this study was to determine the burden, management and outcomes of rotavirus infection in young children presenting to a tertiary paediatric hospital in Sydney, Australia. All laboratory-confirmed cases of rotavirus in children aged more...

Advanced age has been associated with a wide range of defects in both the innate and adaptive immune systems including diminished specific antibody responses that increase the risk of invasive pneumococcal disease (IPD) and limit the effectiveness of vaccines. However, the elderly are a heterogeneous group and measures of overall frailty may be a better indicator of disease susceptibility (or vaccine response) than chronological age alone.To evaluate the immunogenicity of the 7-valent conjugated pneumococcal vaccine (PCV7) versus 23-valent polysaccharide vaccine (23vPPV) and compare the immune response to four serotypes (4, 6B, 18C and 19F), with respect to age or frailty in an elderly population of previously unvaccinated hospitalized patients.241 patients aged 60 years and over, recruited between 16 May 2005 and 20 February 2006, were randomised to 23PPV or PCV7 vaccine. We measured Frailty Index (FI), Barthel index and the MiniMental State. Serotype-specific IgG was measured by ELISA at base line and 6 months after vaccination. Antibody responses were defined by the ratio of post-vaccination to pre-vaccination IgG antibody concentration (poor2-fold increase, acceptableor = 2.0 to 3.99-fold and strongor = 4.0-fold increase).Pre-immunization IgG was generally low and did not differ significantly by age or frailty. Post-immunization, IgG increased to all four serotypes; acceptable or strong response ranged between 29% for (6B) and 57% for (18C). There was no significant difference between the two vaccine types (23PPV versus PCV7). At 6 months post-vaccination, the highest geometric mean IgG concentrations (GMCs) were seen for serotype 19F and the lowest for serotype 4. Although there was some variation by serotype, responses after vaccination were lowest in the most frail or aged subjects.Pneumococcal vaccines are perceived to offer low protection in the frail elderly, but our study showed that the proportion of this vulnerable population with acceptable responses is encouraging. Frailty, as measured by the Frailty Index, appears to be a better predictor of immune response to pneumococcal vaccines than age alone. more...

Pneumococcal disease and influenza are major causes of morbidity and mortality particularly among the elderly. Influenza and pneumococcal vaccination are recommended for people aged 65 years and older or persons with chronic illness. However, despite the burden of disease related to pneumococcus and influenza and the availability safe, efficacious and cost-effective vaccines, health care providers continue to have doubts about these vaccines. Little is known about barriers for pneumococcal vaccination in the health care providers particularly in the primary health care setting. Since 2005 a publicly funded program offering free pneumococcal vaccine for elderly people over 65 years has been implemented in Australia.To investigate knowledge, attitudes and practices around vaccination of elderly patients among hospital health care workers and community general practitioners and to explore the difference between hospital doctors and GP.A self-reported questionnaire survey distrubuted March and June 2007 to General physicians (GP's) whose practices are located in Western Sydney and health care staff consisting of Hospital Doctors (HD), hospital nurses (HN) and allied health care workers at a tertiary referral hospital in Western Sydney. Descriptive analyses were conducted; bivariate analyses were performed to investigate associations between variables.Completed surveys were obtained for 56.3% (335/595) GPs and 42.1% (346/822) for HHCWs. The HHCWs comprised 37.5% (130/346) HD, 57.8% (200/346) HN and 4.6% (16/346) allied health care workers. GP's are more likely to support elderly vaccination than hospital doctors (98.8% compared to 93%, P=0.0007). GPs reported that the reason for not vaccinating patients in 88% (295/335) of the cases was due to patient refusal. GP's and HHCW both agreed that pneumococcal disease is a serious illness and that vaccination is an important preventive measure for the elderly. However, the majority 68.2% (88/129) of hospital doctors report that vaccinations are difficult to address due to multiple competing priorities compared to only 34.6% (116/335) of GPs, P0.0001. Hospital doctors are more likely than GPS (24% vs. 17%) to report that patients often complain of adverse effects from pneumococcal vaccine. Hospital doctors 20% (104/130) are significantly less likely than GPs1% (3/335) to have access to guidelines and other information regarding vaccination in the elderly.GPs and hospital health care workers in our study were aware of, agreed with, immunization recommendation for the pneumococcal vaccine. Physician barriers to vaccination were patient's refusals and competing priorities, particularly for hospital health care workers, who were less likely to see vaccination as a priority. Hospitalisation is an opportunity for vaccination, but utilisation of this opportunity is reduced by lack of access to information about immunization for hospital health care workers and competing priorities. These could be areas to target for improved uptake of the elderly immunization. more...

a National Centre for Immunization Research and Surveillance Sydney, NSW, Australia b The University of Sydney, Sydney, NSW, Australia c Discipline of Medicine, Geriatric Medicine, Westmead Hospital, Sydney, NSW, Australia d School of Public Health and Community Medicine, The University of New South Wales, Australia e The Australian Red Cross Blood Services, Sydney, NSW, Australia f Research Unit of Transfusion Medicine and Immunogenetics, Faculty of Medicine, University of Sydney, Australia more...

Summary Background Infection with Helicobacter pylori is common worldwide and a significant cause of upper gastrointestinal disease. Prevalence of this infection varies in different population groups internationally. Because of the invasiveness of specimen collection for bacteriologic diagnosis and the expense of tests such as labeled urea breath tests, serology is the most feasible means of determining the population epidemiology of H. pylori . The aim of this study was to describe the seroepidemiology of H. pylori infection in Australia. Methods H. pylori -specific ELISA for the presence of IgG antibodies was performed on a representative sample of 2413 sera from Australia in 2002, using validated serosurveillance methods. Results The overall seroprevalence of H. pylori infection in Australia was 15.1% in 2002, with no statistical difference between genders. Seropositivity rates increased progressively with age, ranging between 4.0% in the 1–4-year-olds and 23.3% in the 50–59-year-olds. Conclusions The prevalence of infection with H. pylori in Australia was lower than rates reported in other developed countries, at 15.4%. This study provides important baseline measurements for future preventive measures including vaccine research and development. Further studies to determine subgroups at higher risk of infection may help target the more susceptible populations. more...

Background: Internet-based surveillance systems have become invaluable tools to complement traditional surveillance in the early detection of infectious disease outbreaks. Search results limited to only English-language sources may lead to missed opportunities in global outbreak monitoring efforts. The Malay language has 290 million native speakers across the Southeast Asian region (Indonesia, Malaysia, Brunei, Singapore and the southern parts of Thailand and the Philippines), which is an important region for outbreaks. The aim of this research is to determine the completeness of reports of Malay language outbreak detection by commonly used open source surveillance platforms. Methods: We searched ProMED-mail, HealthMap, and Google News to investigate outbreak events in Malaysia and Indonesia between 1st August 2016 and 31st August 2017. We also cross-checked published epidemic reports in Medline to determine the proportion of outbreaks that are published. Results: A total of 371 entries from ProMED-mail and HealthMap were included. A Google News search query using Malay language keywords resulted in 453 news outbreak reports, 98 of which were missed by either or both ProMED-mail and HealthMap. During the study time frame, only 40 published epidemic reports were found in MEDLINE, showing the importance of informal data sources to identify outbreaks. Some diseases such as mumps, dengue and avian influenza had different local terminology in Indonesia and Malaysia. Conclusions: Search results limited to only English-language sources may lead to reduced outbreak detection. The inclusion of keywords in the Malay language improves epidemic intelligence in the region, but needs to be nuanced for local terminology, which may differ between countries. Informal Internet-based surveillance can improve compliance with International Health Regulations (IHR) for low income countries, because it is less resource-intensive than formal surveillance. However, there is a need to include local language search terms to improve outbreak detection, especially in regions at high risk of emerging infectious diseases. more...

Background In Australia, a Goods and Services Tax (GST) introduced in 2000 led to a decline in the price of ready-to-drink (RTD) beverages relative to other alcohol products. The 2008 RTD (“alcopops”) tax increased RTD prices. The objective of this study was to estimate the change in incidence of Emergency Department (ED) presentations for acute alcohol problems associated with each tax. Methods Segmented regression analyses were performed on age and sex-specific time series of monthly presentation rates for acute alcohol problems to 39 hospital emergency departments across New South Wales, Australia over 15 years, 1997 to 2011. Indicator variables represented the introduction of each tax. Retail liquor turnover controlled for large-scale economic factors such as the global financial crisis that may have influenced demand. Under-age (15–17 years) and legal age (18 years and over) drinkers were included. Results The GST was associated with a statistically significant increase in ED presentations for acute alcohol problems among 18–24 year old females (0 · 14/100 000/month, 95% CI 0 · 05-0 · 22). The subsequent alcopops tax was associated with a statistically significant decrease in males 15–50 years, and females 15–65 years, particularly in 18–24 year old females (−0 · 37/100 000/month, 95% CI −0 · 45 to −0 · 29). An increase in retail turnover of liquor was positively and statistically significantly associated with ED presentations for acute alcohol problems across all age and sex strata. Conclusions Reduced tax on RTDs was associated with increasing ED presentations for acute alcohol problems among young women. The alcopops tax was associated with declining presentations in young to middle-aged persons of both sexes, including under-age drinkers. more...