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The aim of this study was to estimate the effects of climate on childhood diarrhoea hospitalisations across six administrative divisions in Bangladesh and to provide scientific evidence for local health authorities for disease control and prevention. Fortnightly hospital admissions (August/2013–June/2017) for diarrhoea in children under five years of age, and fortnightly average maximum temperature, relative humidity and rainfall recordings for six administrative divisions were modelled using negative binomial regression with distributed lag linear terms. Flexible spline functions were used to adjust models for seasonality and long-term trends. During the study period, 25,385 diarrhoea cases were hospitalised. Overall, each 1 °C rise in maximum temperature increased diarrhoea hospitalisations by 4.6% (IRR = 1.046; 95% CI, 1.007–1.088) after adjusting for seasonality and long-term trends in the unlagged model. Using lagged effects of maximum temperature, and adjusting for relative humidity and rainfall for each of the six administrative divisions, the relationship between maximum temperature and diarrhoea hospitalisations varied between divisions, with positive and negative effect estimates. The temperature-diarrhoea association may be confounded by seasonality and long-term trends. Our findings are a reminder that the effects of climate change may be heterogeneous across regions, and that tailored diarrhoea prevention strategies need to consider region-specific recommendations rather than relying on generic guidelines.

Background COVID-19 has focussed public attention on the management of communicable disease like never before. Surveillance, contact tracing, and case management are recognised as key components of outbreak prevention. Development of guidance for COVID-19 has drawn from existing management of other communicable diseases, including Invasive Meningococcal Disease (IMD). IMD is a rare but severe outcome of Neisseria meningitidis infection that can be prevented through vaccination. Cases still occur sporadically, requiring ongoing surveillance and consistent management. To this end, national and international public health agencies have developed and published guidance for identification and management of IMD cases. Aim To assess national and international guidelines for the public health management of IMD, with a focus on the recommendations for identification and management of “close contacts” to IMD cases. Methods Guidelines from six national and international public health agencies were assessed using a modified version of the Appraisal of Guidelines, Research and Evaluation (AGREE II) Instrument in four key domains: stakeholder involvement, developmental rigour, clarity, and applicability. A direct comparison of terminology and recommendations for identification and management of close contacts to IMD cases was also conducted. Results Guidelines from Europe and the United Kingdom rated most highly using the AGREE II Instrument, both presenting a clear, critical assessment of the strength of the available evidence, and the risks, costs, and benefits behind recommendations for management of close contacts. Direct comparison of guidelines identified inconsistencies in the language defining close contacts to IMD cases. Conclusion Discrepancies between guidelines could be due to limited evidence concerning mechanisms behind disease transmission, along with the lack of a consistent process for development and review of guideline recommendations. COVID-19 management has demonstrated that international collaboration for development of public health guidance is possible, a practice that should be extended to management of other communicable diseases.

Unvaccinated animal science and veterinary students are at risk of Q fever, a vaccine-preventable zoonotic disease transmitted from animals to humans. We investigated students’ perspectives on Q fever prevention using a One Health approach combining animal, human and environmental health. Animal science and veterinary students enrolled at the University of Adelaide in 2019 were invited to participate in an online survey to explore their perceptions about Q fever and prevention strategies. We undertook descriptive analysis and logistic regression. Overall, 46% of students reported little to no knowledge of Q fever. Over three-quarters of students reported transmission of Q fever via aerosol inhalation and animal culling, whilst other modes including sexual transmission between humans (7%) was poorly identified. The majority of students reported exposure to cattle, sheep and goats. Of those who reported vaccination status, 5% veterinary and 61% animal science students were unvaccinated for Q fever. Challenges concerning vaccination included cost, time and access to healthcare with strategies aimed at promoting awareness, improving healthcare access and subsidized and mass vaccination. Knowledge of Q fever among respondents, particularly about disease transmission was suboptimal. As a key principle to One Health approach, adherence to biosecurity guidelines during contact with animals could potentially reduce zoonoses including Q fever transmission. Improving access to Q fever vaccine for unvaccinated students is a priority. Findings underscore that university policy for Q fever vaccination needs to consider subsidized vaccination for both animal science and veterinary students.

To explore animal science and veterinary students' and livestock farmers' perceptions concerning Q fever prevention.An online survey with an open-ended question seeking knowledge and perceptions about Q fever prevention was distributed among participants during March-September 2019. We applied thematic analysis to identify emerging themes.Animal science and veterinary students enrolled at the University of Adelaide and members of Livestock South Australia representing cattle, sheep and goat farmers in South Australia.A total of56 animal science and veterinary students and 154 livestock farmers responded to the open-ended question.Not applicable.Perceived challenges and opportunities for a coordinated Q fever prevention approach including human vaccination reported by the participants.Two major themes arose in each group. Students and farmers viewed Q fever vaccination as important. However, excessive cost for students was a barrier and for farmers, it was general practitioners' lack of knowledge of Q fever and access to an accredited immunisation provider. Similarly, both groups highlighted the need for education and increasing public and community awareness of Q fever.Our findings underscore that a sector-wide approach involving community awareness programmes, education and training for general practitioners, and subsidised vaccination as well as commitment from government and industry partners may contribute to reducing the burden of Q fever among at-risk populations.

To assess the impact of different non-pharmaceutical interventions (NPIs) on COVID-19 cases across Victoria and South Australia.Poisson regression models were fit to examine the effect of NPIs on weekly COVID-19 case numbers.Mask-wearing in Victoria had a pronounced lag effect of two weeks with an incidence rate ratio (IRR) of 0.27 (95%CI 0.26-0.29). Similarly, the effect of border closure (IRR 0.18; 95%CI 0.14-0.22) in South Australia and lockdown (IRR 0.88; 95%CI 0.86-0.91) in Victoria showed a decrease in incidence two weeks after the introduction of these interventions.With the ongoing COVID-19 pandemic, varying levels of vaccination coverage rates and threats from variants of concern, NPIs are likely to remain in place. It is thus important to validate the effectiveness and timing of different interventions for disease control, as those that are more restrictive such as border control and lockdown can have an enormous impact on society.Low case numbers and deaths in Australia's first wave of COVID-19 are thought to be due to the timely use of interventions. The observed two-week lag effect associated with a decrease in incidence provides justification for early implementation of NPIs for COVID-19 management and future pandemics.

ObjectivesThis study was conducted to explore the perspectives and opinions of Intensive Care Unit (ICU) nurses and doctors at a COVID-19 designated pandemic hospital concerning the preparedness and response to COVID-19 and to consolidate the lessons learnt for crisis/disaster management in the future.DesignA qualitative study using in-depth interviews (IDIs) and focus group discussions (FGDs). Purposeful sampling was conducted to identify participants. A semi-structured guide was utilised to facilitate in-depth interviews with individual participants. Two focus group discussions were conducted, one with the ICU doctors and another with the ICU nurses. Thematic analysis identified themes and subthemes informing about the level of preparedness, response measures, processes, and factors that were either facilitators or those that triggered challenges.SettingICU in a quaternary referral centre affiliated to a university teaching COVID-19 designated pandemic hospital, in Adelaide, South Australia.ParticipantsThe participants included eight ICU doctors and eight ICU nurses for the in-depth interviews. Another sixteen clinicians participated in focus group discussions.ResultsThe study identified six themes relevant to preparedness for, and responses to, COVID-19. The themes included: (1) Staff competence and planning, (2) Information transfer and communication, (3) Education and skills for the safe use of PPE, (4) Team dynamics and clinical practice, (5) leadership, and (6) Managing End-of life situations and expectations of caregivers.ConclusionFindings highlight that preparedness and response to the COVID-19 crisis were proportionate to the situation’s gravity. More enablers than barriers were identified. However, opportunities for improvement were recognised in the domains of planning, logistics, self-sufficiency with equipment, operational and strategic oversight, communication, and managing end-of-life care.ARTICLE SUMMARYStrengths and limitations of this studyThis is the first study that provided insights about clinicians’ perspectives and viewpoints to preparing and responding to COVID-19 in Australia.The study used qualitative methodological framework allowing participants to provide in-depth accounts of processes and enabling factors and barriers.Our study provides information on issues that needs to be addressed from a critical care viewpoint and interventions that were effective and efficientThis is a single-center study in a developed country where experience is vastly different from other centers with higher demand and fewer resourcesWe acknowledge the potential for selection bias because of the qualitative design

Background Emerging antibiotic resistance is significant threat to global public health. There is evidence on sub-optimal prescribing as a contributing factor to antibiotic resistance. This study aimed to identify behavioral determinants of antibiotic prescribing that may help design effective interventions. Methods A cross-sectional survey was undertaken with clinicians (hospital and primary care) in Australia from June–October 2019. Multivariate logistic regression was used to determine if clinicians’ characteristics, and guidelines’ use, are associated with barriers of appropriate antibiotic prescribing. Results Inappropriate prescribing behavior is not limited to clinicians’ practices, but also relate to patients’ expectation and clinical culture. Lack of data for evidence-based decision-making and diagnostic uncertainty contribute to sub-optimal antibiotic prescribing. Different care settings and clinicians’ experience influence perceptions of whether unavailability of information, delay in diagnostic results and patient expectations regarding treatment led to inappropriate prescribing behavior. Respondents in primary care and with less experience were more likely to consider that patient demands (primary care: OR 1.76, 95%CI 1.34–2.68 & experience (1-10 years): OR 1.34, 95%CI 1.07–1.59) and lack of data required for decision-making (primary care: OR 1.59, 95%CI 1.09–2.10 & experience (1-10 years): OR 1.63, 95%CI 1.13–1.87) are barriers to appropriate prescribing. Conclusions A complex network of social, contextual and clinical factors influence prescribing practices. A holistic approach addressing clinicians’ practices, setting requirements and patient expectations must be considered. Key messages For optimal antibiotic prescribing, there is a need to focus on contextual requirements, shared decision-making and availability of relevant information at point-of-care.

Background/Objective To identify the issues around the prevention of Q fever as understood by trainee animal health practitioners and livestock farmers and to compare their varying perceptions. Methods An online survey with an open question seeking participants’ suggestions about Q fever prevention was distributed among all animal science and veterinary students enrolled at the University of Adelaide and members of Livestock SA representing livestock farmers during March-September 2019. Students were recruited through their University course whilst livestock farmers were recruited by advertisements and direct emails. Thematic analysis of the data followed the Braun and Clarke framework. Results Two major themes arose in each group, whilst each group identified similar themes and sub themes, there was a differing emphasis on the importance of these. Both students and farmers viewed Q fever vaccination is important, but barriers included excessive cost for students while access to a vaccine provider and general practitioners’ inadequate knowledge were emphasized by farmers. Awareness was another major theme: students – generalized lack of awareness amongst themselves and the public; farmers – increasing public awareness is crucial. Conclusions Both groups recognized the importance of Q fever vaccination and viewed subsidy an enabler, but students’ perceptions were shaped by the high cost of the vaccine while farmers were most concerned with the impacts of the disease. Findings underscore that strengthening targeted and community awareness programs coupled with a subsidy could promote increased uptake of Q fever vaccination. Key messages Increasing awareness and subsidized vaccination could merit Q fever prevention approaches including vaccination.

To examine stakeholder perspectives on the factors of an effective approach to reduce Q fever risk including disease prevention, and the perceived potential benefits of a One Health framework.Semi-structured interviews were conducted with general practitioners (GPs), veterinarians, government authorities, researchers, and representatives from the farming industry. Transcripts were thematically analysed.Six major themes were identified as key factors underpinning an effective approach to Q fever: understanding Q fever burden; effective surveillance; the role of general practitioners and other stakeholders; barriers and enablers of vaccination; an integrated approach; and increased Q fever awareness. Most participants perceived GPs to play a central role in disease detection, notification, treatment and prevention through health promotion and vaccination, despite GPs acknowledging limited awareness of Q fever. Participants suggested leadership is required from the Department of Health (DoH) to foster inter-sectoral communication and collaboration.A One Health approach holds opportunities for zoonosis prevention. We recommend that medical curricula and professional development be enhanced, zoonosis working group networks strengthened, government-industry partnerships established, and relevant stakeholders included within an integrated program.Updating medical curricula, GP professional development programs and inter-sectoral collaboration led by health departments may reduce Q fever burden.

Background This study aims to analyse the distribution characteristics of ideal cardiovascular health (ICH) metrics status of the oldest-old and centenarians, and also to explore the relationships with disability and quality of life. Methods 1002 centenarians and 798 oldest-old were included in the analysis. ICH, disability and quality of life were assessed according to standard methods. Results The median number of ICH metrics among centenarians and oldest-old were 4 (4-5) and 3(3-5) respectively. The highest proportion of ICH metrics at ideal levels were glucose (90.2%), BMI (89.8%), and smoking (89.4%), the lowest proportion of ICH metrics at ideal level was blood pressure (8.3%). The disability rates of BADL and IADL decreased with the number of ICH metrics. BADL disability changed from 100.0% to 73.2%, and the IADL disability rate dropped from 100% to 80.0%. BADL disability rate decreased from 45.0% to 25.3% and IADL disability decreased from 100.0% to 57.1% among the oldest-old. The EQ-5D vas, EQ-5D score showed increasing trend along with the number of ICH metrics (p Conclusions ICH metrics of centenarians and oldest-old were at a relatively good level, and there was a strong and independent inverse relationship between ICH metrics with both disability and lower quality of life. Key messages This was the first survey about the distribution of ICH metrics and association with both disability and quality of life based on elderly aged over 80 years old. The results highlighted the importance of cardiovascular prevention even at 80 years and over, which made up for the evidence gap based on this age group.

Objective The aim of this study was to identify perceived barriers to appropriate antibiotic prescribing across different healthcare settings. Methods A cross-sectional survey of clinicians in Australian hospitals and primary care was undertaken between June and October 2019. The perceived barriers to appropriate antibiotic prescribing were considered as dependent variables, whereas age, sex, clinical experience, healthcare setting and the use of guidelines were considered independent variables. We used multivariate logistic regression to identify factors predictive of inappropriate antibiotic prescribing. Content analysis of free-text responses provided additional insights into the impediments to appropriate prescribing. Results In all, 180 clinicians completed the survey. Overall, diagnostic uncertainty and limited access to guidelines and prescribing information were significant barriers to appropriate antibiotic prescribing. Factors associated with these barriers were clinical experience, care setting (hospitals vs primary care) and the use of guidelines. Experienced clinicians (>11 years) were less likely to consider that limited access to information negatively affected prescribing practices (experience 11–20 years, odds ratio (OR) 0.66, 95% confidence interval (CI) 0.31–0.84; experience >20 years, OR 0.51, 95% CI 0.24–0.91). Conversely, general practitioners considered diagnostic uncertainty (OR 1.31, 95% CI 1.09–1.63) and patient expectations (OR 1.41, 95% CI 1.12–1.84) were more likely to be perceived barriers to appropriate prescribing. The use of guidelines and clinical experience may counteract this. Conclusion Years of experience, use of guidelines and type of setting were predictors of clinicians’ perceptions regarding antibiotic prescribing. Our data highlight the importance of individual and setting characteristics in understanding variations in prescribing practices and designing targeted interventions for appropriate antibiotic prescribing. What is known about the topic? Inappropriate antibiotic prescribing is a significant health issue in Australia. Drivers of inappropriate prescribing are known, but how individual and setting characteristics contribute to variations in prescribing behaviour has not been fully understood. What does this paper add? Diagnostic uncertainty and limited access to prescribing information, including guidelines, formulary restrictions and antibiotic resistance patterns, can limit appropriate antibiotic prescribing. Clinicians’ years of experience, the healthcare settings and clinician use of guidelines are important predictors of antibiotic prescribing behaviour. What are the implications for practitioners? The findings of this study can inform the design of tailored interventions to promote rational antibiotic prescribing practices in general practice and hospital settings.

Background Livestock farmers are at risk of Q fever, a zoonotic disease transmitted to humans from animals such as cattle, sheep and goats. Australia bears substantial Q fever burden, particularly among farmers. A One Health approach engages cross-sectoral collaboration among animal, human and environmental health and is the preferred framework for Q fever prevention. Methods Cattle, sheep and goat farmers were invited to participate in an online survey in 2019 to gauge perceptions about Q fever and its prevention. Participants were recruited via membership newsletters and social media. Descriptive analyses and logistic regressions were performed. Results A total of 351 farmers completed the survey. Most respondents (80%) had been farming for ≥20 years, with sheep and beef cattle their primary stock. 71% reported knowledge of Q fever, and 85% identified transmission through contaminated dust inhalation was highly likely. The majority of respondents (97%) were aware of Q fever vaccine, and 95% agreed it was effective in preventing disease, yet 42% remained unvaccinated. Reported barriers to vaccination included poor access to a trained doctor and time and cost related to vaccination. Most farmers (≥91%) believed that subsidized vaccination and improved awareness would promote higher uptake. Conclusion While Q fever knowledge among respondents was good, their practices related to airborne transmission prevention were poor. Livestock farmers would benefit from adherence to dust and aerosol transmission prevention practices. One Health partnership between government and industry is needed to promote Q fever awareness and address low vaccination rates among livestock farmers by funding vaccination programs., Highlights • Australian livestock farmers have a good understanding of Q fever • Knowledge of farm-level biosecurity measures is suboptimal • Livestock farmers supported a coordinated approach to vaccination • One Health with subsidized vaccination presents an optimal prevention program

IntroductionThe clinical data is increasing at a considerably higher rate than the capacity of the healthcare system and clinicians to manage this data. Digital tools such as clinical decision support systems (CDSS) provide opportunities for evidence-based patient care by intelligently filtering and presenting the information required for clinical decision making at the point of care. Despite the success of pilot projects, CDSS have had limited implementation in broader health systems. We aimed to identify challenges faced by policymakers for CDSS implementation and to provide policy recommendations.MethodsWe conducted eleven semi-structured interviews with Australian policymakers from state and national committees involved in digital health activities. The data were analyzed using reflexive thematic analysis to identify policy priorities.ResultsOur findings indicate that fragmentation of care processes and structures in the digital health ecosystem is one of the main impediments to delivering coordinated care using CDSS. Five themes for policy action were identified: (i) establishing a shared conceptual framework for user-centered design of CDSS that is aligned with stakeholders’ priorities, (ii) maintaining the right balance between the customization and standardization of systems, (iii) developing mutually agreed semantic interoperability standards at the local, state and national level, allowing generation and exchange of information across the health system without changing its context and meaning, (iv) reorienting organizational structures to build capacity to foster change, and (v) developing collaborative care models to avoid conflicting interests between stakeholders.ConclusionsFindings highlight the importance of developing system-wide guidance to establish a clear vision for CDSS implementation and alignment of organizational processes across all levels of health care. There is a need to build a shared policy framework for modelling the innovative activities such as CDSS implementation across the digital health landscape which minimizes the operational and strategic fragmentation of different organizations.

The study evaluated individual and setting-specific factors that moderate clinicians’ perception regarding use of clinical decision support systems (CDSS) for antibiotic management. A cross-sectional online survey examined clinicians’ perceptions about CDSS implementation for antibiotic management in Australia. Multivariable logistic regression determined the association between drivers of CDSS adoption and different moderators. Clinical experience, CDSS use and care setting were important predictors of clinicians’ perception concerning CDSS adoption. Compared to nonusers, CDSS users were less likely to lack confidence in CDSS (OR = 0.63, 95%, CI = 0.32, 0.94) and consider it a threat to professional autonomy (OR = 0.47, 95%, CI = 0.08, 0.83). Conversely, there was higher likelihood in experienced clinicians (&gt, 20 years) to distrust CDSS (OR = 1.58, 95%, CI = 1.08, 2.23) due to fear of comprising their clinical judgement (OR = 1.68, 95%, CI = 1.27, 2.85). In primary care, clinicians were more likely to perceive time constraints (OR = 1.96, 95%, CI = 1.04, 3.70) and patient preference (OR = 1.84, 95%, CI = 1.19, 2.78) as barriers to CDSS adoption for antibiotic prescribing. Our findings provide differentiated understanding of the CDSS implementation landscape by identifying different individual, organisational and system-level factors that influence system adoption. The individual and setting characteristics can help understand the variability in CDSS adoption for antibiotic management in different clinicians.

BackgroundAssociations between climate and childhood diarrhoea are likely, particularly in the face of climate change. We estimated the effects of climate conditions on hospitalizations due to chil...

Background Clinical decision support (CDS) can improve the quality and efficiency of care by increasing access to evidence-based data at the point-of-care. However, CDS adoption is limited in clinical settings. The focus on the technical design have overlooked end-users’ perceptions, social and organisational factors that may influence uptake. Using the Unified Theory of Acceptance and Use of Technology (UTAUT) model, we aimed to identify different challenges and opportunities for CDSS adoption in clinical settings. Methods A cross-sectional online survey was conducted from June-October 2019 with general practitioners, physicians and surgeons in Australia. To measure the impact of UTAUT moderators (age, gender and experience) and care settings (primary care vs. hospitals) on perceived barriers and facilitators to CDS implementation, multivariate logistic regression was carried out. Qualitative data was thematically analysed for emerging patterns and themes. Results Many respondents indicated that CDS can promote evidence-based care (79%) and improve quality and safety (52%). Overall CDS adoption is dependent on factors such as effort expectancy (ease of use), performance expectancy and a facilitating environment for system use. Clinician perceptions of barriers and facilitators to uptake are associated with type of care setting. There was higher likelihood of perceiving ease of use (OR 1.39, 95% CI 1.15-2.07), time limitations (OR 1.95, 95%CI 1.10-3.77), patient' preferences (OR 2.17, 95% CI 1.14-3.37) and threat to professional autonomy (OR 2.15, 95%CI 1.39-3.41) as factors that influence adoption in primary care. Providing relevant information in right format at right time is critical for successful CDS use. Conclusions CDS implementation requires a holistic approach addressing users' perceptions and preferences determined through stakeholder consultation. The system design must be easy to use but also facilitated through the provision of on-site training and support. Key messages CDS adoption is determined by systems’ ease of use and provision of enabling environment. Users and setting characteristics are important moderators and must be considered in CDS implementation.

Background: Clinical decision support systems (CDSS) are designed to promote evidence-based patient care and shared-decision making in healthcare settings. Despite these benefits, adoption and long-term use of the systems remain limited. There is a need to identify different factors that influence CDSS adoption in healthcare settings.Objective: The Unified Theory of Acceptance and Use of Technology (UTAUT) model was applied to determine different factors that influence the adoption of CDSS in healthcare settings.Methods. A cross-sectional online survey examining clinicians’ perceptions about CDSS implementation in hospital and primary care settings in Australia was undertaken from June - October 2019. Multivariate logistic regression was used to examine the association of UTAUT moderators (age, gender and experience) and care settings (hospital and primary care) with perceived benefits, barriers and facilitators to CDSS adoption.Results: Access to information required for evidence-based decision making, and improvements in quality and safety of patient care were the most common perceived benefits of CDSS. Mapping of different barriers and facilitators to the UTAUT model indicated that ease of use (effort expectancy), perceived benefit (performance expectancy) and a facilitating environment greatly influence the adoption of CDSS. Respondents indicated that systems providing a better fit between relevance, content and timeliness greatly facilitates uptake. Adoption of CDSS also depends on the ability of an organisation to create a facilitating environment that can help address the lack of users’ trust in these systems. The type of healthcare setting was found to be a significant predictor of lack of confidence in the content within CDSS, threat to professional autonomy, and time constraints as barriers to CDSS implementation. Therefore, setting dynamics as well as user-specific requirements need to be considered to improve the acceptability and use of CDSS. Conclusion: Our study has explored different factors that may help address implementation challenges for CDSS. By combining internal factors of users’ inclination and perceptions about the system’s perceived benefits, coupled with external factors of system design requirements, training and support, and stakeholders’ consultations, our findings highlight the need for a holistic implementation framework to enable effective CDSS adoption.

IntroductionClinical decision support systems (CDSS) are being developed to support evidence-based antibiotic prescribing and reduce the risk of inappropriate or over-prescribing; however, adoption of CDSS into the health system is rarely sustained. We aimed to understand the implementation challenges at a macro (policymakers), meso (organizational) and micro-level (individual practices) to identify the drivers of CDSS non-adoption.MethodsWe have adopted a mixed-method study design which comprised of: (i) systematic review and meta-analysis to assess the impact of CDSS on appropriate antibiotic prescribing, (ii) Online survey of clinicians in Australia from hospitals and primary care to identify drivers of CDSS adoption and (iii) in-depth interviews with policymakers to evaluate policy-level challenges and opportunities to CDSS implementation.ResultsCDSS implementation can improve compliance with antibiotic prescribing guidelines, with a relative decrease in mortality, volume of antibiotic use and length of hospital stay. However, CDSS provision alone is not enough to achieve these benefits. Important predictors of clinicians’ perception regarding CDSS adoption include the seniority of clinical end-users (years), use of CDSS, and the care setting. Clinicians in primary care and those with significant clinical experience are less likely to use CDSS due to a lack of trust in the system, fear of comprising professional autonomy, and patients’ expectations. Lack of important policy considerations for CDSS integration into a multi-stakeholder healthcare system has limited the organizational capacity to foster change and align processes to support the innovation.ConclusionsThese results using multiple lines of evidence highlight the importance of a holistic approach when undertaking health technology management. There needs to be system-wide guidance that integrates individual, organizational and system-level factors when implementing CDSS so that effective antibiotic stewardship can be facilitated.

SUMMARYCampylobacterspp. is a commonly reported food-borne disease with major consequences for morbidity. In conjunction with predicted increases in temperature, proliferation in the survival of microorganisms in hotter environments is expected. This is likely to lead, in turn, to an increase in contamination of food and water and a rise in numbers of cases of infectious gastroenteritis. This study assessed the relationship ofCampylobacterspp. with temperature and heatwaves, in Adelaide, South Australia.We estimated the effect of (i) maximum temperature and (ii) heatwaves on dailyCampylobactercases during the warm seasons (1 October to 31 March) from 1990 to 2012 using Poisson regression models.There was no evidence of a substantive effect of maximum temperature per 1 °C rise (incidence rate ratio (IRR) 0·995, 95% confidence interval (95% CI) 0·993–0·997) nor heatwaves (IRR 0·906, 95% CI 0·800–1·026) onCampylobactercases. In relation to heatwave intensity, which is the daily maximum temperature during a heatwave, notifications decreased by 19% within a temperature range of 39–40·9 °C (IRR 0·811, 95% CI 0·692–0·952). We found little evidence of an increase in risk and lack of association betweenCampylobactercases and temperature or heatwaves in the warm seasons. Heatwave intensity may play a role in that notifications decreased with higher temperatures. Further examination of the role of behavioural and environmental factors in an effort to reduce the risk of increasedCampylobactercases is warranted.

Objectives To assess the effectiveness of clinical decision support systems (CDSSs) at reducing unnecessary and suboptimal antibiotic prescribing within different healthcare settings. Methods A systematic review of published studies was undertaken with seven databases from database inception to November 2018. A protocol was developed using the PRISMA-P checklist and study selection criteria were determined prior to performing the search. Critical appraisal of studies was undertaken using relevant tools. Meta-analyses were performed using a random-effects model to determine whether CDSS use affected optimal antibiotic management. Results Fifty-seven studies were identified that reported on CDSS effectiveness. Most were non-randomized studies with low methodological quality. However, randomized controlled trials of moderate methodological quality were available and assessed separately. The meta-analyses indicated that appropriate antibiotic therapy was twice as likely to occur following the implementation of CDSSs (OR 2.28, 95% CI 1.82–2.86, k = 20). The use of CDSSs was also associated with a relative decrease (18%) in mortality (OR 0.82, 95% CI 0.73–0.91, k = 18). CDSS implementation also decreased the overall volume of antibiotic use, length of hospital stay, duration and cost of therapy. The magnitude of the effect did vary by study design, but the direction of the effect was consistent in favouring CDSSs. Conclusions Decision support tools can be effective to improve antibiotic prescribing, although there is limited evidence available on use in primary care. Our findings suggest that a focus on system requirements and implementation processes would improve CDSS uptake and provide more definitive benefits for antibiotic stewardship.

Q fever, a zoonotic disease transmitted from animals to humans, is a significant public health problem with a potential for outbreaks to occur. Q fever prevention strategies should incorporate human, animal, and environmental domains. A One Health approach, which engages cross-sectoral collaboration among multiple stakeholders, may be an appropriate framework and has the underlying principles to control Q fever holistically. To assess whether components of One Health for Q fever prevention and control have been applied, a comprehensive literature review was undertaken. We found 16 studies that had practiced or recommended a One Health approach. Seven emerging themes were identified: Human risk assessment, human and animal serology, integrated human–animal surveillance, vaccination for at-risk groups, environmental management, multi-sectoral collaboration, and education and training. Within the multi-sectoral theme, we identified five subthemes: Policy and practice guidelines, information sharing and intelligence exchange, risk communication, joint intervention, and evaluation. One Health practices varied between studies possibly due to differences in intercountry policy, practice, and feasibility. However, the key issue of the need for multi-sectoral collaboration was highlighted across most of the studies. Further research is warranted to explore the barriers and opportunities of adopting a One Health approach in Q fever prevention and control.

Summary Objectives Given increasing frequency of heatwaves and growing public health concerns associated with foodborne disease, we examined the relationship between heatwaves and salmonellosis in Adelaide, Australia. Methods Poisson regression analysis with Generalised Estimating Equations was used to estimate the effect of heatwaves and the impact of intensity, duration and timing on salmonellosis and specific serotypes notified from 1990 to 2012. Distributed lag non-linear models were applied to assess the non-linear and delayed effects of temperature during heatwaves on Salmonella cases. Results Salmonella typhimurium PT135 notifications were sensitive to the effects of heatwaves with a twofold (IRR 2.08, 95% CI 1.14–3.79) increase in cases relative to non-heatwave days. Heatwave intensity had a significant effect on daily counts of overall salmonellosis with a 34% increase in risk of infection (IRR 1.34, 95% CI 1.01–1.78) at >41 °C. The effects of temperature during heatwaves on Salmonella cases and serotypes were found at lags of up to 14 days. Conclusion This study confirms heatwaves have a significant effect on Salmonella cases, and for the first time, identifies its impact on specific serotypes and phage types. These findings will contribute to the understanding of the impact of heatwaves on salmonellosis and provide insights that could mitigate their impact.

To assess food safety practices, food shopping preferences, and eating behaviors of people diagnosed with Salmonella or Campylobacter infection in the warm seasons, and to identify socioeconomic factors associated with behavior and practices.A cross-sectional survey was conducted among Salmonella and Campylobacter cases with onset of illness from January 1 to March 31, 2013. Multivariable logistic regression analyses examined relationships between socioeconomic position and food safety knowledge and practices, shopping and food preferences, and preferences, perceptions, and knowledge about food safety information on warm days.Respondents in our study engaged in unsafe personal and food hygiene practices. They also carried out unsafe food preparation practices, and had poor knowledge of foods associated with an increased risk of foodborne illness. Socioeconomic position did not influence food safety practices. We found that people's reported eating behaviors and food preferences were influenced by warm weather.Our study has explored preferences and practices related to food safety in the warm season months. This is important given that warmer ambient temperatures are projected to rise, both globally and in Australia, and will have a substantial effect on the burden of infectious gastroenteritis including foodborne disease. Our results provide information about modifiable behaviors for the prevention of foodborne illness in the household in the warm weather and the need for information to be disseminated across the general population. An understanding of the knowledge and factors associated with human behavior during warmer weather is critical for public health interventions on foodborne prevention.

SUMMARYChanging trends in foodborne disease are influenced by many factors, including temperature. Globally and in Australia, warmer ambient temperatures are projected to rise if climate change continues.Salmonellaspp. are a temperature-sensitive pathogen and rising temperature can have a substantial effect on disease burden affecting human health. We examined the relationship between temperature andSalmonellaspp. and serotype notifications in Adelaide, Australia. Time-series Poisson regression models were fit to estimate the effect of temperature during warmer months onSalmonellaspp. and serotype cases notified from 1990 to 2012. Long-term trends, seasonality, autocorrelation and lagged effects were included in the statistical models. DailySalmonellaspp. counts increased by 1·3% [incidence rate ratio (IRR) 1·013, 95% confidence interval (CI) 1·008–1·019] per 1 °C rise in temperature in the warm season with greater increases observed in specific serotype and phage-type cases ranging from 3·4% (IRR 1·034, 95% CI 1·008–1·061) to 4·4% (IRR 1·044, 95% CI 1·024–1·064). We observed increased cases ofS. Typhimurium PT9 andS. Typhimurium PT108 notifications above a threshold of 39 °C. This study has identified the impact of warm season temperature on differentSalmonellaspp. strains and confirms higher temperature has a greater effect on phage-type notifications. The findings will contribute targeted information for public health policy interventions, including food safety programmes during warmer weather.

INTRODUCTION: In Australia, heat waves are increasing in frequency, intensity and duration. Warmer ambient temperatures can compromise food safety with an effect on human health. Given the increasi...

We report the sexual transmission of Coxiella burnetii from a man with occupationally acquired Q fever to his wife. Fifteen days after coitus, his wife also developed serologically proven acute Q fever. C. burnetii DNA sequences were detected by polymerase chain reaction (PCR) performed on semen samples obtained from the husband at 4 and 15 months after the onset of acute Q fever, but PCR results were variable at 23 months, indicating the presence of few organisms.

Objective Our study examined the psychological outcomes associated with failed ART treatment outcomes in men and women. Search Strategy A systematic search for studies published between January 1980 and August 2015 was performed across seven electronic databases. Inclusion Criteria Studies were included if they contained data on psychosocial outcomes taken pre and post ART treatment. Data Extraction and Synthesis A standardised form was used to extract data and was verified by two independent reviewers. Studies were meta-analysed to determine the association of depression and anxiety with ART treatment outcomes. Narrative synthesis identified factors to explain variations in the size and directions of effects and relationships explored within and between the studies. Main Results Both depression and anxiety increased after a ART treatment failure with an overall pooled standardised mean difference (SMD) of 0.41 (95% CI: 0.27, 0.55) for depression and 0.21 (95% CI: 0.13, 0.29) for anxiety. In contrast, depression decreased after a successful treatment, SMD of -0.24 (95% CI: -0.37,-0.11). Both depression and anxiety decreased as time passed from ART procedure. Nonetheless, these remained higher than baseline measures in the group with the failed outcome even six months after the procedure. Studies included in the narrative synthesis also confirmed an association with negative psychological outcomes in relation to marital satisfaction and general well-being following treatment failure. Conclusion Linking ART failure and psychosocial outcomes may elucidate the experience of treatment subgroups, influence deliberations around recommendations for resource allocation and health policy and guide patient and clinician decision making.

Despite the availability of a vaccine, the incidence of Q fever disease among populations at risk continues to be high. Q fever is an important cause of morbidity for workers, particularly in the meat and agricultural industries. Following an increase in 1998 in the number of Q fever notifications among meat processors to the Communicable Disease Control Branch, South Australia, a survey was conducted in the same year to assess the uptake of Q fever immunisation programs in meat processors and to identify barriers to offering these programs. This survey was conducted prior to the introduction of the National Q Fever Management Program in 2001 that provided a targeted vaccination program to specific at-risk occupations. The results of the survey highlighted that very few meat processors in South Australia offered a Q fever immunisation program to their workers. More importantly, this article highlights that there was a wide variety of attitudes and beliefs about Q fever disease and its prevention. These attitudes and beliefs have the potential to impact on whether workers at risk are offered or seek Q fever vaccination. Previous attitudes may return and levels of protection in at-risk occupations will decrease without a concerted effort at a state level. A replication of this study should benchmark the prevailing attitudes about Q fever programs. In response to the 1998 survey a number of strategies and initiatives were developed to address the barriers to Q fever vaccination in South Australian meat processors. The National Q Fever Management Program (2001-2005) further enhanced the ability to address barriers such as vaccine cost.

A sustained increase in Salmonella enterica serovar Virchow notifications in South Eastern Australia between September 1997 and May 1998 instigated a case-control study and environmental investigations. Cases were defined as having locally acquired culture-confirmed S. Virchow phage-type 8 infection and diarrhoeal disease. Matched controls were selected by progressive digit dialling based on cases' telephone numbers. An exposure and food history questionnaire was administered by telephone. Phage typing and pulse field gel electrophoresis were performed on case and environmental isolates. Thirty-two notifications of S. Virchow infection met the case definition, 37% reported bloody diarrhoea and S. Virchow was isolated from blood in 13% of cases. Twelve patients were admitted to hospital and one died. Fresh garlic (OR 4·1, 95% CI 1·3–12·8) and semi-dried tomatoes (OR 12·6, 95% CI 1·5–103·1) were associated with these cases. The associations remained significant after adjusting for sex and age. S. Virchow (PT 8) was cultured from two brands of semi-dried tomatoes associated with cases in two different states. We provide sufficient evidence for semi-dried tomatoes and fresh garlic to be considered as potential risk foods in future Salmonella outbreak investigations.

This report investigates an outbreak of acute gastrointestinal illness, microbiologically and epidemiologically linked to an aged-care facility and seeks to determine if there was a point source of infection. A register of cases that included onset date and time of illness and symptoms was maintained by nursing staff. Faecal specimens were tested for conventional gastrointestinal pathogens and for human calicivirus (HuCV). There were 81 cases reported. Specimens were received for testing from 25 cases. Twenty-three of the 25 (92%) specimens were positive for HuCV RNA by reverse transcriptase polymerase chain reaction (RT-PCR). The 2 negative samples contained RT-PCR inhibitors. Descriptive epidemiology suggested that staffing practices were important in prolonging the outbreak. No point source of infection was identified. Instead environmental contamination, aerosol transmission and work practices that fail to take account of the natural history of HuCV infection probably contributed to the size (81 cases) and duration (3 weeks) of this outbreak among the residents, staff and visitors of an aged-care facility and their contacts. Institutional outbreaks caused by HuCV, formerly called Norwalk-like or small round structured viruses, are extremely difficult to control. Infected staff may contribute significantly to the amplification of outbreaks. Rapid confirmation of HuCV infection is now routinely possible using polymerase chain reaction diagnostics but progress in laboratory technology has not yet translated into faster or more effective interventions.