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A panel of 24 international experts met in July 2022 to discuss challenges associated with pertussis detection, monitoring, and vaccination in adults; conclusions from this meeting are presented. There has been a shift in the epidemiology of pertussis toward older children and adults. This shift has been attributed to the waning of infection- or vaccine-induced immunity, newer detection techniques causing detection bias, and possibly the replacement of whole-cell pertussis with acellular vaccines in high-income countries, which may lead to immunity waning more quickly. The burden of adult pertussis is still likely under-ascertained due to widespread under-recognition by healthcare professionals (HCPs), under-diagnosis, and under-reporting in this age group. Non-standardized testing guidance and varied case definitions have contributed to under-reporting. Key barriers to HCP engagement with the tetanus, diphtheria, and pertussis (Tdap) vaccine include low awareness, lack of time/funding, and lack of motivation due to low prioritization of Tdap.

Background: As the COVID-19 pandemic began, cases of respiratory illness of unknown cause could have presented early disease signals. The detection of such signals can provide useful clues regarding disease emergence and opportunities for early outbreak control. This study assessed trends in the global incidence of reports of respiratory illness of unknown cause as early indicators of COVID-19 in late 2019, using the early warning system, EPIWATCH, to investigate the disease’s origins and early epidemiology. Methods: Global news articles published between 1-Oct and 31-Dec in 2019 and collected by EPIWATCH, an open-source Artificial Intelligence (AI)-driven epidemic surveillance system, were searched for keywords relating to unknown respiratory illness. Control periods representing the pre-COVID period (1-Oct to 31-Dec 2016-2018) were used to compare report trends over time. Data on report location, case demographics, outbreak setting, and type of illness, were extracted and descriptively analysed. Fisher’s exact tests were conducted to assess proportional differences between years. Results: Overall, 113 EPIWATCH reports of unknown respiratory illness were identified from 12 countries in 2019. Most reports (n=111 [98.2%]) were published in Northern hemisphere countries, in particular Russia (n=A72 [63.7%]) and the United States (n=17 [15.0%]). China experienced a month-on-month increase in reports. Schools were the most reported outbreak setting (n=49 [43.4%]). The proportion of included reports in 2019 was significantly higher compared to 2016-2018 (p

An epidemic of clade I mpox in the Democratic Republic of Congo, low population immunity to orthopoxviruses and advances in synthetic biology should be the triggers to raise our level of preparedness for resurgent orthopoxvirus epidemics.

BackgroundOn February 25, 2022, Russian forces took control of the Chernobyl power plant after continuous fighting within the Chernobyl exclusion zone. Continual events occurred in the month of March, which raised the risk of potential contamination of previously uncontaminated areas and the potential for impacts on human and environmental health. The disruption of war has caused interruptions to normal preventive activities, and radiation monitoring sensors have been nonfunctional. Open-source intelligence can be informative when formal reporting and data are unavailable. ObjectiveThis paper aimed to demonstrate the value of open-source intelligence in Ukraine to identify signals of potential radiological events of health significance during the Ukrainian conflict. MethodsData were collected from search terminology for radiobiological events and acute radiation syndrome detection between February 1 and March 20, 2022, using 2 open-source intelligence (OSINT) systems, EPIWATCH and Epitweetr. ResultsBoth EPIWATCH and Epitweetr identified signals of potential radiobiological events throughout Ukraine, particularly on March 4 in Kyiv, Bucha, and Chernobyl. ConclusionsOpen-source data can provide valuable intelligence and early warning about potential radiation hazards in conditions of war, where formal reporting and mitigation may be lacking, to enable timely emergency and public health responses.

Introduction: Cruise ship linked COVID-19 outbreaks have been identified as a potential source of community transmission of COVID-19 in Australia and worldwide. The risk factors and potential mitigation around COVID-19 infections on cruise ships and communities is a research gap. Methods: A correlation and regression analyses for risk factors for COVID-19 attack rates oncruise ships worldwide with reported COVID-19 from January 1, 2020 to May 11, 2020 were performed, with a more detailed analysis done for Australia. Geospatial emerging hot spot analysis during key time periods was used to assess temporal trends in spatial clustering of COVID-19 cases related to two cruise ship events in NSW, Australia. Results: For 36 cruise ships with global COVID-19 cases, available cabins had a moderate inverse correlation with the attack rate (-0.4154; 95% CI [-0.0002, -0.00003], P < 0.0118). The number of cabins, the number of decks with cabins, and passenger-to-space ratio were significantly associated with attack rate, however, the duration at sea was not. By May 2020, cruise ship passengers made up 14.9% of COVID-19 cases in Australia and 27% of the COVID-19 related deaths. Emerging hot spots of community transmission in Sydney occurred during 1-2 incubation periods of two cruise ship events. Conclusion: Mitigation of risk on cruise ships should focus on spatial design and reducing crowding, including rapid surveillance and on-board testing. To mitigate this risk during the era of COVID-19, all passengers disembarking an infected ship should be quarantined for at least the 14-day window period and tested for COVID-19, regardless of symptoms. Vaccination should be a pre-requisite for travel of any kind once available.

Over 20 years ago a report commissioned by the European Commission identified air quality in schools as a public health priority. Despite this concern, little action was taken in the following two decades. Over the last two years as classrooms were increasingly recognised as hotspots for the transmission of SARS-CoV-2, renewed interest and resources have been made available in response to this issue. Questions remain, however, over how best to achieve safer classroom air. Our analysis assessed a range of in situ interventions to remove particulate matter (PM _2.5 ) and carbon dioxide from inside a populated classroom. Our approach used saline spray and volunteers’ exhalations as our source of PM _2.5 and carbon dioxide to explore the ability of high efficiency particulate air (HEPA) filters, natural ventilation and a recirculating A/C unit to remove these air pollutants which collectively provided a novel set of data. For a total window opening of 1.86 m ^2 for a 181.7 m ^3 classroom with a HEPA filter with a 703m ^3 /hr clean air delivery rate, our results confirmed that outdoor air was needed to purge the room to reduce carbon dioxide levels that otherwise rose to >1000 ppm in 12 min. Cross and natural ventilation reduced levels of PM _2.5 and carbon dioxide very effectively—in under 5 and 10 min respectively during low levels of outside PM _2.5 . We conclude that natural ventilation supplemented with the use of HEPA filters is the most effective way to reliably improve indoor air quality year-round, balancing the need to have easy to enact approaches to reduce the buildup of PM _2.5 , airborne viruses and carbon dioxide. These results highlight an important knowledge gap. Without having localised real-time outdoor air pollution sensing, evidence-based decisions cannot be made about how often, and for how long, windows can safely remain open to purge classrooms in times of poor quality outdoor air.

The reopening of schools for the 2020 fall academic session in the United States was linked to many cases of COVID-19 infection. This analysis utilized a dataset of school-related outbreaks created by National Education Association (NEA) to study attack rates and COVID-19 trends in schools located in the south and southwestern regions of the United States. The highest attack rate was observed in Mississippi for both students and teachers. In most states, the attack rate was higher for students in high schools than elementary schools, whereas the reverse was true for teachers. Most outbreaks had fewer than five cases, with only a small number of outbreaks that involved more than 10 cases in the duration under study. Outbreak size was found to be the highest in the state of Texas. Epidemic curves of new cases in most of these states showed features of a propagated outbreak. In some states, a rise in school-related cases coincided with rise in cases in the state. Findings related to size and pattern of school outbreaks may have significant implications for defining public health policies related to school functioning during infectious disease outbreaks.

Sydney, Australia, is currently experiencing an outbreak of the Delta variant of Covid-19. The Delta variant is much more transmissible than the original ‘wild’ variant of SARS-CoV-2, which was responsible for Australia’s first wave of infections, and for the second wave largely confined to Melbourne in mid-2020. Our purpose here is to compare growth rates for the current Sydney outbreak with those of the earlier outbreaks, using doubling times as the principal indicator. By such means, it appears that non-pharmaceutical interventions are achieving similar, if not stronger effects in containing Sydney’s Delta-variant outbreak.

This commentary reviews the implications of the gas explosion at the Russian State Research Centre of Virology and Biotechnology building (Vector) on September 16th 2019. Public health and engineering perspectives are provided on the implications of the explosion causing a physical breach of the building, and the potential for dispersion of pathogens in the surrounding area. A global public health and risk analysis perspective is taken in discussing preparedness planning around this event.

The Bradford-Hill criteria are accepted criteria for assessing causality of an association. Here, the criteria were applied to the association between the CHADOX1 NCOV-19 vaccine and vaccine induced thrombotic immune thrombocytopenia (VITT). All criteria for causation are met, with consistency, specificity, temporality and biological plausibility being very clearly met. Strength of association is met, but more data are required to establish the precise estimate of the association, as case ascertainment may be variable between countries, resulting in varied estimates of incidence rates from 25 to 0.5 per 100,000. (2, 4) The application of the modified Bradford-Hill criteria to VITT following CHADOX1 NCOV- vaccine strongly supports a causal relationship.

Objective We aimed to determine the prevalence and outcome of occult infection with SARS-CoV-2 and influenza in patients presenting with myocardial infarction (MI) without COVID-19 symptoms.Methods We conducted an observational study from 28 June to 11 August 2020, enrolling patients admitted to the National Institute of Cardiovascular Disease Hospital, Dhaka, Bangladesh, with ST-segment elevation MI (STEMI) or non-ST-segment elevation MI who did not meet WHO criteria for suspected COVID-19. Samples were collected by nasopharyngeal swab to test for SARS-CoV-2 and influenza virus by real-time reverse transcriptase PCR. We followed up patients at 3 months (13 weeks) postadmission to record adverse cardiovascular outcomes: all-cause death, new MI, heart failure and new percutaneous coronary intervention or stent thrombosis. Survival analysis was performed using the Kaplan-Meier method.Results We enrolled 280 patients with MI, 79% male, mean age 54.5±11.8 years, 140 of whom were diagnosed with STEMI. We found 36 (13%) to be infected with SARS-CoV-2 and 1 with influenza. There was no significant difference between mortality rate observed among SARS-CoV-2 infected patients compared with non-infected (5 (14%) vs 26 (11%); p=0.564). A numerically shorter median time to a recurrent cardiovascular event was recorded among SARS-CoV-2 infected compared with non-infected patients (21 days, IQR: 8–46 vs 27 days, IQR: 7–44; p=0.378).Conclusion We found a substantial rate of occult SARS-CoV-2 infection in the studied cohort, suggesting SARS-CoV-2 may precipitate MI. Asymptomatic patients with COVID-19 admitted with MI may contribute to disease transmission and warrants widespread testing of hospital admissions.

The lack of public health expertise in COVID-19 pandemic decision-making has come at a high price. We outline examples of this and explain why multidisciplinary expertise is critical for good pandemic control.

The COVID-19 pandemic has caused severe health and economic impacts globally. Strategies to safely reopen economies, travel and trade are a high priority. Until a reliable vaccine is available, non-pharmaceutical techniques are the only available means of disease control. In this paper, we aim to evaluate the extent to which social distancing (SD) and facemask (FM) use can mitigate the transmission of COVID-19 when restrictions are lifted. We used a microsimulation activity-based model for Sydney Greater Metropolitan Area, to evaluate the power of SD and FM in controlling the pandemic under numerous scenarios. The hypothetical scenarios are designed to picture feasible futures under different assumptions. Assuming that the isolation of infected cases and the quarantining of close contacts are in place, different numerical tests are conducted and a full factorial two-way MANOVA test is used to evaluate the effectiveness of the FM and SD control strategies. The main and interactive effects of the containment strategies are evaluated by the total number of infections, percentage of infections reduction, the time it takes to get the pandemic under control, and the intensity of active cases.

Face masks and respirators are the most widely used intervention measures for respiratory protection. In the wake of COVID-19, in response to shortages and lack of availability of surgical masks and respirators, the use of cloth masks has become a research focus. Various fabrics have been promoted with little evidence-based foundation and without guidelines on design principles for optimal performance. In these circumstances, it is essential to understand the properties, key performance factors, filter mechanisms and evidence on cloth masks materials. The general community might also need to decontaminate and reuse disposable, single-use devices as a last resort. We present an overview of the filter materials, filter mechanisms and effectiveness, key performance factors, and hydrophobicity of the common disposable masks, as well as cloth masks. We also reviewed decontamination methods for disposable respiratory devices. As an alternative to surgical masks and respirators, we recommend a cloth mask made of at least three layers (300–350 threads per inch) and adding a nylon stocking layer over the mask for a better fit. Water-resistant fabrics (polyesters/nylon), blends of fabrics and water-absorbing fabrics (cotton) should be in the outside layer, middle layer/layers and inside layer, respectively. The information outlined here will help people to navigate their choices if facing shortages of appropriate respiratory protection during the COVID-19 pandemic.

Reflections on Dr J Michael Lane (1936-2020) a global leader in smallpox eradication and the Director of Smallpox Eradication at the US CDC. Dr Lane was an alumnus of the US CDC's Epidemic Intelligence Service and had worked in global health on control of outbreaks in many countries. He was a pivotal figure in smallpox eradication, especially in identifying the risk of continuing smallpox vaccination in the US when disease incidence was low. This article is a reflection on his global contributions to infectious diseases control.

We used open source data from the Epiwatch observatory to monitor for early disease signals in Russia and surrounding countries following an explosion at a BSL 4 laboratory, Vector, in Siberia in September 2019. Upon news of the explosion at Vector on September 16th 2019, the Epiwatch team added the Russian language and key words Russia, Siberia, Novosibirsk, and Koltsovo to the Standard Operating Procedures, in addition to the usual epidemic-specific keywords used in Epiwatch. We also searched for outbreak reports in countries bordering Siberia, including Mongolia, Kazakhstan and China. Given local spread of an epidemic could manifest in these countries, we included searching in Chinese, Mongolian and Kazakh. We added “Ukraine” as a key word, given current conflict between Russia and Ukraine. Data collection began in September 2019, one week after the explosion, with this considered the baseline. We demonstrate a method for rapid epidemic intelligence following an incident of concern, the explosion at Vector. There were some unexplained outbreaks in Russia in the three months following the explosion. No unexplained outbreaks were detected in countries bordering Russia, nor in Ukraine in the three months following the explosion. We detected an accidental release of brucella from a laboratory in China in early December 2019 and two reports of severe pneumonia prior to official reports, which could have been early COVID-19 cases. Best practice in preparedness should include surveillance for disease events in the months following an event of concern at local, national and global levels. In the absence of official surveillance data, open source intelligence may be the only available means of detecting outbreaks and enabling early response and mitigation for the rest of the world. Epiwatch was able to identify reports of Russian outbreaks in the weeks and months following the Vector explosion, which allowed monitoring of outbreaks of concern without a known cause.

Introduction: Pertussis is a highly infectious disease that remains endemic despite a rising vaccination coverage rates globally. Due to the lack of global surveillance data for pertussis, the unconventional use of open-source data gives a glimpse into global outbreaks, compensating for the lack of national reporting systems in some countries. The objective of the study is to describe global reporting of pertussis through open source data. Methods: An open-source database, EpiWATCH was used to analyse global outbreaks of pertussis. Data was retrieved on pertussis and analysed on multiple epidemiological factors from 2016 to 2019. In addition, prevalence rates were calculated for each country and compared to the World Health Organization (WHO) public domain data on global reported cases. Results: A total of 96 reports were collected globally between the years 2016 to 2019. Of those reports, 95.8% (92/96) were from high-income countries. Data from the United States comprised 59.3% (57/96) of the total reports. . In addition, prevalence rates were calculated for each country and compared to the World Health Organization (WHO) public domain data on global reported cases. An outbreak report was identified in Papua New Guinea, which was not reported in WHO surveillance. Discussion: Open-source data gives insight and analysis on pertussis outbreaks globally, given there is no formal global surveillance system for pertussis. There is a bias toward reports from high income countries in open source data. However, the timeliness of reporting coupled with assisting countries with lacking national reporting systems are benefits of open source data.

Awareness and concern over the occupational health and safety of first responders to biological threat and other hazardous exposures has grown. Law enforcement personnel play an important role in the response to such events and may even be the first on the scene to hazardous exposures. Front line police entering a property and expecting to find drugs and weapons may also unexpectedly find biological or chemical agents. In the case of a pandemic like COVID-19, they may be exposed to virus in their ordinary duties. We argue that the risk of exposure is increasing, and will continue to increase, driven by advances in science and biology which makes chemical and biological agents more accessible to a wide range of actors. In addition, serious epidemics of newly emerged infections are increasing in frequency. Although the level of risk to police will vary depending on the exposure, the uniformed officers at the front line may be at highest risk because of a higher likelihood of being unprotected when they encounter biothreats. Planning focuses on response to known events by well-trained and well-equipped HAZMAT (hazardous materials) teams. Better preparedness is required for unexpected exposure of front-line police. This includes expanded training and design of regular uniforms to reduce exposure, provision of personal protective equipment (PPE) kits which include disinfectant wipes, chemical wipes and biosensors. As the use of chemical and biological weapons by nefarious actors increases, these changes may become a necessity to protect the occupational health and safety of police.

Background: Salmonella is one of the leading causes of foodborne outbreaks globally, with chicken and eggs the most common food vehicles associated. Fruit and vegetables have increasingly been reported as vehicles for salmonella. Aims: We aimed to determine the trends in salmonella outbreaks associated with cucumbers, as well as other fruit and vegetables from 2009-2017. Methods: Data from the published and grey literature were searched to investigate outbreaks of Salmonella globally caused by fruit and vegetables and specifically cucumbers. An open-source epidemic database, Epi-Watch, was also searched for salmonella outbreaks. Results: We identified and described 39 Salmonella outbreaks due to fruit and vegetables between 2009 and 2017 from Northern America, Europe, and Australia, including 6 multi-state and 1 state-based outbreaks due to cucumbers, the first being documented in 2013. The proportion of Salmonella outbreaks cause by fruit and vegetables has been increasing, as observed in both the United States of America (USA) and Australia. Conclusions: There has been a shift in the epidemiology of foodborne Salmonella outbreaks, with a higher number and proportion now associated with fruit and vegetables. This includes novel vehicles such as cucumbers, only reported as a vehicle for Salmonella since 2013. Emergence of less common serotypes has been observed in outbreaks from 2017-2019. Prevention at the production stage is important with limited options for consumers to reduce their risk of vegetable-associated Salmonella. Globalisation, changes in farming practices and importation of produce remains a challenge in monitoring and ensuring safety in the food supply chain.

First reported in March 2014, an Ebola epidemic impacted West Africa, most notably Liberia, Guinea and Sierra Leone. We demonstrate the value of social media for automated surveillance of infectious diseases such as the West Africa Ebola epidemic. We experiment with two variations of an existing surveillance architecture: the first aggregates tweets related to different symptoms together, while the second considers tweets about each symptom separately and then aggregates the set of alerts generated by the architecture. Using a dataset of tweets posted from the affected region from 2011 to 2014, we obtain alerts in December 2013, which is three months prior to the official announcement of the epidemic. Among the two variations, the second, which produces a restricted but useful set of alerts, can potentially be applied to other infectious disease surveillance and alert systems.

BACKGROUND:Influenza continues to cause seasonal epidemics and pandemics in humans. The burden of influenza is underestimated by traditional laboratory-based surveillance, and modelled estimates are required for influenza-attributable morbidity and mortality. We aimed to estimate the influenza-attributable hospitalisation in Australia, by influenza type. METHODS:A generalised-additive regression model was used to estimate type- and age-specific influenza-attributable hospitalisation rates per 100,000 population by principal diagnosis in Australia, from 2001 through 2013. Weekly counts of laboratory-confirmed influenza notifications and by type, influenza A and B were used as covariates in the model. Main principal diagnosis categories of interest were influenza and pneumonia and respiratory admissions. A smoothing spline was used to control for unmeasured time varying factors. Results for 2009, in which the pandemic influenza A(H1N1)pdm09 virus circulated, were not included in annual averages and are reported separately. RESULTS:During the study period, the estimated annual average, all-age, annual respiratory hospitalisation rates attributable to seasonal influenza type A, B and total influenza were 45.4 (95% CI: 34.9, 55.9), 32.6 (95% CI: 22.8, 42.4), and 76.9 (95% CI: 73.6, 80.2) per 100,000 population, respectively. During 2009, the estimated total pandemic influenza-attributable, all-age, respiratory hospitalisation rate was 56.1 (95% CI: 47.4, 64.9) per 100,000. Older adults (≥85 years of age) experienced the highest influenza-attributable hospitalisation rates for both seasonal and 2009 pandemic influenza. Collinearity between influenza A and B time series in some years limited the ability of the model to resolve differences in influenza attribution between the two virus types. CONCLUSION:Both seasonal and pandemic influenza caused considerable morbidity in Australia during the years studied, particularly among older adults. The pandemic hospitalisation rate in 2009 was lower than the average overall annual rate for seasonal influenza, but young to middle aged adults experience a hospitalisation rate similar to that of severe seasonal influenza.

Watching brief on 2019nCoV novel coronavirus epidemic - updated January 27th 2020.

[This corrects the article DOI: 10.1371/journal.pone.0174980.].

Herpes zoster (HZ) is a common condition that increases in incidence with older age but vaccines are available to prevent the disease. However, there are limited data estimating the health system burden attributable to herpes zoster by age.In this study, we quantified excess healthcare resource usage associated with HZ during the acute/sub-acute period of disease (21days before to 90 days after onset) in 5952 cases and an equal number of controls matched on age, sex, and prior healthcare resource usage. Estimates were adjusted for potential confounders in multivariable regression models. Using population-based estimates of HZ incidence, we calculated the age-specific excess number of health service usage events attributable to HZ in the population.Per HZ case, there was an average of 0.06 (95% CI 0.04-0.08) excess hospitalisations, 1.61 (95% CI 1.51-1.69) excess general practitioner visits, 1.96 (95% CI 1.86-2.15) excess prescriptions filled and 0.11 (95% CI 0.09-0.13) excess emergency department visits. The average number of healthcare resource use events, and the estimated excess per 100,000 population increased with increasing age but were similar for men and women, except for higher rates of hospitalisation in men. The excess annual HZ associated burden of hospitalisations was highest in adults ≥80 years (N = 2244, 95%CI 1719-2767); GP visits was highest in those 60-69 years (N = 50567, 95%CI 39958-61105), prescriptions and ED visits were highest in 70-79 years (N = 50524, 95%CI 40634-60471 and N = 2891, 95%CI 2319-3449 respectively).This study provides important data to establish the healthcare utilisation associated with HZ against which detailed cost-effectiveness analyses of HZ immunisation in older adults can be conducted.

Elimination of endemic measles transmission is the culmination of a range of control measures at a national level. Current documentation of elimination proposed by WHO's regional offices requires achieving specific targets for surveillance process indicators. We demonstrate how Australia, although not meeting these specific targets, has satisfied multiple criteria that justify the formal declaration of measles elimination. Our review shows that few countries previously declaring measles elimination have satisfied the current WHO surveillance targets. We argue that the requirements for recognition of measles elimination should not restrict countries to a particular type of surveillance system or surveillance criteria.

Serfling-type periodic regression models have been widely used to identify and analyse epidemic of influenza. In these approaches, the baseline is traditionally determined using cleaned historical non-epidemic data. However, we found that the previous exclusion of epidemic seasons was empirical, since year-year variations in the seasonal pattern of activity had been ignored. Therefore, excluding fixed 'epidemic' months did not seem reasonable. We made some adjustments in the rule of epidemic-period removal to avoid potentially subjective definition of the start and end of epidemic periods. We fitted the baseline iteratively. Firstly, we established a Serfling regression model based on the actual observations without any removals. After that, instead of manually excluding a predefined 'epidemic' period (the traditional method), we excluded observations which exceeded a calculated boundary. We then established Serfling regression once more using the cleaned data and excluded observations which exceeded a calculated boundary. We repeated this process until the R2 value stopped to increase. In addition, the definitions of the onset of influenza epidemic were heterogeneous, which might make it impossible to accurately evaluate the performance of alternative approaches. We then used this modified model to detect the peak timing of influenza instead of the onset of epidemic and compared this model with traditional Serfling models using observed weekly case counts of influenza-like illness (ILIs), in terms of sensitivity, specificity and lead time. A better performance was observed. In summary, we provide an adjusted Serfling model which may have improved performance over traditional models in early warning at arrival of peak timing of influenza.

BackgroundOfficial statistics under-estimate influenza deaths. Time series methods allow the estimation of influenza-attributable mortality. The methods often model background, non-influenza mortality using a cyclic, harmonic regression model based on the Serfling approach. This approach assumes that the seasonal pattern of non-influenza mortality is the same each year, which may not always be accurate.AimTo estimate Australian seasonal and pandemic influenza-attributable mortality from 2003 to 2009, and to assess a more flexible influenza mortality estimation approach.MethodsWe used a semi-parametric generalized additive model (GAM) to replace the conventional seasonal harmonic terms with a smoothing spline of time ('spline model') to estimate influenza-attributable respiratory, respiratory and circulatory, and all-cause mortality in persons aged ResultsCompared with the harmonic model, the spline model improved model fit by up to 20%. In ConclusionsThe spline model achieved a better model fit. The study provides additional evidence that seasonal influenza, particularly A/H3N2, remains an important cause of mortality in Australia and that the epidemic of pandemic influenza A (H1N1)pdm09 virus in 2009 did not result in mortality greater than seasonal A/H3N2 influenza mortality, even in younger age groups.

BackgroundHistorically, counting influenza recorded in administrative health outcome databases has been considered insufficient to estimate influenza attributable morbidity and mortality in populations. We used database record linkage to evaluate whether modern databases have similar limitations.MethodsPerson-level records were linked across databases of laboratory notified influenza, emergency department (ED) presentations, hospital admissions and death registrations, from the population (∼6.9 million) of New South Wales (NSW), Australia, 2005 to 2008.ResultsThere were 2568 virologically diagnosed influenza infections notified. Among those, 25% of 40 who died, 49% of 1451 with a hospital admission and 7% of 1742 with an ED presentation had influenza recorded on the respective database record. Compared with persons aged ≥65 years and residents of regional and remote areas, respectively, children and residents of major cities were more likely to have influenza coded on their admission record. Compared with older persons and admitted patients, respectively, working age persons and non-admitted persons were more likely to have influenza coded on their ED record. On both ED and admission records, persons with influenza type A infection were more likely than those with type B infection to have influenza coded. Among death registrations, hospital admissions and ED presentations with influenza recorded as a cause of illness, 15%, 28% and 1.4%, respectively, also had laboratory notified influenza. Time trends in counts of influenza recorded on the ED, admission and death databases reflected the trend in counts of virologically diagnosed influenza.ConclusionsA minority of the death, hospital admission and ED records for persons with a virologically diagnosed influenza infection identified influenza as a cause of illness. Few database records with influenza recorded as a cause had laboratory confirmation. The databases have limited value for estimating incidence of influenza outcomes, but can be used for monitoring variation in incidence over time.

BackgroundElderly people do not mount strong immune responses to vaccines. We compared 23-valent capsular polysaccharide (23vPPV) alone versus 7-valent conjugate (PCV7) vaccine followed by 23vPPV 6 months later in hospitalized elderly.MethodsParticipants were randomized to receive 23vPPV or PCV7-23vPPV. Antibodies against serotypes 3, 4, 6A, 6B, 9V, 14, 18C, 19A, 19F, 23F were measured by enzyme-linked immunosorbent (ELISA) and opsonophagocytic (OPA) assays at baseline, 6 months and 12 months.ResultsOf 312 recruited, between 40% and 72% of subjects had undetectable OPA titres at baseline. After one dose, PCV7 recipients had significantly higher responses to serotypes 9V (both assays) and 23F (OPA only), and 23vPPV recipients had significantly higher responses to serotype 3 (ELISA), 19F and 19A (OPA only). In subjects with undetectable OPA titres at baseline, a proportionately greater rise in OPA titre (PConclusionWe did not show overwhelming benefit of one vaccine over the other. Low baseline immunity does not preclude a robust immune response, reiterating the importance of vaccinating the frail elderly. A schedule of PCV7-23vPPV prevents waning of antibody, suggesting that both vaccines could be useful in the elderly. Follow up studies are needed to determine persistence of immunity.Trial registrationThe Australian Clinical Trials Registry ACTRN12607000387426.

BACKGROUND: In October 2004, Manam Island volcano in Papua New Guinea erupted, causing over 10 000 villagers to flee to internally displaced person (IDP) camps, including 550 from Dugulaba village. Following violence over land access in March 2010, the IDPs fled the camps, and four months later concurrent outbreaks of acute watery diarrhea and unusual neurological complaints were reported in this population. MATERIALS AND METHODS: A retrospective case-control study was conducted to identify the risk factors for peripheral neuropathy. Rectal swabs were collected from cases of acute watery diarrhea. Hair and serum metals and metalloids were analyzed by Inductively Coupled Plasma-Mass Spectrometry (ICP-MS). RESULTS: There were 17 deaths among the 550 village inhabitants during the outbreak period at a crude mortality rate 21-fold that of a humanitarian crisis. Vibrio cholerae O1 El Tor Ogawa was confirmed among the population. Access to community-level rehydration was crucial to mortality. Peripheral neuropathy was diagnosed among cases with neurological symptoms. A balanced diet was significantly protective against neuropathy. A dose-response relationship was seen between peripheral neuropathy and a decreasing number of micronutrient- rich foods in the diet. Deficiencies in copper, iron, selenium and zinc were identified among the cases of peripheral neuropathy. CONCLUSIONS: Cholera likely caused the mostly preventable excess mortality. Peripheral neuropathy was not caused by cholera, but cholera may worsen existing nutritional deficiencies. The peripheral neuropathy was likely caused by complex micronutrient deficiencies linked to non-diversified diets that potentially increased the vulnerability of this population, however a new zinc-associated neuropathy could not be ruled out. Reoccurrence can be prevented by addressing the root cause of displacement and ensuring access to arable land and timely resettlement.

BACKGROUND:The aetiological role of human papillomavirus (HPV) in oesophageal squamous cell carcinoma (OSCC) has been widely researched for more than three decades, with conflicting findings. In the absence of a large, adequately powered single case-control study, a meta-analysis of all available case-control studies is the most rigorous way of identifying any potential association between HPV and OSCC. We present the first global meta-analysis of case-control studies investigating the role of HPV in OSCC. METHODS:Case-control studies investigating OSCC tissue for presence of HPV DNA were identified. 21 case-control studies analyzing a total of 1223 cases and 1415 controls, met our inclusion criteria. HPV detection rates were tabulated for each study and all studies were assessed for quality. The random effects method was used to pool the odds ratios (OR). RESULTS:From all OSCC specimens included in this meta-analysis, 35% (426/1223) were positive for HPV DNA. The pooled OR for an HPV-OSCC association was 3.04 (95% CI 2.20 to 4.20). Meta-regression analysis did not find a significant association between OR and any of the quality domains. Influence analysis was non-significant for the effect of individual studies on the pooled estimate. Studies conducted in countries with low to medium OSCC incidence showed a stronger relationship (OR 4.65, 95% CI 2.47 to 8.76) than regions of high OSCC incidence (OR 2.65, 95% CI 1.80 to 3.91). CONCLUSIONS:Uncertainty around the aetiological role of HPV in OSCC is due largely to the small number and scale of appropriately designed studies. Our meta-analysis of these studies suggests that HPV increases the risk of OSCC three-fold. This study provides the strongest evidence to date of an HPV-OSCC association. The importance of these findings is that prophylactic vaccination could be of public health benefit in prevention of OSCC in countries with high OSCC incidence.

BACKGROUND: Influenza is an important cause of morbidity and mortality for frail older people. Whilst the antiviral drug oseltamivir (a neuraminidase inhibitor) is approved for treatment and prophylaxis of influenza during outbreaks, there have been no trials comparing treatment only (T) versus treatment and prophylaxis (T&P) in Aged Care Facilities (ACFs). Our objective was to compare a policy of T versus T&P for influenza outbreaks in ACFs. METHODS AND FINDINGS: We performed a cluster randomised controlled trial in 16 ACFs, that followed a policy of either "T"-oseltamivir treatment (75 mg twice a day for 5 days)-or "T&P"-treatment and prophylaxis (75 mg once a day for 10 days) for influenza outbreaks over three years, in addition to enhanced surveillance. The primary outcome measure was the attack rate of influenza. Secondary outcomes measures were deaths, hospitalisation, pneumonia and adverse events. Laboratory testing was performed to identify the viral cause of influenza-like illness (ILI) outbreaks. The study period 30 June 2006 to 23 December 2008 included three southern hemisphere winters. During that time, influenza was confirmed as the cause of nine of the 23 ILI outbreaks that occurred amongst the 16 ACFs. The policy of T&P resulted in a significant reduction in the influenza attack rate amongst residents: 93/255 (36%) in residents in T facilities versus 91/397 (23%) in T&P facilities (p=0.002). We observed a non-significant reduction in staff: 46/216 (21%) in T facilities versus 47/350 (13%) in T&P facilities (p=0.5). There was a significant reduction in mean duration of outbreaks (T=24 days, T&P=11 days, p=0.04). Deaths, hospitalisations and pneumonia were non-significantly reduced in the T&P allocated facilities. Drug adverse events were common but tolerated. CONCLUSION: Our trial lacked power but these results provide some support for a policy of "treatment and prophylaxis" with oseltamivir in controlling influenza outbreaks in ACFs. TRIAL REGISTRATION: [corrected] Australian Clinical Trials Registry ACTRN12606000278538.

OBJECTIVES: The aim of the study was to determine rates of mask-wearing, of respiratory infection and the factors associated with mask-wearing and of respiratory infection in healthcare workers (HCWs) in Beijing during the winter of 2007/2008. METHODS: We conducted a survey of 400 HCWs working in eight hospitals in Beijing by face to face interview using a standardized questionnaire. RESULTS: We found that 280/400 (70.0%) of HCWs were compliant with mask-wearing while in contact with patients. Respiratory infection occurred in 238/400 (59.5%) subjects from November, 2007 through February, 2008. Respiratory infection was higher among females (odds ratio [OR], 2.00 [95% confidence interval {CI}, 1.16-3.49]) and staff working in larger hospitals (OR, 1.72 [95% CI, 1.092.72]), but was lower among subjects with seasonal influenza vaccination (OR, 0.46 [95% CI, 0.280.76]), wearing medical masks (reference: cotton-yarn; OR, 0.60 [95% CI, 0.39-0.91]) or with good mask-wearing adherence (OR, 0.60 [95% CI, 0.37-0.98]). The risk of respiratory infection of HCWs working in low risk areas was similar to that of HCWs in high risk area. CONCLUSION: Our data suggest that female HCWs and staffs working in larger hospitals are the focus of prevention and control of respiratory infection in Beijing hospitals. Mask-wearing and seasonal influenza vaccination are protective for respiratory infection in HCWs; the protective efficacy of medical masks is better than that of cotton yarn ones; respiratory infection of HCWs working in low risk areas should also be given attention.