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BACKGROUND: Improving the epidemiological response to emergencies requires an understanding of who the responders are, their role and skills, and the challenges they face during responses. In this paper, we explore the role of the epidemiologist and identify challenges they face during emergency response. METHODS: We conducted a cross-sectional survey to learn more about epidemiologists who respond to public health emergencies. The online survey included open and closed-ended questions on challenges faced while responding, the roles of epidemiology responders, self-rating of skills, and support needed and received. We used purposive sampling to identify participants and a snowballing approach thereafter. We compared data by a number of characteristics, including national or international responder on their last response prior to the survey. We analysed the data using descriptive, content, and exploratory factor analysis. RESULTS: We received 166 responses from individuals with experience in emergency response. The most frequently reported challenge was navigating the political dynamics of a response, which was more common for international responders than national. National responders experienced fewer challenges related to culture, language, and communication. Epidemiology responders reported a lack of response role clarity, limited knowledge sharing, and communication issues during emergency response. Sixty-seven percent of participants reported they needed support to do their job well; males who requested support were statistically more likely to receive it than females who asked. CONCLUSIONS: Our study identified that national responders have additional strengths, such as better understanding of the local political environment, language, and culture, which may in turn support identification of local needs and priorities. Although this research was conducted prior to the COVID-19 pandemic, the results are even more relevant now. This research builds on emerging e

[This corrects the article DOI: 10.2471/BLT.20.276998.].

OBJECTIVE: To determine the challenges met by, and needs of, the epidemiology emergency response workforce, with the aim of informing the development of a larger survey, by conducting key informant interviews of public health experts. METHODS: We defined our study population as public health experts with experience of epidemiology deployment. Using purposive sampling techniques, we applied random number sampling to shortlists of potential interviewees provided by key organizations to obtain 10 study participants; we identified three additional interviewees through snowballing. The same interviewer conducted all key informant interviews during May-August 2019. We thematically analysed de-identified transcripts using a qualitative data analysis computer software package. FINDINGS: Despite our interviewees having a wide range of organizational and field experience, common themes emerged. Interviewees reported a lack of clarity in the definition of an emergency response epidemiologist; the need for a broader range of skills; and inadequate leadership and mentoring in the field. Interviewees identified the lack of interpersonal skills (e.g. communication) and a lack of career progression options as limitations to the effectiveness of emergency response. CONCLUSION: The epidemiology emergency response workforce is currently not achieving collective competence. The lack of a clear definition of the role must be addressed, and leadership is required to develop teams in which complementary skills are harmonized and those less experienced can be mentored. Epidemiology bodies must consider individual professional accreditation to ensure that the required skills are being achieved, as well as enabling continual professional development.

For public health response to be effective, it is essential that we identify support mechanisms for people working in challenging response environments. The Regional Office for the Western Pacific needs programmes, such as Field Epidemiology Training Programmes, to ensure sustained workforce development. However, during crises a modified mentorship-like program may foster temporary support and empowerment within the workforce.

BACKGROUND: Effective implementation requires a comprehensive understanding of individual, organisational and system determinants. This study aimed to compare inductive and deductive analysis techniques to understand a complex implementation issue. We used childhood vaccination as a case study, an issue with wide-ranging barriers contributing to low-vaccine uptake internationally. METHODS: The study is based on the Behaviour Change Wheel framework, which was derived from several levels of theory: the 3 components of the COM-B framework (capability, opportunity and motivation) can be mapped to the 14 domains of the Theoretical Domains Framework (TDF), which is based on 84 underlying constructs. We first conducted a review of systematic reviews of parent-level barriers to childhood vaccination. Subsequently we (1) inductively coded these barriers into a data-driven framework, using thematic analysis, and (2) deductively mapped the barriers to COM-B and TDF domains and constructs. These processes were undertaken by two authors independently, and discrepancies were resolved through discussion. Inductive and deductive results were compared. RESULTS: The inductive process coded 583 descriptions of barriers identified from the literature into a framework of 74 barriers in 7 categories. The initial definitions used to map the barriers to deductive domains/constructs led to 89% agreement at the domain level. Resolving discrepancies required further definitions at the construct level. Of the 14 TDF domains, 10 were clearly identified in the data from the barrier reviews. Some domains were not specific enough to differentiate between types of barriers (e.g. Environmental Context and Resources), while other domains were not represented in the review data (e.g. Behavioural Regulation). CONCLUSIONS: Using both inductive and deductive analysis techniques can help achieve a more comprehensive understanding of barriers to health service implementation. The inductive categories repre

INTRODUCTION: Understanding barriers to childhood vaccination is crucial to inform effective interventions for maximising uptake. Published systematic reviews include different primary studies, producing varying lists of barriers. To make sense of this diverse body of literature, a comprehensive level of summary and synthesis is necessary. This overview of systematic reviews maps all potential parent-level barriers to childhood vaccination identified in systematic reviews. It synthesises these into a conceptual framework to inform development of a vaccine barriers assessment tool. METHODS: We applied Joanna Briggs methodology, searching the Epistemonikos review database and reference lists of included reviews to June 2020. Systematic reviews of qualitative or quantitative data on parent-level barriers to routine vaccination in preschool-aged children were included. Reviews addressing influenza, reporting non-modifiable determinants or reporting barriers not relevant to parents were excluded. Where possible, we extracted review details, barrier descriptions and the number, setting and design of primary studies. Two authors independently screened search results and inductively coded barrier descriptions. RESULTS: We screened 464 papers, identifying 30 relevant reviews with minimal overlap. Fourteen reviews included qualitative and quantitative primary studies, seven included quantitative and seven included qualitative studies only. Two did not report included study designs. Two-thirds of reviews (n=20; 67%) only included primary studies from high-income countries. We extracted 573 barrier descriptions and inductively coded these into 64 unique barriers in six overarching categories: (1) Access, (2) Clinic or Health System Barriers, (3) Concerns and Beliefs, (4) Health Perceptions and Experiences, (5) Knowledge and Information and (6) Social or Family Influence. CONCLUSIONS: A global overview of systematic reviews of parent-level barriers to childhood vaccine uptake id

BACKGROUND: Rapid and effective emergency response to address health security relies on a competent and suitably trained local and international workforce. The COVID-19 pandemic has highlighted that the health security workforce needs to be well equipped to tackle current and future challenges. In this study, we explored whether training in applied epidemiology was meeting the current needs of the applied epidemiology workforce. METHOD: We conducted a cross-sectional online survey that was available in English and French. We used purposive and snowballing sampling techniques to identify potential survey respondents. An online social media advertisement campaign was used to disseminate a REDCap survey link between October 2019 and February 2020 through field epidemiology networks. Survey questions included demographic details of participants, along with their technical background, level of formal education, topics studied during epidemiology training, and years of experience as an epidemiologist. We used Pearson Chi-squared (Chi2) to test the difference between categorical variables, and content analysis to evaluate responses to open-ended questions. RESULTS: In total, 282 people responded to the survey. Participants had a range of formal public health and epidemiology training backgrounds. Respondents applied epidemiology experience spanned almost 30 years, across 64 countries. Overall, 74% (n = 210) were alumni of Field Epidemiology Training Programs (FETP). Basic outbreak and surveillance training was well reported by respondents, however training in specialised techniques related to emergency response, communication, and leadership was less common. FETP graduates reported higher levels of formal training in all survey topics. CONCLUSION: It is critical for the health security workforce to be well-trained and equipped with skills needed to ensure a rapid and effective response to acute public health events. Leadership, communication, interpersonal skills, and spec

Salmonella enterica serovar Wangata (S. Wangata) is an important cause of endemic salmonellosis in Australia, with human infections occurring from undefined sources. This investigation sought to examine possible environmental and zoonotic sources for human infections with S. Wangata in north-eastern New South Wales (NSW), Australia. The investigation adopted a One Health approach and was comprised of three complimentary components: a case-control study examining human risk factors; environmental and animal sampling; and genomic analysis of human, animal and environmental isolates. Forty-eight human S. Wangata cases were interviewed during a 6-month period from November 2016 to April 2017, together with 55 Salmonella Typhimurium (S. Typhimurium) controls and 130 neighbourhood controls. Indirect contact with bats/flying foxes (S. Typhimurium controls (adjusted odds ratio (aOR) 2.63, 95% confidence interval (CI) 1.06-6.48)) (neighbourhood controls (aOR 8.33, 95% CI 2.58-26.83)), wild frogs (aOR 3.65, 95% CI 1.32-10.07) and wild birds (aOR 6.93, 95% CI 2.29-21.00) were statistically associated with illness in multivariable analyses. S. Wangata was detected in dog faeces, wildlife scats and a compost specimen collected from the outdoor environments of cases' residences. In addition, S. Wangata was detected in the faeces of wild birds and sea turtles in the investigation area. Genomic analysis revealed that S. Wangata isolates were relatively clonal. Our findings suggest that S. Wangata is present in the environment and may have a reservoir in wildlife populations in north-eastern NSW. Further investigation is required to better understand the occurrence of Salmonella in wildlife groups and to identify possible transmission pathways for human infections.

Problem The emergence of Zika virus has challenged outbreak surveillance systems in many at-risk, low-resource countries. As the virus has been linked with Guillain-Barré syndrome, routine data on the incidence of acute flaccid paralysis (AFP) may provide a useful early warning system for the emergence of Zika virus. Approach We documented all Zika virus outbreaks and cases in 21 Pacific Islands and territories for the years 2007 to 2015. We extracted data from the Global Polio Eradication Initiative database on the reported and expected annual incidence of AFP in children younger than 15 years. Using a Poisson probability test, we tested the significance of unexpected increases in AFP in years correlating with Zika virus emergence. Data were analysed separately for each Pacific Island country and territory. Local setting In most Pacific Island countries, early warning surveillance for acute public health threats such as Zika virus is hampered by poor health infrastructure, insufficient human resources and geographical isolation. Relevant changes Only one example was found (Solomon Islands in 2015) of a significant increase in reported AFP cases correlating with Zika virus emergence. Lessons learnt We found no conclusive evidence that routinely reported AFP incidence data in children were useful for detecting emergence of Zika virus in this setting. More evidence may be needed from adult populations, who are more likely to be affected by Guillain-Barré syndrome. Reporting of AFP may be deficient in regions certified as polio-free.

BACKGROUND: With few studies conducted to date, very little is known about the epidemiology of rickettsioses in Bhutan. Due to two previous outbreaks and increasing clinical cases, scrub typhus is better recognized than other rickettsial infections and Q fever. METHODOLOGY: A descriptive cross-sectional serosurvey was conducted from January to March 2015 in eight districts of Bhutan. Participants were 864 healthy individuals from an urban (30%) and a rural (70%) sampling unit in each of the eight districts. Serum samples were tested by microimmunofluorescence assay for rickettsial antibodies at the Australian Rickettsial Reference Laboratory. RESULTS: Of the 864 participants, 345 (39.9%) were males and the mean age of participants was 41.1 (range 13-98) years. An overall seroprevalence of 49% against rickettsioses was detected. Seroprevalence was highest against scrub typhus group (STG) (22.6%) followed by spotted fever group (SFG) rickettsia (15.7%), Q fever (QF) (6.9%) and typhus group (TG) rickettsia (3.5%). Evidence of exposure to multiple agents was also noted; the commonest being dual exposure to STG and SFG at 5%. A person's likelihood of exposure to STG and SFG rickettsia significantly increased with age and farmers were twice as likely to have evidence of STG exposure as other occupations. Trongsa district appeared to be a hotspot for STG exposure while Punakha district had the lowest STG exposure risk. Zhemgang had the lowest exposure risk to SFG rickettsia compared to other districts. People living at altitudes above 2000 meters were relatively protected from STG infections but this was not observed for SFG, TG or QF exposure. CONCLUSION: This seroprevalence study highlights the endemicity of STG and SFG rickettsia in Bhutan. The high seroprevalence warrants appropriate public health interventions, such as diagnostic improvements and clinical treatment guidelines. Future studies should focus on vector profiles, geospatial, bio-social and environmental ris

Objective: The Pacific Syndromic Surveillance System (PSSS), launched in 2010, provides a simple mechanism by which 121 sentinel surveillance sites in 21 Pacific island countries and areas perform routine indicator- and event-based surveillance for the early detection of infectious disease outbreaks. This evaluation aims to assess whether the PSSS is meeting its objectives, what progress has been made since a formative evaluation of the system was conducted in 2011, and provides recommendations to enhance the PSSS's performance in the future. Methods: Twenty-one informant interviews were conducted with national operators of the system and regional public health agencies that use information generated by it. Historic PSSS data were analysed to assess timeliness and completeness of reporting. Results: The system is simple, acceptable and useful for public health decision-makers. The PSSS has greatly enhanced Pacific island countries' ability to undertake early warning surveillance and has contributed to efforts to meet national surveillance-related International Health Regulation (2005) capacity development obligations. Despite this, issues with timeliness and completeness of reporting, data quality and system stability persist. Conclusion: A balance between maintaining the system's simplicity and technical advances will need to be found to ensure its long-term sustainability, given the low-resource context for which it is designed.

Background The World Health Organization (WHO) Western Pacific Region (WPR) Guidelines on verification of measles elimination were established in 2012. This article outlines Australia's approach to addressing the guideline's five lines of evidence, which led to formal verification of elimination by the WHO Regional Verification Commission (RVC) in March 2014. Methods The criteria were addressed using national measles notifications, data from selected laboratories, the national childhood immunization register, and three national serosurveys (1998/1999, 2002, 2007). Results Australia met or exceeded all indicator targets with either national or sentinel data. Laboratory and epidemiological surveillance were of high quality, with 85% of cases documented as imported/import-related (target 80%); coverage with the first dose of measles vaccine was close to 94% in 2008–2012 and second dose coverage increased to 91% in 2012 (target >95%). There is ongoing commitment by the Australian Government to increase immunization coverage, and the absence of sustained transmission of any single measles genotype was demonstrated. Conclusions This is the first documentation of the successful application of the WPR RVC guidelines. The indicators afford some flexibility but appear to provide appropriate rigor to judge achievement of measles elimination. Our experience could assist other countries seeking to verify their elimination status.

BACKGROUND: Australia uses acute flaccid paralysis (AFP) surveillance to monitor its polio-free status. The World Health Organization criterion for a sensitive AFP surveillance system is the annual detection of at least one non-polio AFP case per 100,000 children aged less than 15 years, a target Australia has not consistently achieved. Children exhibiting AFP are likely to be hospitalised and may be admitted to an intensive care unit. This provides a potential opportunity for active AFP surveillance. METHODS: A data-linkage study for the period from 1 January 2005 to 31 December 2008 compared 165 non-polio AFP cases classified by the Polio Expert Panel with 880 acute neurological presentations potentially compatible with AFP documented in the Australian and New Zealand Paediatric Intensive Care (ANZPIC) Registry. RESULTS: Forty-two (25%) AFP cases classified by the Polio Expert Panel were matched to case records in the ANZPIC Registry. Of these, nineteen (45%) cases were classified as Guillain-Barré syndrome on both registries. Ten additional Guillain-Barré syndrome cases recorded in the ANZPIC Registry were not notified to the national AFP surveillance system. CONCLUSIONS: The identification of a further ten AFP cases supports inclusion of intensive care units in national AFP surveillance, particularly specialist paediatric intensive care units, to identify AFP cases that may not otherwise be reported to the national surveillance system.