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Funding: Research activities were supported, in part, by the University of New England Faculty of Medicine and Health Discretionary Funds. Open access publishing facilitated by University of New England, as part of the Wiley ‐ University of New England agreement via the Council of Australian University Librarians. Objective : To assess awareness and risk of Q fever among agricultural show attendees. Setting : University of New England's Farm of the Future Pavilion, 2019, Sydney Royal Agricultural Show. Participants : Participants were ≥18 years, fluent in English, Australian residents, and gave their informed consent. Main Outcome Measures : Participants reported whether they had ever heard of Q fever and then completed the ‘Q Tool’ (www.qfevertool.com), which was used to assess participants' demographics and risk profiles. Cross-tabulations and logistic regression analyses were used to examine the relationship between these factors. Results : A total of 344 participants were recruited who, in general, lived in major NSW cities and were aged 40–59 years. 62% were aware of Q fever. Living in regional/remote areas and regular contact with livestock, farms, abattoirs and/or feedlots increased the likelihood of Q fever awareness. Direct or indirect contact with feral animals was not associated with Q fever awareness after controlling for the latter risk factors. 40% of participants had a high, 21% a medium, and 30% a low risk of exposure. Slightly less than 10% reported a likely existing immunity or vaccination against Q fever. Among those who were not immune, living in a regional or remote area and Q fever awareness were independently associated with increased likelihood of exposure. Conclusions : Awareness of Q fever was relatively high. Although 61% of participants had a moderate to high risk of exposure to Q fever, they had not been vaccinated. This highlights the need to explore barriers to vaccination including accessibility of providers and associated cost. Publisher PDF

Background: Q fever often presents as an undifferentiated febrile illness. Cases occur throughout Australia, with higher rates occurring in northern New South Wales and southern Queensland. Objective: This article aims to provide clinicians with an overview of Q fever, and covers epidemiology, clinical features, laboratory diagnosis, sequelae, management and prevention. Discussion: In Australia, Q fever is the most commonly reported zoonotic disease. Presentation includes fever, rigors, chills, headache, extreme fatigue, drenching sweats, weight loss, arthralgia and myalgia, often in conjunction with abnormal liver function tests. These features make it indistinguishable from many other febrile illnesses. Exposure occurs through contact with livestock and other animals. 'Coxiella' bacteria can survive in dust, where infection may result from inhalation. Laboratory diagnosis is made by serology or polymerase chain reaction. An effective vaccine is available for adults (aged >15 years), but can only be administered after a rigorous pre-vaccination assessment to exclude prior exposure to 'Coxiella burnetii', requiring a detailed medical history, skin test and serology.

Q fever remains an important notifiable, zoonotic disease in Australia. Previous epidemiological reviews have noted increased importance of non-abattoir contact with livestock and native/feral animals. Changes to surveillance in New South Wales (NSW) have provided enhanced surveillance data with which to examine exposure pathways.Descriptive analysis of NSW Q fever notification data for the period 2005-2015, with detailed analysis of exposures for the period 2011-2015 (after introduction of improvements to surveillance).Between 2005 and 2015, 1,653 confirmed cases of Q fever were notified in NSW residents who acquired the disease in this state. For the period 2011-2015, a high-risk occupation was reported in 345/660 (52.3%) of notifications with a known occupation. Of 641 cases with a known animal exposure, 345 (53.8%) had direct contact with livestock, while 62 (9.7%) had indirect contact with livestock (e.g. proximity to livestock, livestock holding areas or trucks). Direct or indirect contact with native/feral animals was reported in 111/641 (17.3%) cases. Mowing and close proximity to kangaroos/wallabies were commonly reported indirect exposure pathways, particularly in urban areas.Enhancements to the state based surveillance database in NSW introduced in 2010 have resulted in improved collection of surveillance data for Q fever. Further refinement of Q fever surveillance can be achieved through continuing to improve data quality, standardising data collection and better elucidating exposure pathways of cases.

There is limited evidence of rickettsial diseases in Bhutan. We explored the contribution of rickettsioses as a cause of undifferentiated febrile illness in patients presenting to 14 Bhutanese hospitals from October 2014 to June 2015. Obvious causes of fever were excluded clinically. Clinico-demographic information and acute blood samples were collected. Samples were tested by immunofluorescence assay (IFA) and qPCR against scrub typhus group (STG), spotted fever group (SFG) and typhus group (TG) rickettsiae, and Q fever (QF). Of the 1044 patients, 539 (51.6%) were female and the mean age was 31.5 years. At least 159 (15.2%) of the patients had evidence of a concurrent rickettsial infection. Of these, 70 (6.7%), 46 (4.4%), 4 (0.4%), and 29 (2.8%) were diagnosed as acute infections with STG, SFG, TG, and QF respectively. Ten (1.0%) patients were seropositive for both SFG and TG. Seven of the 70 STG patients were positive by qPCR. Eschar (p < 0.001), myalgia (p = 0.003), and lymphadenopathy (p = 0.049) were significantly associated with STG, but no specific symptoms were associated with the other infections. Disease incidences were not different between age groups, genders, occupations, and districts, except for students with significantly lower odds of infection with STG (OR = 0.43; 95% CI = 0.20, 0.93; p = 0.031). Rickettsioses were responsible for at least 15% of undifferentiated febrile illnesses in Bhutan, scrub typhus being the commonest. Health authorities should ensure that health services are equipped to manage these infections.

Encephalitis is a complex neurological syndrome caused by inflammation of the brain parenchyma. The management of encephalitis is challenging because: the differential diagnosis of encephalopathy is broad; there is often rapid disease progression; it often requires intensive supportive management; and there are many aetiologic agents for which there is no definitive treatment. Patients with possible meningoencephalitis are often encountered in the emergency care environment where clinicians must consider differential diagnoses, perform appropriate investigations and initiate empiric antimicrobials. For patients who require admission to hospital and in whom encephalitis is likely, a staged approach to investigation and management is preferred with the potential involvement of multiple medical specialties. Key considerations in the investigation and management of patients with encephalitis addressed in this guideline include: Which first-line investigations should be performed?; Which aetiologies should be considered possible based on clinical features, risk factors and radiological features?; What tests should be arranged in order to diagnose the common causes of encephalitis?; When to consider empiric antimicrobials and immune modulatory therapies?; and What is the role of brain biopsy?

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 risk assessment and preventive and control strategies., Author summary Rickettsial infections including scrub typhus and Q fever are not widely recognised in Bhutan although the country is situated in an endemic Asian region. With two recorded outbreaks, scrub typhus is known to occur but other rickettsial infections and Q fever have not been recorded. In this first seroprevalence study of rickettsial infections, an overall seroprevalence of 49% was detected against rickettsioses amongst 864 participants. 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 were also noted; the commonest being dual exposure to STG and SFG at 5%. A person’s likelihood of exposure to STG and SFG significantly increased with age and farmers were twice as likely to have evidence of STG exposure as other occupations. Trongsa district in central Bhutan appeared to be a hotspot for STG exposure. People living at altitudes above 2000 meters were relatively protected from STG infections but this was not observed for SFG, TG and QF exposure. The findings from this study may direct future research on rickettsioses in Bhutan. These neglected tropical diseases warrant specific public health interventions in Bhutan.

OBJECTIVES To identify groups at risk of methicillin-resistant Staphylococcus aureus (MRSA) infection, patterns of antimicrobial resistance, and the proportion of patients with MRSA infections but no history of recent hospitalisation. DESIGN, SETTING AND PARTICIPANTS Case series of 39 231 patients with S. aureus isolates from specimens processed by the Hunter New England Local Health District (HNELHD) public pathology provider during 2008-2014. MAIN OUTCOME MEASURES Proportion of MRSA infections among people with S. aureus isolates; antimicrobial susceptibility of MRSA isolates; origin of MRSA infections (community- or health care-associated); demographic factors associated with community-associated MRSA infections. RESULTS There were 71 736 S. aureus-positive specimens during the study period and MRSA was isolated from 19.3% of first positive specimens. Most patients (56.9%) from whom MRSA was isolated had not been admitted to a public hospital in the past year. Multiple regression identified that patients with community-associated MRSA were more likely to be younger (under 40), Indigenous Australians (odds ratio [OR], 2.6; 95% CI, 2.3-2.8), or a resident of an aged care facility (OR, 4.7; 95% CI, 3.8-5.8). The proportion of MRSA isolates that included the dominant multi-resistant strain (AUS-2/3-like) declined from 29.6% to 3.4% during the study period (P < 0.001), as did the rates of hospital origin MRSA in two of the major hospitals in the region. CONCLUSIONS The prevalence of MRSA in the HNELHD region decreased during the study period, and was predominantly acquired in the community, particularly by young people, Indigenous Australians, and residents of aged care facilities. While the dominance of the multi-resistant strain decreased, new strategies for controlling infections in the community are needed to reduce the prevalence of non-multi-resistant strains.

Aim To describe the epidemiology of enteroviral meningoencephalitis in northern New South Wales, Australia, with a specific focus on neonatal and young infant cases. Methods A retrospective review of PCR-confirmed enteroviral meningoencephalitis cases in the Hunter New England Local Health District of northern NSW was conducted for the period 2008–2012. Results One hundred nine patients met the case definition. There was summer seasonality, with 50% (55/109) of cases occurring between December and February. Neonates and young infants ( 100/mm3. Conclusion Early diagnosis of enteroviral meningoencephalitis could alter management, potentially reducing the period of treatment with empirical antimicrobials and permitting earlier discharge.

Background Encephalitis continues to result in substantial morbidity and mortality worldwide. Advances in diagnosis and management have been limited, in part, by a lack of consensus on case definitions, standardized diagnostic approaches, and priorities for research. Methods In March 2012, the International Encephalitis Consortium, a committee begun in 2010 with members worldwide, held a meeting in Atlanta to discuss recent advances in encephalitis and to set priorities for future study. Results We present a consensus document that proposes a standardized case definition and diagnostic guidelines for evaluation of adults and children with suspected encephalitis. In addition, areas of research priority, including host genetics and selected emerging infections, are discussed. Conclusions We anticipate that this document, representing a synthesis of our discussions and supported by literature, will serve as a practical aid to clinicians evaluating patients with suspected encephalitis and will identify key areas and approaches to advance our knowledge of encephalitis.

Cryptosporidium is an enteric parasite of public health significance that causes diarrhoeal illness through faecal oral contamination and via water. Zoonotic transmission is difficult to determine as most species of Cryptosporidium are morphologically identical and can only be differentiated by molecular means. Transmission dynamics of Cryptosporidium in rural populations were investigated through the collection of 196 faecal samples from diarrheic (scouring) calves on 20 farms and 63 faecal samples from humans on 14 of these farms. The overall prevalence of Cryptosporidium in cattle and humans by PCR and sequence analysis of the 18S rRNA was 73.5% (144/196) and 23.8% (15/63), respectively. Three species were identified in cattle; Cryptosporidium parvum, Cryptosporidium bovis and Cryptosporidium ryanae, and from humans, C. parvum and C. bovis. This is only the second report of C. bovis in humans. Subtype analysis at the gp60 locus identified C. parvum subtype IIaA18G3R1 as the most common subtype in calves. Of the seven human C. parvum isolates successfully subtyped, five were IIaA18G3R1, one was IIdA18G2 and one isolate had a mix of IIaA18G3R1 and IIdA19G2. These findings suggest that zoonotic transmission may have occurred but more studies involving extensive sampling of both calves and farm workers are needed for a better understanding of the sources of Cryptosporidium infections in humans from rural areas of Australia.

Problem: Emergencies resulting from disease outbreaks and extreme environmental events present significant challenges for health services.Context: Preparing to effectively manage emergencies is a core activity in public health units. Field exercises support consolidation of biopreparedness by testing plans, identifying weaknesses, providing training opportunities and developing surge capacity.Action: An extended field exercise to test response to a novel influenza strain was conducted in New South Wales, Australia in September 2008, eight months before the influenza A(H1N1) 2009 pandemic emerged. Lasting four days and involving over 300 participants, the exercise was set in the early response phase with the staggered presentation of 41 cases to 36 emergency departments in the health area. An additional 150 contacts were written into a complex scenario to test the public health response.Outcome: The subsequent pandemic emergence in mid-2009 offered a unique opportunity to assess the field exercise format for disaster preparedness. Most roles were adequately tested with recognized benefit during the actual pandemic response. However, the exercise did not adequately challenge the public health planning team that synthesizes surveillance data and forecasts risk, nor did it identify planning issues that became evident during the subsequent pandemic. Discussion: Field exercises offer the opportunity to rigorously test public health emergency preparedness but can be expensive and labour-intensive. Our exercise provided effective and timely preparation for the influenza A(H1N1) 2009 pandemic but showed that more emphasis needs to be placed on the role and training of the public health planning team.

Perception of risk affects compliance with public health control measures., In 2007, adults in Australia were interviewed about their willingness to comply with potential health interventions during a hypothetical influenza outbreak. After the first wave of pandemic (H1N1) 2009 in Australia, many of the same respondents were interviewed about behavior and protection measures they actually adopted. Of the original 1,155 respondents, follow-up interviews were conducted for 830 (71.9%). Overall, 20.4% of respondents in 2009 had recently experienced influenza-like illness, 77.7% perceived pandemic (H1N1) 2009 to be mild, and 77.8% reported low anxiety. Only 14.5% could correctly answer 4 questions about influenza virus transmission, symptoms, and infection control. Some reported increasing handwashing (46.6%) and covering coughs and sneezes (27.8%) to reduce transmission. Compared with intentions reported in 2007, stated compliance with quarantine or isolation measures in 2009 remained high. However, only respondents who perceived pandemic (H1N1) 2009 as serious or who had attained higher educational levels expressed intention to comply with social distancing measures.

Objective: To investigate the Australian public's expectations, concerns and willingness to accept vaccination with the pandemic (H1N1) 2009 influenza vaccine. Design, setting and participants: A computer-assisted telephone interview survey was conducted between 20 August and 11 September 2009 by trained professional interviewers to study issues relating to vaccine uptake and perceived safety. The sample comprised 1155 randomly selected representative adults who had participated in a 2007 national study exploring knowledge and perceptions of pandemic influenza. Main outcome measures: Likely acceptance of pandemic (H1N1) 2009 vaccination, factors associated with acceptance, and respondents' willingness to share Australian vaccine with neighbouring developing countries. Results: Of 1155 possible participants, 830 (72%) were successfully interviewed. Twenty per cent of the study group (169/830) reported that they had developed influenza-like symptoms during the 2009 pandemic period. Most respondents (645/830, 78%) considered pandemic (H1N1) 2009 to be a mild disease, and 211/830 (25%) regarded themselves as being at increased risk of infection. Willingness to accept pandemic (H1N1) 2009 vaccination was high (556/830, 67%) but was significantly lower than when pandemic vaccination uptake was investigated in 2007 (88%; P < 0.0001). Respondents who had already been vaccinated against seasonal influenza and those who perceived pandemic (H1N1) 2009 to be severe were significantly more willing to accept vaccination. Most respondents (793/822, 96%) were willing to share surplus vaccine with developing countries in our region. Conclusion: Although two-thirds of Australian adults surveyed were willing to accept pandemic (H1N1) 2009 vaccination, and most supported sharing vaccine with developing countries, there is a need for accessible information on vaccine safety for those who are undecided about vaccination.

Objective: To improve the capacity of residential aged care facilities (RACFs) to respond to communicable disease outbreaks. Methods: Three computer-assisted telephone interviews were conducted with RACFs. The first survey gathered baseline information. Outbreak prevention resources were then offered to address identified weaknesses. Subsequent surveys enabled the facilities' progress to be monitored. Before the third survey, RACFs were sent a personalised scorecard documenting their standing against 19 readiness criteria. Results: RACFs reporting an outbreak management plan increased from 58 to 98%, and facilities reporting 16 or more of the 19 readiness criteria rose from 24 to 43% (P < 0.0006) at the second interview and 73% at the third interview (P < 0.0001). Conclusions: The strategy resulted in a significant improvement in reported outbreak readiness.

SUMMARYFew countries routinely collect comprehensive encephalitis data, yet understanding the epidemiology of this condition has value for clinical management, detecting novel and emerging pathogens, and guiding timely public health interventions. When this study was conducted there was no standardized diagnostic algorithm to aid identification of encephalitis or systematic surveillance for adult encephalitis. In July 2012 we tested three pragmatic surveillance options aimed at identifying possible adult encephalitis cases admitted to a major Australian hospital: hospital admissions searches, clinician notifications and laboratory test alerts (CSF herpes simplex virus requests). Eligible cases underwent structured laboratory investigation and a specialist panel arbitrated on the final diagnosis. One hundred and thirteen patients were initially recruited into the 10-month study; 20/113 (18%) met the study case definition, seven were diagnosed with infectious or immune-mediated encephalitis and the remainder were assigned alternative diagnoses. The laboratory alert identified 90% (102/113) of recruited cases including six of the seven cases of confirmed encephalitis suggesting that this may be a practical data source for case ascertainment. The application of a standardized diagnostic algorithm and specialist review by an expert clinical panel aided diagnosis of patients with encephalitis.

Encephalitis is caused by inflammation of the brain and is a challenging condition for clinicians to identify and manage. It manifests as a complex neurological syndrome with protean clinical manifestations that may be caused by a large number of aetiologies, many without effective treatments. It can be fatal and survivors often experience significant neurological morbidity. Studies have shown variable quality in case management in multiple settings,1-3 emphasising the need for consensus guidelines.

Background Australian bat lyssavirus (ABLV) infects a number of flying fox and insectivorous bats species in Australia. Human infection with ABLV is inevitably fatal unless prior vaccination and/or post-exposure treatment (PET) is given. Despite ongoing public health messaging about the risks associated with bat contact, surveillance data have revealed a four-fold increase in the number of people receiving PET for bat exposure in NSW between 2007 and 2011. Our study aimed to better understand these human – bat interactions in order to identify additional risk communication messages that could lower the risk of potential ABLV exposure. All people aged 18 years or over whom received PET for non-occupation related potential ABLV exposure in the Hunter New England Local Health District of Australia between July 2011 and July 2013 were considered eligible for the study. Eligible participants were invited to a telephone interview to explore the circumstances of their bat contact. Interviews were then transcribed and thematically analysed by two independent investigators. Results Of 21 eligible participants that were able to be contacted, 16 consented and participated in a telephone interview. Participants reported bats as being widespread in their environment but reported a general lack of awareness about ABLV, particularly the risk of disease from bat scratches. Participants who attempted to ‘rescue’ bats did so because of a deep concern for the bat’s welfare. Participants reported a change in risk perception after the exposure event and provided suggestions for public health messages that could be used to raise awareness about ABLV. Conclusions Reframing the current risk messages to account for the genuine concern of people for bat welfare may enhance the communication. The potential risk to the person and possible harm to the bat from an attempted ‘rescue’ should be promoted, along with contact details for animal rescue groups. The potential risk of ABLV from bat scratches merits greater emphasis.

Zoonotic infections such as Q fever, brucellosis and leptospirosis can lead to serious complications but pose diagnostic and management challenges to general practitioners (GPs) as patients often present with non-specific symptoms such as fever.To develop a tool to assist GPs in the diagnosis and management of common zoonotic infectionsAn algorithm was developed with advice and comments from GPs, laboratory specialists and infectious disease specialists. Emphasis is placed on understanding patient risk factors, such as non-household contact with animals, excluding other possible causes of fever, such as influenza, and commencing empirical treatment as soon as a zoonotic infection is suspected. The algorithm is not exhaustive and GPs are urged to consult infectious disease specialists and medical microbiologists for further guidance if required.

Background Flying foxes (megachiroptera) and insectivorous microbats (microchiroptera) are the known reservoirs for a range of recently emerged, highly pathogenic viruses. In Australia there is public health concern relating to bats’ role as reservoirs of Australian Bat Lyssavirus (ABLV), which has clinical features identical to classical rabies. Three deaths from ABLV have occurred in Australia. A survey was conducted to determine the frequency of bat exposures amongst adults in Australia’s most populous state, New South Wales; explore reasons for handling bats; examine reported practices upon encountering injured or trapped bats or experiencing bat bites or scratches; and investigate knowledge of bat handling warnings. Methods A representative sample of 821 New South Wales adults aged 16 years and older were interviewed during May and June 2011, using a computer assisted telephone interview (CATI) method. Frequencies, proportions and statistical differences in proportion were performed. Using an α-value of 0.05 and power of 80%, it was calculated that a sample size of 800 was required to provide statistical significance of +/− 5% for dichotomous variables. Results One-hundred-and-twenty-seven (15.5%) respondents indicated that they had previously handled a bat, being 22% (48/218) rural and 13% (78/597) urban respondents (χ 2 = 9.8, p = 0.0018). Twenty one percent of males (63/304) had handled bats compared with 12% (64/517) of females (χ 2 = 10.2, p = 0.0014). Overall, 42.0% (n = 345) of respondents reported having seen or heard a warning about handling bats. If faced with an injured or trapped bat, 25% (206/821) indicated that they would handle the bat, with 17% (36/206) saying that they would use their bare hands. For minor scratches, 14% (117/821) indicated that they would ignore the injury while four respondents would ignore major scratches or bites. Conclusions Previous human-bat interactions were relatively common. Bat exposures most frequently occurred with sick or injured bats, which have the highest risk of ABLV. On encountering an injured or sick bat, potentially high risk practices were commonly reported, particularly among rural males. It is important to understand why people still handle bats despite public health warnings to inform future communication strategies.

Objective: To retrospectively review the performance of a near real-time Emergency Department (ED) Syndromic Surveillance System operating in New South Wales for identifying pneumonia outbreaks of public health importance. Methods: Retrospective data was obtained from the NSW Emergency Department data collection for a rural hospital that has experienced a cluster of pneumonia diagnoses among teenage males in August 2006. ED standard reports were examined for signals in the overall count for each respiratory syndrome, and for elevated counts in individual subgroups including; age, sex and admission to hospital status. Results: Using the current thresholds, the ED syndromic surveillance system would have trigged a signal for pneumonia syndrome in children aged 5-16 years four days earlier than the notification by a paediatrician and this signal was maintained for 14 days. Conclusion: If the ED syndromic surveillance system had been operating it could have identified the outbreak earlier than the paediatrician's notification. This may have permitted an earlier public health response. Implications: By understanding the behaviour of syndromes during outbreaks of public health importance, response protocols could be developed to facilitate earlier implementation of control measures.

To describe the epidemiology of enteroviral meningoencephalitis in northern New South Wales, Australia, with a specific focus on neonatal and young infant cases.A retrospective review of PCR-confirmed enteroviral meningoencephalitis cases in the Hunter New England Local Health District of northern NSW was conducted for the period 2008-2012.One hundred nine patients met the case definition. There was summer seasonality, with 50% (55/109) of cases occurring between December and February. Neonates and young infants (3 months of age) accounted for 42% (46/109) of cases, with 20% (9/46) being premature births. Fever (83%) was the most common presentation in this age group, followed by irritability (40%), feeding difficulties (40%) and rash (17%). All received at least one antibiotic during their admission, with 26% (12/46) also treated empirically with acyclovir. There was one death. Where testing was undertaken, cerebrospinal fluid (CSF) protein levels were high in 90% (28/31) of neonates and young infants, but the CSF white cell count was variable, with 57%10/mm(3) and 21%100/mm(3) .Early diagnosis of enteroviral meningoencephalitis could alter management, potentially reducing the period of treatment with empirical antimicrobials and permitting earlier discharge.

Introduction: Barmah Forest virus (BFV) is a mosquito-borne virus causing epidemic polyarthritis in Australia. This study used case follow-up of cases from the surveillance system to demonstrate that routinely collected BFV notification data were an unreliable indicator of the true location of exposure. Methods: BFV notifications from June 2001 to May 2011 were extracted from the New South Wales (NSW) Notifiable Conditions Information Management System to study case distribution. Disease cluster analysis was performed using spatial scan statistics. Exposure history data were collected from cases notified in 2010 and 2011 to accurately determine travel to high-risk areas. Results: Cluster analysis using address data identified an area of increased BFV disease incidence in the mid-north coast of NSW contiguous with estuarine wetlands. When travel to this area was investigated, 96.7% (29/30) cases reported having visited coastal regions within four weeks of developing symptoms. Discussion: Along the central NSW coastline, extensive wetlands occur in close proximity to populated areas. These wetlands provide ideal breeding habitats for a range of mosquito species implicated in the transmission of BFV. This is the first study to fully assess case exposure with findings suggesting that sporadic cases of BFV in people living further away from the coast do not reflect alternative exposure sites but are likely to result from travel to coastal regions. Spatial analysis by case address alone may lead to inaccurate understandings of the true distribution of arboviral diseases. Subsequently, this information has important implications for the collection of mosquito-borne disease surveillance information and public health response strategies.

Recent experience during Australia's initial public health response to the swine influenza pandemic provides valuable lessons for the future. An intense containment effort lasting 7 weeks was unable to prevent local community transmission in some areas of Australia; however, despite the mobility of many people living in rural and remote parts of the country, much of the outback was unaffected. By the end of the Containment Phase, most parts of rural New South Wales only recorded low rates of confirmed H1N109 infection. As Australians living in rural areas often have poorer access to health services than their urban counterparts, they are likely to be more affected by an extended emergency, even one as moderate as the present H1N109 swine influenza pandemic. There may have been benefits in extending containment measures in these less affected areas and in communities where large numbers of vulnerable people such as Indigenous Australians reside. Containment is worthwhile in limiting the spread of disease in specific situations but is unlikely to change the course of a pandemic unless it can be sustained until a large proportion of the population is vaccinated. Strenuous containment efforts should certainly be applied in outbreaks of severe disease, particularly those caused by novel infectious agents with a low reproductive rate (R0). Should advances in vaccine manufacture reduce the time taken to produce a new vaccine, then increased effort to extend containment will be even more worthwhile.

The World Health Organization has directed nations to prepare for a future influenza pandemic. While many countries have developed comprehensive plans, the needs of marginalized communities have often been neglected. In recognition of these weaknesses in current planning practice we strongly support the call that ‘the time is now’ for genuine and respectful partnerships to redress yet another omission for Indigenous people

Resumen Conocimientos sobre la gripe pandemica y cumplimiento de las medidas de contencion en la poblacion australiana Objetivo Determinar el grado de cumplimiento declarado de las medidas de salud publica contra la gripe pandemica y estudiar los factores que influyen en la cooperacion necesaria para controlar esa pandemia en Australia.Metodos Entrevistadores profesionales llevaron a cabo una encuesta telefonica asistida por ordenador a fin de reunir informacion sobre los conocimientos del publico australiano acerca de la gripe pandemica y su determinacion de observar las medidas de salud publica adoptadas para controlarla. La muestra fue seleccionada aleatoriamente a partir de una base de datos electronica y de guias telefonicas impresas para procurar que fuese representativa de todos los estados y territorios australianos. Tras explicar a los encuestados en que consiste la gripe pandemica para que entendieran la importancia del tema, se repitieron las preguntas sobre el cumplimiento. La variacion sufrida por las respuestas fue analizada mediante la prueba de McNemar para datos apareados.Resultados Solo un 23% de los 1166 encuestados demostraron comprender cabalmente lo que supone una «gripe pandemica». Entre los entrevistados, un 94,1% manifesto estar dispuesto a cumplir una cuarentena domiciliaria; el 94,2%, a evitar actos publicos; y el 90,7%, a aplazar encuentros sociales. Despues de haber explicado a los entrevistados el significado del termino «pandemia», el cumplimiento declarado aumento significativamente (al 97,5%, 98,3% y 97,2% respectivamente). Los que manifestaron no conocer bien el significado de la expresion «gripe pandemica,» los encuestados varones y los empleados que no podian trabajar desde su domicilio se mostraron mas reacios a seguir las recomendaciones.Conclusion En Australia, si se materializase la amenaza, el cumplimiento de las medidas de contencion contra la gripe pandemica seria probablemente alto, no obstante lo cual podria mejorarse mediante un programa de educacion del publico que transmitiera simplemente unos cuantos mensajes clave. Unos conocimientos basicos sobre la gripe pandemica se asocian a la voluntad declarada de cumplir las medidas de contencion. Invertir ahora en promover medidas de preparacion para una pandemia u otra emergencia sanitaria constituye una opcion beneficiosa.

During a recent natural disaster public health staff required timely and comprehensive surveillance of priority health conditions, including injury, mental health disorders and selected infectious diseases, to inform response and recovery activities. Although traditional surveillance is of value in such settings it is constrained by a focus on notifiable conditions and delays in reporting. The application of an electronic emergency department syndromic surveillance system proved valuable and timely in informing public health activities following a natural disaster in New South Wales.

Cryptosporidium hominis, which has an anthroponotic transmission cycle and Cryptosporidium parvum, which is zoonotic, are the primary species of Cryptosporidium that infect humans. The present study identified the species/genotypes and subgenotypes of Cryptosporidium in 7 human and 15 cattle cases of sporadic cryptosporidiosis in rural western NSW during the period from November 2005 to January 2006. The species/genotype of isolates was determined by PCR sequence analysis of the 18S rRNA and C. parvum and C. hominis isolates were subgenotyped by sequence analysis of the GP60 gene. Fourteen of 15 cattle-derived isolates were identified as C. parvum and 1 as a C. bovis/C. parvum mixture. Of the human isolates, 4 were C. parvum and 3 were C. hominis. Two different subgenotypes were identified with the human C. hominis isolates and six different subgenotypes were identified within the C. parvum species from humans and cattle. All four of the C. parvum subtypes found in humans were also found in the cattle, indicating that zoonotic transmission may be an important contributor to sporadic human cases cryptosporidiosis in rural NSW.

Streptococcus pneumoniae is a common cause of community acquired pneumonia (CAP). Influenza infection increases susceptibility to S. pneumoniae infection in adults but this link is less well described in children. We report on an outbreak of CAP affecting 25 previously well adolescents in a New South Wales boarding school. S. pneumoniae 1 was confirmed in two cases. During this period, the school also experienced an influenza outbreak with an influenza-like illness attack rate peaking at 27% in Year 8 students. A planned school closure may have contributed to controlling the outbreak. Boarding schools are vulnerable to outbreaks of respiratory illness and strategies for limiting this risk are required.

A severe storm that began on Thursday, 7 June 2007 brought heavy rains and gale-force winds to Newcastle, Gosford, Wyong, Sydney, and the Hunter Valley region of New South Wales. The storm caused widespread flooding and damage to houses, businesses, schools and health care facilities, and damaged critical infrastructure. Ten people died as a result of the storm, and approximately 6000 residents were evacuated. A natural disaster was declared in 19 local government areas, with damage expected to reach $1.5 billion. Additional demands were made on clinical health services, and interruption of the electricity supply to over 200 000 homes and businesses, interruption of water and gas supplies, and sewerage system pump failures presented substantial public health threats. A public health emergency operations centre was established by the Hunter New England Area Health Service to coordinate surveillance activities, respond to acute public health issues and prevent disease outbreaks. Public health activities focused on providing advice, cooperating with emergency service agencies, monitoring water quality and availability, preventing illness from sewage-contaminated flood water, assessing environmental health risks, coordinating the local government public health response, and surveillance for storm-related illness and disease outbreaks, including gastroenteritis. The local ABC (Australian Broadcasting Corporation) radio station played a key role in disseminating public health advice. A household survey conducted within a fortnight of the storm established that household preparedness and storm warning systems could be improved. Language: en

Objective: Between May and June 2002 an outbreak of chickenpox (CP) occurred at a child care centre in Perth, Western Australia. An epidemiological study was undertaken in order to determine the characteristics of the outbreak, assess vaccine effectiveness, and to define the direct and indirect costs associated with CP infections in young children. Methods: A cohort study of the outbreak utilising attendance records and a telephone survey of parents was conducted. Results: Of the 211 children attending the child care centre at the time of the outbreak, 44 contracted CP (attack rate 25.7%). In addition, two staff members, five secondary household contacts (secondary attack rate 38.5%) and four secondary non-household associated contacts were infected. There were no severe complications or any hospitalisations recorded in infected persons. Two cases had been vaccinated previously. Vaccine effectiveness for CP of any severity was 78.0% (95% CI 15.4–94.3%) while vaccine effectiveness against severe CP was 100%. Direct costs during this outbreak were estimated to be $54 per case and the total costs, including cost of parental time off work or study, were estimated to be $525.73 per case. Conclusions and Implications: Although morbidity associated with CP in young children is not great, infection in childhood is almost universal. This study found that the average costs associated with each CP case were considerable. Since varicella vaccine affords good protection against CP, the recent inclusion of this vaccine in the Australian childhood vaccination schedule should save the community a considerable amount in direct and indirect costs if high coverage rates can be achieved.

[Extract] Re: Ratnam I, et al. Incidence and risk factors for acute respiratory illness and influenza virus infections in Australian travellers to Asia. J Clin Virol (2013) http://dx.doi.org/10.1016/j.jcv.2013.01.008 Drs Ratnam et al. raise the importance of respiratory infection, particularly influenza, as a risk to travellers while overseas. In their study of 621 Australians travelling to Asian countries, they report that 6.9% (43/621) contracted either confirmed influenza or an influenza-like infection. Influenza can cause serious illness but even with milder symptoms it can spoil holiday or business plans and cause considerable inconvenience and expense should it be necessary to source medical assistance in a foreign country or re-schedule flights and accommodation.

Background: We report a cluster of gonorrhoea among mainly heterosexual men that occurred in October 2005, which was first identified when routine weekly surveillance review procedures indicated a three-fold increase in reporting rates compared with historical data. Methods: Each case was followed up with the treating medical officer to review treatment regimes and risk exposures, and to carry out enhanced contact tracing. The phenotype and genotype of the outbreak gonococcal isolates and gonococci prevalent in the months preceding and following the cluster were determined. Links between cases reported from the local Sexual Health Clinic and those reported by general practitioners were established. Results: Laboratory data indicated that a particular gonococcal subtype (ST225 and NR/Brpyst) was prevalent during the outbreak. Conclusions: Gonorrhoea rates returned to pre-outbreak levels following a targeted health promotion intervention with no further cases of the outbreak subtype detected.

Early detection of a novel strain (genotype) of influenza virus in the NSW population is the key to controlling a pandemic. If this occurs, ongoing surveillance will help determine the epidemiology and risk factors of the virus as well as its impact on essential services. Important components of surveillance preparedness in NSW include: border surveillance; hospital-based screening for suspected cases; protocols for efficient transport and testing of viral specimens; flexible, robust electronic tools for rapid surveillance data collection; management and reporting; and creation of surveillance surge capacity.

Responding to an infectious disease pandemic requires a coordinated approach from all essential services. Public health units across NSW will play an important role in a range of control activities. These include: surveillance, education, communication, case ascertainment, case management (excluding clinical management), infection control, contact tracing, monitoring contacts in home quarantine, surveillance at borders, epidemiological studies and immunisation. Public health units are currently planning for such an emergency and these plans will need to be tested and refined under simulated conditions.

Background A storm-related disaster in New South Wales, Australia in June 2007 caused infrastructure damage, interrupted essential services, and presented major public health risks. We investigated household disaster preparedness and information sources used before and during the disaster. Methods Rapid cluster survey of 320 randomly selected households in Newcastle and Lake Macquarie, New South Wales, Australia. Results 227 households (71%) responded to the survey. By the day before the storm, 48% (95%CI 40–57%) of households were aware of a storm warning, principally through television (67%; 58–75%) and radio (57%; 49–66%) announcements. Storm preparations were made by 42% (28–56%) of these households. Storm information sources included: radio (78%; 68–88%); family, friends, colleagues and neighbours (50%; 40–60%); and television (41%; 30–52%). Radio was considered more useful than television (62%; 51–73% vs. 29%; 18–40%), even in households where electricity supply was uninterrupted (52%; 31–73% vs. 41%; 20–63%). Only 23% (16–30%) of households were aware that the local government-operated radio network has a designated communication role during disasters. A battery-operated household radio and appropriate batteries were available in 42% (34–50%) of households, while only 23% (16–29%) had all of: a torch, battery-operated radio, appropriate batteries, mobile phone, emergency contact list and first aid equipment. Conclusion Broadcast media are important information sources immediately before and during disasters. Health services should promote awareness of broadcast networks' disaster role, especially the role of radio, and encourage general household disaster preparedness. A rapid cluster survey conducted shortly after a natural disaster provided practical, robust information for disaster planning.