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To assess associations between SARS-CoV-2 infection and the incidence of hospitalisation with selected respiratory and non-respiratory conditions in a largely SARS-CoV-2 vaccine-naïve population .Self-control case series; analysis of population-wide surveillance and administrative data for all laboratory-confirmed COVID-19 cases notified to the Victorian Department of Health (onset, 23 January 2020 - 31 May 2021; ie, prior to widespread vaccination rollout) and linked hospital admissions data (admission dates to 30 September 2021).Hospitalisation of people with acute COVID-19; incidence rate ratios (IRRs) comparing incidence of hospitalisations with defined conditions (including cardiac, cerebrovascular, venous thrombo-embolic, coagulative, and renal disorders) from three days before to within 89 days of onset of COVID-19 with incidence during baseline period (60-365 days prior to COVID-19 onset).A total of 20 594 COVID-19 cases were notified; 2992 people (14.5%) were hospitalised with COVID-19. The incidence of hospitalisation within 89 days of onset of COVID-19 was higher than during the baseline period for several conditions, including myocarditis and pericarditis (IRR, 14.8; 95% CI, 3.2-68.3), thrombocytopenia (IRR, 7.4; 95% CI, 4.4-12.5), pulmonary embolism (IRR, 6.4; 95% CI, 3.6-11.4), acute myocardial infarction (IRR, 3.9; 95% CI, 2.6-5.8), and cerebral infarction (IRR, 2.3; 95% CI, 1.4-3.9).SARS-CoV-2 infection is associated with higher incidence of hospitalisation with several respiratory and non-respiratory conditions. Our findings reinforce the value of COVID-19 mitigation measures such as vaccination, and awareness of these associations should assist the clinical management of people with histories of SARS-CoV-2 infection.

Background Policy responses to COVID-19 in Victoria, Australia over 2020–2021 have been supported by evidence generated through mathematical modelling. This study describes the design, key findings, and process for policy translation of a series of modelling studies conducted for the Victorian Department of Health COVID-19 response team during this period. Methods An agent-based model, Covasim, was used to simulate the impact of policy interventions on COVID-19 outbreaks and epidemic waves. The model was continually adapted to enable scenario analysis of settings or policies being considered at the time (e.g. elimination of community transmission versus disease control). Model scenarios were co-designed with government, to fill evidence gaps prior to key decisions. Results Understanding outbreak risk following incursions was critical to eliminating community COVID-19 transmission. Analyses showed risk depended on whether the first detected case was the index case, a primary contact of the index case, or a ‘mystery case’. There were benefits of early lockdown on first case detection and gradual easing of restrictions to minimise resurgence risk from undetected cases. As vaccination coverage increased and the focus shifted to controlling rather than eliminating community transmission, understanding health system demand was critical. Analyses showed that vaccines alone could not protect health systems and need to be complemented with other public health measures. Conclusions Model evidence offered the greatest value when decisions needed to be made pre-emptively, or for questions that could not be answered with empiric data and data analysis alone. Co-designing scenarios with policy-makers ensured relevance and increased policy translation.

During 2020, Victoria was the Australian state hardest hit by COVID-19, but was successful in controlling its second wave through aggressive policy interventions. We calibrated a detailed compartmental model of Victoria’s second wave to multiple geographically-structured epidemic time-series indicators. We achieved a good fit overall and for individual health services through a combination of time-varying processes, including case detection, population mobility, school closures, physical distancing and face covering usage. Estimates of the risk of death in those aged ≥75 and of hospitalisation were higher than international estimates, reflecting concentration of cases in high-risk settings. We estimated significant effects for each of the calibrated time-varying processes, with estimates for the individual-level effect of physical distancing of 37.4% (95%CrI 7.2−56.4%) and of face coverings of 45.9% (95%CrI 32.9−55.6%). That the multi-faceted interventions led to the dramatic reversal in the epidemic trajectory is supported by our results, with face coverings likely particularly important., The state of Victoria, Australia experienced a substantial second wave of COVID-19 but brought it under control with strict non-pharmaceutical interventions. Here, the authors model the second wave in Victoria to estimate the impacts of the different interventions.

Background A key feature of the global public health response to contain and slow the spread of COVID-19 has been community-based quarantine and self-isolation. As part of The Optimise Study, this research sought to understand the factors that influence people’s ability to undertake home-based quarantine and isolation to contain the spread of COVID-19. Methods Semi-structured qualitative phone interviews (n = 25) were conducted by telephone with people who participated in community-based quarantine in Australia before 31 March 2020. The Capability Opportunity Motivation Behaviour model was used to conduct a thematic analysis. Results Participants required clear, accessible and trusted information to guide them in home-based quarantine and isolation. A sense of social responsibility and belief in the efficacy of the restrictions to reduce viral transmission aided their motivation. Access to essential needs, supportive living environments, and emotional support were required to adhere to restrictions, but few were prepared. Conclusions Findings demonstrate that in addition to having the capability and motivation to adhere to restrictions, it is vital that people are also encouraged to prepare for the challenge to ensure access to physical, social and emotional support. Findings also illustrate the importance of engaging communities in planning and preparedness for quarantine and self-isolation public health responses.

Genomic sequencing has significant potential to inform public health management for SARS-CoV-2. Here we report high-throughput genomics for SARS-CoV-2, sequencing 80% of cases in Victoria, Australia (population 6.24 million) between 6 January and 14 April 2020 (total 1,333 COVID-19 cases). We integrate epidemiological, genomic and phylodynamic data to identify clusters and impact of interventions. The global diversity of SARS-CoV-2 is represented, consistent with multiple importations. Seventy-six distinct genomic clusters were identified, including large clusters associated with social venues, healthcare and cruise ships. Sequencing sequential samples from 98 patients reveals minimal intra-patient SARS-CoV-2 genomic diversity. Phylodynamic modelling indicates a significant reduction in the effective viral reproductive number (Re) from 1.63 to 0.48 after implementing travel restrictions and physical distancing. Our data provide a concrete framework for the use of SARS-CoV-2 genomics in public health responses, including its use to rapidly identify SARS-CoV-2 transmission chains, increasingly important as social restrictions ease globally., Genome sequencing can be used to infer pathogen transmission dynamics and inform public health responses. Here, the authors sequence >1,200 SARS-CoV-2 samples from Victoria, Australia and find genomic support for the effectiveness of social restrictions in reducing transmission.

The Primitive Baptists are among a small group of American churches which survived the nineteenth century with their Calvanism intact, and which still hold to doctrines long abandoned by both evangelicals and liberals. In the sense that the church believes in the Bible as a literal and infallible guide to Christian life, it is fundamentalist, but its fundamentalism actually runs deeper than a belief in Biblical inerrancy. The church views itself as a lineal descendant of the original apostolic church, a "primitive" church, not in the sense of "crude," but in the sense of "first," numbering among its ancestors independent and persecuted sects such as the Montanists, the Novatians, the Paulicians, the Albigenses, the Waldenses, and other groups which resisted the domination of the institutionalized church in the years before the Protestant Reformation. Primitive Baptist rejection of much of what has become commonplace in modern Christianity, including the use of musical instruments in church, complications in ecclesiastical organization, elaborately decorated church buildings, and the professional ministry, stems from the church's commitment to preserve the faith exactly as Christ established it, and to practice nothing not explicitly mentioned in the New Testament.

Summary: Background: A cornerstone of Australia's ability to control COVID-19 has been effective border control with an extensive supervised quarantine programme. However, a rapid recrudescence of COVID-19 was observed in the state of Victoria in June, 2020. We aim to describe the genomic findings that located the source of this second wave and show the role of genomic epidemiology in the successful elimination of COVID-19 for a second time in Australia. Methods: In this observational, genomic epidemiological study, we did genomic sequencing of all laboratory-confirmed cases of COVID-19 diagnosed in Victoria, Australia between Jan 25, 2020, and Jan 31, 2021. We did phylogenetic analyses, genomic cluster discovery, and integrated results with epidemiological data (detailed information on demographics, risk factors, and exposure) collected via interview by the Victorian Government Department of Health. Genomic transmission networks were used to group multiple genomic clusters when epidemiological and genomic data suggested they arose from a single importation event and diversified within Victoria. To identify transmission of emergent lineages between Victoria and other states or territories in Australia, all publicly available SARS-CoV-2 sequences uploaded before Feb 11, 2021, were obtained from the national sequence sharing programme AusTrakka, and epidemiological data were obtained from the submitting laboratories. We did phylodynamic analyses to estimate the growth rate, doubling time, and number of days from the first local infection to the collection of the first sequenced genome for the dominant local cluster, and compared our growth estimates to previously published estimates from a similar growth phase of lineage B.1.1.7 (also known as the Alpha variant) in the UK. Findings: Between Jan 25, 2020, and Jan 31, 2021, there were 20 451 laboratory-confirmed cases of COVID-19 in Victoria, Australia, of which 15 431 were submitted for sequencing, and 11 711 met all quality control metrics and were included in our analysis. We identified 595 genomic clusters, with a median of five cases per cluster (IQR 2–11). Overall, samples from 11 503 (98·2%) of 11 711 cases clustered with another sample in Victoria, either within a genomic cluster or transmission network. Genomic analysis revealed that 10 426 cases, including 10 416 (98·4%) of 10 584 locally acquired cases, diagnosed during the second wave (between June and October, 2020) were derived from a single incursion from hotel quarantine, with the outbreak lineage (transmission network G, lineage D.2) rapidly detected in other Australian states and territories. Phylodynamic analyses indicated that the epidemic growth rate of the outbreak lineage in Victoria during the initial growth phase (samples collected between June 4 and July 9, 2020; 47·4 putative transmission events, per branch, per year [1/years; 95% credible interval 26·0–85·0]), was similar to that of other reported variants, such as B.1.1.7 in the UK (mean approximately 71·5 1/years). Strict interventions were implemented, and the outbreak lineage has not been detected in Australia since Oct 29, 2020. Subsequent cases represented independent international or interstate introductions, with limited local spread. Interpretation: Our study highlights how rapid escalation of clonal outbreaks can occur from a single incursion. However, strict quarantine measures and decisive public health responses to emergent cases are effective, even with high epidemic growth rates. Real-time genomic surveillance can alter the way in which public health agencies view and respond to COVID-19 outbreaks. Funding: The Victorian Government, the National Health and Medical Research Council Australia, and the Medical Research Future Fund.

BACKGROUND: A cornerstone of Australia’s ability to control COVID-19 has been effective border control, using an extensive supervised quarantine program. However, a rapid recrudescence in COVID-19 cases was observed in the state of Victoria in June 2020. Here, we describe the genomic findings that located the source of this second wave as a breach in supervised hotel quarantine and demonstrate the successful elimination of COVID-19 for a second time in Australia. METHODS: Genome sequencing was performed on all available SARS-CoV-2-positive samples in Victoria and integrated genomic and epidemiological investigation undertaken. RESULTS: At 31st January 2021, 20,451 COVID-19 cases were reported in Victoria; samples were sequenced from 75% of cases (15,431/20,451). Genomics revealed 98% (10,426/10,646) of locally-acquired cases during the second wave were derived from a single incursion from hotel quarantine, with the outbreak strain rapidly detected in other Australian states and territories. Phylodynamic analyses indicated an epidemic growth rate comparable to emerging variants, such as B.1.1.7 in the United Kingdom. Strict public health interventions resulted in the elimination of the outbreak strain by 29th October 2020. Subsequent cases represented independent international or interstate introductions, with limited local spread. CONCLUSIONS: Rapid escalation of clonal outbreaks can occur from even a single breach of control practices, as revealed through our genomic ‘enhanced outbreak-detection' system. The subsequent elimination and rapid control of new SARS-CoV-2 incursions reinforce that decisive public health responses to emergent cases are effective even with high epidemic growth rates, and “elimination” should be favored in settings where this is achievable. FUNDING STATEMENT: The Microbiological Diagnostic Unit Public Health Laboratory (MDU PHL) and the Victorian Infectious Diseases Reference Laboratory (VIDRL) at The Doherty Institute are funded by the Victorian Government. This work was supported by the National Health and Medical Research Council, Australia (NHMRC); Partnership Grant (APP1149991), Investigator Grant to BPH (APP1196103), Investigator Grant to DAW (APP1174555), Research Fellowship to TPS (APP1105525), MRFF COVID-19 Genomics Grant (MRF9200006). DECLARATION OF INTERESTS: None to declare. ETHICS APPROVAL STATEMENT: Data were collected in accordance with the Victorian Public Health and Wellbeing Act 2008. Ethical approval was received from the University of Melbourne Human Research Ethics Committee (study number 1954615.3).

Background: The COVID-19 pandemic shows variable dynamics in WHO Regions, with lowest disease burden in the Western-Pacific Region. While China has been able to rapidly eliminate transmission of SARS-CoV-2, Germany – as well as most of Europe and the Americas – is struggling with high numbers of cases and deaths. Objective: We analyse COVID-19 epidemiology and control strategies in China and in Germany, two countries which have chosen profoundly different approaches to deal with the epidemic. Methods: In this narrative review, we searched the literature from 1 December 2019, to 4 December 2020. Results: China and several neighbours (e.g. Australia, Japan, South Korea, New Zealand, Thailand) have achieved COVID-19 elimination or sustained low case numbers. This can be attributed to: (1) experience with previous coronavirus outbreaks; (2) classification of SARS-CoV-2 in the highest risk category and consequent early employment of aggressive control measures; (3) mandatory isolation of cases and contacts in institutions; (4) broad employment of modern contact tracking technology; (5) travel restrictions to prevent SARS-CoV-2 re-importation; (6) cohesive communities with varying levels of social control. Conclusions: Early implementation of intense and sustained control measures is key to achieving a near normal social and economic life.

Importance The COVID-19 pandemic is the greatest global test of health leadership of our generation. There is an urgent need to provide guidance for leaders at all levels during the unprecedented preresolution recovery stage. Objective To create an evidence- and expertise-informed framework of leadership imperatives to serve as a resource to guide health and public health leaders during the postemergency stage of the pandemic. Evidence Review A literature search in PubMed, MEDLINE, and Embase revealed 10 910 articles published between 2000 and 2021 that included the terms leadership and variations of emergency, crisis, disaster, pandemic, COVID-19, or public health. Using the Standards for Quality Improvement Reporting Excellence reporting guideline for consensus statement development, this assessment adopted a 6-round modified Delphi approach involving 32 expert coauthors from 17 countries who participated in creating and validating a framework outlining essential leadership imperatives. Findings The 10 imperatives in the framework are: (1) acknowledge staff and celebrate successes; (2) provide support for staff well-being; (3) develop a clear understanding of the current local and global context, along with informed projections; (4) prepare for future emergencies (personnel, resources, protocols, contingency plans, coalitions, and training); (5) reassess priorities explicitly and regularly and provide purpose, meaning, and direction; (6) maximize team, organizational, and system performance and discuss enhancements; (7) manage the backlog of paused services and consider improvements while avoiding burnout and moral distress; (8) sustain learning, innovations, and collaborations, and imagine future possibilities; (9) provide regular communication and engender trust; and (10) in consultation with public health and fellow leaders, provide safety information and recommendations to government, other organizations, staff, and the community to improve equitable and integrated care and emergency preparedness systemwide. Conclusions and Relevance Leaders who most effectively implement these imperatives are ideally positioned to address urgent needs and inequalities in health systems and to cocreate with their organizations a future that best serves stakeholders and communities.

Countries worldwide are experiencing a second wave of coronavirus disease 2019 (COVID-19), which is proving to be difficult to control. We describe the combination of physical distancing, mandatory mask wearing, movement restrictions, and enhanced test, trace, and isolation efforts that can be used to successfully suppress community transmission to zero.

Background Multiresistant organisms (MROs) pose a critical threat to public health. Population-based programs for control of MROs such as carbapenemase-producing Enterobacterales (CPE) have emerged and evaluation is needed. We assessed the feasibility and impact of a statewide CPE surveillance and response program deployed across Victoria, Australia (population 6.5 million). Methods A prospective multimodal intervention including active screening, carrier isolation, centralized case investigation, and comparative pathogen genomics was implemented. We analyzed trends in CPE incidence and clinical presentation, risk factors, and local transmission over the program’s first 3 years (2016–2018). Results CPE case ascertainment increased over the study period to 1.42 cases/100 000 population, linked to increased screening without a concomitant rise in active clinical infections (0.45–0.60 infections/100 000 population, P = .640). KPC-2 infection decreased from 0.29 infections/100 000 population prior to intervention to 0.03 infections/100 000 population in 2018 (P = .003). Comprehensive case investigation identified instances of overseas community acquisition. Median time between isolate referral and genomic and epidemiological assessment for local transmission was 11 days (IQR, 9–14). Prospective surveillance identified numerous small transmission networks (median, 2; range, 1–19 cases), predominantly IMP and KPC, with median pairwise distance of 8 (IQR, 4–13) single nucleotide polymorphisms; low diversity between clusters of the same sequence type suggested genomic cluster definitions alone are insufficient for targeted response. Conclusions We demonstrate the value of centralized CPE control programs to increase case ascertainment, resolve risk factors, and identify local transmission through prospective genomic and epidemiological surveillance; methodologies are transferable to low-prevalence settings and MROs globally., A statewide multimodal intervention for the control of carbapenemase-producing Enterobacterales was associated with a significant increase in case ascertainment, with no rise in clinical infections. Timely prospective epidemiological and genomic surveillance identified numerous small local transmission networks permitting rapid response.

Background Despite recognition that palliative care is an essential component of any humanitarian response, serious illness-related suffering continues to be pervasive in these settings. There is very limited evidence about the need for palliative care and symptom relief to guide the implementation of programs to alleviate the burden of serious illness-related suffering in these settings. A basic package of essential medications and supplies can provide pain relief and palliative care; however, the practical availability of these items has not been assessed. This study aimed to describe the illness-related suffering and need for palliative care in Rohingya refugees and caregivers in Bangladesh. Methods and findings Between November 20 and 24, 2017, we conducted a cross-sectional study of individuals with serious health problems (n = 156, 53% male) and caregivers (n = 155, 69% female) living in Rohingya refugee camps in Bangladesh, using convenience sampling to recruit participants at the community level (i.e., going house to house to identify eligible individuals). The serious health problems, recent healthcare experiences, need for medications and medical supplies, and basic needs of participants were explored through interviews with trained Rohingya community members, using an interview guide that had been piloted with Rohingya individuals to ensure it reflected the specificities of their refugee experience and culture. The most common diagnoses were significant physical disabilities (n = 100, 64.1%), treatment-resistant tuberculosis (TB) (n = 32, 20.5%), cancer (n = 15, 9.6%), and HIV infection (n = 3, 1.9%). Many individuals with serious health problems were experiencing significant pain (62%, n = 96), and pain treatments were largely ineffective (70%, n = 58). The average age was 44.8 years (range 2–100 years) for those with serious health problems and 34.9 years (range 8–75 years) for caregivers. Caregivers reported providing an average of 13.8 hours of care per day. Sleep difficulties (87.1%, n = 108), lack of appetite (58.1%, n = 72), and lack of pleasure in life (53.2%, n = 66) were the most commonly reported problems related to the caregiving role. The main limitations of this study were the use of convenience sampling and closed-ended interview questioning. Conclusions In this study we found that many individuals with serious health problems experienced significant physical, emotional, and social suffering due to a lack of access to pain and symptom relief and other essential components of palliative care. Humanitarian responses should develop and incorporate palliative care and symptom relief strategies that address the needs of all people with serious illness-related suffering and their caregivers., Megan Doherty and co-workers report on illness, suffering and treatment needs among Rohingya refugees and caregivers in Bangladesh., Author summary Why was this study done? Palliative care and symptom relief have been recognized as essential in humanitarian crises, which by their nature generate a large burden of suffering and mortality. A basic and inexpensive package of essential medicines and supplies can address pain relief and palliative care during humanitarian crises, but the availability of these items during a crisis has not been assessed. There is minimal evidence to guide the implementation of palliative care in humanitarian responses, with few studies describing palliative care needs or programs in these settings. What did the researchers do and find? We conducted a cross-sectional study of individuals with serious illnesses and caregivers to describe the illness-related suffering and need for palliative care in Rohingya refugees in Bangladesh. Many individuals with serious health problems experienced significant pain (62%, n = 96), the pain treatments prescribed were largely ineffective (70%, n = 58), and effective pain treatments were rarely available. Caregivers most commonly assisted with bathing (n = 117, 94%), administering medications (n = 99, 80%), and feeding (n = 98, 79%). Despite having limited training or money, caregivers provided many hours per day of care, which caused sadness, worry, and discrimination. What do these findings mean? In the Rohingya humanitarian crisis, the specific physical, emotional, and social needs of individuals with serious conditions and their caregivers are not being addressed adequately. Efforts to incorporate palliative care must address the barriers to accessing essential medications, supplies, and medical care, including opioid availability. Assessments of palliative care needs during humanitarian crises should be used to direct palliative care priorities and guide the development of effective interventions in these settings. Future research should quantify the occurrence of serious illness-related suffering, evaluate programs designed to alleviate this suffering, and validate published guidelines and recommendations.

Background: Multi-resistant organisms (MROs) pose a critical threat to public health. Recently, population-based systems for surveillance and control of MROs such as Carbapenemase-producing Enterobacterales (CPE) have emerged globally and evaluation is needed. In this study, we assess the feasibility and impact of a state-wide CPE surveillance and response program deployed in December 2015 across Victoria, Australia (population 6·5 million). Methods: A prospective population-based multi-modal intervention, including active screening, carrier isolation, centralised case investigation and comparative pathogen genomics was implemented. We assess impact by analysing trend in CPE incidence and clinical presentation, risk factors for acquisition and local transmission, using data from the first three years of implementation (January 2016 to December 2018). Findings: CPE case ascertainment increased over the study period to 1·42 cases/100,000 population, linked to increased screening without a concomitant rise in active clinical infections (0·45-0·60 infections/100,000 population, p=0·640). Occurrence of KPC-2 infection decreased from 0·29 infections/100,000 population prior to intervention to 0·03 infections/100,000 population in 2018 (p=0·003). Comprehensive case investigation enabled identification of novel risk factors, including non-healthcare-related overseas acquisition. Median time between isolate referral and initial centralised genomic and epidemiological assessment for local transmission was 11 days (IQR 9-14). Prospective surveillance identified numerous small transmission networks (median 2, range 1-19 cases), predominantly IMP- and KPC-producing organisms. Genomic and epidemiologically defined clusters had a median pairwise distance of 8 (IQR 4-13) single nucleotide polymorphisms, however low diversity between clusters of the same sequence type suggested genomic cluster definitions alone are insufficient for targeted control measures. Interpretation: Our results demonstrate the value of centralised CPE surveillance and control programs to increase case ascertainment, resolve risk factors and identify putative local transmission through combined genomic and epidemiological surveillance; methodologies are transferable to other low-prevalence settings and MROs globally. Funding Statement: National Health and Medical Research Council (NHMRC) partnership grant (GNT1149991) and the Victorian Government. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: All data were collected in accordance with the Victorian Public Health and Wellbeing Act 2008. Ethical approval was obtained from the Human Ethics Advisory Group of the School of Biomedical Sciences, University of Melbourne (Ethics ID 1954615.2).

Objectives: To assess variations by time of year and hospital in the uptake of influenza and pertussis vaccinations by pregnant women in Victoria; to identify factors associated with vaccination uptake. Design, setting: Retrospective analysis of data in the Victorian Perinatal Data Collection (VPDC), a population surveillance system for obstetric conditions, procedures, and pregnancy and birth outcomes. Participants: Women whose pregnancies ended in a live or stillbirth during July 2015-June 2017. Main outcome measures: Influenza and pertussis vaccinations during pregnancy. Results: 153 980 pregnancies in 67 hospitals ended during July 2015-June 2017; 59 968 pregnant women (39.0%) were vaccinated against influenza and 98 583 (64.0%) against pertussis. Coverage varied by pregnancy end date, rising for influenza during winter and spring, but for pertussis rising continuously across the two years from 37.5% to 82.2%. Differences between hospitals in coverage were marked. Factors associated with vaccination included greater maternal age, primigravidity, early antenatal care, and GP-led care. The odds of vaccination were statistically significantly lower for women born overseas and those who smoked during pregnancy; the odds of vaccination were also lower for Aboriginal and Torres Strait Islander women. Conclusions: Pertussis vaccination of pregnant women in Victoria has increased, but influenza vaccination rates remain moderate and variable. Structural changes at the system level may improve maternal vaccination rates. Embedding the delivery of maternal vaccination programs in antenatal care pathways should be a priority.

Objective: To determine the proportion of healthcare workers (HCWs) in smaller Victorian public healthcare facilities with documented evidence of measles immunity. Methods: A cross‐sectional survey, developed by the Victorian Healthcare Associated Surveillance System Coordinating Centre, was completed by all eligible facilities. HCWs were reported as having evidence or no evidence of measles immunity. Those without evidence of immunity were sub‐classified as incomplete, declined or unknown status. Results: Seventy‐five facilities reported measles immunity status of 17,522 employed HCWs. Of these, 11,751 (67.1%) had documented evidence of immunity. The proportion with evidence of immunity was lowest (45.6%) in facilities with ≤50 HCWs. The majority of HCWs without evidence of immunity (88.2%) had ‘unknown’ status. Declination or incomplete status comprised very low overall proportions (0.3% and 3.6%, respectively). Conclusions: Reported evidence of HCW measles immunity was moderate in surveyed facilities, with a large proportion having unknown status. HCW immunisation programs in some facilities require refinement to appropriately support public health responses to measles cases and prevention of occupational acquisition of measles. Implications for public health: Non‐immune HCWs are at increased risk for acquiring and transmitting measles. Timely access to accurate HCW immunisation records is required to ensure that public health responses are effective.

Palliative care has, historically, largely been absent or deprioritized in humanitarian emergencies. There is now increasing recognition of the need for it to be an integral part of any humanitarian response and, equally, for its integration to be routine across the many dimensions of a response. Such integration requires an understanding of the core principles and practice of humanitarian responses, and the structures of local, regional, and international agencies and their teams. The Sphere standards, now incorporating palliative care, comprise the fundamental standards and guidelines for humanitarian responses; they should provide key guidance for palliative care practitioners and organizations. Equally, the cluster system provides a structure for coordination of all the sectors in emergencies, and palliative care must be provided within this structure when it is in place for humanitarian events, whether acute or protracted. One core principle that humanitarian action increasingly incorporates is that of localization, whereby the response must recognize and respect local leadership and decision-making. This is equally true with emergency medical teams (EMTs), even when deploying internationally, because local responses have been overwhelmed. Finally, integration must incorporate all components of a robust palliative care response, including policy and guidance; community, primary, and specialist practitioners; training and mentorship; equipment, medication, and infrastructure appropriate for palliative care; and a referral system that uses both local and national structures.

OBJECTIVE: To describe the epidemiological and clinical features of acute Q fever in Victoria from 1994 to 2013. DESIGN: Retrospective case series and spatiotemporal analyses of human notification data. METHODS: Records for all confirmed cases of Q fever in Victoria notified between 1994 and 2013 were reviewed. Clinical and epidemiological features of the cases were described and spatiotemporal analysis undertaken for all cases potentially acquired within Victoria. RESULTS: A total of 659 confirmed acute Q fever cases were notified over the study period. Cases decreased at a rate of 4.2% per annum (95% confidence interval (CI): 0.9, 7.4%). Notification rates decreased among abattoir workers and related occupations by 10.9% per annum (95% CI: 6.5, 15.0%), whereas those among dairy farmers rose by 14.9% per annum (95% CI: 4.7, 26.0%). The mean age of cases increased over the study period while the ratio of male to female cases decreased. Spatiotemporal analysis suggested endemic transmission, with 55% of cases associated with abattoirs and related businesses and a further 30% considered to have acquired the infection locally. In addition to abattoir-associated clusters, important foci for local acquisition included South and East Gippsland, Wodonga and an outbreak centred on a dairy goat farm west of Melbourne. CONCLUSIONS: There has been a reduction in cases of acute Q fever in Victoria over the past 20 years and a changing epidemiology with respect to age, sex and acquisition source. Epidemiological and spatiotemporal analyses suggested a low level of endemic transmission within the state, with multiple foci of increased zoonotic transmission.

Q-Vax®, a whole cell formalin inactivated vaccine, is currently the only licensed Q fever vaccine for humans world-wide. Efficacy is high, although vaccine failures have been described for those vaccinated within the incubation of a naturally acquired infection. In Australia, it is widely used to prevent occupational acquisition of Q fever and is the mainstay for outbreak control. A retrospective review of all notified cases of acute Q fever to the Victorian department of health, 1993-2013, revealed 34 of 659 cases were previously vaccinated and 10 cases were positive on pre-vaccination screening, precluding vaccination. Twenty-one cases described high-risk exposures for C. burnetii prior to and within 15 days post vaccination and are likely to have been vaccinated within the incubation period of a natural infection. Thirteen cases described symptom onset more than 15 days post vaccination and thus may represent the first described series of Q-Vax vaccine failures following appropriate vaccination.

Gram-negative bacteria that are resistant to antimicrobials, including carbapenems, have emerged as a significant global public health threat. Multidrug-resistant gram-negative bacteria, including carbapenemase-producing Enterobacteriaceae (CPE), place patients at risk of potentially untreatable infection. Australia has not reported a large number of CPE cases compared to Europe, North America, and the Middle East, creating an opportunity to prevent CPE from becoming established in Australia. An outbreak of Klebsiella pneumoniae carbapenemase in 2014 demonstrated there was variable testing, reporting, response to and communication of CPE. In response, the Australian Commission on Safety and Quality in Health Care formed a taskforce to assist health facilities to respond to the threat of CPE. Recommendations for state and territory health departments include coordinating a risk assessment, undertaking epidemiological and microbiological investigations, determining the requirement for control measures, and coordinating risk-communication activities. The response should take advice from experts in infectious diseases, microbiology, public health, infection prevention and control and epidemiologists. The guide aims to: •Alert healthcare professionals, health departments and hospital executives to the emerging threat of CPE in Australia •Recommend strategies to prevent, detect and contain CPE •Provide information and resources for hospital executives, healthcare professionals and consumers •Recommend laboratory screening and confirmation methods. The recommendations with rationale and commentary have been structured into sections depending on the burden of CPE in the health facility. The sections include: planning, preparing and prevention; CPE screening and surveillance; strategies to reduce CPE transmission; outbreak management; laboratory screening and confirmation methods.

Introduction: Students comprised the majority of early cases of influenza A(H1N1)pdm09 in Melbourne, Australia. Students and school settings were targeted for public health interventions following the emergence of pH1N1. This study was conducted to describe changes in social contacts among the earliest confirmed student cases of pH1N1 in Melbourne, Australia, to inform future pandemic control policy and explore transmission model assumptions. Methods: A retrospective cross-sectional behavioural study of student cases with laboratory-confirmed pH1N1 between 28 April and 3 June 2009 was conducted in 2009. Demographics, symptom onset dates and detailed information on regular and additional extracurricular activities were collected. Summary measures for activities were calculated, including median group size and median number of close contacts and attendance during the students’ exposure and infectious periods or during school closures. A multivariable model was used to assess associations between rates of participation in extracurricular activities and both school closures and students’ infectious periods. Results: Among 162 eligible cases, 99 students participated. Students reported social contact in both curricular and extra-curricular activities. Group size and total number of close contacts varied. While participation in activities decreased during the students’ infectious periods and during school closures, social contact was common during periods when isolation was advised and during school closures. Discussion: This study demonstrates the potential central role of young people in pandemic disease transmission given the level of non-adherence to prevention and control measures. These finding have public health implications for both informing modelling estimates of future pandemics and targeting prevention and control strategies to young people.

To assess variations by time of year and hospital in the uptake of influenza and pertussis vaccinations by pregnant women in Victoria; to identify factors associated with vaccination uptake.Retrospective analysis of data in the Victorian Perinatal Data Collection (VPDC), a population surveillance system for obstetric conditions, procedures, and pregnancy and birth outcomes.Women whose pregnancies ended in a live or stillbirth during July 2015 - June 2017.Influenza and pertussis vaccinations during pregnancy.153 980 pregnancies in 67 hospitals ended during July 2015 - June 2017; 59 968 pregnant women (39.0%) were vaccinated against influenza and 98 583 (64.0%) against pertussis. Coverage varied by pregnancy end date, rising for influenza during winter and spring, but for pertussis rising continuously across the two years from 37.5% to 82.2%. Differences between hospitals in coverage were marked. Factors associated with vaccination included greater maternal age, primigravidity, early antenatal care, and GP-led care. The odds of vaccination were statistically significantly lower for women born overseas and those who smoked during pregnancy; the odds of vaccination were also lower for Aboriginal and Torres Strait Islander women.Pertussis vaccination of pregnant women in Victoria has increased, but influenza vaccination rates remain moderate and variable. Structural changes at the system level may improve maternal vaccination rates. Embedding the delivery of maternal vaccination programs in antenatal care pathways should be a priority.

Objective: In Australia, the notification rate for measles fluctuates greatly between baseline and outbreak periods. We aimed to identify characteristics of notified cases that allow risk stratification in order to improve the efficiency of the public health response in an outbreak setting. Methods: Retrospective descriptive case series for all measles notifications made to the Victorian Government Department of Health between 1 August and 30 September 2013. Results: A total of 151 notifications were included in the analyses, of which 17 (11%) were confirmed as measles. Applying the clinical criteria of the measles case definition or identifying susceptible cases (determined by vaccination status) correctly identified all measles cases. Requiring cases to meet both criteria reduced sensitivity to 88%, but improved the positive predictive value (48% vs 25%) and retained a high negative predictive value (98.33%). Application of a risk stratification approach based on these features would have saved intensive public health follow-up for 79.5% of notifications in this outbreak. Conclusions: Immune status and clinical features can reliably be used to predict which notifications are unlikely to become confirmed cases. Implications: Risk stratification and modification of current surveillance practices may provide for a more efficient public health response, particularly during periods of increased case notification.

Carbapenemase-producing Enterobacteriaceae (CPE) infections are increasingly reported in Australian hospitals, but prevalence is unknown. In 2016, Victorian hospitals conducted CPE point-prevalence surveys in high-risk wards (intensive care, haematology, transplant). Forty-three hospitals performed 134 surveys, with 1839/2342 (79%) high-risk patients screened. Twenty-four surveys were also performed in other wards. Inability to obtain patient consent was the leading reason for non-participation. In high-risk wards, no CPE cases were detected; three cases were identified in other wards. Since there is low prevalence in high-risk wards, continuous screening is not recommended. Targeted screening may be enhanced by review of patient consent processes.

Background Poor access to health services is a significant barrier to achieving the World Health Organization’s hepatitis C virus (HCV) elimination targets. We demonstrate how geospatial analysis can be performed with commonly available data to identify areas with the greatest unmet demand for HCV services. Methods We performed an Australia-wide cross-sectional analysis of 2015 HCV notification rates using local government areas (LGAs) as our unit of analysis. A zero-inflated negative binomial regression was used to determine associations between notification rates and socioeconomic/demographic factors, health service and geographic remoteness area (RA) classification variables. Additionally, component scores were extracted from a principal component analysis (PCA) of the healthcare service variables to provide rankings of relative service coverage and unmet demand across Australia. Results Among LGAs with non-zero notifications, higher rates were associated with areas that had increased socioeconomic disadvantage, more needle and syringe services (incidence rate ratio [IRR] 1.022; 95%CI 1.001, 1.044) and more alcohol and other drug services (IRR 1.019; 1.005, 1.034). The distribution of PCA component scores indicated that per-capita healthcare service coverage was lower in areas outside of major Australian cities. Areas outside of major cities also contained 94% of LGAs in the lowest two socioeconomic quintiles, as well as 35% of HCV notifications despite only representing 29% of the population. Conclusions As countries aim for HCV elimination, routinely collected data can be used to identify geographical areas for priority service delivery. In Australia, the unmet demand for HCV treatment services is greatest in socioeconomically disadvantaged and non-metropolitan areas.

This retrospective case series identifies the largest cohort of non-O1, non-O139 Vibrio cholerae bacteraemia in an Australian population from 2000 to 2013. We examine the risk factors, epidemiology, clinical presentations and mortality of non-O1, non-O139 V. cholerae bacteraemia in Victoria and compare them with published cases in the literature. This case series highlights the pathogenic potential of non-O1, non-O139 V. cholerae and identifies possible associations with host (underlying chronic liver disease and malignancy) and environmental factors (contaminated water supply and raw seafood). Clinicians should be aware of the morbidity and mortality associated with invasive non-O1, non-O139 V. cholerae infections, particularly in immunocompromised patients.

SUMMARYA recent outbreak of Q fever was linked to an intensive goat and sheep dairy farm in Victoria, Australia, 2012-2014. Seventeen employees and one family member were confirmed with Q fever over a 28-month period, including two culture-positive cases. The outbreak investigation and management involved a One Health approach with representation from human, animal, environmental and public health. Seroprevalence in non-pregnant milking goats was 15% [95% confidence interval (CI) 7–27]; active infection was confirmed by positive quantitative PCR on several animal specimens. Genotyping ofCoxiella burnetiiDNA obtained from goat and human specimens was identical by two typing methods. A number of farming practices probably contributed to the outbreak, with similar precipitating factors to the Netherlands outbreak, 2007-2012. Compared to workers in a high-efficiency particulate arrestance (HEPA) filtered factory, administrative staff in an unfiltered adjoining office and those regularly handling goats and kids had 5·49 (95% CI 1·29–23·4) and 5·65 (95% CI 1·09–29·3) times the risk of infection, respectively; suggesting factory workers were protected from windborne spread of organisms. Reduction in the incidence of human cases was achieved through an intensive human vaccination programme plus environmental and biosecurity interventions. Subsequent non-occupational acquisition of Q fever in the spouse of an employee, indicates that infection remains endemic in the goat herd, and remains a challenge to manage without source control.

Background. Knowledge of relationships between antibiotic susceptibility of Shigella isolates and travel destination or other risk factors can assist clinicians in determining appropriate antibiotic therapy prior to susceptibility testing. We describe relationships between resistance patterns and risk factors for acquisition in Shigella isolates using routinely collected data for notified cases of shigellosis between 2008 and 2012 in Victoria, Australia. Methods. We included all shigellosis patients notified during the study period, where Shigella isolates were tested for antimicrobialsensitivity using Clinical and Laboratory Standards Institute breakpoints. Cases were interviewed to collect data on risk factors,including recent travel. Data were analyzed using Stata 13.1 to examine associations between risk factors and resistant strains. Results. Of the 500 cases of shigellosis, 249 were associated with overseas travel and 210 were locally acquired. Forty-six of 51 isolates of Indian origin displayed decreased susceptibility or resistance to ciprofloxacin. All isolates of Indonesian origin were susceptible to ciprofloxacin. Twenty-six travel-related isolates were resistant to all tested oral antimicrobials. Male-to-male sexual contact was the primary risk factor for 80% (120/150) of locally acquired infections among adult males, characterized by distinct periodic Shigella sonnei outbreaks. Conclusions. Clinicians should consider travel destination as a marker for resistance to common antimicrobials in returning travelers, where severe disease requires empirical treatment prior to receipt of individual sensitivity testing results. Repeated outbreaks of locally acquired shigellosis among men who have sex with men highlight the importance of prevention and control measures in this high-risk group.

Introduction: The eradication of a human infectious disease is a major challenge and, if achieved, represents a enormous achievement. This article explores the long and difficult journey towards eradication for polio and guinea worm. Methods: The authors reviewed the programmatic approaches taken in the eradication strategies for these two diseases and the unique socio-political contexts in which these strategies are couched. The epidemiology of the last 15 years is compared and contrasted. The specific challenges for both programs are outlined and some key elements for success are highlighted. Discussion: The success of these eradication programs is contingent upon many factors. Nothing is assured, and progress remains fragile and vulnerable to setbacks. Security must be ensured in guinea worm transmission areas in Africa and polio transmission areas in Pakistan and Afghanistan. Technical solutions alone cannot guarantee eradication. National leadership and continued international focus and support are necessary, today more than ever. The legacy of success would be extraordinary. It would reverberate to future generations in the same way that the eradication of smallpox does for this generation.

Smith Darren, Lee Hamilton, Pickard Robert, Sutton Brett, Hunter Erik. Puissance délivrée dans la partie cycliste d'un triathlon Élite en compétition. In: Les Cahiers de l'INSEP, n°24, 1999. 2e Congrès international de triathlon de l’INSEP – 2nd INSEP international triathlon Congress pp. 217-223.

Smith Darren, Lee Hamilton, Pickard Robert, Sutton Brett, Hunter Erik. Power demands of the cycle leg during elite triathlon competition. In: Les Cahiers de l'INSEP, n°24, 1999. 2e Congrès international de triathlon de l’INSEP – 2nd INSEP international triathlon Congress pp. 224-230.

This is the sixth article on social science, humanities, news and general (SSH) databases in a continuing series of articles summarising and commenting on new database products. There are two companion articles, one covering science, technology and medicine (STM) which appeared in the August 1995 issue (Online & CDROM Review, vol. 19 issue 4) and the other covering business and law (BSL) which will appear in the December issue of this journal (Online & CDROM Review, vol. 19 issue 6). The articles are based on the newly appearing database products in the Gale Directory of Databases. The Gale Directory of Databases (GDD) was created in January 1993 by merging Computer‐Readable Databases: A Directory and Data Sourcebook (CRD) together with the Directory of Online Databases (DOD) and the Directory of Portable Databases (DPD).

This is the fifth article on Social Science, Humanities, News and General (SSH) databases in a continuing series of articles summarising and commenting on new database products. Two companion articles, one covering science, technology and medicine (STM) (Online & CDROM Review, vol. 19 issue 1) appeared in the February 1995 issue, and the other covering business and law (BSL) (Online & CDROM Review, vol. 19 issue 3) will appear in the June issue of this journal. The articles are based on the newly appearing database products in the Gale Directory of Databases. The Gale Directory of Databases (GDD) was created in January 1993 by merging Computer‐Readable Databases: A Directory and Data Sourcebook (CRD) together with the Directory of Online Databases (DOD) and the Directory of Portable Databases (DPD).

This is the fourth article on Social Science, Humanities, News and General (SSH) Databases in a continuing series of articles summarizing and commenting on new database products. Two companion articles, one covering science, technology and medicine (STM) (Online & CDROM Review vol. 18 issue 4) and the other covering business and law (BSL) (Online & CDROM Review vol. 18 issue 6) complement this article. The articles are based on the newly appearing database products in the most current edition of the Gale Directory of Databases. The Gale Directory of Databases (GDD) was created in January 1993 by merging Computer‐Readable Databases: A Directory and Data Sourcebook (CRD) with the Directory of Online Databases (DOD) and the Directory of Portable Databases (DPD).

This is the third article on Social Science, Humanities, News and General Databases in a continuing series of articles summarizing and commenting on new database products. Two companion articles, one covering science, technology and medicine (Online & CDROM Review vol. 18 issue 1) and the other covering business and law (Online & CDROM Review vol. 18 issue 3), complement this article. The articles are based on the newly appearing database products in the Gale Directory of Databases. The Gale Directory of Databases (GDD) was created in January 1993by merging Computer‐Readable Databases: A Directory and Data Sourcebook (CRD) together with the Directory of Online Databases (DOD) and the Directory of Portable Databases (DPD).

Planning and implementing library services for interdisciplinary research communities pose special challenges for academic librarians. Data were collected on journal reading patterns in an interdisciplinary research institute (the Beckman Institute at the University of Illinois at Urbana-Champaign). Analysis of these data produced a number of maps of the intellectual structure of this user community. This understanding of the structure of the academic community and how it changes over time provides a basis for developing library services that will meet the special needs of this community

This is the second article on Social Science, Humanities, News and General Databases in a continuing series of articles summarizing and commenting on new database products. Two companion articles, one covering science, technology and medicine (Online & CDROM Review vol. 17 issue 4) and the other covering business and law (Online & CDROM Review vol. 17 issue 6), complement this article. The articles are based on the newly appearing database products in the Gale Directory of Databases. The Gale Directory of Databases (GDD) was created in January 1993 by merging Computer‐Readable Databases: A Directory and Data Sourcebook (CRD) together with the Directory of Online Databases (DOD) and the Directory of Portable Databases (DPD).

This is the second in a continuing series of articles summarizing and commenting on new database products and the first one covering the topics of social sciences, humanities, general, multidisciplinary and news. Companion articles covering science, technology and medicine (which appeared in the previous issue of Online & CDROM Review) and covering business and law (to appear in the next issue) complement this article. The articles are based on the newly‐appearing database products in the Gale Directory of Databases (GDD). This was created by merging Computer‐Readable Databases: A Directory and Data Sourcebook (CRD) together with the Directory of Online Databases (DOD) and the Directory of Portable Databases (DPD). The first of GDD was published in January 1993.

Sutton's essay is a masterpiece of concise, clear, and measured exposition on this difficult area of methodological theory and practice. As Sutton notes at the beginning: �What we call qualitative research out of convenience is actually a diverse collection of philosophies, historical traditions, discipline-specific concepts, and useful practices. One goal of this article is to articulate this diversity. Another is to demonstrate that the dualistic character that the methodological debate has sometimes taken, pitting qualitative against quantitative approaches, is unproductive, not to say unrealistic.�

The Medical Journal of Australia ISSN: 0025-729X 1/ 15 December 2003 179 11/12 591-593 ©The Medical Journal of Austral ia 2003 www.mja.com.au Frontline Medicine THIS IS A brief account of my six months in Afghanistan in 2003. I worked as the Medecins Sans Frontieres (MSF) project doctor in the western province of Herat, spending alternate weeks in Herat City and in Kushk-e-Kohna, a sparsely populated district some two hours north of the provincial capital by four-wheel drive. I arrived in February, just over two years after the US-backed overthrow of the Taliban. Herat is now controlled by its Emir and Governor, Ismail Khan, who rules beyond the reach of Afghanistan’s central government. With a private army of sixty thousand men and control of customs revenue from trade with Iran, it is no wonder he has not, despite invitation, joined the government of Hamid Karzai. His unchallenged power and the considerable wealth at his disposal have in fact made Herat relatively more stable and prosperous than the rest of the country. It is February, and the winter snows are just thinning as I arrive to work in the mobile clinic in Kushk-e-Kohna, which I affectionately call “Kushk”, or “palace”, in the local language of Farsi. The name clearly harks back to a more prosperous time, for there is no palace to be found in this district of sixty thousand people. The inhabitants have mudbrick houses and live mostly off subsistence farming, growing wheat (Box 1) and raising livestock (Box 2). They have lived like this for generations, and life was little different under the Taliban, although now it is evident that young girls are going to newly built schools. There are only two doctors for the entire population — myself and an Afghan doctor recently recruited by MSF. Dr Mohammad Amin has recently graduated, and is enthusiastic about working with MSF, learning English and broadening his knowledge. Before 2003, locals had to gamble on the only “healthcare” available — drugs sold in private pharmacies by untrained “drug sellers”. And so it is that after a week I begin getting used to the hundreds of patients presenting every day, many having walked for hours, thronging around the makeshift consultation room and desperately pressing to be seen (Box 3). The mobile clinics are situated across the district, with MSF’s base in the district centre of Kooklam. We visit one or two An Afghanistan experience