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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.

Introduction Healthcare facilities are high-risk settings for coronavirus disease 2019 (COVID-19) transmission. Early in the COVID-19 pandemic, the first large healthcare-associated outbreak within Australia occurred in Tasmania. Several operational research studies were conducted amongst workers from the implicated hospital campus, to learn more about COVID-19 transmission. Methods Healthcare workers (HCWs) from the implicated hospital campus were invited to complete an online survey and participate in a serology study. Blood samples for serological testing were collected at approximately 12 weeks (round one) and eight months (round two) after the outbreak. A descriptive analysis was conducted of participant characteristics, serology results, and longevity of antibodies. Results There were 261 HCWs in round one, of whom 44 (17%) were polymerase chain reaction (PCR) confirmed outbreak cases; 129 of the 261 (49%) participated in round two, of whom 34 (27%) were outbreak cases. The prevalence of positive antibodies at round one was 15% (n = 38) and at round two was 12% (n = 15). There were 15 participants (12%) who were seropositive in both rounds, with a further 9% (n = 12) of round two participants having equivocal results after previously being seropositive. Six HCWs not identified as cases during the outbreak were seropositive in round one, with three still seropositive in round two. Of those who participated in both rounds, 68% (n = 88) were seronegative at both time points. Discussion Our findings demonstrate that serological testing after this large healthcare-associated COVID-19 outbreak complemented the findings of earlier diagnostic testing, with evidence of additional infections to those diagnosed when use of PCR testing had been restricted. The results also provide evidence of persisting SARS-CoV-2 antibody response eight months after an outbreak in an unvaccinated population. The high proportion of HCWs who remained seronegative is consistent with low community transmission in Tasmania after this outbreak.

Problem: One month after the initial case of coronavirus disease 2019 (COVID-19) in Tasmania, an island state of Australia, two health-care workers (HCWs) from a single regional hospital were notified to public health authorities following positive tests for SARS-CoV-2 nucleic acid. These were the first recognized cases in an outbreak that overwhelmed the hospital’s ability to function. Context: The outbreak originated from two index cases. Both had returned to Tasmania following travel on a cruise ship and required hospital admission for management of COVID-19. A total of 138 cases were subsequently linked to this outbreak: 81 HCWs (most being nurses) and 23 patients across three hospitals, one resident of an aged-care facility and 33 close contacts. Action: The outbreak was controlled through the identification and isolation of cases, identification and quarantining of close contacts and their household members, closure of the affected facilities and community-level restrictions to reduce social mixing in the affected region. Lessons learnt: Factors that were likely to have contributed to ongoing transmission in this setting included workplace practices that prevented adequate physical distancing, attending work while symptomatic, challenges in rapidly identifying contacts, mobility of staff and patients between facilities, and challenges in the implementation of infection control practices. Discussion: Many commonly accepted hospital practices before the COVID-19 pandemic amplified the outbreak. The lessons learnt from this investigation changed work practices for HCWs and led to wider public health interventions in the management of potential primary and secondary contacts.

Background While the relationship between outdoor particulate matter (PM) and lower respiratory tract infections in children and adolescents is accepted, we know little about the impacts of outdoor PM on the risk of developing or aggravating upper respiratory tract infections (URTIs). Methods We aimed to review the literature examining the relationship between outdoor PM exposure and URTIs in children and adolescents. A systematic search of EMBASE, MEDLINE, PubMed, Scopus, CINAHL and Web of Science databases was undertaken on April 3, 2020 and October 27, 2021. Comparable short-term studies of time-series or case-crossover designs were pooled in meta-analyses using random-effects models, while the remainder of studies were combined in a narrative analysis. Quality, risk of bias and level of evidence for health effects were appraised using a combination of emerging frameworks in environmental health. Results Out of 1366 articles identified, 34 were included in the systematic review and 16 of these were included in meta-analyses. Both PM2.5 and PM10 levels were associated with hospital presentations for URTIs (PM2.5: RR = 1.010, 95%CI = 1.007–1.014; PM10: RR = 1.016, 95%CI = 1.011–1.021) in the meta-analyses. Narrative analysis found unequivocally that total suspended particulates were associated with URTIs, but mixed results were found for PM2.5 and PM10 in both younger and older children. Conclusion This study found some evidence of associations between PM and URTIs in children and adolescents, the relationship strength increased with PM10. However, the number of studies was limited and heterogeneity was considerable, thus there is a need for further studies, especially studies assessing long-term exposure and comparing sources.

The Inter-Agency Standing Committee (IASC), created by the United Nations (UN) General Assembly in 1991, serves as the global humanitarian coordination forum of the UN s system. The IASC brings 18 agencies together, including the World Health Organization (WHO), for humanitarian preparedness and response policies and action. Early in the COVID-19 pandemic, the IASC recognized the importance of providing intensified support to countries with conflict, humanitarian, or complex emergencies due to their weak health systems and fragile contexts. A Global Humanitarian Response Plan (GHRP) was rapidly developed in March 2020, which reflected the international support needed for 63 target countries deemed to have humanitarian vulnerability. This paper assessed whether WHO provided intensified technical, financial, and commodity inputs to GHRP countries (n = 63) compared to non-GHRP countries (n = 131) in the first year of the COVID-19 pandemic. The analysis showed that WHO supported all 194 countries regardless of humanitarian vulnerability. Health commodities were supplied to most countries globally (86%), and WHO implemented most (67%) of the $1.268 billion spent in 2020 at country level. However, proportionally more GHRP countries received health commodities and nearly four times as much was spent in GHRP countries per capita compared to non-GHRP countries ($232 vs. $60 per 1,000 capita). In countries with WHO country offices (n = 149), proportionally more GHRP countries received WHO support for developing national response plans and monitoring frameworks, training of technical staff, facilitating logistics, publication of situation updates, and participation in research activities prior to the characterization of the pandemic or first in-country COVID-19 case. This affirms WHO's capacity to scale country support according to its humanitarian mandate. Further work is needed to assess the impact of WHO's inputs on health outcomes during the COVID-19 pandemic, which will strengthen WHO's scaled support to countries during future health emergencies.

BACKGROUND AND OBJECTIVES Infant influenza and pertussis disease causes considerable morbidity and mortality worldwide. We examined the effectiveness of maternal influenza and pertussis vaccines in preventing these diseases in infants. METHODS This inception cohort study comprised women whose pregnancies ended between September 1, 2015, and December 31, 2017, in Victoria, Australia. Maternal vaccination status was sourced from the Victorian Perinatal Data Collection and linked to 5 data sets to ascertain infant outcomes and vaccination. The primary outcome of interest was laboratory-confirmed influenza or pertussis disease in infants aged RESULTS Among 186 962 pregnant women, 85 830 (45.9%) and 128 060 (68.5%) were vaccinated against influenza and pertussis, respectively. There were 175 and 51 infants with laboratory-confirmed influenza and pertussis disease, respectively. Influenza VE was 56.1% (95% CI, 23.3% to 74.9%) for infants aged CONCLUSIONS Our study provides evidence of the direct effectiveness of maternal influenza and pertussis vaccination in preventing these diseases in infants aged

Dance injury research has mainly focused on ballet and modern dance with little data on musical theatre dancers. The purpose was to assess the incidence and severity of injuries in a musical theatre dance college over a 5-year period; 198 pre-professional musical theatre dancers (3 cohorts on a 3-year training course) volunteered for the study; 21 students left the course over the study period. Injury aetiology data were collected by an in-house physiotherapy team. Differences between academic year and sex were analysed using a Poisson distribution model; significant difference was set at p≤0.05. In total, 913 injuries were recorded, and more injuries occurred in academic year 1 than year 2 and 3. Overall injury incidence was 1.46 injuries per 1000 hours (95% CI 1.34, 1.56); incidence significantly decreased between year 1, 2 and 3 (p0.05). There was no significant sex difference for incidence or severity. Most injuries were classified as overuse (71% female, 67% male). Pre-professional musical theatre dancers report a high proportion of lower limb and overuse injuries comparable to other dance genres. Unlike other studies on pre-professional dancers, injury incidence and severity decreased with academic year, even though workload increased across the course.Dance injury research has mainly focused on ballet and modern dance with little data on musical theatre dancers. The purpose was to assess the incidence and severity of injuries in a musical theatre dance college over a 5-year period; 198 pre-professional musical theatre dancers (3 cohorts on a 3-year training course) volunteered for the study; 21 students left the course over the study period. Injury aetiology data were collected by an in-house physiotherapy team. Differences between academic year and sex were analysed using a Poisson distribution model; significant difference was set at p≤0.05. In total, 913 injuries were recorded, and more injuries occurred in academic year 1 than year 2 and 3. Overall injury incidence was 1.46 injuries per 1000 hours (95% CI 1.34, 1.56); incidence significantly decreased between year 1, 2 and 3 (p0.05). There was no significant sex difference for incidence or severity. Most injuries were classified as overuse (71% female, 67% male). Pre-professional musical theatre dancers report a high proportion of lower limb and overuse injuries comparable to other dance genres. Unlike other studies on pre-professional dancers, injury incidence and severity decreased with academic year, even though workload increased across the course.

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.

Objectives: To review the use of data linkage by Australian state and territory communicable disease control units, and to identify barriers to and enablers of data linkage to inform communicable disease surveillance and control activities. Methods: Semi-structured telephone interviews were carried out with one key informant from communicable disease control units in all eight Australian states and territories between October 2017 and January 2018. Results: Key informants from all Australian states and territories participated in the interview. A variety of existing practices were identified, with few jurisdictions making systematic use of available data linkage infrastructure. Key barriers identified from the review included: a lack of perceived need; system factors; and resources. Existing regulatory tools enable data linkage to enhance communicable disease surveillance and control. Conclusions: We identified considerable variation in the use of data linkage to inform communicable disease surveillance and control activities between jurisdictions. We suggest that routinely collected, disparate data are systematically integrated into existing surveillance and response policy cycle to improve communicable disease prevention and control efforts. Implications for public health: Existing gaps in communicable disease surveillance data may affect prevention and control efforts. Data linkage is recognised as a valuable method to close surveillance gaps and should be used to enhance the value of publicly held health data.

BackgroundIn urban Australia, the burden of shigellosis is either in returning travelers from shigellosis-endemic regions or in men who have sex with men (MSM). Here, we combine genomic data with comprehensive epidemiological data on sexual exposure and travel to describe the spread of multidrug-resistant Shigella lineages.MethodsA population-level study of all cultured Shigella isolates in the state of Victoria, Australia, was undertaken from 1 January 2016 through 31 March 2018. Antimicrobial susceptibility testing, whole-genome sequencing, and bioinformatic analyses of 545 Shigella isolates were performed at the Microbiological Diagnostic Unit Public Health Laboratory. Risk factor data on travel and sexual exposure were collected through enhanced surveillance forms or by interviews.ResultsRates of antimicrobial resistance were high, with 17.6% (95/541) and 50.6% (274/541) resistance to ciprofloxacin and azithromycin, respectively. There were strong associations between antimicrobial resistance, phylogeny, and epidemiology. Specifically, 2 major MSM-associated lineages were identified: a Shigellasonnei lineage (n = 159) and a Shigella flexneri 2a lineage (n = 105). Of concern, 147/159 (92.4%) of isolates within the S. sonnei MSM-associated lineage harbored mutations associated with reduced susceptibility to recommended oral antimicrobials: namely, azithromycin, trimethoprim-sulfamethoxazole, and ciprofloxacin. Long-read sequencing demonstrated global dissemination of multidrug-resistant plasmids across Shigella species and lineages, but predominantly associated with MSM isolates.ConclusionsOur contemporary data highlight the ongoing public health threat posed by resistant Shigella, both in Australia and globally. Urgent multidisciplinary public health measures are required to interrupt transmission and prevent infection.

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 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: 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.

Background: During a pertussis epidemic in 2009, the Department of Health, Victoria, Australia, implemented a cocoon program offering parents of new babies a funded-dose of pertussis-containing vaccine. We assessed vaccine effectiveness (VE) of the program in reducing pertussis infection in infants. Methods: Using a matched case-control design, infants aged

SUMMARYIdentification of priority populations such as men who have sex with men (MSM) is important in surveillance systems to monitor trends of sexually transmitted infections (STIs). We explored using routinely collected non-behavioural data as a means to establish MSM status in surveillance by assessing anorectal swab as a marker of male-to-male sexual exposure. We used chlamydia testing data from a sexual health clinic, 2007–2012. Men reporting any male sexual partner(s) in the previous 12 months were considered MSM. The dataset was split into development and validation samples to develop a univariate predictive model and assess the model fit. The dataset included 30 358 individual men and 48 554 episodes of STI testing; 45% were among reported MSM and an anorectal swab was performed in 40% of testing episodes. Anorectal swabbing had good diagnostic performance as a marker for MSM status (sensitivity = 87%, specificity = 99%, positive predictive value = 98·6%, negative predictive value = 90·3%). The model showed good fit against the internal validation sample (area under the curve = 0·93). Anorectal swabs are a valid marker of MSM behaviour in surveillance data from sexual health clinics, and they are likely to be particularly useful for monitoring STI trends among MSM with higher risk behaviour.

Objective: To assess the impact of an enhanced viral hepatitis surveillance program on data completeness and on epidemiological assessment of affected populations. Methods: Notified cases of non-acute hepatitis B and C were analysed to determine demographic characteristics and risk factors during the period prior to July 2015–June 2016, and during enhanced surveillance of the period July 2016–June 2017, during which time doctors were contacted for information about new diagnoses. Results: During the enhanced period, completeness for country of birth and Indigenous status doubled for both hepatitis B and hepatitis C, from 18–37% to 48–65%. The incidence ratio of hepatitis C among Aboriginal and Torres Strait Islander people increased from eight-fold to 11.4- fold, and the proportion of hepatitis B cases reported as born in China and Vietnam relative to other countries increased. New data fields identified that 12% of hepatitis C diagnoses occurred in a correctional facility, and 2% of hepatitis B cases were healthcare workers. Conclusions: Improved data completeness highlighted the underlying epidemiology of chronic viral hepatitis, demonstrating the increased burden of infection among specific priority populations. Implications for public health: Enhanced surveillance provides greater insight into the epidemiology of chronic viral hepatitis, identifying groups at risk and opportunities for public health action.

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.

SUMMARYImmigrants and their children who return to their country of origin to visit friends and relatives (VFR) are at increased risk of acquiring infectious diseases compared to other travellers. VFR travel is an important disease control issue, as one quarter of Australia's population are foreign-born and one quarter of departing Australian international travellers are visiting friends and relatives. We conducted a 1-year prospective enhanced surveillance study in New South Wales and Victoria, Australia to determine the contribution of VFR travel to notifiable diseases associated with travel, including typhoid, paratyphoid, measles, hepatitis A, hepatitis E, malaria and chikungunya. Additional data on characteristics of international travel were collected. Recent international travel was reported by 180/222 (81%) enhanced surveillance cases, including all malaria, chikungunya and paratyphoid cases. The majority of cases who acquired infections during travel were immigrant Australians (96, 53%) or their Australian-born children (43, 24%). VFR travel was reported by 117 (65%) travel-associated cases, highest for typhoid (31/32, 97%). Cases of children (aged P< 0·001). VFR travel is an important contributor to imported disease in Australia. Communicable disease control strategies targeting these travellers, such as targeted health promotion, are likely to impact importation of these travel-related infections.

An increase in notifications of cryptosporidiosis was observed in Victoria between March and April 2015. Cases mostly resided in one metropolitan region and hypothesis-generating interviews identified common exposures to aquatic facilities. We conducted a case-control study to determine exposure source(s) and facilitate control measures.Laboratory-confirmed cases of cryptosporidiosis from the region of interest notified between 1 March and 23 April 2015 were included. Controls residing in the same region were recruited from participants in a population health survey and frequency matched (2 per case) by age group. Details of exposure to potential risk factors were collected using a standardised telephone questionnaire for the 14-days prior to illness for cases, and an analogous exposure period for controls. Univariable and multivariable logistic regression were used to determine risk factors associated with illness using STATA SE 13.1.Thirty cases and 66 controls were included in the study. Half the cases were less than 12 years of age and 62% were female. Illness was most strongly associated with recreational water exposure at any waterpark (adjusted odds ratio (aOR)=73.5; 95% confidence interval (CI):6.74-802), and specifically at Victorian waterparks (aOR=45.6; 95% CI:5.20-399). Cases were linked with attendance at either a waterpark in the region or an adjacent region. As a result of this investigation, hyperchlorination was completed at identified facilities and swim hygiene information distributed.This study reinforces the potential for recreational water facilities, particularly waterparks, to act as a transmission source of Cryptosporidium infections. Continued communication to patrons is required to ensure healthy swimming practice in Victorian aquatic facilities.

Objective: Recent studies have used Bayesian methods to predict timing of influenza epidemics many weeks in advance, but there is no documented evaluation of how such forecasts might support the day‐to‐day operations of public health staff. Methods: During the 2015 influenza season in Melbourne, Australia, weekly forecasts were presented at Health Department surveillance unit meetings, where they were evaluated and updated in light of expert opinion to improve their accuracy and usefulness. Results: Predictive capacity of the model was substantially limited by delays in reporting and processing arising from an unprecedented number of notifications, disproportionate to seasonal intensity. Adjustment of the predictive algorithm to account for these delays and increased reporting propensity improved both current situational awareness and forecasting accuracy. Conclusions: Collaborative engagement with public health practitioners in model development improved understanding of the context and limitations of emerging surveillance data. Incorporation of these insights in a quantitative model resulted in more robust estimates of disease activity for public health use. Implications for public health: In addition to predicting future disease trends, forecasting methods can quantify the impact of delays in data availability and variable reporting practice on the accuracy of current epidemic assessment. Such evidence supports investment in systems capacity.

Infectious disease notification practices in Victoria were reviewed to identify areas for potential improvement.Confirmed or probable cases of certain infectious diseases required to be notified to the Department of Health and Human Services (DHHS) Victoria in 2013, excluding elevated blood lead, foodborne or water-borne illness with 2 or more related cases and chlamydial infection, were analysed according to: notification source of doctor ± laboratory vs. laboratory-only; routine follow-up by public health staff for selected conditions vs. not routine; priority for Indigenous status reporting for 18 priority conditions with a target of ≥ 95% completeness vs. other conditions with a target of ≥ 80% completeness; and urgency of notification (conditions requiring immediate [same day] notification vs. conditions requiring notification within 5 days).Almost half (49%) the 34,893 confirmed and probable cases were notified by laboratory report alone. Indigenous status was complete for 48% of cases. Indigenous status was more likely to be completed for conditions with active vs. no active follow-up (RR 1.88 (95% CI 1.84-1.92)) and priority conditions for Indigenous status reporting vs. other conditions (RR 1.62 (95% CI 1.59-1.66)). Among conditions without active follow-up, doctor-notified cases had more complete Indigenous status reporting than laboratory-only notified cases (86% vs. 6%, RR 15.06 (95% CI 14.15-16.03)). Fewer notifications requiring same day notification were received within the legislated time frame (59%) than notifications required to be notified within 5 days (90%).DHHS Victoria handles a large volume of infectious disease notifications. Incomplete Indigenous status reporting, particularly for conditions without active follow-up, and delayed notification of conditions requiring immediate attention warrant attention. These findings will be used to improve notification practices in Victoria. Commun Dis Intell 2016;40(3):E317-E325.

SUMMARYMycobacterium tuberculosisis primarily a pathogen of humans. Infections have been reported in animal species and it is emerging as a significant disease of elephants in the care of humans. With the close association between humans and animals, transmission can occur. In November 2010, a clinically healthy Asian elephant in an Australian zoo was found to be sheddingM. tuberculosis; in September 2011, a sick chimpanzee at the same zoo was diagnosed with tuberculosis caused by an indistinguishable strain ofM. tuberculosis.Investigations included staff and animal screening. Four staff had tuberculin skin test conversions associated with spending at least 10 hours within the elephant enclosure; none had disease. Six chimpanzees had suspected infection. A pathway of transmission between the animals could not be confirmed. Tuberculosis in an elephant can be transmissible to people in close contact and to other animals more remotely. The mechanism for transmission from elephants requires further investigation.

Clinical guidelines for testing for Chlamydia tra- chomatis (chlamydia) infection recommend annual screening of all sexually active people aged 15 to 29 years. 1 Lower chlamydia testing rates have been reported in areas in Australia with less access to ser- vices. 2 The Australian Bureau of Statistics’ (ABS) Remoteness Structure of the Australian Standard Geo- graphical Standard divides Australia into regions that share common characteristics of remoteness. 3 Under the ABS structure, Tasmania has no major cities and its mainland population is classified as residing mostly in inner (65%) and outer (33%) regional areas with a small proportion (1.5%) residing in remote areas. 3 Due to its small geographical size compared to other Australian states, it has been suggested that chlamydia testing rates in Tasmania are less influenced by geo- graphical location; 4 however, this has not been previ- ously explored at a state-wide level. The aim of this study was to describe geographical differences in chlamydia testing in young people in regional and remote Tasmania to inform clinical practice.

Background Clinical guidelines recommend annual chlamydia tests for all sexually active people aged 15–29 years. This study measured adherence to these guidelines and compared testing rates to the projected levels required to reduce chlamydia prevalence. Methods: All chlamydia tests conducted in Tasmania during 2012–13, for residents aged 15–29 years, were linked. Data linkage allowed individuals who had multiple tests across different healthcare settings to be counted only once each year in analyses. Rates of testing and test positivity by age, sex, rebate status and socioeconomic indicators were measured. Results: There were 31 899 eligible tests conducted in 24 830 individuals. Testing coverage was higher in females (21%, 19 404/92 685) than males (6%, 5426/98 123). Positivity was higher in males (16%, 862/5426) than females (10%, 1854/19 404). Most tests (81%, 25 803/31 899) were eligible for a rebate. Positivity was higher in females with non-rebatable tests (12%, 388/3116 compared with those eligible for a rebate (9%, 1466/16 285). More testing occurred in areas of middle disadvantage (10%, 9688/93 678) compared with least (8%, 1680/21 670) and most (10%, 7284/75 460) (both P

Background Chlamydia re-infection increases the likelihood of adverse long-term sequelae. Clinical guidelines recommend retesting at 3–12 months for individuals with positive results, to detect re-infections. Retesting and test positivity levels were measured in young people who previously tested positive for chlamydia infection. Methods: All chlamydia tests conducted during 2012–13 in Tasmanian residents aged 15–29 years were linked. Retesting and retest positivity rates were calculated by sex, age, socioeconomic indicators and test timeframe. Results: Retesting rates were higher in females than males at 3 months (14.5%, n = 242/1673 vs 10%, n = 71/721) (P

SUMMARYTwenty-two confirmed cases ofSalmonellaInfantis were identified in 70 residents of high-level care areas of a residential aged care facility in Sydney in April 2010 during an outbreak of gastroenteritis. A retrospective cohort study was conducted to identify a possible cause. Consuming a soft diet, puréed diet, or thickened fluid were each independently associated with illness. A logistic regression showed consumption of thickened fluid to be the only significant exposure associated with illness (adjusted odds ratio 11·8, 95% confidence interval 1·9–75·9). It was postulated that the thickened fluid had been contaminated by chicken mince, a sample of which also culturedS. Infantis. This finding reinforces the need to educate food-handlers on the risk of potential cross-contamination; it also highlights the need to consider all dietary components, such as thickened fluids, as potential vehicles for transmission in an outbreak.

Cryptosporidiosis is one of the most common waterborne diseases reported worldwide. Outbreaks of this gastrointestinal disease, which is caused by the Cryptosporidium parasite, are often attributed to public swimming pools and municipal water supplies. Between the months of January and April in 2009, New South Wales, Australia, experienced the largest waterborne cryptosporidiosis outbreak reported in Australia to date. Through the course of the contamination event, 1,141 individuals became infected with Cryptosporidium . Health authorities in New South Wales indicated that public swimming pool use was a contributing factor in the outbreak. To identify the Cryptosporidium species responsible for the outbreak, fecal samples from infected patients were collected from hospitals and pathology companies throughout New South Wales for genetic analyses. Genetic characterization of Cryptosporidium oocysts from the fecal samples identified the anthroponotic Cryptosporidium hominis IbA10G2 subtype as the causative parasite. Equal proportions of infections were found in males and females, and an increased susceptibility was observed in the 0- to 4-year age group. Spatiotemporal analysis indicated that the outbreak was primarily confined to the densely populated coastal cities of Sydney and Newcastle.

Objectives: To investigate trends in notification rates of Chlamydia trachomatis in Tasmania, Australia, by population sub-groups, from 1 January 2001 to 31 December 2007. Methods: An enhanced surveillance dataset was used to supplement case notifications. Rates based on age group were analysed by sex, geographic region, indigenous status, sexual exposure, reason for testing and healthcare provider. Results: In all age groups, the notification rate increased steeply. The highest rates were seen in the ages 15-24 years; this age group represented 15% of the population but accounted for 74% of the chlamydial notifications. The increased rates in females aged 15-24 years and males 15-19 years in Tasmania were larger than the increases observed nationally. Rates were consistently higher in urban areas. Females were more likely to have been tested as a result of screening, and males were more likely to have been tested when presenting with symptoms or as a result of contact tracing. The majority of cases reported sexual exposure with opposite sex partners only. Conclusions: This study highlights the increasing significance of chlamydial infection as a public health issue, the gender differences in health-seeking behaviour, and the discrepancies in testing patterns. These findings will assist with the design of health promotion programs. ©2010 The Authors.

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.

©2017 AMPCo Pty Ltd. Produced with Elsevier B.V. All rights reserved. Traditional herbal products are widely used in Australia to treat a broad range of conditions and diseases. It is popularly believed that these products are safer than prescribed drugs. While many may be safe, it is worrying that the specific effects and harmful interactions of a number of their components with prescription medications is not well understood. Some traditional herbal preparations contain heavy metals and toxic chemicals, as well as naturally occurring organic toxins. The effects of these substances can be dire, including acute hepatic and renal failure, exacerbation of pre-existing conditions and diseases, and even death. The content and quality of herbal preparations are not tightly controlled, with some ingredients either not listed or their concentrations recorded inaccurately on websites or labels. Herbal products may also include illegal ingredients, such as ephedra, Asarum europaeum (European wild ginger) and endangered animal species (eg, snow leopard). An additional problem is augmentation with prescription medications to enhance the apparent effectiveness of a preparation. Toxic substances may also be deliberately or inadvertently added: less expensive, more harmful plants may be substituted for more expensive ingredients, and processing may not be adequate. The lack of regulation and monitoring of traditional herbal preparations in Australia and other Western countries means that their contribution to illness and death is unknown. We need to raise awareness of these problems with health care practitioners and with the general public.

Background Chlamydia remains Australia’s most frequently notified communicable disease; however, interpretation of notification data is difficult without knowledge of testing practices. This study examined the value of reporting positivity trends. Methods: Tasmanian population-level chlamydia laboratory tests and notification data from 2001 to 2010 were compared. Results: Notifications, tests and positivity increased, most significantly in males and females aged 15–29 years. Conclusions: Analysis of chlamydia positivity trends can inform the development, monitoring and evaluation of prevention and control activities and improves the interpretation of notification trends. After allowing for testing effort, an increase in chlamydia infections in young people was found.

The structure and function of subcutaneous small arteries from patients with mild heart failure ( n = 27) 6–43 mo after myocardial infarction were compared with vessels from healthy control subjects ( n = 10). Patients were randomized to treatment with placebo or the angiotensin-converting enzyme inhibitor ramipril starting 3–10 days after myocardial infarction. Dissected arterial vessels were mounted on a wire myograph for measurement of morphology and isometric tension. Morphology was not different in arteries from the three groups. Responses to norepinephrine, angiotensin II, and electrical field stimulation were similar in arteries from placebo-treated patients with mild heart failure and control subjects. Similarly, endothelium-dependent and -independent relaxation was normal in arteries from patients with mild heart failure. Ramipril therapy was associated with functional alterations: vasoconstrictor responses to norepinephrine and angiotensin II were significantly enhanced compared with placebo ( P < 0.001). These data suggest that vascular structure and function are not different in vitro in subcutaneous arteries from placebo-treated patients with mild heart failure. Angiotensin-converting enzyme inhibitor therapy is associated with enhanced vasoconstriction to norepinephrine and angiotensin II, which may reflect upregulation of receptor-mediated events.

Poster: "RANZCR ASM 2013 / R-0053 / Incidental extraspinal findings at CT Lumbar spine on wide field of view reconstructions." by: "T. Sutherland1, N. Stephens1, J. M. E. Chock2, J. Watts2, K. Yap1; 1Fitzroy/AU, 2Melbourne/AU"