P2/N95 fit testing and the risk of COVID-19 in Healthcare Workers.

BACKGROUND: Guidelines recommend healthcare workers (HCWs) undertake fit testing of P2/N95 respirators to mitigate the risk of infectious aerosols, however few studies have assessed whether fit testing reduces COVID-19 infection. METHODS: A retrospective cohort study was conducted amongst HCWs across two tertiary health services in Melbourne, Australia during a period of low community transmission. Institution-wide quantitative fit testing and detailed questionnaires assessing COVID-19 acquisition risk factors were undertaken from September 2020. HCWs diagnosed with COVID-19 in the period prior to the fit testing program (February 1st - August 31st 2020) were matched on a 1:3 ratio to HCWs who had not been diagnosed with COVID-19. Risk factors for COVID-19 acquisition, including fit testing outcome, were compared between groups. RESULTS: A total of 1571 HCWs took part in fit testing programs. Seventy-two (4.6%) were diagnosed with COVID-19 within the study period. Younger age, nursing staff, close contact with a COVID-19 case, and working longer periods in wards with COVID-19 patients, were associated with COVID-19 infection. After matching for intensity of occupational exposure to infectious aerosols, close contact was the only independent variable associated with COVID-19 infection (OR 3.50, 95% CI:1.65-7.44, p = 0.001). Adequate fit test for the respirator predominately worn before the fit testing period was not associated with COVID-19 (OR 1.08, 95% CI:0.59-1.98, p = 0.815). CONCLUSION: After controlling for intensity of occupational exposure to infectious aerosols, P2/N95 respirator fit testing was not associated with reduced risk of COVID-19 infection. The utility of widespread fit testing to reduce HCW COVID-19 infections should be reconsidered.

Surveillance testing using salivary RT-PCR for SARS-CoV-2 in managed quarantine facilities in Australia: A laboratory validation and implementation study.

Background: Regular repeat surveillance testing is a strategy to identify asymptomatic individuals with SARS-CoV-2 infections in high-risk work settings to prevent onward community transmission. Saliva sampling is less invasive compared to nasal/oropharyngeal sampling, thus making it suitable for regular testing. In this multi-centre evaluation, we aimed to validate RT-PCR using salivary swab testing of SARS-CoV-2 for large-scale surveillance testing and assess implementation amongst staff working in the hotel quarantine system in Victoria, Australia. Methods: A multi-centre laboratory evaluation study was conducted to systematically validate the in vitro and clinical performance of salivary swab RT-PCR for implementation of SARS-CoV-2 surveillance testing. Analytical sensitivity for multiple RT-PCR platforms was assessed using a dilution series of known SARS-CoV-2 viral loads, and assay specificity was examined using a panel of viral pathogens other than SARS-CoV-2. In addition, we tested capacity for large-scale saliva testing using a four-sample pooling approach, where positive pools were subsequently decoupled and retested. Regular, frequent self-collected saliva swab RT-PCR testing was implemented for staff across fourteen quarantine hotels. Samples were tested at three diagnostic laboratories validated in this study, and results were provided back to staff in real-time. Findings: The agreement of self-collected saliva swabs for RT-PCR was 84.5% (95% CI 68.6 to 93.8) compared to RT-PCR using nasal/oropharyngeal swab samples collected by a healthcare practitioner, when saliva samples were collected within seven days of symptom onset. Between 7th December 2020 and 17th December 2021, almost 500,000 RT-PCR tests were performed on saliva swabs self-collected by 102 staff working in quarantine hotels in Melbourne. Of these, 20 positive saliva swabs were produced by 13 staff (0.004%). The majority of staff that tested positive occurred during periods of community transmission of the SARS-CoV-2 Delta variant. Interpretation: Salivary RT-PCR had an acceptable level of agreement compared to standard nasal/oropharyngeal swab RT-PCR within early symptom onset. The scalability, tolerability and ease of self-collection highlights utility for frequent or repeated testing in high-risk settings, such as quarantine or healthcare environments where regular monitoring of staff is critical for public health, and protection of vulnerable populations. Funding: This work was funded by the Victorian Department of Health.

State-wide genomic epidemiology investigations of COVID-19 in healthcare workers in 2020 Victoria, Australia: Qualitative thematic analysis to provide insights for future pandemic preparedness.

Background: COVID-19 has affected many healthcare workers (HCWs) globally. We performed state-wide SARS-CoV-2 genomic epidemiological investigations to identify HCW transmission dynamics and provide recommendations to optimise healthcare system preparedness for future outbreaks. Methods: Genome sequencing was attempted on all COVID-19 cases in Victoria, Australia. We combined genomic and epidemiologic data to investigate the source of HCW infections across multiple healthcare facilities (HCFs) in the state. Phylogenetic analysis and fine-scale hierarchical clustering were performed for the entire dataset including community and healthcare cases. Facilities provided standardised epidemiological data and putative transmission links. Findings: Between March-October 2020, approximately 1,240 HCW COVID-19 infection cases were identified; 765 are included here, requested for hospital investigations. Genomic sequencing was successful for 612 (80%) cases. Thirty-six investigations were undertaken across 12 HCFs. Genomic analysis revealed that multiple introductions of COVID-19 into facilities (31/36) were more common than single introductions (5/36). Major contributors to HCW acquisitions included mobility of staff and patients between wards and facilities, and characteristics and behaviours of patients that generated numerous secondary infections. Key limitations at the HCF level were identified. Interpretation: Genomic epidemiological analyses enhanced understanding of HCW infections, revealing unsuspected clusters and transmission networks. Combined analysis of all HCWs and patients in a HCF should be conducted, supported by high rates of sequencing coverage for all cases in the population. Established systems for integrated genomic epidemiological investigations in healthcare settings will improve HCW safety in future pandemics. Funding: The Victorian Government, the National Health and Medical Research Council Australia, and the Medical Research Future Fund.

Travellers' diarrhoea-a survey of practice.

BACKGROUND.: Travellers' diarrhoea (TD) is a common problem, affecting millions of tourists each year and creating a large economic burden. Risk factors for TD are known and guidelines exist to assist practitioners in advising travellers on how to prevent and treat TD. However, data are lacking regarding actual prescribing practices or approaches used in TD management. This study aims to establish a baseline which identifies uniformities and diversities in practice. METHODS.: An online survey created using the SurveyMonkey tool was developed to test respondent approaches to TD pre-travel management. An invitation to participate in the survey was distributed early 2016 through selected Australian and New Zealand speciality travel medicine centres and through the electronic mailing list of the International Society of Travel Medicine (ISTM). Descriptive statistics and analyses using Chi Square analysis and two-sided Fishers exact tests for significance were used. RESULTS.: Three hundred and sixty-four completed or partially completed surveys were collected from respondents in 23 countries. Approach to TD, antibiotic choice and management of four different clinical scenarios were assessed, with analyses focused on identifying significant differences in approach according to region of practice, professional background and level of experience. The responses to the clinical scenarios suggest most uniformity in recommended treatment strategies in clearly mild or severe disease, and greater variability in moderate disease. CONCLUSIONS.: There is practice diversity in the discussion of preventative techniques and prescribing of self-treatment medications for TD, especially for moderate TD disease. Evidence-based guidelines that address the competing issues of patient health and morbidity vs the risk of colonization with resistant organisms may lead to more consistent antibiotic prescribing practices.

Shigella sonnei bacteraemia occurring in a young man with shigellosis.

A 34-year-old man presented with a 6-day history of diarrhoea, abdominal cramps and fever. Blood cultures were initially reported as positive for Escherichia coli using matrix-assisted laser desorption/ionisation time of flight (MALDI-TOF) mass spectrometry. Contrast CT of the abdomen and pelvis revealed pancolitis and terminal ileal thickening. The patient was treated empirically with ampicillin, ciprofloxacin and metronidazole. Stool cultures were positive for Shigella sonnei. Subsequent testing on the initial blood culture correctly identified the organism as S. sonnei. On further questioning, the patient reported unprotected men who have sex with men (MSM) 3 months previously. His symptoms resolved during his 3-day admission, and he was discharged on 14 days of ciprofloxacin. He remains well. This case highlights that shigellosis is increasingly seen in MSM, with no history of travel, and may result in bacteraemia. This case also highlights the benefits (rapid identification of organisms) and limitations (inability to distinguish between E. coli and Shigella spp) of new technologies such as MALDI-TOF.

Desorption of nitramine and nitroaromatic explosive residues from soils detonated under controlled conditions.

Potentially toxic nitroaromatic and nitramine compounds are introduced onto soils during detonation of explosives. The present study was conducted to investigate the desorption and transformation of explosive compounds loaded onto three soils through controlled detonation. The soils were proximally detonated with Composition B, a commonly used military explosive containing 2,4,6-trinitrotoluene (TNT), hexahydro-1,3,5-trinitro-1,3,5-triazine (RDX), and octahydro 1,3,5,7-tetranitro-1,3,5,7-tetrazocine (HMX). Gas-exchangeable surface areas were measured from pristine and detonated soils. Aqueous batches of detonated soils were prepared by mixing each soil with ultrapure water. Samples were collected for 141 d and concentrations of Composition B compounds and TNT transformation products 2-amino-4,6-dinitrotoluene (2ADNT), 4-amino-2,6-dinitrotoluene (4ADNT), and 1,3,5-trinitrobenzene (1,3,5-TNB) were measured. The RDX, HMX, and TNT concentrations in detonated soil batches exhibited first-order physical desorption for the first, roughly, 10 d and then reached steady state apparent equilibrium within 40 d. An aqueous batch containing powdered Composition B in water was sampled over time to quantify TNT, RDX, and HMX dissolution from undetonated Composition B particles. The TNT, RDX, and HMX concentrations in aqueous batches of pure Composition B reached equilibrium within 6, 11, and 20 d, respectively. Detonated soils exhibited lower gas-exchangeable surface areas than their pristine counterparts. This is likely due to an explosive residue coating on detonated soil surfaces, shock-induced compaction, sintering, and/or partial fusion of soil particles under the intense heat associated with detonation. Our results suggest that explosive compounds loaded to soils through detonation take longer to reach equilibrium concentrations in aqueous batches than soils loaded with explosive residues through aqueous addition. This is likely due to the heterogeneous interactions between explosive residues and soil particle surfaces.

Investigating the fate of nitroaromatic (TNT) and nitramine (RDX and HMX) explosives in fractured and pristine soils.

Explosives compounds, known toxins, are loaded to soils on military training ranges predominantly during explosives detonation events that likely fracture soil particles. This study was conducted to investigate the fate of explosives compounds in aqueous slurries containing fractured and pristine soil particles. Three soils were crushed with a piston to emulate detonation-induced fracturing. X-ray diffraction, energy-dispersive X-ray spectrometry, gas adsorption surface area measurements, and scanning electron microscopy were used to quantify and image pristine and fractured soil particles. Aqueous batches were prepared by spiking soils with solutions containing 2,4,6-trinitrotoluene (TNT), hexahydro-1,3,5-trinitro-1,3,5-triazine (RDX), octahydro 1,3,5,7-tetranitro-1,3,5,7-tetrazocine (HMX), and 2,4-dinitrotoluene (2,4-DNT). Samples were collected over 92 d and the concentrations of the spiked explosives compounds and TNT transformation products 2-amino-4,6-dinitrotoluene (2ADNT) and 4-amino-2,6-dinitrotoluene (4ADNT) were measured. Our results suggest soil mineralogical and geochemical compositions were not changed during piston-induced fracturing but morphological differences were evident with fractured soils exhibiting more angular surfaces, more fine grained particles, and some microfracturing that is not visible in the pristine samples. TNT, 2,4-DNT, RDX, and HMX exhibited greater analyte loss over time in batch solutions containing fractured soil particles compared to their pristine counterparts. 2ADNT and 4ADNT exhibited greater concentrations in slurries containing pristine soils than in slurries containing fractured soils. Explosives compound transformation is greater in the presence of fractured soil particles than in the presence of pristine soil particles. Our results imply fractured soil particles promote explosive compound transformation and/or explosives compounds have a greater affinity for adsorption to fractured soil particle surfaces.