Cardiac procedures in ST-segment-elevation myocardial infarction - the influence of age, geography and Aboriginality.

BACKGROUND: Timely restoration of bloodflow acute ST-segment elevation myocardial infarction (STEMI) reduces myocardial damage and improves prognosis. The objective of this study was describe the association of demographic factors with hospitalisation rates for STEMI and time to angiography, Percutaneous Coronary Intervention (PCI) and Coronary Artery Bypass Graft (CABG) in New South Wales (NSW) and the Australian Capital Territory (ACT), Australia. METHODS: This was an observational cohort study using linked population health data. We used linked records of NSW and the ACT hospitalisations and the Australian Government Medicare Benefits Schedule (MBS) for persons aged 35 and over hospitalised with STEMI in the period 1 July 2010 to 30 June 2014. Survival analysis was used to determine the time between STEMI admission and angiography, PCI and CABG, with a competing risk of death without cardiac procedure. RESULTS: Of 13,117 STEMI hospitalisations, 71% were among males; 55% were 65-plus years; 64% lived in major cities, and 2.6% were Aboriginal people. STEMI hospitalisation occurred at a younger age in males than females. Angiography and PCI rates decreased with age: angiography 69% vs 42% and PCI 60% vs 34% on day 0 for ages 35-44 and 75-plus respectively. Lower angiography and PCI rates and higher CABG rates were observed outside major cities. Aboriginal people with STEMI were younger and more likely to live outside a major city. Angiography, PCI and CABG rates were similar for Aboriginal and non-Aboriginal people of the same age and remoteness area. CONCLUSIONS: There is a need to improve access to definitive revascularisation for STEMI among appropriately selected older patients and in regional areas. Aboriginal people with STEMI, as a population, are disproportionately affected by access to definitive revascularisation outside major cities. Improving access to timely definitive revascularisation in regional areas may assist in closing the gap in cardiovascular outcomes between Aboriginal and non-Aboriginal people.

NSW Health COVID-19 Emergency Response Priority Research program: a case study of rapid translation of research into health decision making.

OBJECTIVES: The NSW Health COVID-19 Research Program was established in April 2020 to contribute to minimising the health, social and economic impacts of the coronavirus disease 2019 (COVID-19) pandemic in New South Wales (NSW). This paper describes the establishment and implemention of one element of the Program, the Emergency Response Priority Research (Emergency Response) workstream, which is focused on the rapid creation of evidence to support urgent operational work for the public health management of COVID-19 in NSW. METHODS: Narrative description. RESULTS: As at June 2021, nine Emergency Response projects had been funded. Mechanisms used to expedite projects included: embedding academic researchers in NSW Health to work directly with routinely collected NSW Health data; adapting existing research projects to include a COVID-19 component; leveraging established research partnerships to conduct rapid pilots; and directly commissioning urgent projects with experienced and trusted local researchers. LESSONS LEARNT: Evidence from Emergency Response projects has contributed directly to informing the NSW public health response. For example, findings from a study of COVID-19 transmission in schools and childcare settings in the early stages of the pandemic informed decisions around the resumption of on-campus education in 2020 and helped shape policy around higher risk activities to help reduce transmission in education settings. Similarly, findings from a project to validate methods for identifying SARS-CoV-2 virus fragments in wastewater were subsequently incorporated into the NSW Sewage Surveillance Program, which continues to provide NSW Health with information to support targeted messaging and testing. The approach to establishing and implementing the Emergency Response workstream highlights the importance of continuing to ensure a well-trained public health research community and actively supporting a collaborative research sector.

Population-level effectiveness of rapid, targeted, high-coverage roll-out of HIV pre-exposure prophylaxis in men who have sex with men: the EPIC-NSW prospective cohort study.

BACKGROUND: HIV pre-exposure prophylaxis (PrEP) is highly effective in men who have sex with men (MSM) at the individual level, but data on population-level impact are lacking. We examined whether rapid, targeted, and high-coverage roll-out of PrEP in an MSM epidemic would reduce HIV incidence in the cohort prescribed PrEP and state-wide in Australia's most populous state, New South Wales. METHODS: The Expanded PrEP Implementation in Communities-New South Wales (EPIC-NSW) study is an implementation cohort study of daily co-formulated tenofovir disoproxil fumarate and emtricitabine as HIV PrEP. We recruited high-risk gay men in a New South Wales-wide network of 21 clinics. We report protocol-specified co-primary outcomes at 12 months after recruitment of the first 3700 participants: within-cohort HIV incidence; and change in population HIV diagnoses in New South Wales between the 12-month periods before and after PrEP roll-out. The study is registered with ClinicalTrials.gov, number NCT02870790. FINDINGS: We recruited 3700 participants in the 8 months between March 1, 2016, and Oct 31, 2016. 3676 (99%) were men, 3534 (96%) identified as gay, and 149 (4%) as bisexual. Median age was 36 years (IQR 30-45 years). Overall, 3069 (83%) participants attended a visit at 12 months or later. Over 4100 person-years, two men became infected with HIV (incidence 0·048 per 100 person-years, 95% CI 0·012-0·195). Both had been non-adherent to PrEP. HIV diagnoses in MSM in New South Wales declined from 295 in the 12 months before PrEP roll-out to 221 in the 12 months after (relative risk reduction [RRR] 25·1%, 95% CI 10·5-37·4). There was a decline both in recent HIV infections (from 149 to 102, RRR 31·5%, 95% CI 11·3 to 47·3) and in other HIV diagnoses (from 146 to 119, RRR 18·5%, 95% CI -4·5 to 36·6). INTERPRETATION: PrEP implementation was associated with a rapid decline in HIV diagnoses in the state of New South Wales, which was greatest for recent infections. As part of a combination prevention approach, rapid, targeted, high-coverage PrEP implementation is effective to reduce new HIV infections at the population level. FUNDING: New South Wales Ministry of Health, Gilead Sciences.

High hepatitis C incidence in new injecting drug users: a policy failure?

OBJECTIVE: Evidence of ongoing hepatitis C (HCV) transmission among injecting drug users (IDUs) suggests a need for a better understanding of seroconversion characteristics among new IDUs and other vulnerable subgroups. This study aimed to determine incidence of HCV and associated risk factors among new IDUs in Sydney. METHODS: IDUs who had injected drugs in the past six months and who were unaware of their antibody HCV status or knew their serostatus to be negative were recruited through street-based outreach, methadone clinics and needle and syringe programs in south-western Sydney. Anti-HCV negative IDUs (n = 215) were enrolled and followed-up at 3-6 monthly intervals. New IDUs (n = 204) were defined as aged below 30 years or injecting for < or = 6 years at baseline. RESULTS: A total of 61 seroconversions were observed and incidence was 45.8 per 100 person years. Independent predictors of seroconversion were duration of injecting < 1 year (IRR = 3.10; 95% CI 1.47-6.54), female gender (IRR = 2.0; 95% CI 1.16-3.45), culturally and linguistically diverse background (CALDB) (IRR = 2.03; 95% CI 1.06-3.89) and intravenous cocaine use (IRR = 2.37; 95% CI 1.26-4.44). While new IDUs shared common risk factors, strong associations were observed between HCV seroconversion and sharing syringes, sharing other injecting equipment and backloading in CALDB new IDUs. CONCLUSION: Incidence of HCV infection among new IDUs in Sydney is unacceptably high. IMPLICATIONS: Extremely high rates of incident infection among newly initiated CALDB IDUs indicate an urgent need for enhanced policy and resource commitments to reduce the vulnerability of this group to HCV and other blood-borne infections.

Incidence and risk factors for hepatitis C seroconversion in injecting drug users in Australia.

AIMS: To determine the incidence of hepatitis C virus (HCV) infection and identify risk factors for seroconversion. DESIGN: Prospective cohort study. Participants were recruited through direct approaches, street-based outreach, methadone and sexual health clinics and needle and syringe programmes. SETTING: Urban, regional and rural settings in New South Wales, Australia. PARTICIPANTS: Injecting drug users (IDUs) (n = 584) were screened and tested for exposure to HCV. Between 1999 and 2002 antibody HCV negative IDUs (n = 368) were enrolled and followed-up every 3-6 months until seroconversion or study completion. MEASUREMENTS: Interviewer-administered baseline and follow-up questionnaires consisted of 131 items and included demographics, drug use and risk behaviour. Approximately 10 cc of whole blood was drawn at each visit. Specimens were stored at -70C and serology performed using one or two third-generation enzyme-linked immunosorbent assays and polymerase chain reaction testing. FINDINGS: Sixty-eight seroconversions were observed and incidence was 30.8 per 100 person-years, with incidence in IDUs injecting < 1 year, 133 per 100 person-years. Independent predictors of seroconversion were female gender, duration of injecting, injecting cocaine, shared use of filters and recruitment strategy. CONCLUSIONS: Women, new initiates and IDUs recruited via outreach appear to be at increased risk of infection. Results confirm the significance of cocaine injection as a risk factor and provide the first evidence outside North America of the link between shared use of drug preparation equipment and incident HCV infection. Prevention efforts should attempt to raise awareness of the risks associated with drug sharing and, in particular, the role of potentially contaminated syringes in HCV infection.

Preparing for the next influenza pandemic: a New South Wales perspective.

Pandemic influenza is one of a small number of infectious diseases that pose a significant global threat. Pandemic preparedness has accelerated around the world in recent years in response to the perceived increased risk of a pandemic developing following the emergence of H5N1 avian influenza in domestic poultry flocks in Asia, Africa and Europe. There is a hierarchy of pandemic plans - international, national, state, and local - and harmonisation of all of these is imperative for a coordinated and effective response. At the national and state levels, plans have been developed for a whole-of-government response to a pandemic, in addition to plans specifically for the health sector. It is inevitable that influenza pandemics will occur and careful planning is crucial to mitigate their potentially devastating effects.

Meningococcal disease--probable transmission during an international flight.

Two cases of meningococcal disease were identified in passengers who travelled on the same international flight. Both cases were serogroup B with the same allelic profile. The public health action involved chemoprophylaxis for persons seated adjacent to, and in the rows in front and behind, each case. The most likely scenario is that transmission of N. meningitidis occurred on board a long distance flight, either from one case to the other or from an asymptomatic carrier to both cases. This scenario and the absence of reports of similar cases in the literature, indicate the risk to other passengers in this setting is low. This investigation reinforces the need for, and the distribution of, good national and international surveillance information to better inform public health decision making.

Risk behaviors and antibody hepatitis B and C prevalence among injecting drug users in south-western Sydney, Australia.

BACKGROUND AND AIM: Hepatitis C virus (HCV) infection is now the leading notifiable disease in Australia. The current study aimed to determine the prevalence of HCV and hepatitis B virus (HBV) infection and associated risk behaviors among injecting drug users (IDUs) screened in south-western Sydney as part of a multisite prospective cohort study. METHODS: Using a combination of snowball sampling and word-of-mouth recruitment strategies, 377 IDUs were interviewed using a structured questionnaire and tested for exposure to HCV and HBV. Entry criteria were injecting drug use in the previous 6 months and antibody HCV serostatus not known to be positive. RESULTS: More than one-third (36.6%) tested HCV antibody positive and one-quarter (28%) had been exposed to HBV. Independent predictors of HCV seropositivity were HBV core antibody positive serostatus, incarceration in the past year, injecting in public, Asian ethnicity and duration of injecting. Individual risk behaviors, including sharing needles and syringes, sharing other injecting equipment and being injected by others, were not significant in either bivariate or multivariate models. CONCLUSIONS: Results indicate an urgent need for structural interventions designed to reduce the exposure of IDUs, particularly indigenous Australian and Asian injectors, to risk environments. Structural interventions, including population-based hepatitis B immunization, expanded access to needle and syringe programs and drug treatment, prison diversion programs and medically supervised injecting facilities, should be incorporated into existing blood-borne virus prevention efforts.

A novel hepatitis B vaccination regimen for adolescents: two doses 12 months apart.

BACKGROUND: Two- and three-dose hepatitis B vaccinations for adolescents are usually administered using dosing schedules of 6 months duration. This does not suit all circumstances. A 12-month schedule would be useful in schools and settings where only annual vaccination is the most practical option. AIM: To examine the efficacy of a 12-month dosing interval for two-dose hepatitis B vaccination of adolescents. SUBJECTS: Four hundred and fifty-eight healthy first-year high school (Year 7) students. VACCINATION REGIMEN: Engerix-B (GlaxoSmithKline Biologicals) 20 micro g: two doses, 12 months apart. SERUM COLLECTION: #1, same day as first vaccine dose given; #2, >1 month after second vaccine dose. RESULTS: Of the 458 children: 15 did not provide serum #1, 17 had prior vaccination, 2 had prior infection, 18 moved, 7 failed to provide serum #2, 12 withdrew (only 1 cited vaccine adverse reactions as the reason). Three hundred and eighty-seven (210 males, 177 females) aged 11.8-14.2 years (mean: 12.9+/-0.42 years) at entry completed both injections 321-381 days (mean: 359+/-10.7 days) apart and supplied serum #2, 30-57 days (mean: 41+/-5.6 days) after the second vaccine dose.Anti-HBs responses: 379 of the 387 subjects (97.9%; 95% CI: 95.9-99.1%) achieved anti-HBs > or =10 mIU/ml (range 10-170,460 mIU/ml, geometric mean concentration (GMC) 4155 mIU/ml-95% CI of mean: 3381-5106 mIU/ml). Sex was the only determinant of anti-HBs concentration (206 males: GMC 3073 mIU/ml-95% CI: 2285-4134 mIU/ml; 173 females: GMC 5944 mIU/ml-95% CI: 4508-7851 mIU/ml; P=0.001). CONCLUSION: A high seroprotection rate and GMC were achieved using two 20 micro g doses of Engerix-B administered 12 months apart. These results are similar to those achieved by others using 6-month three- and two-dose regimens in adolescents.