Q fever seroprevalence in Australia suggests one in twenty people have been exposed.

Q fever (caused by Coxiella burnetii) is thought to have an almost world-wide distribution, but few countries have conducted national serosurveys. We measured Q fever seroprevalence using residual sera from diagnostic laboratories across Australia. Individuals aged 1-79 years in 2012-2013 were sampled to be proportional to the population distribution by region, distance from metropolitan areas and gender. A 1/50 serum dilution was tested for the Phase II IgG antibody against C. burnetii by indirect immunofluorescence. We calculated crude seroprevalence estimates by age group and gender, as well as age standardised national and metropolitan/non-metropolitan seroprevalence estimates. Of 2785 sera, 99 tested positive. Age standardised seroprevalence was 5.6% (95% confidence interval (CI 4.5%-6.8%), and similar in metropolitan (5.5%; 95% CI 4.1%-6.9%) and non-metropolitan regions (6.0%; 95%CI 4.0%-8.0%). More males were seropositive (6.9%; 95% CI 5.2%-8.6%) than females (4.2%; 95% CI 2.9%-5.5%) with peak seroprevalence at 50-59 years (9.2%; 95% CI 5.2%-13.3%). Q fever seroprevalence for Australia was higher than expected (especially in metropolitan regions) and higher than estimates from the Netherlands (2.4%; pre-outbreak) and US (3.1%), but lower than for Northern Ireland (12.8%). Robust country-specific seroprevalence estimates, with detailed exposure data, are required to better understand who is at risk and the need for preventive measures.

A One Health investigation of Salmonella enterica serovar Wangata in north-eastern New South Wales, Australia, 2016-2017.

Salmonella enterica serovar Wangata (S. Wangata) is an important cause of endemic salmonellosis in Australia, with human infections occurring from undefined sources. This investigation sought to examine possible environmental and zoonotic sources for human infections with S. Wangata in north-eastern New South Wales (NSW), Australia. The investigation adopted a One Health approach and was comprised of three complimentary components: a case-control study examining human risk factors; environmental and animal sampling; and genomic analysis of human, animal and environmental isolates. Forty-eight human S. Wangata cases were interviewed during a 6-month period from November 2016 to April 2017, together with 55 Salmonella Typhimurium (S. Typhimurium) controls and 130 neighbourhood controls. Indirect contact with bats/flying foxes (S. Typhimurium controls (adjusted odds ratio (aOR) 2.63, 95% confidence interval (CI) 1.06-6.48)) (neighbourhood controls (aOR 8.33, 95% CI 2.58-26.83)), wild frogs (aOR 3.65, 95% CI 1.32-10.07) and wild birds (aOR 6.93, 95% CI 2.29-21.00) were statistically associated with illness in multivariable analyses. S. Wangata was detected in dog faeces, wildlife scats and a compost specimen collected from the outdoor environments of cases' residences. In addition, S. Wangata was detected in the faeces of wild birds and sea turtles in the investigation area. Genomic analysis revealed that S. Wangata isolates were relatively clonal. Our findings suggest that S. Wangata is present in the environment and may have a reservoir in wildlife populations in north-eastern NSW. Further investigation is required to better understand the occurrence of Salmonella in wildlife groups and to identify possible transmission pathways for human infections.

Gastroenteritis outbreak at a health function caused by an emerging recombinant strain of Norovirus GII.P16/GII.4 Sydney 2012, Australia.

An emerging recombinant norovirus GII.P16/GII.4 Sydney 2012 strain caused a gastroenteritis outbreak amongst attendees at a large health function in regional New South Wales, Australia. This was the third outbreak caused by the recombinant GII.P16/GII.4 Sydney 2012 strain in this region in 2017, which appears to be emerging as a common strain in the Hunter New England region.

Adult encephalitis surveillance: experiences from an Australian prospective sentinel site study.

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

Consensus guidelines for the investigation and management of encephalitis in adults and children in Australia and New Zealand.

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

Case definitions, diagnostic algorithms, and priorities in encephalitis: consensus statement of the international encephalitis consortium.

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

Prevention and surveillance of public health risks during extended mass gatherings in rural areas: the experience of the Tamworth Country Music Festival, Australia.

OBJECTIVE: To describe and evaluate the public health response to the Tamworth Country Music Festival, an annual extended mass gathering in rural New South Wales, Australia; and to propose a framework for responding to similar rural mass gatherings. STUDY DESIGN: Process evaluation by direct observation, archival analysis and focus group discussion. METHODS: The various components of the public health response to the 2011 Tamworth Country Music Festival were actively recorded. An archival review of documentation from 2007 to 2010 was performed to provide context. A focus group was also conducted to discuss the evolution of the public health response and the consequences of public health involvement. RESULTS: Public health risks increased with increasing duration of the rural mass gathering. Major events held within the rural mass gathering further strained resources. The prevention, preparedness, response and recovery principles provided a useful framework for public health actions. Particular risks included inadequately trained food preparation volunteers functioning in poorly equipped temporary facilities, heat-related ailments and arboviral disease. CONCLUSION: Extended mass gatherings in rural areas pose particular public health challenges; surge capacity is limited and local infrastructure may be overwhelmed in the event of an acute incident or outbreak. There is value in proactive public health surveillance and monitoring. Annual mass gatherings provide opportunities for continual systems improvement. Early multi-agency planning can identify key risks and identify opportunities for partnership. Special consideration is required for major events within mass gatherings.

Key lessons from the COVID-19 public health response in Australia.

Australia avoided the worst effects of the COVID-19 pandemic, but still experienced many negative impacts. Reflecting on lessons from Australia's public health response, an Australian expert panel composed of relevant discipline experts identified the following key lessons: 1) movement restrictions were effective, but their implementation requires careful consideration of adverse impacts, 2) disease modelling was valuable, but its limitations should be acknowledged, 3) the absence of timely national data requires re-assessment of national surveillance structures, 4) the utility of advanced pathogen genomics and novel vaccine technology was clearly demonstrated, 5) decision-making that is evidence informed and consultative is essential to maintain trust, 6) major system weaknesses in the residential aged-care sector require fixing, 7) adequate infection prevention and control frameworks are critically important, 8) the interests and needs of young people should not be compromised, 9) epidemics should be recognised as a 'standing threat', 10) regional and global solidarity is important. It should be acknowledged that we were unable to capture all relevant nuances and context specific differences. However, the intent of this review of Australia's public health response is to critically reflect on key lessons learnt and to encourage constructive national discussion in countries across the Western Pacific Region.

Preventing Q fever endocarditis: a review of cardiac assessment in hospitalised Q fever patients.

INTRODUCTION: Acute Q fever is an important zoonotic disease in some parts of rural Australia. Q Fever can lead to chronic disease such as endocarditis, this complication occurring more commonly in patients with underlying heart valve pathology or an impaired immune system. Untreated Q fever endocarditis has a high mortality rate, but even with appropriate therapy, 10% of patients will die. Cardiac assessment can identify patients at risk. The aim of this review was to examine recorded cardiac assessment of hospitalised Q fever patients within the regional area of Hunter New England (HNE), New South Wales (NSW). METHODS: Medical records of patients with Q fever admitted to hospitals in HNE during the period 2005-2009 were identified through the NSW Notifiable Diseases Database and the NSW Inpatient Statistics Collection. A standardised medical record review tool was used to undertake the review. RESULTS: Eighty-nine records were reviewed. Over 50% of patients were admitted to a district hospital staffed by local GPs. Cardiac assessment was not routinely documented and for 91% there was no record of a cardiac history being taken. Approximately 25% had no record of a cardiac physical examination and only 6 cases had a record of a complete cardiac examination. CONCLUSION: Q Fever remains an important disease in some parts of rural Australia. Q Fever endocarditis is a serious sequel to acute Q fever and underlying heart valve pathology. Due to its indolent progression and poor outcome when diagnosis is delayed, a thorough cardiac assessment of all patients with suspected or confirmed Q fever is important. The level of documentation of cardiac assessment for Q fever patients is of concern because it may indicate cardiac assessments were not performed. General practitioners, especially in rural and regional areas, are encouraged to conduct cardiac assessments for all patients with acute Q fever to identify patients at risk of developing Q fever endocarditis.

Blood, guts and knife cuts: reducing the risk of swine brucellosis in feral pig hunters in north-west New South Wales, Australia.

INTRODUCTION: Humans who have close contact with livestock, wild or feral animals can risk acquiring zoonotic infections such as brucellosis, Q fever, and leptospirosis. Human infection with Brucella suis (swine brucellosis) usually follows occupational or recreational exposure to infected animals. Worldwide, many cases of human infection follow contact with infected feral pigs. In Australia there is a growing market for the export of 'wild boar' and a considerable number of people are involved in feral pig hunting. However, feral pig hunters are often hard to reach with health strategies. According to Australian authorities the most important means of preventing disease in humans includes covering cuts; wearing gloves; washing hands; and avoiding blood when coming into contact with feral pigs. There has not been an evaluation of the acceptability of these recommended risk-reduction strategies in the settings where feral pig hunting and evisceration occurs. METHODS: Semi-structured interviews and small focus groups were conducted with feral pig hunters in north-west New South Wales (NSW), Australia, to explore their hunting experiences and views on the brucellosis prevention strategies. Interview and focus group notes were thematically analysed. RESULTS: There was a range of experiences of feral pig hunting, from a very professional approach to a purely recreational approach. The main domains that emerged from participants' experiences during their most recent feral pig hunting activity and their reflections on current swine brucellosis risk reduction strategies were: 'you've gotta be tough to be a feral pig hunter'; 'most of the suggested strategies won't work as they are'; 'reducing risk in the scrub'; and 'how to let pig hunters know'. The recreational nature and prevailing macho perspective of participants demand a pragmatic approach to risk reduction if it is going to prove acceptable to feral pig hunters. The 'you've gotta be tough to be a feral pig hunter' context of the activity and the reality that many feral pig hunters participate with little preparation and a 'just keep going' approach, may counteract currently recommended risk-reduction strategies. The alternate strategies that emerged from the interviews need to be tested in the real activity, especially evisceration 'in the scrub' (at the site of slaughter). But the following ideas were grounded in the participants' experiences: take more time and watch your hands when making cuts; have good lighting; take care when cutting near a sow's uterus; use latex gloves to cover cuts on hands. CONCLUSIONS: Swine brucellosis is a zoonosis of concern for feral pig hunters in many parts of Australia, including north-west NSW. Many of the current strategies to reduce the risk of brucellosis did not appear appropriate or acceptable to the feral pig hunters interviewed. More acceptable strategies when eviscerating, such as taking more time, watching hands when cutting, ensuring good lighting, being careful in the vicinity of the uterus and using a latex glove to cover cuts and abrasions on hands need to be field tested. Further development of the food safety regulations is required to also support zoonosis risk reduction strategies.

Hendra in the Hunter Valley.

In June 2019 the first equine case of Hendra virus in the Hunter Valley, New South Wales, Australia was detected. An urgent human and animal health response took place, involving biosecurity measures, contact tracing, promotion of equine vaccinations and investigation of flying fox activity in the area. No human or additional animal cases occurred. Equine vaccination uptake increased by over 30-fold in the surrounding region in the three months following the case. Black flying fox and grey-headed flying fox species were detected in the Valley. The incident prompted review of Hendra virus resources at local and national levels. This event near the "horse capital of Australia", is the southernmost known equine Hendra case. Management of the event was facilitated by interagency collaboration involving human and animal health experts. Ongoing One Health partnerships are essential for successful responses to future zoonotic events.

Participant centred safety surveillance of health care workers receiving influenza vaccination.

Following the introduction of mandatory influenza vaccination for staff working in high risk clinical areas in 2018, we conducted active surveillance for adverse events following immunisation utilising an automated online survey to vaccine recipients at three and 42 days post immunisation. Most participants 2285 (92%) agreed to participate; 515 (32%) staff reported any symptom and eight (1.6%) sought medical attention. The odds of having a reaction decreased with age by approximately 2% per year. The system was acceptable to staff, and the data demonstrated rates of reported symptoms within expected rates for influenza vaccines from clinical trials. Rates of medical attendance were similar to previous surveillance. Participant centred real-time safety surveillance proved useful in this staff influenza vaccination context, providing reassurance with expected rates and profile of common adverse events following staff influenza vaccination.

Diagnosing childhood tuberculosis in rural clinics in Mpumalanga Province, South Africa.

BACKGROUND: Tuberculosis is a major global public health challenge and disease in young children is particularly severe. Diagnosing tuberculosis in children is complex as clinical presentation is often atypical and available diagnostic modalities are imperfect. Diagnosis is particularly challenging in developing countries where resources and access to sophisticated facilities are limited. The South African primary health care system requires frontline nurses to be equipped to suspect, diagnose and treat children with tuberculosis, but their capacity to diagnose childhood tuberculosis is unknown. Relatively low rates of childhood tuberculosis notification suggested that tuberculosis may have been under-diagnosed in Mpumalanga Province. OBJECTIVE: To determine the ability of the primary health care nurses to diagnose childhood tuberculosis in primary care public health facilities in Gert Sibande District, Mpumalanga Province. METHODOLOGY: Within-method triangulation by means of a self-completed questionnaire and a facility audit of records and diagnostic aids, was used to assess nurses' knowledge and determine whether primary health care facilities were adequately equipped to facilitate the diagnosis of childhood tuberculosis. RESULTS: There was a limited appreciation of the need to use complementary clinical and epidemiological features and diagnostic approaches to diagnose childhood tuberculosis. Child contacts had only been screened in 22.6% (111/491) of confirmed smear positive adult tuberculosis cases reviewed. The diagnostic score chart advocated by the World Health Organization and South African Department of Health was only used by 16% (10/62) of the facilities. Nurses who had been specifically trained on tuberculosis were more knowledgeable about diagnostic approaches and all respondents who were using the score chart had received specific tuberculosis training. CONCLUSION: The deficiencies in knowledge and practice evident during this survey and practice audit could at least partially explain the relatively low detection rates of childhood tuberculosis in Gert Sibande district, Mpumalanga Province. There is a need to equip primary health care nurses with the knowledge, support and access to diagnostic tests required to ensure a high index of suspicion and early, effective, diagnosis of tuberculosis in children.

The argument for integrating vector control with multiple drug administration campaigns to ensure elimination of lymphatic filariasis.

BACKGROUND: There is a danger that mass drug administration campaigns may fail to maintain adequate treatment coverage to achieve lymphatic filariasis elimination. Hence, additional measures to suppress transmission might be needed to ensure the success of the Global Program for the Elimination of Lymphatic Filariasis. DISCUSSION: Vector control successfully eliminated lymphatic filariasis when implemented alone or with mass drug administration. Challenges to lymphatic filariasis elimination include uncertainty of the exact level and duration of microfilarial suppression required for elimination, the mobility of infected individuals, consistent non-participation of some infected individuals with mass drug administration, the possible development of anti-filarial drug resistance and treatment strategies in areas co-endemic with loasis. Integration of vector control with mass drug administration can address some of these challenges. The potential benefits of vector control would include: (1) the ability to suppress filariasis transmission without the need to identify all individual 'foci of infection'; (2) minimizing the risk of reestablishment of transmission from imported microfilaria positive individuals; and (3) decreasing the risk of dengue or malaria transmission where, respectively, Aedes or Anopheles are lymphatic filariasis vectors. SUMMARY: With adequate sustained treatment coverage, mass drug administration should meet the criteria for elimination of lymphatic filariasis. However, it may be difficult to sustain sufficiently high mass drug administration coverage to achieve lymphatic filariasis elimination in some areas, particularly, where Aedes species are the vectors. Since vector control was effective in controlling and even eliminating lymphatic filariasis transmission, integration of vector control with mass drug administration will ensure the sustainability of transmission suppression and thereby better ensure the success of national filariasis elimination programs. Although trials of some vector control interventions are needed, proven vector control strategies are ready for immediate integration with mass drug administration for many important vectors. Vector control is the only presently available additional lymphatic filariasis control measure with the potential for immediate implementation.

Verification of measles elimination in Australia: Application of World Health Organization regional guidelines.

BACKGROUND: The World Health Organization (WHO) Western Pacific Region (WPR) Guidelines on verification of measles elimination were established in 2012. This article outlines Australia's approach to addressing the guideline's five lines of evidence, which led to formal verification of elimination by the WHO Regional Verification Commission (RVC) in March 2014. METHODS: The criteria were addressed using national measles notifications, data from selected laboratories, the national childhood immunization register, and three national serosurveys (1998/1999, 2002, 2007). RESULTS: Australia met or exceeded all indicator targets with either national or sentinel data. Laboratory and epidemiological surveillance were of high quality, with 85% of cases documented as imported/import-related (target 80%); coverage with the first dose of measles vaccine was close to 94% in 2008-2012 and second dose coverage increased to 91% in 2012 (target >95%). There is ongoing commitment by the Australian Government to increase immunization coverage, and the absence of sustained transmission of any single measles genotype was demonstrated. CONCLUSIONS: This is the first documentation of the successful application of the WPR RVC guidelines. The indicators afford some flexibility but appear to provide appropriate rigor to judge achievement of measles elimination. Our experience could assist other countries seeking to verify their elimination status.

Infectivity of Plasmodium falciparum gametocytes to Anopheles arabiensis after treatment with sulfadoxine-pyrimethamine.

Sulfadoxine-pyrimethamine induces increased gametocytaemia when used for treating Plasmodium falciparum malaria. Laboratory-reared Anopheles arabiensis mosquitoes were fed with blood from patients with post-therapeutic gametocytaemia using a membrane feeder. Fourteen days later the heads and thoraxes of 613 mosquitoes were negative for P. falciparum sporozoites by enzyme-linked immunosorbent assay.

Risk to tourists posed by wild mammals in South Africa.

BACKGROUND: One of South Africa's principal tourist attractions is the opportunity to encounter Africa's large mammals in the wild. Attacks by these mammals can be exceptionally newsworthy with potentially deleterious effects on tourism. Little is known about the risk of injury and death caused by wild mammals to visitors to South Africa's nature reserves. The aim of this study was to determine the incidence of fatal and nonfatal attacks on tourists by wild mammals in South Africa and to ascertain avoidable factors, if any. METHODS: Commercial press records covering all South African Newspapers archived at the Independent Newspapers' central library were systematically reviewed for a 10-year period, January 1988 to December 1997 inclusive, to identify all deaths and injuries to domestic and international tourists resulting from encounters with wild mammals in South Africa. All of these incidents were analyzed to ascertain avoidable factors. RESULTS: During the review period seven tourists, including two students from Thailand and a German traveler, were killed by wild mammals in South Africa. Three of the four deaths ascribed to lions resulted from tourists carelessly approaching prides on foot in lion reserves. A judicial inquiry found that the management of a KwaZulu-Natal Reserve was culpable for the remaining death. Tourist ignorance of animal behavior and flagrant disregard of rules contributed to the two fatalities involving hippopotami. The unusual behavior manifested by the bull elephant responsible for the final death, resulted from discomfort caused by a dental problem to this pachyderm. During the same period there were 14 nonfatal attacks on tourists, including five by hippo, three by buffalo, two by rhino, and one each by a lion, leopard, zebra and musth elephant. Only the latter occurred while the visitor was in a motor vehicle. Tourist ethological naivete and failure to determine the experience of trail guides prior to travel, resulted in inadvertent agonistic behavior, unnecessary risk-taking and avoidable injury. CONCLUSIONS: This retrospective study has shown that attacks on tourists by wild mammals in South Africa are an uncommon cause of injury and death. Sensible precautions to minimize this risk include remaining in a secure motor vehicle or adequately fenced precincts while in the vicinity of large mammals, rigidly observing nature reserve instructions, never approaching animals that appear ill, malnourished, displaying aggressive behavior traits or female wild mammals with young, and demanding adequately trained and experienced game rangers when embarking on walking trails. Any behavior that might be construed as antagonistic and which could provoke an attack by large mammals should be avoided (e.g., driving directly at a lion). Visitors need to be informed of classic signs of aggression, in particular in elephants, which will allow timely avoidance measures to be taken. The risk-enhancing effect of excessive alcohol intake is undesirable in the game reserve setting, as is driving at high speed after dusk in areas where hippos graze. Local advice on personal safety in wildlife reserves and the credentials of trail guides should be obtained from lodge or reserve management, tourism authorities or the travel industry prior to travel to game reserves.

Risk of malaria in visitors to the Kruger National Park, South Africa.

BACKGROUND: The risk of malaria to visitors to South Africa's nature reserves is unknown. Current recommendations for travelers are based on malaria incidence rates in local communities. These rates may well overestimate travelers' malaria risk and lead to unnecessary use of antimalarial prophylaxis with associated drug-related adverse events. This study investigated the incidence of malaria in visitors to South Africa's Kruger National Park (KNP). METHODS: Postal questionnaires were sent to the cohort of visitors staying in the KNP during April 1996, 6 to 8 weeks after they returned to their homes. Nonrespondents received duplicate questionnaires 8 weeks later. Responses from 3267 groups, representing 11,107 visitors (56. 8%) allowed determination of the malaria attack rate in this group of travelers and assessment of associations between malaria risk and a number of factors, including type of accommodation used during the visit; duration of stay; use of chemoprophylaxis; and use of personal protection measures. All travelers indicating that they had suffered an episode of malaria following their visit were telephonically contacted and their health providers traced to determine the basis of diagnosis and clinical outcome. RESULTS: One clinically suspected and four confirmed cases of Plasmodium falciparum malaria among the visitors suggest a low attack rate of 4. 5 cases per 10,000 visitors during April, the highest risk month for malaria in South Africa. No association was found between malaria risk and accommodation type, duration of stay, use and type of chemoprophylaxis, and use and number of personal protection measures. CONCLUSIONS: These findings confirm the importance of careful assessment of local malaria risk before individualized advice is provided to travelers.

Leprosy in Mpumalanga Province, South Africa--eliminated or hidden?

In South Africa, leprosy has been a notifiable condition since 1921. Although the WHO elimination target of less than one case per 10,000 population has been achieved at country level, the distribution of leprosy in the country is distinctly heterogeneous, with a prominent 'leprosy belt' of greater prevalence stretching across Mpumalanga Province into northern Kwa-Zulu Natal. The highest prevalence in this 'belt' has historically been in Ermelo District. Recent trends of few newly detected leprosy patients in this district raised concerns that health system changes may have resulted in failure to detect leprosy cases. Thus a large-scale community awareness campaign was conducted followed by an intensively advertised screening programme of 3-month duration at schools and central gathering points in villages and farms from 1 June to 31 August 2000. One thousand one hundred and seventy-seven people presented for clinical screening at designated points, while 790 scholars were screened at schools and an additional 1433 people were screened at their homes by the field team. Forty-four people with skin or nervous system lesions compatible with leprosy were referred for specialized assessment and biopsy where indicated. Four new leprosy patients were diagnosed, including an elderly lady with pronounced disability. Two of these patients had prior contact with the health service due to dermatological manifestations of leprosy without diagnosis being made. All patients provided a history of close prolonged contact with known leprosy patients. Ongoing intense tracing and follow-up of close contacts of proven leprosy cases may be a more efficient method of detecting leprosy cases in areas with relatively stable populations that have accomplished 'leprosy elimination', than resource intensive community surveys.