Liver and cardiometabolic markers and conditions in a cross-sectional study of three Australian communities living with environmental per- and polyfluoroalkyl substances contamination.

BACKGROUND: Per- and polyfluoroalkyl substances (PFAS) have been associated with higher cholesterol and liver function markers in some studies, but the evidence for specific cardiometabolic conditions has been inconclusive. OBJECTIVES: We quantified the associations of single and combined PFAS with cardiometabolic markers and conditions in a cross-sectional study of three Australian communities with PFAS-contaminated water from the historical use of aqueous film-forming foam in firefighting activities, and three comparison communities. METHODS: Participants gave blood samples for measurement of nine PFAS, four lipids, six liver function markers, and completed a survey on sociodemographic characteristics and eight cardiometabolic conditions. We estimated differences in mean biomarker concentrations per doubling in single PFAS concentrations (linear regression) and per interquartile range increase in the PFAS mixture (Bayesian kernel machine regression). We estimated prevalence ratios of biomarker concentrations outside reference limits and self-reported cardiometabolic conditions (Poisson regression). RESULTS: We recruited 881 adults in exposed communities and 801 in comparison communities. We observed higher mean total cholesterol with higher single and mixture PFAS concentrations in blood serum (e.g., 0.18 mmol/L, 95% credible interval -0.06 to 0.42, higher total cholesterol concentrations with an interquartile range increase in all PFAS concentrations in Williamtown, New South Wales), with varying certainty across communities and PFAS. There was less consistency in direction of associations for liver function markers. Serum perfluorooctanoic acid (PFOA) concentrations were positively associated with the prevalence of self-reported hypercholesterolemia in one of three communities, but PFAS concentrations were not associated with self-reported type II diabetes, liver disease, or cardiovascular disease. DISCUSSION: Our study is one of few that has simultaneously quantified the associations of blood PFAS concentrations with multiple biomarkers and cardiometabolic conditions in multiple communities. Our findings for total cholesterol were consistent with previous studies; however, substantial uncertainty in our estimates and the cross-sectional design limit causal inference.

Neglected tropical diseases in Australia: a narrative review.

•Neglected tropical diseases (NTDs) represent a threat to the health, wellbeing and economic prosperity of billions of people worldwide, often causing serious disease or death. •Commonly considered diseases of low and middle-income nations, the presence of NTDs in high income countries such as Australia is often overlooked. •Seven of the 20 recognised NTDs are endemic in Australia: scabies, soil-transmitted helminths and strongyloidiasis, echinococcosis, Buruli ulcer, leprosy, trachoma, and snakebite envenoming. •Dengue, while not currently endemic, poses a risk of establishment in Australia. There are occasional outbreaks of dengue fever, with local transmission, due to introductions in travellers from endemic regions. •Similarly, the risk of introduction of other NTDs from neighbouring countries is a concern. Many NTDs are only seen in Australia in individuals travelling from endemic areas, but they need to be recognised in health settings as the potential consequences of infection can be severe. •In this review, we consider the status of NTDs in Australia, explore the risk of introducing and contracting these infections, and emphasise the negative impact they have on the health of Australians, especially Aboriginal and Torres Strait Islander peoples.

Relationships between extreme flows and microbial contamination in inland recreational swimming areas.

Inland recreational swimming sites provide significant social value globally. This study focused on public recreational swimming sites across the Murrumbidgee River and its tributaries in the Australian Capital Territory (ACT) throughout the swimming season (September-April) from 2009 to 2020 to determine whether high intestinal enterococci concentrations could be predicted with flow exceedance and routinely monitored physical and chemical parameters of water quality. Enterococci concentrations were positively correlated with the turbidity associated with high-flow conditions. The predictive accuracy of high enterococci levels during high-flow conditions was good (mean percentage correctly classified, 60%). The prediction of high enterococci levels at low flows was significantly less reliable (mean percentage correctly classified, 12-15%). As the ACT is expected to experience decreases in rainfall overall but increases in extreme rainfall events due to climate change, understanding the drivers of elevated intestinal enterococci under extreme flow conditions remains important from a public health perspective.

Comparison of heat-illness associations estimated with different temperature metrics in the Australian Capital Territory, 2006-2016.

While the associations of heat with health outcomes is well researched, there is less consensus on the measures used to define heat exposure and the short-term and delayed impacts of different temperature metrics on health outcomes. We investigate the nonlinear and short-term relationship of three temperature metrics and reported incidence of three gastrointestinal illnesses: salmonellosis, campylobacteriosis and cryptosporidiosis in the Australian Capital Territory (ACT). We also examine the nonlinear association of these illnesses with extreme heat (5th, 75th, 90th percentile of all heat measures). Generalized linear models with Poisson regression accounting for overdispersion, seasonal and long-term trend, weekly number of outbreaks and rainfall were developed for mean and maximum weekly temperature and the heat stress index (EHIaccl). Bacterial illnesses (salmonellosis and campylobacteriosis) showed an overall positive association with extreme heat (75th and 90th percentile of all three heat measures) and an inverse association with low temperature (5th percentile). The shape of the exposure-response curve across a range of temperatures and the lagged effects varied for each disease. Modelling the short-term and delayed effects of heat using different metrics across a range of illnesses can help identify the most appropriate measure to inform local public health intervention planning for heat-related emergencies.

Establishing thresholds and parameters for pandemic influenza severity assessment, Australia.

OBJECTIVE: To implement the World Health Organization's pandemic influenza severity assessment tool in Australia, using multiple sources of data to establish thresholds and measure influenza severity indicators. METHODS: We used data from four reliable sources: sentinel general practitioner surveillance, hospital surveillance, a public health hotline and an influenza-like illness survey system. We measured three influenza severity indicators (transmissibility, impact and disease seriousness) defined using pandemic influenza severity assessment guidelines. We used the moving epidemic method and a seriousness indicator-specific method to set thresholds for indicator parameters using 2012-2016 data. We then applied the thresholds to data from the 2017 influenza season. FINDINGS: We were able to measure and produce thresholds for each severity indicator. At least one laboratory-confirmed influenza parameter was used to measure each indicator. When thresholds were applied to the 2017 season, there was good agreement across all data sources in measuring activity for each indicator. The season was characterized as having high transmissibility and extraordinary impact. Seriousness was characterized as moderate overall and in all age groups except those aged ≥ 65 years for whom it was high. This matched the description of the season produced by the Australian national influenza surveillance committee, based on expert opinion and historical ranges. CONCLUSION: The pandemic influenza severity assessment and moving epidemic method provide a robust and flexible method to enable an evidence-based assessment of seasonal influenza severity across diverse data sources. This is useful for national assessment and will contribute to global monitoring and response to circulating influenza with pandemic potential.

Beyond reasonable drought: hotspots reveal a link between the 'Big Dry' and cryptosporidiosis in Australia's Murray Darling Basin.

There is little evidence on how the health impacts of drought vary spatially and temporally. With a focus on waterborne cryptosporidiosis, we identify spatio-temporal hotspots and by using interrupted time series analysis, examine the impact of Australia's Big Dry (2001-2009) in these disease clusters in the Murray Darling Drainage Basin. Analyses revealed a statistically significant hotspot in the north of the Australian Capital Territory (ACT) and a hotspot in the north-eastern end of the basin in Queensland. After controlling for long-term trend and seasonality in cryptosporidiosis, interrupted time series analysis of reported cases in these hotspots indicated a statistically significant link with the Big Dry. In both areas, the end of the Big Dry was associated with a lower risk of reported cryptosporidiosis; in the ACT, the estimated relative risk (RR) was 0.16 (95% confidence interval: 0.07; 0.33), and in Queensland the RR was 0.42 (95% confidence interval: 0.19; 0.42). Although these data do not establish a causal association, this research highlights the potential for drought-related health risks.

Indian Ocean Dipole and Cryptosporidiosis in Australia: Short-Term and Nonlinear Associations.

The Indian Ocean Dipole (IOD) is a global climate phenomenon that influences the spread of human infectious diseases through climate extremes including droughts and floods. The Dipole Mode Index (DMI), which measures the strength of the IOD, is one of the main indicators of rainfall variability across Australia. Using an ecological, time-series approach we examined the short-term and nonlinear relationship between the DMI and weekly cryptosporidiosis reported from 2001 to 2012 across the temperate, subtropical, and tropical climate zones in Australia, controlling for season, long-term trends, and cryptosporidiosis counts from the past week. The association of DMI with cryptosporidiosis was nonlinear and varied in the short term and by climatic zone. Including cryptosporidiosis counts from the previous week improved model fit in all three zones and modified the DMI-disease relationship in the subtropical and temperate regions. In the temperate zone, a 0.1 unit increase in an extreme positive DMI was associated with a higher risk of reported cryptosporidiosis [Relative Risk (RR) 1.23 (95% confidence interval (CI), 1.00-1.52)], compared to the risk associated with mean DMI. This methodology shows the potential for quantifying the short-term and nonlinear response of infections like cryptosporidiosis with climate variability. These findings also suggest that future models that account for lagged disease effects may better represent the time varying environmental exposure-disease relationship. The expected increases in the frequency of positive DMI events will likely result in decreased rainfall across temperate Australia, with potential implications for public health.

Tuberculosis in elderly Australians: a 10-year retrospective review.

Objective: This report describes the epidemiology of active tuberculosis (TB) in elderly Australians (≥ 65 years) with analysis of the factors associated with TB disease and successful treatment outcomes. Methods: A retrospective study of TB cases reported to the National Notifiable Diseases Surveillance System over a 10-year period from 2011 to 2020 was conducted. Cases were stratified by sex, age, risk factors, drug resistance, treatment type and outcome. Notification rates and incidence rate ratios with 95% confidence intervals were calculated and factors associated with treatment success analysed using multivariable logistic regression. Results: A total of 2231 TB cases among elderly people were reported over the study period, with a 10-year mean incidence rate of 6.2 per 100 000 population. The median age of cases was 75 years (range 65-100 years); most were male (65%) and born overseas (85%). Multivariable analysis found that successful treatment outcome was strongly associated with younger age, while unsuccessful treatment outcome was associated with being diagnosed within the first 2 years of arrival in Australia, ever having resided in an aged-care facility and resistance to fluoroquinolones. Discussion: Compared to other low-incidence settings in the Western Pacific Region, TB incidence in elderly people is low and stable in Australia, with most cases occurring among recent migrants from TB-endemic settings. Continued efforts to reduce TB importation and address migrant health, especially among elderly people, are important.

The Impact of Climate Change on Aeromedical Retrieval Services in Remote Northern Australia: Planning for a Hotter Future.

It is known that environmental heat is associated with increased morbidity manifesting as increasing demand on acute care health services including pre-hospital transport and emergency departments. These services play a vital role in emergency care, and in rural and remote locations, where resource capacity is limited, aeromedical and other retrieval services are a vital part of healthcare delivery. There is no research examining how heat impacts remote retrieval service delivery. The Northern Territory (NT) of Australia is characterised by very remote communities with limited acute healthcare capacities and is a region subject to regular extreme tropical heat. In this study, we examine the relationship between aeromedical retrievals and hot weather for all NT retrievals between February 2018 and December 2019. A regression analysis was performed on the number of retrievals by clinical reason for retrieval matched to the temperature on the day of retrieval. There was a statistically significant exposure response relationship with increasing retrievals of obstetric emergencies in hotter weather in the humid climate zone and surgical retrievals in the arid zone. Retrieval services appeared to be at capacity at all times of the year. Given that there are no obstetric services in remote communities and that obstetric emergencies are a higher triage category than other emergencies (i.e., more urgent), such an increase will impede overall retrieval service delivery in hot weather. Increasing surgical retrievals in the arid zone may reflect an increase in soft tissue infections occurring in overcrowded houses in the hotter months of the year. Given that retrieval services are at capacity throughout the year, any increase in demand caused by increasing environmental heat will have broad implications for service delivery as the climate warms. Planning for a hotter future must include building resilient communities by optimising local healthcare capacity and addressing housing and other socioeconomic inequities that amplify heat-related illness.

Spatio-Temporal Variation in the Exceedance of Enterococci in Lake Burley Griffin: An Analysis of 16 Years' Recreational Water Quality Monitoring Data.

Recreational waterbodies with high levels of faecal indicator bacteria (FIB) pose health risks and are an ongoing challenge for urban-lake managers. Lake Burley Griffin (LBG) in the Australian Capital city of Canberra is a popular site for water-based recreation, but analyses of seasonal and long-term patterns in enterococci that exceed alert levels (>200 CFU per 100 mL, leading to site closures) are lacking. This study analysed enterococci concentrations from seven recreational sites from 2001-2021 to examine spatial and temporal patterns in exceedances during the swimming season (October-April), when exposure is highest. The enterococci concentrations varied significantly across sites and in the summer months. The frequency of the exceedances was higher in the 2009-2015 period than in the 2001-2005 and 2015-2021 periods. The odds of alert-level concentrations were greater in November, December, and February compared to October. The odds of exceedance were higher at the Weston Park East site (swimming beach) and lower at the Ferry Terminal and Weston Park West site compared to the East Basin site. This preliminary examination highlights the need for site-specific assessments of environmental and management-related factors that may impact the public health risks of using the lake, such as inflows, turbidity, and climatic conditions. The insights from this study confirm the need for targeted monitoring efforts during high-risk months and at specific sites. The study also advocates for implementing measures to minimise faecal pollution at its sources.

Cohorting children in a childcare setting: a strategy to reduce SARS-CoV-2 Delta transmission, August-September 2021.

Background: Childcare centres can be high-risk settings for SARS-CoV-2 transmission due to age, vaccination status, and infection control challenges. We describe the epidemiology and clinical characteristics of a childcare SARS-CoV-2 Delta outbreak. When the outbreak occurred, little was known about the transmission dynamics of SARS-CoV-2 ancestral and Delta strains among children. Vaccinations for coronavirus disease 2019 (COVID-19) were not mandatory for childcare staff, and children (< 12 years) were ineligible. Methods: A retrospective cohort design of childcare attendees was used to investigate age-cohorts exposure and transmission of SARS-CoV-2. We defined a case as a person who tested positive to SARS-CoV-2; we defined a close contact as a person who attended the childcare during 16-20 August 2021. Childcare centre exposures were defined by three cohorts: younger children (0-< 2.5 years) with designated staff; older children (2.5-5 years) with designated staff; and a staff-only group that moved between both age cohorts. We calculated the number and proportion of SARS-CoV-2 Delta infections, symptom profile and severity in children and adults, secondary attack rates, and relative risks (RR) with 95% confidence intervals (CIs) to compare age-cohort exposures and SARS-CoV-2 infection. Results: There were 38 outbreak cases that tested positive to SARS-CoV-2 Delta infection, comprising one primary case, 11 childcare attendees and 26 household members. Child attendees were in two non-interacting groups, 0-< 2.5 years and 2.5-5 years, with designated staff, separate rooms, and independent ventilation. The greatest risk of infection to childcare attendees was in the < 2.5 years age cohort which had a secondary attack rate of 41% and were five times more likely to be infected with SARS-CoV-2 (RR = 5.73; 95% CI: 1.37-23.86; p ≤ 0.01). No identified transmission (n = 0/21) occurred in the ≥ 2.5 years age cohort. Conclusion: Young children play an important role in SARS-CoV-2 Delta transmission to their peers and staff in childcare settings and to household members. Cohorting may be effective at limiting the propagation of SARS-CoV-2 in childcare settings. These findings highlight a need for multi-layered mitigation strategies and implementation support to manage respiratory infection control challenges at childcares. If prevention measures are not in place, this may facilitate ongoing transmission in these settings and into the broader community.

The relative value of sociocultural and infrastructural adaptations to heat in a very hot climate in northern Australia: a case time series of heat-associated mortality.

BACKGROUND: Climate change is increasing heat-associated mortality particularly in hotter parts of the world. The Northern Territory is a large and sparsely populated peri-equatorial state in Australia. The Northern Territory has the highest proportion of Aboriginal and Torres Strait Islander people in Australia (31%), most of whom live in remote communities of over 65 Aboriginal Nations defined by ancient social, cultural, and linguistic heritage. The remainder non-Indigenous population lives mostly within the two urban centres (Darwin in the Top End region and Alice Springs in the Centre region of the Northern Territory). Here we aim to compare non-Indigenous (eg, high income) and Indigenous societies in a tropical environment and explore the relative importance of physiological, sociocultural, and technological and infrastructural adaptations to heat. METHODS: In this case time series, we matched temperature at the time of death using a modified distributed lag non-linear model for all deaths in the Northern Territory, Australia, from Jan 1, 1980, to Dec 31, 2019. Data on deaths came from the national registry of Births, Deaths and Marriages. Cases were excluded if location or date of death were not recorded or if the person was a non-resident. Daily maximum and minimum temperature were measured and recorded by the Bureau of Meteorology. Hot weather was defined as mean temperature greater than 35°C over a 3-day lag. Socioeconomic status as indicated by Index of Relative Socioeconomic Disadvantage was mapped from location at death. FINDINGS: During the study period, 34 782 deaths were recorded; after exclusions 31 800 deaths were included in statistical analysis (15 801 Aboriginal and 15 999 non-Indigenous). There was no apparent reduction in heat susceptibility despite infrastructural and technological improvements for the majority non-Indigenous population over the study period with no heat-associated mortality in the first two decades (1980-99; relative risk 1·00 [95% CI 0·87-1·15]) compared with the second two decades (2000-19; 1·14 [1·01-1·29]). Despite marked socioeconomic inequity, Aboriginal people are not more susceptible to heat mortality (1·05, [0·95-1·18]) than non-Indigenous people (1·18 [1·06-1·29]). INTERPRETATION: It is widely believed that technological and infrastructural adaptations are crucial in preparing for hotter climates; however, this study suggests that social and cultural adaptations to increasing hot weather are potentially powerful mechanisms for protecting human health. Although cool shelters are essential during extreme heat, research is required to determine whether excessive exposure to air-conditioned spaces might impair physiological acclimatisation to the prevailing environment. Understanding sociocultural practices from past and ancient societies provides insight into non-technological adaptation opportunities that are protective of health. FUNDING: None.

Psychological distress in three Australian communities living with environmental per- and polyfluoroalkyl substances contamination.

BACKGROUND: Environmental chemical contamination is a recognised risk factor for psychological distress, but has been seldom studied in the context of per- and polyfluoroalkyl substances (PFAS) contamination. We examined psychological distress in a cross-sectional study of three Australian communities exposed to PFAS from the historical use of aqueous film-forming foam in firefighting activities, and three comparison communities without environmental contamination. METHODS: Participation was voluntary following recruitment from a PFAS blood-testing program (exposed) or random selection (comparison). Participants provided blood samples and completed a survey on their exposure history, sociodemographic characteristics, and four measures of psychological distress (Kessler-6, Distress Questionnaire-5, Patient Health Questionnaire-15, and Generalised Anxiety Disorder-7). We estimated prevalence ratios (PR) of clinically-significant psychological distress scores, and differences in mean scores: (1) between exposed and comparison communities; (2) per doubling in PFAS serum concentrations in exposed communities; (3) for factors that affect the perceived risk of living in a community exposed to PFAS; and (4) in relation to self-reported health concerns. RESULTS: We recruited 881 adults in exposed communities and 801 in comparison communities. We observed higher levels of self-reported psychological distress in exposed communities than in comparison communities (e.g., Katherine compared to Alice Springs, Northern Territory: clinically-significant anxiety scores, adjusted PR = 2.82, 95 % CI 1.16-6.89). We found little evidence to suggest that psychological distress was associated with PFAS serum concentrations (e.g., Katherine, PFOS and anxiety, adjusted PR = 0.85, 95 % CI 0.65-1.10). Psychological distress was higher among exposed participants who were occupationally exposed to firefighting foam, used bore water on their properties, or were concerned about their health. CONCLUSION: Psychological distress was substantially more prevalent in exposed communities than in comparison communities. Our findings suggest that the perception of risks to health, rather than PFAS exposure, contribute to psychological distress in communities with PFAS contamination.

Association between severe cyclone events and birth outcomes in Queensland, Australia, 2008-2018: a population based retrospective cohort study.

OBJECTIVE: Investigate an association between severe tropical cyclones (TCs) and birth outcomes in an Australian population. METHODS: We analysed over 600,000 singleton livebirths collected through the Queensland Perinatal Data Collection between 2008 and 2018. We estimated the odds ratios (ORs) of adverse birth outcomes using logistic multi-level modelling. RESULTS: Exposure to TCs in early pregnancy was associated with significantly higher odds of preterm births in affected compared to unaffected areas during the TC year [OR=1.28, 95%CI=1.11, 1.49, p=0.001] and slightly significant higher odds in affected areas during TC years compared to non-TC years. Significantly higher odds of low birthweight births were associated with mid-pregnancy exposure to cyclone Marcia [OR=1.62, 95%CI=1.00, 2.40, p=0.016] . CONCLUSIONS: Findings aligned with studies demonstrating an association between exposure to environmental stressors in early to mid-pregnancy and adverse birth outcomes. IMPLICATIONS FOR PUBLIC HEALTH: There is limited research into TCs and perinatal health in Australia despite most of the population residing along coastlines and TCs presenting one of the nation's most devastating weather events. This study will inform public health practice and contribute to further research into mitigating environmental risks faced by pregnant women.

Distribution and Risk Factors of Malaria in the Greater Accra Region in Ghana.

Malaria remains a serious public health challenge in Ghana including the Greater Accra Region. This study aimed to quantify the spatial, temporal and spatio-temporal patterns of malaria in the Greater Accra Region to inform targeted allocation of health resources. Malaria cases data from 2015 to 2019 were obtained from the Ghanaian District Health Information and Management System and aggregated at a district and monthly level. Spatial analysis was conducted using the Global Moran's I, Getis-Ord Gi*, and local indicators of spatial autocorrelation. Kulldorff's space-time scan statistics were used to investigate space-time clustering. A negative binomial regression was used to find correlations between climatic factors and sociodemographic characteristics and the incidence of malaria. A total of 1,105,370 malaria cases were reported between 2015 and 2019. Significant seasonal variation was observed, with June and July being the peak months of reported malaria cases. The hotspots districts were Kpone-Katamanso Municipal District, Ashaiman Municipal Districts, Tema Municipal District, and La-Nkwantanang-Madina Municipal District. While La-Nkwantanang-Madina Municipal District was high-high cluster. The Spatio-temporal clusters occurred between February 2015 and July 2017 in the districts of Ningo-Prampram, Shai-Osudoku, Ashaiman Municipal, and Kpone-Katamanso Municipal with a radius of 26.63 km and an relative risk of 4.66 (p < 0.001). Malaria cases were positively associated with monthly rainfall (adjusted odds ratio [AOR] = 1.01; 95% confidence interval [CI] = 1.005, 1.016) and the previous month's cases (AOR = 1.064; 95% CI 1.062, 1.065) and negatively correlated with minimum temperature (AOR = 0.86, 95% CI = 0.823, 0.899) and population density (AOR = 0.996, 95% CI = 0.994, 0.998). Malaria control and prevention should be strengthened in hotspot districts in the appropriate months to improve program effectiveness.

Acceptability measures of water, sanitation and hygiene interventions in low- and middle-income countries, a systematic review.

BACKGROUND: Inadequate access to water, sanitation, and hygiene (WASH) is an environmental risk factor for poor health outcomes globally, particularly for children in low- and middle-income countries (LMIC). Despite technological advancements, many interventions aimed at improving WASH access return less than optimal results on long term impact, efficacy and sustainability. Research focus in the 'WASH sector' has recently expanded from investigating 'which interventions work' to 'how they are best implemented'. The 'acceptability' of an intervention is a key component of implementation that can influence initial uptake and sustained use. Acceptability assessments are increasingly common for health interventions in clinical settings. A broad scale assessment of how acceptability has been measured in the WASH sector, however, has not yet been conducted. METHODS/PRINCIPAL FINDINGS: We conducted a systematic literature review of intervention studies published between 1990 and 2021 that evaluated the acceptability of WASH interventions in LMIC settings. Using an implementation science approach, focused outcomes included how acceptability was measured and defined, and the timing of acceptability assessment. We conducted quality assessment for all included studies using the Cochrane Risk of Bias tool for randomised studies, and the Newcastle-Ottawa Scale for non-randomised studies. Of the 1238 records; 36 studies were included for the analysis, 22 of which were non-randomized interventions and 16 randomized or cluster-randomized trials. We found that among the 36 studies, four explicitly defined their acceptability measure, and six used a behavioural framework to inform their acceptability study design. There were few acceptability evaluations in schools and healthcare facilities. While all studies reported measuring WASH acceptability, the measures were often not comparable or described. CONCLUSIONS: As focus in WASH research shifts towards implementation, a consistent approach to including, defining, and measuring acceptability is needed.

Bayesian spatio-temporal modelling to assess the role of extreme weather, land use change and socio-economic trends on cryptosporidiosis in Australia, 2001-2018.

BACKGROUND: Intensification of land use threatens to increase the emergence and prevalence of zoonotic diseases, with an adverse impact on human wellbeing. Understanding how the interaction between agriculture, natural systems, climate and socioeconomic drivers influence zoonotic disease distribution is crucial to inform policy planning and management to limit the emergence of new infections. OBJECTIVES: Here we assess the relative contribution of environmental, climatic and socioeconomic factors influencing reported cryptosporidiosis across Australia from 2001 to 2018. METHODS: We apply a Bayesian spatio-temporal analysis using Integrated Nested Laplace Approximation (INLA). RESULTS: We find that area-level risk of reported disease are associated with the proportions of the population under 5 and over 65 years of age, socioeconomic disadvantage, annual rainfall anomaly, and the proportion of natural habitat remaining. This combination of multiple factors influencing cryptosporidiosis highlights the benefits of a sophisticated spatio-temporal statistical approach. Two key findings from our model include: an estimated 4.6% increase in the risk of reported cryptosporidiosis associated with 22.8% higher percentage of postal area covered with original habitat; and an estimated 1.8% increase in disease risk associated with a 77.99 mm increase in annual rainfall anomaly at the postal area level. DISCUSSION: These results provide novel insights regarding the predictive effects of extreme rainfall and the proportion of remaining natural habitat, which add unique explanatory power to the model alongside the variance associated with other predictive variables and spatiotemporal variation in reported disease. This demonstrates the importance of including perspectives from land and water management experts for policy making and public health responses to manage environmentally mediated diseases, including cryptosporidiosis.

Seasonality in testing and positive respiratory bacterial infections in the Australian Capital Territory, 1997-2007.

BACKGROUND: Chlamydia pneumoniae (Cp) and Mycoplasma pneumoniae (Myco) bacteria are atypical pathogens that can cause pneumonia and exacerbate underlying conditions such as asthma and chronic obstructive pulmonary disease. In the Australian Capital Territory, there is limited information on how seasonal patterns for positive infections and testing may vary, a gap that has implications for control strategies. METHODS: We examined seasonal patterns of immunoassay results of patients from Canberra Hospital, Australia, who were tested for Cp and/or Myco. Pathology data, collected from August 1997 to March 2007 from 7,275 patients, were analysed with time series additive decomposition and time series regression. RESULTS: The proportion of positive Cp infections was highest in March and April (autumn) and lowest in June and August (winter). The proportion of positive Myco infections was highest in December and January (summer) and lowest in August (winter), even though testing for the pathogen peaked in winter with a low in summer. Models with a long-term trend and a variable for month were a better fit for the data than the null models for both infections. CONCLUSION: We found differences in seasonal patterns of testing and in the proportion of positive infections. These findings suggest that preventative measures for common infections need to account for seasonal testing practices so as to build an accurate picture of temporal changes in these infections.

Health Risk Assessment for Exposure to Nitrate in Drinking Water in Central Java, Indonesia.

Since 2005, over 30 epidemiological studies have evaluated the association between nitrate in drinking water and adverse health outcomes. Conditions that lead to nitrate pollution in water, such as open defecation, the proximity of septic tanks to water sources, and the use of inorganic fertilizer, are rampant in Indonesia, which has experienced little research evaluating nitrate in drinking water. We conducted a health risk assessment for exposure to nitrate in drinking water and evaluated the nitrate concentration in key water sources in two villages of rural Central Java, Indonesia. The nitrate concentrations in the drinking water ranged from 3.55 mg/L to 26.75 mg/L as NO3-. Daily nitrate intake estimates, calculated at 50% and 95% exposure to the maximum nitrate concentration of the drinking water in both villages, were above the levels associated with birth defects, colorectal cancer, and thyroid conditions observed in other studies. There was a large variation in nitrate concentrations between and within the villages at different water sources. Further research into whether these health outcomes exist in rural Central Java, Indonesia will be required to better understand this risk.

Physical and Mental Health Effects of Bushfire and Smoke in the Australian Capital Territory 2019-20.

The 2019-20 bushfire season in south-eastern Australia was one of the most severe in recorded history. Bushfire smoke-related air pollution reached hazardous levels in major metropolitan areas, including the Australian Capital Territory (ACT), for prolonged periods of time. Bushfire smoke directly challenges human health through effects on respiratory and cardiac function, but can also indirectly affect health, wellbeing and quality of life. Few studies have examined the specific health effects of bushfire smoke, separate from direct effects of fire, and looked beyond physical health symptoms to consider effects on mental health and lifestyle in Australian communities. This paper describes an assessment of the health impacts of this prolonged exposure to hazardous levels of bushfire smoke in the ACT and surrounding area during the 2019-20 bushfire season. An online survey captured information on demographics, health (physical and mental health, sleep) and medical advice seeking from 2,084 adult participants (40% male, median age 45 years). Almost all participants (97%) experienced at least one physical health symptom that they attributed to smoke, most commonly eye or throat irritation, and cough. Over half of responders self-reported symptoms of anxiety and/or feeling depressed and approximately half reported poorer sleep. Women reported all symptoms more frequently than men. Participants with existing medical conditions or poorer self-rated health, parents and those directly affected by fire (in either the current or previous fire seasons) also experienced poorer physical, mental health and/or sleep symptoms. Approximately 17% of people sought advice from a medical health practitioner, most commonly a general practitioner, to manage their symptoms. This study demonstrated that prolonged exposure to bushfire smoke can have substantial effects on health. Holistic approaches to understanding, preventing and mitigating the effects of smoke, not just on physical health but on mental health, and the intersection of these, is important. Improved public health messaging is needed to address uncertainty about how individuals can protect their and their families health for future events. This should be informed by identifying subgroups of the population, such as those with existing health conditions, parents, or those directly exposed to fire who may be at a greater risk.