Accuracy of automatic syndromic classification of coded emergency department diagnoses in identifying mental health-related presentations for public health surveillance.

BACKGROUND: Syndromic surveillance in emergency departments (EDs) may be used to deliver early warnings of increases in disease activity, to provide situational awareness during events of public health significance, to supplement other information on trends in acute disease and injury, and to support the development and monitoring of prevention or response strategies. Changes in mental health related ED presentations may be relevant to these goals, provided they can be identified accurately and efficiently. This study aimed to measure the accuracy of using diagnostic codes in electronic ED presentation records to identify mental health-related visits. METHODS: We selected a random sample of 500 records from a total of 1,815,588 ED electronic presentation records from 59 NSW public hospitals during 2010. ED diagnoses were recorded using any of ICD-9, ICD-10 or SNOMED CT classifications. Three clinicians, blinded to the automatically generated syndromic grouping and each other's classification, reviewed the triage notes and classified each of the 500 visits as mental health-related or not. A "mental health problem presentation" for the purposes of this study was defined as any ED presentation where either a mental disorder or a mental health problem was the reason for the ED visit. The combined clinicians' assessment of the records was used as reference standard to measure the sensitivity, specificity, and positive and negative predictive values of the automatic classification of coded emergency department diagnoses. Agreement between the reference standard and the automated coded classification was estimated using the Kappa statistic. RESULTS: Agreement between clinician's classification and automated coded classification was substantial (Kappa = 0.73. 95% CI: 0.58 - 0.87). The automatic syndromic grouping of coded ED diagnoses for mental health-related visits was found to be moderately sensitive (68% 95% CI: 46%-84%) and highly specific at 99% (95% CI: 98%-99.7%) when compared with the reference standard in identifying mental health related ED visits. Positive predictive value was 81% (95% CI: 0.57 - 0.94) and negative predictive value was 98% (95% CI: 0.97-0.99). CONCLUSIONS: Mental health presentations identified using diagnoses coded with various classifications in electronic ED presentation records offers sufficient accuracy for application in near real-time syndromic surveillance.

Field effectiveness of hepatitis A vaccine and uptake of post exposure prophylaxis following a change to the Australian guidelines.

BACKGROUND: In 2009, national guidelines for hepatitis A control in Australia changed to recommend hepatitis A vaccine (HAV), instead of normal human immune globulin (NHIG), for post-exposure prophylaxis (PEP). AIMS: (1) Determine whether the uptake of PEP among contacts of hepatitis A cases changed after the introduction of the new guidelines, and (2) assess the field effectiveness of the HAV used as PEP in preventing infection among contacts of hepatitis A cases. METHODS: A retrospective cohort of contacts from hepatitis A cases reported to metropolitan Public Health Units in Sydney, Australia, between October 2008 and June 2010, was identified. Contacts were analysed by time period, age, PEP type, and susceptibility to hepatitis A. The relative risk (RR) of hepatitis A infection among susceptible contacts who received HAV, compared with susceptible contacts who had not received HAV, was calculated to estimate the effectiveness of the HAV when used as PEP. RESULTS: The uptake of PEP by susceptible contacts increased from 76% (n=133) to 89% (n=127) after the introduction of the new guidelines. Before the change in guidelines, no one who received PEP was later reported with hepatitis A. After the change in guidelines, one of the 123 contacts who received HAV as PEP was subsequently reported with hepatitis A. However, this case was likely to have been co-exposed with a primary case. Conservatively, assuming this was a secondary case, the vaccine effectiveness of HAV was 95.6% (66.1%-99.4%). Nine of 10 incident cases of hepatitis A were contacts who did not receive any PEP. CONCLUSION: The improved uptake of PEP and the high estimate of the effectiveness of HAV provides support for using HAV for PEP. The very high occurrence of hepatitis A among contacts who did not receive any PEP further highlights the importance of PEP in preventing hepatitis A infection.

Influenza vaccination during pregnancy: a qualitative study of the knowledge, attitudes, beliefs, and practices of general practitioners in Central and South-Western Sydney.

BACKGROUND: Pregnant women have an increased risk of influenza complications. Influenza vaccination during pregnancy is safe and effective, however coverage in Australia is less than 40%. Pregnant women who receive a recommendation for influenza vaccination from a health care provider are more likely to receive it, however the perspectives of Australian general practitioners has not previously been reported. The aim of the study was to investigate the knowledge, attitudes, beliefs, and practices of general practitioners practicing in South-Western Sydney, Australia towards influenza vaccination during pregnancy. METHODS: A qualitative descriptive study was conducted, with semi-structured interviews completed with seventeen general practitioners in October 2012. A thematic analysis was undertaken by four researchers, and transcripts were analysed using N-Vivo software according to agreed codes. RESULTS: One-third of the general practitioners interviewed did not consider influenza during pregnancy to be a serious risk for the mother or the baby. The majority of the general practitioners were aware of the government recommendations for influenza vaccination during pregnancy, but few general practitioners were confident of their knowledge about the vaccine and most felt they needed more information. More than half the general practitioners had significant concerns about the safety of influenza vaccination during pregnancy. Their practices in the provision of the vaccine were related to their perception of risk of influenza during pregnancy and their confidence about the safety of the vaccine. While two-thirds reported that they are recommending influenza vaccination to their pregnant patients, many were adopting principles of patient-informed choice in their approach and encouraged women to decide for themselves whether they would receive the vaccine. CONCLUSIONS: General practitioners have varied knowledge, attitudes, and beliefs about influenza vaccination during pregnancy, which influence their practices. Addressing these could have a significant impact on improving vaccine uptake during pregnancy.

Applying process mapping and analysis as a quality improvement strategy to increase the adoption of fruit, vegetable, and water breaks in Australian primary schools.

Over the past decade, public health policy in Australia has prioritized the prevention and control of obesity and invested in programs that promote healthy eating-related behaviors, which includes increasing fruit and vegetable consumption in children. This article reports on a study that used process mapping and analysis as a quality improvement strategy to improve the delivery of a nutrition primary prevention program delivered in primary schools in New South Wales, Australia. Crunch&Sip® has been delivered since 2008. To date, adoption is low with only 25% of schools implementing the program. We investigated the cause of low adoption and propose actions to increase school participation. We conducted semistructured interviews with key stakeholders and analyzed the process of delivering Crunch&Sip to schools. Interviews and process mapping and analysis identified a number of barriers to schools adopting the program. The analyses identified the need to simplify and streamline the process of delivering the program to schools and introduce monitoring and feedback loops to track ongoing participation. The combination of stakeholder interviews and process mapping and analysis provided important practical solutions to improving program delivery and also contributed to building an understanding of factors that help and hinder program adoption. The insight provided by this analysis helped identify usable routine measures of adoption, which were an improvement over those used in the existing program plan. This study contributed toward improving the quality and efficiency of delivering a health promoting program to work toward achieving healthy eating behaviors in children.

Influenza vaccination during pregnancy: coverage rates and influencing factors in two urban districts in Sydney.

BACKGROUND: Pregnant women have an increased risk of complications from influenza. Influenza vaccination during pregnancy is considered effective and safe; however estimates of vaccine coverage are low. This study aimed to determine influenza vaccination coverage and factors associated with vaccine uptake in pregnant women in two Sydney-based health districts. METHODS: A random sample of women who delivered a baby in a public hospital in Sydney and South-Western Sydney Local Health Districts between June and September 2012 were surveyed using a computer assisted telephone interviewing service. RESULTS: Of the 462 participants (participation rate 92%), 116 (25%) reported receiving the influenza vaccine during their pregnancy. In univariate analysis, vaccination coverage varied significantly depending on antenatal care type, hospital of birth, and parity (p<0.05), but not for age category, highest level of education, country of birth, language spoken at home, or Aboriginal status. Women who received antenatal care through a general practitioner (GP) had 2.3 (95% CI 1.4-3.6) times the odds (unadjusted) of receiving the influenza vaccination than those who received their antenatal care through a public hospital. The main reason cited for vaccination was GP recommendation (37%), while non-recommendation (33%) and lack of knowledge (26%) were cited as main reasons for not receiving the vaccination. 30% of women recalled receiving a provider recommendation for the vaccination and these women had 33.0 times the odds (unadjusted) of receiving the vaccination than women who had not received a recommendation. In a multivariate model a provider recommendation was the only variable that was significantly associated with vaccination (OR 41.9; 95% CI 20.7-84.9). CONCLUSION: Rates of influenza vaccination during pregnancy are low. There is a significant relationship between healthcare provider recommendation for the vaccination and vaccine uptake. Increasing provider recommendation rates has the potential to increase coverage rates of influenza vaccination in pregnant women.

Trends in notifiable blood lead levels in NSW, 1998-2008.

AIM: In the absence of published statewide notification data, the aim of this study was to analyse trends in notifiable blood lead levels (hereafter referred to as lead poisoning) in NSW from 1998 to 2008, to help inform lead poisoning notification policy. METHODS: NSW blood lead poisoning notification data for 1998-2008 were extracted from the Notifiable Diseases Database and analysed by age, gender and Area Health Service of residence. RESULTS: There were 6000 lead poisoning notifications from 1998 to 2008, with an average annual notification rate of 11.8 per 100 000 population for 1998-2003. This rate declined to an average of 4.0 per 100 000 population in the period 2004-2008. Males accounted for 92% of notifications, and males aged 20-59 years had average notification rates between 20 and 27 per 100 000 population. Children aged 0-4 years had notification rates of 9.3 per 100 000 population in girls and 13.6 per 100 000 population in boys. CONCLUSION: Notification rates have fallen dramatically, however children aged 0-4 years and men are disproportionately represented in lead poisoning notifications.

Trends and risk factors for hepatitis A in NSW, 2000-2009: the trouble with travel.

AIM: To analyse trends in hepatitis A notifications and information on exposure to risk factors, in particular international travel, collected through routine surveillance in NSW. METHODS: Hepatitis A notification data for the period 2000-2009 were extracted from the Notifiable Diseases Database and analysed by age group, gender, area of residence and exposure risk factors, including travel, food eaten and contact with other possible infectious cases. RESULTS: The notification rate for hepatitis A in NSW fell from 3.0 cases per 100000 population in 2000 to 1.4 cases per 100000 population in 2009. Notification rates were highest among people aged 20-24 years and residents of metropolitan Sydney. Travel to a country where hepatitis A is endemic was a risk exposure identified in 43% of cases. CONCLUSION: International travel to highly endemic countries continues to be the most common risk factor for hepatitis A infection notified in NSW despite recommendations that travellers be vaccinated prior to travel to these areas.

Eye health services for Aboriginal people in the western region of NSW, 2010.

AIM: To assess the availability, accessibility and uptake of eye health services for Aboriginal people in western NSW in 2010. METHODS: The use of document review, observational visits, key stakeholder consultation and service data reviews, including number of cataract operations performed, to determine regional service availability and use. RESULTS: Aboriginal people in western NSW have a lower uptake of tertiary eye health services, with cataract surgery rates of 1750 per million for Aboriginal people and 9702 per million for non-Aboriginal people. Public ophthalmology clinics increase access to tertiary services for Aboriginal people. CONCLUSION: Eye health services are not equally available and accessible for Aboriginal people in western NSW. Increasing the availability of culturally competent public ophthalmology clinics may increase access to tertiary ophthalmology services for Aboriginal people. The report of the review was published online, and outlines a list of recommendations.

The Early Childhood Oral Health Program: promoting prevention and timely intervention of early childhood caries in NSW through shared care.

ISSUE ADDRESSED: Early childhood caries (ECC) continues to have high prevalence worldwide, despite being largely preventable. The Early Childhood Oral Health (ECOH) Program was established in New South Wales (NSW) using a model of shared responsibility for oral health, which involves a partnership between child health professionals, oral health professionals and parents of young children, to facilitate the primary prevention, early identification and early intervention of ECC. METHODS: An evaluation of the ECOH program was conducted, using mixed methods. Data were obtained through document review, surveys and interviews with program implementers, and analysis of the Information System for Oral Health (ISOH) database for public oral health services activity in NSW. RESULTS: Key achievements of the ECOH program include the establishment of governance mechanisms, policy, structures and responsibilities for implementation, support mechanisms for child health professionals, referral processes, communications resources, and the delivery of training. Parents receive oral health information, education and support through written resources and contact with child health professionals. Child and family health nurses interviewed reported routinely incorporating oral health promotion and early identification for ECC into their practices. The referral rate to public oral health services for children under five years of age by community health professionals has increased steadily since the program began, with the rate in 2009 five times higher than in 2007. CONCLUSIONS: Models of shared responsibility for oral health between parents, child health professionals and oral health professionals can facilitate primary prevention and early intervention for ECC.

Relationship between the population incidence of febrile convulsions in young children in Sydney, Australia and seasonal epidemics of influenza and respiratory syncytial virus, 2003-2010: a time series analysis.

BACKGROUND: In 2010, intense focus was brought to bear on febrile convulsions in Australian children particularly in relation to influenza vaccination. Febrile convulsions are relatively common in infants and can lead to hospital admission and severe outcomes. We aimed to examine the relationships between the population incidence of febrile convulsions and influenza and respiratory syncytial virus (RSV) seasonal epidemics in children less than six years of age in Sydney Australia using routinely collected syndromic surveillance data and to assess the feasibility of using this data to predict increases in population rates of febrile convulsions. METHODS: Using two readily available sources of routinely collected administrative data; the NSW Emergency Department (ED) patient management database (1 January 2003 - 30 April 2010) and the Ambulance NSW dispatch database (1 July 2006 - 30 April 2010), we used semi-parametric generalized additive models (GAM) to determine the association between the population incidence rate of ED presentations and urgent ambulance dispatches for 'convulsions', and the population incidence rate of ED presentations for 'influenza-like illness' (ILI) and 'bronchiolitis' - proxy measures of influenza and RSV circulation, respectively. RESULTS: During the study period, when the weekly all-age population incidence of ED presentations for ILI increased by 1/100,000, the 0 to 6 year-old population incidence of ED presentations for convulsions increased by 6.7/100,000 (P < 0.0001) and that of ambulance calls for convulsions increased by 3.2/100,000 (P < 0.0001). The increase in convulsions occurred one week earlier relative to the ED increase in ILI. The relationship was weaker during the epidemic of pandemic (H1N1) 2009 influenza virus.When the 0 to 3 year-old population incidence of ED presentations for bronchiolitis increased by 1/100,000, the 0 to 6 year-old population incidence of ED presentations for convulsions increased by 0.01/100,000 (P < 0.01). We did not find a meaningful and statistically significant association between bronchiolitis and ambulance calls for convulsions. CONCLUSIONS: Influenza seasonal epidemics are associated with a substantial and statistically significant increase in the population incidence of hospital attendances and ambulance dispatches for reported febrile convulsions in young children. Monitoring syndromic ED and ambulance data facilitates rapid surveillance of reported febrile convulsions at a population level.

Annual report: surveillance of adverse events following immunisation in Australia, 2009.

This report summarises Australian passive surveillance data for adverse events following immunisation (AEFI) reported to the Therapeutic Goods Administration (TGA) for 2009, and describes reporting trends over the 10-year period 2000 to 2009. There were 2,396 AEFI records for vaccines administered in 2009, the highest number reported, a 46% increase over the 1,638 in 2008. The increase was almost entirely due to reports related to the introduction of pandemic H1N1 (pH1N1) 2009 influenza vaccine from September 2009 (n = 1,312) largely from the members of the public. The pH1N1 AEFI reporting rate for people aged > or = 18 years was 34.2 per 100,000 administered doses compared with 2.8 for seasonal influenza vaccine. The rates in > or = 65 year-olds were 28.0, 1.6 and 13.3 for pH1N1, seasonal influenza and polysaccharide pneumococcal, respectively. The high reporting rate for pH1N1 vaccine is likely to be at least partly due to enhanced reporting seen for all new vaccines and greater levels of reporting from members of the public in response to the implementation of strategies to encourage reporting, as part of the pH1N1 program. For children < 7 years, AEFI reporting rates in 2009 (14.1 per 100,000 administered doses) were similar to previous years. There were 193 (8%) AEFI reports classified as serious; 6 deaths temporally associated with immunisation were reported but none were judged to have a causal association. As in previous years, the most commonly reported reactions were allergic reaction, injection site reaction, fever, headache, malaise, nausea and myalgia. The most commonly reported reactions following pH1N1 influenza vaccine were allergic reaction (n = 381), headache (n = 289), fever (n = 235), pain (n = 186), nausea (n = 180) and injection site reaction (n = 178). The data within the limitation of passive surveillance provide a reference point for ongoing reporting of trends in AEFI by age group, severity and vaccine type and illustrate the value of the national TGA database as a surveillance tool for monitoring AEFI nationally.

Impact of faxed health alerts on the preparedness of general practitioners during communicable disease outbreaks.

The NSW Department of Health (NSW Health) faxed health alerts to general medical practitioners during measles outbreaks in March and May 2006. We conducted a retrospective cohort study of randomly selected general practitioners (GPs) (1 per medical practice) in New South Wales to investigate the effectiveness of faxing health alerts to GPs during a communicable disease outbreak. Fax transmission data allowed comparison of GPs sent and not sent the measles alert for self-reported awareness and practice actions aimed at the prevention and control of measles. A total of 328 GPs participated in the study. GPs who were sent the alert were more likely to be aware of the measles outbreak (RR 1.18, 95% CI 1.02, 1.38). When analysed by whether a fax had been received from either NSW Health or the Australian General Practice Network, GPs who reported receiving a faxed measles alert were more likely to be aware of the outbreak (RR 2.56, 95% CI 1.84, 3.56), to offer vaccination to susceptible staff (RR 6.46, 95% CI 2.49, 16.78), and be aware of other infection control recommendations. Respondents reported that the faxed alerts were useful with 65% reporting that the alerts had reminded them to consider measles in the differential diagnosis. This study shows that faxed health alerts were useful for preparing GPs to respond effectively to a communicable disease outbreak. The fax alert system could be improved by ensuring that all general practices in New South Wales are included in the faxstream database and that their contact details are updated regularly.

Modern trends in mortality from meningococcal disease in Australia.

Between 1979 and 2006, there were 610 deaths recorded as due to meningococcal disease in Australia. Mortality rates per capita consistently increased on average by 6% per annum between 1979 and 2002, but then fell significantly in 2003, coinciding with the introduction of the meningococcal C conjugate vaccine. In 2002, the mortality rate was 0.24 per 100,000. In the 4 years since, it fell progressively to 0.06 per 100,000. Since the introduction of conjugate Hib and pneumococcal vaccines, meningococcal disease has emerged as the number 1 infectious cause of death in children but conjugate meningococcal C vaccine appears to have greatly reduced total meningococcal disease deaths.

Australia's national Q fever vaccination program.

A nationally funded Q fever vaccination program was introduced in Australia in 2002. The evaluation of this unique program included measures of program uptake, safety, and notification and hospitalisation rates for Q fever pre- and post-program implementation. Program uptake ranged from close to 100% amongst abattoir workers to 43% in farmers. The most commonly reported adverse event was injection site reaction. Q fever notification rates declined by over 50% between 2002 and 2006, particularly in young adult males, consistent with the profile of the abattoir workforce. Hospitalisation data showed similar trends. Available evidence suggests a significant impact of Australia's Q fever vaccination program; such a program merits consideration in other countries with a comparable Q fever disease burden.

Annual report: surveillance of adverse events following immunisation in Australia, 2008.

This report summarises Australian passive surveillance data for adverse events following immunisation (AEFI) reported to the Therapeutic Goods Administration (TGA) for 2008, and describes reporting trends over the 9-year period 2000 to 2008. There were 1,542 AEFI records for vaccines administered in 2008. This was an annual AEFI reporting rate of 7.2 per 100,000 population, a 5% decrease compared with 2007. The majority of AEFI reports described non-serious events while 10% (n = 152) were classified as serious. Two deaths temporally associated with immunisation were reported; there was no evidence to suggest a causal association. The most commonly reported reactions were injection site reaction, allergic reaction, fever and headache. AEFI reporting rates in 2008 were 2.7 events per 100,000 administered doses of influenza vaccine for adults aged > or = 18 years, 18.9 per 100,000 administered doses of pneumococcal polysaccharide vaccine for those aged > or = 65 years, and 17.2 per 100,000 administered doses of scheduled vaccines for children aged < 7 years. Reports for infants increased in 2008, mainly related to gastrointestinal system events temporally associated with receipt of rotavirus vaccine in the 1st full year of the rotavirus immunisation program, while there was a substantial decrease in AEFI reports for human papilIoma virus vaccine in adolescents compared with 2007 when the program commenced. Increases in reports in children and adults were also partly attributed to the implementation of enhanced passive surveillance in Victoria. The consistently low reporting rate of serious AEFI highlights the safety of vaccines in Australia and illustrates the value of the national TGA database as a surveillance tool for monitoring AEFIs nationally.

Annual report: surveillance of adverse events following immunisation in Australia, 2007.

This report summarises Australian passive surveillance data for adverse events following immunisation (AEFI) reported to the Therapeutic Goods Administration for 2007, and describes reporting trends over the 8-year period 2000 to 2007. There were 1,538 AEFI records for vaccines administered in 2007. This is an annual AEFI reporting rate of 7.3 per 100,000 population, the highest since 2003 and an 85% increase compared with 2006 (835 AEFI records; 4.0 records per 100,000 population). The increase was almost entirely due to reports following the commencement of the national 3-dose human papillomavirus (HPV) vaccine program for females aged 12 to 26 years in April 2007 (n = 705 reports) and the national infant rotavirus vaccine program in July 2007 (n = 72 reports). AEFI reporting rates in 2007 were 2.3 per 100,000 administered doses of influenza vaccine for adults aged > or = 18 years, 18.6 per 100,000 administered doses of pneumococcal polysaccharide vaccine for those aged > or = 65 years and 12.7 per 100,000 administered doses of scheduled vaccines for children aged < 7 years. The majority of the 1,538 AEFI reports for 2007 described non-serious events while 9% (n = 141) were classified as serious. Two deaths temporally associated with immunisation were reported; there was no evidence to suggest a causal association. The most significant AEFI reported following HPV vaccine were anaphylaxis (n = 11) and convulsion (n = 18), mostly associated with syncope. The most commonly reported reactions were allergic reaction, injection site reaction, headache and nausea. The data confirm that, despite the low rate of AEFI reporting in Australia, the passive surveillance system is sufficiently robust to detect safety signals which are expected following changes in the immunisation program, allowing these to be investigated further.