Serology study of healthcare workers following a hospital-based outbreak of COVID-19 in North West Tasmania, Australia, 2020.

Introduction: Healthcare facilities are high-risk settings for coronavirus disease 2019 (COVID-19) transmission. Early in the COVID-19 pandemic, the first large healthcare-associated outbreak within Australia occurred in Tasmania. Several operational research studies were conducted amongst workers from the implicated hospital campus, to learn more about COVID-19 transmission. Methods: Healthcare workers (HCWs) from the implicated hospital campus were invited to complete an online survey and participate in a serology study. Blood samples for serological testing were collected at approximately 12 weeks (round one) and eight months (round two) after the outbreak. A descriptive analysis was conducted of participant characteristics, serology results, and longevity of antibodies. Results: There were 261 HCWs in round one, of whom 44 (17%) were polymerase chain reaction (PCR) confirmed outbreak cases; 129 of the 261 (49%) participated in round two, of whom 34 (27%) were outbreak cases. The prevalence of positive antibodies at round one was 15% (n = 38) and at round two was 12% (n = 15). There were 15 participants (12%) who were seropositive in both rounds, with a further 9% (n = 12) of round two participants having equivocal results after previously being seropositive. Six HCWs not identified as cases during the outbreak were seropositive in round one, with three still seropositive in round two. Of those who participated in both rounds, 68% (n = 88) were seronegative at both time points. Discussion: Our findings demonstrate that serological testing after this large healthcare-associated COVID-19 outbreak complemented the findings of earlier diagnostic testing, with evidence of additional infections to those diagnosed when use of PCR testing had been restricted. The results also provide evidence of persisting SARS-CoV-2 antibody response eight months after an outbreak in an unvaccinated population. The high proportion of HCWs who remained seronegative is consistent with low community transmission in Tasmania after this outbreak.

Antibodies against Spike protein correlate with broad autoantigen recognition 8 months post SARS-CoV-2 exposure, and anti-calprotectin autoantibodies associated with better clinical outcomes.

Autoantibodies to multiple targets are found during acute COVID-19. Whether all, or some, persist after 6 months, and their correlation with sustained anti-SARS-CoV-2 immunity, is still controversial. Herein, we measured antibodies to multiple SARS-CoV-2 antigens (Wuhan-Hu-1 nucleoprotein (NP), whole spike (S), spike subunits (S1, S2 and receptor binding domain (RBD)) and Omicron spike) and 102 human proteins with known autoimmune associations, in plasma from healthcare workers 8 months post-exposure to SARS-CoV-2 (n=31 with confirmed COVID-19 disease and n=21 uninfected controls (PCR and anti-SARS-CoV-2 negative) at baseline). IgG antibody responses to SARS-CoV-2 antigens were significantly higher in the convalescent cohort than the healthy cohort, highlighting lasting antibody responses up to 8 months post-infection. These were also shown to be cross-reactive to the Omicron variant spike protein at a similar level to lasting anti-RBD antibodies (correlation r=0.89). Individuals post COVID-19 infection recognised a common set of autoantigens, specific to this group in comparison to the healthy controls. Moreover, the long-term level of anti-Spike IgG was associated with the breadth of autoreactivity post-COVID-19. There were further moderate positive correlations between anti-SARS-CoV-2 responses and 11 specific autoantigens. The most commonly recognised autoantigens were found in the COVID-19 convalescent cohort. Although there was no overall correlation in self-reported symptom severity and anti-SARS-CoV-2 antibody levels, anti-calprotectin antibodies were associated with return to healthy normal life 8 months post infection. Calprotectin was also the most common target for autoantibodies, recognized by 22.6% of the overall convalescent cohort. Future studies may address whether, counter-intuitively, such autoantibodies may play a protective role in the pathology of long-COVID-19.

The World Health Organization's Frontline Support to Countries During the COVID-19 Pandemic in 2020.

The World Health Organization (WHO) declared the SARS-CoV-2 outbreak a Public Health Emergency of International Concern (PHEIC) on January 30, 2020. WHO rapidly scaled up its response including through its 149 country offices to support Member States prepare for and respond to the COVID-19 pandemic. This article describes the frontline role of the WHO Country Offices (WCOs) and demonstrates that WHO utilized its existing country presence to deliver its global program of work during this unprecedented emergency. Using data collected from the 2020 WHO COVID-19 Strategic Preparedness and Response Plan monitoring and evaluation framework assessments, plus data collected in a quantitative survey completed by 149 WCOs during 2020, this article describes how WHO supported national authorities and partners through leadership, policy dialogue, strategic support, technical assistance, and service delivery, in line with WHO's current 5-year strategic plan, the WHO 13th General Programme of Work 2019-2023. Country level case studies were used to further illustrate actions taken by WCOs. WHO's achievements notwithstanding, the Organization faced several key challenges in the first year of the response. Recommendations to enhance WHO presence in countries for future emergency prevention, preparedness and response, from several independent reviews, were presented to the World Health Assembly in May 2021 and relevant recommendations are presented in this article.

The World Health Organization's Actions Within the United Nations System to Facilitate a Whole-of-Society Response to COVID-19 at Country Level.

The coronavirus disease (COVID-19) pandemic highlighted that managing health emergencies requires more than an effective health response, but that operationalizing a whole-of-society approach is challenging. The World Health Organization (WHO), as the lead agency for health within the United Nations (UN), led the UN response at the global level through the Crisis Management Team, and at the country level through the UN Country Teams (UNCTs) in accordance with its mandate. Three case studies-Mali, Cox's Bazar in Bangladesh, and Uzbekistan-provide examples of how WHO contributed to the whole-of-society response for COVID-19 at the country level. Interviews with WHO staff, supplemented by internal and external published reports, highlighted that the action of WHO comprised technical expertise to ensure an effective whole-of-society response and to minimize social disruption, including those affecting peacekeeping in Mali, livelihood sectors in Cox's Bazar, and the education sector in Uzbekistan. Leveraging local level volunteers from various sectors led to both a stronger public health response and the continuation of other sectoral work. Risk communication and community engagement (RCCE) emerged as a key theme for UN engagement at country level. These collective efforts of operationalizing whole-of-society response at the country level need to continue for the COVID-19 response, but also in preparedness for other health and non-health emergencies. Building resilience for future emergencies requires developing and exercising multi-sectoral preparedness plans and benefits from collective UN support to countries. Coronavirus disease had many impacts outside of health, and therefore emergency preparedness needs to occur outside of health too.

Lessons learnt from the first large outbreak of COVID-19 in health-care settings in Tasmania, Australia.

PROBLEM: One month after the initial case of coronavirus disease 2019 (COVID-19) in Tasmania, an island state of Australia, two health-care workers (HCWs) from a single regional hospital were notified to public health authorities following positive tests for SARS-CoV-2 nucleic acid. These were the first recognized cases in an outbreak that overwhelmed the hospital's ability to function. CONTEXT: The outbreak originated from two index cases. Both had returned to Tasmania following travel on a cruise ship and required hospital admission for management of COVID-19. A total of 138 cases were subsequently linked to this outbreak: 81 HCWs (most being nurses) and 23 patients across three hospitals, one resident of an aged-care facility and 33 close contacts. ACTION: The outbreak was controlled through the identification and isolation of cases, identification and quarantining of close contacts and their household members, closure of the affected facilities and community-level restrictions to reduce social mixing in the affected region. LESSONS LEARNT: Factors that were likely to have contributed to ongoing transmission in this setting included workplace practices that prevented adequate physical distancing, attending work while symptomatic, challenges in rapidly identifying contacts, mobility of staff and patients between facilities, and challenges in the implementation of infection control practices. DISCUSSION: Many commonly accepted hospital practices before the COVID-19 pandemic amplified the outbreak. The lessons learnt from this investigation changed work practices for HCWs and led to wider public health interventions in the management of potential primary and secondary contacts.

COVID-19: Integrating genomic and epidemiological data to inform public health interventions and policy in Tasmania, Australia.

OBJECTIVE: We undertook an integrated analysis of genomic and epidemiological data to investigate a large health-care-associated outbreak of coronavirus disease 2019 (COVID-19) and to better understand the epidemiology of COVID-19 cases in Tasmania, Australia. METHODS: Epidemiological data collected on COVID-19 cases notified in Tasmania between 2 March and 15 May 2020, and positive samples of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or RNA extracted from the samples were included. Sequencing was conducted by tiled amplicon polymerase chain reaction with ARTIC v1 or v3 primers and Illumina sequencing. Consensus sequences were generated, sequences were aligned to a reference sequence and phylogenetic analysis was performed. Genomic clusters were determined and integrated with epidemiological data to provide additional information. RESULTS: All 231 COVID-19 cases notified in Tasmania during the study period and 266 SARS-CoV-2-positive samples, representing 217/231 (94%) notified cases, were included; 184/217 (84%) were clustered, 21/217 (10%) were unique and 12/217 (6%) could not be sequenced. Genomics confirmed the presence of seven clusters already identified through epidemiological links, clarified transmission networks in which the epidemiology had been unclear and identified one cluster that had not previously been recognized. DISCUSSION: Genomic analysis provided useful additional information on COVID-19 in Tasmania, including evidence of a large health-care-associated outbreak linked to an overseas cruise, the probable source of infection in cases with no previously identified epidemiological link and confirmation that there was no identified community transmission from other imported cases. Genomic insights are an important component of the response to COVID-19, and continuing genomic surveillance is warranted.

Expansion of the Lyme Disease Vector Ixodes Scapularis in Canada Inferred from CMIP5 Climate Projections.

BACKGROUND: A number of studies have assessed possible climate change impacts on the Lyme disease vector, Ixodes scapularis. However, most have used surface air temperature from only one climate model simulation and/or one emission scenario, representing only one possible climate future. OBJECTIVES: We quantified effects of different Representative Concentration Pathway (RCP) and climate model outputs on the projected future changes in the basic reproduction number (R0) of I. scapularis to explore uncertainties in future R0 estimates. METHODS: We used surface air temperature generated by a complete set of General Circulation Models from the Coupled Model Intercomparison Project Phase 5 (CMIP5) to hindcast historical (1971-2000), and to forecast future effects of climate change on the R0 of I. scapularis for the periods 2011-2040 and 2041-2070. RESULTS: Increases in the multimodel mean values estimated for both future periods, relative to 1971-2000, were statistically significant under all RCP scenarios for all of Nova Scotia, areas of New Brunswick and Quebec, Ontario south of 47°N, and Manitoba south of 52°N. When comparing RCP scenarios, only the estimated R0 mean values between RCP6.0 and RCP8.5 showed statistically significant differences for any future time period. CONCLUSION: Our results highlight the potential for climate change to have an effect on future Lyme disease risk in Canada even if the Paris Agreement's goal to keep global warming below 2°C is achieved, although mitigation reducing emissions from RCP8.5 levels to those of RCP6.0 or less would be expected to slow tick invasion after the 2030s. https://doi.org/10.1289/EHP57.

A positive association between cryptosporidiosis notifications and ambient temperature, Victoria, Australia, 2001-2009.

Increased temperatures provide optimal conditions for pathogen survival, virulence and replication as well as increased opportunities for human-pathogen interaction. This paper examined the relationship between notifications of cryptosporidiosis and temperature in metropolitan and rural areas of Victoria, Australia between 2001 and 2009. A negative binomial regression model was used to analyse monthly average maximum and minimum temperatures, rainfall and the monthly count of cryptosporidiosis notifications. In the metropolitan area, a 1 °C increase in monthly average minimum temperature of the current month was associated with a 22% increase in cryptosporidiosis notifications (incident rate ratio (IRR) 1.22; 95% confidence interval (CI) 1.13-1.31). In the rural area, a 1 °C increase in monthly average minimum temperature, lagged by 3 months, was associated with a 9% decrease in cryptosporidiosis notifications (IRR 0.91; 95% CI 0.86-0.97). Rainfall was not associated with notifications in either area. These relationships should be considered when planning public health response to ecological risks as well as when developing policies involving climate change. Rising ambient temperature may be an early warning signal for intensifying prevention efforts, including appropriate education for pool users about cryptosporidiosis infection and management, which might become more important as temperatures are projected to increase as a result of climate change.

A review of the evidence to support influenza vaccine introduction in countries and areas of WHO's Western Pacific Region.

BACKGROUND: Immunization against influenza is considered an essential public health intervention to control both seasonal epidemics and pandemic influenza. According to the World Health Organization (WHO), there are five key policy and three key programmatic issues that decision-makers should consider before introducing a vaccine. These are (a) public health priority, (b) disease burden, (c) efficacy, quality and safety of the vaccine, (d) other inventions, (e) economic and financial issues, (f) vaccine presentation, (g) supply availability and (h) programmatic strength. We analyzed the body of evidence currently available on these eight issues in the WHO Western Pacific Region. METHODOLOGY/PRINCIPAL FINDINGS: Studies indexed in PubMed and published in English between 1 January 2000 and 31 December 2010 from the 37 countries and areas of the Western Pacific Region were screened for keywords pertaining to the five policy and three programmatic issues. Studies were grouped according to country income level and vaccine target group. There were 133 articles that met the selection criteria, with most (90%) coming from high-income countries. Disease burden (n = 34), vaccine efficacy, quality and safety (n = 27) and public health priority (n = 27) were most frequently addressed by studies conducted in the Region. Many studies assessed influenza vaccine policy and programmatic issues in the general population (42%), in the elderly (24%) and in children (17%). Few studies (2%) addressed the eight issues relating to pregnant women. CONCLUSIONS/SIGNIFICANCE: The evidence for vaccine introduction in countries and areas in this Region remains limited, particularly in low- and middle-income countries that do not currently have influenza vaccination programmes. Surveillance activities and specialized studies can be used to assess the eight issues including disease burden among vaccine target groups and the cost-effectiveness of influenza vaccine. Multi-country studies should be considered to maximize resource utilization for cross-cutting issues such as vaccine presentation and other inventions.

Using HIV notification data to identify priority migrant groups for HIV prevention, New South Wales, 2000-2008.

Non-Australian-born people comprise a third of HIV notifications in Australia. With increasing numbers of immigrants in Australia, public health and health promotion programs will need to adapt to the emerging epidemic of HIV among people from culturally and linguistically diverse (CALD) backgrounds. This study uses HIV notification data to compare Australian-born and non-Australian-born cases in New South Wales and aims to determine if income of source country is useful in identifying high priority CALD groups. Notified cases of newly diagnosed HIV between 2000 and 2008 in New South Wales were divided into Australian-born, persons born in high-income countries and persons born in middle and low-income countries based on World Bank classifications. These three groups were then compared to determine their risk factors for HIV infection. Of the 3,397 newly diagnosed HIV infections in New South Wales, 2,906 (86%) had a country of birth reported from 102 different countries. Cases born in high-income countries were similar to Australian-born cases; predominantly men reporting homosexual acquisition. Both these groups were different to cases born in middle and low-income countries; they were younger, more commonly female and reported heterosexual acquisition of HIV. Using income from source countries is useful as a model to better understand and target responses to HIV in non-Australian-born populations in New South Wales as it suggests that the public health and health promotion response in New South Wales and Australia should also focus on the priority communities drawn from low and middle income countries.

Economic costs of Shiga toxin-producing Escherichia coli infection in Australia.

Shiga toxin-producing Escherichia coli (STEC) infections are an important cause of foodborne disease in Australia. Three percent to 7% of sporadic patients develop hemolytic uremic syndrome (HUS) and 40% of patients with HUS develop chronic complications. To examine costs associated with illness, we interviewed patients notified to the South Australian Department of Health with a structured questionnaire regarding severity of illness, medical treatment, time lost from work, hospitalization, and other costs. In 2003-2006, we interviewed 46 patients of STEC infection, 2 of whom developed HUS. The median duration of illness was 7 days (range 3-31 days) and 41% (19/46) of patients were admitted to hospital. The estimated total cost for the 46 STEC cases in South Australia was AUD$144,087, equating to a mean cost of AUD$3132 per case. We estimate that the annual total costs of STEC infection in South Australia and Australia are AUD$200,283 and AUD$2,633,181, respectively. We used linear regression to identify that STEC infection costs increase by AUD$608 per day regardless of severity, and that more severe illness is strong predictor of cost. This is the first Australian study to examine costs of STEC infection and highlights the significant impact of this illness.

How does the HIV epidemic in NSW compare to other Australian jurisdictions and internationally?

AIM: To review the epidemiology of HIV in NSW and compare HIV rates in NSW with those of other comparable jurisdictions. METHOD: The rate of newly diagnosed cases of HIV reported in NSW was compared with those published from other Australian and comparable international jurisdictions. RESULTS: Until recent years, NSW has consistently reported the highest rate of newly diagnosed HIV infections in Australia with a peak of 29.1 per 100,000 population in 1987. Since then the notification rate has decreased significantly and has been stable since 2000 at an average annual rate of 5.6 per 100,000. Rates in NSW and in other Australian states and territories are lower than most comparable international jurisdictions, although stability in rates has been observed elsewhere. Between 1984 and 2008, 82% of infections that reported a risk exposure occurred among men who have sex with men. CONCLUSION: Rates of HIV infection in NSW have been stable over the last decade, remaining among the highest in Australia but lower than those in other comparable industrialised jurisdictions. In NSW, the majority of cases continue to occur among men who have sex with men.

Serogroup-specific risk factors for Shiga toxin-producing Escherichia coli infection in Australia.

BACKGROUND: Shiga toxin-producing Escherichia coli (STEC) is an important cause of foodborne illness. In Australia, risk factors for STEC infection have not been examined at a national level. METHODS: We conducted a case-control study in 6 Australian jurisdictions from 2003 through 2007. A case patient was defined as a person from whom STEC was isolated or toxin production genes were detected in stool. Case patients were recruited from notifiable disease registers, and 3 control subjects frequency matched by age were selected from databases of controls. Using structured questionnaires, interviewers collected data on clinical illness, foods consumed, and exposures to potential environmental sources. RESULTS: We recruited 43 case patients infected with STEC serogroup O157, 71 case patients infected with non-O157 serogroups, and 304 control subjects. One patient infected with serogroup O157 and 7 infected with non-O157 serogroups developed hemolytic uremic syndrome. Compared with control subjects, case patients infected with STEC O157 were more likely to eat hamburgers, visit restaurants, have previously used antibiotics, or have family occupational exposure to red meat. Case patients infected with non-O157 STEC were more likely to eat sliced chicken meat or corned beef from a delicatessen, camp in the bush, eat catered meals, or have family occupational exposure to animals. Negative associations were observed for certain foods, particularly homegrown vegetables, fruits, or herbs. CONCLUSION: This study of risk factors for STEC infection by serogroup highlights risks associated with eating hamburgers and occupational handling of raw meat. To prevent infection, hamburgers must be cooked thoroughly, and people handling raw meat or who have close contact with animals must ensure adequate hygiene.