Seven Salmonella Typhimurium Outbreaks in Australia Linked by Trace-Back and Whole Genome Sequencing.

Salmonella Typhimurium is a common cause of foodborne illness in Australia. We report on seven outbreaks of Salmonella Typhimurium multilocus variable-number tandem-repeat analysis (MLVA) 03-26-13-08-523 (European convention 2-24-12-7-0212) in three Australian states and territories investigated between November 2015 and March 2016. We identified a common egg grading facility in five of the outbreaks. While no Salmonella Typhimurium was detected at the grading facility and eggs could not be traced back to a particular farm, whole genome sequencing (WGS) of isolates from cases from all seven outbreaks indicated a common source. WGS was able to provide higher discriminatory power than MLVA and will likely link more Salmonella Typhimurium cases between states and territories in the future. National harmonization of Salmonella surveillance is important for effective implementation of WGS for Salmonella outbreak investigations.

HIV testing rates and co-infection among patients with tuberculosis in south-eastern Sydney, 2008-2013.

OBJECTIVE: To evaluate the rate of HIV and tuberculosis co-infection and changes in HIV testing practices for patients with tuberculosis managed in South Eastern Sydney Local Health District (SESLHD), New South Wales, Australia. DESIGN, PARTICIPANTS AND SETTING: A retrospective review of tuberculosis notification data from four public tuberculosis treatment clinics in SESLHD (population, >800,000), 2008-2013. Data were extracted from the NSW Notifiable Conditions Information Management System. INTERVENTION: Published evidence regarding clinical management of HIV and tuberculosis co-infection and feedback of HIV testing rates was provided to senior clinicians managing tuberculosis in SESLHD between 2008 and 2012. MAIN OUTCOME MEASURES: Proportion of patients with tuberculosis with HIV infection status ascertained and proportion with HIV co-infection. RESULTS: Of 506 people with notified tuberculosis treated in SESLHD during the study period, 369 had their HIV status ascertained (72.9%), of whom 20 were HIV co-infected (5.4%). Eleven of these cases were new HIV diagnoses. Seven people offered an HIV test declined the offer. The rates of HIV co-infection varied between clinics (1.5%-9.7%; P=0.02) as did the rate of HIV status ascertainment (61.5%-85.4%; P<0.001). The rate of HIV status ascertainment increased between 2008 and 2013 (52.9%-87.1%; P<0.001). CONCLUSIONS: The rate of HIV co-infection among people treated for tuberculosis in south-eastern Sydney is of clinical importance. Rates of HIV testing in this population have increased, but further gains are desirable. It is unclear if the intervention influenced the increase in HIV testing rates.

Staff immunisation: policy and practice in child care.

AIM: The aims of this study were to determine the level of knowledge among child-care centre directors regarding the National Health and Medical Research Council (NHMRC) recommendations for the immunisation of child-care workers, the extent to which this knowledge was translated into practice and any organisational barriers to the development and implementation of staff immunisation policy. METHODS: A cross-sectional survey, conducted in August 2006, in which a postal questionnaire was sent to a random sample of 784 NSW child-care centres. Centre directors were asked to complete the questionnaire on immunisation knowledge, policy and practice for the centre. A multivariate logistic-regression model was used to identify factors independently associated with centres with an immunisation policy for staff and centres that offered to pay all or part of the cost of vaccination of staff. RESULTS: Directors from 437 centres participated in the study for a response rate of 56%. Of these, 49% were aware of the NHMRC recommendations, and 57% had a staff immunisation policy in place. In the logistic regression model, centres with a written immunisation policy for staff were more likely to be aware of the NHMRC guidelines and offer long day care services. Centres that offered to pay all or part of the cost of immunisation for staff were more likely to be aware of the NHMRC guidelines, offer other child-care services and not operate for profit. Barriers to staff immunisation were related to the implementation of policy and included cost, time and access to information. CONCLUSIONS: The level of awareness of specific staff immunisation recommendations was relatively low. The transition of knowledge to policy was encouraging, although implementation of policies requires further commitment.

An outbreak of Salmonella typhimurium 108/170 at a privately catered barbeque at a Sydney sports club.

An outbreak of gastrointestinal illness was identified among attendees at a large community barbeque at a Sydney sports club on 30 January 2009. A retrospective cohort study was initiated, and attendees were identified through hospital emergency department gastroenteritis presentations, snowball recruitment through known cases, responders to linguistically specific press, and those returning to the venue the next week. A symptom and food history was collected from attendees, and stool samples were provided for microbiological investigation. An environmental investigation and trace back of implicated foods was also undertaken. Attendance estimates at the barbeque ranged from 100 to 180, and the food was prepared by a family that was not registered as a food business. Seventy one of the 87 attendees identified met the case definition. Thirty attendees (42%) had laboratory confirmed Salmonella Typhimurium phage-type 108/170, all with the same multilocus variable number of tandem repeat analysis typing. Burden of illness was high with 76% of cases seeking medical attention and 18% admitted to hospital. Microbiological evidence confirmed that a number of food items were contaminated with Salmonella Typhimurium 108/170, with the raw egg mayonnaise used in a Russian salad being the most likely primary food vehicle (adjusted odds ratio=10.3 [95% confidence interval 1.79-59.5]). Further, having Russian salad on the plate even if it was not consumed increased the relative risk of illness, thus suggesting that other food items may have been contaminated when they came into contact with it on the plate. This Salmonella outbreak highlighted the risks associated with the improper handling of food in private residences, which are then sold at a large public event.

Using a computerised database (REDCap) to monitor influenza vaccination coverage of healthcare workers and staff in South Eastern Sydney Local Health District.

Objective New South Wales (NSW) experienced a severe influenza season in 2017. In 2018, NSW Health implemented a campaign to improve healthcare worker (HCW) influenza vaccination coverage. The South Eastern Sydney Local Health District (LHD) trialled a centralised online database to monitor HCW uptake of the vaccination. This paper outlines how the monitoring system was chosen and developed, the process of implementation and the effectiveness of the system in this setting. Methods A literature review was conducted to identify an appropriate database. Stakeholder working groups took place across the LHD regarding implementation. An online vaccination consent form was developed and installed on the LHD network within 2 weeks. Administrative staff ensured timely entry of HCW data and vaccination status and analysis of uptake using Microsoft Excel. Results REDCap (Vanderbilt University, Nashville, TN, USA) was identified as the most appropriate web-based platform based on the ease of developing a secure and inexpensive data collection tool in a short time period. In all, 10064 employees were recorded in REDCap as having received the influenza vaccine. Customised REDCap reports allowed managers to follow up staff yet to receive their vaccination, which resulted in further vaccinations. Conclusions REDCap was successfully used as a data collection tool to track the influenza vaccination rates of staff. The data assisted the District Workforce Services in ensuring that facilities complied with NSW Health policy. This study highlights how REDCap may be used by similar organisations to monitor influenza vaccination of HCWs. What is known about the topic? There is increasing recognition of the need to ensure high-quality monitoring of HCW influenza vaccination rates, yet coverage is often difficult to measure accurately due to a lack of centralised reporting and monitoring systems. What does this paper add? This paper outlines how a computerised database (REDCap) was used by a NSW Health jurisdiction to monitor a vaccination program. REDCap is an inexpensive and easy to use system that allowed public health authorities rapid analysis of HCW vaccination coverage rates. What are the implications for practitioners? The findings add to the growing body of evidence demonstrating the utility of online systems for monitoring HCW influenza vaccinations. These results will be relevant to healthcare organisations and public health practitioners seeking quick and feasible research and data collection platforms.

Gonorrhoea enhanced surveillance for indigenous status and risk factors in the south-eastern Sydney population

Background: Gonorrhoea incidence is increasing in the Australian population. As a laboratory notifiable disease in NSW, information is not routinely available on indigenous status, sexual preference or other risk factors for infection. We conducted a 12-month pilot of enhanced surveillance in south-eastern Sydney in order to assess the feasibility of gathering this additional information. Methods: For each notification in a south-eastern Sydney resident with a 2013 specimen date, we sent a letter and questionnaire to the requesting doctor seeking additional demographic and risk factor information. Results: Of 1,341 questionnaires sent, 1,073 (79.5%) were returned, and men comprised 947 (88.3%). Indigenous status was provided for 1,009 (94.1%) cases, with seven (0.7%) identified as Aboriginal or Torres Strait Islander. Most men (83%) but a minority of women (19%) had same sex partners (p<0.001). Whilst 70% of men reported acquisition from a casual partner, only 46% of women thought they had acquired infection from a casual partner. Conclusions: The high response rate and completeness of indigenous status were strong features of this enhanced surveillance pilot which also provided valuable information on sexual preference and other risk factors for infection. However, gathering of this information was very labour intensive for both clinical and public health staff.

Opportunistic immunisation of infants admitted to hospital: are we doing enough?

AIM: To determine the accuracy and effectiveness of opportunistic immunisation of children admitted to the paediatric unit of a large teaching hospital using retrospectively collected data. METHODS: Immunisation status, documented using clinical indicator (CI) forms, of all admissions over a 1-year period was compared with that recorded by the Australian Childhood Immunisation Register. In order to determine the effectiveness of providing catch-up plans, we analysed the difference in catch-up times of the children with and without a catch-up plan on their CI form. RESULTS: The details of 614 admissions in the study period were included. Comparing the Australian Childhood Immunisation Register with the CI for assessing immunisation status, we found that 83 of the 573 (14.5%) were incorrectly recorded, and only 25 of the 82 admissions in which the infant was overdue were identified on the ward. Children were more likely to be vaccinated within 30 days and 90 days of admission if they had been given a catch-up plan. Of the children who had not been given a catch-up plan, almost half were still overdue at 90 days. CONCLUSIONS: Admission to hospital provides opportunities for both routine and catch-up immunisation; however, for opportunistic immunisation to be effective, health service screening and immunisation documentation must be accurate.

Emerging recombinant noroviruses identified by clinical and waste water screening.

Norovirus is estimated to cause 677 million annual cases of gastroenteritis worldwide, resulting in 210,000 deaths. As viral gastroenteritis is generally self-limiting, clinical samples for epidemiological studies only partially represent circulating noroviruses in the population and is biased towards severe symptomatic cases. As infected individuals from both symptomatic and asymptomatic cases shed viruses into the sewerage system at a high concentration, waste water samples are useful for the molecular epidemiological analysis of norovirus genotypes at a population level. Using Illumina MiSeq and Sanger sequencing, we surveyed circulating norovirus within Australia and New Zealand, from July 2014 to December 2016. Importantly, norovirus genomic diversity during 2016 was compared between clinical and waste water samples to identify potential pandemic variants, novel recombinant viruses and the timing of their emergence. Although the GII.4 Sydney 2012 variant was prominent in 2014 and 2015, its prevalence significantly decreased in both clinical and waste water samples over 2016. This was concomitant with the emergence of multiple norovirus strains, including twoGII.4 Sydney 2012 recombinant viruses, GII.P4 New Orleans 2009/GII.4 Sydney 2012 and GII.P16/GII.4 Sydney 2012, along with three other emerging strains GII.17, GII.P12/GII.3 and GII.P16/GII.2. This is unusual, as a single GII.4 pandemic variant is generally responsible for 65-80% of all human norovirus infections at any one time and predominates until it is replaced by a new pandemic variant. In sumary, this study demonstrates the combined use of clinical and wastewater samples provides a more complete picture of norovirus circulating within the population.

Epidemic infectious syphilis in inner Sydney--strengthening enhanced surveillance.

OBJECTIVE: To report the results of a 2001-04 enhanced syphilis surveillance program in south-eastern Sydney and a subset of cases from the Sydney Sexual Health Centre (SSHC). METHODS: For all laboratory syphilis notifications, a questionnaire was sent to the referring doctor requesting demographic data, clinical information about disease classification and the presence of symptoms. Sex of partner/s and HIV status were collected from a subset of cases seen at SSHC. RESULTS: During 2001-04, 1,275 syphilis notifications were received and 1,112 (87%) were able to be classified as 361 (28%) cases of infectious syphilis, 221 (17%) non-infectious syphilis and 530 (42%) treated syphilis. From mid 2002, an increase in the number of infectious syphilis notifications was noted. Of the 361 cases of infectious syphilis, most were in men (348, 97%). From a subset of 47 cases of infectious syphilis from SSHC, 43 (91%) were in gay men and nine (21%) had concurrent HIV infection. CONCLUSIONS: Inner Sydney has recently experienced a rapid increase in infectious syphilis affecting a defined population: men, aged 30-39, English speaking and Australian born. These results support recent reports of outbreaks among men who have sex with men, but without routine collection of additional risk factors control programs may be misguided. IMPLICATIONS: In light of the review of the NSW Public Health Act 1991, it is recommended that reducing barriers to the collection of HIV status and sex of sexual partners in de-identified syphilis notifications be explored as a matter of urgency.

Enhanced surveillance of a lymphogranuloma venereum outbreak in Sydney 2010-2012.

OBJECTIVES: To investigate an increase in lymphogranuloma venereum (LGV) notifications in New South Wales (NSW). METHODS: Enhanced surveillance of notified LGV cases in NSW between May 2010 and April 2012 using doctor and patient questionnaires. RESULTS: Thirty-seven doctors who had diagnosed 67 (76%) of 88 notified anorectal LGV infections were interviewed. The majority (n=33, 89%) of treating doctors were formally trained and accredited in HIV management and prescribing, and most (n=32, 86%) worked in a public sexual health clinic or a general practice with a high caseload of men who have sex with men (MSM). All 67 cases were MSM who resided in inner-city Sydney and all were serovar L2b. Anal symptoms had been present in 64 cases (96%, 95%CI 87-99%) for a median of 8 days (range 2-1,825) prior to presentation. Almost one-third (n=20) had another concurrent STI diagnosed. Most (82%) of the 22 interviewed patients reported being HIV positive and having other STIs diagnosed over the past year. In the preceding month, all 22 men reported condomless anal sex and the median number of casual sexual partners was 5 (range 0-100). CONCLUSIONS: Characteristics of LGV cases in NSW are similar to those described worldwide, suggesting that a sexually adventurous subgroup of MSM are at particular risk of infection. IMPLICATIONS: Education of non-sexual-health clinicians on LGV risk factors, presentation, testing and management may allow more timely diagnosis and notification of contacts to reduce LGV transmission in the community.

Men who have sex with men, infectious syphilis and HIV coinfection in inner Sydney: results of enhanced surveillance.

UNLABELLED: Background The resurgence of infectious syphilis in men who have sex with men (MSM) has been documented worldwide; however, HIV coinfection and syphilis reinfections in MSM in inner Sydney have not been published. METHODS: For all laboratory syphilis notifications assessed as a newly notified case or reinfection, a questionnaire was sent to the requesting physician seeking demographic data and disease classification. Sex of partner and HIV status were collected for all infectious syphilis notifications in men received from 1 April 2006 to March 2011. RESULTS: From April 2001 to March 2011, 3664 new notifications were received, 2278 (62%) were classified as infectious syphilis. Infectious syphilis notifications increased 12-fold from 25 to 303 in the first and last year respectively, and almost all notifications were in men (2220, 97.5%). During April 2006 to March 2011, 1562 infectious syphilis notifications in males were received and 765 (49%) of these men were HIV-positive and 1351 (86%) reported a male sex partner. Reinfections increased over time from 17 (9%) to 56 (19%) in the last year of the study and were significantly more likely to be in HIV-positive individuals (χ(2)=140.92, degrees of freedom= 1, P=<0.001). CONCLUSION: Inner Sydney is experiencing an epidemic of infectious syphilis in MSM and about half of these cases are in HIV-positive patients. Reinfections are increasing and occur predominantly in HIV-positive men. Accurate surveillance information is needed to inform effective prevention programs, and community and clinician education needs to continue until a sustained reduction is achieved.

Compliance with sharps waste standards by a sample of Sydney acupuncture premises.

AIM: To examine current practices with regard to the safe collection, storage and disposal of sharps waste in acupuncture premises and to determine compliance with the NSW Public Health (Skin Penetration) Regulation 2000 and the NSW Health Skin Penetration Code of Best Practice. METHODS: A random sample of acupuncturists in the City of Sydney local government area was selected and surveyed using a structured questionnaire. RESULTS: All 26 acupuncturists surveyed had sharps disposal bins and complied with the Regulation, but the following elements of the Code were not uniformly followed: regular disposal of sharps (77%), disposal through a waste contractor (23%) and placement of bins out of reach of visitors (8%). CONCLUSION: Regular disposal of sharps containers in acupuncture premises could be improved.

A community outbreak of cryptosporidiosis in sydney associated with a public swimming facility: a case-control study.

In February, 2008, the South Eastern Sydney Illawarra Public Health Unit investigated an outbreak of cryptosporidiosis within the south east region of Sydney, Australia. Thirty-one cases with laboratory-confirmed cryptosporidiosis and 97 age- and geographically matched controls selected by random digit dialling were recruited into a case-control study and interviewed for infection risk factors. Cryptosporidiosis was associated with swimming at Facility A (matched odds ratio = 19.4, 95% confidence interval: 3.7-100.8) and exposure to household contacts with diarrhoea (matched odds ratio = 7.7, 95% confidence interval: 1.9-31.4) in multivariable conditional logistic regression models. A protective effect for any animal contact was also found (matched odds ratio = 0.2, 95% confidence interval: 0.1-0.7). Cryptosporidium hominis subtype IbA10G2 was identified in 8 of 11 diagnostic stool samples available for cases. This investigation reaffirms the importance of public swimming pools as potential sources of Cryptosporidium infection and ensuring their compliance with water-quality guidelines. The protective effect of animal contact may be suggestive of past exposure leading to immunity.

Bound for Sydney town: health surveillance on international cruise vessels visiting the Port of Sydney.

A program for routine health surveillance on international cruise ships visiting the Port of Sydney has been developed since 1998. Before introduction of this program, ships only reported quarantinable diseases and were not aware of the Australian requirement to report other infectious diseases. Voluntary routine reporting, developed in partnership with the cruise ship industry, provides timely information on all infectious diseases of public health interest during every cruise. During 1999-2003, the program resulted in detection of and response to 14 outbreaks of gastroenteritis or acute respiratory infection, affecting more than 1400 passengers and crew. The program has improved preventive action, and risk communication and management by cruise ship operators, and led to more timely investigation and support by public health authorities.