Measuring school level attributable risk to support school-based HPV vaccination programs.

BACKGROUND: In Australia in 2017, 89% of 15-year-old females and 86% of 15-year-old males had received at least one dose of the HPV vaccine. However, considerable variation in HPV vaccination initiation (dose one) across schools remains. It is important to understand the school-level characteristics most strongly associated with low initiation and their contribution to the overall between-school variation. METHODS: A population-based ecological analysis was conducted using school-level data for 2016 on all adolescent students eligible for HPV vaccination in three Australian jurisdictions. We conducted logistic regression to determine school-level factors associated with lower HPV vaccination initiation (< 75% dose 1 uptake) and estimated the population attributable risk (PAR) and the proportion of schools with the factor (school-level prevalence). RESULTS: The factors most strongly associated with lower initiation, and their prevalence were; small schools (OR = 9.3, 95%CI = 6.1-14.1; 33% of schools), special education schools (OR = 5.6,95%CI = 3.7-8.5; 8% of schools), higher Indigenous enrolments (OR = 2.7,95% CI:1.9-3.7; 31% of schools), lower attendance rates (OR = 2.6,95%CI = 1.7-3.7; 35% of schools), remote location (OR = 2.6,95%CI = 1.6-4.3; 6% of schools,) and lower socioeconomic area (OR = 1.8,95% CI = 1.3-2.5; 33% of schools). The highest PARs were small schools (PAR = 79%, 95%CI:76-82), higher Indigenous enrolments (PAR = 38%, 95%CI: 31-44) and lower attendance rate (PAR = 37%, 95%CI: 29-46). CONCLUSION: This analysis suggests that initiatives to support schools that are smaller, with a higher proportion of Indigenous adolescents and lower attendance rates may contribute most to reducing the variation of HPV vaccination uptake observed at a school-level in these jurisdictions. Estimating population-level coverage at the school-level is useful to guide policy and prioritise resourcing to support school-based vaccination programs.

Parental disease prevention health beliefs and triggers for keeping children home from childcare-a qualitative study in Sydney, Australia.

BACKGROUND: Infectious diseases cause considerable morbidity and mortality in children less than 5 years of age. Children attending childcare centres are at increased risk of contracting infections. It is of public health interest to understand what triggers and underpins parental decisions to send an unwell child to childcare, with the obvious attendant risks to other children and childcare staff as well as the affected child. This study aimed to examine parents' disease prevention health beliefs and practices with a particular focus on how these factors influence childcare attendance decisions. METHODS: Semistructured, in-depth interviews were conducted between June 2009 and May 2011 with parents who had at least one child under 5 years of age enrolled in a childcare centre. Six centres in the metropolitan area of Sydney, Australia, were selected to include parents from a range of demographic and socio-economic backgrounds. RESULTS: Forty-two interviews were conducted, recorded, and transcribed. Themes emerging from the data included "vitamin dirt," contagion, and contagion prevention and control. These interacted with parents' decision-making about childcare attendance, and parents made choices in a complex context of obligations to their child, social contract obligations to others, peer expectations, and the need to work. Vaccination received only scant mention as a preventive health measure. Decision-making by parents concerning childcare attendance was made without reference to any external guidelines. CONCLUSIONS: This study provides insights into parental disease prevention beliefs, behaviours, and decision-making. It reveals a need for policies to support parents with unwell children. In addition, resources and educative efforts to raise awareness of vaccination as a preventive health measure, and awareness of infectious disease contagion more broadly, would assist in providing parents with a greater evidence base for making decisions about childcare attendance when their child is unwell.

An audit of the quality of online immunisation information available to Australian parents.

BACKGROUND: The Internet is increasingly a source of health information for parents, who use the Internet alongside health care providers for immunisation information. Concerns have been raised about the reliability of online immunisation information, however to date there has been no audit of the quality or quantity of what is available to Australian parents. The objective of this study was to address this gap by simulating a general online search for immunisation information, and assessing the quality and quantity of the web sites returned by the search. METHODS: We used Google trends to identify the most common immunisation search terms used in Australia. The ten most common terms were entered into five search engines and the first ten non-commercial results from each search collated. A quality assessment tool was developed using the World Health Organization Global Advisory Committee on Vaccine Safety (GACVS) criteria for assessing the quality of vaccine safety web sites, and used to assess and score the quality of the sites. RESULTS: Seven hundred web pages were identified, of which 514 were duplicates, leaving 186 pages from 115 web sites which were audited. Forty sites did not include human immunisation information, or presented personal opinion about individuals, and were not scored. Of the 75 sites quality scored, 65 (87%) were supportive of immunisation, while 10 (13%) were not supportive. The overall mean quality score was 57/100 (range 14/100 to 92/100). When stratified by pro and anti-vaccination stance, the average quality score for pro-vaccine sites was 61/100, while the average score for anti-vaccine sites was 30/100. Pro-vaccine information could be divided into three content groups: generalist overview with little detail; well-articulated and understandable detail; and lengthy and highly technical explanations. The main area found to be lacking in pro-vaccine sites was lack of transparent authorship. CONCLUSION: Our findings suggest a need for information which is easily found, transparently authored, well-referenced, and written in a way that is easily understood.

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

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

Successful treatment of Rhizopus arrhizus rhino-orbital-cerebral mucormycosis with isavuconazole salvage therapy following extensive debridement.

A 61-year old lady with poorly-controlled type 2 diabetes mellitus was diagnosed with rhino-orbital-cerebral mucormycosis following presentation with sinusitis, ophthalmoplegia, proptosis and facial numbness. She was treated successfully with aggressive surgical intervention including orbital exenteration, accompanied by anti-fungal therapy with liposomal amphotericin B and posaconazole, followed by isavuconazole as salvage therapy. We discuss the challenges around optimising antifungal therapy of this lethal infection in the context of hepatic and renal toxicity.

A user-centered approach to developing a new tool measuring the behavioural and social drivers of vaccination.

BACKGROUND: Children around the world remain under-vaccinated for many reasons. To develop effective vaccine delivery programmes and monitor intervention impact, vaccine programme implementers need to understand reasons for under-vaccination within their local context. The World Health Organization (WHO) Working Group on the Behavioural and Social Drivers of Vaccination (BeSD) is developing standardised tools for assessing childhood vaccine acceptance and uptake that can be used across regions and countries. The tools will include: (1) a validated survey; (2) qualitative interview guides; and (3) corresponding user guidance. We report a user-centred needs assessment of key end-users of the BeSD tools. METHODS: Twenty qualitative interviews (Apr-Aug 2019) with purposively sampled vaccine programme managers, partners and stakeholders from UNICEF and WHO country and regional offices. The interviews assessed current systems, practices and challenges in data utilisation and reflections on how the BeSD tools might be optimised. Framework analysis was used to code the interviews. RESULTS: Regarding current practices, participants described a variety of settings, data systems, and frequencies of vaccination attitude measurement. They reported that the majority of data used is quantitative, and there is appetite for increased use of qualitative data. Capacity for conducting studies on social/behavioural drivers of vaccination was high in some jurisdictions and needed in others. Issues include barriers to collecting such data and variability in sources. Reflecting on the tools, participants described the need to explore the attitudes and practices of healthcare workers in addition to parents and caregivers. Participants were supportive of the proposed mixed-methods structure of the tools and training in their usage, and highlighted the need for balance between tool standardisation and flexibility to adapt locally. CONCLUSIONS: A user-centred approach in developing the BeSD tools has given valuable direction to their design, bringing the use of behavioural and social data to the heart of programme planning.

Differences in school factors associated with adolescent HPV vaccination initiation and completion coverage in three Australian states.

BACKGROUND: Schools are the primary setting for the delivery of adolescent HPV vaccination in Australia. Although this strategy has achieved generally high vaccination coverage, gaps persist for reasons that are mostly unknown. This study sought to identify school-level correlates of low vaccination course initiation and completion in New South Wales, Tasmania, and Western Australia to inform initiatives to increase uptake. METHODS: Initiation was defined as the number of first doses given in a school in 2016 divided by vaccine-eligible student enrolments. Completion was the number of third doses given in a school in 2015-2016 divided by the number of first doses. Low initiation and completion were defined as coverage ≤ 25thpercentile of all reporting schools. We investigated correlations between covariates using Spearman's rank correlation coefficients. Due to multicollinearity, we used univariable logistic regression to investigate associations between school characteristics and low coverage. RESULTS: Median initiation was 84.7% (IQR: 75.0%-90.4%) across 1,286 schools and median completion was 93.8% (IQR: 86.0%-97.3%) across 1,295 schools. There were strong correlations between a number of school characteristics, particularly higher Indigenous student enrolments and lower attendance, increasing remoteness, higher postcode socioeconomic disadvantage, and smaller school size. Characteristics most strongly associated with low initiation in univariate analyses were small school size, location in Tasmania, and schools catering for special educational needs. Low completion was most strongly associated with schools in Tasmania and Western Australia, remote location, small size, high proportion of Indigenous student enrolments, and low attendance rates. CONCLUSION: This study provides indicative evidence that characteristics of schools and school populations are associated with the likelihood of low initiation and completion of the HPV vaccination course. The findings will guide further research and help target initiatives to improve vaccination uptake in schools with profiles associated with lower coverage.

Midwives' attitudes, beliefs and concerns about childhood vaccination: A review of the global literature.

Vaccine hesitancy in industrialised countries is an area of concern. Health professionals play a significant role in parental vaccination decisions, however, to date the role of midwives has not been widely explored. This review sought to describe the attitudes and communication practices of midwives in developed countries towards childhood vaccines. Medline, Cinahl, PsychInfo, Embase and the grey literature were searched. Inclusion criteria were qualitative and quantitative studies reporting midwives' beliefs, attitudes and communication practices toward childhood vaccination. The search returned 366 articles, of which 359 were excluded by abstract. Two additional articles were identified from the grey literature and references, resulting in nine studies from five countries included in the review. Across the studies, the majority of midwives supported vaccination, although a spectrum of beliefs and concerns emerged. A minority expressed reservations about the scientific justification for vaccination, which focussed on what is not yet known rather than mistrust of current evidence. Most midwives felt that vaccines were safe; a minority were unsure, or believed they were unsafe. The majority of midwives agreed that childhood vaccines are necessary. Among those who expressed doubt, a commonly held opinion was that vaccine preventable diseases such as measles are relatively benign and didn't warrant vaccination against them. Finally, the midwifery model of care was shown to focus on providing individualised care, with parental choice being placed at a premium. The midwifery model care appears to differ in approach from others, possibly due to a difference in the underpinning philosophies. Research is needed to understand how midwives see vaccination, and why there appears to be a spectrum of views on the subject. This information will inform the development of resources tailored to the midwifery model of care, supporting midwives in advocating for childhood vaccination.

Vaccine decision-making begins in pregnancy: Correlation between vaccine concerns, intentions and maternal vaccination with subsequent childhood vaccine uptake.

INTRODUCTION: Maternal and childhood vaccine decision-making begins prenatally. Amongst pregnant Australian women we aimed to ascertain vaccine information received, maternal immunisation uptake and attitudes and concerns regarding childhood vaccination. We also aimed to determine any correlation between a) intentions and concerns regarding childhood vaccination, (b) concerns about pregnancy vaccination, (c) socioeconomic status (SES) and (d) uptake of influenza and pertussis vaccines during pregnancy and routine vaccines during childhood. METHODS: Women attending public antenatal clinics were recruited in three Australian states. Surveys were completed on iPads. Follow-up phone surveys were done three to six months post delivery, and infant vaccination status obtained via the Australian Childhood Immunisation Register (ACIR). RESULTS: Between October 2015 and March 2016, 975 (82%) of 1184 mothers consented and 406 (42%) agreed to a follow up survey, post delivery. First-time mothers (445; 49%) had significantly more vaccine concerns in pregnancy and only 73% had made a decision about childhood vaccination compared to 89% of mothers with existing children (p-value<0.001). 66% of mothers reported receiving enough information during pregnancy on childhood vaccination. In the post delivery survey, 46% and 82% of mothers reported receiving pregnancy influenza and pertussis vaccines respectively. The mother's degree of vaccine hesitancy and two attitudinal factors were correlated with vaccine uptake post delivery. There was no association between reported maternal vaccine uptake or SES and childhood vaccine uptake. CONCLUSION: First time mothers are more vaccine hesitant and undecided about childhood vaccination, and only two thirds of all mothers believed they received enough information during pregnancy. New interventions to improve both education and communication on childhood and maternal vaccines, delivered by midwives and obstetricians in the Australian public hospital system, may reduce vaccine hesitancy for all mothers in pregnancy and post delivery, particularly first-time mothers.

Review article: treatment as prevention - targeting people who inject drugs as a pathway towards hepatitis C eradication.

BACKGROUND: Hepatitis C virus (HCV) is a leading cause of chronic liver disease worldwide. HCV predominates in people who inject drugs; a group in whom anti-viral therapy has previously been withheld on the basis of chaotic lifestyles and associated risks of reinfection. New research has emerged which suggests that by specifically targeting HCV-infected people who inject drugs for treatment, the pool of HCV would deplete, thus reducing overall transmission and eventually leading to HCV eradication. AIM: To outline the requirements for HCV eradication and review the evidence that this is achievable. METHODS: Expert review of the literature. RESULTS: The achievement of HCV eradication using 'treatment as prevention' is supported by numerous epidemiological modelling studies employing a variety of models in several contexts including people who inject drugs, men who have sex with men and prisoners. More recent studies also incorporate the newer, more efficacious direct-acting anti-viral drugs. These drugs have been shown to be safe and effective in people who inject drugs in clinical trials. There is no empirical evidence of the impact of treatment as prevention strategies on population prevalence. CONCLUSIONS: This review highlights the efforts to control HCV and evaluates the possibilities of achieving eradication of HCV. Currently, the technologies required to achieve HCV eradication exist, but the infrastructure to deliver them is not generally available or of insufficient scale outside of specific areas. Such areas are yet to demonstrate that elimination is possible, but results of studies in these areas are awaited. Such a demonstration would be proof of principle for eradication. Although we are aspiring towards HCV eradication, elimination is the more realistic prospect.

The bifocal diverging collimator: a means of simultaneous biplane imaging of the heart during equilibrium radionuclide ventriculography.

We have constructed a bifocal diverging collimator (BDC), capable of simultaneously recording two views of the heart 50 degrees apart on each half of a standard imaging field. In this study, simultaneous two-view blood-pool scans using the BDC were compared with the same two separate views obtained using an all-purpose parallel-hole collimator (PHC), assessing left-ventricular ejection fraction and regional wall motion in 20 patients undergoing contrast left ventriculography (CV). Ejection fraction by BDC correlated closely with PHC (r = 0.94) and with CV (r = 0.88). Regional wall motion was scored qualitatively on a five-point scale from 3 (normal) to--1 (dyskinesis) with an 88% agreement between BDC and PHC and PHC for segment scores. The percentages for agreement between BDC and CV, and between PHC and CV, were identical, 79%. A single blood-pool scan acquisition using a new BDC provides information about global and regional left-ventricular function in two planes, comparable with that of a PHC.

Superfusion in vitro in the study of ovarian steroidogenesis.

A method for the continuous superfusion of porcine corpus luteum tissue is described which readily allows both the introduction of regulatory factors to the incubating tissue, and sampling of the tissue. Oestrogen (principally oestradiol) and progestin (principally progesterone) can be measured for up to 24 h in the superfusate from corpora lutea of all ages, and the secretion of both steroids is stimulated by the addition of luteinizing hormone. The pattern of response of both steroids to a pulse of gonadotrophin was similar in that a rapid transient increase in secretion occurred followed some time later by a secondary and more prolonged response. A second pulse of gonadotrophin introduced 6 h after the first also stimulated steroid secretion, indicating that during superfusion in vitro the porcine corpus luteum does not become refractory to the steroidogenic effect of gonadotrophin.

Metabolism of testosterone by forehead skin of the roebuck (Capreolus capreolus).

Roebucks have a specialized region of skin on the forehead which contains sebaceous and apocrine glands that produce secretions used in territorial marking. These glands enlarge during the breeding season and regress after the rut as the testes regress. The metabolism of testosterone by this forehead skin in vitro was studied in two captive roebucks over the period of glandular enlargement and subsequent regression, and compared with that of dorsal skin. In May, June and July, both areas of skin actively metabolized testosterone and the metabolites detected were androstenedione, androstanedione, dihydrotestosterone, epiandrosterone, androsterone and 5alpha-androstanediols. There were no major differences in testosterone metabolism between the two body sites, although dorsal skin appeared to be more active in total metabolism than forehead skin. There was a peak in the extent of metabolism in June/July, with a subsequent gradual decline to December. The decline in metabolism occurred at a time when the associated glands were still enlarged, which suggests that the availability of androgen to the skin glands is determined not only by the amount of testosterone in the circulation, but also by a decrease in the metabolizing capacity of the tissue.

Effect of fenoprofen on thyroid function tests.

We observed that a few patients taking the anti-inflammatory drug fenoprofen showed increases in total and free T3 serum levels without convincing evidence of an associated thyrotoxicosis. To confirm these findings, two volunteers were given fenoprofen for two weeks. Within this time total T3 levels almost doubled and free T3 levels increased threefold. Administration of fenoprofen did not have any measurable effect on T4 or TSH estimations. Cross-reactivities of fenoprofen and 4'-hydroxyfenoprofen were studied with antisera from various total and free T3 assays. Results show that the metabolite cross-reacts with the antisera from Amerlex total and free T3 assay kits. A lesser degree of interference was observed with the Corning total and free T3 assays. 4'-hydroxyfenoprofen had no effect on an 'in house' total T3 assay. Laboratories should therefore be aware of the possibility that their assay may be subject to interference by fenoprofen or its metabolites while clinicians should be aware of this interference in order that they may avoid unnecessary and harmful treatment.

In vitro metabolism of androgens by mammalian cauda epididymal spermatozoa.

The in vitro metabolism of [3H] testosterone (17beta-hydroxy-4-androsten-3-one), [3H] androstenedione (4-androstene-3,17-dione) and [3H] dehydroepiandrosterone (3beta-hydroxy-5-androsten-17-one) by cauda epididymal spermatozoa from the rat, rabbit, hamster, guinea-pig and ram, varied between species. There were differences in the androgens utilized, the extent of their conversion and the identities of the metabolites formed. Of the steroid substrates tested rat spermatozoa metabolized testosterone preferentially while spermatozoa from guinea-pig transformed [3H] dehydroepiandrosterone (DHEA) almost exclusively. Rabbit spermatozoa converted all three [3H] androgens while hamster sperm utilized [3H] testosterone and [3H] DHEA. Spermatozoa collected from rams killed at the abattoir metabolized both [3H] androstenedione and [3H] DHEA but this capacity was dramatically reduced in spermatozoa collected from rams subjected to short-term anaesthesea. The results are discussed in relation to the possible direct roles of androgens in sperm physiology.

An attempt to swindle nature: press anti-immunisation reportage 1993-1997.

There is some evidence that low childhood immunisation rates in Australia may be attributed partly to parental antipathy toward immunisation. The anti-immunisation movement is becoming more organised in its efforts to lobby against childhood immunisation, while the lessening of the public's exposure to the effects of vaccine-preventable disease has provided a climate ripe for such a lobby to have a disproportionate influence on parents. Forty months of Australian print media coverage of immunisation were reviewed for anti-immunisation arguments and their underlying ideological subtexts. Of 2440 articles about childhood immunisation, 115 (4.7 per cent) contained statements opposing immunisation. Eight subtexts that referenced wider discourses about medicine, the state and the body dominated anti-immunisation discourse (cover-up; excavation of the facts; unholy alliance for profit; towards totalitarianism; us and them; vaccines as poisonous chemical cocktails; vaccines as cause of idiopathic ills; and back to nature). Attempts to redress claims made against immunisation must not only address specific claims about vaccine efficacy and safety but be grounded in a reframing of the ideological appeals that currently frame the contents of anti-immunisation discourse.

Focus group composition: a comparison between natural and constructed groups.

OBJECTIVE: To provide insight into the effects of focus group composition. METHOD: In an early phase of an ongoing study of parental reception to messages about childhood immunisation, we conducted four focus groups; two with participants who had never met before (constructed groups) and two with participants who were part of a pre-established first-time mothers' group (natural groups). RESULTS: Marked differences were noted in the group dynamics, depth of interaction and diversity between groups. Discussions with constructed groups were animated, enthusiastic, expressed more divergent views and articulated greater complexities of the topic. Discussions with natural groups were generally flatter and less enthusiastic, displaying a higher level of apparent conformity to conventional wisdom. The need to protect other participants from potentially disturbing information about vaccination was expressed across groups but acted to censor natural groups, where participants knew more of each others' sensitivities. IMPLICATIONS: Insight into the factors contributing to such differences may enhance understanding of the contexts in which constructed groups are more appropriate. The processes of social censorship may be of primary interest to the researcher. However, where it is paramount to elicit a range of opinions about a potentially controversial topic, we suggest that natural groups in the delicate stage of norming be avoided. The peculiarities of each individual research circumstance are best explored in pilot studies.

Pregnant women's intention to take up a post-partum pertussis vaccine, and their willingness to take up the vaccine while pregnant: a cross sectional survey.

INTRODUCTION: Post-partum vaccination of new mothers is currently recommended in Australia to reduce pertussis infection in infants. Internationally, vaccination recommendations now include pregnant women in some countries. Understanding the awareness of pertussis vaccination recommendations among pregnant women, and their willingness to have the vaccine while pregnant is important for informing vaccine program implementation. OBJECTIVE: To determine awareness and intentions toward current recommendations for post-partum pertussis vaccination among Australian pregnant women, and their willingness to accept pertussis vaccine during pregnancy, should it be recommended in Australia in the future. DESIGN: Quantitative self-administered survey, using a non-random stratified sampling plan based on representative proportions by age, parity and region of residence. PARTICIPANTS AND SETTING: Pregnant women receiving antenatal care through three large, demographically diverse referral hospitals in metropolitan, urban and rural New South Wales, Australia. RESULTS: The response rate was 815/939 (87%). Most women (80%) reported willingness to have the pertussis vaccine during pregnancy, should it be recommended. Thirty four per cent of women intended to receive a pertussis vaccine post-partum, 17% had received it previously, while 45% had never heard of pertussis vaccine, had not thought about it, or were undecided about having it. Compared with those who had not received a recommendation to have the vaccine post-partum, women who had received a recommendation were 7 times more likely (95% CI 4-14) to report intention to have the vaccine. CONCLUSIONS: Health care provider recommendation is paramount to raising awareness of pertussis vaccination recommendations among pregnant women. Women's willingness to have the vaccine while pregnant is encouraging, and indicates the potential for high pertussis vaccine coverage among pregnant women, should it be recommended in Australia.