Q Fever awareness and risk profiles among agricultural show attendees.

OBJECTIVE: To assess awareness and risk of Q fever among agricultural show attendees. SETTING: University of New England's Farm of the Future Pavilion, 2019, Sydney Royal Agricultural Show. PARTICIPANTS: Participants were ≥18 years, fluent in English, Australian residents, and gave their informed consent. MAIN OUTCOME MEASURES: Participants reported whether they had ever heard of Q fever and then completed the 'Q Tool' (www.qfevertool.com), which was used to assess participants' demographics and risk profiles. Cross-tabulations and logistic regression analyses were used to examine the relationship between these factors. RESULTS: A total of 344 participants were recruited who, in general, lived in major NSW cities and were aged 40-59 years. 62% were aware of Q fever. Living in regional/remote areas and regular contact with livestock, farms, abattoirs and/or feedlots increased the likelihood of Q fever awareness. Direct or indirect contact with feral animals was not associated with Q fever awareness after controlling for the latter risk factors. 40% of participants had a high, 21% a medium, and 30% a low risk of exposure. Slightly less than 10% reported a likely existing immunity or vaccination against Q fever. Among those who were not immune, living in a regional or remote area and Q fever awareness were independently associated with increased likelihood of exposure. CONCLUSIONS: Awareness of Q fever was relatively high. Although 61% of participants had a moderate to high risk of exposure to Q fever, they had not been vaccinated. This highlights the need to explore barriers to vaccination including accessibility of providers and associated cost.

Rickettsial Infections and Q Fever Amongst Febrile Patients in Bhutan.

There is limited evidence of rickettsial diseases in Bhutan. We explored the contribution of rickettsioses as a cause of undifferentiated febrile illness in patients presenting to 14 Bhutanese hospitals from October 2014 to June 2015. Obvious causes of fever were excluded clinically. Clinico-demographic information and acute blood samples were collected. Samples were tested by immunofluorescence assay (IFA) and qPCR against scrub typhus group (STG), spotted fever group (SFG) and typhus group (TG) rickettsiae, and Q fever (QF). Of the 1044 patients, 539 (51.6%) were female and the mean age was 31.5 years. At least 159 (15.2%) of the patients had evidence of a concurrent rickettsial infection. Of these, 70 (6.7%), 46 (4.4%), 4 (0.4%), and 29 (2.8%) were diagnosed as acute infections with STG, SFG, TG, and QF respectively. Ten (1.0%) patients were seropositive for both SFG and TG. Seven of the 70 STG patients were positive by qPCR. Eschar (p < 0.001), myalgia (p = 0.003), and lymphadenopathy (p = 0.049) were significantly associated with STG, but no specific symptoms were associated with the other infections. Disease incidences were not different between age groups, genders, occupations, and districts, except for students with significantly lower odds of infection with STG (OR = 0.43; 95% CI = 0.20, 0.93; p = 0.031). Rickettsioses were responsible for at least 15% of undifferentiated febrile illnesses in Bhutan, scrub typhus being the commonest. Health authorities should ensure that health services are equipped to manage these infections.

Q fever: A rural disease with potential urban consequences

BACKGROUND: Q fever often presents as an undifferentiated febrile illness. Cases occur throughout Australia, with higher rates occurring in northern New South Wales and southern Queensland. OBJECTIVE: This article aims to provide clinicians with an overview of Q fever, and covers epidemiology, clinical features, laboratory diagnosis, sequelae, management and prevention. DISCUSSION: In Australia, Q fever is the most commonly reported zoonotic disease. Presentation includes fever, rigors, chills, headache, extreme fatigue, drenching sweats, weight loss, arthralgia and myalgia, often in conjunction with abnormal liver function tests. These features make it indistinguishable from many other febrile illnesses. Exposure occurs through contact with livestock and other animals. Coxiella bacteria can survive in dust, where infection may result from inhalation. Laboratory diagnosis is made by serology or polymerase chain reaction. An effective vaccine is available for adults (aged >15 years), but can only be administered after a rigorous pre-vaccination assessment to exclude prior exposure to Coxiella burnetii, requiring a detailed medical history, skin test and serology.

Surveillance system enhancements for Q fever in NSW, 2005-2015.

INTRODUCTION: Q fever remains an important notifiable, zoonotic disease in Australia. Previous epidemiological reviews have noted increased importance of non-abattoir contact with livestock and native/feral animals. Changes to surveillance in New South Wales (NSW) have provided enhanced surveillance data with which to examine exposure pathways. METHODS: Descriptive analysis of NSW Q fever notification data for the period 2005-2015, with detailed analysis of exposures for the period 2011-2015 (after introduction of improvements to surveillance). RESULTS: Between 2005 and 2015, 1,653 confirmed cases of Q fever were notified in NSW residents who acquired the disease in this state. For the period 2011-2015, a high-risk occupation was reported in 345/660 (52.3%) of notifications with a known occupation. Of 641 cases with a known animal exposure, 345 (53.8%) had direct contact with livestock, while 62 (9.7%) had indirect contact with livestock (e.g. proximity to livestock, livestock holding areas or trucks). Direct or indirect contact with native/feral animals was reported in 111/641 (17.3%) cases. Mowing and close proximity to kangaroos/wallabies were commonly reported indirect exposure pathways, particularly in urban areas. CONCLUSIONS: Enhancements to the state based surveillance database in NSW introduced in 2010 have resulted in improved collection of surveillance data for Q fever. Further refinement of Q fever surveillance can be achieved through continuing to improve data quality, standardising data collection and better elucidating exposure pathways of cases.

Seroprevalence of rickettsial infections and Q fever in Bhutan.

BACKGROUND: With few studies conducted to date, very little is known about the epidemiology of rickettsioses in Bhutan. Due to two previous outbreaks and increasing clinical cases, scrub typhus is better recognized than other rickettsial infections and Q fever. METHODOLOGY: A descriptive cross-sectional serosurvey was conducted from January to March 2015 in eight districts of Bhutan. Participants were 864 healthy individuals from an urban (30%) and a rural (70%) sampling unit in each of the eight districts. Serum samples were tested by microimmunofluorescence assay for rickettsial antibodies at the Australian Rickettsial Reference Laboratory. RESULTS: Of the 864 participants, 345 (39.9%) were males and the mean age of participants was 41.1 (range 13-98) years. An overall seroprevalence of 49% against rickettsioses was detected. Seroprevalence was highest against scrub typhus group (STG) (22.6%) followed by spotted fever group (SFG) rickettsia (15.7%), Q fever (QF) (6.9%) and typhus group (TG) rickettsia (3.5%). Evidence of exposure to multiple agents was also noted; the commonest being dual exposure to STG and SFG at 5%. A person's likelihood of exposure to STG and SFG rickettsia significantly increased with age and farmers were twice as likely to have evidence of STG exposure as other occupations. Trongsa district appeared to be a hotspot for STG exposure while Punakha district had the lowest STG exposure risk. Zhemgang had the lowest exposure risk to SFG rickettsia compared to other districts. People living at altitudes above 2000 meters were relatively protected from STG infections but this was not observed for SFG, TG or QF exposure. CONCLUSION: This seroprevalence study highlights the endemicity of STG and SFG rickettsia in Bhutan. The high seroprevalence warrants appropriate public health interventions, such as diagnostic improvements and clinical treatment guidelines. Future studies should focus on vector profiles, geospatial, bio-social and environmental risk assessment and preventive and control strategies.

The increasing importance of community-acquired methicillin-resistant Staphylococcus aureus infections.

OBJECTIVES: To identify groups at risk of methicillin-resistant Staphylococcus aureus (MRSA) infection, patterns of antimicrobial resistance, and the proportion of patients with MRSA infections but no history of recent hospitalisation. DESIGN, SETTING AND PARTICIPANTS: Case series of 39 231 patients with S. aureus isolates from specimens processed by the Hunter New England Local Health District (HNELHD) public pathology provider during 2008-2014. MAIN OUTCOME MEASURES: Proportion of MRSA infections among people with S. aureus isolates; antimicrobial susceptibility of MRSA isolates; origin of MRSA infections (community- or health care-associated); demographic factors associated with community-associated MRSA infections. RESULTS: There were 71 736 S. aureus-positive specimens during the study period and MRSA was isolated from 19.3% of first positive specimens. Most patients (56.9%) from whom MRSA was isolated had not been admitted to a public hospital in the past year. Multiple regression identified that patients with community-associated MRSA were more likely to be younger (under 40), Indigenous Australians (odds ratio [OR], 2.6; 95% CI, 2.3-2.8), or a resident of an aged care facility (OR, 4.7; 95% CI, 3.8-5.8). The proportion of MRSA isolates that included the dominant multi-resistant strain (AUS-2/3-like) declined from 29.6% to 3.4% during the study period (P < 0.001), as did the rates of hospital origin MRSA in two of the major hospitals in the region. CONCLUSIONS: The prevalence of MRSA in the HNELHD region decreased during the study period, and was predominantly acquired in the community, particularly by young people, Indigenous Australians, and residents of aged care facilities. While the dominance of the multi-resistant strain decreased, new strategies for controlling infections in the community are needed to reduce the prevalence of non-multi-resistant strains.

Understanding human - bat interactions in NSW, Australia: improving risk communication for prevention of Australian bat lyssavirus.

BACKGROUND: Australian bat lyssavirus (ABLV) infects a number of flying fox and insectivorous bats species in Australia. Human infection with ABLV is inevitably fatal unless prior vaccination and/or post-exposure treatment (PET) is given. Despite ongoing public health messaging about the risks associated with bat contact, surveillance data have revealed a four-fold increase in the number of people receiving PET for bat exposure in NSW between 2007 and 2011. Our study aimed to better understand these human - bat interactions in order to identify additional risk communication messages that could lower the risk of potential ABLV exposure. All people aged 18 years or over whom received PET for non-occupation related potential ABLV exposure in the Hunter New England Local Health District of Australia between July 2011 and July 2013 were considered eligible for the study. Eligible participants were invited to a telephone interview to explore the circumstances of their bat contact. Interviews were then transcribed and thematically analysed by two independent investigators. RESULTS: Of 21 eligible participants that were able to be contacted, 16 consented and participated in a telephone interview. Participants reported bats as being widespread in their environment but reported a general lack of awareness about ABLV, particularly the risk of disease from bat scratches. Participants who attempted to 'rescue' bats did so because of a deep concern for the bat's welfare. Participants reported a change in risk perception after the exposure event and provided suggestions for public health messages that could be used to raise awareness about ABLV. CONCLUSIONS: Reframing the current risk messages to account for the genuine concern of people for bat welfare may enhance the communication. The potential risk to the person and possible harm to the bat from an attempted 'rescue' should be promoted, along with contact details for animal rescue groups. The potential risk of ABLV from bat scratches merits greater emphasis.

Diagnosis and management of zoonoses - a tool for general practice.

BACKGROUND: Zoonotic infections such as Q fever, brucellosis and leptospirosis can lead to serious complications but pose diagnostic and management challenges to general practitioners (GPs) as patients often present with non-specific symptoms such as fever. OBJECTIVE: To develop a tool to assist GPs in the diagnosis and management of common zoonotic infections DISCUSSION: An algorithm was developed with advice and comments from GPs, laboratory specialists and infectious disease specialists. Emphasis is placed on understanding patient risk factors, such as non-household contact with animals, excluding other possible causes of fever, such as influenza, and commencing empirical treatment as soon as a zoonotic infection is suspected. The algorithm is not exhaustive and GPs are urged to consult infectious disease specialists and medical microbiologists for further guidance if required.

Cross sectional survey of human-bat interaction in Australia: public health implications.

BACKGROUND: Flying foxes (megachiroptera) and insectivorous microbats (microchiroptera) are the known reservoirs for a range of recently emerged, highly pathogenic viruses. In Australia there is public health concern relating to bats' role as reservoirs of Australian Bat Lyssavirus (ABLV), which has clinical features identical to classical rabies. Three deaths from ABLV have occurred in Australia. A survey was conducted to determine the frequency of bat exposures amongst adults in Australia's most populous state, New South Wales; explore reasons for handling bats; examine reported practices upon encountering injured or trapped bats or experiencing bat bites or scratches; and investigate knowledge of bat handling warnings. METHODS: A representative sample of 821 New South Wales adults aged 16 years and older were interviewed during May and June 2011, using a computer assisted telephone interview (CATI) method. Frequencies, proportions and statistical differences in proportion were performed. Using an α-value of 0.05 and power of 80%, it was calculated that a sample size of 800 was required to provide statistical significance of +/- 5% for dichotomous variables. RESULTS: One-hundred-and-twenty-seven (15.5%) respondents indicated that they had previously handled a bat, being 22% (48/218) rural and 13% (78/597) urban respondents (χ2 = 9.8, p = 0.0018). Twenty one percent of males (63/304) had handled bats compared with 12% (64/517) of females (χ2 = 10.2, p = 0.0014). Overall, 42.0% (n = 345) of respondents reported having seen or heard a warning about handling bats. If faced with an injured or trapped bat, 25% (206/821) indicated that they would handle the bat, with 17% (36/206) saying that they would use their bare hands. For minor scratches, 14% (117/821) indicated that they would ignore the injury while four respondents would ignore major scratches or bites. CONCLUSIONS: Previous human-bat interactions were relatively common. Bat exposures most frequently occurred with sick or injured bats, which have the highest risk of ABLV. On encountering an injured or sick bat, potentially high risk practices were commonly reported, particularly among rural males. It is important to understand why people still handle bats despite public health warnings to inform future communication strategies.

Epidemiology of enteroviral meningoencephalitis in neonates and young infants.

AIM: To describe the epidemiology of enteroviral meningoencephalitis in northern New South Wales, Australia, with a specific focus on neonatal and young infant cases. METHODS: A retrospective review of PCR-confirmed enteroviral meningoencephalitis cases in the Hunter New England Local Health District of northern NSW was conducted for the period 2008-2012. RESULTS: One hundred nine patients met the case definition. There was summer seasonality, with 50% (55/109) of cases occurring between December and February. Neonates and young infants (<3 months of age) accounted for 42% (46/109) of cases, with 20% (9/46) being premature births. Fever (83%) was the most common presentation in this age group, followed by irritability (40%), feeding difficulties (40%) and rash (17%). All received at least one antibiotic during their admission, with 26% (12/46) also treated empirically with acyclovir. There was one death. Where testing was undertaken, cerebrospinal fluid (CSF) protein levels were high in 90% (28/31) of neonates and young infants, but the CSF white cell count was variable, with 57% <10/mm(3) and 21% >100/mm(3) . CONCLUSION: Early diagnosis of enteroviral meningoencephalitis could alter management, potentially reducing the period of treatment with empirical antimicrobials and permitting earlier discharge.

Evidence of Cryptosporidium transmission between cattle and humans in northern New South Wales.

Cryptosporidium is an enteric parasite of public health significance that causes diarrhoeal illness through faecal oral contamination and via water. Zoonotic transmission is difficult to determine as most species of Cryptosporidium are morphologically identical and can only be differentiated by molecular means. Transmission dynamics of Cryptosporidium in rural populations were investigated through the collection of 196 faecal samples from diarrheic (scouring) calves on 20 farms and 63 faecal samples from humans on 14 of these farms. The overall prevalence of Cryptosporidium in cattle and humans by PCR and sequence analysis of the 18S rRNA was 73.5% (144/196) and 23.8% (15/63), respectively. Three species were identified in cattle; Cryptosporidium parvum, Cryptosporidium bovis and Cryptosporidium ryanae, and from humans, C. parvum and C. bovis. This is only the second report of C. bovis in humans. Subtype analysis at the gp60 locus identified C. parvum subtype IIaA18G3R1 as the most common subtype in calves. Of the seven human C. parvum isolates successfully subtyped, five were IIaA18G3R1, one was IIdA18G2 and one isolate had a mix of IIaA18G3R1 and IIdA19G2. These findings suggest that zoonotic transmission may have occurred but more studies involving extensive sampling of both calves and farm workers are needed for a better understanding of the sources of Cryptosporidium infections in humans from rural areas of Australia.

Surveillance should be strengthened to improve epidemiological understandings of mosquito-borne Barmah Forest virus infection.

INTRODUCTION: Barmah Forest virus (BFV) is a mosquito-borne virus causing epidemic polyarthritis in Australia. This study used case follow-up of cases from the surveillance system to demonstrate that routinely collected BFV notification data were an unreliable indicator of the true location of exposure. METHODS: BFV notifications from June 2001 to May 2011 were extracted from the New South Wales (NSW) Notifiable Conditions Information Management System to study case distribution. Disease cluster analysis was performed using spatial scan statistics. Exposure history data were collected from cases notified in 2010 and 2011 to accurately determine travel to high-risk areas. RESULTS: Cluster analysis using address data identified an area of increased BFV disease incidence in the mid-north coast of NSW contiguous with estuarine wetlands. When travel to this area was investigated, 96.7% (29/30) cases reported having visited coastal regions within four weeks of developing symptoms. DISCUSSION: Along the central NSW coastline, extensive wetlands occur in close proximity to populated areas. These wetlands provide ideal breeding habitats for a range of mosquito species implicated in the transmission of BFV. This is the first study to fully assess case exposure with findings suggesting that sporadic cases of BFV in people living further away from the coast do not reflect alternative exposure sites but are likely to result from travel to coastal regions. Spatial analysis by case address alone may lead to inaccurate understandings of the true distribution of arboviral diseases. Subsequently, this information has important implications for the collection of mosquito-borne disease surveillance information and public health response strategies.

Surveillance should be strengthened to improve epidemiological understandings of mosquito-borne Barmah Forest virus infection

Introduction:Barmah Forest virus (BFV) is a mosquito-borne virus causing epidemic polyarthritis in Australia. This study used case follow-up of cases from the surveillance system to demonstrate that routinely collected BFV notification data were an unreliable indicator of the true location of exposure.Methods:BFV notifications from June 2001 to May 2011 were extracted from the New South Wales (NSW) Notifiable Conditions Information Management System to study case distribution. Disease cluster analysis was performed using spatial scan statistics. Exposure history data were collected from cases notified in 2010 and 2011 to accurately determine travel to high-risk areas.Results:Cluster analysis using address data identified an area of increased BFV disease incidence in the mid-north coast of NSW contiguous with estuarine wetlands. When travel to this area was investigated, 96.7% (29/30) cases reported having visited coastal regions within four weeks of developing symptoms.Discussion:Along the central NSW coastline, extensive wetlands occur in close proximity to populated areas. These wetlands provide ideal breeding habitats for a range of mosquito species implicated in the transmission of BFV. This is the first study to fully assess case exposure with findings suggesting that sporadic cases of BFV in people living further away from the coast do not reflect alternative exposure sites but are likely to result from travel to coastal regions. Spatial analysis by case address alone may lead to inaccurate understandings of the true distribution of arboviral diseases. Subsequently, this information has important implications for the collection of mosquito-borne disease surveillance information and public health response strategies.

Responses to pandemic (H1N1) 2009, Australia.

In 2007, adults in Australia were interviewed about their willingness to comply with potential health interventions during a hypothetical influenza outbreak. After the first wave of pandemic (H1N1) 2009 in Australia, many of the same respondents were interviewed about behavior and protection measures they actually adopted. Of the original 1,155 respondents, follow-up interviews were conducted for 830 (71.9%). Overall, 20.4% of respondents in 2009 had recently experienced influenza-like illness, 77.7% perceived pandemic (H1N1) 2009 to be mild, and 77.8% reported low anxiety. Only 14.5% could correctly answer 4 questions about influenza virus transmission, symptoms, and infection control. Some reported increasing handwashing (46.6%) and covering coughs and sneezes (27.8%) to reduce transmission. Compared with intentions reported in 2007, stated compliance with quarantine or isolation measures in 2009 remained high. However, only respondents who perceived pandemic (H1N1) 2009 as serious or who had attained higher educational levels expressed intention to comply with social distancing measures.

Acceptance of pandemic (H1N1) 2009 influenza vaccination by the Australian public.

OBJECTIVE: To investigate the Australian public's expectations, concerns and willingness to accept vaccination with the pandemic (H1N1) 2009 influenza vaccine. DESIGN, SETTING AND PARTICIPANTS: A computer-assisted telephone interview survey was conducted between 20 August and 11 September 2009 by trained professional interviewers to study issues relating to vaccine uptake and perceived safety. The sample comprised 1155 randomly selected representative adults who had participated in a 2007 national study exploring knowledge and perceptions of pandemic influenza. MAIN OUTCOME MEASURES: Likely acceptance of pandemic (H1N1) 2009 vaccination, factors associated with acceptance, and respondents' willingness to share Australian vaccine with neighbouring developing countries. RESULTS: Of 1155 possible participants, 830 (72%) were successfully interviewed. Twenty per cent of the study group (169/830) reported that they had developed influenza-like symptoms during the 2009 pandemic period. Most respondents (645/830, 78%) considered pandemic (H1N1) 2009 to be a mild disease, and 211/830 (25%) regarded themselves as being at increased risk of infection. Willingness to accept pandemic (H1N1) 2009 vaccination was high (556/830, 67%) but was significantly lower than when pandemic vaccination uptake was investigated in 2007 (88%; P < 0.0001). Respondents who had already been vaccinated against seasonal influenza and those who perceived pandemic (H1N1) 2009 to be severe were significantly more willing to accept vaccination. Most respondents (793/822, 96%) were willing to share surplus vaccine with developing countries in our region. CONCLUSION: Although two-thirds of Australian adults surveyed were willing to accept pandemic (H1N1) 2009 vaccination, and most supported sharing vaccine with developing countries, there is a need for accessible information on vaccine safety for those who are undecided about vaccination.

Field exercises are useful for improving public health emergency responses.

PROBLEM: Emergencies resulting from disease outbreaks and extreme environmental events present significant challenges for health services. CONTEXT: Preparing to effectively manage emergencies is a core activity in public health units. Field exercises support consolidation of biopreparedness by testing plans, identifying weaknesses, providing training opportunities and developing surge capacity. ACTION: An extended field exercise to test response to a novel influenza strain was conducted in New South Wales, Australia in September 2008, eight months before the influenza A(H1N1) 2009 pandemic emerged. Lasting four days and involving over 300 participants, the exercise was set in the early response phase with the staggered presentation of 41 cases to 36 emergency departments in the health area. An additional 150 contacts were written into a complex scenario to test the public health response. OUTCOME: The subsequent pandemic emergence in mid-2009 offered a unique opportunity to assess the field exercise format for disaster preparedness. Most roles were adequately tested with recognized benefit during the actual pandemic response. However, the exercise did not adequately challenge the public health planning team that synthesizes surveillance data and forecasts risk, nor did it identify planning issues that became evident during the subsequent pandemic. DISCUSSION: Field exercises offer the opportunity to rigorously test public health emergency preparedness but can be expensive and labour-intensive. Our exercise provided effective and timely preparation for the influenza A(H1N1) 2009 pandemic but showed that more emphasis needs to be placed on the role and training of the public health planning team.