Otitis media at 6-monthly assessments of Australian First Nations children between ages 12-36 months: Findings from two randomised controlled trials of combined pneumococcal conjugate vaccines.

OBJECTIVES: In remote communities of northern Australia, First Nations children with hearing loss are disproportionately at risk of poor school readiness and performance compared to their peers with no hearing loss. The aim of this trial is to prevent early childhood persisting otitis media (OM), associated hearing loss and developmental delay. To achieve this, we designed a mixed pneumococcal conjugate vaccine (PCV) schedule that could maximise immunogenicity and thereby prevent bacterial otitis media (OM) and a trajectory of educational and social disadvantage. METHODS: In two sequential parallel, open-label, randomised controlled trials, eligible infants were first allocated 1:1:1 to standard or mixed PCV primary schedules at age 28-38 days, then at age 12 months to a booster dose (1:1) of 13-valent PCV, PCV13 (Prevenar13®, +P), or 10-valent pneumococcal non-typeable Haemophilus influenzae protein D conjugated vaccine, PHiD-CV10 (Synflorix®, +S). Here we report findings of standardised ear assessments conducted six-monthly from age 12-36 months, by booster dose. RESULTS: From March 2013 to September 2018, 261 children were allocated to booster + P (n = 131) or + S (n = 130). There were no significant differences in prevalence of any OM diagnosis by booster dose or when stratified by primary schedule. We found high, almost identical prevalence of OM in both boost groups at each age (for example 88% of 129 and 91% of 128 children seen, respectively, at primary endpoint age 18 months, difference -3% [95% Confidence Interval -11, 5]). At each age prevalence of bilateral OM was 52%-78%, and tympanic membrane perforation was 10%-18%. CONCLUSION: Despite optimal pneumococcal immunisation, the high prevalence of OM persists throughout early childhood. Novel approaches to OM prevention are needed, along with improved early identification strategies and evaluation of expanded valency PCVs.

Hospitalized community-acquired pneumonia in the elderly: an Australian case-cohort study.

This study describes the epidemiology of community-acquired pneumonia (CAP) in elderly Australians for the first time. Using a case-cohort design, cases with CAP were in-patients aged > or = 65 years with ICD-10-AM codes J10-J18 admitted over 2 years to two tertiary hospitals. The cohort sample was randomly selected from all hospital discharges, frequency-matched to cases by month. Logistic regression was used to estimate risk ratios for factors predicting CAP or associated mortality. A total of 4772 in-patients were studied. There were 1952 cases with CAP that represented 4% of all elderly admissions: mean length of stay was 9.0 days and 30-day mortality was 18%. Excluding chest radiograph, 520/1864 (28%) cases had no investigations performed. The strongest predictors of CAP were previous pneumonia, history of other respiratory disease, and aspiration. Intensive-care-unit admission, renal disease and increasing age were the strongest predictors of mortality, while influenza vaccination conferred protection. Hospitalization with CAP in the elderly is common, frequently fatal and a considerable burden to the Australian community. Investigation is ad hoc and management empirical. Influenza vaccination is associated with reduced mortality. Patient characteristics can predict risk of CAP and subsequent mortality.

ICD-10 codes are a valid tool for identification of pneumonia in hospitalized patients aged > or = 65 years.

This study examines the validity of using ICD-10 codes to identify hospitalized pneumonia cases. Using a case-cohort design, subjects were randomly selected from monthly cohorts of patients aged > or = 65 years discharged from April 2000 to March 2002 from two large tertiary Australian hospitals. Cases had ICD-10-AM codes J10-J18 (pneumonia); the cohort sample was randomly selected from all discharges, frequency matched to cases by month. Codes were validated against three comparators: medical record notation of pneumonia, chest radiograph (CXR) report and both. Notation of pneumonia was determined for 5098/5101 eligible patients, and CXR reports reviewed for 3349/3464 (97%) patients with a CXR. Coding performed best against notation of pneumonia: kappa 0.95, sensitivity 97.8% (95% CI 97.1-98.3), specificity 96.9% (95% CI 96.2-97.5), positive predictive value (PPV) 96.2% (95% CI 95.4-97.0) and negative predictive value (NPV) 98.2% (95% CI 97.6-98.6). When medical record notation of pneumonia is used as the standard, ICD-10 codes are a valid method for retrospective ascertainment of hospitalized pneumonia cases and appear superior to use of complexes of symptoms and signs, or radiology reports.

Missed opportunities for a diagnosis of acute otitis media in Aboriginal children.

OBJECTIVE: Severe otitis media and its sequelae are common in rural and remote Aboriginal children. Identification of acute otitis media (AOM) is likely to reduce the number of children who go on to develop chronic suppurative otitis media and associated complications. The aim of this study was to compare the diagnoses made by researchers with that documented in the medical records of children admitted to the paediatric isolation ward of the Royal Darwin Hospital, Darwin, Northern Territory. METHODS: Children aged <8 years admitted to Royal Darwin Hospital were eligible for assessment by pneumatic otoscopy, video-otoscopy and tympanometry. A diagnosis was made for each child according to the state of their worst ear. Comparisons were made between the researcher diagnoses of ear disease and those documented in the hospital notes by medical staff. RESULTS: Thirty-one children were enrolled during 32 admissions. Most were aged <2 years, Aboriginal, and resided in remote communities. Sixty-one video-otoscopic assessments were attempted and sufficiently good images to allow diagnosis were obtained in 105 of 122 ears. Acute otitis media was diagnosed by the research team in 20 of 32 child admissions. Of 29 children who had ear examinations documented by hospital staff, only seven had a diagnosis of AOM recorded. Overall, the research team were almost three times more likely to make this diagnosis (relative risk 2.9, 95% confidence interval 1.6, 5.2). This difference was unlikely to have occurred by chance (P = 0.0002, McNemar's Chi-squared test). CONCLUSIONS: In this small study, young Aboriginal children with clear bulging of their tympanic membrane were not diagnosed with AOM by medical staff. Further training in diagnosis, including cleaning of the ear canal, may lead to more accurate assessment and appropriate recommendations for ongoing management.

Screening for intestinal parasites in recently arrived children from East Africa.

BACKGROUND: Intestinal parasitic carriage is common in East African populations with a wide spectrum of clinical severity. There are scant data on the rates of carriage in East African immigrants to Australia. This study describes the prevalence of and risk factors for intestinal parasite carriage among children recently arrived from East African countries. METHODS: Children aged 0-17 years, who attended an outpatient clinic, were born in East Africa and had immigrated since 1998 were eligible to participate. A single preserved stool specimen was collected for faecal microscopy, and blood tests were conducted for Strongyloides and Schistosoma serology, full blood examination and serum ferritin. RESULTS: One hundred and thirty-five children (median age 8.1 years, range 1.0-17.5) participated, of whom 133 (99%) provided a stool specimen. Parasites were detected in 50% of samples, and 18% of children carried a possibly pathogenic species. No child was symptomatic at diagnosis. Positive or equivocal serology occurred in 11% of children for Strongyloides and 2% for Schistosoma. Anaemia and iron deficiency were detected in 16% of all children. Those carrying an intestinal parasite were older (mean age 9.8 vs 7.4 years, P= 0.002) and less likely to be anaemic (odds ratio 0.37, 95% confidence interval 0.14-0.96) than those who were not carriers. CONCLUSIONS: Carriage of intestinal parasites is common among children from East Africa. Those carrying pathogenic organisms require treatment and follow up to ensure eradication. The results of this survey support the need for routine assessment of newly arrived immigrants from East Africa for intestinal parasites, anaemia and iron deficiency.

Re-visioning refugee health: the Victorian Immigrant Health Programme.

Few published data are available to support the development and management of health services for refugees in developed countries, despite evidence that refugees are at high risk of suffering a wide range of both physical and mental health problems. Meeting the health needs of increasing numbers of refugees worldwide in culturally acceptable and financially feasible ways is a key challenge to our healthcare systems. This paper reports on seven platforms identified in the development of the Victorian Immigrant Health Programme (VIHP) that the VIHP believes should underpin the management and delivery of healthcare to newly arrived refugees. Sharing this information facilitates and promotes essential collaborative work in the field of refugee health, and assists to prevent duplicate efforts, given constraints on resources for refugee healthcare provision in Australia and elsewhere.

Vitamin D deficiency is common and unrecognized among recently arrived adult immigrants from The Horn of Africa.

The prevalence of and risk factors for vitamin D deficiency were examined for recent adult immigrants from East Africa living in Melbourne. Demographic data were collected via a face-to-face questionnaire and risk factors predicting deficiency were examined. Suboptimal levels <25 nmol/L were found in 61 patients (53%; 74% of women; 20% of men). Lower levels were more likely in: (i) patients with a longer duration of residence in Australia, (ii) patients who were mostly covered when outdoors and (iii) women. Routine assessment for vitamin D deficiency should be considered for male and female immigrants from East Africa.

Poor health care worker vaccination coverage and knowledge of vaccination recommendations in a tertiary Australia hospital.

OBJECTIVES: Guidelines for vaccination of health care workers (HCWs) have been available in Victoria since 1998. We estimated knowledge and attitudes towards vaccination among HCWs as well as self-reported vaccination status in a tertiary adult hospital in Melbourne, Australia. METHODS: A cross-sectional survey was conducted in July 2000 using a telephone questionnaire and proportionate random sampling. RESULTS: Only 18% of 269 HCWs were fully vaccinated. Most (76%) had not heard of or seen current guidelines for HCW vaccination despite a stated belief in the importance of full vaccination (94%) and a willingness to update their vaccination status if necessary (96%). Less than half kept vaccination records (39%). Hepatitis B vaccination (95%) was most commonly completed. However, only half of all HCWs had received influenza vaccination in the past 12 months and other vaccines often had suboptimal coverage. A common reason cited for avoiding vaccination was concern over vaccine side effects (17%). While the hospital staff clinic was an acceptable site for vaccination, improved access was seen as important. CONCLUSIONS: HCW vaccination coverage and knowledge of vaccination requirements were poor. Concerns about vaccine side effects were common. IMPLICATIONS: Adequately resourced HCW vaccination programs that include ongoing education for HCWs and improved access to vaccination are necessary to improve vaccination coverage and reduce the risk of vaccine-preventable diseases among staff and patients.

Evaluation of health-care worker vaccination in a tertiary Australian hospital.

BACKGROUND: Maintaining a complete vaccination status for health-care workers (HCWs) is important to minimize morbidity among staff and patients. Despite recommendations from public-health authorities to support this process, not all hospitals have adequate policy and practice in place. AIMS: To independently assess the implementation and impact of a new policy aimed at improving HCW vaccination coverage in a tertiary Victorian hospital. METHODS: Two cross-sectional surveys were conducted by telephone in July and October 2000 for a random sample of HCWs, before and after the introduction of the policy. These surveys examined knowledge, attitudes and practices surrounding vaccination and self-reported vaccination status. Policy implementation was assessed by ascertaining completion of compulsory vaccination status forms and attendance at suggested appointments to review vaccination status. RESULTS: Only 19% of 269 HCWs reported a complete vaccination status at baseline. Most (76%) had not heard of or seen vaccination guidelines and 39% kept written vaccination records. This was despite a belief in the importance of vaccination (94%) and a willingness to update if necessary (96%). At follow up there was no improvement in any outcome. Only 11/26 (42%) newly employed HCWs surveyed received and returned compulsory vaccination status forms. Of the few HCWs who attended recommended vaccination appointments, all received vaccinations. CONCLUSIONS: HCW vaccination coverage and knowledge of vaccination requirements were poor. Although attending a physician to discuss vaccination status did result in vaccination, few HCWs made such an appointment. While policy development is an important first step towards improving vaccination coverage, effective implementation requires ongoing evaluation, adequate resources and HCW education.

Should programmes for community-level meningococcal vaccination be considered in Australia? An economic evaluation.

BACKGROUND: Disease due to serogroup C Neisseria meningitidis is life-threatening and potentially preventable by vaccination. In 1999, the UK instigated mass vaccination after a sustained increase in serogroup C meningococcal disease. In the same year, Victoria, Australia experienced a similar change in disease epidemiology. It is timely to undertake an economic evaluation of options for community vaccination in Australia based on local data. METHODS: Cost-effectiveness and cost-benefit analyses of three options for use of polysaccharide vaccine were undertaken for a hypothetical population aged 15--19 years. Baseline analyses assumed 5 years' duration of vaccine protection following a single year of programme implementation. Sensitivity analyses of key variables were performed, including vaccine coverage and effectiveness, case fatality rate and the discount rate. Outcomes included the number of people vaccinated, cases averted, life-years saved and disability-adjusted life-years (DALY) averted. Cost-benefit analysis used lost earnings avoided as a measure of vaccination benefit. RESULTS: Vaccination of people aged 15--19 years in a defined population with a high rate of disease was the most cost-effective option. Compared with no vaccination and assuming 5 years' duration of protection and exclusion of direct cost savings, this resulted in a discounted cost per life-year saved of $23,623, a cost per DALY avoided of $21,097 and benefits exceeding costs in discounted terms. The 'break-even' incidence rate for this option with exclusion of direct cost savings was 14.0/100,000. CONCLUSIONS: Community use of polysaccharide vaccination may be cost effective in Australia under certain conditions. Economic evidence favours use of vaccination in well-defined populations with a high rate of disease. Policy decision-making also requires consideration of non-economic factors, including feasibility of implementation and risk perception by the community.

An evidence-based review of current guidelines for the public health control of typhoid in Australia: a case for simplification and resource savings.

BACKGROUND: Although an uncommon disease in Australia, public health control measures for typhoid remain important to prevent further cases, however, they are labour intensive. METHODS: We reviewed current guidelines from all Australian states and territories, England and the United States to ascertain whether recommended control measures for typhoid are supported by evidence from the medical literature or data from Victorian typhoid notifications. RESULTS: Guidelines lacked consistency and were overly complex, particularly with reference to the frequency and timing of faecal specimens required to demonstrate eradication of typhoid from cases and contacts. Data from the medical literature are limited and do not support the superiority of any one approach, or multiple approaches based on risk groups of cases or contacts. Victorian data suggest that a general approach, with a reduction in the number of specimens collected and duration of follow-up is reasonable. CONCLUSIONS: Potential exists for simplification and improved consistency between guidelines for the public health control of typhoid, with associated resource savings.

Meningococcal vaccination for adolescents? An economic evaluation in Victoria.

OBJECTIVE: To undertake an economic evaluation of the options for vaccination of adolescents using meningococcal polysaccharide vaccine based on Victorian data. METHODOLOGY: Cost-effectiveness and cost-benefit analyses of three options for vaccination were undertaken for hypothetical populations aged 15-19 years. Baseline analyses assumed a single year of programme implementation and vaccine protection of 5 years. Sensitivity analyses of key variables were performed. Outcomes included the number of people vaccinated, cases averted, life years saved and disability adjusted life years (DALY) averted. Lost earnings avoided were included as a measure of vaccination benefit in cost-benefit analyses. RESULTS: Vaccination of people in Years 10-12 (secondary school) and first year university within a defined population with a high rate of disease was the most cost-effective option. Excluding direct cost savings and compared with no vaccination, this resulted in a discounted cost per DALY avoided of $17646 and benefits exceeding costs in discounted terms. The 'break-even' incidence rate for this option in the cost-benefit analysis was 11.9/100000. CONCLUSIONS: Economic evidence favours the use of vaccination within well-defined populations with a high rate of disease.

Child care center staff contribute to physician visits and pressure for antibiotic prescription.

OBJECTIVE: To determine whether child care center (CCC) providers contribute to unnecessary physician referrals and antibiotic prescriptions in young children with upper respiratory tract infections. DESIGN: A survey using a structured telephone questionnaire between May 3, 1998, and July 27, 1998. PARTICIPANTS: Child care center providers from randomly selected licensed Ontario CCCs accepting diapered children. MAIN OUTCOME MEASURES: Knowledge, attitudes, and practices concerning physician referral; exclusion; and antibiotic use for children with upper respiratory tract infections. Indications for exclusion were compared with published Canadian guidelines. RESULTS: Contact was made with 42 eligible CCCs to obtain the requisite number of 36 participants (participation rate, 86%). Of the 36 centers, staff reported advising that children visit a physician for colored nasal discharge in 28 (78%), for productive cough in 23 (64%), and for unusual behavior in 9 (25%). Also of the 36 centers, staff reported excluding children for colored nasal discharge in 20 (56%), for productive cough in 16 (44%), and for unusual behavior in 15 (42%). Antibiotics were thought useful for nonspecific upper respiratory tract infections to prevent the spread of infection in 9 (26%), to speed up recovery in 7 (21%), and to prevent bacterial infection in 13 (38%) of 34 centers. In the previous 6 months, 25 (69%) of 36 staff members reported making an exception to exclusion because a child had an antibiotic prescription. CONCLUSIONS: Many children are referred by CCC staff to physicians contrary to established guidelines. As staff must act on behalf of parents, a low threshold for referral is not unreasonable. However, this survey confirms that CCC staff recommend children to receive antibiotics and exclude children inappropriately. These practices are based on incomplete knowledge. Research on appropriate management of upper respiratory tract infections by CCC staff is needed. Education to correct specific knowledge deficits should be initiated.

Middle ear effusion: rate and risk factors in Australian children attending day care.

There have been no previous longitudinal studies of otitis media conducted in non-Aboriginal Australian children. This paper describes the rate and risk factors for middle ear effusion (MEE) in children attending day care in Darwin, Australia. A prospective cohort study of 252 children under 4 years was conducted in 9 day care centres over 12 fortnights between 24 March and 15 September 1997. Tympanometry was conducted fortnightly and multivariate analysis used to determine risk factors predicting MEE. The outcome of interest was the rate of type B tympanograms per child detected in either ear at fortnightly examinations. After adjusting for clustering by child, MEE was detected on average 4.4 times in 12 fortnights (37% of all examinations conducted). Risk factors associated with presence of effusion were younger age, a family history of ear infection, previous grommets (tympanostomy tubes), ethnicity and the day care centre attended. A history of wheeze appeared protective. These effects were modest (RR 0.57-1.70). Middle ear effusion is very common in children attending day care in Darwin. This has clinical importance, since MEE during early childhood may affect optimal hearing, learning and speech development. There is little scope for modification for many of the risk factors for MEE predicted by this model. Further study of the day care environment is warranted.

A retrospective search for lyssavirus in humans in the Northern Territory.

BACKGROUND: Following the 1996 discovery of a rabies-like lyssavirus in Australian flying foxes, it was unclear whether this was a new epizootic or an unrecognised, previously existing disease. OBJECTIVE: To review cases of unexplained encephalitis in the Northern Territory (NT) to test available clinical specimens for lyssavirus and survey the use of diagnostic tests by clinicians. METHODS: The NT hospital morbidity database was searched from January 1992 to September 1996 for all Royal Darwin Hospital (RDH) cases with an ICD-9 code encompassing encephalitis or viral meningitis. Final diagnoses were determined by hospital record review. For cases of unexplained encephalitis, we assessed the use of diagnostic tests and located clinical specimens for testing for lyssavirus-specific inclusion bodies via immunohistochemistry, immunofluorescence and reverse-transcriptase polymerase chain reaction (RT-PCR). RESULTS: Encephalitis occurred in 34/154 (22%) cases located by the search; 53% (18/34) of encephalitis cases were unexplained. Of these, 24% had no serology performed and 47% had no blood cultures taken. Four (22%) died and two had autopsies. These were the only two cases with clinical specimens available for testing. They were negative for lyssavirus. None of the 71 cases coded as viral meningitis had unexplained encephalitis. CONCLUSION: There was a considerable proportion of unexplained illness among NT cases of encephalitis. IMPLICATIONS: Clinicians should test for lyssavirus in patients with encephalitic symptoms and a postmortem should be sought where death is unexplained. Specimens should be stored to enable testing for emerging infectious diseases.

Investigation of a cluster of Staphylococcus aureus invasive infection in the top end of the Northern Territory.

INTRODUCTION: Staphylococcus aureus invasive infection remains a serious condition associated with considerable morbidity and mortality. Following notification of five cases at Royal Darwin Hospital (RDH), we searched for related cases, determined their epidemiological characteristics and attempted to identify the source of this apparent cluster. METHODS: We reviewed RDH microbiology records between June 1996 and April 1997 for S. aureus isolates with similar antibiograms to notified cases. We used antibiotic resistance patterns, bacteriophage typing and two molecular typing techniques to subtype implicated isolates. Hospital records were reviewed for admission details and associated costs were estimated. RESULTS: Fifty-four cluster-related isolates occurred in 47 separate presentations. The peak incidence was in the wet season. The most important risk factor for staphylococcal invasive infection was the presence of skin sores/scabies in 17/54 cases (31%), followed by intravascular line use in 14/54 (26%), open trauma in 11/54 (20%), underlying end stage renal failure and alcoholism each in ten of 54 (18%). The mean admission length was 30 days and antibiotics were given for an average of 23 days. Death due to S. aureus infection occurred in eight of 47 (17%) presentations. S. aureus pneumonia was community acquired in 12/13 patients (92%) and six of 13 (46%) died. Ten of 13 (80%) pneumonia patients had at least one other focus of S. aureus infection. The cost of antibiotics and hospital bed per presentation was approximately $16,000. Presentations with skin sores/scabies cost considerably more ($31,000). No common epidemiologic features were found for community or hospital acquired cases. CONCLUSION: Considerable mortality and cost was attributable to cases of S. aureus invasive infection during this cluster; particularly those with community acquired pneumonia or skin sores/scabies. Staphylococcal antibiotic cover should be considered early for unwell patients presenting to hospital with pneumonia and other signs of potential S. aureus infection. It is appropriate to target public health efforts to prevent skin sores and to provide adequate treatment when they occur.