The impact of pneumococcal serotype replacement on the effectiveness of a national immunization program: a population-based active surveillance cohort study in New Zealand.

Background: In Aotearoa New Zealand (NZ) PCV7 was introduced in 2008, then PCV10 in 2011 and PCV13 in 2014. In 2017 PCV10 was re-introduced, replacing PCV13. In the present study, we investigate the resultant rapidly changing invasive pneumococcal disease (IPD) epidemiology. Methods: We compare the IPD incidence rate ratio (IRR) in NZ (2022 versus 2020) with other countries, and describe the IPD epidemiology (including trends in overall IPD and serotype 19A, and antimicrobial resistance) within NZ. Additionally, we performed a genomic-epidemiology investigation identifying the most common 19A sequence types and associated risk factors. Findings: Though IPD incidence rates have increased in the US and Australia (2021-22) after declines in 2020, in NZ the incidence rate is the highest since 2011 with a significantly higher IRR than US (p < 0.01). Incidence rates among children <2 and adults 65 or over in 2022 are the highest since 2009, driven by significant increases of serotype 19A (p = 0.01). Maori and Pacific peoples are experiencing the highest rates since 2009. Further, penicillin resistance among 19A isolates has increased from 39% (2012) to 84% (2021) (p = 0.02). Genomic sequencing identified the more virulent ST-2062 as most common among 19A isolates sequenced, increasing from 5% (2010) to 55% (2022). Interpretation: With very high incidence rates of IPD in NZ, inadequate protection against 19A, increasing resistance, and a more virulent 19A clade, targeted public health campaigns and increased PCV13 availability are needed. Funding: The NZ Ministry of Health funds IPD surveillance and typing in NZ.

An evaluation of the COVID-19 self-service digital contact tracing system in New Zealand.

BACKGROUND: Digital contact tracing (DCT) aims to improve time-to-isolation (timeliness) and find more potentially exposed individuals (sensitivity) to enhance the utility of contact tracing. The aim of this study was to evaluate the public uptake of a DCT self-service survey and its integration with the Bluetooth exposure notification system within the New Zealand Covid Tracer App (NZCTA). METHODS: We adopted a retrospective cohort study design using community COVID-19 cases from February 2022 to August 2022 in New Zealand (1.2 million cases). We examined the proportion of cases completing a self-service survey and the time to complete the survey by age, sex and ethnicity. RESULTS: Overall, 66 % of cases completed their self-service survey. Completion was influenced by age, sex and ethnicity. The median completion time was 1.8 h (IQR 0.2, 17.2), with 95 % of those completing this survey doing so within 48 h of case identification. Around 13 % of all survey completers also uploaded their Bluetooth data, which resulted in an average of 663 cases per day notifying 4.5 contacts per case. CONCLUSION: The combination of high public uptake and rapid response times suggest self-service DCT could be a useful tool for future outbreaks, particularly if implemented in conjunction with manual processes and other DCT tools (e.g. Bluetooth) to address issues related to performance (sensitivity, timeliness), effectiveness, and health equity.

Population and contact tracer uptake of New Zealand's QR-code-based digital contact tracing app for COVID-19.

This study aimed to understand the population and contact tracer uptake of the quick response (QR)-code-based function of the New Zealand COVID Tracer App (NZCTA) used for digital contact tracing (DCT). We used a retrospective cohort of all COVID-19 cases between August 2020 and February 2022. Cases of Asian and other ethnicities were 2.6 times (adjusted relative risk (aRR) 2.58, 99 per cent confidence interval (95% CI) 2.18, 3.05) and 1.8 times (aRR 1.81, 95% CI 1.58, 2.06) more likely than Maori cases to generate a token during the Delta period, and this persisted during the Omicron period. Contact tracing organization also influenced location token generation with cases handled by National Case Investigation Service (NCIS) staff being 2.03 (95% CI 1.79, 2.30) times more likely to generate a token than cases managed by clinical staff at local Public Health Units (PHUs). Public uptake and participation in the location-based system independent of contact tracer uptake were estimated at 45%. The positive predictive value (PPV) of the QR code system was estimated to be close to nil for detecting close contacts but close to 100% for detecting casual contacts. Our paper shows that the QR-code-based function of the NZCTA likely made a negligible impact on the COVID-19 response in New Zealand (NZ) in relation to isolating potential close contacts of cases but likely was effective at identifying and notifying casual contacts.

Impact of the COVID-19 related border restrictions on influenza and other common respiratory viral infections in New Zealand.

BACKGROUND: New Zealand's (NZ) complete absence of community transmission of influenza and respiratory syncytial virus (RSV) after May 2020, likely due to COVID-19 elimination measures, provided a rare opportunity to assess the impact of border restrictions on common respiratory viral infections over the ensuing 2 years. METHODS: We collected the data from multiple surveillance systems, including hospital-based severe acute respiratory infection surveillance, SHIVERS-II, -III and -IV community cohorts for acute respiratory infection (ARI) surveillance, HealthStat sentinel general practice (GP) based influenza-like illness surveillance and SHIVERS-V sentinel GP-based ARI surveillance, SHIVERS-V traveller ARI surveillance and laboratory-based surveillance. We described the data on influenza, RSV and other respiratory viral infections in NZ before, during and after various stages of the COVID related border restrictions. RESULTS: We observed that border closure to most people, and mandatory government-managed isolation and quarantine on arrival for those allowed to enter, appeared to be effective in keeping influenza and RSV infections out of the NZ community. Border restrictions did not affect community transmission of other respiratory viruses such as rhinovirus and parainfluenza virus type-1. Partial border relaxations through quarantine-free travel with Australia and other countries were quickly followed by importation of RSV in 2021 and influenza in 2022. CONCLUSION: Our findings inform future pandemic preparedness and strategies to model and manage the impact of influenza and other respiratory viral threats.

Healthcare outcomes assessed with observational study designs compared with those assessed in randomized trials: a meta-epidemiological study.

BACKGROUND: Researchers and decision-makers often use evidence from randomised controlled trials (RCTs) to determine the efficacy or effectiveness of a treatment or intervention. Studies with observational designs are often used to measure the effectiveness of an intervention in 'real world' scenarios. Numerous study designs and their modifications (including both randomised and observational designs) are used for comparative effectiveness research in an attempt to give an unbiased estimate of whether one treatment is more effective or safer than another for a particular population. An up-to-date systematic analysis is needed to identify differences in effect estimates from RCTs and observational studies. This updated review summarises the results of methodological reviews that compared the effect estimates of observational studies with RCTs from evidence syntheses that addressed the same health research question. OBJECTIVES: To assess and compare synthesised effect estimates by study type, contrasting RCTs with observational studies. To explore factors that might explain differences in synthesised effect estimates from RCTs versus observational studies (e.g. heterogeneity, type of observational study design, type of intervention, and use of propensity score adjustment). To identify gaps in the existing research comparing effect estimates across different study types. SEARCH METHODS: We searched MEDLINE, the Cochrane Database of Systematic Reviews, Web of Science databases, and Epistemonikos to May 2022. We checked references, conducted citation searches, and contacted review authors to identify additional reviews. SELECTION CRITERIA: We included systematic methodological reviews that compared quantitative effect estimates measuring the efficacy or effectiveness of interventions tested in RCTs versus in observational studies. The included reviews compared RCTs to observational studies (including retrospective and prospective cohort, case-control and cross-sectional designs). Reviews were not eligible if they compared RCTs with studies that had used some form of concurrent allocation. DATA COLLECTION AND ANALYSIS: Using results from observational studies as the reference group, we examined the relative summary effect estimates (risk ratios (RRs), odds ratios (ORs), hazard ratios (HRs), mean differences (MDs), and standardised mean differences (SMDs)) to evaluate whether there was a relatively larger or smaller effect in the ratio of odds ratios (ROR) or ratio of risk ratios (RRR), ratio of hazard ratios (RHR), and difference in (standardised) mean differences (D(S)MD). If an included review did not provide an estimate comparing results from RCTs with observational studies, we generated one by pooling the estimates for observational studies and RCTs, respectively. Across all reviews, we synthesised these ratios to produce a pooled ratio of ratios comparing effect estimates from RCTs with those from observational studies. In overviews of reviews, we estimated the ROR or RRR for each overview using observational studies as the reference category. We appraised the risk of bias in the included reviews (using nine criteria in total). To receive an overall low risk of bias rating, an included review needed: explicit criteria for study selection, a complete sample of studies, and to have controlled for study methodological differences and study heterogeneity. We assessed reviews/overviews not meeting these four criteria as having an overall high risk of bias. We assessed the certainty of the evidence, consisting of multiple evidence syntheses, with the GRADE approach. MAIN RESULTS: We included 39 systematic reviews and eight overviews of reviews, for a total of 47. Thirty-four of these contributed data to our primary analysis. Based on the available data, we found that the reviews/overviews included 2869 RCTs involving 3,882,115 participants, and 3924 observational studies with 19,499,970 participants. We rated 11 reviews/overviews as having an overall low risk of bias, and 36 as having an unclear or high risk of bias. Our main concerns with the included reviews/overviews were that some did not assess the quality of their included studies, and some failed to account appropriately for differences between study designs - for example, they conducted aggregate analyses of all observational studies rather than separate analyses of cohort and case-control studies. When pooling RORs and RRRs, the ratio of ratios indicated no difference or a very small difference between the effect estimates from RCTs versus from observational studies (ratio of ratios 1.08, 95% confidence interval (CI) 1.01 to 1.15). We rated the certainty of the evidence as low. Twenty-three of 34 reviews reported effect estimates of RCTs and observational studies that were on average in agreement. In a number of subgroup analyses, small differences in the effect estimates were detected: - pharmaceutical interventions only (ratio of ratios 1.12, 95% CI 1.04 to 1.21); - RCTs and observational studies with substantial or high heterogeneity; that is, I2 ≥ 50% (ratio of ratios 1.11, 95% CI 1.04 to 1.18); - no use (ratio of ratios 1.07, 95% CI 1.03 to 1.11) or unclear use (ratio of ratios 1.13, 95% CI 1.03 to 1.25) of propensity score adjustment in observational studies; and - observational studies without further specification of the study design (ratio of ratios 1.06, 95% CI 0.96 to 1.18). We detected no clear difference in other subgroup analyses. AUTHORS' CONCLUSIONS: We found no difference or a very small difference between effect estimates from RCTs and observational studies. These findings are largely consistent with findings from recently published research. Factors other than study design need to be considered when exploring reasons for a lack of agreement between results of RCTs and observational studies, such as differences in the population, intervention, comparator, and outcomes investigated in the respective studies. Our results underscore that it is important for review authors to consider not only study design, but the level of heterogeneity in meta-analyses of RCTs or observational studies. A better understanding is needed of how these factors might yield estimates reflective of true effectiveness.

Sexually Transmitted Infections and the Risk of Reinfection Within 12 Months: A Population-Based Cohort.

BACKGROUND: Chlamydia, gonorrhea, and syphilis are common sexually transmitted infections that disproportionately affect specific groups in New Zealand (NZ). Predictors of reinfection are not well studied in NZ but could inform public health strategies to decrease sexually transmitted infection (STI) incidence. METHODS: New Zealand-wide chlamydia, gonorrhea, and syphilis cases during 2019 were identified using nationally collected data. Cases were followed-up to identify reinfection with the same STI within 12 months of initial infections. Logistic regression models were used to identify predictors for each STI reinfection. RESULTS: Determinants identified for increased odds of chlamydia reinfection were age groups 16-19 and 20-24 years, females, Maori and Pacific peoples, cases in the Northern region, and cases with at least one test before the initial infection. Age 40 years and older was associated with lower odds of gonorrhea reinfection, as was being of Asian ethnicity, living in Midland or Southern regions, and reporting heterosexual behavior. Region was the only statistically significant predictor for syphilis reinfection, with higher odds of reinfection for people living in the Central region. CONCLUSIONS: Our findings reflect disproportionate STI rates for some groups in NZ, with younger age groups, Maori and Pacific peoples, men who have sex with men, and people living in the Northern region experiencing higher odds of reinfection. Groups identified with higher odds for reinfection require increased access to culturally responsive health services to treat, understand, and prevent possible reinfection. Changes to current public health strategies could include culturally specific behavioral counseling, and improvements to and adherence to effective contract tracing.

Comparison of the epidemiology of invasive pneumococcal disease between Australia and New Zealand in 2017-2021: an observational study based on surveillance data.

Background: The Australian immunisation schedule uses 13-valent pneumococcal conjugate vaccine (PCV13), while New Zealand (NZ) changed from PCV13 to 10-valent PCV (PCV10) in 2017. In NZ, cases of serotype 19A (not in PCV10) have been increasing since 2017. We compared invasive pneumococcal disease (IPD) epidemiology between Australia and NZ in 2017-2021. Methods: We collated IPD notification data from national surveillance systems. Between Australia and NZ, we compared IPD incidence rates and assessed the proportion of serotype 19A, and stratified for ethnicity and age. Findings: Between 2017 and 2021, the crude IPD incidence per 100,000 in Australia ranged from 4.3 to 8.4, and ranged from 6.9 to 11.4 in NZ. The highest age-adjusted IPD rates were observed in Australian Indigenous people (range: 27.3-35.5) followed by NZ Maori/Pacific peoples (range 19.7-30.4). For children <2 years, ethnicity-adjusted IPD rates were similar between Australia and NZ in 2017-2020. In 2021, however, the ethnicity-adjusted incidence in children <2 years was higher in NZ (30.2; 95% CI 21.1-39.4) than in Australia (23.3 95% CI: 19.5-27.1) (p < 0.01). In Australia, the proportion of serotype 19A remained 5%, whereas in NZ serotype 19A increased from 11.5% to 29.5% with the largest increase in children <2 years and 2-4 years. Interpretation: Despite higher risks in Indigenous populations in Australia compared to all other groups, the overall IPD rate in NZ is increasing, particularly among children. The numbers and proportions of IPD due to serotype 19A are increasing in NZ especially in children. These data support the NZ decision from December 2022 to change to PCV13. Funding: This research received no specific funding.

Network Analysis for Formative Evaluation of Collaborative, Team Science Research Partnerships.

Cancer health disparities persist across the cancer care continuum despite decades of effort to eliminate them. Among the strategies currently used to address these disparities are multi-institution research initiatives that engage multiple stakeholders and change efforts. Endemic to the theory of change of such programs is the idea that collaboration-across institutions, research disciplines, and academic ranks-is necessary to improve outcomes. Despite this emphasis on collaboration, however, it is not often a focus of evaluation for these programs and others like them. In this paper we describe a method for evaluating collaboration within the Meharry-Vanderbilt-Tennessee State University Cancer Partnership using network analysis. Specifically, we used network analysis of co-authorship on academic publications to visualize the growth and patterns of scientific collaboration across partnership institutions, research disciplines, and academic ranks over time. We presented the results of the network analysis to internal and external advisory groups, creating the opportunity to discuss partnership collaboration, celebrate successes, and identify opportunities for improvement. We propose that basic network analysis of existing data along with network visualizations can foster conversation and feedback and are simple and effective ways to evaluate collaboration initiatives.

Gaps in measles immunisation coverage for pre-school children in Aotearoa New Zealand: a cross-sectional study.

AIMS: To evaluate gaps in measles immunisation coverage for children <5 years in Aotearoa New Zealand. METHODS: In this cross-sectional study, we extracted coverage rates for the first measles, mumps and rubella (MMR1) vaccine and second MMR vaccine (MMR2) from the National Immunisation Register for birth cohorts 2017 to 2020. We described measles coverage rates per birth cohort, and stratified per district health board (DHB), ethnicity and deprivation quintile. RESULTS: Coverage for MMR1 declined from 95.1% for those born in 2017 to 88.9% for those born in 2020. The coverage for MMR2 was below 90% for all the birth cohorts, with the lowest MMR2 coverage in the birth cohort of 2018 (61.6%). MMR1 coverage was lowest for children of Maori ethnicity and coverage declined over time: 92.8% for those born in 2017 to 78.4% for those born in 2020. Six DHBs had average MMR1 coverage <90% including Bay of Plenty, Lakes, Northland, Tairawhiti, West Coast and Whanganui. CONCLUSIONS: Immunisation coverage rates for measles are insufficient to prevent a potential measles outbreak in children <5 years. Concerningly, the coverage for MMR1 is declining, especially in Maori children. Catch-up immunisation programmes are urgently needed to improve immunisation coverage.

The August 2020 COVID-19 outbreak in Aotearoa, New Zealand: Delayed contact tracing for Pacific people contributes to widening health disparities.

Background: After COVID-19 arrived in New Zealand, a national system was developed to improve the efficiency of contact tracing. The first outbreak was followed by a period of 'COVID-19 elimination', until a community outbreak occurred in August 2020. We describe the characteristics of cases and their contacts during this outbreak, focused on the results of contact tracing. Methods: COVID-19 case data from the national surveillance database were linked to contacts from the national contact tracing database. Demographic and clinical characteristics of cases, number of contacts, and timeliness of contact tracing were analysed by ethnicity. Findings: Most of the 179 cases were Pacific people (59%) or Maori (25%), living in areas of high socioeconomic deprivation, who had higher rates of comorbidity and accounted for almost all (21/22) hospitalisations, all 8 ICU admissions and all 3 deaths. Only 6% belonged to the European majority ethnic group. Of 2,528 registered contacts, 46% were Pacific, 14% Maori and 19% European. Only contacts that were reached were registered. Overall, 41% of contacts were reached within 4 days of onset of disease of the case, which was significantly lower for Pacific (31%) than for other ethnic groups. Interpretation: Our findings confirm the greater health burden that ethnic minorities face from COVID-19. The significant delay in the timeliness of care for Pacific people shows that the public health response was inequitable for those at highest risk. Tailored public health responses and better registration of marginalised groups are necessary to provide better access to services and to improve insights for optimal future outbreak management.

Pilot of a digital contact tracing card in a hospital setting in New Zealand, 2020.

Countries are rapidly developing digital contact tracing solutions to augment manual contact tracing. There is limited empirical evidence evaluating these tools. We conducted a feasibility study of a Bluetooth-enabled card with hospital staff in New Zealand (n = 42). We compared the card data against self-report contact surveys and a stronger Bluetooth device. The cards detected substantially more contacts than self-report contact surveys, while the concordance between Bluetooth devices was high, suggesting that the cards detected clinically relevant close contacts. There was high acceptability among participants, suggesting that their integration would be accepted by healthcare staff. As the pandemic shifts, there is a need to rapidly contact trace and conduct informed risk management, particularly in critical settings such as healthcare.

Invasive Pneumococcal Disease: Concerning Trends in Serotype 19A Notifications in New Zealand.

New Zealand (NZ) is one of few countries to shift from PCV13 to PCV10. The number of serotype 19A cases in young children and the proportions of isolates that are penicillin-resistant have been steadily increasing since. It is time for NZ to reconsider its choice of pneumococcal vaccine.

Population rates of HIV, gonorrhoea and syphilis diagnoses by sexual orientation in New Zealand.

INTRODUCTION: Globally, gay and bisexual men (GBM) are over-represented in HIV, syphilis and gonorrhoea cases. However, surveillance systems rarely provide meaningful measures of inequity, such as population-specific rates, due to a lack of sexual orientation denominators. HIV, gonorrhoea and syphilis are legally notifiable diseases in New Zealand (NZ); we calculate rates by sexual orientation for the first time. METHODS: We analysed 2019 national surveillance data on HIV, syphilis and gonorrhoea notifications disaggregated by sexual orientation. Unique health records identified duplicate notifications and reinfections. Missing data were imputed from known cases. We used the NZ Health Survey 2014/2015 to estimate population sizes by sexual orientation, measured in two ways (current sexual identity, sexual contact in the previous 12 months with men, women or both). We calculated notification rates per 100 000 for each sexual orientation subgroup and rate ratios. RESULTS: In 2019, GBM accounted for 76.3%, 65.7% and 39.4% of HIV, syphilis and gonorrhoea notifications, respectively. Population rates per 100 000 for HIV were 158.3 (gay/bisexual men) and 0.5 (heterosexuals); for syphilis, population rates per 100 000 were 1231.1 (gay/bisexual men), 5.0 (lesbian/bisexual women) and 7.6 (heterosexuals); for gonorrhoea (imputed), population rates per 100 000 were 6843.2 (gay/bisexual men), 225.1 (lesbian/bisexual women) and 120.9 (heterosexuals). The rate ratios for GBM compared with heterosexuals were: 348.3 (HIV); 162.7 (syphilis); and 56.6 (gonorrhoea). Inequities remained in sensitivity analysis (substituting sexual identity with sexual behaviour in the previous 12 months). CONCLUSION: GBM in NZ experience profound inequities in HIV, syphilis and gonorrhoea. Rate ratios by sexual orientation provide useful 'at-a-glance' measures of inequity in disease incidence.

Identifying Perceived Barriers to Human Papillomavirus Vaccination as a Preventative Strategy for Cervical Cancer in Nigeria.

Background: Cervical cancer deaths are disproportionately higher in developing countries depicting one of the most profound health disparities existing today and is ranked as the second most frequent cancer among women in Nigeria. The Human Papillomavirus (HPV) vaccine as a primary prevention strategy is not widely used in Nigeria. This study investigated perceived barriers to HPV vaccination in a Nigerian community, targeting health workers' perceptions. Methods: This descriptive study captured responses from a cross-sectional, convenience sample of adult health workers within Anambra State, Nigeria. An anonymous 42-item survey with multiple validated scales was developed based on the Theory of Planned Behavior model and previous studies. The self-administered survey was distributed by research assistants at study sites within Anambra State which were identified through local constituents by the regional zones Adazi-Ani, Onitsha, and Awka. Data analyses were performed using Microsoft Excel for descriptive statistics and R software for the logistic regression, with a statistical significance level of 5%. Subgroup analysis was performed for the baseline knowledge questionnaire to determine if there were any differences in correct responses based on demographics such as: Institution type, profession, age, sex, religion and parental status. Results: Responses were collected from 137 Nigerian health workers; 44% nurses, 14% physicians, 6% pharmacists and 31% other health workers. The majority of respondents were female (69%), between 18 and 39 years of age (78%), from urban settings (82%), and identified as having Christian religious beliefs (97%). The most significant barriers identified were lack of awareness (39%), vaccine availability (39%), and cost (13%). When asked baseline knowledge questions regarding HPV, females were more likely to answer incorrectly as compared to males. Significant differences were found for statements: (1) HPV is sexually transmitted (p = 0.008) and (2) HPV is an infection that only affects women (p = 0.004). Conclusions: Perceived barriers to HPV vaccination identified by Nigerian health workers include lack of awareness, vaccine availability/accessibility, cost, and concerns about acceptability. Ongoing efforts to subsidize vaccine costs, campaigns to increase awareness of HPV vaccine, and interventions to improve attainability could advance administration rates in Nigeria, and ultimately improve death rates due to cervical cancer in this population.

Will Coronavirus Disease 2019 Become Seasonal?

This manuscript explores the question of the seasonality of severe acute respiratory syndrome coronavirus 2 by reviewing 4 lines of evidence related to viral viability, transmission, ecological patterns, and observed epidemiology of coronavirus disease 2019 in the Southern Hemispheres' summer and early fall.