The value of universal screening for COVID-19 cases on cruise ships during outbreaks.

OBJECTIVES: To describe the impact of universal screening for coronavirus disease 2019 (COVID-19) on passengers on cruise ships docking in Sydney, Australia, during 2022 that experienced a significant outbreak of COVID-19. Type of program or service: Cruise ship disease surveillance Methods: Case series, based on analysis of cruise ship voyages where universal screening of passengers was requested by a NSW health authority and undertaken by the cruise ship. RESULTS: Of 111 voyages in 2022, three fit the definition for this study. Universal screening during these voyages resulted in the detection of up to 1.8 times the number of existing COVID-19 cases, increasing attack rates of the three voyages from 14% to 24%; 13% to 28%; and 3% to 8% respectively. Case demographics showed an even gender distribution, with a majority 70 years or older. Asymptomatic case percentage ranged from 2% to 54%, with age and gender not associated with symptomatic status. Almost all cases were reported as being fully vaccinated. Genomic testing of cases showed multiple lineages of COVID-19 circulating in all three voyages. LESSONS LEARNT: Public health authorities, the cruise industry and passengers should be aware that a large number of unidentified cases of COVID-19 may disembark from a cruise ship that has experienced a large outbreak of the virus. These cases can seed the infection into vulnerable communities. Universal screening as part of the response to a significant outbreak will help identify cases and limit the spread of COVID-19.

Investigation of a legionellosis outbreak in Sydney CBD - a brief report.

OBJECTIVE: To identify and control a source of Legionella in Sydney CBD. METHODS: Clinical, epidemiological, environmental and genomic techniques were employed to identify cases and the source of Legionella. RESULTS: Eleven legionellosis cases were linked to Sydney CBD with a median age of 69 years. All were hospitalised and had risk factors for Legionella infection. Eight of 11 cases identified as male. Genomic analysis linked three cases to a contaminated cooling water source in Sydney CBD, with a further case infected with a similar strain to that found in Sydney CBD. Another case, although epidemiologically linked to Sydney CBD, was infected with a genomically different strain to that found in Sydney CBD. Six other cases had no viable sample for genomic analysis. CONCLUSION/IMPLICATIONS FOR PUBLIC HEALTH: An outbreak of legionellosis is a serious public health threat that requires rapid investigation and environmental control. We were able to identify a source in Sydney CBD through the application of clinical, epidemiological, environmental and genomic techniques. Genomic analysis is a powerful tool that can be used to confirm the source location but requires close collaboration between clinicians, public health units and microbiologists to recover viable sputum cultures from cases diagnosed with legionellosis.

The value of active follow up of a newly acquired hepatitis B infection - lessons for current approaches.

Abstract: The standard practice of blood borne virus (BBV) follow-up in New South Wales is a passive approach of general-practitioner-led testing. The value of this approach is unknown. We undertook an active contact tracing method with the aims of investigating a potential hepatitis B source, along with accurately measuring the participation rate, to consider the value of this and other follow-up methods for future BBV investigations. Investigation of a newly-acquired hepatitis B infection was undertaken at a dental practice identified as a possible exposure site. To screen for hepatitis B infection among potential source or co-exposed clients, we actively followed up with staff and clients of the practice to request they undertake hepatitis B serology. Eligible staff and clients received up to four phone calls and were provided with a pathology request form by the public health unit (PHU). Access to free serology was offered to people who did not have access to Medicare. Reminder calls were made if serology results were not received by the PHU. As the ordering doctor, the public health physician was responsible for providing results and referring for follow-up care. Of 160 clients, 63 (39%) undertook hepatitis B serology. Of these 63, none were found to have hepatitis B infection. It was estimated the active investigation involved an extra 430 hours of PHU staff time at a cost in Australian dollars of $30,000. Active follow-up allows an accurate participation rate to be documented. Despite intense active follow-up, only 39% of clients undertook testing, bringing into question the yield of the usual approach in which active follow-up of potential mass BBV exposures is not undertaken. While active follow-up is resource intensive, it should be considered where the risks and consequences from the BBV infection are high.

The suitability and usability of a tool to assess contact status from COVID-19 exposures in the workplace.

OBJECTIVE: To assess the usability of a self-assessment COVID-19 exposure tool for workplaces. METHODS: A COVID-19 exposure tool for workplaces was developed using five risk criteria. Public Health Unit (PHU) assessors who administered the tool documented when they administered the tool, the time taken for finalisation of the assessment and ease of administration. The System Usability Scale was used for workplace managers' perceptions on tool use. Data were assessed using both quantitative and qualitative analysis. RESULTS: Eighty-four workplaces used the tool to assess COVID-19 exposure risk. Of those, the outcome provided by the tool did not require modification by the PHU assessor in 70% of workplaces. Eighty per cent of the assessments were completed by the next day. PHU assessors rated the overall ease of administration of the tool as 'easy' or 'very easy' for 85% of workplaces and indicated they would employ the tool across a number of settings including complex workplaces. The mean System Usability Scale was 82. Workplace managers were predominately positive regarding its suitability. CONCLUSION: The tool provides an easy-to-use assessment of SARS-CoV-2 exposure in the workplace. IMPLICATIONS FOR PUBLIC HEALTH: The tool's adoption will empower workplace managers and improve the capacity of public health units to prevent further transmission of SARS-CoV-2 in workplaces.

Bondi and beyond. Lessons from three waves of COVID-19 from 2020.

OBJECTIVES: To describe local operational aspects of the coronavirus disease 2019 (COVID-19) response during the first three waves of outbreaks in New South Wales (NSW), Australia, which began in January, July and December 2020. Type of program or service: Public health outbreak response. METHODS: Narrative with epidemiological linking and genomic testing. RESULTS: Epidemiological linking and genomic testing found that during the first wave of COVID-19 in NSW, a large number of community transmissions went undetected because of limited testing for the virus and limited contact tracing of cases. The second wave of COVID-19 in NSW emerged following reintroduction from the second wave in Victoria, Australia in July 2020, and the third wave followed undetected introduction from overseas. By the second and third waves, cases could be more effectively detected and isolated through an increased ability to test and contact trace, and to rapidly genomic sequence severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) isolates, allowing most cases to be identified and epidemiologically linked. This greater certainty in understanding chains of transmission resulted in control of the outbreaks despite less stringent restrictions on the community, by using a refined strategy of targeted shutdown, restrictions on cases, their close contacts, identified hotspots and venues of concern rather than a whole of community lockdown. Risk assessments of potential transmission sites were constantly updated through our evolving experience with transmission events. However, this refined strategy did leave the potential for large point source outbreaks should any cases go undetected. [Addendum] A fourth wave that began in Sydney in June 2021 challenged this strategy due to the more transmissible nature of the Delta variant of SARS-CoV-2. LESSONS LEARNT: A wave of COVID-19 infections can develop quickly from one infected person. The community needs to remain vigilant, adhering to physical distancing measures, signing in to venues they visit, and getting tested if they have any symptoms. Signing out of venues on exit allows public health resources to be used more efficiently to respond to outbreaks.

Risk factors leading to COVID-19 cases in a Sydney restaurant.

OBJECTIVE: To explore the factors associated with the transmission of SARS-CoV-2 to patrons of a restaurant. METHODS: A retrospective cohort design was undertaken, with spatial examination and genomic sequencing of cases. The cohort included all patrons who attended the restaurant on Saturday 25 July 2020. A case was identified as a person who tested positive to a validated specific Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) nucleic acid test. Associations were tested using chi-squared analysis of case versus non-case behaviours. RESULTS: Twenty cases were epidemiologically linked to exposure at the restaurant on 25 July 2020. All cases dined indoors. All cases able to be genomic sequenced were found to have the same unique mutational profile. Factors tested for an association to the outcome included attentiveness by staff, drink consumption, bathroom use and payment by credit card. No significant results were found. CONCLUSION: Indoor dining was identified as a key factor in SARS-CoV-2 transmission, and outdoor dining as a way to limit transmission. Implications for public health: This investigation provides empirical evidence to support public health policies regarding indoor dining.

A multiple site community outbreak of COVID-19 in Sydney, Australia.

OBJECTIVE: To investigate an outbreak of COVID-19 in Sydney, Australia. METHODS: Epidemiological linking and analysis of cases of COVID-19 across multiple outbreak sites. RESULTS: Fifteen cases of COVID-19 and 41 contacts were identified and linked in a cluster that included one workplace and five households. The mean incubation period in the cases ranged from 4.6 to 6.4 days, while the median incubation period was shorter, ranging from 3 to 5 days. The overall range of incubation periods was 2 to 12 days. Differential attack rates were found within households (86% adults vs. 9% children) and workplace (32%) settings. Conclusions and implications for public health: Our investigation links cases between multiple households and a workplace. When exploring these links using a rapid workplace assessment, real-time cluster data along with objective measurements of exposure, such as with the Australian Government COVIDSafe app, may have allowed these links to be identified more readily and potentially reduced further spread of COVID-19. We found age as a factor for infection, with children being less likely to both acquire SARS-CoV-2 infection and to develop symptoms. This finding aids in our understanding of how the virus affects children and cautiously supports face-to-face classroom teaching.

Prisoners' experience and perceptions of health care in Australian prisons: a qualitative study.

PURPOSE: Patient-centred care is a key approach used in Australia for the delivery of quality health care, and understanding experiences and perceptions is a key part to this. This paper aims to explore prisoners' experiences and perceptions of health-care service provision in New South Wales, Australia. DESIGN/METHODOLOGY/APPROACH: In February and March 2017, 24 focus groups, consisting of 128 participants, were undertaken using semi-structured interviews that explored experiences of health care in prison. FINDINGS: A conceptualisation of the prisoners' health-care experience around the core category of access to health care emerged from the data. Enablers or barriers to this access were driven by three categories: a prison construct - how the prisoners "see" the prison system influencing access to health care; a health-care system construct - how the prisoners "see" the prison health-care system and the pathways to navigate it; and personal factors. Communication was the category with the greatest number of relational connections. RESEARCH LIMITATIONS/IMPLICATIONS: This study takes a pragmatic approach to the analysis of data, the findings forming the basis for a future quantitative study. The findings identify communication as a key issue for access to health care. ORIGINALITY/VALUE: This study provides first-hand accounts of enablers and barriers to accessing health-care services in the prison environment. To the best of the authors' knowledge, this study is the first of its kind to identify access to health care as a core category and is of value to health workers and researchers that work with the prison population.

An Australian incremental guideline for particulate matter (PM2.5) to assist in development and planning decisions.

OBJECTIVES: Many large-scale developments in Australia, such as road infrastructure, are subject to community concern due to their ongoing emission of particulate matter that may lead to adverse health impacts. The assessment of these impacts is guided by planning and health policies, but these policies have limitations. The objective of this paper is to provide an approach to setting an incremental guideline that can be used by regulators and health professionals to assess the impact of particulate matter from a development on a population, specifically the impact of particulate matter less than or equal to 2.5 micrometres in diameter (PM2.5). Type of program or service: Environmental health policy. METHODS: The calculation of PM2.5 concentrations and life days lost using concentration response functions and life tables. RESULTS: We calculated annual incremental concentrations of PM2.5 for a 1 in 1 000 000 increased risk of mortality, a 1 in 100 000 increased risk of mortality and a 1 in 10 000 increased risk of mortality along with associated life days lost. These values can be used to assess the acceptability of PM2.5 health impacts from a development. LESSONS LEARNT: An incremental annual PM2.5 concentration of up to 0.02 µg/m³ could be considered negligible, while concentrations between 0.02 and 1.7 µg/m³ could be considered acceptable/tolerable, with concentrations greater than 1.7 µg/m³ considered unacceptable.

Communicating about risk: strategies for situations where public concern is high but the risk is low.

In this article, we summarise research that identifies best practice for communicating about hazards where the risk is low but public concern is high. We apply Peter Sandman's 'risk = hazard + outrage' formulation to these risks, and review factors associated with the amplification of risk signals. We discuss the structures that determine the success of risk communication strategies, such as the capacity for early communication to 'capture' the dominant representation of risk issues, the importance of communicating uncertainty, and the usefulness of engaging with communities. We argue that, when facing trade-offs in probable outcomes from communication, it is always best to choose strategies that maintain or build trust, even at the cost of initial overreactions. We discuss these features of successful risk communication in relation to a range of specific examples, particularly opposition to community water fluoridation, Ebola, and routine childhood immunisation.

Communicating with the public about the risks of naturally occurring asbestos.

OBJECTIVES: To explore the application of evidence based risk communication to community messaging about naturally occurring asbestos (NOA). Type of program or service: Risk communication education about NOA. METHODS: We apply principles and determinants of risk communication to the topic of NOA. RESULTS: We emphasise the importance of erring on the side of transparency and trust, even when officials may be concerned about inadvertently heightening needless public concern. We offer a range of practical suggestions for how to lower public concern and outrage relating to the issue of NOA when it arises in local contexts. LESSONS LEARNT: Public concern and outrage can be reduced by favouring early and frequent communication, awareness and use of the 'rule of threes' in media communication, open acknowledgement of uncertainty, prioritising response to community concern above narrow myth-busting strategies, and supporting community action.

A systematic review of the health risks from passive exposure to electronic cigarette vapour.

OBJECTIVES: Electronic cigarettes (ECs) have recently become popular around the world, and their safety is being widely discussed in the scientific literature. Previous studies have examined the chemicals in e-liquids and vapour, and demonstrated that the aerosol from ECs can contain toxic chemicals that are harmful to health. However, little is known about the potential adverse health effects of passive exposure to EC vapour. The aim of this paper is to summarise and review all studies that have examined potential adverse health effects of passive exposure from inhaling EC vapour. Specifically, our research objectives were to describe 1) the absolute impact of passive exposure from inhaling vapour when compared with background, and 2) the relative impact of passive exposure from inhaling vapour when compared with passive exposure from inhaling conventional cigarette smoke. METHODS: A systematic review was conducted to identify articles published from 1996 to 10 September 2015 from Embase, Ovid MEDLINE and PreMEDLINE. Papers eligible for inclusion had to be written in English, study health effects from passive exposure to EC vapour in animals or humans, test or analyse the EC vapour directly or in the ambient air (with an inference made about passive or second-hand vapour exposure). The review was conducted using the PRISMA guidelines for reporting on systematic reviews. We identified 312 studies, and 16 were relevant for inclusion in our review. RESULTS: A variety of study designs were used to investigate potential health risks from passive exposure to EC vapour. These included direct exposure studies involving humans and animals, and indirect exposure studies using volunteer EC users or smoking machines. The majority of studies determined that passive exposure to EC vapour may pose a health risk to bystanders. All papers encountered a number of limitations. CONCLUSION: Our review found that the absolute impact from passive exposure to EC vapour has the potential to lead to adverse health effects. The risk from being passively exposed to EC vapour is likely to be less than the risk from passive exposure to conventional cigarette smoke.

Is the risk from nanomaterials perceived as different from the risk of 'chemicals' by the Australian public?

INTRODUCTION: Manufactured nanomaterials in Australia are managed predominantly through existing chemical regulatory frameworks. Many Australian government regulators have suggested the framing of manufactured nanomaterials as 'chemicals' when communicating about manufactured nanomaterials to the general public. This paper aims to determine whether the Australian public perception of manufactured nanomaterials differs to that of 'chemicals', and to examine the relationship between attitudes towards chemicals and perceptions of nanomaterial risk. METHODS: We undertook a computerised assisted telephone survey of the Australian public. Analysis was undertaken using descriptive, paired tests of proportion, paired t-test and logistic regression techniques. We explored perceptions of nanomaterial risk and their relationship to perceptions of chemical risk and 'chemical attitudes'. RESULTS: We found that the public perceives nanomaterials in a more favourable light than it does chemicals. Perception of risk from chemicals had the greatest association with perceived nanomaterial risk (adjusted odds ratios between 0.1 and 0.2) and that attitudes to chemicals were associated with perception of nanomaterial risk in some cases. CONCLUSION: Risk communicators and policy makers need to consider the differences and associations between nanomaterials and chemicals when addressing the regulatory aspects of nanomaterials with the public. This is relevant for communication strategies that attempt to normalise the risks from nanomaterials compared with those of chemicals, especially as nanomaterials are perceived to be less risky than chemicals.

Comparative analysis of the labelling of nanotechnologies across four stakeholder groups.

Societies are constantly challenged to develop policies around the introduction of new technologies, which by their very nature contain great uncertainty. This uncertainty gives prominence to varying viewpoints which are value laden and have the ability to drastically shift policy. The issue of nanotechnologies is a prime example. The labelling of products that contain new technologies has been one policy tool governments have used to address concerns around uncertainty. Our study develops evidence regarding opinions on the labelling of products made by nanotechnologies. We undertook a computer-assisted telephone (CATI) survey of the Australian public and those involved in nanotechnologies from the academic, business and government sectors using a standardised questionnaire. Analysis was undertaken using descriptive and logistic regression techniques. We explored reluctance to purchase as a result of labelling products which contained manufactured nanomaterials both generally and across five broad products (food, cosmetics/sunscreens, medicines, pesticides, tennis racquets/computers) which represent the broad categories of products regulated by differing government agencies in Australia. We examined the relationship between reluctance to purchase and risk perception, trust, and familiarity. We found irrespective of stakeholder, most supported the labelling of products which contained manufactured nanomaterials. Perception of risk was the main driver of reluctance to purchase, while trust and familiarity were likely to have an indirect effect through risk perception. Food is likely to be the greatest product impacted by labelling. Risk perception surrounding nanotechnologies and label 'framing' on the product are key issues to be addressed in the implementation of a labelling scheme.

Perceptions of risk from nanotechnologies and trust in stakeholders: a cross sectional study of public, academic, government and business attitudes.

BACKGROUND: Policy makers and regulators are constantly required to make decisions despite the existence of substantial uncertainty regarding the outcomes of their proposed decisions. Understanding stakeholder views is an essential part of addressing this uncertainty, which provides insight into the possible social reactions and tolerance of unpredictable risks. In the field of nanotechnology, large uncertainties exist regarding the real and perceived risks this technology may have on society. Better evidence is needed to confront this issue. METHODS: We undertook a computer assisted telephone interviewing (CATI) survey of the Australian public and a parallel survey of those involved in nanotechnology from the academic, business and government sectors. Analysis included comparisons of proportions and logistic regression techniques. We explored perceptions of nanotechnology risks both to health and in a range of products. We examined views on four trust actors. RESULTS: The general public's perception of risk was significantly higher than that expressed by other stakeholders. The public bestows less trust in certain trust actors than do academics or government officers, giving its greatest trust to scientists. Higher levels of public trust were generally associated with lower perceptions of risk. Nanotechnology in food and cosmetics/sunscreens were considered riskier applications irrespective of stakeholder, while familiarity with nanotechnology was associated with a reduced risk perception. CONCLUSIONS: Policy makers should consider the disparities in risk and trust perceptions between the public and influential stakeholders, placing greater emphasis on risk communication and the uncertainties of risk assessment in these areas of higher concern. Scientists being the highest trusted group are well placed to communicate the risks of nanotechnologies to the public.

Are Australians concerned about nanoparticles? A comparative analysis with established and emerging environmental health issues.

OBJECTIVE: Introducing new technologies into society raises considerable public concern. We determine the public concern about nanoparticles, and compare this concern to other environmental health issues such as wind farms and coal seam gas production. METHODS: A repeat cross sectional survey examining views on environmental health issues, risk, chemicals and trust was undertaken in more than 1,300 Australian residents in 2000 and 2013. Logistic regression and principal component analysis was used to investigate predictors of nanoparticle concern and identify a component structure for environmental health issues that could explain a trend of future nanoparticle concern. RESULTS: Australians have a relatively low level of concern about the risks of nanoparticles to health when compared to their concerns about other environmental health issues. Items associated with concern included gender, a general wish to avoid chemicals and possibly trust in politicians. Concern over nanoparticles clustered with similar views on technological risks. CONCLUSIONS: Current public concern over the risks of nanoparticles is low. However, a reframing of the issue towards 'chemicals' is likely to have a negative effect on risk perceptions. This paper raises questions about appropriate channels for the effective communication of risk.

Navigating public health chemicals policy in Australia: a policy maker's and practitioner's guide.

Chemicals are ubiquitous in everyday life. Environmental health practitioners rely on a complex web of regulators and policy bodies to ensure the protection of public health, yet few understand the full extent of this web. A lack of understanding can hamper public health response and impede policy development. In this paper we map the public health chemicals policy landscape in Australia and conclude that an understanding of this system is essential for effective environmental health responses and policy development.

Trends in notifiable blood lead levels in NSW, 1998-2008.

AIM: In the absence of published statewide notification data, the aim of this study was to analyse trends in notifiable blood lead levels (hereafter referred to as lead poisoning) in NSW from 1998 to 2008, to help inform lead poisoning notification policy. METHODS: NSW blood lead poisoning notification data for 1998-2008 were extracted from the Notifiable Diseases Database and analysed by age, gender and Area Health Service of residence. RESULTS: There were 6000 lead poisoning notifications from 1998 to 2008, with an average annual notification rate of 11.8 per 100 000 population for 1998-2003. This rate declined to an average of 4.0 per 100 000 population in the period 2004-2008. Males accounted for 92% of notifications, and males aged 20-59 years had average notification rates between 20 and 27 per 100 000 population. Children aged 0-4 years had notification rates of 9.3 per 100 000 population in girls and 13.6 per 100 000 population in boys. CONCLUSION: Notification rates have fallen dramatically, however children aged 0-4 years and men are disproportionately represented in lead poisoning notifications.

Investigating health effects in a community surrounding a road tunnel stack--a cross sectional study.

BACKGROUND: Extended tunnelled roadways requiring ventilation via exhaust stacks are an increasingly common solution to traffic congestion around the world. In response to community concerns about adverse health effects associated with emissions from a new road tunnel exhaust stack, despite no demonstrable change in local ambient air quality, we conducted a cross sectional study to test for an association between exposure to the exhaust stack emissions and the presence of eye, nose and throat symptoms. METHODS: Stack emissions were modelled and categorised into areas of high, medium and low levels of exposure to emissions. A telephone interview survey was conducted in these three zones. Multivariate analysis was undertaken using Cox Proportional Hazards modelling to estimate prevalence ratios between zones for eye, nose and throat symptoms. RESULTS: The prevalence of eye, nose and throat symptoms in the study area were 50 percent, 67 percent and 33 percent respectively and did not differ between the exposure zones. The presence of these symptoms was associated with a measure of reported "environmental worry". CONCLUSION: The study did not demonstrate a community wide health impact associated with modelled emissions but is unable to exclude the possibility of sensitive individuals being adversely affected.

Serum dioxin levels in Sydney Harbour commercial fishers and family members.

BACKGROUND: Commercial fishing in Sydney Harbour (SH) was banned in February 2006 as a result of high dioxin levels in some SH seafood. Because of concerns by some fishers about their own dioxin levels, testing of serum dioxin levels was offered to SH commercial fishers and their families. OBJECTIVES: Aims of this study were to describe blood dioxin levels of SH fishers and family members; compare these levels to background Australian levels and international data; analyze association between intake of SH seafood and dioxin levels; and assess whether blood dioxin levels were useful to inform ongoing care of SH fishers. METHODS: NSW Department of Health conducted clinics at which 112 fishers and family members gave blood for analysis of dioxin levels. Dioxin exposure was assessed through a questionnaire. Seafood dioxin levels were provided by the NSW Department of Environment and Climate Change. RESULTS: For the fishers (n=26), median TCDD and total TEQ levels were 27.3 and 62.4 pg g(-1) lipid, respectively. For the whole group (n=112), median TCDD and total TEQ levels were 9.3 and 26.1 pg g(-1) lipid, respectively. Age was the strongest predictor of increased dioxin levels (p<0.01), and consumption of SH seafood was also strongly associated (p=0.01). CONCLUSIONS: Serum dioxin levels in the SH fisher cohort were higher than Australian background levels, but comparable with other international high fish-eating communities, and lower than occupationally and accidentally exposed cohorts. High TCDD levels in commonly eaten seafood by the SH fishers confirms this as the likely exposure source.