Heat illness presentations to emergency departments in Western Sydney: surveillance for environmental, personal and behavioural risk factors.

OBJECTIVE: To pilot surveillance to describe environmental, personal and behavioural risk factors for people presenting to hospital emergency departments (EDs) with heat illness. METHODS: We conducted a retrospective case series and telephone interview study of people presenting to EDs across South Western Sydney, Western Sydney and Nepean Blue Mountains Local Health Districts with heat illness over the 2017/18 and 2018/19 summer periods (1 December to 28 February). We used the Public Health Rapid Emergency Disease Syndromic Surveillance (PHREDSS) 'heat problems' syndrome to identify people with heat illness and medical records to find contact details. We developed a detailed questionnaire instrument to guide the telephone interview. RESULTS: A total of 129 individuals presented with 'heat problems' (57 in 2017/18 and 72 in 2018/19). The median age was 44 years (range 1-89 years). Most attended hospitals via the NSW Ambulance Service (58%) or private car (40%). Of the total, 53% were classified as triage category 3 (potentially life-threatening), 27% as category 4 (potentially serious) and 16% as category 2 (imminently life-threatening). The main supplementary codes were heat exhaustion (35%), heat syncope (39%), and heat stroke (30%). The majority were discharged from the emergency department after completing treatment (73%), with 21% requiring admission. A total of 38 follow-up interviews were completed (29% response rate). Almost all individuals were exposed to heat outside their home environment: 11 (29%) were engaged in paid work, 5 (13%) in outdoor housework, and 10 (26%) in outdoor recreational activities. CONCLUSION: Our pilot surveillance study successfully collected home, local environment and behavioural risk factors on a small cohort presenting with 'heat problems' to EDs in Western Sydney during the summer months. Most were exposed to heat outdoors while engaged in work or recreation outside the home, and were preventable.

Developing a climate change inequality health impact assessment for health services.

OBJECTIVES: To develop a Climate Change Inequality Health Impact Assessment (CCIHIA) framework for health services; to provide a systematic process for assessing potential unequal health impacts of climate change on vulnerable and marginalised populations and places; to support effective planning to address these impacts; and to develop contextually appropriate local strategies. Type of program: A collaborative interdisciplinary scoping research project involving two universities and two local health districts (LHDs) in New South Wales (NSW) to develop a CCIHIA framework. This work builds upon the health impact assessment (HIA) approach, which systematically assesses proposals' potential health and equity impacts by involving stakeholders in developing responses. METHODS: The project involved four main activities: understanding stakeholder requirements; conceptualising climate change vulnerability; considering the role of health services; and integrating findings into a conceptual framework. RESULTS: Stakeholders identified key functions that should be addressed across the framing, process and utility of the CCIHIA framework. The resulting conceptual framework outlines contexts and social stratification, the differential impacts of climate change (including factors influencing unequal impacts) and the health system's position, and also identifies key potential points of intervention. LESSONS LEARNT: The challenge of addressing the complexity of factors and resulting health impacts is reflected within the CCIHIA framework. While there are many intervention points within this framework for health services to address, many factors influencing unequal impacts are created outside the health sector's direct control. The framework's development process reflected the focus on collaboration and the interdisciplinary nature of climate change response. Ultimately, the CCIHIA framework is an assessment tool and an approach for prioritising inclusive, cross-cutting, multisector working, and problem-solving.

Measles control in Australia - threats, opportunities and future needs.

Control of measles was the focus of a national workshop held in 2015 in Sydney, Australia, bringing together stakeholders in disease control and immunisation to discuss maintaining Australia's measles elimination status in the context of regional and global measles control. The global epidemiology of measles was reviewed, including outbreaks in countries that have achieved elimination, such as the Disneyland outbreak in the United States and large outbreaks in Sydney, Australia. Transmission of measles between Australia and New Zealand occurs, but has not been a focus of control measures. Risk groups, the genetic and seroepidemiology of measles as well as surveillance, modelling and waning vaccine-induced immunity were reviewed. Gaps in policy, research and practice for maintaining measles elimination status in Australia were identified and recommendations were developed. Elimination of measles globally is challenging because of the infectiousness of measles and the need for 2-dose vaccine coverage rates in excess of 95% in all countries to achieve it. Until this occurs, international travel will continue to permit measles importation from endemic countries to countries that have achieved elimination. When measles cases are imported, failure to diagnose and isolate cases places the health system at risk of measles outbreaks. Vaccine funding models can result in gaps in vaccine coverage for adults and migrants. Australia introduced a whole-of-life immunisation register in 2016 and catch-up vaccination for at-risk communities, which will improve measles control. Research on diagnosis, immunology, case management and modelling of vaccination strategies are important to ensure continued control of measles.

Effectiveness of maternal pertussis vaccination in preventing infection and disease in infants: The NSW Public Health Network case-control study.

BACKGROUND: Infants are at the highest risk of severe complications - including death - as a result of pertussis infection. Controlling pertussis in this group has been challenging, particularly in those too young to be vaccinated. Following revised national recommendations in March 2015, the state of New South Wales, Australia, introduced a funded maternal vaccination campaign at 28 - 32 weeks of gestation using a 3-component tetanus-diphtheria-acellular pertussis vaccine (dTpa; Boostrix, GSK). This study aimed to assess the effectiveness of maternal vaccination and add to the growing body of evidence for this strategy. METHODS: A 1:1 matched case-control study was conducted between 16 August 2015 and 17 August 2016. Cases were laboratory or doctor notified, laboratory confirmed (nucleic acid testing or culture) and aged <6 months at onset. Each control infant was randomly selected from public hospital births in the same geographical area in the period up to 3 days before and after the case's birthdate. Odds ratios (OR) were calculated using conditional logistic regression. Vaccine effectiveness (VE) was calculated as 1 - OR. FINDINGS: In total, 117 cases and 117 controls were recruited. The overall VE estimate was non-significantly protective for infants <6 months old (VE 39%, 95% CI -12 to 66%). Higher VE was observed for infants <3 months old (VE 69%, 95% CI 13-89%) and against hospitalisation (VE 94%, 95% CI 59-99%). INTERPRETATION: Maternal pertussis vaccination with a 3-component acellular vaccine was found to be highly effective at preventing severe disease in infants, but was less effective at preventing disease which did not require hospitalisation. The overall VE reported in this study was lower than in prior studies and suggests that maternal vaccination, while an effective strategy at preventing severe pertussis, is less effective at protecting against infection or mild disease.

A Salmonella Typhimurium outbreak linked to Vietnamese bread rolls in South Western Sydney, Australia, 2015.

INTRODUCTION: In September 2015, the South Western Sydney (SWS) Public Health Unit was notified of a cluster of Salmonella Typhimurium (STm) cases with a common multiple-locus variable-number tandem repeats analysis (MLVA) pattern. An investigation was conducted to identify a source and contain the outbreak. METHODS: The cluster was initially identified through routine geographic information system cluster scanning applied to the New South Wales Notifiable Conditions Management System. Additional cases were identified through a complaint to local council about a bakery. The bakery was inspected and 48 environmental and food swabs were collected for analysis. RESULTS: A total of 26 suspected cases were identified, of which 14 were interviewed. STm MLVA type 3-16-9-11-523 was identified in 19 of 26 case stool specimens. Most cases (12/14) consumed bread rolls containing pork or chicken with chicken liver pâté and raw egg mayonnaise filling. Five cases identified a common bakery exposure. Environmental and food samples from the bakery isolated STm with an identical MLVA pattern. DISCUSSION: An STm cluster in SWS was investigated and found to be linked to Vietnamese bread rolls containing pork or chicken with chicken liver pâté and raw egg mayonnaise filling. Confirmation of a distinct MLVA pattern among STm isolates from clinical, food and environmental samples provided evidence to establish an epidemiological link between the cases and the implicated premises and informed public health action to contain the outbreak.

Effect of antiviral prophylaxis on influenza outbreaks in aged care facilities in three local health districts in New South Wales, Australia, 2014.

BACKGROUND: There was a record number (n = 111) of influenza outbreaks in aged care facilities in New South Wales, Australia during 2014. To determine the impact of antiviral prophylaxis recommendations in practice, influenza outbreak data were compared for facilities in which antiviral prophylaxis and treatment were recommended and for those in which antivirals were recommended for treatment only. METHODS: Routinely collected outbreak data were extracted from the Notifiable Conditions Information Management System for two Local Health Districts where antiviral prophylaxis was routinely recommended and one Local Health District where antivirals were recommended for treatment but not routinely for prophylaxis. Data collected on residents included counts of influenza-like illness, confirmed influenza, hospitalizations and related deaths. Dates of onset, notification, influenza confirmation and antiviral recommendations were also collected for analysis. The Mann-Whitney U test was used to assess the significance of differences between group medians for key parameters. RESULTS: A total of 41 outbreaks (12 in the prophylaxis group and 29 in the treatment-only group) were included in the analysis. There was no significant difference in overall outbreak duration; outbreak duration after notification; or attack, hospitalization or case fatality rates between the two groups. The prophylaxis group had significantly higher cases with influenza-like illness (P = 0.03) and cases recommended antiviral treatment per facility (P = 0.01). DISCUSSION: This study found no significant difference in key outbreak parameters between the two groups. However, further high quality evidence is needed to guide the use of antivirals in responding to influenza outbreaks in aged care facilities.

The changing epidemiology of measles in an era of elimination: lessons from health-care-setting transmissions of measles during an outbreak in New South Wales, Australia, 2012.

INTRODUCTION: In countries where measles is rare, health-care-setting transmissions remain problematic. Australia experienced its largest measles outbreak in 15 years in 2012 with 199 cases reported nationally; 170 cases occurred in the state of New South Wales (NSW) with symptom onset between 7 April and 29 November 2012. METHODS: A descriptive study was conducted using measles case data obtained from metropolitan Sydney local health districts in NSW in 2012. Characteristics of measles source and secondary cases were described. Details of health-care presentations resulting and not resulting in measles transmission were also analysed. RESULTS: There were 168 confirmed and two probable cases resulting in 405 documented health-care presentations. Thirty-four secondary cases acquired in health-care settings were identified, including 29 cases resulting from 14 source cases and 5 cases whose source could not be identified. Health-care-acquired cases accounted for 20% of all cases in this outbreak. Source cases were more likely to be of Pacific Islander descent (P = 0.009) and to have had more presentations before diagnosis (P = 0.012) compared to other cases. The percentage of presentations to emergency departments was higher for presentations that resulted in transmission compared to those that did not (71.4% and 37.6%, respectively, P = 0.028). There were no significant differences between transmission and non-transmission presentations with respect to presence of rash and infection control measures (P = 0.762 and P = 0.221, respectively), although the power to detect these differences was limited. Rash was reported at 66% of the presentations. CONCLUSION: Development of and adherence to protocols for the management of patients presenting to hospitals with fever and rash will minimize secondary transmission of measles.

A Q fever cluster among workers at an abattoir in south-western Sydney, Australia, 2015.

BACKGROUND: In September 2015, the Public Health Unit of the South Western Sydney Local Health District was notified of two possible Q fever cases. Case investigation identified that both cases were employed at an abattoir, and both cases advised that co-workers had experienced similar symptoms. Public Health Unit staff also recalled interviewing in late 2014 at least one other Q fever case who worked at the same abattoir. This prompted an outbreak investigation. METHODS: The investigation incorporated active case finding, microbiological analysis, field investigation and a risk factor survey. Included cases were laboratory definitive or suspected cases occurring from October 2014 to October 2015, residing or working in south-western Sydney. A suspected case had clinically compatible illness, high-risk exposure and was epidemiologically linked to another confirmed case. A confirmed case included laboratory detection of C. burnetti. RESULTS: Eight cases met the case definition with seven confirmed (including a deceased case) and one suspected. The eight cases were all males who had been employed at an abattoir in south-western Sydney during their incubation period; symptom onset dates ranged from November 2014 to September 2015. Field investigation identified multiple potential risk factors at the abattoir, and the majority (75%) of employees were not vaccinated against Q fever despite this high-risk setting. CONCLUSION: This cluster of Q fever in a single abattoir confirms the significance of this zoonotic disease as an occupational hazard among persons working in high-risk environments. Implementation of Q fever vaccination programmes should eliminate Q fever in high-risk occupational settings.

Investigating an outbreak of staphylococcal food poisoning among travellers across two Australian states.

INTRODUCTION: Staphylococcus aureus is a common cause of staphylococcal food poisoning in Australia with several outbreaks associated with foods prepared by commercial caterers. Laboratory testing on cases of gastrointestinal illness caused by enterotoxin-producing S. aureus is not routinely done as this condition is self-limiting. Hence outbreaks of such illness may go undetected. METHODS: A retrospective cohort study was conducted among a group of tourists who were hospitalized in Sydney shortly after flying from Queensland. The group had consumed food prepared by a restaurant on the Gold Coast before transit. Laboratory analyses on stool specimens were conducted in Sydney. An environmental assessment of the restaurant in the Gold Coast was conducted, and environmental specimens were assessed for contamination. RESULTS: Epidemiological investigations linked the outbreak to a restaurant in the Gold Coast where the suspected food was produced. Stool samples from two of the hospitalized cases were confirmed to have enterotoxin-producing S. aureus, and several environmental samples were found to be contaminated with S. aureus as well. Investigations suggested that absence of hand washing and other unhygienic food handling at the implicated restaurant was the likely cause of this outbreak. CONCLUSION: Food poisoning due to toxin-mediated S. aureus is frequently undetected and underreported. Public health units should consider toxin-producing pathogens such as S. aureus when investigating outbreaks where vomiting is the predominant symptom and occurs rapidly after consuming food.

Investigating an outbreak of staphylococcal food poisoning among travellers across two Australian states

Introduction：Staphylococcus aureus is a common cause of staphylococcal food poisoning in Australia with several outbreaks associated with foods prepared by commercial caterers. Laboratory testing on cases of gastrointestinal illness caused by enterotoxin-producing S. aureus is not routinely done as this condition is self-limiting. Hence outbreaks of such illness may go undetected.Methods：A retrospective cohort study was conducted among a group of tourists who were hospitalized in Sydney shortly after flying from Queensland. The group had consumed food prepared by a restaurant on the Gold Coast before transit. Laboratory analyses on stool specimens were conducted in Sydney. An environmental assessment of the restaurant in the Gold Coast was conducted, and environmental specimens were assessed for contamination.Results：Epidemiological investigations linked the outbreak to a restaurant in the Gold Coast where the suspected food was produced. Stool samples from two of the hospitalized cases were confirmed to have enterotoxin-producing S. aureus, and several environmental samples were found to be contaminated with S. aureus as well. Investigations suggested that absence of hand washing and other unhygienic food handling at the implicated restaurant was the likely cause of this outbreak.Conclusion：Food poisoning due to toxin-mediated S. aureus is frequently undetected and underreported. Public health units should consider toxin-producing pathogens such as S. aureus when investigating outbreaks where vomiting is the predominant symptom and occurs rapidly after consuming food.

Influenza vaccination during pregnancy: a qualitative study of the knowledge, attitudes, beliefs, and practices of general practitioners in Central and South-Western Sydney.

BACKGROUND: Pregnant women have an increased risk of influenza complications. Influenza vaccination during pregnancy is safe and effective, however coverage in Australia is less than 40%. Pregnant women who receive a recommendation for influenza vaccination from a health care provider are more likely to receive it, however the perspectives of Australian general practitioners has not previously been reported. The aim of the study was to investigate the knowledge, attitudes, beliefs, and practices of general practitioners practicing in South-Western Sydney, Australia towards influenza vaccination during pregnancy. METHODS: A qualitative descriptive study was conducted, with semi-structured interviews completed with seventeen general practitioners in October 2012. A thematic analysis was undertaken by four researchers, and transcripts were analysed using N-Vivo software according to agreed codes. RESULTS: One-third of the general practitioners interviewed did not consider influenza during pregnancy to be a serious risk for the mother or the baby. The majority of the general practitioners were aware of the government recommendations for influenza vaccination during pregnancy, but few general practitioners were confident of their knowledge about the vaccine and most felt they needed more information. More than half the general practitioners had significant concerns about the safety of influenza vaccination during pregnancy. Their practices in the provision of the vaccine were related to their perception of risk of influenza during pregnancy and their confidence about the safety of the vaccine. While two-thirds reported that they are recommending influenza vaccination to their pregnant patients, many were adopting principles of patient-informed choice in their approach and encouraged women to decide for themselves whether they would receive the vaccine. CONCLUSIONS: General practitioners have varied knowledge, attitudes, and beliefs about influenza vaccination during pregnancy, which influence their practices. Addressing these could have a significant impact on improving vaccine uptake during pregnancy.

Sustained outbreak of measles in New South Wales, 2012: risks for measles elimination in Australia.

OBJECTIVE: On 7 April 2012, a recently returned traveller from Thailand to Australia was confirmed to have measles. An outbreak of measles subsequently occurred in the state of New South Wales, prompting a sustained and coordinated response by public health authorities. The last confirmed case presented on 29 November 2012. This report describes the outbreak and its characteristics. METHODS: Cases were investigated following Australian protocols, including case interviews and assessment of contacts for post-exposure prophylaxis. RESULTS: Of the 168 cases identified, most occurred in south-western and western Sydney (92.9%, n = 156). Notable features of this outbreak were the disproportionately high number of cases in the 10-19-year-old age group (29.2%, n = 49), the overrepresentation among people of Pacific Islander descent (21.4%, n = 36) and acquisition in health-care facilities (21.4%, n = 36). There were no reported cases of encephalitis and no deaths. DISCUSSION: This was the largest outbreak of measles in Australia since 1997. Its occurrence highlights the need to maintain vigilant surveillance systems for early detection and containment of measles cases and to maintain high population immunity to measles through routine childhood immunization. Vaccination campaigns targeting susceptible groups may also be necessary to sustain Australia's measles elimination status.

Sustained outbreak of measles in New South Wales, 2012: risks for measles elimination in Australia

Objective：On 7 April 2012, a recently returned traveller from Thailand to Australia was confirmed to have measles. An outbreak of measles subsequently occurred in the state of New South Wales, prompting a sustained and coordinated response by public health authorities. The last confirmed case presented on 29 November 2012. This report describes the outbreak and its characteristics.Methods：Cases were investigated following Australian protocols, including case interviews and assessment of contacts for post-exposure prophylaxis.Results：Of the 168 cases identified, most occurred in south-western and western Sydney (92.9%, n = 156). Notable features of this outbreak were the disproportionately high number of cases in the 10–19-year-old age group (29.2%, n = 49), the overrepresentation among people of Pacific Islander descent (21.4%, n = 36) and acquisition in health-care facilities (21.4%, n = 36). There were no reported cases of encephalitis and no deaths.Discussion: This was the largest outbreak of measles in Australia since 1997. Its occurrence highlights the need to maintain vigilant surveillance systems for early detection and containment of measles cases and to maintain high population immunity to measles through routine childhood immunization. Vaccination campaigns targeting susceptible groups may also be necessary to sustain Australia’s measles elimination status.

Influenza vaccination during pregnancy: coverage rates and influencing factors in two urban districts in Sydney.

BACKGROUND: Pregnant women have an increased risk of complications from influenza. Influenza vaccination during pregnancy is considered effective and safe; however estimates of vaccine coverage are low. This study aimed to determine influenza vaccination coverage and factors associated with vaccine uptake in pregnant women in two Sydney-based health districts. METHODS: A random sample of women who delivered a baby in a public hospital in Sydney and South-Western Sydney Local Health Districts between June and September 2012 were surveyed using a computer assisted telephone interviewing service. RESULTS: Of the 462 participants (participation rate 92%), 116 (25%) reported receiving the influenza vaccine during their pregnancy. In univariate analysis, vaccination coverage varied significantly depending on antenatal care type, hospital of birth, and parity (p<0.05), but not for age category, highest level of education, country of birth, language spoken at home, or Aboriginal status. Women who received antenatal care through a general practitioner (GP) had 2.3 (95% CI 1.4-3.6) times the odds (unadjusted) of receiving the influenza vaccination than those who received their antenatal care through a public hospital. The main reason cited for vaccination was GP recommendation (37%), while non-recommendation (33%) and lack of knowledge (26%) were cited as main reasons for not receiving the vaccination. 30% of women recalled receiving a provider recommendation for the vaccination and these women had 33.0 times the odds (unadjusted) of receiving the vaccination than women who had not received a recommendation. In a multivariate model a provider recommendation was the only variable that was significantly associated with vaccination (OR 41.9; 95% CI 20.7-84.9). CONCLUSION: Rates of influenza vaccination during pregnancy are low. There is a significant relationship between healthcare provider recommendation for the vaccination and vaccine uptake. Increasing provider recommendation rates has the potential to increase coverage rates of influenza vaccination in pregnant women.

Nosocomial pulmonary tuberculosis contact investigation in a neonatal intensive care unit.

The diagnosis of smear-positive pulmonary tuberculosis in a medical officer working in a metropolitan Australian neonatal intensive care unit led to a contact investigation involving 125 neonates, 165 relatives, and 122 healthcare workers with varying degrees of exposure. There was no evidence of nosocomial tuberculosis transmission from the index case.

Men who have sex with men, infectious syphilis and HIV coinfection in inner Sydney: results of enhanced surveillance.

UNLABELLED: Background The resurgence of infectious syphilis in men who have sex with men (MSM) has been documented worldwide; however, HIV coinfection and syphilis reinfections in MSM in inner Sydney have not been published. METHODS: For all laboratory syphilis notifications assessed as a newly notified case or reinfection, a questionnaire was sent to the requesting physician seeking demographic data and disease classification. Sex of partner and HIV status were collected for all infectious syphilis notifications in men received from 1 April 2006 to March 2011. RESULTS: From April 2001 to March 2011, 3664 new notifications were received, 2278 (62%) were classified as infectious syphilis. Infectious syphilis notifications increased 12-fold from 25 to 303 in the first and last year respectively, and almost all notifications were in men (2220, 97.5%). During April 2006 to March 2011, 1562 infectious syphilis notifications in males were received and 765 (49%) of these men were HIV-positive and 1351 (86%) reported a male sex partner. Reinfections increased over time from 17 (9%) to 56 (19%) in the last year of the study and were significantly more likely to be in HIV-positive individuals (χ(2)=140.92, degrees of freedom= 1, P=<0.001). CONCLUSION: Inner Sydney is experiencing an epidemic of infectious syphilis in MSM and about half of these cases are in HIV-positive patients. Reinfections are increasing and occur predominantly in HIV-positive men. Accurate surveillance information is needed to inform effective prevention programs, and community and clinician education needs to continue until a sustained reduction is achieved.

Influenza virus A (H10N7) in chickens and poultry abattoir workers, Australia.

In March 2010, an outbreak of low pathogenicity avian influenza A (H10N7) occurred on a chicken farm in Australia. After processing clinically normal birds from the farm, 7 abattoir workers reported conjunctivitis and minor upper respiratory tract symptoms. Influenza virus A subtype H10 infection was detected in 2 workers.