Protecting Older Adult Residents in Care Facilities Against Influenza and COVID-19 Using the Influenza Communication, Advice and Reporting (FluCARE) App: Prospective Cohort Mixed Methods Study.

BACKGROUND: Early detection and response to influenza and COVID-19 outbreaks in aged care facilities (ACFs) are critical to minimizing health impacts. The Sydney Local Health District (SLHD) Public Health Unit (PHU) has developed and implemented a novel web-based app with integrated functions for online line listings, detection algorithms, and automatic notifications to responders, to assist ACFs in outbreak response. The goal of the Influenza Outbreak Communication, Advice and Reporting (FluCARE) app is to reduce time delays to notifications, which we hope will reduce the spread, duration, and health impacts of an influenza or COVID-19 outbreak, as well as ease workload burdens on ACF staff. OBJECTIVE: The specific aims of the study were to (1) evaluate the acceptability and user satisfaction of the implementation and use of FluCARE in helping ACFs recognize, notify, and manage influenza and COVID-19 outbreaks in their facility; (2) identify the safety of FluCARE and any potential adverse outcomes of using the app; and (3) identify any perceived barriers or facilitators to the implementation and use of FluCARE from the ACF user perspective. METHODS: The FluCARE app was piloted from September 2019 to December 2020 in the SLHD. Associated implementation included promotion and engagement, user training, and operational policies. Participating ACF staff were invited to complete a posttraining survey. Staff were also invited to complete a postpilot evaluation survey that included the user Mobile Application Rating Scale (uMARS) measuring app acceptance, utility, and barriers and facilitators to use. An issues log was also prospectively maintained to assess safety. Survey data were analyzed descriptively or via content analysis where appropriate. RESULTS: Surveys were completed by 31 consenting users from 27 ACFs. FluCARE was rated 3.91 of 5 overall on the uMARS. Of the 31 users, 25 (80%) would definitely use FluCARE for future outbreaks, and all users agreed that the app was useful for identifying influenza and COVID-19 outbreaks at their facilities. There were no reported critical issues with incorrect or missed outbreak detection. User training, particularly online training modules, and technical support were identified as key facilitators to FluCARE use. CONCLUSIONS: FluCARE is an acceptable, useful, and safe app to assist ACF staff with early detection and response to influenza and COVID-19 outbreaks. This study supports feasibility for ongoing implementation and efficacy evaluation, followed by scale-up into other health districts in New South Wales.

Web-Based Apps for Responding to Acute Infectious Disease Outbreaks in the Community: Systematic Review.

BACKGROUND: Web-based technology has dramatically improved our ability to detect communicable disease outbreaks, with the potential to reduce morbidity and mortality because of swift public health action. Apps accessible through the internet and on mobile devices create an opportunity to enhance our traditional indicator-based surveillance systems, which have high specificity but issues with timeliness. OBJECTIVE: The aim of this study is to describe the literature on web-based apps for indicator-based surveillance and response to acute communicable disease outbreaks in the community with regard to their design, implementation, and evaluation. METHODS: We conducted a systematic search of the published literature across four databases (MEDLINE via OVID, Web of Science Core Collection, ProQuest Science, and Google Scholar) for peer-reviewed journal papers from January 1998 to October 2019 using a keyword search. Papers with the full text available were extracted for review, and exclusion criteria were applied to identify eligible papers. RESULTS: Of the 6649 retrieved papers, 23 remained, describing 15 web-based apps. Apps were primarily designed to improve the early detection of disease outbreaks, targeted government settings, and comprised either complex algorithmic or statistical outbreak detection mechanisms or both. We identified a need for these apps to have more features to support secure information exchange and outbreak response actions, with a focus on outbreak verification processes and staff and resources to support app operations. Evaluation studies (6 out of 15 apps) were mostly cross-sectional, with some evidence of reduction in time to notification of outbreak; however, studies lacked user-based needs assessments and evaluation of implementation. CONCLUSIONS: Public health officials designing new or improving existing disease outbreak web-based apps should ensure that outbreak detection is automatic and signals are verified by users, the app is easy to use, and staff and resources are available to support the operations of the app and conduct rigorous and holistic evaluations.

Factors associated with adverse outcomes during influenza outbreaks in aged care facilities.

OBJECTIVE: To explore factors associated with adverse outcomes during influenza outbreaks in residential aged care facilities. METHODS: A retrospective cohort study of all outbreaks reported to three Sydney metropolitan Public Health Units during 2017. RESULTS: A total of 123 outbreaks affected 1,787 residents and 543 staff. Early notification to a Public Health Unit was associated with shorter outbreak duration (p<0.001; B=0.674). Resident attack rates and resident mortality rates were lower in outbreaks notified early, on univariate analysis (p=0.034 and p=0.048 respectively) but not on an adjusted model. Staff attack rates were significantly associated with resident attack rates (p=0.001; B=0.736). Data on staff vaccination rates was incomplete and reported coverage rates were low (median 39%). Resident vaccination coverage ≥95% was associated with shorter outbreak duration in univariate testing but not on an adjusted model. CONCLUSIONS: Early public health notification is associated with improved outbreak parameters; sick staff may pose a risk to residents, yet vaccination rates are low. Resident vaccination may also be valuable. Implications for public health: Measures that facilitate early PHU involvement in influenza outbreaks should be implemented, such as compulsory reporting requirements and processes that permit easier notification through technology. Actions that enhance staff and resident vaccination coverage should also be undertaken.

Surveillance methods to detect the impact of a significant cold chain breach.

In January 2015, a significant cold chain breach on a postnatal ward in a tertiary hospital in Sydney, Australia was noted to have been occurring since August 2013. Surveillance, amongst the 1178 mothers and 1178 babies affected, for vaccine-preventable diseases (VPDs) and adverse events following immunisation (AEFIs) using linkage with a notifiable diseases database was subsequently undertaken; no directly related instances of VPDs or AEFIs were detected. We evaluate this novel systematic surveillance method which has not been previously reported to determine whether it is effective in determining the impact of cold chain breaches on an individual and population level. The recommendation for revaccination of the affected mothers and subsequent surveillance was resource-intensive and future studies related to such incidents should focus on detailing the resources used to allow the costs versus benefits of such systematic surveillance to be determined.

Understanding barriers to effective management of influenza outbreaks by residential aged care facilities.

OBJECTIVE: To identify the perceived barriers to the implementation of the Australian national guidelines on influenza outbreak management with Sydney Local Health District (SLHD) residential aged care facility (RACF) staff. METHODS: All SLHD RACFs were invited to participate in a telephone interview. The questionnaire collected information about demographic characteristics and participants' level of agreement with statements regarding perceived barriers to implementing the national guidelines for influenza outbreak management. RESULTS: Twenty-eight of 61 RACFs (46%) participated in the study. The three most common barriers identified were as follows: scepticism towards staff influenza vaccination (n = 13, 46%); the effort required to read the national guidelines (n = 11, 39%); and lack of infrastructure to physically separate residents during an outbreak (n = 10, 36%). CONCLUSIONS: We recommend implementing and evaluating programmes which address misconceptions about influenza vaccination amongst RACF staff. Further, all RACF staff, including care staff, should receive targeted education on the role of infection control in influenza outbreak management.

Culture-positive shigellosis cases are epidemiologically different to culture-negative/PCR-positive cases.

OBJECTIVE: To review the epidemiological differences between culture-positive and culture-negative (but ipaH PCR-positive) cases of shigellosis in Sydney Local Health District (SLHD), NSW, to inform whether changes to the national case definition for shigellosis are required. METHODS: An audit of all cases of shigellosis (culture-positive vs. culture-negative/PCR-positive) in SLHD from 1 January 2013 to 30 June 2015 was conducted and demographic, clinical and risk factors were analysed and compared between these groups. RESULTS: Of the 148 shigellosis cases notified to SLHD, 122 cases (85 culture-positive vs. 37 culture-negative) were included for analysis. Culture-positive cases were more likely than culture-negative/PCR-positive cases to have experienced at least three symptoms (OR 3.18, 95%CI 1.3-7.5), been hospitalised (OR 4.2, 95%CI 1.4-13.2), and have had men-who-have-sex-with-men exposure identified as the source of their infection (OR 28.7, 95%CI 6.2-132.6). CONCLUSIONS: This study has identified that culture-positive vs. culture-negative/PCR-positive shigellosis cases in NSW differ by clinical severity and risk factors for infection. Implications for public health: The study findings warrant further research to determine the true diagnostic prevalence of Shigella in the culture-negative/PCR-positive group in the Australian context, in order to inform further changes to the national case definition for shigellosis.

Lessons Learned From Implementing an Incident Command System During a Local Multiagency Response to a Legionnaires' Disease Cluster in Sydney, NSW.

The incident command system (ICS) provides a common structure to control and coordinate an emergency response, regardless of scale or predicted impact. The lessons learned from the application of an ICS for large infectious disease outbreaks are documented. However, there is scant evidence on the application of an ICS to manage a local multiagency response to a disease cluster with environmental health risks. The Sydney Local Health District Public Health Unit (PHU) in New South Wales, Australia, was notified of 5 cases of Legionnaires' disease during 2 weeks in May 2016. This unusual incident triggered a multiagency investigation involving an ICS with staff from the PHU, 3 local councils, and the state health department to help prevent any further public health risk. The early and judicious use of ICS enabled a timely and effective response by supporting clear communication lines between the incident controller and field staff. The field team was key in preventing any ongoing public health risk through inspection, sampling, testing, and management of water systems identified to be at-risk for transmission of legionella. Good working relationships between partner agencies and trust in the technical proficiency of environmental health staff aided in the effective management of the response. (Disaster Med Public Health Preparedness. 2018;12:539-542).

Foodborne Illness Outbreak Investigation in a High-Profile Sports Club.

A foodborne illness outbreak involving an elite sports team was investigated by a public health unit in Sydney, Australia. An epidemiological association was established between gastrointestinal illness and the consumption of food supplied by an external caterer, with a lamb meal most strongly associated with illness. Genetically identical Salmonella isolates were identified from clinical specimens, residual food items, and an environmental swab taken from the catering premises. The training schedule and other club operations were significantly affected by this outbreak. Increased susceptibility due to regular shared activities and the potential for significant impact upon performance indicates that sports clubs must ensure that food suppliers comply with the highest standards of hygiene. Collaboration with public health authorities assists in source identification and prevention of further transmission.

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.

Characteristics of gonorrhoea cases notified in inner and south-western Sydney, Australia: results of population-based enhanced surveillance.

Background: Gonorrhoea disproportionately affects young people and men who have sex with men (MSM). In Australia, the highest notification rates in urban areas occur in MSM, although characteristics of those infected are poorly described. Enhanced surveillance can provide population-based data to inform service delivery and health promotion activities. Methods: An enhanced surveillance and data collection form was sent to the ordering doctor for residents of Sydney and South Western Sydney Local Health Districts with positive gonorrhoea results notified between 1 August 2013 and 28 February 2014. Results: Questionnaires were sent for 777 notifications and 698 (89.8%) were returned. Eighty-five per cent (n = 594) were male. The majority (55.1%) resided in inner city Sydney. Of these, 91.9% were male, and 70.8% of these identified as MSM. Among females, regular partners were the most likely source of infection (44.1%), while MSM and heterosexual men identified casual partners as the likely source of infection (75.4% and 61.1% respectively). General practitioners diagnosed 60.5% of cases. MSM were more commonly diagnosed by sexual health clinics. Females were most commonly tested for contact tracing (35.6%), heterosexual males because of symptoms (86.3%), and MSM as part of sexually transmissible infection screening (40.6%). Conclusions: Our population-based analysis identified differing risk factors and testing characteristics between MSM, heterosexual males and females. Increasing rates of gonorrhoea and concerns over antibiotic resistance highlight the importance of obtaining accurate sexual histories to ensure appropriate testing. Intermittent enhanced surveillance can monitor trends in specific populations and help determine the impact of health promotion strategies.

A survey of Sydney general practitioners' management of patients with chronic hepatitis B.

OBJECTIVE: To examine the chronic hepatitis B (CHB) assessment and management practices of general practitioners in the Sydney and South Western Sydney Local Health Districts, areas with a high prevalence of CHB, and to obtain their views on alternative models of care. DESIGN, SETTING AND PARTICIPANTS: We used a descriptive, cross-sectional study design to survey GPs who had seen at least one patient aged 18 years or over who had been notified as having CHB to the Public Health Unit between 1 June 2012 and 31 May 2013. There were 213 eligible GPs; the response rate was 57.7%. MAIN OUTCOME MEASURES: The CHB assessment, management and referral practices of the GPs, and their opinions about different models of care. RESULTS: Most GPs (78.9%) were at least reasonably confident about managing CHB. GPs were generally most comfortable with a model of care that involved initial referral to a specialist; managing CHB without specialist input or with only review by a specialised nurse practitioner were less popular. CONCLUSION: These results suggest that barriers, including dependence on specialist input, still hinder the appropriate assessment and management of CHB patients by GPs. Well designed and targeted support programs that include specialist support are needed if there is to be a successful shift to an increased role for GPs in the model of care for managing CHB.

Influenza outbreak preparedness: lessons from outbreaks in residential care facilities in 2014.

This report describes 6 influenza outbreaks in residential care facilities during the 2014 influenza season in the Sydney Local Health District. Vaccination rates were high among residents (95%) and low among staff (39%). The majority of residents with laboratory confirmed influenza (67%) did not meet the influenza-like illness case definition.Positive influenza specimens were subtyped as H3N2 (40%), H1N1 (5%) or not subtyped (55%). We illustrate the implications of low vaccine effectiveness and antigenic drift, and provide recommendations for the effective management of future influenza outbreaks.

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.