Exit strategies: optimising feasible surveillance for detection, elimination, and ongoing prevention of COVID-19 community transmission.

BACKGROUND: Following implementation of strong containment measures, several countries and regions have low detectable community transmission of COVID-19. We developed an efficient, rapid, and scalable surveillance strategy to detect remaining COVID-19 community cases through exhaustive identification of every active transmission chain. We identified measures to enable early detection and effective management of any reintroduction of transmission once containment measures are lifted to ensure strong containment measures do not require reinstatement. METHODS: We compared efficiency and sensitivity to detect community transmission chains through testing of the following: hospital cases; fever, cough and/or ARI testing at community/primary care; and asymptomatic testing; using surveillance evaluation methods and mathematical modelling, varying testing capacities, reproductive number (R) and weekly cumulative incidence of COVID-19 and non-COVID-19 respiratory symptoms using data from Australia. We assessed system requirements to identify all transmission chains and follow up all cases and primary contacts within each chain, per million population. RESULTS: Assuming 20% of cases are asymptomatic and 30% of symptomatic COVID-19 cases present for testing, with R = 2.2, a median of 14 unrecognised community cases (8 infectious) occur when a transmission chain is identified through hospital surveillance versus 7 unrecognised cases (4 infectious) through community-based surveillance. The 7 unrecognised community upstream cases are estimated to generate a further 55-77 primary contacts requiring follow-up. The unrecognised community cases rise to 10 if 50% of cases are asymptomatic. Screening asymptomatic community members cannot exhaustively identify all cases under any of the scenarios assessed. The most important determinant of testing requirements for symptomatic screening is levels of non-COVID-19 respiratory illness. If 4% of the community have respiratory symptoms, and 1% of those with symptoms have COVID-19, exhaustive symptomatic screening requires approximately 11,600 tests/million population using 1/4 pooling, with 98% of cases detected (2% missed), given 99.9% sensitivity. Even with a drop in sensitivity to 70%, pooling was more effective at detecting cases than individual testing under all scenarios examined. CONCLUSIONS: Screening all acute respiratory disease in the community, in combination with exhaustive and meticulous case and contact identification and management, enables appropriate early detection and elimination of COVID-19 community transmission. An important component is identification, testing, and management of all contacts, including upstream contacts (i.e. potential sources of infection for identified cases, and their related transmission chains). Pooling allows increased case detection when testing capacity is limited, even given reduced test sensitivity. Critical to the effectiveness of all aspects of surveillance is appropriate community engagement, messaging to optimise testing uptake and compliance with other measures.

Acute respiratory infection symptoms and COVID-19 testing behaviour: results based on South Australian health surveys.

BACKGROUND: Effective syndromic surveillance alongside COVID-19 testing behaviours in the population including in higher risk and hard to reach subgroups is vital to detect re-emergence of COVID-19 transmission in the community. The aim of this paper was to identify the prevalence of acute respiratory infection symptoms and coronavirus testing behaviour among South Australians using data from a population based survey. METHODS: We used cross-sectional data from the 2020 state-wide population level health survey on 6857 respondents aged 18 years and above. Descriptive statistics were used to explore the risk factors and multivariable logistic regression models were used to assess the factors associated with the acute respiratory infection symptoms and coronavirus testing behaviour after adjusting for gender, age, household size, household income, Aboriginal and/or Torres Strait Islander status, SEIFA, Country of birth, number of chronic diseases, wellbeing, psychological distress, and mental health. RESULTS: We found that 19.3% of respondents reported having symptoms of acute respiratory infection and the most commonly reported symptoms were a runny nose (11.2%), coughing (9.9%) and sore throat (6.2%). Fever and cough were reported by 0.8% of participants. Of the symptomatic respondents, 32.6% reported seeking health advice from a nurse, doctor or healthcare provider. Around 18% (n = 130) of symptomatic respondents had sought testing and a further 4.3% (n = 31) reported they intended to get tested. The regression results suggest that older age, larger household size, a higher number of chronic disease, mental health condition, poor wellbeing, and psychological distress were associated with higher odds of ARI symptoms. Higher household income was associated with lower odds of being tested or intending to be tested for coronavirus after adjusting for other explanatory variables. CONCLUSIONS: There were relatively high rates of self-reported acute respiratory infection during a period of very low COVID-19 prevalence and low rate of coronavirus testing among symptomatic respondents. Ongoing monitoring of testing uptake, including in higher-risk groups, and possible interventions to improve testing uptake is key to early detection of disease.

Meta-analysis of the procedural risks of carotid endarterectomy and carotid artery stenting over time.

BACKGROUND: Stroke/death rates within 30 days of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in RCTs inform current clinical guidelines. However, the risks may have changed in recent years with wider use of effective stroke prevention therapies, especially statins, improved patient selection and growing operator expertise. The aim of this study was to investigate whether the procedural stroke/death risks from CEA and CAS have changed over time. METHODS: MEDLINE and Embase were searched systematically from inception to May 2016 for observational cohort studies of CEA and CAS. Studies included reported on more than 1000 patients, with 30-day outcomes after the procedure according to patients' symptom status (recent stroke or transient ischaemic attack). Restricted maximum likelihood random-effects and meta-regressions methods were used to synthesize procedural stroke/death rates of CEA and CAS according to year of study recruitment completion. RESULTS: Fifty-one studies, including 223 313 patients undergoing CEA and 72 961 undergoing CAS, were reviewed. Procedural stroke/death risks of CEA decreased over time in symptomatic and asymptomatic patients. Risks were substantially lower in studies completing recruitment in 2005 or later, both in symptomatic (5·11 per cent before 2005 versus 2·68 per cent from 2005 onwards; P = 0·002) and asymptomatic (3·17 versus 1·50 per cent; P < 0·001) patients. Procedural stroke/death rates of CAS did not change significantly over time (4·77 per cent among symptomatic and 2·59 per cent among asymptomatic patients). There was substantial heterogeneity in event rates and recruitment periods were long. CONCLUSIONS: Risks of procedural stroke/death following CEA appear to have decreased substantially. There was no evidence of a change in stroke/death rates following CAS.

Implementation of a national school-based Human Papillomavirus (HPV) vaccine campaign in Fiji: knowledge, vaccine acceptability and information needs of parents.

BACKGROUND: In 2008 Fiji implemented a nationwide Human Papillomavirus (HPV) vaccine campaign targeting all girls aged 9-12 years through the existing school-based immunisation program. Parents of vaccine-eligible girls were asked to provide written consent for vaccination. The purpose of this study was to describe parents' knowledge, experiences and satisfaction with the campaign, the extent to which information needs for vaccine decision-making were met, and what factors were associated with vaccine consent. METHODS: Following vaccine introduction, a cross-sectional telephone survey was conducted with parents of vaccine-eligible girls from randomly selected schools, stratified by educational district. Factors related to vaccine consent were explored using Generalised Estimating Equations. RESULTS: There were 560 vaccine-eligible girls attending the participating 19 schools at the time of the campaign. Among these, 313 parents could be contacted, with 293 agreeing to participate (93.6%). Almost 80% of participants reported having consented to HPV vaccination (230/293, 78.5%). Reported knowledge of cervical cancer and HPV prior to the campaign was very low. Most respondents reported that they were satisfied with their access to information to make an informed decision about HPV vaccination (196/293, 66.9%). and this was very strongly associated with provision of consent. Despite their young age, the vaccine-eligible girls were often involved in the discussion and decision-making. Most consenting parents were satisfied with the campaign and their decision to vaccinate, with almost 90% indicating they would consent to future HPV vaccination. However, negative media reports about the vaccine campaign created confusion and concern. Local health staff were cited as a trusted source of information to guide decision-making. Just over half of the participants who withheld consent cited vaccine safety fears as the primary reason (23/44, 52.3%). CONCLUSION: This is the first reported experience of HPV introduction in a Pacific Island nation. In a challenging environment with limited community knowledge of HPV and cervical cancer, media controversy and a short lead-time for community education, Fiji has implemented an HPV vaccine campaign that was largely acceptable to the community and achieved a high level of participation. Community sensitisation and education is critical and should include a focus on the local health workforce and the vaccine target group.

Influenza control can be achieved in a custodial setting: pandemic (H1N1) 2009 and 2011 in an Australian prison.

OBJECTIVES: Information on the effectiveness of interventions regarding control in closed institutional settings, including prisons, is limited. This study gathered evidence relating to influenza control in an Australian prison. STUDY DESIGN: This study built on a 2009 H1N1 outbreak investigation at the Alexander Maconochie Centre (AMC) in the Australian Capital Territory (ACT). METHODS: Influenza surveillance data, ACT 2010 Inmate Health Survey data, New South Wales 2001 and 2009 Inmate Health Survey data, ACT Department of Corrective Services administrative data, and ACT Health clinical data were analysed. RESULTS: In 2011, the AMC was exposed to influenza virus, resulting in a single case. Public health activities included exclusion of symptomatic cases from the health facility, isolation of cases, and quarantine of contacts. Contact between prisoners and the ACT community was maintained; the AMC detainee visitor rate was one visitor per prisoner every 10 days. CONCLUSIONS: The rehabilitative benefits of human contact for AMC detainees were not compromised during the surveillance period, despite the potential that a higher visitor rate may suggest. This highlights some features of the AMC which make its operational context different from many other correctional settings, but gives some indication of how good public health practice supports human rights.

Mental health services for children exposed to armed conflict: Médecins Sans Frontières' experience in the Democratic Republic of Congo, Iraq and the occupied Palestinian territory.

BACKGROUND: Armed conflict has broad-ranging impacts on the mental health and wellbeing of children and adolescents. Mental health needs greatly exceed service provision in conflict settings, particularly for these age groups. The provision and targeting of appropriate services requires better understanding of the characteristics and requirements of children and adolescents exposed to armed conflict. METHODS: Routine patient and programme monitoring data were analysed for patients <20 years of age attending mental health services provided by Médecins Sans Frontières (MSF) in three countries affected by armed conflict: the Democratic Republic of Congo (DRC), Iraq and the occupied Palestinian territory (oPt). The demographic characteristics, presenting mental health complaint, attributed precipitating event, services provided and short-term outcomes for mental health services users in each country are described. RESULTS: Between 2009 and 2012, 3025 individuals <20 years of age presented for care in DRC and Iraq, and in 2012 in oPt, constituting 14%, 17.5% and 51%, respectively, of all presentations to MSF mental health services in those three countries. The most common precipitating event was sexual violence in DRC (36.5%), domestic violence in Iraq (17.8%) and incarceration or detention in oPt (33%). Armed conflict-related precipitants were reported by 25.9%, 55.0% and 76.4% of youths in DRC, Iraq and oPt, respectively. The most common presenting complaints in children and adolescents were anxiety-related, followed by mood-related, behaviour-related and somatisation problems; these varied according to country and precipitating event. Although a high proportion (45.7%) left programmes early, 97% of those who completed care self-reported improvement in their presenting complaint. CONCLUSIONS: Brief trauma-focused therapy, the current MSF mental health therapeutic intervention, appears to be effective in reducing symptoms arising from the experience of trauma. Although inferences on outcomes are limited by high default rates, this provides a feasible tool for addressing the mental health needs of children exposed to armed conflict. Priorities for future research include understanding why children and adolescents constitute a small proportion of patients in some programmes, why many leave care early and how to address these issues, but this research must occur within the context of efforts to provide access to mental health services for children.