Locally acquired lymphocytic choriomeningitis virus infections in South-East Queensland: an outbreak of a pathogen rarely described in Australia.

Lymphocytic choriomeningitis virus (LCMV) is a zoonotic virus that can cause clinically significant illnesses in humans. Although cases of LCMV infection are well described globally, and there is evidence that the virus is present in Australian rodent populations, there has been only one case of domestically acquired LCMV infection published previously. Here, we describe a cluster of LCMV infections in South-East Queensland identified in early 2021, and the diagnostic testing processes implemented. This identifies LCMV as an under-recognised human pathogen in Australia.

Critical care nurses' perceptions of essential elements for an intensive care liaison or critical care outreach nurse curriculum.

BACKGROUND: For over a decade, patients experiencing clinical deterioration have been attended to by specialised nurses, the most senior of which are intensive care unit liaison nurses (ICU LNs) or critical care outreach nurses. These roles have evolved without consistent and formal recognised educational preparation. To continue to advance patient safety, an understanding of the educational requirements for these vital roles is required. AIM: The aim of this study was to ascertain nurses' perceptions of the curriculum required to perform the roles of ICU LNs or critical care outreach nurses within an acute care sector rapid response system. METHODS: An exploratory descriptive study was conducted at an international rapid response system conference in 2016 following ethics approval. Using convenience sampling, extended response surveys were completed by nurses with rapid response system leadership experience and roles. Data were analysed using content analysis according to a priori themes of theoretical knowledge, skills, and attributes. RESULTS: Seventy-seven registered nurses volunteered to take part in the study, forming 14 groups, each with four to seven members. Participants identified key concepts for desired theoretical knowledge, practical skills, and personal attributes. Professional behaviours were more frequently emphasised than theoretical knowledge or practical skills, suggesting personal attributes were highly valued in these leadership roles. CONCLUSIONS: A curriculum designed to prepare patient safety leadership roles of the ICU LN or critical care outreach nurse has been identified. These findings can inform the development of postgraduate courses and training requirements, along with position descriptions and expectations of employers regarding the skill set expected in these leadership roles.

Differences in the characteristics, treatment, and outcomes of patient groups reviewed by intensive care liaison nurses in Australia: A multicentre prospective study.

BACKGROUND: There is a lack of knowledge about tasks intensive care unit liaison nurses (ICU LNs) perform during patient review, despite this role operating in at least 31 acute care hospitals in Australia. OBJECTIVES: To evaluate the tasks that ICU LNs perform during patient review in the following referral subcategories: review after ICU discharge, rapid response team (RRT) review, and ward referral. METHODS: A 2-month prospective observational study using standardised case report forms to collect data on patients reviewed by ICU LNs in 20 Australian hospitals was conducted. RESULTS: From 3799 patients screened, 3542 were included, among whom 1933 (54.6%) were men, and the mean (standard deviation) age was 63 (19.4) years. The admitting units were surgical 1765 (49.8%) and medical 1696 (47.9%), and the breakdown of referral types were routine review after ICU discharge (1732; 47.9%), RRT review (1208; 34.1%), and ward referral (602; 17.0%). Patients subject to ward and RRT reviews were older, more likely to be medical admissions with less favourable vital signs on the initial review, and less likely to have repeat reviews. Of note, ward reviews were more likely to receive palliative care. Intensive care liaison nurse-initiated medication prescription and investigation ordering was uncommon. The most common interventions included consultation with medical staff, bedside education, adjusting oxygen flow and patient position, and directing the change in frequency of vital sign measurement. In-hospital mortality was lower in patients reviewed after ICU discharge (2.3%), compared with those after RRT review (2.8%) and ward referral (4.4%). CONCLUSIONS: Most patients were reviewed after ICU discharge or in the context of the RRT. RRT and ward patients were less physiologically stable and more likely to die in hospital. The most common interventions performed by the ICU LN were nontechnical skills including clinical education, consultation with medical staff, and changes to vital sign frequency. Finally, the most common medication therapies administered related to intravenous therapy and electrolyte administration.

Implications of dengue outbreaks for blood supply, Australia.

Dengue outbreaks have increased in size and frequency in Australia, and transfusion-transmitted dengue poses a risk to transfusion safety. Using whole blood samples collected during the large 2008-2009 dengue epidemic, we estimated the risk for a dengue-infectious blood donation as ≈1 in 7,146 (range 2,218-50,021).

Improving the management of medical emergency team calls due to suspected infections: A before-after study.

Objective: To introduce a management guideline for sepsis-related MET calls to increase lactate and blood culture acquisition, as well as prescription of appropriate antibiotics. Design: Prospective before (Jun-Aug 2018) and after (Oct-Dec 2018) study was designed. Setting: A public university linked hospital in Melbourne, Australia. Participants: Adult patients with MET calls related to sepsis/infection were included. Main outcome measures: The primary outcome measure was the proportion of MET calls during which both a blood culture and lactate level were ordered. Secondary outcomes included the frequency with which new antimicrobials were commenced by the MET, and the presence and class of administered antimicrobials. Results: There were 985 and 955 MET calls in the baseline and after periods, respectively. Patient features, MET triggers, limitations of treatment and disposition after the MET call were similar in both groups. Compliance with the acquisition of lactates (p = 0.101), respectively. There was a slight reduction in compliance with lactate acquisition in the after period (97% vs 99%; p = 0.06). In contrast, there was a significant increase in acquisition of blood cultures in the after period (69% vs 78%; p = 0.035). Conclusions: Introducing a sepsis management guideline and enhanced linkage with an AMS program increased blood culture acquisition and decreased broad spectrum antimicrobial use but didn't change in-hospital mortality.

No evidence of prolonged Hendra virus shedding by 2 patients, Australia.

To better understand the natural history of Hendra virus infection and its tendency to relapse, 2 humans infected with this virus were monitored after acute infection. Virus was not detected in blood samples when patients were followed-up at 2 and 6 years. Thus, no evidence was found for prolonged virus shedding.

A survey of ward nurses attitudes to the Intensive Care Nurse Consultant service in a teaching hospital.

The aim of an Intensive Care Nurse Consultant (ICNC) service is to optimise care of complex ward patients and reduce adverse events. Despite their widespread implementation, specific assessment of ward nurses' attitudes towards such is lacking. Accordingly, we surveyed ward nurses' attitudes towards our ICNC service in five domains: (a) accessibility and approachability; (b) perceived ICNC skill and knowledge; (c) perceived influence on patient management; (d) usefulness as a resource of clinical information; (e) impact upon adverse outcomes. To achieve this, an anonymous Liker-type questionnaire was distributed to 208 ward nurses in our hospital. We also included space for free text. Completed questionnaires were entered manually into a SURVEYMONKEY™ pro-forma to permit automatic report generation and results summary. The major findings were that ICNC staff were perceived as being approachable and good communicators, were skilled at early detection of deteriorating patients, and that they reduce serious adverse events. In addition, nurses believe the ICNC service provides continuity of care post discharge from the intensive care unit (ICU), as well as assisting staff to prioritise clinical issues following medical emergency team (MET) review or ICU discharge. The ward nurses did not believe that the ICNC service reduced their skills in managing ward patients. In contrast, respondents stated that the ICNC service needed to improve the processes of referral to allied health and education of ward staff regarding deteriorating patients. Finally, ward nurses suggest they would call the MET service rather than the ICNC service for patients who had already deteriorated. This survey suggests that the ICNC service is valued, and is perceived to prevent the development of adverse events, rather than playing a major role in the management of the deteriorating patient. There is a need to improve referrals to allied health and further educate ward nurses.

Human Hendra virus encephalitis associated with equine outbreak, Australia, 2008.

A recent Hendra virus outbreak at a veterinary clinic in Brisbane, Queensland, Australia, involved 5 equine and 2 human infections. In contrast to previous outbreaks, infected horses had predominantly encephalitic, rather than respiratory, signs. After an incubation period of 9-16 days, influenza-like illnesses developed in the 2 persons before progressing to encephalitis; 1 died. Both patients were given ribavirin. Basal serum and cerebrospinal fluid levels were 10-13 mg/L after intravenous administration and 6 mg/L after oral administration (isolate 90% inhibitory concentration 64 mg/L). Both patients were exposed to infected horses, 1 during the late incubation period in a horse. The attack rate for veterinary clinic staff exposed to infected horses was 10%. An isolate from this outbreak showed genetic heterogeneity with isolates from a concurrent, but geographically remote, outbreak and from previous outbreaks. Emergence of Hendra virus is a serious medical, veterinary, and public health challenge.

COVID-19 in a complex obstetric patient with cystic fibrosis.

We report the first case of COVID-19 in a pregnant patient with cystic fibrosis. We describe the diagnosis, clinical course and management of the patient and their family with regards to clinical, social and infection control measures around delivery. This case highlights the importance of the cooperation of multidisciplinary teams to achieve good clinical outcomes in complex patients with COVID-19.

A Case of Japanese Encephalitis with a Fatal Outcome in an Australian Who Traveled from Bali in 2019.

A severe case of Japanese encephalitis virus (JEV) infection, resulting in fatality, occurred in an unvaccinated Australian male traveler from Bali, Indonesia, in 2019. During hospitalisation in Australia, patient cerebrospinal fluid (CSF) yielded JEV-specific IgM antibodies and RNA, and an isolate of the virus. Ongoing transmission of JEV in Bali underscores this pathogen as a public health risk and the importance of appropriate health, vaccination and mosquito avoidance advice to prospective travelers to the region.

Erratum: Pyke, A.T. et al. On the Home Front: Specialized Reference Testing for Dengue in the Australasian Region. Trop. Med. Infect. Dis. 2018, 3, 75.

The authors wish to make the following correction to Table 1 of this paper [...].

A recombinant platform for flavivirus vaccines and diagnostics using chimeras of a new insect-specific virus.

Flaviviruses such as dengue, yellow fever, Zika, West Nile, and Japanese encephalitis virus present substantial global health burdens. New vaccines are being sought to address safety and manufacturing issues associated with current live attenuated vaccines. Here, we describe a new insect-specific flavivirus, Binjari virus, which was found to be remarkably tolerant for exchange of its structural protein genes (prME) with those of the aforementioned pathogenic vertebrate-infecting flaviviruses (VIFs). Chimeric BinJ/VIF-prME viruses remained replication defective in vertebrate cells but replicated with high efficiency in mosquito cells. Cryo-electron microscopy and monoclonal antibody binding studies illustrated that the chimeric BinJ/VIF-prME virus particles were structurally and immunologically similar to their parental VIFs. Pilot manufacturing in C6/36 cells suggests that high yields can be reached up to 109.5 cell culture infectious dose/ml or ≈7 mg/liter. BinJ/VIF-prME viruses showed utility in diagnostic (microsphere immunoassays and ELISAs using panels of human and equine sera) and vaccine applications (illustrating protection against Zika virus challenge in murine IFNAR-/- mouse models). BinJ/VIF-prME viruses thus represent a versatile, noninfectious (for vertebrate cells), high-yield technology for generating chimeric flavivirus particles with low biocontainment requirements.

Heterogeneity of susceptibility to fluoroquinolones in Bartonella isolates from Australia reveals a natural mutation in gyrA.

OBJECTIVES: Bartonella sp. are intracellular bacteria associated with an increasing number of clinical manifestations but with few published data on in vitro susceptibility testing of antibiotics. Our objective was to evaluate in vitro antibiotic susceptibilities of 20 new Bartonella isolates from animals in Australia. METHODS: MICs were determined using Etest assay on Columbia agar supplemented with 5% horse blood. The presence of mutations in the quinolone-resistance-determining region (QRDR) of gyrA was searched for after PCR amplification and DNA sequencing using specific oligonucleotide primers. RESULTS: Bartonella isolates from Australia were susceptible to rifampicin, tetracyclines, beta-lactam and macrolide compounds but were resistant to vancomycin. We found heterogeneity of susceptibility for fluoroquinolones with ciprofloxacin being more effective (MICs from 0.06 to 0.5 mg/L) than ofloxacin (MICs from 0.5 to 4 mg/L). This heterogeneity was linked to a natural mutation Ser-83-->Ala (Escherichia coli numbering) in the QRDR. Surprisingly, this mutation was also present in the QRDR of Bartonella henselae, Bartonella quintana and Bartonella bacilliformis. CONCLUSIONS: Etest is a sensitive and reliable assay for evaluation of antibiotic susceptibility in the genus Bartonella. The higher sensitivity of this method allowed us to detect heterogeneity of susceptibility among fluoroquinolones that was associated with natural mutation in the QRDR of the DNA gyrase. Because a high level of resistance to fluoroquinolones due to a second mutation may be obtained easily in vitro, we believe that fluoroquinolone compounds should be avoided for the treatment of any Bartonella-related diseases.

On the Home Front: Specialised Reference Testing for Dengue in the Australasian Region.

Reference laboratories are vital for disease control and interpreting the complexities and impact of emerging pathogens. The role of these centralized facilities extends beyond routine screening capabilities to provide rapid, specific, and accurate diagnoses, advanced data analysis, consultation services, and sophisticated disease surveillance and monitoring. Within the Australasian region, the Public Health Virology Laboratory (PHV), Forensic and Scientific Services, Department of Health, Queensland Government, Australia, and the Institute of Environmental Science and Research Limited (ESR), New Zealand (NZ) perform specialised reference testing and surveillance for dengue viruses (DENVs) and other emerging arthropod-borne viruses (arboviruses), including chikungunya virus (CHIKV) and Zika virus (ZIKV). With a focus on DENV, we review the reference testing performed by PHV (2005 to 2017) and ESR (2008 to 2017). We also describe how the evolution and expansion of reference-based methodologies and the adoption of new technologies have provided the critical elements of preparedness and early detection that complement frontline public health control efforts and limit the spread of arboviruses within Australasia.

Detection of Specific ZIKV IgM in Travelers Using a Multiplexed Flavivirus Microsphere Immunoassay.

Zika virus (ZIKV) has spread widely in the Pacific and recently throughout the Americas. Unless detected by RT-PCR, confirming an acute ZIKV infection can be challenging. We developed and validated a multiplexed flavivirus immunoglobulin M (IgM) microsphere immunoassay (flaviMIA) which can differentiate ZIKV-specific IgM from that due to other flavivirus infections in humans. The flaviMIA bound 12 inactivated flavivirus antigens, including those from ZIKV and yellow fever virus (YFV), to distinct anti-flavivirus antibody coupled beads. These beads were used to interrogate sera from patients with suspected ZIKV infection following travel to relevant countries. FlaviMIA results were validated by comparison to the ZIKV plaque reduction neutralization test (PRNT). The results highlight the complexity of serological ZIKV diagnosis, particularly in patients previously exposed to or vaccinated against other flaviviruses. We confirmed 99 patients with ZIKV infection by a combination of RT-PCR and serology. Importantly, ZIKV antibodies could be discriminated from those ascribed to other flavivirus infections. Serological results were sometimes confounded by the presence of pre-existing antibodies attributed to previous flavivirus infection or vaccination. Where RT-PCR results were negative, testing of appropriately timed paired sera was necessary to demonstrate seroconversion or differentiation of recent from past infection with or exposure to ZIKV.

Multiple outbreaks of dengue serotype 2 in north Queensland, 2003/04.

OBJECTIVES: To describe the various investigations and responses to multiple outbreaks of dengue serotype 2 that occurred in north Queensland in 2003/04. METHODS: Details about each case were collated so as to target mosquito-control responses including control of mosquito breeding sites, interior spraying of selected premises, and a novel 'lure and kill' approach using lethal ovitraps. Phylogenetic analyses were undertaken to determine the genetic relatedness of viruses isolated during the outbreaks. RESULTS: Except for a two-month hiatus in mid-2003, the outbreaks continued for 16 months and included approximately 900 confirmed cases, with three severe cases and one death. The available evidence suggests that the mosquito-control measures were effective, but delays in recognising the outbreaks in Cairns and the Torres Strait coupled with intense mosquito breeding contributed to the extensive nature of the outbreaks. Phylogenetic analyses showed that there had been only two major outbreaks, one that spread from Cairns to Townsville, the other from the Torres Strait to Cairns; both were initiated by viraemic travellers from Papua New Guinea. CONCLUSIONS: Phylogenetic analyses were essential in understanding how the outbreaks were related to each other, and in demonstrating that dengue had not become endemic. Further innovative approaches to dengue surveillance and mosquito control in north Queensland are necessary. IMPLICATIONS: Dengue outbreaks have become more frequent and more severe in north Queensland in recent years, raising the possibility that dengue viruses could become endemic in the region leading to outbreaks of dengue haemorrhagic fever.

Highly divergent dengue virus type 1 genotype sets a new distance record.

Dengue viruses (DENVs) are the leading cause of mosquito-borne viral disease of humans. They exist in both endemic and sylvatic ecotypes. In 2014, a viremic patient who had recently visited the rainforests of Brunei returned to Australia displaying symptoms consistent with DENV infection. A unique DENV strain was subsequently isolated from the patient, which we propose belongs to a new genotype within DENV serotype 1 (DENV-1). Bayesian evolutionary phylogenetic analysis suggests that the putative sylvatic DENV-1 Brunei 2014 (Brun2014) is the most divergent DENV-1 yet recorded and increases the time to the most recent common ancestor (MRCA) for DENV-1 from ≈120 years to ≈315 years. DENV-1 classification of the Brun2014 strain was further supported by monoclonal antibody serotyping data. Phenotypic characterization demonstrated that Brun2014 replication rates in mosquito cells and infection rates in Aedes aegypti mosquitoes were not significantly different from an epidemic DENV-1 strain. Given its ability to cause human illness and infect Ae. aegypti, potential urban spillover and clinical disease from further Brun2014 transmission cannot be discounted.