Masks and respirators for prevention of respiratory infections: a state of the science review.

SUMMARYThis narrative review and meta-analysis summarizes a broad evidence base on the benefits-and also the practicalities, disbenefits, harms and personal, sociocultural and environmental impacts-of masks and masking. Our synthesis of evidence from over 100 published reviews and selected primary studies, including re-analyzing contested meta-analyses of key clinical trials, produced seven key findings. First, there is strong and consistent evidence for airborne transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and other respiratory pathogens. Second, masks are, if correctly and consistently worn, effective in reducing transmission of respiratory diseases and show a dose-response effect. Third, respirators are significantly more effective than medical or cloth masks. Fourth, mask mandates are, overall, effective in reducing community transmission of respiratory pathogens. Fifth, masks are important sociocultural symbols; non-adherence to masking is sometimes linked to political and ideological beliefs and to widely circulated mis- or disinformation. Sixth, while there is much evidence that masks are not generally harmful to the general population, masking may be relatively contraindicated in individuals with certain medical conditions, who may require exemption. Furthermore, certain groups (notably D/deaf people) are disadvantaged when others are masked. Finally, there are risks to the environment from single-use masks and respirators. We propose an agenda for future research, including improved characterization of the situations in which masking should be recommended or mandated; attention to comfort and acceptability; generalized and disability-focused communication support in settings where masks are worn; and development and testing of novel materials and designs for improved filtration, breathability, and environmental impact.

Associations between severe and notifiable respiratory infections during the first trimester of pregnancy and congenital anomalies at birth: a register-based cohort study.

BACKGROUND: Evidence regarding the association between acute respiratory infections during pregnancy and congenital anomalies in babies, is limited and conflicting. The aim of this study was to examine the association between acute respiratory infections during the first trimester of pregnancy and congenital anomalies in babies using record linkage. METHODS: We linked a perinatal register to hospitalisation and disease notifications in the Australian state of New South Wales (NSW) between 2001 to 2016. We quantified the risk of congenital anomalies, identified from the babies' linked hospital record in relation to notifiable respiratory and other infections during pregnancy using generalized Estimating Equations (GEE) adjusted for maternal sociodemographic and other characteristics. RESULTS: Of 1,453,037 birth records identified from the perinatal register between 2001 and 2016, 11,710 (0.81%) mothers were hospitalised for acute respiratory infection, 2850 (0.20%) had influenza and 1011 (0.07%) had high risk infections (a record of cytomegalovirus, rubella, herpes simplex, herpes zoster, toxoplasmosis, syphilis, chickenpox (varicella) and zika) during the pregnancy. During the first trimester, acute respiratory infection, influenza and high-risk infections were reported by 1547 (0.11%), 399 (0.03%) and 129 (0.01%) mothers. There were 15,644 (1.08%) babies reported with major congenital anomalies, 2242 (0.15%) with cleft lip/ plate, 7770 (0.53%) with all major cardiovascular anomalies and 1746 (0.12%) with selected major cardiovascular anomalies. The rate of selected major cardiovascular anomalies was significantly higher if the mother had an acute respiratory infection during the first trimester of pregnancy (AOR 3.64, 95% CI 1.73 to 7.66). The rates of all major congenital anomalies and all major cardiovascular anomalies were also higher if the mother had an acute respiratory infection during the first trimester of pregnancy, however the difference was no statistically significant. Influenza during the first trimester was not associated with major congenital anomalies, selected major cardiovascular anomalies or all major cardiovascular anomalies in this study. CONCLUSION: This large population-based study found severe acute respiratory infection in first trimester of pregnancy was associated with a higher risk of selected major cardiovascular anomalies in babies. These findings support measures to prevent acute respiratory infections in pregnant women including through vaccination.

Recommendations related to occupational infection prevention and control training to protect healthcare workers from infectious diseases: a scoping review of infection prevention and control guidelines.

BACKGROUND: Events such as the COVID-19 pandemic remind us of the heightened risk that healthcare workers (HCWs) have from acquiring infectious diseases at work. Reducing the risk requires a multimodal approach, ensuring that staff have the opportunity to undertake occupational infection prevention and control (OIPC) training. While studies have been done within countries to look at availability and delivery of OIPC training opportunities for HCWs, there has been less focus given to whether their infection prevention and control (IPC) guidelines adhere to recommended best practices. OBJECTIVES: To examine national IPC guidelines for the inclusion of key recommendations on OIPC training for HCWs to protect them from infectious diseases at work and to report on areas of inconsistencies and gaps. METHODS: We applied a scoping review method and reviewed guidelines published in the last twenty years (2000-2020) including the IPC guidelines of World Health Organization and the United States Centers for Disease Control and Prevention. These two guidelines were used as a baseline to compare the inclusion of key elements related to OIPC training with IPC guidelines of four high-income countries /regions i.e., Gulf Cooperation Council, Australia, Canada, United Kingdom and four low-, and middle-income countries (LMIC) i.e. India, Indonesia, Pakistan and, Philippines. RESULTS: Except for the Filipino IPC guideline, all the other guidelines were developed in the last five years. Only two guidelines discussed the need for delivery of OIPC training at undergraduate and/or post graduate level and at workplace induction. Only two acknowledged that training should be based on adult learning principles. None of the LMIC guidelines included recommendations about evaluating training programs. Lastly the mode of delivery and curriculum differed across the guidelines. CONCLUSIONS: Developing a culture of learning in healthcare organizations by incorporating and evaluating OIPC training at different stages of HCWs career path, along with incorporating adult learning principles into national IPC guidelines may help standardize guidance for the development of OIPC training programs. Sustainability of this discourse could be achieved by first updating the national IPC guidelines. Further work is needed to ensure that all relevant healthcare organisations are delivering a package of OIPC training that includes the identified best practice elements.

Reemergence of Human Monkeypox and Declining Population Immunity in the Context of Urbanization, Nigeria, 2017-2020.

A monkeypox outbreak in Nigeria during 2017-2020 provides an illustrative case study for emerging zoonoses. We built a statistical model to simulate declining immunity from monkeypox at 2 levels: At the individual level, we used a constant rate of decline in immunity of 1.29% per year as smallpox vaccination rates fell. At the population level, the cohort of vaccinated residents decreased over time because of deaths and births. By 2016, only 10.1% of the total population in Nigeria was vaccinated against smallpox; the serologic immunity level was 25.7% among vaccinated persons and 2.6% in the overall population. The substantial resurgence of monkeypox in Nigeria in 2017 appears to have been driven by a combination of population growth, accumulation of unvaccinated cohorts, and decline in smallpox vaccine immunity. The expanding unvaccinated population means that entire households, not just children, are now more susceptible to monkeypox, increasing risk of human-to-human transmission.

Effectiveness of Cloth Masks for Protection Against Severe Acute Respiratory Syndrome Coronavirus 2.

Cloth masks have been used in healthcare and community settings to protect the wearer from respiratory infections. The use of cloth masks during the coronavirus disease (COVID-19) pandemic is under debate. The filtration effectiveness of cloth masks is generally lower than that of medical masks and respirators; however, cloth masks may provide some protection if well designed and used correctly. Multilayer cloth masks, designed to fit around the face and made of water-resistant fabric with a high number of threads and finer weave, may provide reasonable protection. Until a cloth mask design is proven to be equally effective as a medical or N95 mask, wearing cloth masks should not be mandated for healthcare workers. In community settings, however, cloth masks may be used to prevent community spread of infections by sick or asymptomatically infected persons, and the public should be educated about their correct use.

Standardizing definitions and reporting guidelines for the infertility core outcome set: an international consensus development study† ‡.

STUDY QUESTION: Can consensus definitions for the core outcome set for infertility be identified in order to recommend a standardized approach to reporting? SUMMARY ANSWER: Consensus definitions for individual core outcomes, contextual statements and a standardized reporting table have been developed. WHAT IS KNOWN ALREADY: Different definitions exist for individual core outcomes for infertility. This variation increases the opportunities for researchers to engage with selective outcome reporting, which undermines secondary research and compromises clinical practice guideline development. STUDY DESIGN, SIZE, DURATION: Potential definitions were identified by a systematic review of definition development initiatives and clinical practice guidelines and by reviewing Cochrane Gynaecology and Fertility Group guidelines. These definitions were discussed in a face-to-face consensus development meeting, which agreed consensus definitions. A standardized approach to reporting was also developed as part of the process. PARTICIPANTS/MATERIALS, SETTING, METHODS: Healthcare professionals, researchers and people with fertility problems were brought together in an open and transparent process using formal consensus development methods. MAIN RESULTS AND THE ROLE OF CHANCE: Forty-four potential definitions were inventoried across four definition development initiatives, including the Harbin Consensus Conference Workshop Group and International Committee for Monitoring Assisted Reproductive Technologies, 12 clinical practice guidelines and Cochrane Gynaecology and Fertility Group guidelines. Twenty-seven participants, from 11 countries, contributed to the consensus development meeting. Consensus definitions were successfully developed for all core outcomes. Specific recommendations were made to improve reporting. LIMITATIONS, REASONS FOR CAUTION: We used consensus development methods, which have inherent limitations. There was limited representation from low- and middle-income countries. WIDER IMPLICATIONS OF THE FINDINGS: A minimum data set should assist researchers in populating protocols, case report forms and other data collection tools. The generic reporting table should provide clear guidance to researchers and improve the reporting of their results within journal publications and conference presentations. Research funding bodies, the Standard Protocol Items: Recommendations for Interventional Trials statement, and over 80 specialty journals have committed to implementing this core outcome set. STUDY FUNDING/COMPETING INTEREST(S): This research was funded by the Catalyst Fund, Royal Society of New Zealand, Auckland Medical Research Fund and Maurice and Phyllis Paykel Trust. Siladitya Bhattacharya reports being the Editor-in-Chief of Human Reproduction Open and an editor of the Cochrane Gynaecology and Fertility Group. J.L.H.E. reports being the Editor Emeritus of Human Reproduction. R.S.L. reports consultancy fees from Abbvie, Bayer, Ferring, Fractyl, Insud Pharma and Kindex and research sponsorship from Guerbet and Hass Avocado Board. B.W.M. reports consultancy fees from Guerbet, iGenomix, Merck, Merck KGaA and ObsEva. C.N. reports being the Editor-in-Chief of Fertility and Sterility and Section Editor of the Journal of Urology, research sponsorship from Ferring, and a financial interest in NexHand. E.H.Y.N. reports research sponsorship from Merck. A.S. reports consultancy fees from Guerbet. J.W. reports being a statistical editor for the Cochrane Gynaecology and Fertility Group. A.V. reports that he is a Statistical Editor of the Cochrane Gynaecology & Fertility Review Group and of the journal Reproduction. His employing institution has received payment from Human Fertilisation and Embryology Authority for his advice on review of research evidence to inform their 'traffic light' system for infertility treatment 'add-ons'. N.L.V. reports consultancy and conference fees from Ferring, Merck and Merck Sharp and Dohme. The remaining authors declare no competing interests in relation to the work presented. All authors have completed the disclosure form. TRIAL REGISTRATION NUMBER: Core Outcome Measures in Effectiveness Trials Initiative: 1023.

Epidemiology of paediatric Middle East respiratory syndrome coronavirus and implications for the control of coronavirus virus disease 2019.

AIM: To compare the clinical features of Middle East respiratory syndrome coronavirus (MERS-CoV) infection between paediatric and adult cases. METHODS: Using multiple public data sources, we created an enhanced open-source surveillance dataset of all MERS-CoV cases between 20 September 2012 and 31 December 2018 in Saudi Arabia including available risk factor data. RESULTS: Of the 1791 cases of MERS-CoV identified, 30 cases (1.7%) were aged under 18 years and 1725 cases (96.3%) were aged 18 years and over. Three paediatric cases were fatal, aged 0, 2 and 15 years. The odds of asymptomatic MERS-CoV infection among cases under 18 years (n = 10/23; 44%) was significantly higher (odds ratio (OR) = 4.98; 95% confidence interval (CI): 2.15-11.51; P = 0.001) compared to adults (n = 199/1487; 13%). The odds of hospitalisation were significantly lower (OR = 0.17; 95% CI: 0.08-0.39; P < 0.001) among cases under 18 years (n = 12/24; 50%) compared to adults (n = 1231/1443; 85%). Children were more likely to have a known source of exposure compared to adults (OR = 2.68; 95% CI: 1.29-5.56; P = 0.008). CONCLUSIONS: Clinically severe illness is less common in children, although death can occur, and the proportion of paediatric cases (1.7%) is similar to that reported for COVID-19. Age-specific differences in the clinical presentation of MERS-CoV cases could have implications for transmission for other betacoronaviruses including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Children may be at risk within the household with an infected adult. More studies are required on the role of children in transmission of betacoronaviruses.

Application of a Risk Analysis Tool to Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Outbreak in Saudi Arabia.

The Grunow-Finke assessment tool (GFT) is an accepted scoring system for determining likelihood of an outbreak being unnatural in origin. Considering its high specificity but low sensitivity, a modified Grunow-Finke tool (mGFT) has been developed with improved sensitivity. The mGFT has been validated against some past disease outbreaks, but it has not been applied to ongoing outbreaks. This study is aimed to score the outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) in Saudi Arabia using both the original GFT and mGFT. The publicly available data on human cases of MERS-CoV infections reported in Saudi Arabia (2012-2018) were sourced from the FluTrackers, World Health Organization, Saudi Ministry of Health, and published literature associated with MERS outbreaks investigations. The risk assessment of MERS-CoV in Saudi Arabia was analyzed using the original GFT and mGFT criteria, algorithms, and thresholds. The scoring points for each criterion were determined by three researchers to minimize the subjectivity. The results showed 40 points of total possible 54 points using the original GFT (likelihood: 74%), and 40 points of a total possible 60 points (likelihood: 67%) using the mGFT, both tools indicating a high likelihood that human MERS-CoV in Saudi Arabia is unnatural in origin. The findings simply flag unusual patterns in this outbreak, but do not prove unnatural etiology. Proof of bioattacks can only be obtained by law enforcement and intelligence agencies. This study demonstrated the value and flexibility of the mGFT in assessing and predicting the risk for an ongoing outbreak with simple criteria.

Hospitalizations for Influenza-Associated Severe Acute Respiratory Infection, Beijing, China, 2014-2016.

We analyzed surveillance data for 2 sentinel hospitals to estimate the influenza-associated severe acute respiratory infection hospitalization rate in Beijing, China. The rate was 39 and 37 per 100,000 persons during the 2014-15 and 2015-16 influenza seasons, respectively. Rates were highest for children <5 years of age.

Gestational age-specific perinatal mortality rates for assisted reproductive technology (ART) and other births.

STUDY QUESTION: Is perinatal mortality rate higher among births born following assisted reproductive technology (ART) compared to non-ART births? SUMMARY ANSWER: Overall perinatal mortality rates in ART births was higher compared to non-ART births, but gestational age-specific perinatal mortality rate of ART births was lower for very preterm and moderate to late preterm births. WHAT IS KNOWN ALREADY: Births born following ART are reported to have higher risk of adverse perinatal outcomes compared to non-ART births. STUDY DESIGN, SIZE, DURATION: This population-based retrospective cohort study included 407 368 babies (391 952 non-ART and 15 416 ART)-393 491 singletons and 10 877 twins or high order multiples. PARTICIPANTS/MATERIALS, SETTING, METHODS: All births (≥20 weeks of gestation and/or ≥400 g of birthweight) in five states and territories in Australia during the period 2007-2009 were included in the study, using National Perinatal Data Collection (NPDC). Primary outcome measures were rates of stillbirth, neonatal and perinatal deaths. Adjusted odds ratio (AOR) and 95% confidence interval (CI) were used to estimate the likelihood of perinatal death. MAIN RESULTS AND THE ROLE OF CHANCE: Rates of multiple birth and low birthweight were significantly higher in ART group compared to the non-ART group (P < 0.01). Overall perinatal mortality rate was significantly higher for ART births (16.5 per 1000 births, 95% CI 14.5-18.6), compared to non-ART births (11.3 per 1000 births, 95% CI 11.0-11.6) (AOR 1.45, 95% CI 1.26-1.68). However, gestational age-specific perinatal mortality rate of ART births (including both singletons and multiples) was lower for very preterm (<32 weeks' gestation) and moderate to late preterm births (32-36 weeks' gestation) (AOR 0.61, 95% CI 0.53-0.70 and AOR 0.61, 95% CI 0.53-0.70, respectively) compared to non-ART births. Congenital abnormality and spontaneous preterm were the most common causes of neonatal deaths in both ART and non-ART group. LIMITATIONS, REASONS FOR CAUTION: Due to different cut-off limit for perinatal period in Australia, the results of this study should be interpreted with cautions for other countries. Australian definition of perinatal period commences at 20 completed weeks (140 days) of gestation and ends 27 completed days after birth which is different from the definition by World Health Organisation (commences at 22 completed weeks (154 days) of gestation and ends seven completed days after birth) and by Centers for Disease Control and Prevention (includes infant deaths under age 7 days and fetal deaths at 28 weeks of gestation or more). WIDER IMPLICATIONS OF THE FINDINGS: Preterm birth is the single most important contributing factor to increased risk of perinatal mortality among ART singletons compared to non-ART singletons. Further research on reducing early preterm delivery, with the aim of reducing the perinatal mortality among ART births is needed. Couples who access ART treatment should be fully informed regarding the risk of preterm birth and subsequent risk of perinatal death. STUDY FUNDING/COMPETING INTEREST(S): There was no funding associated with this study. No conflict of interest was declared.

The association between acute flaccid myelitis (AFM) and Enterovirus D68 (EV-D68) - what is the evidence for causation?

BackgroundEnterovirus D68 (EV-D68) has historically been a sporadic disease, causing occasional small outbreaks of generally mild infection. In recent years, there has been evidence of an increase in EV-D68 infections globally. Large outbreaks of EV-D68, with thousands of cases, occurred in the United States, Canada and Europe in 2014. The outbreaks were associated temporally and geographically with an increase in clusters of acute flaccid myelitis (AFM).Aims: We aimed to evaluate a causal association between EV-D68 and AFM. Methods: Using data from the published and grey literature, we applied the Bradford Hill criteria, a set of nine principles applied to examine causality, to evaluate the relationship between EV-D68 and AFM. Based on available evidence, we defined the Bradford Hill Criteria as being not met, or met minimally, partially or fully. Results: Available evidence applied to EV-D68 and AFM showed that six of the Bradford Hill criteria were fully met and two were partially met. The criterion of biological gradient was minimally met. The incidence of EV-D68 infections is increasing world-wide. Phylogenetic epidemiology showed diversification from the original Fermon and Rhyne strains since the year 2000, with evolution of a genetically distinct outbreak strain, clade B1. Clade B1, but not older strains, is associated with AFM and is neuropathic in animal models. Conclusion: While more research is needed on dose-response relationship, application of the Bradford Hill criteria supported a causal relationship between EV-D68 and AFM.

Translation of Real-Time Infectious Disease Modeling into Routine Public Health Practice.

Infectious disease dynamic modeling can support outbreak emergency responses. We conducted a workshop to canvas the needs of stakeholders in Australia for practical, real-time modeling tools for infectious disease emergencies. The workshop was attended by 29 participants who represented government, defense, general practice, and academia stakeholders. We found that modeling is underused in Australia and its potential is poorly understood by practitioners involved in epidemic responses. The development of better modeling tools is desired. Ideal modeling tools for operational use would be easy to use, clearly indicate underlying parameterization and assumptions, and assist with policy and decision making.

Morbidity and mortality among very preterm singletons following fertility treatment in Australia and New Zealand, a population cohort study.

BACKGROUND: Due to high rates of multiple birth and preterm birth following fertility treatment, the rates of mortality and morbidity among births following fertility treatment were higher than those conceived spontaneously. However, it is unclear whether the rates of adverse neonatal outcomes remain higher for very preterm (<32 weeks gestational age) singletons born after fertility treatment. This study aims to compare adverse neonatal outcomes among very preterm singletons born after fertility treatment including assisted reproductive technology (ART) hyper-ovulution (HO) and artificial insemination (AI) to those following spontaneous conception. METHODS: The population cohort study included 24069 liveborn very preterm singletons who were admitted to Neonatal Intensive Care Unit (NICU) in Australia and New Zealand from 2000 to 2010. The in-hospital neonatal mortality and morbidity among 21753 liveborn very preterm singletons were compared by maternal mode of conceptions: spontaneous conception, HO, ART and AI. Univariate and multivariate binary logistic regression analysis was used to examine the association between mode of conception and various outcome factors. Odds ratio (OR) and adjusted odds ratio (AOR) and 95% confidence interval (CI) were calculated. RESULTS: The rate of small for gestational age was significantly higher in HO group (AOR 1.52, 95% CI 1.02-2.67) and AI group (AOR 2.98, 95% CI 1.53-5.81) than spontaneous group. The rate of birth defect was significantly higher in ART group (AOR 1.71, 95% CI 1.36-2.16) and AI group (AOR 3.01, 95% CI 1.47-6.19) compared to spontaneous group. Singletons following ART had 43% increased odds of necrotizing enterocolitis (AOR 1.43, 95% CI 1.04-1.97) and 71% increased odds of major surgery (AOR 1.71, 95% CI 1.37-2.13) compared to singletons conceived spontaneously. Other birth and NICU outcomes were not different among the comparison groups. CONCLUSIONS: Compared to the spontaneous conception group, risk of congenital abnormality significantly increases after ART and AI; the risk of morbidities increases after ART, HO and AI. Preconception planning should include comprehensive information about the benefits and risks of fertility treatment on the neonatal outcomes.

Application of the Modified Grunow-Finke Risk Assessment Tool to the Sverdlovsk Anthrax Outbreak of 1979.

INTRODUCTION: The modified Grunow-Finke tool (mGFT) is an improved scoring system for distinguishing unnatural outbreaks from natural ones. The 1979 Sverdlovsk anthrax outbreak was due to the inhalation of anthrax spores from a military laboratory, confirmed by Russian President Boris Yeltsin in 1992. At the time the Soviet Union insisted that the outbreak was caused by meat contaminated by diseased animals. At the time there was no available risk assessment tool capable of thoroughly examine the origin of the outbreak. METHODS: This study aimed to retrospectively apply the mGFT to test its ability to correctly identify the origin of the Sverdlovsk anthrax outbreak of 1979 as unnatural, using data available up to 1992, before the disclosure of a laboratory leak. Data spanning from 1979 to 1992 were collected through literature reviews. Evidence related to each mGFT criterion was scored on a scale of 0 to 3 and independently reviewed by 3 assessors. These scores were then multiplied with a weighting factor and summed to obtain a maximum score. A final score exceeding 30 was indicative of an unnatural origin. RESULTS: The mGFT results assigned a total of 47 points to the Sverdlovsk anthrax outbreak, suggesting an unnatural origin with a 78% likelihood. CONCLUSIONS: These findings align with the confirmed unnatural origin of the outbreak, highlighting the value of tools such as the mGFT in identifying unnatural outbreaks. Such tools integrate both intelligence evidence and biological evidence in the identification of unnatural outbreaks. The use of such tools for identifying unnatural outbreaks is limited. Outbreak investigation can be improved if risk assessment tools become integral to routine public health practice and outbreak investigations.

Gender disparity in tuberculosis cases in eastern and western provinces of Pakistan.

BACKGROUND: Although globally, the number of notified TB cases is higher for males, a few countries in the Eastern Mediterranean Region (Afghanistan; Lebanon; Iran and Pakistan) of the World Health Organization have a relatively higher number of female cases. Pakistan ranks fifth amongst the highest TB burden countries and poses a rich ground for exploratory research to address the gender differences in TB cases. It is uniquely neighboured by India on the East, having higher number of cases in males than in females, and by Afghanistan and Iran on the West, having higher number of cases in females than in males. The objective is to see whether these gender differences are evenly distributed across the country or vary by geographies, to enable effective targeting of TB control strategies. METHODS: Cross-sectional analysis was carried out on secondary data, obtained from National Tuberculosis Program. Disaggregated at the provincial level, the sex-specific case notification rates (CNR) were calculated and trends over a 10-year span (2001-2010) were examined. Sex-specific differences for the four Pakistani provinces were analyzed using chi-square test and odds ratios with corresponding confidence intervals. Cumulative countrywide sex-specific notification rates were used as the reference group. RESULTS: The trends for 2001-2010 in the western provinces of Pakistan show higher female CNR as compared to those seen in the eastern provinces having slightly higher male CNR. The proportions of female notified TB cases are approximately twice as high in the western provinces when compared to the eastern provinces and Pakistan over all. CONCLUSIONS: These findings suggest that females are particularly affected by TB disease burden in the west parts of Pakistan. This gender disparity requires a coordinated regional and international effort to further explore triggers and moderators of increased acquisition and progression of TB disease among females in the region to guarantee effective TB control.

Factors associated with repeated influenza vaccine uptake among aged care staff in an Australian sample from 2017 to 2019.

BACKGROUND/AIM: Influenza vaccination is strongly recommended every year for aged care staff to protect themselves and minimise risk of transmission to residents. This study aimed to determine the factors associated with repeated annual influenza vaccine uptake among Australian aged care staff from 2017 to 2019. METHODS: Demographic, medical and vaccination data collected from the staff, who participated in an observational study from nine aged care facilities under a single provider in Sydney Australia, were analysed retrospectively. Based on the pattern of repeated influenza vaccination from 2017 to 2019, three groups were identified: (1) unvaccinated all three years; (2) vaccinated occasionally(once or twice) over three years; and (3)vaccinated all threeyears. Multinomial logistic regression analysis was performed to better understand the factors associated with the pattern of repeated influenza vaccination. RESULTS: From a total of 138 staff, between 2017 and 2019, 28.9 % (n = 40) never had a vaccination, while 44.2 % (n = 61) had vaccination occasionally and 26.8 % (n = 37) had vaccination all three years. In the multinomial logistic regression model, those who were<40 years old (OR = 0.57, 95 % CI: 0.19-0.90, p < 0.05) and those who were current smokers (OR = 0.20; 95 % CI: 0.03-0.76, p < 0.05) were less likely to have repeated vaccination for all three years compared to the unvaccinated group. Those who were<40 years old (OR = 0.61; 95 % CI: 0.22-0.68, p < 0.05) and those who were born overseas (OR = 0.50; 95 % CI:0.27-0.69, p < 0.05) were more likely to be vaccinated occasionally compared to the unvaccinated group. CONCLUSION: The significant predictors of repeated vaccine uptake across the three-year study period among aged care staff were age, smoking status and country of birth (Other vs Australia). Targeted interventions towards the younger age group (<40 years old), smokers and those who were born overseas could improve repeated influenza vaccination uptake in the aged care workforce.

Factors Associated With SARS-CoV-2 Attack Rates in Aged Care-A Meta-analysis.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has resulted in significant morbidity and mortality in aged-care facilities worldwide. The attention of infection control in aged care needs to shift towards the built environment, especially in relation to using the existing space to allow social distancing and isolation. Physical infrastructure of aged care facilities has been shown to present challenges to the implementation of isolation procedures. To explore the relationship of the physical layout of aged care facilities with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) attack rates among residents, a meta-analysis was conducted. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol (PRISMA-P), studies were identified from 5 databases using a registered search strategy with PROSPERO. Meta-analysis for pooled attack rates of SARS-CoV-2 in residents and staff was conducted, with subgroup analysis for physical layout variables such as total number of beds, single rooms, number of floors, number of buildings in the facility, and staff per 100 beds. RESULTS: We included 41 articles across 11 countries, reporting on 90 657 residents and 6521 staff in 757 facilities. The overall pooled attack rate was 42.0% among residents (95% CI, 38.0%-47.0%) and 21.7% in staff (95% CI, 15.0%-28.4%). Attack rates in residents were significantly higher in single-site facilities with standalone buildings than facilities with smaller, detached buildings. Staff-to-bed ratio significantly explains some of the heterogeneity of the attack rate between studies. CONCLUSIONS: The design of aged care facilities should be smaller in size, with adequate space for social distancing.

Effectiveness estimates for enhanced trivalent influenza vaccines in an aged care summer outbreak.

An influenza outbreak occurred during summer (February 2019) in an aged-care facility in Sydney, Australia. Residents had not received the annual 2019 influenza vaccine while 76.7% had received 2018 influenza vaccines about 9 months prior. Overall, 2018 influenza vaccine effectiveness during this outbreak was high (93.6%). The effectiveness of the high-dose trivalent vaccine (HD-TIV) and adjuvanted trivalent (a-TIV) vaccine were 89.8% (95% confidence interval: 18.8%-98.7%) and 72.5% (95% confidence interval: -106.7%-96.3%) respectively. The differences in effectiveness between HD-TIV, a-TIV and SD-QIV, during the summer outbreak were not significant.

Policy Analysis for Prevention and Control of Influenza in Aged Care.

OBJECTIVE: This study aimed to analyze national influenza infection control policy documents within aged care settings by identifying the consistencies, inconsistencies, and gaps with the current evidence and by evaluating methodological quality. Aged care providers can use these findings to identify their policy documents' strengths and weaknesses. DESIGN: A quality and content analysis of national level policy documents. SETTING AND PARTICIPANTS: Aged care settings rely on national agencies' policy recommendations to control and prevent outbreaks. There is limited research on the effectiveness of control measures to prevent and treat influenza within aged care settings. Because of the complexities around aged care governance, the primary responsibility in developing a comprehensive facility-level, infection-prevention policy, falls to the providers. METHODS: The analysis was conducted using the (1) International Appraisal of Guidelines, Research and Evaluation assessment tool, containing 23 items across 6 domains; and the (2) Influenza Related Control Measures in Aged Care settings checklist, developed by the authors, with 82 recommendations covering: medical interventions, nonmedical interventions, and physical layout. RESULTS: There were 19 documents from 9 different high-income countries, with a moderately high methodological quality in general. The quality assessment's average score was 40.2% (95% CI 31.9%-44.7%). "Stakeholder involvement" ranked third, and "Editorial independence" and "Rigor of development" had the lowest average scores across all domains. The content analysis' average score was 37.2% (95% CI 10.5%-21.5%). The highest scoring document (59.1%) included term definitions, cited evidence for recommendations, and clear measurable instructions. "Physical Layout" had the least coverage and averaged 21.9% (95% CI 4.2%-37.5%), which shows a substantial gap in built environment recommendations. CONCLUSIONS AND IMPLICATIONS: Existing policy documents vary in their comprehensiveness. The higher scoring documents provide an ideal model for providers. The checklist tools can be used to assess and enhance documents. Further research on document end-user evaluation would be useful, as there is room for improvement in methodological quality and coverage of recommendation coverage, especially related to physical layout.