Abstract: A household matched case-control study design was used to explore associations between household characteristics and malaria risk in seven study towns in the hypoendemic area of Mpumalanga Province, South Africa. Controls were identified from neighboring households of each case. Principle component analysis was used to calculate a wealth index for households to allow comparison across socioeconomic groups. Conditional univariate and multiple logistic regression analyses were used to assess associations between household malaria risk and potential risk factors. Univariate analysis demonstrated an increased household malaria risk for people living in mud-walled houses compared with those in brick dwellings (OR=5.10, 95% CI 2.03-12.80, P=0.001). Multivariate analysis confirmed the association between malaria risk and mud-wall construction (OR=6.12, 95% CI 2.26-16.59, P=0.001) and demonstrated an association with opening windows after retiring to sleep (OR=4.01, 95% CI 1.32-12.18, P=0.014). An inverse association between household wealth, third (OR=0.24, 95% CI 0.09-0.65, P=0.005) and fourth quartiles (OR=0.27, 95% CI 0.10-0.79, P=0.016), and malaria risk was observed. Associations found here include increased household malaria risk and mud-wall construction, the practice of opening of windows at night and relative household poverty. Education campaigns targeting risk behavior may reduce malaria risk, but economic development is a more important intervention.
Abstract: INTRODUCTION: Invasive meningococcal disease (IMD) is the most common infectious cause of death in childhood in developed countries. This disease may cause severe disability or death if a patient is sub-optimally managed. An audit was performed in Australia of all 2005-06 notified IMD cases to elicit correctable issues. METHODS: Over the 2 year period, 24 cases were notified in the Hunter New England Health area. These cases were reviewed by an expert panel to highlight key correctable issues in recognition and management of IMD. RESULTS: The 24 patients were aged between 1 month and 70 years. Thirteen (54%) were children and 14 (58%) were women. Six (25%) cases developed complications, two being severe (one death, one limb amputations). These patients had risk factors for IMD. The emergency department average delay between assessment and administration of antibiotics was 57.8 min. CONCLUSION: There were avoidable factors identified in both patients with a poor outcome. Length of delay in initiating antibiotic therapy has been associated with poor outcome, thus the delay in our series is of concern. The audit highlighted many potentially correctable issues in the medical, laboratory and public health management of IMD cases.
Abstract: OBJECTIVE: To investigate the Australian public's expectations, concerns and willingness to accept vaccination with the pandemic (H1N1) 2009 influenza vaccine. DESIGN, SETTING AND PARTICIPANTS: A computer-assisted telephone interview survey was conducted between 20 August and 11 September 2009 by trained professional interviewers to study issues relating to vaccine uptake and perceived safety. The sample comprised 1155 randomly selected representative adults who had participated in a 2007 national study exploring knowledge and perceptions of pandemic influenza. MAIN OUTCOME MEASURES: Likely acceptance of pandemic (H1N1) 2009 vaccination, factors associated with acceptance, and respondents' willingness to share Australian vaccine with neighbouring developing countries. RESULTS: Of 1155 possible participants, 830 (72%) were successfully interviewed. Twenty per cent of the study group (169/830) reported that they had developed influenza-like symptoms during the 2009 pandemic period. Most respondents (645/830, 78%) considered pandemic (H1N1) 2009 to be a mild disease, and 211/830 (25%) regarded themselves as being at increased risk of infection. Willingness to accept pandemic (H1N1) 2009 vaccination was high (556/830, 67%) but was significantly lower than when pandemic vaccination uptake was investigated in 2007 (88%; P < 0.0001). Respondents who had already been vaccinated against seasonal influenza and those who perceived pandemic (H1N1) 2009 to be severe were significantly more willing to accept vaccination. Most respondents (793/822, 96%) were willing to share surplus vaccine with developing countries in our region. CONCLUSION: Although two-thirds of Australian adults surveyed were willing to accept pandemic (H1N1) 2009 vaccination, and most supported sharing vaccine with developing countries, there is a need for accessible information on vaccine safety for those who are undecided about vaccination.
Abstract: Aim: To determine factors associated with microbiological safety of public drinking water systems in regional New South Wales (NSW), Australia.Method: We analysed 107,000 end-user drinking water samples for an association between detection of Escherichia coli and drinking water system features, sample year and season using NSW Health Drinking Water Monitoring Program data, 2001-2007. We used negative binomial generalized estimating equations with adjustment for autocorrelation and clustering.Results: We detected E. coli in over 2% of samples from 40% (129/323) of systems. E. coli detection was significantly more common in earlier years and during summer (p<0.001). On multivariate analysis E. coli detection was significantly associated with smaller systems; watercourse sources; no disinfection or disinfection with ultraviolet only; and higher post-treatment mean turbidity (all p</=0.01). Detection was most strongly associated with lack of disinfection (incidence rate ratio 12.6, p<0.001) and smaller supply systems (1% reduction in E. coli detection for each 1,000 person increase in supply population, p=0.004). Ultraviolet disinfection alone was the least effective disinfection method (p<0.001).Conclusion: Even in developed countries, drinking water systems without disinfection or serving small populations appear vulnerable to the effects of faecal contamination, which presents a risk of waterborne disease outbreaks.
Abstract: The association between farming risks and Q fever is not well documented in Australia. In a review of New South Wales notifications, data were analysed using 3-year study periods from 1993 to 2007 to investigate possible trends and explore reported risk exposures. A retrospective case series was also conducted using acute Q fever cases notified during 2007 from a rural area of New South Wales. Occupation was recorded for less than 50% of Q fever notifications in New South Wales during the study period. A significant decline in the proportion of notifications occurred in the occupational group reported as 'Abattoir/ Meat' worker and a significant increase occurred in the 'Farmer/Livestock' category. The case series found that in the month prior to illness onset 78% (42/54) reported direct contact with animals. In the month prior to becoming ill with Q fever 71% (31/51) of employed cases had contact with newly introduced livestock in their workplace. As a result of their Q fever illness 93% of cases required time off work or school, with a median of 21 days. At the time of the structured interviews 63% had not fully recovered. The epidemiology of Q fever disease in New South Wales has changed and amongst notified cases the relative importance of non-abattoir contact with livestock, wildlife or feral animals appears to be increasing. The surveillance field 'Occupation' no longer alone adequately describes risk exposure for many of the people notified with Q fever and a new field that better describes risk exposures is required. This may allow more finely tuned vaccination policy.
Abstract: A multi-state outbreak of Salmonella enterica serovar Saintpaul infection occurred in Australia during October 2006. A case-control study conducted in three affected jurisdictions, New South Wales, Victoria and Australian Capital Territory, included 36 cases with the outbreak-specific strain of S. Saintpaul identified by multiple locus variable-number tandem repeat analysis (MLVA) in a faecal specimen and 106 controls. Consumption of cantaloupe (rockmelon) was strongly associated with illness (adjusted OR 23.9 95%, 95% CI 5.1-112.4). S. Saintpaul, with the outbreak MLVA profile, was detected on the skin of two cantaloupes obtained from an implicated retailer. Trace-back investigations did not identify the specific source of the outbreak strain of S. Saintpaul, but multiple Salmonella spp. were detected in environmental samples from farms and packing plants investigated during the trace-back operation. Cantaloupe production and processing practices pose a potential public health threat requiring regulatory and community educational interventions.
Abstract: Summer outbreaks of respiratory illness in residential aged care facilities are uncommonly reported in New South Wales. A respiratory illness outbreak in an aged care facility during January 2008 prompted a response to contain the outbreak by implementing infection control measures, including cohorting of symptomatic residents, cohorting nursing care, closure to new admissions and the use of personal protective equipment by staff. In addition, respiratory tract specimens were collected to determine the causative agent. Human metapneumovirus (hMPV) was detected by polymerase chain reaction assay in 3 specimens with no other respiratory pathogens found. This is the 1st reported outbreak of hMPV in an aged care facility in Australia. hPMV should be considered as the possible cause of outbreaks in aged care facilities when influenza and respiratory syncytial virus have been excluded.
Abstract: BACKGROUND: Mpumalanga Province, South Africa is a low malaria transmission area that is subject to malaria epidemics. SaTScan methodology was used by the malaria control programme to detect local malaria clusters to assist disease control planning. The third season for case cluster identification overlapped with the first season of implementing an outbreak identification and response system in the area. METHODS: SaTScan software using the Kulldorf method of retrospective space-time permutation and the Bernoulli purely spatial model was used to identify malaria clusters using definitively confirmed individual cases in seven towns over three malaria seasons. Following passive case reporting at health facilities during the 2002 to 2005 seasons, active case detection was carried out in the communities, this assisted with determining the probable source of infection. The distribution and statistical significance of the clusters were explored by means of Monte Carlo replication of data sets under the null hypothesis with replications greater than 999 to ensure adequate power for defining clusters. RESULTS AND DISCUSSION: SaTScan detected five space-clusters and two space-time clusters during the study period. There was strong concordance between recognized local clustering of cases and outbreak declaration in specific towns. Both Albertsnek and Thambokulu reported malaria outbreaks in the same season as space-time clusters. This synergy may allow mutual validation of the two systems in confirming outbreaks demanding additional resources and cluster identification at local level to better target resources. CONCLUSION: Exploring the clustering of cases assisted with the planning of public health activities, including mobilizing health workers and resources. Where appropriate additional indoor residual spraying, focal larviciding and health promotion activities, were all also carried out.
Abstract: OBJECTIVE: To examine the level of stated compliance with public health pandemic influenza control measures and explore factors influencing cooperation for pandemic influenza control in Australia. METHODS: A computer-assisted telephone interview survey was conducted by professional interviewers to collect information on the Australian public's knowledge of pandemic influenza and willingness to comply with public health control measures. The sample was randomly selected using an electronic database and printed telephone directories to ensure sample representativeness from all Australian states and territories. After we described pandemic influenza to the respondents to ensure they understood the significance of the issue, the questions on compliance were repeated and changes in responses were analysed with McNemar's test for paired data FINDINGS: Only 23% of the 1166 respondents demonstrated a clear understanding of the term 'pandemic influenza'. Of those interviewed, 94.1% reported being willing to comply with home quarantine; 94.2%, to avoid public events; and 90.7%, to postpone social gatherings. After we explained the meaning of 'pandemic' to interviewees, stated compliance increased significantly (to 97.5%, 98.3% and 97.2% respectively). Those who reported being unfamiliar with the term 'pandemic influenza,' male respondents and employed people not able to work from home were less willing to comply. CONCLUSION: In Australia, should the threat arise, compliance with containment measures against pandemic influenza is likely to be high, yet it could be further enhanced through a public education programme conveying just a few key messages. A basic understanding of pandemic influenza is associated with stated willingness to comply with containment measures. Investing now in promoting measures to prepare for a pandemic or other health emergency will have considerable value.
Abstract: BACKGROUND: Lymphatic Filariasis (LF) is an important Neglected Tropical Disease, being a major cause of disability worldwide. The Global Programme to Eliminate Lymphatic Filariasis aims to eliminate LF as a public health problem by the year 2020, primarily through repeated Mass Drug Administration (MDA). The Pacific region programme commenced in 1999. By June 2007, five of the eleven countries classified as endemic had completed five MDA campaigns and post-MDA prevalence surveys to assess their progress. We review available programme data and discuss their implications for other LF elimination programs in developing countries. METHODS: Reported MDA coverage and results from initial surveys and post-MDA surveys of LF using the immunochromatographic test (ICT) from these five Pacific Island countries (Tonga, Niue, Vanuatu, Samoa and Cook Islands) were analysed to provide an understanding of their quality and programme progress towards LF elimination. Denominator data reported by each country programme for 2001 was compared to official sources to assess the accuracy of MDA coverage data. RESULTS: Initial survey results from these five countries revealed an ICT prevalence of between 2.7 and 8.6 percent in individuals tested prior to commencement of the programme. Country MDA coverage results varied depending on the source of denominator data. Of the five countries in this case study, three countries (Tonga, Niue and Vanuatu) reached the target prevalence of <1% antigenaemia following five rounds of MDA. However, endpoint data could not be reliably compared to baseline data as survey methodology varied. CONCLUSION: Accurate and representative baseline and post-campaign prevalence data is crucial for determining program effectiveness and the factors contributing to effectiveness. This is emphasised by the findings of this case study. While three of the five Pacific countries reported achieving the target prevalence of <1% antigenaemia, limitations in the data preclude identification of key determinants of this achievement.
Abstract: Salmonellosis is a bacterial disease that causes acute gastroenteritis, with sudden onset of headache, abdominal pain, diarrhoea, nausea and sometimes vomiting. Infection is often associated with the consumption of foods prepared using raw eggs. During July to August 2008 an outbreak at an aged care facility (ACF) in New South Wales was confirmed as Salmonella Typhimurium phage type 44 (Stm 44) in eight of 45 residents. Two additional probable cases also occurred. Cases were located in each unit of the ACF and for 5 cases, onset of diarrhoea was between 45 to 64 hours (median of 46 hours) after consumption of a dessert containing raw eggs. Onset for 5 further cases occurred up to 9 days after this meal. Eggs were supplied to the ACF from a local farm. Stm 44 was detected on an egg in an unopened box at the ACF from this supplier. The raw-egg dessert was epidemiologically implicated as the likely source of the Salmonella and delayed onset cases may have resulted from ingestion of a smaller dose of Salmonella, or ongoing transmission through cross-contamination of kitchen machinery or surfaces. This outbreak demonstrates that inadequate cooking of eggs continues to pose a risk for Salmonella infection in settings with vulnerable populations. The findings of the investigation provide support for the importance of food safety regulations and demand further advocacy for measures to reduce the risks associated with the distribution, storage and preparation of shell eggs.
Abstract: Surveillance for influenza is an important public health function as it allows initiation and evaluation of public health measures. Flutracking is a weekly online survey of influenza-like illness (ILI) completed by community members that has been trialled in the 2006, 2007, and 2008 winter influenza seasons. The online survey allows participants to record their past and current influenza immunisation status and they receive a weekly email prompt to answer questions on the previous week's experience of cough, fever and time absent from normal activities. The weekly survey takes participants less than 15 seconds to complete. Symptom rates of Flutracking participants were compared by influenza vaccination status to estimate the incidence and severity of influenza and the field effectiveness of influenza vaccine. Participation rates increased from 394 in 2006 to 982 in 2007 and 4,827 in 2008. In 2008, 56% of participants were from New South Wales and 26% were from Tasmania. Greater than 70% of respondents replied within 24 hours of the survey being sent in 2007 and 2008. The 2008 influenza season appeared milder than 2007 with the peak weekly rate of cough and fever among all unvaccinated participants at 7% in 2008 compared with 15% in 2007. The peak week of influenza activity detected by Flutracking in 2008 was the week ending 31 August, which was contemporaneous with the peak week in other syndromic and laboratory influenza surveillance systems. Participation in the survey continues to grow and appears sustainable. A more balanced recruitment across jurisdictions will provide a more national perspective.
Abstract: General practice and hospital surveillance for influenza-like illness (ILI) and laboratory influenza surveillance provide useful but incomplete information on influenza incidence. Flutracking is an Australian pilot of an Internet-based community ILI syndromic surveillance system designed to detect inter-pandemic and, potentially, pandemic influenza. Presence of fever and/or cough and absence from normal duties are collected weekly. Influenza vaccination status of respondents is recorded. New South Wales Flutracking data for 2007 were compared with New South Wales laboratory notifications for confirmed influenza to validate it's ability to provide alerts of influenza activity. Symptom rates amongst vaccinated and unvaccinated Flutracking respondents were compared using a variety of case definitions, with New South Wales laboratory influenza notifications. Time series methods were used to estimate the degree of correlation between each Flutracking case definition and the laboratory data. For the unvaccinated group, the correlations between all Flutracking case definitions and laboratory data were statistically significant, while for the vaccinated group no case definitions were significantly correlated with laboratory data. Thus Flutracking ILI data amongst unvaccinated participants correlated well with influenza laboratory surveillance.
Abstract: A multi-agency investigation followed the notification of four locally acquired human brucellosis cases in north-west NSW. Feral pig hunting within a geographically discrete region was identified as the likely exposure with Brucella suis the suspected cause. To test whether feral pigs in the region were infected with Brucella, serological testing was performed on trapped feral pigs and testicular abscesses from condemned carcasses bound for export were cultured. Although no Brucella species were identified in the feral pigs tested in NSW, Leptospira species were. Strengthening of human surveillance and ongoing collaboration between animal and human health agencies is required to confirm that Brucella suis causes brucellosis in humans and feral pigs in north-west NSW.
Abstract: BACKGROUND: Outbreak investigation is a core function of public health agencies. Suboptimal outbreak investigation endangers both public health and agency reputations. While audits of clinical medical and nursing practice are conducted as part of continuous quality improvement, public health agencies rarely make systematic use of structured audits to ensure best practice for outbreak responses, and there is limited guidance or policy to guide outbreak audit. METHODS: A framework for prioritising which outbreak investigations to audit, an approach for conducting a successful audit, and a template for audit trigger questions was developed and trialled in four foodborne outbreaks and a respiratory disease outbreak in Australia. RESULTS: The following issues were identified across several structured audits: the need for clear definitions of roles and responsibilities both within and between agencies, improved communication between agencies and with external stakeholders involved in outbreaks, and the need for development of performance standards in outbreak investigations - particularly in relation to timeliness of response. Participants considered the audit process and methodology to be clear, useful, and non-threatening. Most audits can be conducted within two to three hours, however, some participants felt this limited the scope of the audit. CONCLUSION: The framework was acceptable to participants, provided an opportunity for clarifying perceptions and enhancing partnership approaches, and provided useful recommendations for approaching future outbreaks. Future challenges include incorporating feedback from broader stakeholder groups, for example those of affected cases, institutions and businesses; assessing the quality of a specific audit; developing training for both participants and facilitators; and building a central capacity to support jurisdictions embarking on an audit. The incorporation of measurable performance criteria or sharing of benchmark performance criteria will assist in the standardisation of outbreak investigation audit and further quality improvement.
Abstract: OBJECTIVES: Campylobacteriosis is not notifiable in NSW and the number of cases of Campylobacter disease is thus not well described. METHODS: De-identified campylobacteriosis records for 2004-2007 were requested from laboratories in the Hunter region of NSW. Based on notifying laboratory, a Salmonella notification weighting was applied to laboratory-confirmed campylobacteriosis cases to provide an overall estimate of Campylobacter disease in the area. RESULTS: The estimated median of the annual number of laboratory-confirmed campylobacteriosis cases was 788 (range 700-1022). The ratio of estimated Campylobacter cases to Salmonella notifications was 5.5 : 1. CONCLUSION: Campylobacter infection causes considerable disease in the Hunter, and likely in NSW. Regular review of Campylobacter laboratory results may be valuable.
Abstract: Recent experience during Australia's initial public health response to the swine influenza pandemic provides valuable lessons for the future. An intense containment effort lasting 7 weeks was unable to prevent local community transmission in some areas of Australia; however, despite the mobility of many people living in rural and remote parts of the country, much of the outback was unaffected. By the end of the Containment Phase, most parts of rural New South Wales only recorded low rates of confirmed H1N109 infection. As Australians living in rural areas often have poorer access to health services than their urban counterparts, they are likely to be more affected by an extended emergency, even one as moderate as the present H1N109 swine influenza pandemic. There may have been benefits in extending containment measures in these less affected areas and in communities where large numbers of vulnerable people such as Indigenous Australians reside. Containment is worthwhile in limiting the spread of disease in specific situations but is unlikely to change the course of a pandemic unless it can be sustained until a large proportion of the population is vaccinated. Strenuous containment efforts should certainly be applied in outbreaks of severe disease, particularly those caused by novel infectious agents with a low reproductive rate (R0). Should advances in vaccine manufacture reduce the time taken to produce a new vaccine, then increased effort to extend containment will be even more worthwhile.
Abstract: CONTEXT: Aboriginal people are particularly vulnerable to pandemic influenza A, H1N109. This was first recognized in the First Nations of Canada. There have been calls for close planning with Aboriginal people to manage these risks. This article describes the process and findings from preliminary community consultations into reducing influenza risk, including pandemic H1N1(09) swine influenza, in Aboriginal communities in the Hunter New England area of northern New South Wales, Australia. ISSUE: Consultation was conducted with 6 Aboriginal communities in response to the rapidly evolving pandemic and was designed to further develop shared understanding between health services and Aboriginal communities about appropriate and culturally safe ways to reduce the influenza risk in communities. Agreed risk mitigation measures identified in partnership are being introduced throughout Hunter New England area. LESSONS LEARNED: Five theme areas were identified that posed particular challenges to limiting the negative impact of pandemic influenza; and a number of potential solutions emerged from focus group discussions: (1) local resource person: local identified 'go to' people are heard and trusted, but need to have an understanding of H1N109; (2) clear communication: information must be presented simply, clearly and demonstrating respect for local culture; (3) access to health services: sick people need to know where to get help and how to get there without infecting others; (4) households and funerals: infection control messages should be aligned with the reality of life in Aboriginal communities, and the importance of attending family and cultural gatherings; (5) social and community support issues: Aboriginal people need to have a say in how support is provided. Influenza pandemics are a serious threat to the health and social functioning of Aboriginal communities. Measures to reduce the risk of influenza in communities must be developed with the communities to maximise their acceptance. The process of engagement and ongoing respectful negotiations with communities is critical to developing culturally appropriate pandemic mitigation and management strategies.
Abstract: The acute encephalitis syndrome has heralded the emergence of multiple virulent pathogens, including Murray Valley encephalitis, Hendra virus and Australian bat lyssavirus, which may result in severe morbidity and mortality. In Australia, encephalitis is not notifiable and there has been no analysis of trends in encephalitis death rates or causation. Australian Bureau of Statistics mortality and population data for the period 1979-2006 were obtained and cause of death data were extracted using ICD-9 (1979-1998) and ICD-10 (1999-2006) codes that included all relevant encephalitis related diagnoses. Encephalitis-associated deaths were analysed by cause, year, age and gender. Between 1979 and 2006 there were 1,118 encephalitis-associated deaths in Australia. The average annual death rate was 2.3 per 1 million population (range 1.3-3.6). There was a significant decline in encephalitis-associated deaths, particularly due to 'known' pathogens (4.3% decline per year, 95% CI 3.1-5.4%, P<0.0001). The aetiology of 576 deaths were unknown and the proportion of deaths due to 'unknown' encephalitis increased from 47.0% between 1979 and 1992, to 57.2% from 1993 to 2006. Downward trends in encephalitis deaths due to 'known' causes can largely be explained by changes in treatment and prevention methods, particularly for herpes encephalitis (use of acyclovir), and measles encephalitis and subacute sclerosing panencephalitis (measles vaccination). The high proportion of encephalitis deaths from 'unknown' pathogens in Australia highlights the importance of monitoring encephalitis morbidity and mortality with a view to improving pathogen diagnosis and identifying emerging infectious diseases.
Abstract: Encephalitis is a clinical syndrome commonly caused by emerging pathogens, which are not under surveillance in Australia. We reviewed rates of hospitalization for patients with encephalitis in Australia's most populous state, New South Wales, from January 1990 through December 2007. Encephalitis was the primary discharge diagnosis for 5,926 hospital admissions; average annual hospitalization rate was 5.2/100,000 population. The most commonly identified pathogen was herpes simplex virus (n = 763, 12.9%). Toxoplasma encephalitis and subacute sclerosing panencephalitis showed notable declines. The average annual encephalitis case-fatality rate (4.6%) and the proportion of patients hospitalized with encephalitis with no identified pathogen (69.8%, range 61.5%-78.7%) were stable during the study period. The nonnotifiable status of encephalitis in Australia and the high proportion of this disease with no known etiology may conceal emergence of novel pathogens. Unexplained encephalitis should be investigated, and encephalitis hospitalizations should be subject to statutory notification in Australia.
Abstract: Norovirus is a common cause of gastroenteritis outbreaks associated with raw shellfish consumption. In Australia there have been several reports of norovirus outbreaks associated with oysters despite the application of regulatory measures recommended by Food Standards Australia New Zealand. This study describes an outbreak of norovirus gastroenteritis following the consumption of New South Wales oysters. In September 2007, OzFoodNet conducted a cohort study of a gastroenteritis outbreak amongst people that had dined at a Port Macquarie restaurant. Illness was strongly associated with oyster consumption, with all cases having eaten oysters from the same lease (RR undefined, p < 0.0001). Norovirus was detected in a faecal specimen. Although no pathogen was identified during the environmental investigation, the source oyster lease had been closed just prior to harvesting due to sewage contamination. Australian quality assurance programs do not routinely test oysters for viral contamination that pose a risk to human health. It is recommended that the feasibility of testing oysters for norovirus, particularly after known faecal contamination of oyster leases, be assessed.
Abstract: During a recent natural disaster public health staff required timely and comprehensive surveillance of priority health conditions, including injury, mental health disorders and selected infectious diseases, to inform response and recovery activities. Although traditional surveillance is of value in such settings it is constrained by a focus on notifiable conditions and delays in reporting. The application of an electronic emergency department syndromic surveillance system proved valuable and timely in informing public health activities following a natural disaster in New South Wales.
Abstract: BACKGROUND: A storm-related disaster in New South Wales, Australia in June 2007 caused infrastructure damage, interrupted essential services, and presented major public health risks. We investigated household disaster preparedness and information sources used before and during the disaster. METHODS: Rapid cluster survey of 320 randomly selected households in Newcastle and Lake Macquarie, New South Wales, Australia. RESULTS: 227 households (71%) responded to the survey. By the day before the storm, 48% (95%CI 40-57%) of households were aware of a storm warning, principally through television (67%; 58-75%) and radio (57%; 49-66%) announcements. Storm preparations were made by 42% (28-56%) of these households.Storm information sources included: radio (78%; 68-88%); family, friends, colleagues and neighbours (50%; 40-60%); and television (41%; 30-52%). Radio was considered more useful than television (62%; 51-73% vs. 29%; 18-40%), even in households where electricity supply was uninterrupted (52%; 31-73% vs. 41%; 20-63%). Only 23% (16-30%) of households were aware that the local government-operated radio network has a designated communication role during disasters. A battery-operated household radio and appropriate batteries were available in 42% (34-50%) of households, while only 23% (16-29%) had all of: a torch, battery-operated radio, appropriate batteries, mobile phone, emergency contact list and first aid equipment. CONCLUSION: Broadcast media are important information sources immediately before and during disasters. Health services should promote awareness of broadcast networks' disaster role, especially the role of radio, and encourage general household disaster preparedness. A rapid cluster survey conducted shortly after a natural disaster provided practical, robust information for disaster planning.
Abstract: What is already known about this subject. Studies conducted primarily in developed countries have shown that adverse drug reactions (ADRs) are a significant cause of hospital admission, prolong hospital stay and consequently increase the cost of disease management in patients. Cardiovascular medicines, hypoglycaemic agents, nonsteroidal anti-inflammatory drugs and antibiotics are the most frequently implicated medicines in these studies. A large proportion of these ADRs have been shown to be preventable through improved drug prescribing, administration and monitoring for adverse effects. What this paper adds. This is the first Sub-Saharan African study in the HIV/AIDS era that describes the contribution of ADRs to patient morbidity, hospitalisation and mortality. Cardiovascular medicines and antiretroviral therapy contributed the most to community-acquired ADRs at the time of hospital admission while medicines used for opportunistic infections (such as antifungals, antibiotics and antituberculosis medicines were most frequently implicated in hospital acquired ADRs. ADRs in HIV-infected patients were less likely to be preventable. AIMS: To describe the frequency, nature and preventability of community-acquired and hospital-acquired adverse drug reactions (ADRs) in a South African hospital serving a community with a high prevalence of human immunodeficiency virus (HIV)/ acquired immunodeficiency syndrome. METHODS: A 3-month prospective observational study of 665 adults admitted to two medical wards. RESULTS: Forty-one (6.3%) patients were admitted as a result of an ADR and 41 (6.3%) developed an ADR in hospital. Many of the ADRs (46.2%) were considered preventable, although less likely to be preventable in HIV-infected patients than in those with negative or unknown HIV status (community-acquired ADRs 2/24 vs. 35/42; P < 0.0001; hospital-acquired ADRs 3/25 vs. 14/26; P = 0.003). Patients admitted with ADRs were older than patients not admitted with an ADR (median 53 vs. 42 years, P = 0.003), but 60% of community-acquired ADRs at hospital admission were in patients <60 years old. Among patients <60 years old, those HIV infected were more likely to be admitted with an ADR [odds ratio (OR) 2.32, 95% confidence interval (CI) 1.17, 4.61; P = 0.017]. Among HIV-infected patients, those receiving antiretroviral therapy (ART) were more likely to be admitted with an ADR than those not receiving ART (OR 10.34, 95% CI 4.50, 23.77; P < 0.0001). No ART-related ADRs were fatal. Antibiotics and drugs used for opportunistic infections were implicated in two-thirds of hospital-acquired ADRs. CONCLUSIONS: ADRs are an important, often preventable cause of hospitalizations and inpatient morbidity in South Africa, particularly among the elderly and HIV-infected. Although ART-related injury contributed to hospital admissions, many HIV-related admissions were among patients not receiving ART, and many ADRs were associated with medicines used for managing opportunistic infections.
Abstract: Cryptosporidium hominis, which has an anthroponotic transmission cycle and Cryptosporidium parvum, which is zoonotic, are the primary species of Cryptosporidium that infect humans. The present study identified the species/genotypes and subgenotypes of Cryptosporidium in 7 human and 15 cattle cases of sporadic cryptosporidiosis in rural western NSW during the period from November 2005 to January 2006. The species/genotype of isolates was determined by PCR sequence analysis of the 18S rRNA and C. parvum and C. hominis isolates were subgenotyped by sequence analysis of the GP60 gene. Fourteen of 15 cattle-derived isolates were identified as C. parvum and 1 as a C. bovis/C. parvum mixture. Of the human isolates, 4 were C. parvum and 3 were C. hominis. Two different subgenotypes were identified with the human C. hominis isolates and six different subgenotypes were identified within the C. parvum species from humans and cattle. All four of the C. parvum subtypes found in humans were also found in the cattle, indicating that zoonotic transmission may be an important contributor to sporadic human cases cryptosporidiosis in rural NSW.
Abstract: BACKGROUND AND OBJECTIVE: To evaluate the performance of a novel malaria outbreak identification system in the epidemic prone rural area of Mpumalanga Province, South Africa, for timely identification of malaria outbreaks and guiding integrated public health responses. METHODS: Using five years of historical notification data, two binomial thresholds were determined for each primary health care facility in the highest malaria risk area of Mpumalanga province. Whenever the thresholds were exceeded at health facility level (tier 1), primary health care staff notified the malaria control programme, which then confirmed adequate stocks of malaria treatment to manage potential increased cases. The cases were followed up at household level to verify the likely source of infection. The binomial thresholds were reviewed at village/town level (tier 2) to determine whether additional response measures were required. In addition, an automated electronic outbreak identification system at town/village level (tier 2) was integrated into the case notification database (tier 3) to ensure that unexpected increases in case notification were not missed.The performance of these binomial outbreak thresholds was evaluated against other currently recommended thresholds using retrospective data. The acceptability of the system at primary health care level was evaluated through structured interviews with health facility staff. RESULTS: Eighty four percent of health facilities reported outbreaks within 24 hours (n = 95), 92% (n = 104) within 48 hours and 100% (n = 113) within 72 hours. Appropriate response to all malaria outbreaks (n = 113, tier 1, n = 46, tier 2) were achieved within 24 hours. The system was positively viewed by all health facility staff. When compared to other epidemiological systems for a specified 12 month outbreak season (June 2003 to July 2004) the binomial exact thresholds produced one false weekly outbreak, the C-sum 12 weekly outbreaks and the mean + 2 SD nine false weekly outbreaks. Exceeding the binomial level 1 threshold triggered an alert four weeks prior to an outbreak, but exceeding the binomial level 2 threshold identified an outbreak as it occurred. CONCLUSION: The malaria outbreak surveillance system using binomial thresholds achieved its primary goal of identifying outbreaks early facilitating appropriate local public health responses aimed at averting a possible large-scale epidemic in a low, and unstable, malaria transmission setting.
Abstract: BACKGROUND: Although malaria treatment aims primarily to eliminate the asexual blood stages that cause illness, reducing the carriage of gametocytes is critical for limiting malaria transmission and the spread of resistance. METHODS: Clinical and parasitological responses to the fixed-dose combination of sulfadoxine and pyrimethamine in patients with uncomplicated falciparum malaria were assessed biannually since implementation of this treatment policy in 1998 in Mpumalanga Province, South Africa. RESULTS: Despite sustained cure rates of > 90% (P = .14), the duration of gametocyte carriage increased from 3 to 22 weeks (per 1000 person-weeks) between 1998 and 2002 (P < .001). The dhfr and dhps mutations associated with sulfadoxine-pyrimethamine resistance were the most important drivers of the increased gametocytemia, although these mutations were not associated with increased pretreatment asexual parasite density or slower asexual parasite clearance times. The geometric mean gametocyte duration and area under the gametocyte density time curve (per 1000 person-weeks) were 7.0 weeks and 60.8 gametocytes/microL per week, respectively, among patients with wild-type parasites, compared with 45.4 weeks (P = .016) and 1212 gametocytes/microL per week (P = .014), respectively, among those with parasites containing 1-5 dhfr/dhps mutations. CONCLUSIONS: An increased duration and density of gametocyte carriage after sulfadoxine-pyrimethamine treatment was an early indicator of drug resistance. This increased gametocytemia among patients who have primary infections with drug-resistant Plasmodium falciparum fuels the spread of resistance even before treatment failure rates increase significantly.
Abstract: OBJECTIVE: To retrospectively review the performance of a near real-time Emergency Department (ED) Syndromic Surveillance System operating in New South Wales for identifying pneumonia outbreaks of public health importance. METHODS: Retrospective data was obtained from the NSW Emergency Department data collection for a rural hospital that has experienced a cluster of pneumonia diagnoses among teenage males in August 2006. ED standard reports were examined for signals in the overall count for each respiratory syndrome, and for elevated counts in individual subgroups including; age, sex and admission to hospital status. RESULTS: Using the current thresholds, the ED syndromic surveillance system would have trigged a signal for pneumonia syndrome in children aged 5-16 years four days earlier than the notification by a paediatrician and this signal was maintained for 14 days. CONCLUSION: If the ED syndromic surveillance system had been operating it could have identified the outbreak earlier than the paediatrician's notification. This may have permitted an earlier public health response. IMPLICATIONS: By understanding the behaviour of syndromes during outbreaks of public health importance, response protocols could be developed to facilitate earlier implementation of control measures.
Abstract: NSW has a putative malaria vector in Anopheles annulipes, and increased numbers of immigrants from malaria endemic countries who may be infective to mosquitoes but asymptomatic. We examine the factors known to influence malaria transmission and conclude that local transmission is possible but unlikely. The public health implications are that there should be systematic screening of immigrants from malaria endemic countries on arrival, and that the public health capacity to identify and respond to a malaria outbreak should be maintained.
Abstract: BACKGROUND: Tuberculosis is a major global public health challenge and disease in young children is particularly severe. Diagnosing tuberculosis in children is complex as clinical presentation is often atypical and available diagnostic modalities are imperfect. Diagnosis is particularly challenging in developing countries where resources and access to sophisticated facilities are limited. The South African primary health care system requires frontline nurses to be equipped to suspect, diagnose and treat children with tuberculosis, but their capacity to diagnose childhood tuberculosis is unknown. Relatively low rates of childhood tuberculosis notification suggested that tuberculosis may have been under-diagnosed in Mpumalanga Province. OBJECTIVE: To determine the ability of the primary health care nurses to diagnose childhood tuberculosis in primary care public health facilities in Gert Sibande District, Mpumalanga Province. METHODOLOGY: Within-method triangulation by means of a self-completed questionnaire and a facility audit of records and diagnostic aids, was used to assess nurses' knowledge and determine whether primary health care facilities were adequately equipped to facilitate the diagnosis of childhood tuberculosis. RESULTS: There was a limited appreciation of the need to use complementary clinical and epidemiological features and diagnostic approaches to diagnose childhood tuberculosis. Child contacts had only been screened in 22.6% (111/491) of confirmed smear positive adult tuberculosis cases reviewed. The diagnostic score chart advocated by the World Health Organization and South African Department of Health was only used by 16% (10/62) of the facilities. Nurses who had been specifically trained on tuberculosis were more knowledgeable about diagnostic approaches and all respondents who were using the score chart had received specific tuberculosis training. CONCLUSION: The deficiencies in knowledge and practice evident during this survey and practice audit could at least partially explain the relatively low detection rates of childhood tuberculosis in Gert Sibande district, Mpumalanga Province. There is a need to equip primary health care nurses with the knowledge, support and access to diagnostic tests required to ensure a high index of suspicion and early, effective, diagnosis of tuberculosis in children.
Abstract: Barmah Forest virus (BFV) is a commonly occurring arbovirus in Australia. Notifications of Barmah Forest infections diagnosed by a single positive IgM serology test have been increasing in coastal New South Wales north of Newcastle. We report on a 6 month prospective review of all routine notifications of BFV from the Lower Mid North Coast of New South Wales. Sera from 37 consecutive cases were sent for confirmatory testing by ELISA and neutralisation assays and 32 cases were interviewed. On confirmatory testing, 7 patients' sera (19%) was found to contain no BFV antibodies and 6 (16%) had BFV IgG only. Only 4 cases had antibody levels compatible with recent infection. A clinical presentation of fever with either rash or joint pain was associated with confirmation of recent BFV infection. On the basis of these findings, caution is advised in the interpretation of a single positive IgM for Barmah Forest disease and the clinical picture is an important factor in the diagnosis. Serological notifications of BFV alone should not prompt public health action such as public warning and targeted vector control in endemic areas.
Abstract: During an influenza pandemic, public health staff may not report to work due to illness, transport disruptions or care responsibilities, including care of children if school closures occur. A survey was conducted in a population health unit to estimate the impact of closure of schools and day care facilities on staff ability to work at their usual workplace or at home, and determine their access to the Internet for communication. Staff were also asked about concerns associated with working from home. Eighty-seven staff completed a paper based survey. Thirty-eight per cent (33/87) of staff may be absent from work due to the impact of childcare and school closure, however 24 (73%) of these staff would be able to work from home with most having access to dial-up (87%) and broadband Internet access (71%). Staff reported concerns about potential exposure to pandemic influenza, the need for personal protection and clearly defined roles and training, availability of adequate equipment and technology to work from home, and sick leave provisions during a pandemic. While school and childcare closures will have a significant impact on public health agency staff, they have the capacity and willingness to work from home. Their practical concerns should be addressed to optimise their participation.
Abstract: ISSUE ADDRESSED: The Mackay Whitsunday Safe Communities (MWSC) was established in February 2000 in response to high rates of injury observed in the region. A key objective was to consolidate and better coordinate a network of community groups already working in community safety promotion. METHODS: This study used Social Network Analysis (SNA) to document and analyse the social resources, or social capital, mobilised by the network. Using a snowballing methodology, the chain of relationships that constitute MWSC and its Support Network (SN) was elucidated and quantified. RESULTS: Since it was launched in February 2000, MWSC and its SN almost doubled its bonding social capital, while bridging social capital increased 160% and linking social capital increased 280%. Relationships were not evenly distributed. Forty-four per cent of relationships were maintained by six actors who also maintained 60% of the network's brokerage potential. CONCLUSION: SNA proved a powerful tool for describing and analysing relationships within the MWSC and its SN. It provided diagrammatic representation of the social structure and quantified important aspects of its structure and function. It highlighted the asymmetric distribution of relationships, resources and power that had a profound impact on how the network functioned.
Abstract: Ten years after the recognition of Australian Bat Lyssavirus, it is timely to review the occurrence of the virus in native microbat and flying fox species in Australia, and the effectiveness of post-exposure treatment in humans. Differences between post-exposure treatment protocols adopted by state and territory health departments were examined. In Queensland and the United States of America, post-exposure treatment is withheld in people who are bitten by bats that subsequently test negative for ABLV and rabies, respectively. The good outcomes from these protocols support the revised NSW policy, which delays post-exposure treatment for up to 48 hours for minor exposures while awaiting bat test results. Post-exposure treatment can be withheld or ceased if the bat test result is negative.
Abstract: OBJECTIVE: To assess the completeness of data describing Aboriginal and Torres Strait Islander status in NSW invasive meningococcal disease notifications and determine the relative risk for invasive meningococcal disease among Aboriginal and Torres Strait Islander peoples in NSW. METHODS: Surveillance data from the NSW Notifiable Diseases Database was reviewed for 5-year periods between 1991 and 2005. RESULTS: Invalid and missing data on Aboriginal and Torres Strait Islander status decreased from 42% to 8% during the study period. Higher rates of disease were found in young children and significantly higher rates in Aboriginal and Torres Strait Islander children aged 0-4 years compared with their non-Aboriginal counterparts. CONCLUSION: Aboriginal and Torres Strait Islander children in NSW experience higher rates of notified invasive meningococcal disease than non-Aboriginal children.
Abstract: OBJECTIVE: To improve the capacity of residential aged care facilities (RACFs) to respond to communicable disease outbreaks. METHODS: Three computer-assisted telephone interviews were conducted with RACFs. The first survey gathered baseline information. Outbreak prevention resources were then offered to address identified weaknesses. Subsequent surveys enabled the facilities' progress to be monitored. Before the third survey, RACFs were sent a personalized scorecard documenting their standing against 19 readiness criteria. RESULTS: RACFs reporting an outbreak management plan increased from 58 to 98%, and facilities reporting 16 or more of the 19 readiness criteria rose from 24 to 43% (P < 0.0006) at the second interview and 73% at the third interview (P < 0.0001). CONCLUSIONS: The strategy resulted in a significant improvement in reported outbreak readiness.
Abstract: In regional and rural areas of NSW, drinking water is provided by 107 local water utilities serving a total population of some 1.7 million and operating 323 water supply systems. NSW Health exercises public health oversight of these regional water utilities through the NSW Health Drinking Water Monitoring Program, which provides guidance to water utilities on implementing elements of the Australian Drinking Water Guidelines 2004, including drinking water monitoring.
Abstract: OBJECTIVES: To identify case management, health system and antimalarial drug factors contributing to malaria deaths. METHOD: We investigated malaria-related deaths in South Africa's three malaria endemic provinces from January 2002 to July 2004. Data from healthcare facility records and a semi-structured interview with patients' contacts were reviewed by an expert panel, which sought to reach consensus on factors contributing to the death. This included possible health system failures, adverse reactions to antimalarials, inappropriate medicine use and failing to respond to treatment. RESULTS: Approximately 177 of 197 cases met inclusion criteria for the study. Delay in seeking formal health care was significantly longer for patients who sought traditional health care [median 4; inter-quartile range (IQR) 3-7 days] than for patients who did not (median 3; IQR 1-5 days; P = 0.033). Patients with confirmed or suspected HIV/AIDS were significantly more likely to use traditional approaches (25%) than those with other comorbidities (0%; P = 0.002). Malaria was neither suspected nor tested for at a primary care facility in 23% of cases with adequate records. Initial hospital assessment was considered inadequate in 74% of cases admitted to hospital and in-patient monitoring and management was adequate in only 27%. There were 32 suspected adverse reactions to antimalarial therapy. CONCLUSION: A confidential enquiry into malaria-related deaths is a useful tool for identifying preventable factors, health system failures and adverse events affecting malaria case management.
Abstract: Measles is now rare in Australia, and cases can usually be linked to its importation from endemic countries. To prevent measles outbreaks in Australia, high vaccination coverage with two doses of vaccine must be sustained. All medical practitioners should consider a diagnosis of measles in a patient of any age who presents with fever and a non-vesiculating, non-itchy rash. If measles is suspected clinically, public health authorities should be immediately notified, so that testing and management of patients can be discussed and contact tracing initiated. When a patient is suspected of having measles, testing of a serum sample for measles-specific IgM and IgG antibodies should be requested urgently. Pathology laboratories should have effective protocols for immediately reporting positive measles-specific IgM antibody tests, or other results indicative of measles, to public health authorities.
Abstract: OBJECTIVE: To characterise a pulmonary tuberculosis (TB) cluster in the Hunter Area of New South Wales using a combination of traditional epidemiological methods and molecular typing. DESIGN, SETTING AND PARTICIPANTS: Review of all notifications of TB in the Hunter Area between January 1994 and June 2005, with a detailed analysis of cases among people born in Australia or New Zealand. MAIN OUTCOME MEASURES: Comparison of genotypes of Mycobacterium tuberculosis isolates; extent of TB cluster. RESULTS: Over the period studied, there were 72 TB notifications among people born in Australia or New Zealand. Genotypic testing was available for 20 of these cases, of which nine were confirmed to be part of a cluster. Two further cases for which genotyping was not available were epidemiologically linked to the cluster and regarded as probable cluster cases. Members of the cluster were relatively young (median age at diagnosis, 35 years; range, 21-57 years), and eight were women. Over the same period, there were 83 TB notifications among people born overseas, the majority being from Asia (47%) or central and eastern Europe (24%) (median age, 54 years; range, 9-63 years). CONCLUSION: Clinicians should maintain a high index of suspicion for pulmonary TB in a person presenting with a productive cough lasting more than 3 weeks, weight loss, haemoptysis, night sweats and chest pain, even if the person is not overseas-born or elderly. A comprehensive tuberculosis genotyping network at regional and national level in Australia could help identify clusters resulting from recent transmission.
Abstract: BACKGROUND: Papua New Guinea is the only endemic country in the Western Pacific Region that has not yet introduced a countrywide programme to eliminate lymphatic filariasis. However, on Misima Island in Milne Bay Province, government and private sectors have collaborated to implement a pilot elimination programme. Although interim evaluation indicated that the programme has been parasitologically successful, an appreciation that sustainable health gains depend on understanding and accommodating local beliefs prompted this qualitative study. METHODS: We investigated Misima community members knowledge and attitudes about lymphatic filariasis and the elimination programme. A combination of focus groups and key informant interviews were used to explore participants perceptions of health; knowledge of the aetiology and symptoms of filariasis, elephantiasis and hydrocele; attitudes towards the disease and mass drug distribution; and the social structure and decision-making protocols within the villages. RESULTS: Focus group discussions proved inferior to key informant interviews for gathering rich data. Study participants did not consider lymphatic filariasis ("pom") a major health problem but were generally positive about mass drug administration campaigns. A variety of conditions were frequently and incorrectly attributed to filariasis. Participants expressed the belief that individuals infected with filariasis always had visible manifestations of disease. A common misconception was that taking drugs during campaigns provided long-term immunity against disease. The role of mosquito vectors in transmission was not generally appreciated and certain clinical presentations, particularly hydrocele, were associated with supernatural forces. Multiple adverse events were associated with mass drug administration campaigns and most study participants mentioned community members who did not participate in campaigns. CONCLUSION: Important issues requiring educational intervention and elimination activity modification in the Misima region were identified during this study. Research outcomes should assist Papua New Guinea in developing and implementing a national elimination strategy and inform discussions regarding the appropriateness of current elimination strategies.
Abstract: BACKGROUND: Q fever remains an important occupational zoonosis in rural Australia. Although Q fever vaccine is recommended in high-risk occupational groups, its availability has been limited in recent years. METHOD: A literature review of the efficacy of the human Q fever vaccine registered in Australia was conducted. RESULTS: Seven relevant vaccine efficacy studies were identified but no large double-blind, randomised, placebo-controlled studies have been conducted. Vaccine efficacy has ranged from 83-100% but limitations of study designs hamper a precise estimate of vaccine efficacy. CONCLUSION: Despite the shortcomings of efficacy studies, the Q fever vaccine available in Australia has considerable protective benefit in established high-risk environments, particularly of an occupational nature.
Abstract: The Lubombo Spatial Development Initiative is a joint development program between the governments of Mozambique, Swaziland, and South Africa, which includes malaria control as a core component of the initiative. Vector control through indoor residual spraying (IRS) was incrementally introduced in southern Mozambique between November 2000 and February 2004. Surveillance to monitor its impact was conducted by annual cross-sectional surveys to assess the prevalence of Plasmodium falciparum infection, entomologic monitoring, and malaria case notification in neighboring South Africa and Swaziland. In southern Mozambique, there was a significant reduction in P. falciparum prevalence after the implementation of IRS, with an overall relative risk of 0.74 for each intervention year (P < 0.001), ranging from 0.66 after the first year to 0.93 after the fifth intervention year. Substantial reductions in notified malaria cases were reported in South Africa and Swaziland over the same period. The success of the program in reducing malaria transmission throughout the target area provides a strong argument for investment in regional malaria control.
Abstract: BACKGROUND: Sustainable and equitable health programmes require a grounded understanding of the context in which they are being implemented. This socio-cultural understanding is pivotal for effective delivery of elimination programmes. Standardised valid methods are needed for gathering authentic socio-cultural insights. The currently recommended protocol for collecting Lymphatic Filariasis (LF) related socio-cultural data, while moving in the right direction, is inadequate. To collect data which provides an understanding of local health beliefs and practices, and communities' understanding of LF, techniques must be developed that are both valid and time efficient. An approach developed in the Pacific provides a basic snapshot of socio-cultural insights which are crucial to the development of relevant and sustainable health education and elimination programmes. SUMMARY: The increasing interest in socio-cultural LF research presents a unique opportunity for coupling socio-cultural and bio-medical understandings of LF. To address the backlog in the socio-cultural sphere will require investment of time and effort to integrate valid qualitative approaches into current data collection methodologies.
Abstract: Lymphatic filariasis (LF) is endemic in approximately 80 tropical and subtropical countries. About 120 million people are infected with the parasite and a billion are estimated to be at risk of infection. The main focus of the LF elimination programme to date has been to interrupt transmission by means of annual community-wide treatment campaigns with diethylcarbamazine and albendazole, or albendazole and ivermectin, for a period of four to six years. Although substantial progress has been recorded wherever the strategy has been successfully implemented, initial gains have been accompanied by a realization that this strategy alone will not ensure a permanent solution in all settings. The fairly extensive LF literature is dominated by laboratory research and quantitative field measurement of the impact of LF, particularly local prevalence studies of parasite-infected humans and vectors. As the global elimination programme expands, the absence of sociocultural understanding is being recognized as a critical flaw in ensuring that programmes are appropriate and responsive to local needs and understanding. This paper assesses the current state of sociocultural understanding pertaining to LF. It concludes that, at present, there is insufficient understanding of the sociocultural factors associated with the presence and treatment of the disease, and that appropriate social science methods should be used to address this deficiency and ensure community partnership in delivering and sustaining the success of LF elimination programmes.
Abstract: BACKGROUND: We report a cluster of gonorrhoea among mainly heterosexual men that occurred in October 2005, which was first identified when routine weekly surveillance review procedures indicated a three-fold increase in reporting rates compared with historical data. METHODS: Each case was followed up with the treating medical officer to review treatment regimes and risk exposures, and to carry out enhanced contact tracing. The phenotype and genotype of the outbreak gonococcal isolates and gonococci prevalent in the months preceding and following the cluster were determined. Links between cases reported from the local Sexual Health Clinic and those reported by general practitioners were established. RESULTS: Laboratory data indicated that a particular gonococcal subtype (ST 225 and NR/Brpyst) was prevalent during the outbreak. CONCLUSIONS: Gonorrhoea rates returned to pre-outbreak levels following a targeted health promotion intervention with no further cases of the outbreak subtype detected.
Abstract: BACKGROUND AND OBJECTIVES: Prior to the introduction of artemisinin-based combination antimalarial therapy in Mpumalanga province, South Africa, a pharmacovigilance strategy was developed to pilot locally relevant surveillance methods for detecting serious adverse drug reactions (ADRs) and signals related to artesunate plus sulfadoxine/pyrimethamine. STUDY DESIGN: From 1 March 2002 to 30 June 2004, five methods for detecting ADRs in patients receiving antimalarials were piloted in the rural communities of Mpumalanga province in South Africa: (i) home follow-up of patients by malaria control staff; (ii) enhanced spontaneous reporting of suspected ADRs by health professionals at clinics and hospitals; (iii) active hospital surveillance for malaria-related admissions and patients recently treated for malaria; (iv) a confidential enquiry into malaria-related deaths; and (v) adverse events monitoring during two therapeutic efficacy studies conducted in 2002 and 2004. RESULTS: During the study period, the malaria control programme was notified of 4778 cases of malaria while sulfadoxine/pyrimethamine monotherapy was the recommended treatment and 7692 cases after the introduction of artesunate plus sulfadoxine/pyrimethamine in January 2003. Of 2393 home follow-up visits of reported cases of malaria, three fatal adverse events were identified where recent use of artesunate plus sulfadoxine/pyrimethamine treatment was reported. Two cases were attributed to poor response to treatment, while one case was considered possibly related to artesunate plus sulfadoxine/pyrimethamine treatment. Clinic and hospital surveillance reported six ADRs in association with sulfadoxine/pyrimethamine treatment, five being treatment failures and one being a non-serious rash. During active hospital surveillance, 38 inpatients exposed to sulfadoxine/pyrimethamine were identified, including one child who experienced pancytopenia following treatment with sulfadoxine/pyrimethamine 11 days before admission; this adverse effect was considered to be possibly due to sulfadoxine/pyrimethamine treatment. The confidential enquiry into malaria-related deaths identified three adverse events, including a death where the contribution of treatment could not be excluded. A therapeutic efficacy study of 95 patients followed over 42 days identified one case of repeated vomiting possibly associated with artesunate plus sulfadoxine/pyrimethamine. CONCLUSION: Multifaceted monitoring throughout the malaria patient journey is necessary in developing countries implementing new treatments to safeguard against missing serious complications associated with malaria treatment.
Abstract: BACKGROUND: Malaria is an important disease for Australian travellers, particularly to Papua New Guinea. Travellers often seek health advice from their general practitioner before travel or if they develop illness after travel. METHOD: A retrospective cohort investigation into malaria risk in a group of adult Australians that trekked the Kokoda trail in Papua New Guinea. RESULTS: Six of 38 group members were diagnosed with malaria on return from Papua New Guinea. None of the 12 individuals who took chemoprophylaxis for the recommended period post-travel developed malaria compared to 4/24 travellers who terminated prophylaxis prematurely or 2/2 who took no chemoprophylaxis. DISCUSSION: Chemoprophylaxis is effective if taken for the full recommended period following travel to a malaria endemic area; 4 weeks for doxycycline and mefloquine, and 7 days for atovaquone+proguanil. Malaria is a likely cause of illness in recently returned travellers from Papua New Guinea who develop a febrile illness.
Abstract: We describe an 18-month intervention that was designed to improve opportunistic screening for chlamydia in General Practice. Key strategies included engaging and informing general practitioners, adopting a simplified screening protocol, providing feedback on practice testing performance and developing resources for use with patients. This uncontrolled before and after study found that the overall impact on testing was modest and largely transient, and was insufficient to impact on the current chlamydia epidemic. Major additional measures would be required to further substantially increase testing levels. These could include financial incentives linked to screening performance and increased community awareness to increase patient demand for testing.
Abstract: Streptococcus pneumoniae is a common cause of community acquired pneumonia (CAP). Influenza infection increases susceptibility to S. pneumoniae infection in adults but this link is less well described in children. We report on an outbreak of CAP affecting 25 previously well adolescents in a New South Wales boarding school. S. pneumoniae 1 was confirmed in two cases. During this period, the school also experienced an influenza outbreak with an influenza-like illness attack rate peaking at 27% in Year 8 students. A planned school closure may have contributed to controlling the outbreak. Boarding schools are vulnerable to outbreaks of respiratory illness and strategies for limiting this risk are required.
Abstract: A severe storm that began on Thursday, 7 June 2007 brought heavy rains and gale-force winds to Newcastle, Gosford, Wyong, Sydney, and the Hunter Valley region of New South Wales. The storm caused widespread flooding and damage to houses, businesses, schools and health care facilities, and damaged critical infrastructure. Ten people died as a result of the storm, and approximately 6000 residents were evacuated. A natural disaster was declared in 19 local government areas, with damage expected to reach $1.5 billion. Additional demands were made on clinical health services, and interruption of the electricity supply to over 200,000 homes and businesses, interruption of water and gas supplies, and sewerage system pump failures presented substantial public health threats. A public health emergency operations centre was established by the Hunter New England Area Health Service to coordinate surveillance activities, respond to acute public health issues and prevent disease outbreaks. Public health activities focused on providing advice, cooperating with emergency service agencies, monitoring water quality and availability, preventing illness from sewage-contaminated flood water, assessing environmental health risks, coordinating the local government public health response, and surveillance for storm-related illness and disease outbreaks, including gastroenteritis. The local ABC (Australian Broadcasting Corporation) radio station played a key role in disseminating public health advice. A household survey conducted within a fortnight of the storm established that household preparedness and storm warning systems could be improved.
Abstract: BACKGROUND: There is a danger that mass drug administration campaigns may fail to maintain adequate treatment coverage to achieve lymphatic filariasis elimination. Hence, additional measures to suppress transmission might be needed to ensure the success of the Global Program for the Elimination of Lymphatic Filariasis. DISCUSSION: Vector control successfully eliminated lymphatic filariasis when implemented alone or with mass drug administration. Challenges to lymphatic filariasis elimination include uncertainty of the exact level and duration of microfilarial suppression required for elimination, the mobility of infected individuals, consistent non-participation of some infected individuals with mass drug administration, the possible development of anti-filarial drug resistance and treatment strategies in areas co-endemic with loasis. Integration of vector control with mass drug administration can address some of these challenges. The potential benefits of vector control would include: (1) the ability to suppress filariasis transmission without the need to identify all individual 'foci of infection'; (2) minimizing the risk of reestablishment of transmission from imported microfilaria positive individuals; and (3) decreasing the risk of dengue or malaria transmission where, respectively, Aedes or Anopheles are lymphatic filariasis vectors. SUMMARY: With adequate sustained treatment coverage, mass drug administration should meet the criteria for elimination of lymphatic filariasis. However, it may be difficult to sustain sufficiently high mass drug administration coverage to achieve lymphatic filariasis elimination in some areas, particularly, where Aedes species are the vectors. Since vector control was effective in controlling and even eliminating lymphatic filariasis transmission, integration of vector control with mass drug administration will ensure the sustainability of transmission suppression and thereby better ensure the success of national filariasis elimination programs. Although trials of some vector control interventions are needed, proven vector control strategies are ready for immediate integration with mass drug administration for many important vectors. Vector control is the only presently available additional lymphatic filariasis control measure with the potential for immediate implementation.
Abstract: In the past two years there has been a resurgence of polio with 21 previously polio-free countries importing wild poliovirus. Wild poliovirus importations into polio-free areas will continue to occur until endemic transmission is interrupted globally. Australia's acute flaccid paralysis (AFP) surveillance falls well short of the target of more than 80 per cent of AFP cases having two adequate stool specimens taken at least 24 hours apart within 14 days of onset for poliovirus examination. As most AFP cases are hospitalised, AFP should be immediately notifiable by hospitals to public health units or state or territory public health authorities to ensure appropriate follow up, including stool specimens.
Abstract: BACKGROUND: The population of Nukufetau, a remote coral atoll island in Tuvalu in the Western Pacific, received annual mass drug administration (MDA) of diethylcarbamazine and albendazole under the Pacific Elimination of Lymphatic Filariasis program in 2001, 2002 and 2003, with the last MDA occurring six months before a cross-sectional survey of the whole population for soil transmitted helminths (STH). METHODS: A cross-sectional survey in May 2004 recruited 206 residents (35.2% of the population) who provided a single faecal sample that was preserved, concentrated and examined microscopically. RESULTS: Overall prevalence of STH was 69.9%; only hookworm and Trichuris trichiura were diagnosed. Trichuris was present in 68.4% with intensity of infection being light in 56.3%, medium in 11.7% and heavy in 0.5%. Hookworm occurred in 11.7% with intensity of infection 11.2% being light and medium in 0.5%. Twenty individuals (9.7%) had dual infections. The prevalence of Trichuris was constant across all ages while the prevalence of hookworm was significantly lower in residents below 30 years of age. In the age group 5-12 years comparison of results with a 2001 survey 1 suggested that the prevalence of STH has declined minimally, due to sustained high prevalence of Trichuris, while hookworm has declined dramatically from 34.4% to 1.6%. CONCLUSION: The results of this survey suggest that although the MDA appears to have reduced hookworm prevalence in residents below 30 years of age, there has been minimal effect on Trichuris prevalence. An integrated program to control STH is required.
Abstract: Successful communicable disease surveillance depends on effective bidirectional information flow between clinicians at the periphery and communicable disease control units at regional, national and global levels. Resource-poor countries often struggle to establish and maintain the crucial link with the periphery. A simple syndrome-based outbreak surveillance system initially developed and evaluated in Mpumalanga Province, South Africa was adapted for the Pacific island nation of Tuvalu. Eight syndromes were identified for surveillance: acute flaccid paralysis (poliomyelitis), profuse watery diarrhoea (cholera), diarrhoea outbreak, dysentery outbreak, febrile disease with abdominal symptoms and headache (typhoid), febrile disease with generalized non-blistering rash (measles), febrile disease with intense headache and/or neck stiffness with or without haemorrhagic rash (meningococcal meningitis), and outbreaks of other febrile diseases of unknown origin. A user-oriented manual, the Tuvalu Outbreak Manual (http://www.wepi.org/books/tom/), was developed to support introduction of the surveillance system. Nurses working in seven outer island clinics and the hospital outpatient department on the main island rapidly report suspected outbreaks and submit weekly zero-reports to the central communicable disease control unit. An evaluation of the system after 12 months indicated that the Outbreak Manual was regarded as very useful by clinic nurses, and there was early evidence of improved surveillance and response to the disease syndromes under surveillance.
Abstract: BACKGROUND: Anthrax bioterrorism is a new threat to Australians. How they would respond to an anthrax bioterrorism event is unknown. METHOD: A national telephone survey of Australian adults. RESULTS: We successfully interviewed 1001 Australian adults (response rate 63%). The threat of anthrax bioterrorism was of medium to high concern to 57% of survey participants. In the event of an anthrax bioterrorism event, the first point of care would be GPs for 60% of survey participants, and 71% were confident in their doctor's ability to recognise anthrax. Most would accept vaccination if anthrax bioterrorism cases were reported locally, or even elsewhere in Australia. DISCUSSION: Australian GPs should be included in any bioterrorism planning to respond to such threats.
Abstract: Responding to an infectious disease pandemic requires a coordinated approach from all essential services. Public health units across NSW will play an important role in a range of control activities. These include: surveillance, education, communication, case ascertainment, case management (excluding clinical management), infection control, contact tracing, monitoring contacts in home quarantine, surveillance at borders, epidemiological studies and immunisation. Public health units are currently planning for such an emergency and these plans will need to be tested and refined under simulated conditions.
Abstract: BACKGROUND: Between 1995 and 2000, KwaZulu-Natal province, South Africa, experienced a marked increase in Plasmodium falciparum malaria, fuelled by pyrethroid and sulfadoxine-pyrimethamine resistance. In response, vector control was strengthened and artemether-lumefantrine (AL) was deployed in the first Ministry of Health artemisinin-based combination treatment policy in Africa. In South Africa, effective vector and parasite control had historically ensured low-intensity malaria transmission. Malaria is diagnosed definitively and treatment is provided free of charge in reasonably accessible public-sector health-care facilities. METHODS AND FINDINGS: We reviewed four years of malaria morbidity and mortality data at four sentinel health-care facilities within KwaZulu-Natal's malaria-endemic area. In the year following improved vector control and implementation of AL treatment, malaria-related admissions and deaths both declined by 89%, and outpatient visits decreased by 85% at the sentinel facilities. By 2003, malaria-related outpatient cases and admissions had fallen by 99%, and malaria-related deaths had decreased by 97%. There was a concomitant marked and sustained decline in notified malaria throughout the province. No serious adverse events were associated causally with AL treatment in an active sentinel pharmacovigilance survey. In a prospective study with 42 d follow up, AL cured 97/98 (99%) and prevented gametocyte developing in all patients. Consistent with the findings of focus group discussions, a household survey found self-reported adherence to the six-dose AL regimen was 96%. CONCLUSION: Together with concurrent strengthening of vector control measures, the antimalarial treatment policy change to AL in KwaZulu-Natal contributed to a marked and sustained decrease in malaria cases, admissions, and deaths, by greatly improving clinical and parasitological cure rates and reducing gametocyte carriage.
Abstract: OBJECTIVES: To assess the therapeutic efficacy of sulfadoxinepyrimethamine (SP) after 5 years of use as first-line treatment of uncomplicated Plasmodium falciparum malaria, and thus guide the selection of artemisinin-based combination therapy in Mpumalanga, South Africa. DESIGN: An open-label, in vivo therapeutic efficacy study of patients with uncomplicated P. falciparum malaria treated with a single oral dose of SP, with response to treatment monitored clinically and parasitologically on days 1, 2, 3, 7, 14, 21, 28 and 42. SETTING: Mangweni and Naas public health care clinics, Tonga district in rural Mpumalanga. SUBJECTS, OUTCOME MEASURES AND RESULTS: Of 152 patients recruited sequentially, 149 (98%) were successfully followed up for 42 days. One hundred and thirty-four patients (90%) demonstrated adequate clinical and parasitological response. Of the 15 patients (10%) who failed treatment, 2 (1.3%) had an early treatment failure, and polymerase chain reaction confirmed recrudescent infection in all 13 patients (8.7%) who had late parasitological (N = 11) or clinical (N = 2) failure. Gametocyte carriage was prevalent following SP treatment (84/152) and this has increased significantly since implementation in 1998 (relative risk 2.77 (confidence interval 1.65 - 4.66); p = 0.00004). CONCLUSION: Asexual P. falciparum parasites in Mpumalanga remain sensitive to SP, with no significant difference between the baseline cure rate (94.5%) at introduction in 1998, and the present 90% cure rate (p = 0.14). However, since gametocyte carriage has increased significantly we recommend that SP be combined with artesunate in Mpumalanga to reduce gametocyte carriage and thus decrease malaria transmission and potentially delay antimalarial resistance.
Abstract: INTRODUCTION: Irukandji syndrome, a potentially life-threatening condition that follows the sting of small carybdeid jellyfish, occurs along the northern Australian coastline from Broome, Western Australia in the west to Rockhampton, Queensland in the east. Much of this area is classified rural or remote. Because correct patient management is essential to avoid unnecessary fatality, and stings are relatively uncommon in any specific location, it was considered important to document current approaches to Irukandji syndrome management throughout coastal northern Australia, comparing urban and more rural health facilities, and to assess the availability of management guidelines for health staff. METHODS: A telephone survey of the clinicians responsible for Irukandji syndrome patient management at 34 coastal northern Australian health facilities that might encounter this patient presentation was conducted during November and December 2003. Healthcare providers responsible for Irukandji syndrome management on the day of survey were interviewed using a structured, standardized questionnaire, which included a description of a hypothetical patient with Irukandji syndrome. This was used to stimulate a spontaneous description of the usual response of the particular health facility to such a patient presentation. Additional vignettes were used to investigate further specific aspects of patient management, including first aid, and pain and blood pressure management. Respondents were also asked about the existence of Irukandji treatment guidelines at their facility. RESULTS: All 34 facilities contacted agreed to participate. Five health facilities were in urban centres with a population of 50,000 or greater, four were within 50 km of such centres, 20 were more remote and five facilities were on islands. Basic clinical monitoring (blood pressure, pulse, respiratory rate and oxygen saturation) was generally adequately practised. Topical application of vinegar as a first aid measure was described by 79% of respondents, with spontaneous mention of vinegar significantly associated with increasing remoteness (p = 0.023). Other sting site management was variable, with uncertainty about the use of pressure immobilisation bandaging. Intravenous opiate analgesia was administered at 91% of facilities, and magnesium sulphate, a treatment that is still being evaluated for its role in Irukandji syndrome-related pain and hypertension, was mentioned by 12% of respondents for pain relief. Twelve different pharmacological treatments were used for syndrome-associated hypertension, with magnesium sulphate being mentioned by 21% of respondents. Of the 22 facilities with guidelines, 14 used either the Primary Clinical Care Manual or the Central Australian Rural Practitioners Association Standard Treatment Manual. The remaining guidelines were independently produced protocols. The availability of guidelines was associated with appropriate use of intravenous opiate for adequate pain relief (p = 0.037). Although all urban health centres and 75% of health facilities <50 km away had guidelines, only 56% of more remote or island facilities reported the availability of guidelines. CONCLUSIONS: Although monitoring and pain management of patients with Irukandji syndrome were generally appropriate, a variety of inappropriate first aid and hypertension management approaches were found. In general, appropriate practice was associated with the presence of guidelines but, unfortunately, guidelines were less often present in remote health facilities. This is particularly important because the majority of respondents who reported no experience of managing Irukandji syndrome were located in more remote settings. There is a need for uniform, evidence-based guidelines, and mechanisms for effective dissemination of these guidelines with training for all health staff who may be required to manage Irukandji syndrome, particularly in remote areas of northern Australia.
Abstract: OBJECTIVES: We explored the prevalence of faecal incontinence (FI) in a referral hospital outpatient population, to explore suspicions that FI is inadequately studied, underestimated and poorly appreciated in the rural North Queensland (NQ) community. DESIGN: Prospective cross-sectional study using a specifically designed questionnaire. SETTING: The Townsville Hospital, a referral centre serving rural NQ. SUBJECTS: A total of 435 consecutive patients attending the gynaecology (n = 261) and colorectal clinics (n = 174) between 31 January and 12 June 2003 were enrolled (participating proportion 96.5%). MAIN OUTCOME MEASURES: FI prevalence, severity, impact on patients' lives, and risk factors. RESULTS: The prevalence of FI in the study population (median age 53 years) was 20.7%. Amongst affected patients (n = 90) the median duration of FI was 2 years with more than half of those affected soiling themselves at least once a month. Many patients with FI (42%) reported feeling hopeless at least some of the time. Rectal prolapse, chronic constipation, psychiatric problems, colon disease, and urinary incontinence were all significantly associated with FI. A CART analysis revealed that many patients (45%) with urinary incontinence and chronic constipation also experienced FI. CONCLUSIONS: This FI prevalence in a clinical setting in NQ is, apart from nursing home studies, the highest reported in the literature. FI negatively impacted on affected persons' lives. In patients presenting with urinary incontinence and chronic constipation, physicians should specifically enquire whether FI is also present. Definitive community studies to determine the scale of this 'silent epidemic' in northern Australia are now required.
Abstract: ISSUE ADDRESSED: A systematic ecological framework in which to design sustainable, community-based, safety promotion interventions is presented. METHOD: A literature review was undertaken of English-language articles addressing the topics of 'ecological injury prevention or safety promotion', 'ecological health promotion', 'sustainable economic, health or ecological systems' and 'steady state', with 143 articles retrieved and reviewed. RESULTS: Injury prevention is a biomedical construct, in which injury is perceived to be a physical event resulting from the sudden release of environmental energy producing tissue damage in an individual. This reductionist perspective overlooks the importance of psychological and sociological determinants of injury. Safety has physical, psychological and sociological dimensions. It is inherently an ecological concept. Interventions aiming to achieve long-term improvements in community safety must seek to develop sustainable safety promoting characteristics within the target community. CONCLUSION: To reduce a community's risk of injury and sustain this lowered risk, the community 'ecological system' must have access to the resources necessary to maintain the desired outcome and the ability to mobilise these resources.
Abstract: BACKGROUND: Little is known about the travel health advice obtained by tourists travelling to Magnetic Island, which is a known risk area for the potentially fatal 'Irukandji' jellyfish on the Great Barrier Reef coast of north Queensland, Australia. METHODS: Structured interviews were conducted with 208 ferry passengers (93% response) travelling between Townsville (Latitude 19 degrees S) and Magnetic Island. RESULTS: Less than half of the international tourists (21, 46%) had obtained travel health advice before coming to north Queensland, although they were significantly more likely to have done so than domestic tourists (p<0.001). Travel health advice obtained by international tourists was sourced mainly from their general practitioner (8, 50%) or from a guidebook (6, 38%). Eighty-eight percent of north Queensland residents, 70% of domestic tourists, and 34% of international tourists knew what an Irukandji jellyfish was (p<0.001), although this was not associated with having obtained travel health advice. For those passengers returning from the Island, 8 (44%) domestic tourists and 4 (35%) international tourists recalled seeing some information on the Island that improved their knowledge about Irukandji jellyfish. Most of the international tourists travelled to north Queensland by bus (30, 65%), while most domestic tourists arrived by private car (12, 40%) or plane (10, 33%). CONCLUSIONS: Only a small proportion of international tourists knew about Irukandji jellyfish and most tourists had not received travel health advice. The majority of tourists had not received further information about Irukandji jellyfish risk whilst on the island. All travellers to popular north Queensland tourist areas need travel health advice, which includes advice on avoiding contact with Irukandji and Chironex box jellyfish. Health promotion campaigns directed at providing this advice need to be aware that most tourists to north Queensland arrive by bus or car and the only 'shared' vehicle, at least to Magnetic Island, is the passenger ferry.
Abstract: A national survey of 1,001 Australians found that most were concerned about a bioterrorist attack and were ill-informed about smallpox prevention and response. Since general practitioners were commonly identified as the initial point of care, they should become a focus of bioterrorism response planning in Australia.
Abstract: OBJECTIVE: To determine the knowledge, beliefs, and behavior of local residents and visitors to North Queensland who may be at risk of contact with "Irukandji" jellyfish. METHODS: Structured interviews were conducted with 208 ferry passengers (92.9% response) traveling between Magnetic Island and Townsville (19 degrees S). RESULTS: A total of 88.1% of the locals, 69.8% of the domestic tourists, and 34% of the international tourists knew what an Irukandji was (P < .001). Half of the international tourists, 20% of the domestic tourists, and 3.9% of the locals with this knowledge incorrectly assumed it was safe to swim inside stinger-resistant enclosures or were unsure (P < .001). Visitors to Magnetic Island who had swum or intended to swim in the sea (47%) knew less about Irukandji than other visitors (P = .05). Only 42.3% of the respondents realized that Irukandji posed a risk to swimmers on the outer reefs, and only 33.1% knew that Irukandji were also found outside North Queensland. CONCLUSIONS: International tourists had little knowledge about Irukandji. Thus, accurate educational messages may need to be targeted at this group. Offshore water sport and reef tour operators should be encouraged to provide clients with protective clothing to minimize the risk of stings. A coordinated educational response across northern Australia may be necessary to inform the public about both the box jellyfish (Chironex fleckeri) and Irukandji.
Abstract: Melioidosis is a potentially fatal disease caused by the bacterium Burkholderia pseudomallei. Individuals with subclinical melioidosis have no apparent clinical signs or symptoms, and are identified only by positive serology. The present study is the first to investigate cell-mediated immune (CMI) responses following in vitro stimulation with B. pseudomallei antigens in peripheral blood mononuclear cells (PBMC), collected under field conditions in Papua New Guinea (PNG) from individuals with exposure to B. pseudomallei (n = 13). While five had a clinical history of melioidosis (C(+)), the remaining individuals (n = 8) were seropositive, yet healthy with no clinical history of melioidosis (S(+)/C(-)). Proliferation and IFN-gamma production were significantly greater in lymphocyte cultures from S(+)/C(-) individuals compared to C(+) individuals (P < 0.001 and P < 0.05, respectively). These findings demonstrate that compared to C(+) patients, individuals with subclinical melioidosis have a stronger CMI response to B. pseudomallei antigens in vitro. Such a response may be essential for protection against disease progression.
Abstract: Artemisinin-class Combination Therapy (ACT) remains the most plausible means by which the ambitious goal of halving malaria mortality by the year 2010 may be achieved. Convincing evidence of ACT efficacy in treating uncomplicated malaria now exists. ACT appears safe but most safety studies have been weak methodologically. Thus there is an acute need for sensitive ongoing pharmacovigilance. Limited availability of ACT in those countries most likely to benefit from its public health use, has resulted in allegations of 'medical malpractice' against the World Health Organization and Global Fund for AIDS, TB and malaria. The ethical principles of autonomy, sanctity of life, beneficence and justice are pertinent to the adoption of ACT as first-line therapy of uncomplicated malaria by endemic countries.
Abstract: General practitioners who care for Aboriginal patients in rural and remote communities from tropical Australia must be aware of strongyloidiasis. The prevalence of this parasitic infection is high and occasional cases can have a fatal outcome. Other groups in Australia at high risk of strongyloidiasis are immigrants from endemic countries, particularly from Southeast Asia, and military personnel who have served overseas in endemic areas. Elimination programs for enteric parasites in rural Australian Indigenous communities are so important that a nationally coordinated approach has been advocated. Wisely used, cost-effective diagnostic tests are a critical component of an elimination program. Strongyloidiasis must be confirmed by laboratory diagnosis and the strongyloides ELISA, although not ideal, is a useful test that can be used to diagnose strongyloidiasis and to monitor cure. In this article the value of the current strongyloides ELISA is discussed and a cost-benefit analysis is conducted using direct costs only. In a typical rural Aboriginal community in tropical Australia with prevalence of strongyloidiasis at 20% each true positive case detected by the strongyloides ELISA is estimated to cost approximately AU590 dollars to diagnose and manage until cure, proven by negative serology.
Abstract: Widespread resistance of Plasmodium falciparum parasites to commonly used antimalarials, such as chloroquine, has resulted in many endemic countries considering changing their malaria treatment policy. Identifying and understanding the key influences that affect decision-making, and factors that facilitate or undermine policy implementation, is critical for improving the policy process and guiding resource allocation during this process. A historical review of archival documents from Malaŵi and data obtained from in-depth policy studies in four countries (Tanzania, South Africa, Kenya and Peru) that have changed malaria treatment policy provides important lessons about decision-making, the policy cycle and complex policy environment, while specifically identifying strategies successfully employed to facilitate policy-making and implementation. Findings from these country-level studies indicate that the process of malaria drug policy review should be institutionalized in endemic countries and based on systematically collected data. Key stakeholders need to be identified early and engaged in the process, while improved communication is needed on all levels. Although malaria drug policy change is often perceived to be a daunting task, using these and other proven strategies should assist endemic countries to tackle this challenge in a systematic fashion that ensures the development and implementation of the rational malaria drug policy.
Abstract: A major pre-requisite for polio-free certification by the World Health Organization is that the local surveillance system successfully detects one case of non-polio acute flaccid paralysis (AFP) per 100,000 children below 15 years of age per annum and that no cases of polio occur for three consecutive years. Mpumalanga, a rural province in the northeast of South Africa, implemented an enhanced surveillance system, which consisted of training hospital ICNs to rapidly report and correctly respond to nine infectious disease syndromes, including AFP. Weekly zero reporting is a component of the system. The non-polio AFP reporting rate per 100,000 children below the age of 15 years increased from 0.56 in 1997 to 0.91 in 1998 after introduction of the enhanced surveillance system, with more than 80% of the units reporting weekly. All units reported weekly from April 1999 to December 2001. Although non-polio AFP reporting rates were 0.27 (1999), 1.18 (2000) and 0.87 (2001), the 95% binomial exact confidence intervals for all years included 1 per 100,000. A review of paediatric admissions from January 1998 to December 2001 at all hospitals revealed that only five AFP cases had been missed by the enhanced surveillance system. The low international AFP reference rate and attendant variation expected due to chance, particularly in areas with relatively small populations, is an important factor that deserves more attention as we approach global polio eradication.
Abstract: BACKGROUND: Malaria control programmes utilising indoor residual spraying are only effective if a high coverage of targeted structures is achieved and an insecticide that is effective against the specific mosquito vector is correctly applied. Ongoing monitoring of spraying operations is essential to assure optimal programme performance and early corrective action, where indicated. METHODS: Successful development and application of a computerised spraying operations management system in Mpumalanga Province, South Africa during 1998 resulted in its adaptation and introduction in neighbouring Maputo Province, southern Mozambique during 2000. The structure and components of this computerised management system are described, and its' operational benefit in southern Mozambique, where community-based spray operators apply intradomiciliary insecticide, are reviewed. CONCLUSIONS: The computerised management system allowed malaria programme management and field supervisors to monitor spraying coverage, insecticide consumption and application rates on an ongoing basis. The system supported a successful transition to community-based spraying, while assuring correct insecticide application and spraying completion according to schedule.
Abstract: Sulfadoxine-pyrimethamine induces increased gametocytaemia when used for treating Plasmodium falciparum malaria. Laboratory-reared Anopheles arabiensis mosquitoes were fed with blood from patients with post-therapeutic gametocytaemia using a membrane feeder. Fourteen days later the heads and thoraxes of 613 mosquitoes were negative for P. falciparum sporozoites by enzyme-linked immunosorbent assay.
Abstract: Experience from successful global elimination programmes highlights the pivotal role of functional surveillance programmes for confirming cessation of local disease transmission. Lymphatic filariasis is targeted for global elimination by 2020 with an earlier target of 2010 for the Pacific Island countries. No surveillance protocol for confirming filariasis elimination in small island countries has yet been agreed evaluated. Currently recommended surveillance strategies for confirming lymphatic filariasis elimination are not ideal for small Pacific countries. Relying on occasional surveys to detect an increasingly rare health condition has inherent epidemiological weaknesses. Characteristics of effective surveillance for confirming filariasis elimination would include adequate sensitivity for detecting residual transmission, ongoing population scrutiny, and integration within a resource-sensitive system that includes other important conditions requiring public health surveillance. We propose that acute adenolymphangitis (ALA) may prove a suitable surveillance condition. ALA surveillance nested within a syndromic communicable disease surveillance programme implemented universally by health facilities may provide a solution to the current conundrum facing Pacific lymphatic filariasis elimination programmes and should be carefully evaluated.
Abstract: Neonatal tetanus (NNT) is a serious but preventable disease, and the World Health Organization (WHO) wants to eliminate NNT globally by reducing its incidence to <1 case per 1000 live births. South Africa adopted this goal in 1995, but Mpumalanga, a rural province, has consistently reported cases of NNT despite an appropriate vaccination strategy to eliminate the disease. The aim of the study was to investigate the completeness of the passive notification system and to explore reasons for ongoing NNT cases despite implementation of the provincial vaccination strategy. We reviewed all hospital admissions in the province between 1996 and 2000 meeting the case definition for NNT and interviewed mothers of the NNT cases reported in 2000. We identified 26 NNT cases, of which only 14 (54%) were reported through the routine notification system. Most cases occurred as a result of the cultural practice of applying cow dung or rat faeces to the umbilical stump in the neonatal period. Although all districts met the WHO elimination target during the review period, there is scope to prevent unnecessary NNT deaths through culturally acceptable public awareness campaigns aimed at changing harmful practices, and encouraging hygienic births and postnatal cord care.
Abstract: Rabies is an important disease in rural South Africa, and vaccine and immunoglobulin are provided, at the State's expense, to humans following suspected exposure to rabies virus by bite, scratch or mucosal splash. Health facilities where post-exposure treatment is available are listed, with contact telephone numbers, in national rabies guidelines. To verify the accuracy of this recently updated information, members of the national Rabies Advisory Group were tasked to complete a rapid survey. A simple standardized telephone interview technique was used. This revealed startling deficiencies in the availability of vaccine and immunoglobulin at the indicated sites and led to decisive corrective action. This 'quick and dirty' survey technique provided valuable information for improving an important public health programme, and should be considered when auditing other health programmes, particularly where a means for validating responses is readily available.
Abstract: The malaria vector Anopheles arabiensis Patton (Diptera: Culicidae) shows a marked predilection (> 80%) for biting the ankles and feet of human subjects, as revealed by our previous observations at Malahlapanga in the Kruger National Park, South Africa. Topical application of insect repellent, 15% deet (N,N-diethyl-3-methylbenzamide), to feet and ankles reduced the overall biting rate of An. arabiensis by 69%. A focal malaria epidemic in Albertsnek village (25 degrees 33'S, 31 degrees 59' E) near the Mozambique border, following flooding during February 2000, provided an opportunity to apply these findings of operational research for outbreak containment. Twice-nightly topical application of deet to ankles and feet of Albertsnek inhabitants was followed by rapid restoration of preepidemic malaria incidence levels after one incubation period. This encouraging outcome should be attempted in other outbreak-prone settings where infective mosquito bites are sporadic and malaria has unstable endemicity.
Abstract: BACKGROUND: Much communicable disease control research has had little impact on local control programme policy and practice for want of an operational component. The operational research model - the systematic search for knowledge on interventions, tools or strategies that enhance programme effectiveness - is gaining recognition as an appropriate method for addressing perplexing questions within public health programmes. METHODS: A series of operational research studies were conducted to refine malaria diagnosis in Mpumalanga Province, South Africa between 1995 and 1999. The grounded theory approach was used with groups of experienced Masters of Public Health students in South Africa and Australia to analyse a compilation of these studies for determining positive and negative attributes of operational research that affect its ability to influence communicable disease control policy and practice. RESULTS: The principal positive attributes of the operational research studies were high local relevance, greater ability to convince local decision-makers, relatively short lag-time before implementation of findings, and the cost-effective nature of this form of research. Potential negative features elicited included opportunities forfeited by using scarce resources to conduct research and the need to adequately train local health staff in research methodology to ensure valid results and accurate interpretation of findings. CONCLUSIONS: Operational research effectively influenced disease control policy and practice in rural South Africa, by providing relevant answers to local questions and engaging policy-makers. This resulted in accelerated inclusion of appropriate measures into a local communicable disease control programme.
Abstract: The World Health Organization estimates that more than 300 million cases of malaria exist worldwide each year, resulting in more than 3 million deaths, with more than 1 million deaths of children in sub-Saharan Africa alone. Malaria is also a reemerging disease in some parts of Africa, including South Africa. Malaria prevention is multi-faceted with no single precaution offering complete protection. Taking chemoprophylaxis decreases the severity and frequency of death from malaria due to Plasmodium falciparum when compared with taking no chemoprophylaxis.
Abstract: In South Africa, leprosy has been a notifiable condition since 1921. Although the WHO elimination target of less than one case per 10,000 population has been achieved at country level, the distribution of leprosy in the country is distinctly heterogeneous, with a prominent 'leprosy belt' of greater prevalence stretching across Mpumalanga Province into northern Kwa-Zulu Natal. The highest prevalence in this 'belt' has historically been in Ermelo District. Recent trends of few newly detected leprosy patients in this district raised concerns that health system changes may have resulted in failure to detect leprosy cases. Thus a large-scale community awareness campaign was conducted followed by an intensively advertised screening programme of 3-month duration at schools and central gathering points in villages and farms from 1 June to 31 August 2000. One thousand one hundred and seventy-seven people presented for clinical screening at designated points, while 790 scholars were screened at schools and an additional 1433 people were screened at their homes by the field team. Forty-four people with skin or nervous system lesions compatible with leprosy were referred for specialized assessment and biopsy where indicated. Four new leprosy patients were diagnosed, including an elderly lady with pronounced disability. Two of these patients had prior contact with the health service due to dermatological manifestations of leprosy without diagnosis being made. All patients provided a history of close prolonged contact with known leprosy patients. Ongoing intense tracing and follow-up of close contacts of proven leprosy cases may be a more efficient method of detecting leprosy cases in areas with relatively stable populations that have accomplished 'leprosy elimination', than resource intensive community surveys.
Abstract: BACKGROUND: In South Africa, as part of an effort to eliminate indigenous measles by 2002, vaccination campaigns were conducted in 1996-1997 targeting all children aged 9 months to 14 years; coverage was estimated at 85%. The impact of the campaigns on measles disease burden was evaluated in 1999. METHODS: We analysed routine measles surveillance data and undertook a retrospective review of hospital registers in two of South Africa's nine provinces. RESULTS: In Mpumalanga in the pre-campaign years (1992-1996), 4,498 measles cases and 6 deaths were reported; 182 cases and no deaths were reported in 1997-1998. Hospital registers showed 1,647 measles hospitalizations and 11 deaths in the pre-campaign period, and 60 hospitalizations and no deaths after the campaign (1997-April 1999). In Western Cape in pre-campaign years (1992-1997), 5,164 measles cases and 19 deaths were reported; 132 cases and no deaths were reported in 1998. Hospital registers showed 736 measles hospitalizations and 23 deaths in the pre-campaign period, and 29 measles hospitalizations and no deaths post-campaign (1998-July 1999). CONCLUSIONS: Study findings indicate that reported measles cases, measles-related hospitalizations and deaths were considerably reduced in both provinces after the campaign compared with the pre-campaign period. Longer observation is needed to evaluate the long-term impact of the campaigns.
Abstract: Distribution of biting sites on the human body by the malaria vector Anopheles arabiensis Patton (Diptera: Culicidae) was investigated near a source of mosquitoes in the Kruger National Park, South Africa. Eight adult male volunteers (2 teams x 2 pairs of subjects) conducted human bait collections while seated on camp chairs in the open-air, wearing only short trousers (no shirt, socks or shoes). Mosquito collections during 18.30-22.30 hours on five consecutive nights in April 1998 yielded a total of 679 An. arabiensis females biting subjects with or without their ankles and feet treated with deet insect repellent (15% diethyl-3-methylbenzamide, Tabard lotion). On subjects whose feet and ankles were smeared with repellent, 160 An. arabiensis females were captured biting in 60 manhours: 88.1% on the legs, 1.4% on the arms and 1.2% on other parts of the body, but none on the repellent-treated feet or ankles. On subjects without repellent treatment, 519 An. arabiensis were caught biting in 60 man-hours: 81.1% on feet and ankles, 16.4% on legs, 1.4% on arms and 1.2% on the rest of the body. For individual subjects, the reduction of An. arabiensis bites ranged from 36.4 to 78.2% (mean protection 69.2%). Results of this study confirm previous findings that, in this part of South Africa - inhabited only by wildlife - when people sit outside during the evening An. arabiensis prefers to bite their lower limbs: 97.5% below the knees. Overall, the number of bites by the malaria vector An. arabiensis was reduced more than three-fold (from 26 to 8/person/evening), simply by treating ankles and feet with a consumer brand of deet repellent. Whether or not this provides a satisfactory degree of protection against malaria risk would depend on the malaria sporozoite rate in the malaria vector population.
Abstract: INTRODUCTION: Quinine therapy for 7 days remains the mainstay for treating hospitalised malaria cases in South Africa. However, limited resources, including available beds and staff, often result in early discharge of non-severe cases, with quinine tablets for outpatient use. The effectiveness of shorter course quinine therapy coupled with a long-acting antimalarial drug has never been established in Africa, in particular in a population without malaria immunity. METHODS: A study was conducted to evaluate the effectiveness of a 3-day course of therapy with quinine sulphate (10 mg/kg 8-hourly) followed by a single dose of sulfadoxine-pyrimethamine (SP) according to weight category, before discharge, for 133 hospitalised patients with uncomplicated Plasmodium falciparum malaria at Shongwe Hospital, Mpumalanga province, between February and July 1998. Study endpoints included clinical recovery and parasitological cure, including polymerase chain reaction (PCR) 42 days after initiating treatment. RESULTS: One hundred and thirty of 131 patients (99%) successfully followed up for 42 days demonstrated clinical and parasitological cure. The remaining patient, who had evidence of a recrudescent infection on PCR, was 1 of 61 patients who were still parasitaemic on discharge from hospital. CONCLUSION: The abbreviated course of quinine therapy coupled with a single dose of SP for the treatment of non-severe hospitalised cases of P. falciparum malaria, in an area with demonstrated low levels of SP resistance, was highly effective. This approach has potential benefits, including reduced duration of hospitalisation, fewer quinine-associated adverse events and protection against the evolution of quinine resistance by limiting unsupervised quinine therapy in the community. It may, however, be prudent to document a negative blood film before discharge from hospital.
Abstract: OBJECTIVE: To study a novel surveillance system introduced in Mpumalanga Province, a rural area in the north-east of South Africa, in an attempt to address deficiencies in the system of notification for infectious conditions that have the potential for causing outbreaks. METHODS: Hospital-based infection control nurses in all of Mpumalanga's 32 public and private hospitals were trained to recognize, report, and respond to nine clinical syndromes that require immediate action. Sustainability of the system was assured through a schedule of regular training and networking, and by providing feedback to the nurses. The system was evaluated by formal review of hospital records, evidence of the effective containment of a cholera outbreak, and assessment of the speed and appropriateness of responses to other syndromes. FINDINGS: Rapid detection, reporting and response to six imported cholera cases resulted in effective containment, with only 19 proven secondary cholera cases, during the two-year review period. No secondary cases followed detection and prompt response to 14 patients with meningococcal disease. By the end of the first year of implementation, all facilities were providing weekly zero-reports on the nine syndromes before the designated time. Formal hospital record review for cases of acute flaccid paralysis endorsed the value of the system. CONCLUSION: The primary goal of an outbreak surveillance system is to ensure timely recognition of syndromes requiring an immediate response. Infection control nurses in Mpumalanga hospitals have excelled in timely weekly zero-reporting, participation at monthly training and feedback sessions, detection of priority clinical syndromes, and prompt appropriate response. This review provides support for the role of hospital-based nurses as valuable sentinel surveillance agents providing timely data for action.
Abstract: OBJECTIVES: To assess therapeutic efficacy of sulfadoxine-pyrimethamine (SP) in treatment of uncomplicated Plasmodium falciparum malaria 3 years after introduction in Mpumalanga, South Africa. SETTING: Tonga district with a population of 116,418 and subject to seasonal malaria, with an average annual incidence of 3,200 cases. SUBJECTS: One hundred and nineteen malaria patients presenting to a sentinel surveillance clinic and recruited according to World Health Organisation (WHO) criteria. METHODOLOGY: Patients satisfying WHO inclusion criteria were treated with a single oral dose of SP and the response of infection to treatment in each patient was routinely monitored clinically and parasitologically on days 1, 2, 3, 7, 14, 21, 28 and 42 post-treatment. One hundred and ten patients completed follow-up to day 42 or evidence of clinical or parasitological failure. RESULTS: The cure rate at day 42 was 93.6% (103/110). Two patients (1.8%, RII) were early treatment failures on day 3, while recrudescence (4.5%, RI) occurred in 5 patients on day 28 (N = 3) and on day 42 (N = 2). CONCLUSION: In Mpumalanga P. falciparum remains sensitive to SP, with no significant difference between the baseline cure rate (94.5%) and the cure rate in the present study (93.6%).
Abstract: Malaria is a re-emerging disease in much of Africa. In response, the World Health Organization launched the Roll Back Malaria (RBM) initiative. One of six key principles adopted is the early detection of malaria cases. However, the importance of definitive diagnosis and potential value of field deployment of rapid malaria tests in RBM has been largely ignored. The Lowveld Region of Mpumalanga Province, South Africa, is home to a predominantly non-immune population, of approximately 850000 inhabitants, who are at risk of seasonal Plasmodium falciparum malaria. Malaria treatment in this area is usually only initiated on detection of malaria parasites in the peripheral bloodstream, as many other rickettsial and viral febrile illness mimic malaria. The malaria control programme traditionally relied on light microscopy of Giemsa-stained thick blood films for malaria diagnosis. This review summarizes operational research findings that led to the introduction of rapid malaria card tests for primary diagnosis of malaria throughout the Mpumalanga malaria area. Subsequent operational research and extensive experience over a four-year period since introducing the ICT Malaria Pf test appears to confirm the local appropriateness of this diagnostic modality. A laboratory is not required and clinic staff are empowered to make a prompt definitive diagnosis, limiting delays in initiating correct therapy. The simple, accurate and rapid non-microscopic means now available for diagnosing malaria could play an important role in Rolling Back Malaria in selected areas.
Abstract: Three commercial repellents marketed in South Africa: Bio-Skincare (BSC, oils of coconut, jojoba, rapeseed and vitamin E), Mosiguard towelletes with 0.574 g quwenling (p-menthane-3,8-diol, PMD) and the standard deet (15% diethyl-3-methylbenzamide, Tabard lotion), were compared against a laboratory colony of the mosquito Anopheles arabiensis Patton (Diptera: Culicidae), the predominant malaria vector in South Africa. Human forearms were treated with 1.2 g BSC, 0.8 g PMD towelette or 0.5 g deet and exposed to 200 hungry An. arabiensis females for 1 min, at intervals of 1-6 h post-treatment. Tests were conducted by three adult male volunteers (aged 30-45 years, crossover controlled test design for 3 consecutive days), using their left arm for treatment and right arm for untreated control. Biting rates averaged 39-52 bites/min on untreated arms. All three repellents provided complete protection against An. arabiensis for up to 3-4 h post-application; deet and PMD gave 90-100% protection up to 5-6h, but BSC declined to only 52% protection 6h post-treatment. These results are interpreted to show that all three repellent products give satisfactory levels of personal protection against An. arabiensis for 4-5 h, justifying further evaluation in the field.
Abstract: OBJECTIVE: To assess community knowledge and perceptions about malaria and its control in a rural setting. DESIGN: Descriptive cross-sectional survey. SETTING: Tonga district with a population of 116,418, seasonal malaria with an annual incidence of 3,200 cases. SUBJECTS: Female heads of 299 randomly selected households. METHODOLOGY: A total of 299 households were selected from a random sample of 30 clusters. Community knowledge and perceptions about malaria and its control were assessed by interviews with the female head of each of the 299 selected households. RESULTS: Respondents ranked malaria as the third most serious health problem facing the community after TB and AIDS. Seventy-two per cent (214/299) of respondents reported that they knew what malaria disease was and of these, 92.1% (197/214) mentioned mosquito bites as the cause of malaria. The respondents' understanding of the causal role of mosquitoes in malaria was significantly related to their knowledge about disease symptoms (P < 0.001). Reported community compliance with the malaria control programme (MCP) was satisfactory; 86.6% (259/299) of respondents reported that their homes had been sprayed during the past 2 years but 10.0% (30/299) did not know why homes were sprayed. Hospitals or clinics were the facilities where respondents most commonly sought treatment for fever; 66.9% (200/299) reported that they would seek treatment immediately after the onset of high fever. Specific practices such as replastering or washing of inside walls compromised the effectiveness of the MCP. Personal preventive measures were sometimes used against malaria (50.8%, 152/299) and use was positively associated with education level (P = 0.001). Respondents expressed their desire for more information about malaria and their willingness to contribute to the control of malaria in their community. CONCLUSION: The survey collected information which was directly relevant to the development of health education messages to increase community awareness of the problem of malaria, to emphasise the importance of early diagnosis and prompt treatment of malaria, to improve community understanding of the function of indoor residual spraying, and to enlighten the population of the role of mosquitoes in malaria transmission and the availability and benefits of personal protection measures against mosquito bites.
Abstract: OBJECTIVE: To determine routine measles coverage at district level and to explore reasons for immunisation failure in Mpumalanga Province, South Africa. DESIGN: An adaptation of the World Health Organisation (WHO) Expanded Programme on Immunisation (EPI) cluster sampling method was used to make a random selection of 30 clusters in each of 21 health districts, 630 clusters in total. Seven individuals from the age group 12-23 months were randomly selected from each cluster and immunisation status and source were transcribed from their child health records. Where no immunisations were administered, reasons provided by parents or guardians were recorded. SETTING: Mpumalanga Province, South Africa. RESULTS: The weighted valid population coverage with measles vaccine for children aged 12-23 months in Mpumalanga Province was 71.1% (95% confidence interval 64.9-78.5%); this was the lowest of all EPI antigens. There was marked heterogeneity in measles coverage across the province, with a coefficient of variation of 22.2%. Districts with the lowest coverage shared borders with neighbouring provinces. District measles coverage was highly positively correlated with diphtheria, pertussis and tetanus (DPT3) coverage (r = 0.960, P = 0.000). There was a strong negative correlation between ranked measles campaign coverage and routine measles immunisation coverage. Obstacles to immunisation accounted for nearly half (49%) of all reasons for immunisation failure, while lack of information and lack of motivation accounted for 30% and 22%, respectively. CONCLUSIONS: Survey results highlight the need for supplementary immunisation, including non-selective campaigns, if Mpumalanga is to achieve the South African goal of measles elimination by 2002. The value of determining district resolution coverage in order to identify areas with low measles coverage requiring supplementary intervention was also demonstrated. A strong negative correlation between routine and campaign coverage deserves further study in other settings.
Abstract: OBJECTIVE: To assess the repellency effect of three local plants; fever tea (Lippia javanica), rose geranium (Pelargonium reniforme) and lemon grass (Cymbopogon excavatus) against laboratory reared Anopheles arabiensis mosquitoes. DESIGN: A laboratory experimental study. SETTING: Mpumalanga Province, South Africa. SUBJECTS: Three adult male volunteers. MAIN OUTCOME MEASURES: Affordable alternatives to synthetic repellents against biting of Anopheles arabiensis mosquitoes. RESULTS: All three alcohol plant extracts provided significantly more protection (p = 0.012) than alcohol control. The alcohol plant extract of L. javanica provided 76.7% protection against An. arabiensis after a four hour period, and C. excavatus and P. reniforme provided 66.7% and 63.3% protection for three hours, respectively. At five hours post application only L. javanica alcohol extract provided appreciable protection (59.3%) against An. arabiensis. CONCLUSION: The results of this study indicate that L. javanica, P. reniforme and C. excavatus protect against An. arabiensis mosquito bites with the repellent effect of L. javanica lasting significantly longer than that of the other two plants.
Abstract: INTRODUCTION: Sustainable control of malaria in sub-Saharan Africa is jeopardized by dwindling public health resources resulting from competing health priorities that include an overwhelming acquired immunodeficiency syndrome (AIDS) epidemic. In Mpumalanga province, South Africa, rational planning has historically been hampered by a case surveillance system for malaria that only provided estimates of risk at the magisterial district level (a subdivision of a province). METHODS: To better map control programme activities to their geographical location, the malaria notification system was overhauled and a geographical information system implemented. The introduction of a simplified notification form used only for malaria and a carefully monitored notification system provided the good quality data necessary to support an effective geographical information system. RESULTS: The geographical information system displays data on malaria cases at a village or town level and has proved valuable in stratifying malaria risk within those magisterial districts at highest risk, Barberton and Nkomazi. The conspicuous west-to-east gradient, in which the risk rises sharply towards the Mozambican border (relative risk = 4.12, 95% confidence interval = 3.88-4.46 when the malaria risk within 5 km of the border was compared with the remaining areas in these two districts), allowed development of a targeted approach to control. DISCUSSION: The geographical information system for malaria was enormously valuable in enabling malaria risk at town and village level to be shown. Matching malaria control measures to specific strata of endemic malaria has provided the opportunity for more efficient malaria control in Mpumalanga province.
Abstract: OBJECTIVES: To determine the use of antimalarial prophylaxis and the relative frequency of adverse events with different regimens in visitors to the Kruger National Park. DESIGN: Retrospective postal survey of a cohort of 7,397 visitors during April 1996. Telephonic interviews were conducted with all respondents who reported neuropsychiatric adverse events necessitating medical attention, and their medical caregivers. RESULTS: The most commonly used regimens were chloroquine and proguanil in combination (C&P) (35.6%) and mefloquine (18.4%). However, non-recommended regimens were also used by travellers to this chloroquine-resistant area, including chloroquine alone (15.7%). Adverse events were reported by 23.8% of travellers and were more common in the C&P group than the mefloquine group (28.9% v. 25.0%, P = 0.0100). Gastro-intestinal side-effects were significantly more common in the C&P group (nausea (P = 0.0170), diarrhoea (P = 0.0008), mouth ulcers (P = 0.0000)), while neuropsychiatric side-effects were more common in the mefloquine group (depression (P = 0.0000), light-headedness (P = 0.0009), anxiety (P = 0.0060)). Only 30% of travellers reported using antimalarial drugs both regularly as prescribed and for 4 weeks after leaving the malaria area. The most commonly reported reason for changing prophylaxis was advice from a physician or pharmacist (41.9%). CONCLUSIONS: Health professionals providing medical advice to prospective travellers to malarious areas must tailor recommendations based on the balance between malaria risk in a specific geographical area and the benefits and tolerance of protective measures. Mosquito-avoidance measures should always be advocated, but counselling on antimalarial prophylaxis will be guided by the malaria/prophylaxis (serious adverse events) risk ratio. Where drug measures are indicated, the importance of their correct use should be emphasised.
Abstract: The results of a confidential inquiry into mortality attributed to malaria in South Africa's Mpumalanga Province are being used to guide the design of strategies for improving the management of cases and reducing the probability of deaths from the disease.
Abstract: SETTING: The Kruger National Park (KNP), Mpumalanga Province, South Africa. OBJECTIVE: The prevalence of tuberculosis caused by Mycobacterium bovis exceeds 70% in African buffalo in the southern region of the KNP. Inter-species transmission (lion, cheetah, baboon, antelope) has also been confirmed. Regular culling of emaciated buffalo and processing of meat and hides constitute routine control policy. Following extensive media coverage of the problem, public health concerns about the transmission of M. bovis to humans, including visitors to the KNP, prompted this investigation. DESIGN: The study was designed to determine the prevalence of infection and/or active disease due to M. bovis among KNP employees selected from three defined risk groups based on occupation category. RESULTS: Of 206 persons screened for active disease by sputum bacteriology, two persons with disease due to M. tuberculosis were identified. No isolate of M. bovis was found. Differential skin testing using three antigens failed to show any degree of M. bovis infection risk, even among high risk occupations. Reasons for these results are discussed. CONCLUSIONS: Bovine tuberculosis was not indicated as an occupational zoonosis in the KNP, nor was aerosol transmission implicated as a mechanism for human infection. Concerns about the public health implications of tuberculosis in buffalo in the KNP have therefore not been validated.
Abstract: BACKGROUND: One of South Africa's principal tourist attractions is the opportunity to encounter Africa's large mammals in the wild. Attacks by these mammals can be exceptionally newsworthy with potentially deleterious effects on tourism. Little is known about the risk of injury and death caused by wild mammals to visitors to South Africa's nature reserves. The aim of this study was to determine the incidence of fatal and nonfatal attacks on tourists by wild mammals in South Africa and to ascertain avoidable factors, if any. METHODS: Commercial press records covering all South African Newspapers archived at the Independent Newspapers' central library were systematically reviewed for a 10-year period, January 1988 to December 1997 inclusive, to identify all deaths and injuries to domestic and international tourists resulting from encounters with wild mammals in South Africa. All of these incidents were analyzed to ascertain avoidable factors. RESULTS: During the review period seven tourists, including two students from Thailand and a German traveler, were killed by wild mammals in South Africa. Three of the four deaths ascribed to lions resulted from tourists carelessly approaching prides on foot in lion reserves. A judicial inquiry found that the management of a KwaZulu-Natal Reserve was culpable for the remaining death. Tourist ignorance of animal behavior and flagrant disregard of rules contributed to the two fatalities involving hippopotami. The unusual behavior manifested by the bull elephant responsible for the final death, resulted from discomfort caused by a dental problem to this pachyderm. During the same period there were 14 nonfatal attacks on tourists, including five by hippo, three by buffalo, two by rhino, and one each by a lion, leopard, zebra and musth elephant. Only the latter occurred while the visitor was in a motor vehicle. Tourist ethological naivete and failure to determine the experience of trail guides prior to travel, resulted in inadvertent agonistic behavior, unnecessary risk-taking and avoidable injury. CONCLUSIONS: This retrospective study has shown that attacks on tourists by wild mammals in South Africa are an uncommon cause of injury and death. Sensible precautions to minimize this risk include remaining in a secure motor vehicle or adequately fenced precincts while in the vicinity of large mammals, rigidly observing nature reserve instructions, never approaching animals that appear ill, malnourished, displaying aggressive behavior traits or female wild mammals with young, and demanding adequately trained and experienced game rangers when embarking on walking trails. Any behavior that might be construed as antagonistic and which could provoke an attack by large mammals should be avoided (e.g., driving directly at a lion). Visitors need to be informed of classic signs of aggression, in particular in elephants, which will allow timely avoidance measures to be taken. The risk-enhancing effect of excessive alcohol intake is undesirable in the game reserve setting, as is driving at high speed after dusk in areas where hippos graze. Local advice on personal safety in wildlife reserves and the credentials of trail guides should be obtained from lodge or reserve management, tourism authorities or the travel industry prior to travel to game reserves.
Abstract: BACKGROUND: The risk of malaria to visitors to South Africa's nature reserves is unknown. Current recommendations for travelers are based on malaria incidence rates in local communities. These rates may well overestimate travelers' malaria risk and lead to unnecessary use of antimalarial prophylaxis with associated drug-related adverse events. This study investigated the incidence of malaria in visitors to South Africa's Kruger National Park (KNP). METHODS: Postal questionnaires were sent to the cohort of visitors staying in the KNP during April 1996, 6 to 8 weeks after they returned to their homes. Nonrespondents received duplicate questionnaires 8 weeks later. Responses from 3267 groups, representing 11,107 visitors (56. 8%) allowed determination of the malaria attack rate in this group of travelers and assessment of associations between malaria risk and a number of factors, including type of accommodation used during the visit; duration of stay; use of chemoprophylaxis; and use of personal protection measures. All travelers indicating that they had suffered an episode of malaria following their visit were telephonically contacted and their health providers traced to determine the basis of diagnosis and clinical outcome. RESULTS: One clinically suspected and four confirmed cases of Plasmodium falciparum malaria among the visitors suggest a low attack rate of 4. 5 cases per 10,000 visitors during April, the highest risk month for malaria in South Africa. No association was found between malaria risk and accommodation type, duration of stay, use and type of chemoprophylaxis, and use and number of personal protection measures. CONCLUSIONS: These findings confirm the importance of careful assessment of local malaria risk before individualized advice is provided to travelers.
Abstract: The Acheson Report concluded that the process of infectious disease notification in England and Wales was unsatisfactory and recommended that it should be reviewed. However, the success of any notification system will depend on the knowledge and motivation of general practitioners, who are responsible for a large proportion of infectious disease notifications. A district-wide telephone survey was conducted in Croydon among general practitioners to assess the level of awareness of which diseases are on the statutory notification list. Respondents' opinions were also sought on the composition of the present list. Results indicated that a generally high level of awareness contrasted with a relative paucity in knowledge of certain of the more common diseases. Differences in knowledge were not associated with the sex, the length of time since the doctor qualified or the number of partners in the particular practice. Motivation may be a particularly important factor underlying the present incompleteness of notifications. A large proportion of doctors stated that legionellosis, AIDS, brucellosis and listeriosis merited statutory notification.
Abstract: Tetraparesis developing in a female, during pregnancy, was found to be due to an intradural cervical lipoma, associated with a subcutaneous lipoma at the same level in the midline posteriorly. Sub-total removal produced a return to near normal function with the patient being fully ambulant 7 months later.
Abstract: Since it was first described in 1956, reading epilepsy, an uncommon disorder, has engendered great interest among neurologists, the reason being that it is probably one of the most complex of the sensory-evoked reflex epilepsies and one in which the mechanism of seizure production is as yet unresolved. Unfortunately, it often defies the standard medications useful in the treatment of other forms of epilepsy. A patient with typical reading epilepsy, preceded by jaw-jerking, is described in this report. An additional feature of this case is the presence of a stutter from early childhood. Therapy with phenytoin, carbamazepine and sodium valproate failed to provide satisfactory control. Flunarizine, as add-on therapy to sodium valproate, produced an excellent therapeutic response.
