Abstract: To the Editor: We applaud Mann et al. on their use of a school-based absenteeism surveillance system to compare daily all-causes absenteeism data against a historic baseline to detect outbreaks of influenza-like illness (ILI) as an adjunct to traditional disease reporting (1). The growing availability of electronic human resources systems has increased the potential to harness near real-time workplace absenteeism data to complement school absenteeism surveillance and other sources of traditional outbreak surveillance.
Abstract: Human encephalitis in Australia causes substantial mortality and morbidity, with frequent severe neurological sequelae and long-term cognitive impairment. This review discusses a number of highly pathogenic zoonotic viruses which have recently emerged in Australia, including Hendra virus and Australian bat lyssavirus which present with an encephalitic syndrome in humans. Encephalitis surveillance currently focuses on animals at sentinel sites and animal disease or definitive diagnosis of notifiable conditions that may present with encephalitis. This is inadequate for detecting newly emerged viral encephalatides. Hospital-based sentinel surveillance may aid in identifying increases in known pathogens or emergence of new pathogens that require a prompt public health response.
Abstract: OBJECTIVES: To develop culturally appropriate and effective strategies to reduce the risk from pandemic influenza (H1N109) in rural and remote Australian Aboriginal and Torres Strait Islander communities. METHODS: Participatory Action Research (PAR) approach that enabled communities and researchers to work together to develop understanding and take action to reduce risk. RESULTS: The H1N109 pandemic raised deep concerns and serious issues in all of the Aboriginal and Torres Strait Islander communities involved in this project. The participants expressed distrust and scepticism in relation to current Australian health policies on containment and told the researchers that specific plans for Aboriginal and Torres Strait Islander peoples were needed. Respondents indicated that policies and plans had been developed without respectful engagement with communities. The strong and recurring themes that emerged from the PAR cycles were: the importance of family; ways of life and realities of living in response to influenza; and key messages to government and health services to focus on communication, understanding and respect. CONCLUSION: The essential work of reducing risk of pandemic influenza with Aboriginal and Torres Strait Islander communities is not straightforward, but this project has highlighted a number of useful pathways to continue to journey along with communities. A number of strategies to reduce the spread of pandemic influenza in Aboriginal and Torres Strait Islander communities were identified. These strategies would make a good starting point for conversations with communities and health services. In Aboriginal and Torres Strait Islander communities the environment, community structures and traditions vary. Respectful engagement with communities is needed to develop effective policy.
Abstract: Aim:  The aim of this study was to determine the proportion of children less than 12 months of age presenting to Hunter New England (HNE) emergency departments (EDs) during 2009 who were overdue for immunisations and identify factors associated with overdue status. Methods:  The immunisation status of all children aged between 3 months and 1 year (120-365 days) who presented at an HNE ED between 1 January and 31 December 2009 was determined using Australian Childhood Immunisation Register (ACIR) 30-day overdue reports. The ED dataset and ACIR reports were linked using a deterministic method. Results:  Six per cent (253/4218) of children who attended an HNE ED in 2009 were overdue for immunisation and 28.1% (71/253) presented multiple times while overdue. There was a median delay of 77 days from their first presentation while overdue until they no longer appeared on the ACIR 30-day overdue report. Children who presented while overdue were more likely to present multiple times to EDs (RR = 1.45; P = 0.0025), be in a life-threatening triage category (P = 0.012) and present at tertiary referral hospitals (P < 0.001). Conclusions:  Important missed immunisation opportunities occurred in HNE EDs and may occur in other EDs in Australia. Half of the children who presented to Hunter New England emergency departments while overdue for immunisation remained overdue for greater than 77 days following their presentation. Opportunities exist in EDs and paediatric inpatient wards for ensuring that all children are protected against vaccine-preventable diseases.
Abstract: On May 26, 2009, the first confirmed case of Pandemic (H1N1) 2009 virus (pH1N1) infection in Hunter New England (HNE), New South Wales (NSW), Australia (population 866,000) was identified. We used local surveillance data to estimate pH1N1-associated disease burden during the first wave of pH1N1 circulation in HNE.
Abstract: 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.
Abstract: In 2007, adults in Australia were interviewed about their willingness to comply with potential health interventions during a hypothetical influenza outbreak. After the first wave of pandemic (H1N1) 2009 in Australia, many of the same respondents were interviewed about behavior and protection measures they actually adopted. Of the original 1,155 respondents, follow-up interviews were conducted for 830 (71.9%). Overall, 20.4% of respondents in 2009 had recently experienced influenza-like illness, 77.7% perceived pandemic (H1N1) 2009 to be mild, and 77.8% reported low anxiety. Only 14.5% could correctly answer 4 questions about influenza virus transmission, symptoms, and infection control. Some reported increasing handwashing (46.6%) and covering coughs and sneezes (27.8%) to reduce transmission. Compared with intentions reported in 2007, stated compliance with quarantine or isolation measures in 2009 remained high. However, only respondents who perceived pandemic (H1N1) 2009 as serious or who had attained higher educational levels expressed intention to comply with social distancing measures.
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: To investigate the Australian public's expectations, concerns and willingness to accept vaccination with the pandemic (H1N1) 2009 influenza vaccine.
Abstract: The clinical diagnosis of encephalitis is often difficult and identification of a causative organism is infrequent. The encephalitis syndrome may herald the emergence of novel pathogens with outbreak potential. Individual treatment and an effective public health response rely on identifying a specific pathogen. In Australia there have been no studies to try to improve the identification rate of encephalitis pathogens. This study aims to review the diagnostic assessment of adult suspected encephalitis cases.
Abstract: We compared the accuracy of online data obtained from the Flutracking surveillance system during pandemic (H1N1) 2009 in Australia with data from other influenza surveillance systems. Flutracking accurately identified peak influenza activity timing and community influenza-like illness activity and was significantly less biased by treatment-seeking behavior and laboratory testing protocols than other systems.
Abstract: The Convention on the Rights of the Child and the principles of social justice demand that all children have equal access to effective childhood immunization. Although there has been substantial progress in increasing global childhood immunization coverage, routinely reported data conceal marked disparities between and within countries. As a global community we still fall substantially short of our moral obligation to guarantee all children equal access to effective vaccines. Governments of developed and less-developed nations must unite to ensure the leadership planning, governance, and human and financial resources necessary to deliver on this critical global equity agenda.
Abstract: A pilot study was conducted in rural northern New South Wales from 15 July to 28 August 2009, during Australia's Protect Phase response to the Influenza A H1N1 California 7/09 pandemic. This study explored the feasibility of using administrative data, generated from the distribution of stockpiled antivirals, as a syndromic surveillance system. The purpose was to identify recently affected towns or those with increasing influenza-like illness activity to assist in rural health service operational planning. Analysis of antiviral distribution data was restricted to 113 general practices in rural parts of the Hunter New England Area Health Service. By 2 September 2009 a total of 6,670 courses of antivirals for adults, of which 455 courses were replacement orders, had been distributed to these general practices. Distribution of replacement antivirals were mapped to local government areas on a weekly basis. The syndromic surveillance system delivered timely data on antiviral distribution; used readily available software to generate visual activity maps in less than 30 minutes; proved adaptable; was of low cost; and was well received by health service planners. Full evaluation of the system's utility was limited by the relatively large initial distribution of antivirals and the brief nature of Australia's first pandemic wave. The pilot study demonstrated that a syndromic surveillance system based on distribution of supplies, such as treatment or vaccines, can support local health service operational planning during health emergencies.
Abstract: Communicable disease monitoring and response activities must be based upon local public health surveillance systems, even during infectious disease emergence, natural disasters, and during bioterrorism events. The NSW Department of Health has developed an emergency department surveillance system intended to monitor important public health conditions during mass gatherings and to identify outbreaks of importance. An evaluation of this system conducted in the Hunter New England region of New South Wales emphasised its usefulness when it was focused on a limited number of syndromes of public health importance and during mass gatherings and public health disaster responses.
Abstract: We reviewed Flutracking's (an Australian weekly online survey of community members) performance in estimating influenza vaccine effectiveness using New South Wales data for participants aged 18-60 years of age from 2007, 2008 and 2009. Flutracking results were consistent with previous findings that the 2009 seasonal influenza vaccine was ineffective in preventing the dominant pH1N109 strain of influenza, and that 2007 and 2008 vaccine strains were considered well matched to the circulating virus in Australia. Flutracking may offer an opportunity to estimate real time vaccine effectiveness during an influenza season.
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: 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: 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: 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.
Abstract: 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.
Abstract: 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.
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: 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: 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.
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: 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: 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.
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: 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: 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.
Abstract: 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.
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: 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.
Abstract: 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.
Abstract: 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.
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: 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: 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.
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: 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: 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: 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.
Abstract: 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.
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: 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: 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.
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: 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.
Abstract: 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.
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: 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: 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: 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.
Abstract: 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.
Abstract: 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.
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: 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: 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: 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).
Abstract: 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.
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: 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.
Abstract: 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.
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: 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.
Abstract: 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.
Abstract: 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.
Abstract: 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.
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: 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: 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: 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: 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: 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.
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: 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.
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: 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: 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.
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: 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.
Abstract: 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.
Abstract: To assess therapeutic efficacy of sulfadoxine-pyrimethamine (SP) in treatment of uncomplicated Plasmodium falciparum malaria 3 years after introduction in Mpumalanga, South Africa.
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: To determine routine measles coverage at district level and to explore reasons for immunisation failure in Mpumalanga Province, South Africa.
Abstract: 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).
Abstract: 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.
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: To determine the use of antimalarial prophylaxis and the relative frequency of adverse events with different regimens in visitors to the Kruger National Park.
Abstract: 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.
Abstract: 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).
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.
