Publications by authors named "Holly Seale"

144 Publications

Seroprevalence of hepatitis B antibodies among international and domestic university students.

J Viral Hepat 2021 Jul 26. Epub 2021 Jul 26.

Serology and Virology Division (SAViD), NSW Health Pathology SEALS-Randwick, Australia.

Chronic hepatitis B prevalence is low in most Australian populations, with universal infant HBV vaccination introduced in 2000. Migrants from high prevalence countries are at risk of acquisition before arrival and non-immune adults are potentially at risk through skin penetrating procedures and sexual contact, particularly during international travel. The risk profile of young adult students, many from high prevalence countries, is inadequately understood.A cross-sectional online survey conducted among university students collected data on demographic, vaccination and travel characteristics and blood samples were tested for hepatitis B surface antibody (HBsAb) and hepatitis B core antibody (HBcAb). Analyses identified factors associated with HBsAb seroprevalence and self-reported vaccination. The serosurvey was completed by 804 students born between 1988 and 1993, with 613/804 (76.2%, 95% CI 73.2-79.1) self-reporting prior HBV vaccination. Overall, 526/804 (65.4%, 95%CI 62.0-68.6%) students were seropositive to HBsAb, including 438/613 (71.5%, 95%CI 67.8-74.9) students self-reporting a prior HBV vaccine and 88/191 (46.1%, 95%CI 39.2-53.2) students self-reporting no prior HBV vaccine. Overall, 8/804 (1.0%, 95%CI 0.5-2.0%) students were HBcAb positive, of whom 1/804 (0.1%, 95%CI 0.02-0.7%) was currently infectious. The prevalence of chronic HBV infection was low. However, more than one in four students were susceptible to HBV and over-estimated their immunity. Future vaccination efforts should focus on domestic students born before the introduction of the infant program and all international students. Screening and vaccination of students, including through campus-based health services, is an opportunity to catch-up young adults prior to undertaking at-risk activities, including international travel.
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http://dx.doi.org/10.1111/jvh.13580DOI Listing
July 2021

How do health services engage culturally and linguistically diverse consumers? An analysis of consumer engagement frameworks in Australia.

Health Expect 2021 Jul 15. Epub 2021 Jul 15.

School of Population Health, UNSW Sydney, Kensington, New South Wales, Australia.

Background: Engagement frameworks provide the conceptual structure for consumer engagement in healthcare decision making, but the level to which these frameworks support culturally and linguistically diverse (CALD) consumer engagement is not known.

Objective: This study aimed to investigate how consumer engagement is conceptualised and operationalized and to determine the implications of current consumer engagement frameworks for engagement with CALD consumers.

Method: Altheide's document analysis approach was used to guide a systematic search, selection and analytic process. Australian Government health department websites were searched for eligible publicly available engagement frameworks. A narrative synthesis was conducted.

Results: Eleven engagement frameworks published between 2007 and 2019 were identified and analysed. Only four frameworks discussed engagement with CALD consumers distinctly. Organisational prerequisites to enhance engagement opportunities and approaches to enable activities of engagement were highlighted to improve CALD consumers' active participation in decision making; however, these largely focused on language, with limited exploration of culturally sensitive services.

Conclusion: There is limited discussion of what culturally sensitive services look like and what resources are needed to enhance CALD consumer engagement in high-level decision making. Health services and policy makers can enhance opportunities for engagement with CALD consumers by being flexible in their approach, implementing policies for reimbursement for participation and evaluating and adapting the activities of engagement in collaboration with CALD consumers.

Patient/public Contribution: This study is part of a wider 'CanEngage' project, which includes a consumer investigator, and is supported by a consumer advisory group. The study was conceived with inputs from the consumer advisory group, which continued to meet regularly with the project team to discuss the methodology and emerging findings.
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http://dx.doi.org/10.1111/hex.13315DOI Listing
July 2021

Trust in government, intention to vaccinate and COVID-19 vaccine hesitancy: A comparative survey of five large cities in the United States, United Kingdom, and Australia.

Vaccine 2021 Jun 23. Epub 2021 Jun 23.

Biosecurity Research Program, The Kirby Institute, University of New South Wales, Sydney, Australia. Electronic address:

Background: There is widespread hesitancy towards COVID-19 vaccines in the United States, United Kingdom, and Australia.

Objective: To identify predictors of willingness to vaccinate against COVID-19 in five cities with varying COVID-19 incidence in the US, UK, and Australia.

Design: Online, cross-sectional survey of adults from Dynata's research panel in July-September 2020.

Participants, Setting: Adults aged 18 and over in Sydney, Melbourne, London, New York City, or Phoenix.

Main Outcomes And Measures: Willingness to receive a COVID-19 vaccine; reason for vaccine intention.

Statistical Methods: To identify predictors of intention to receive a COVID-19 vaccine, we used Poisson regression with robust error estimation to produce prevalence ratios.

Results: The proportion willing to receive a COVID-19 vaccine was 70% in London, 71% NYC, 72% in Sydney, 76% in Phoenix, and 78% in Melbourne. Age was the only sociodemographic characteristic that predicted willingness to receive a COVID-19 vaccine in all five cities. In Sydney and Melbourne, participants with high confidence in their current government had greater willingness to receive the vaccine (PR = 1.24; 95% CI = 1.07-1.44 and PR = 1.38; 95% CI = 1.74-1.62), while participants with high confidence in their current government in NYC and Phoenix were less likely to be willing to receive the vaccine (PR = 0.78; 95% CI = 0.72-0.85 and PR = 0.85; 95% CI = 0.76-0.96).

Limitations: Consumer panels can be subject to bias and may not be representative of the general population.

Conclusions: Success for COVID-19 vaccination programs requires high levels of vaccine acceptance. Our data suggests more than 25% of adults may not be willing to receive a COVID-19 vaccine, but many of them were not explicitly anti-vaccination and thus may become more willing to vaccinate over time. Among the three countries surveyed, there appears to be cultural differences, political influences, and differing experiences with COVID-19 that may affect willingness to receive a COVID-19 vaccine.
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http://dx.doi.org/10.1016/j.vaccine.2021.06.048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8220944PMC
June 2021

Minimising missed opportunities to promote and deliver immunization services to middle and older age adults: Can hospital-based programs be a solution?

Vaccine 2021 06 20;39(26):3467-3472. Epub 2021 May 20.

School of Population Health, University of New South Wales, NSW, Australia. Electronic address:

Background: There has been a recent recognized shift towards a whole-of-life or life-course approach to immunisation. However, coverage amongst at-risk adults for recommended vaccines continues to be suboptimal. This study examined the perceptions of middle and older aged Australian adults towards hospital-based immunization programs and their previous exposures to receiving vaccines via tertiary care.

Methods: A cross-sectional survey was conducted with Australian adults 45 years and older in late 2019 to capture influenza and pneumococcal vaccine uptake, exposure to hospital-based immunization programs, missed opportunities to vaccinate and receptiveness towards the promotion and/or delivery of vaccines in the hospital setting.

Results: Only 13 respondents reported receiving a vaccine at hospital, yet 72.2% (931/1292) indicated that they were willing to be vaccinated in that setting. Amongst those who attended hospital during 2019 and were eligible for vaccination, 57.2% and 28.3% of respondents were not immunized for pneumococcal and influenza, respectively. Missed opportunities for both vaccines were significantly higher amongst those at low-risk for influenza (≤65 years (low-risk): 52.9%, ≤65 years (high-risk): 18.3%, >65 years: 15.1%; p < 0.001) and pneumococcal (≤65 years (low-risk): 79.1%, ≤65 years (high-risk): 52.4%, >65 years: 44%; p < 0.001). Among those with a missed opportunity for hospital-based vaccination, the most common reason for not getting immunized was a lack of recommendation. Most (86.4%) reported that their general practitioner was the person or group they trusted most to receive vaccine information from.

Conclusions: The findings from this Australian study support international work that shows very low rates of opportunistic vaccination in hospitals despite national recommendations to vaccinate prior to discharge. Considering the need for high levels of uptake of the COVID-19 vaccine, hospitals may need to be considered to opportunistically capture those not accessing the vaccine in other settings.
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http://dx.doi.org/10.1016/j.vaccine.2021.05.027DOI Listing
June 2021

The COVID-19 pandemic momentum: can it be used to support improvements in healthcare worker influenza vaccination?

Authors:
Holly Seale

Expert Rev Vaccines 2021 Jun 7:1-2. Epub 2021 Jun 7.

School of Population Health, University of New South Wales, Sydney, Australia.

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http://dx.doi.org/10.1080/14760584.2021.1930533DOI Listing
June 2021

COVID-19 vaccine rumors and conspiracy theories: The need for cognitive inoculation against misinformation to improve vaccine adherence.

PLoS One 2021 12;16(5):e0251605. Epub 2021 May 12.

School of Population Health, University of New South Wales, Sydney, Australia.

Introduction: Rumors and conspiracy theories, can contribute to vaccine hesitancy. Monitoring online data related to COVID-19 vaccine candidates can track vaccine misinformation in real-time and assist in negating its impact. This study aimed to examine COVID-19 vaccine rumors and conspiracy theories circulating on online platforms, understand their context, and then review interventions to manage this misinformation and increase vaccine acceptance.

Method: In June 2020, a multi-disciplinary team was formed to review and collect online rumors and conspiracy theories between 31 December 2019-30 November 2020. Sources included Google, Google Fact Check, Facebook, YouTube, Twitter, fact-checking agency websites, and television and newspaper websites. Quantitative data were extracted, entered in an Excel spreadsheet, and analyzed descriptively using the statistical package R version 4.0.3. We conducted a content analysis of the qualitative information from news articles, online reports and blogs and compared with findings from quantitative data. Based on the fact-checking agency ratings, information was categorized as true, false, misleading, or exaggerated.

Results: We identified 637 COVID-19 vaccine-related items: 91% were rumors and 9% were conspiracy theories from 52 countries. Of the 578 rumors, 36% were related to vaccine development, availability, and access, 20% related to morbidity and mortality, 8% to safety, efficacy, and acceptance, and the rest were other categories. Of the 637 items, 5% (30/) were true, 83% (528/637) were false, 10% (66/637) were misleading, and 2% (13/637) were exaggerated.

Conclusions: Rumors and conspiracy theories may lead to mistrust contributing to vaccine hesitancy. Tracking COVID-19 vaccine misinformation in real-time and engaging with social media to disseminate correct information could help safeguard the public against misinformation.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0251605PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8115834PMC
June 2021

Context matters: Examining the factors impacting the implementation of tuberculosis infection prevention and control guidelines in health settings in seven high tuberculosis burden countries.

J Infect Public Health 2021 May 8;14(5):588-597. Epub 2021 Feb 8.

School of Public Health and Community Medicine, University of New South Wales, Room 212, Samuels Building, Sydney, Australia.

Background: Healthcare workers (HCWs) in high tuberculosis (TB) burden countries are at increased risk of TB infection due to increased exposures to TB patients and inadequate implementation of TB infection prevention and control (TB IPC) measures in health settings. While various guidelines on TB IPC exist, there is little understanding of the content of these guidelines, whether they are relevant to the context and are being appropriately implemented in low-and middle-income high TB burden countries. This study aimed to critically examine the implementation of TB IPC guidelines, along with factors impacting TB IPC implementation in health settings in seven high TB burden countries.

Methods: The WHO 2009 and national level TB IPC guidelines and the published literature from seven TB high burden countries were reviewed and relevant information extracted. Eleven key-stakeholders from the case study countries were interviewed to elucidate further facilitators and barriers impacting TB IPC guidelines implementation.

Results: Our study identified that all the study countries adopted the WHO 2009 guidelines with no or minimal modifications for the local context. Therefore, the subsequent translation of the TB IPC recommendations into practice has been limited and impaired in some settings. Poor infrastructure, inadequate space for isolation, lack of TB IPC training, limited supply of personal protective equipment, the discomfort of using N95 respirators, and a high number of TB patients were some of the factors impacting the implementation of TB IPC guidelines.

Conclusion: The implementation of TB IPC guidelines in all seven countries was limited. It was affected by the diverse context where each of the countries and each of the facilities had a different health infrastructure and TB disease burdens. The findings warrant re-assessment of the current context prevailing in these high TB burden countries and subsequent revisions of national guidelines based to account for local context and evidence.
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http://dx.doi.org/10.1016/j.jiph.2021.01.014DOI Listing
May 2021

Mask use, risk-mitigation behaviours and pandemic fatigue during the COVID-19 pandemic in five cities in Australia, the UK and USA: A cross-sectional survey.

Int J Infect Dis 2021 May 23;106:199-207. Epub 2021 Mar 23.

School of Population Health, UNSW Medicine, University of New South Wales, Sydney, NSW, Australia.

Objectives: To determine patterns of mask wearing and other infection prevention behaviours, over two time periods of the COVID-19 pandemic, in cities where mask wearing was not a cultural norm.

Methods: A cross-sectional survey of masks and other preventive behaviours in adults aged ≥18 years was conducted in five cities: Sydney and Melbourne, Australia; London, UK; and Phoenix and New York, USA. Data were analysed according to the epidemiology of COVID-19, mask mandates and a range of predictors of mask wearing.

Results: The most common measures used were avoiding public areas (80.4%), hand hygiene (76.4%), wearing masks (71.8%) and distancing (67.6%). Over 40% of people avoided medical facilities. These measures decreased from March-July 2020. Pandemic fatigue was associated with younger age, low perceived severity of COVID-19 and declining COVID-19 prevalence. Predictors of mask wearing were location (US, UK), mandates, age <50 years, education, having symptoms and knowing someone with COVID-19. Negative experiences with mask wearing and low perceived severity of COVID-19 reduced mask wearing. Most respondents (98%) believed that hand washing and distancing were necessary, and 80% reported no change or stricter adherence to these measures when wearing masks.

Conclusion: Pandemic mitigation measures were widely reported across all cities, but decreased between March and July 2020. Pandemic fatigue was more common in younger people. Cities with mandates had higher rates of mask wearing. Promotion of mask use for older people may be useful. Masks did not result in a reduction of other hygiene measures.
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http://dx.doi.org/10.1016/j.ijid.2021.03.056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7985682PMC
May 2021

Knowledge, beliefs and attitudes of general practitioners and general practice nurses regarding influenza vaccination for young children.

Aust J Prim Health 2021 Mar 3. Epub 2021 Mar 3.

Annual vaccination is effective in reducing the harms associated with seasonal influenza. However, the uptake of influenza vaccine has historically been low in children. This paper reports a descriptive survey that sought to explore the beliefs, attitudes, and knowledge of general practitioners (GPs) and general practice nurses (GPNs) towards influenza vaccination in young children. Both GPs and GPNs working in the Illawarra Shoalhaven Local Health District (ISLHD) in NSW, Australia, were invited via email, fax and social media to participate in the study. A total of 121 participants completed the survey. Most participants had a high level of support and knowledge of influenza immunisation in young children. Barriers to influenza immunisation in young children included perceived hesitancy in parents and competing clinical demands. The participants strongly supported funding of the vaccine, with 90.9% feeling that parents would be less likely to vaccinate their children if the vaccine were no longer free. Both GPs and GPNs differed in the use of influenza vaccination resources. The participants had a positive attitude to influenza immunisation in young children and strongly supported continued funding of the vaccine. Dedicated young children's influenza vaccination clinics run by general practices or in the community could reduce the impact of competing clinical demands.
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http://dx.doi.org/10.1071/PY20175DOI Listing
March 2021

Improving Influenza Vaccination in Children With Comorbidities: A Systematic Review.

Pediatrics 2021 03 8;147(3). Epub 2021 Feb 8.

Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Western Australia, Australia.

Context: Children with medical comorbidities are at greater risk for severe influenza and poorer clinical outcomes. Despite recommendations and funding, influenza vaccine coverage remains inadequate in these children.

Objective: We aimed to systematically review literature assessing interventions targeting influenza vaccine coverage in children with comorbidities and assess the impact on influenza vaccine coverage.

Data Sources: PubMed, Scopus, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine Database, and Web of Science databases were searched.

Study Selection: Interventions targeting influenza vaccine coverage in children with medical comorbidities.

Data Extraction: Two reviewers independently screened articles, extracting studies' methods, interventions, settings, populations, and results. Four reviewers independently assessed risk of bias.

Results: From 961 screened articles, 35 met inclusion criteria. Published studies revealed that influenza vaccine coverage was significantly improved through vaccination reminders and education directed at either patients' parents or providers, as well as by vaccination-related clinic process changes. Interventions improved influenza vaccine coverage by an average 60%, but no significant differences between intervention types were detected. Significant bias and study heterogeneity were also identified, limiting confidence in this effect estimate.

Limitations: A high risk of bias and overall low quality of evidence limited our capacity to assess intervention types and methods.

Conclusions: Interventions were shown to consistently improve influenza vaccine coverage; however, no significant differences in coverage between different intervention types were observed. Future well-designed studies evaluating the effectiveness of different intervention are required to inform future optimal interventions.
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http://dx.doi.org/10.1542/peds.2020-1433DOI Listing
March 2021

Examining Australian public perceptions and behaviors towards a future COVID-19 vaccine.

BMC Infect Dis 2021 Jan 28;21(1):120. Epub 2021 Jan 28.

Office of Medical Education, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.

Background: As immunisation program launches have previously demonstrated, it is essential that careful planning occurs now to ensure the readiness of the public for a COVID-19 vaccine. As part of that process, this study aimed to understand the public perceptions regarding a future COVID-19 vaccine in Australia.

Methods: A national cross-sectional online survey of 1420 Australian adults (18 years and older) was undertaken between 18 and 24 March 2020. The statistical analysis of the data included univariate and multivariable logistic regression model analysis.

Results: Respondents generally held positive views towards vaccination. Eighty percent (n = 1143) agreed with the statement that getting myself vaccinated for COVID-19 would be a good way to protect myself against infection. Females (n = 614, 83%) were more likely to agree with the statement than males (n = 529, 78%) (aOR = 1.4 (95% CI: 1.1-1.8); P = 0.03), while 91% of those aged 70 years and above agreed compared to 76% of 18-29-year-olds (aOR = 2.3 (95% CI:1.2-4.1); P = 0.008). Agreement was also higher for those with a self-reported chronic disease (aOR = 1.4 (95% CI: 1.1-2.0); P = 0.04) and among those who held private health insurance (aOR = 1.7 (95% CI: 1.3-2.3); P < 0.001). Beyond individual perceptions, 78% stated that their decision to vaccinate would be supported by family and friends.

Conclusion: This study presents an early indication of public perceptions towards a future COVID-19 vaccine and represents a starting point for mapping vaccine perceptions. To support an effective launch of these new vaccines, governments need to use this time to understand the communities concerns and to identify the strategies that will support engagement.
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http://dx.doi.org/10.1186/s12879-021-05833-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7840792PMC
January 2021

Key policy and programmatic factors to improve influenza vaccination rates based on the experience from four high-performing countries.

Drugs Context 2021 5;10. Epub 2021 Jan 5.

Corporate Value Associates, Paris, France.

Background: Many countries consistently fail to achieve the target influenza vaccine coverage rate (VCR) of 75% for populations at risk of complications, recommended by the World Health Organization and European Council. We aimed to identify factors for achieving a high VCR in the scope of four benchmark countries with high influenza VCRs: Australia, Canada, UK and USA.

Methods: Publicly available evidence was first reviewed at a global level and then for each of the four countries. Semi-structured interviews were then conducted with stakeholders meeting predefined criteria. Descriptive cluster analyses were performed to identify key factors and pillars for establishing and maintaining high VCRs.

Results: No single factor led to a high VCR, and each benchmark country used a different combination of tailored approaches to achieve a high vaccine coverage. In each country, specific triggers were important to stimulate changes that led to improved vaccine coverage. A total of 42 key factors for a successful influenza vaccination programme were identified and clustered into five pillars: (1) Health Authority accountability and strengths of the influenza programme, (2) facilitated access to vaccination, (3) healthcare professional accountability and engagement, (4) awareness of the burden and severity of disease and (5) belief in influenza vaccination benefit. Each benchmark country has implemented multiple factors from each pillar.

Conclusion: A wide range of factors were identified from an evaluation of four high-performing benchmark countries, classified into five pillars, thus providing a basis for countries with lower VCRs to tailor their own particular solutions to improve their influenza VCR.
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http://dx.doi.org/10.7573/dic.2020-9-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7789908PMC
January 2021

Vaccine coverage in children born to migrant mothers in Australia: A population-based cohort study.

Vaccine 2021 02 9;39(6):984-993. Epub 2021 Jan 9.

Kirby Institute, University of New South Wales, Kensington, NSW, Australia; Sanofi Pasteur, Macquarie Park, NSW, Australia.

Background: Overall, infant immunisation coverage is currently >90% in Australia, but there are pockets of under-immunised children including children from migrant backgrounds. This study aimed to examine whether on-time vaccination coverage of diphtheria-tetanus-pertussis dose 3 (DTP3) for children born in Australia differed by mother's region of birth and if so, what factors were associated with these differences.

Methods: We conducted a population-based cohort study using linked data on perinatal, immunisation and birth records for 2 million children born in Western Australia and New South Wales between 1996 and 2012. We assessed on-time coverage of DTP3 (vaccination from 2 weeks prior to, and up until 30 days after, the due date) in children with mothers born overseas. Logistic regression models were developed to determine factors associated with on-time coverage for each maternal region of birth and all regions combined, adjusting for a range of demographic factors. Adjusted estimates of coverage were calculated for the different regions of birth.

Results: On-time DTP3 coverage was 76.2% in children of Australian born mothers, lower in children of mothers from Oceania (66.7%) and North America (68%), and higher in children born to mothers from South-East Asia (79.9%) and Southern Asia (79.3%). While most variables were consistently associated with lower coverage in all regions of birth, higher socioeconomic status and jurisdiction of birth showed varied results. Adjusted estimates of DTP3 coverage increased in children born to mothers from Australia (78.3%), Oceania (70.5%), Northern Africa (81.5%) and the Middle East (79.6%). DTP3 coverage decreased in children born to mothers from Europe and former USSR (74.6%), North-east Asia (75.2%), Southern Asia (76.7%), North America (65.5) and South/Central America and the Caribbean (73.2%).

Conclusions: On-time vaccination rates differed by mother's region of birth. More research is needed to determine the main reasons for these remaining differences to improve vaccine uptake and also help guide policy and practice.
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http://dx.doi.org/10.1016/j.vaccine.2020.12.058DOI Listing
February 2021

A review of hospital-based interventions to improve inpatient influenza vaccination uptake for high-risk adults.

Vaccine 2021 01 21;39(4):658-666. Epub 2020 Dec 21.

School of Population Health, University of New South Wales, Sydney, NSW, Australia. Electronic address:

Background: Despite positive steps towards transforming immunisation understanding and practice to better incorporate adults, coverage, especially those at higher risk, is not where it should be. One way to increase uptake is to take advantage of environments outside of primary care which present easy opportunities for vaccination. This study provides a narrative review of hospital-based strategies in acute care settings aimed at improving influenza vaccination rates for adult inpatients.

Methods: A search was conducted using Scopus, Embase and PubMed databases for articles reporting on hospital-based interventions aimed at improving influenza vaccination for adults. Studies published in English were included and descriptively analysed.

Results: A total of 31 articles were included. Tested interventions included 7 standing order protocols (SOP); 4 reminders; 4 assessment/administration programs; 1 patient education program; 1 organisational-based program; 7 multi-component strategies and 8 studies comparing SOPs with other strategies. One article was included in both SOPs and reminders categories. Studies were published between 1983 and 2017 and conducted in the USA, Canada, or Australia. 18 studies reported statistical significance. Individually, each type of intervention showed success. SOPs were significantly more effective than other individual interventions, but multi-component interventions (which included an SOP) were more effective than SOPs alone. Three articles reported no significant increase in uptake attributed mainly to patient refusals, even with a strategy involving patient education. Only three studies tested provider-level strategies including hospital campaigns, hospital reward programs and interdepartmental competitions, and showed success.

Conclusions: Hospital-based interventions are an effective means of improving opportunistic inpatient vaccination. Suggestions for future research include organisational or system-based interventions; qualitative review of barriers and enablers to inpatient vaccination programs; and re-examination of outpatient settings for vaccine delivery. Most studies were not randomised or controlled; therefore, we also recommend additional RCT studies to confirm existing findings on individual strategies.
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http://dx.doi.org/10.1016/j.vaccine.2020.12.042DOI Listing
January 2021

A tuberculin skin test survey among healthcare workers in two public tertiary care hospitals in Bangladesh.

PLoS One 2020 17;15(12):e0243951. Epub 2020 Dec 17.

School of Population Health, University of New South Wales, Sydney, Australia.

In Bangladesh, there is currently no data on the burden of latent TB infection (LTBI) amongst hospital healthcare workers (HCWs). This study aimed to determine the prevalence of LTBI and compare the prevalence among HCWs in two public tertiary care hospitals. Between September 2018 and August 2019, we conducted a cross-sectional study in two public tertiary care general hospitals. Using a survey and tuberculin skin test (TST), we assessed risk factors for LTBI, adjusting for known and plausible confounders. In addition, a facility assessment was undertaken to understand the implementation of relevant IPC measures. The prevalence of LTBI among HCWs was 42%. HCWs spent a median of 6 hours (SD = 1.76, IQR 2.00) per day and attended an average of 1.87 pulmonary TB patients per week. HCWs did not receive any TB IPC training, the wards lacked a symptom checklist to screen patients for TB, and no masks were available for coughing patients. Seventy-seven percent reportedly did not use any facial protection (masks or respirators) while caring for patients. In the multivariable model adjusting for hospital level clustering effect, TST positivity was significantly higher among HCWs aged 35-45 years (aOR1.36, 95% CI: 1.06-1.73) and with >3 years of service (aOR 1.67, 95% CI: 1.62-1.72). HCWs working in the medicine ward had 3.65 (95% CI: 2.20-6.05) times, and HCWs in the gynecology and obstetrics ward had 2.46 (95% CI: 1.42-4.27) times higher odds of TST positivity compared to HCWs working in administrative areas. This study identified high prevalence of LTBI among HCWs. This may be due to the level of exposure to pulmonary TB patients, and/or limited use of personal protective equipment along with poor implementation of TB IPC in the hospitals. Considering the high prevalence of LTBI, we recommend the national TB program consider providing preventative therapy to the HCWs as the high-risk group, and implement TB IPC in the hospitals.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0243951PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7745963PMC
February 2021

Contamination and washing of cloth masks and risk of infection among hospital health workers in Vietnam: a post hoc analysis of a randomised controlled trial.

BMJ Open 2020 09 28;10(9):e042045. Epub 2020 Sep 28.

School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia.

Background: In a previous randomised controlled trial (RCT) in hospital healthcare workers (HCWs), cloth masks resulted in a higher risk of respiratory infections compared with medical masks. This was the only published RCT of cloth masks at the time of the COVID-19 pandemic.

Objective: To do a post hoc analysis of unpublished data on mask washing and mask contamination from the original RCT to further understand poor performance of the two-layered cotton cloth mask used by HCWs in that RCT.

Setting: 14 secondary-level/tertiary-level hospitals in Hanoi, Vietnam.

Participants: A subgroup of 607 HCWs aged ≥18 years working full time in selected high-risk wards, who used a two-layered cloth mask and were part of a randomised controlled clinical trial comparing medical masks and cloth masks.

Intervention: Washing method for cloth masks (self-washing or hospital laundry). A substudy of contamination of a sample of 15 cloth and medical masks was also conducted.

Outcome Measure: Infection rate over 4 weeks of follow up and viral contamination of masks tested by multiplex PCR.

Results: Viral contamination with rhinovirus was identified on both used medical and cloth masks. Most HCW (77% of daily washing) self-washed their masks by hand. The risk of infection was more than double among HCW self-washing their masks compared with the hospital laundry (HR 2.04 (95% CI 1.03 to 4.00); p=0.04). There was no significant difference in infection between HCW who wore cloth masks washed in the hospital laundry compared with medical masks (p=0.5).

Conclusions: Using self-reported method of washing, we showed double the risk of infection with seasonal respiratory viruses if masks were self-washed by hand by HCWs. The majority of HCWs in the study reported hand-washing their mask themselves. This could explain the poor performance of two layered cloth masks, if the self-washing was inadequate. Cloth masks washed in the hospital laundry were as protective as medical masks. Both cloth and medical masks were contaminated, but only cloth masks were reused in the study, reiterating the importance of daily washing of reusable cloth masks using proper method. A well-washed cloth mask can be as protective as a medical mask.

Trial Resgistration Number: ACTRN12610000887077.
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http://dx.doi.org/10.1136/bmjopen-2020-042045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7523194PMC
September 2020

What factors shape doctors' trustworthiness? Patients' perspectives in the context of hypertension care in rural Tanzania.

Rural Remote Health 2020 08 19;20(3):5826. Epub 2020 Aug 19.

School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Kensington, Sydney, NSW, Australia

Introduction: There is increasing evidence that improving patient trust in doctors can improve patients' use of healthcare services, compliance and continuing engagement with care -particularly for chronic diseases. Consequently, much of the current literature on trust in therapeutic relationships focuses on factors shaping doctors' trustworthiness. However, few studies on this issue have been conducted among rural populations in low-income Africa, where health service delivery, cultural norms and patient expectations differ from those in high-income countries. This study examined patients' perspectives of factors that shape doctors' trustworthiness in rural Tanzania in the context of hypertension care.

Methods: A qualitative inquiry using in-depth interviews was conducted between 2015 and 2016 in two characteristically rural districts of Tanzania. Data were analysed thematically.

Results: The accounts of 34 patients from a Western-based care setting were examined. There was broad consensus about factors shaping doctors' trustworthiness along the care trajectory (before, during and after a therapeutic encounter). Two major themes emerged: doctors' interpersonal behaviours and doctors' technical competence. Good interpersonal behaviour and technical skills in healthcare settings were factors that constructed a positive reputation in the community and shaped patients' initial trust before a physical encounter. Doctors' interpersonal behaviours that portrayed good customer care, understanding and sympathy shaped trustworthiness during a physical encounter. Finally, doctors' technical competence shaped trustworthiness during and after an encounter. Participants used these factors to differentiate a trustworthy ('good') doctor from an untrustworthy ('bad') doctor.

Conclusion: Good interpersonal behaviours and good technical skills are important in shaping patients' judgements of doctors' trustworthiness in rural Tanzania. The present findings provide useful insights for designing interventions to improve patient trust in doctors to address challenges associated with non-communicable diseases in rural low-income Africa.
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http://dx.doi.org/10.22605/RRH5826DOI Listing
August 2020

Improving the impact of non-pharmaceutical interventions during COVID-19: examining the factors that influence engagement and the impact on individuals.

BMC Infect Dis 2020 Aug 17;20(1):607. Epub 2020 Aug 17.

School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Level 2, Samuels Building, Sydney, 2052, Australia.

Background: During an evolving outbreak or pandemic, non-pharmaceutical interventions (NPIs) including physical distancing, isolation, and mask use may flatten the peak in communities. However, these strategies rely on community understanding and motivation to engage to ensure appropriate compliance and impact. To support current activities for COVID-19, the objectives of this narrative review was to identify the key determinants impacting on engagement.

Methods: An integrative narrative literature review focused on NPIs. We aimed to identify published peer-reviewed articles that focused on the general community (excluding healthcare workers), NPIs (including school closure, quarantine, isolation, physical distancing and hygiene behaviours), and factors/characteristics (including social, physical, psychological, capacity, motivation, economic and demographic) that impact on engagement.

Results: The results revealed that there are a range of demographic, social and psychological factors underpinning engagement with quarantine, school closures, and personal protective behaviours. Aside from the factors impacting on acceptance and compliance, there are several key community concerns about their use that need to be addressed including the potential for economic consequences.

Conclusion: It is important that we acknowledge that these strategies will have an impact on an individual and the community. By understanding the barriers, we can identify what strategies need to be adopted to motivate individuals and improve community compliance. Using a behavioural framework to plan interventions based on these key barriers, will also ensure countries implement appropriate and targeted responses.
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http://dx.doi.org/10.1186/s12879-020-05340-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7430133PMC
August 2020

Evaluating the health literacy demand and cultural appropriateness of online immunisation information available to refugee and migrant communities in Australia.

Vaccine 2020 09 14;38(41):6410-6417. Epub 2020 Aug 14.

School of Public Health and Community Medicine, University of New South Wales, New South Wales, Australia.

Background: The internet is a source of health information for many consumers. However, little is known about the availability of online resources about immunisation (for children and adults) directed at refugee and migrant populations. The aim of this study was to evaluate the health literacy demand (understandability, actionability & readability) and cultural appropriateness of immunisation resources in Australia for these communities.

Methods: Our study involved two search approaches. Firstly, Google trends was used to identify the most common search terms used in Australia. Search terms used included 'immunisation', 'vaccine' and 'refugee immunisation' amongst others. These search terms were entered into: Google, Bing, Duck Duck Go and Yahoo and the first 5 pages of results for each search were examined. Searches were conducted from November 2018 to June 2019. Secondly, requests were sent out directly to key stakeholders in local health districts and state/territory health departments. Understandability and actionability were assessed using the Patient Education Materials Assessment Tool (PEMAT). The Simple Measure of Gobbledygook (SMOG) and the Flesch readability ease tools were used to assess readability. Cultural appropriateness was assessed using additional criteria developed by the Centre for Culture, Ethnicity and Health (CEH), Victoria, Australia.

Results: 27/33 resources were included in the analysis. The overall mean understandability score was 70% (range: 50-100%). The overall mean actionability score of the resources was 47% (range: 0-83%). In terms of readability, the mean score was a 10.5, which was indicative of an eleventh grade reading level. The average Flesch-Kincaid readability score was 47.7. The average score for cultural appropriateness was 79% (range: 29-100%).

Conclusions: Our findings suggest that there are currently not many refugee-specific resources on immunisation. Future work needs to better improve the health literacy demand of online immunisation information. Engaging with members from migrant communities is also recommended so that appropriately tailored resources are co-developed.
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http://dx.doi.org/10.1016/j.vaccine.2020.07.071DOI Listing
September 2020

COVID-19-Related Infodemic and Its Impact on Public Health: A Global Social Media Analysis.

Am J Trop Med Hyg 2020 10;103(4):1621-1629

School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia.

Infodemics, often including rumors, stigma, and conspiracy theories, have been common during the COVID-19 pandemic. Monitoring social media data has been identified as the best method for tracking rumors in real time and as a possible way to dispel misinformation and reduce stigma. However, the detection, assessment, and response to rumors, stigma, and conspiracy theories in real time are a challenge. Therefore, we followed and examined COVID-19-related rumors, stigma, and conspiracy theories circulating on online platforms, including fact-checking agency websites, Facebook, Twitter, and online newspapers, and their impacts on public health. Information was extracted between December 31, 2019 and April 5, 2020, and descriptively analyzed. We performed a content analysis of the news articles to compare and contrast data collected from other sources. We identified 2,311 reports of rumors, stigma, and conspiracy theories in 25 languages from 87 countries. Claims were related to illness, transmission and mortality (24%), control measures (21%), treatment and cure (19%), cause of disease including the origin (15%), violence (1%), and miscellaneous (20%). Of the 2,276 reports for which text ratings were available, 1,856 claims were false (82%). Misinformation fueled by rumors, stigma, and conspiracy theories can have potentially serious implications on the individual and community if prioritized over evidence-based guidelines. Health agencies must track misinformation associated with the COVID-19 in real time, and engage local communities and government stakeholders to debunk misinformation.
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http://dx.doi.org/10.4269/ajtmh.20-0812DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7543839PMC
October 2020

The safety of health care for ethnic minority patients: a systematic review.

Int J Equity Health 2020 07 8;19(1):118. Epub 2020 Jul 8.

School of Public Health and Community Medicine, University of New South Wales, Sydney, 2052, NSW, Australia.

Introduction: Evidence to date indicates that patients from ethnic minority backgrounds may experience disparity in the quality and safety of health care they receive due to a range of socio-cultural factors. Although heightened risk of patient safety events is of key concern, there is a dearth of evidence regarding the nature and rate of patient safety events occurring amongst ethnic minority consumers, which is critical for the development of relevant intervention approaches to enhance the safety of their care.

Objectives: To establish how ethnic minority populations are conceptualised in the international literature, and the implications of this in shaping of our findings; the evidence of patient safety events arising among ethnic minority healthcare consumers internationally; and the individual, service and system factors that contribute to unsafe care.

Method: A systematic review of five databases (MEDLINE, PUBMED, PsycINFO, EMBASE and CINAHL) were undertaken using subject headings (MeSH) and keywords to identify studies relevant to our objectives. Inclusion criteria were applied independently by two researchers. A narrative synthesis was undertaken due to heterogeneity of the study designs of included studies followed by a study appraisal process.

Results: Forty-five studies were included in this review. Findings indicate that: (1) those from ethnic minority backgrounds were conceptualised variably; (2) people from ethnic minority backgrounds had higher rates of hospital acquired infections, complications, adverse drug events and dosing errors when compared to the wider population; and (3) factors including language proficiency, beliefs about illness and treatment, formal and informal interpreter use, consumer engagement, and interactions with health professionals contributed to increased risk of safety events amongst these populations.

Conclusion: Ethnic minority consumers may experience inequity in the safety of care and be at higher risk of patient safety events. Health services and systems must consider the individual, inter- and intra-ethnic variations in the nature of safety events to understand the where and how to invest resource to enhance equity in the safety of care.

Review Registration: This systematic review is registered with Research Registry: reviewregistry761.
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http://dx.doi.org/10.1186/s12939-020-01223-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7346414PMC
July 2020

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

Emerg Infect Dis 2020 10 8;26(10). Epub 2020 Jul 8.

Cloth masks have been used in healthcare and community settings to protect the wearer from respiratory infections. The use of cloth masks during the coronavirus disease (COVID-19) pandemic is under debate. The filtration effectiveness of cloth masks is generally lower than that of medical masks and respirators; however, cloth masks may provide some protection if well designed and used correctly. Multilayer cloth masks, designed to fit around the face and made of water-resistant fabric with a high number of threads and finer weave, may provide reasonable protection. Until a cloth mask design is proven to be equally effective as a medical or N95 mask, wearing cloth masks should not be mandated for healthcare workers. In community settings, however, cloth masks may be used to prevent community spread of infections by sick or asymptomatically infected persons, and the public should be educated about their correct use.
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http://dx.doi.org/10.3201/eid2610.200948DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7510705PMC
October 2020

Why is influenza vaccine uptake so low among Aboriginal adults?

Aust N Z J Public Health 2020 Aug 24;44(4):279-283. Epub 2020 Jun 24.

School of Public Health and Community Medicine, University of NSW, New South Wales.

Objectives: Determine major barriers to, and facilitators of, influenza vaccination of Aboriginal adults, in order to improve coverage from the current level of 30%.

Methods: i) A focus group with 13 Aboriginal Immunisation Healthcare Workers; and ii) a cross-sectional survey of Aboriginal people aged ≥18 years at the 2017 New South Wales Koori Knockout (29 September-2 October).

Results: The focus group nominated poor identification of Aboriginality in general practice. Of 273 survey respondents, a substantial minority (30%) were unaware of their eligibility for free influenza vaccination. More than half (52%) believed the vaccine could cause influenza, 40% reported there were better ways than vaccination for avoiding infection and 30% said they would not have the vaccine if it was offered to them. Regarding health service access, few reported experiencing difficulty (17%), feeling uncomfortable (15%) or being discriminated against (8%), but 53% reported not receiving a reminder from a health professional.

Conclusions: Misconceptions about influenza disease and vaccine among Aboriginal people and inadequate identification of Aboriginality in general practice appear to be the greatest barriers to vaccination, rather than health service access in general. Implications for public health: More active communication to and targeting of Aboriginal adults is required; this is even more urgent following the arrival of COVID-19.
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http://dx.doi.org/10.1111/1753-6405.13004DOI Listing
August 2020

Ten considerations for effectively managing the COVID-19 transition.

Nat Hum Behav 2020 07 24;4(7):677-687. Epub 2020 Jun 24.

Center for Empirical Research in Economics and Behavioral Sciences, Media and Communication Science, University of Erfurt, Erfurt, Germany.

Governments around the world have implemented measures to manage the transmission of coronavirus disease 2019 (COVID-19). While the majority of these measures are proving effective, they have a high social and economic cost, and response strategies are being adjusted. The World Health Organization (WHO) recommends that communities should have a voice, be informed and engaged, and participate in this transition phase. We propose ten considerations to support this principle: (1) implement a phased approach to a 'new normal'; (2) balance individual rights with the social good; (3) prioritise people at highest risk of negative consequences; (4) provide special support for healthcare workers and care staff; (5) build, strengthen and maintain trust; (6) enlist existing social norms and foster healthy new norms; (7) increase resilience and self-efficacy; (8) use clear and positive language; (9) anticipate and manage misinformation; and (10) engage with media outlets. The transition phase should also be informed by real-time data according to which governmental responses should be updated.
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http://dx.doi.org/10.1038/s41562-020-0906-xDOI Listing
July 2020

COVID-19 is rapidly changing: Examining public perceptions and behaviors in response to this evolving pandemic.

PLoS One 2020 23;15(6):e0235112. Epub 2020 Jun 23.

Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.

Background: Since the emergence of SARS-CoV-2, the virus that causes coronavirus disease (COVID-19) in late 2019, communities have been required to rapidly adopt community mitigation strategies rarely used before, or only in limited settings. This study aimed to examine the attitudes and beliefs of Australian adults towards the COVID-19 pandemic, and willingness and capacity to engage with these mitigation measures. In addition, we aimed to explore the psychosocial and demographic factors that are associated with adoption of recommended hygiene-related and avoidance-related behaviors.

Methods: A national cross-sectional online survey of 1420 Australian adults (18 years and older) was undertaken between the 18 and 24 March 2020. The statistical analysis of the data included univariate and multivariate logistic regression analysis.

Findings: The survey of 1420 respondents found 50% (710) of respondents felt COVID-19 would 'somewhat' affect their health if infected and 19% perceived their level of risk as high or very high. 84·9% had performed ≥1 of the three recommended hygiene-related behaviors and 93·4% performed ≥1 of six avoidance-related behaviors over the last one month. Adopting avoidance behaviors was associated with trust in government/authorities (aOR: 6.0, 95% CI 2.6-11·0), higher perceived rating of effectiveness of behaviors (aOR: 4·0, 95% CI: 1·8-8·7), higher levels of perceived ability to adopt social distancing strategies (aOR: 5.0, 95% CI: 1·5-9.3), higher trust in government (aOR: 6.0, 95% CI: 2.6-11.0) and higher level of concern if self-isolated (aOR: 1.8, 95% CI: 1.1-3.0).

Interpretation: In the last two months, members of the public have been inundated with messages about hygiene and social (physical) distancing. However, our results indicate that a continued focus on supporting community understanding of the rationale for these strategies, as well as instilling community confidence in their ability to adopt or sustain the recommendations is needed.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0235112PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7310732PMC
June 2020

Human coronavirus data from four clinical trials of masks and respirators.

Int J Infect Dis 2020 Jul 1;96:631-633. Epub 2020 Jun 1.

Institute for Infectious Disease and Endemic Disease Control, Beijing CDC, China.

There are few published data on the efficacy of masks or respirators against coronavirus infections. This is an important research question to inform the response to the COVID-19 epidemic. The transmission modes of human coronaviruses are similar, thought to be by droplet, contact, and sometimes airborne routes. There are several randomized clinical trials of masks and respirators, but most used clinical endpoints or tested only for influenza. In four trials that we conducted, we tested for human coronaviruses, but only composite viral endpoints were reported in the trials. We reviewed and analyzed the coronavirus data from four of our trials. Laboratory-confirmed coronavirus infections were identified in our community household trial (one case), health worker trials (eight cases), and trial of mask use by sick patients (19 cases). No coronavirus infections were transmitted in households to parents who wore P2 or surgical masks, but one child with coronavirus infection transmitted infection to a parent in the control arm. No transmissions to close contacts occurred when worn by sick patients with coronavirus infections. There was a higher risk of coronavirus infection in HCWs who wore a mask compared to a respirator, but the difference was not statistically significant. These are the only available clinical trial data on coronavirus infections associated with mask or respirator use. More clinical trials are needed to assess the efficacy of respiratory protection against coronavirus infections.
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http://dx.doi.org/10.1016/j.ijid.2020.05.092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7263249PMC
July 2020

Current knowledge of COVID-19 and infection prevention and control strategies in healthcare settings: A global analysis.

Infect Control Hosp Epidemiol 2020 10 15;41(10):1196-1206. Epub 2020 May 15.

School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia.

Objective: In the current absence of a vaccine for COVID-19, public health responses aim to break the chain of infection by focusing on the mode of transmission. We reviewed the current evidence on the transmission dynamics and on pathogenic and clinical features of COVID-19 to critically identify any gaps in the current infection prevention and control (IPC) guidelines.

Methods: In this study, we reviewed global COVID-19 IPC guidelines by organizations such as the World Health Organization (WHO), the US Centers for Disease Control and Prevention (CDC), and the European Centre for Disease Prevention and Control (ECDC). Guidelines from 2 high-income countries (Australia and United Kingdom) and from 1 middle-income country (China) were also reviewed. We searched publications in English on 'PubMed' and Google Scholar. We extracted information related to COVID-19 transmission dynamics, clinical presentations, and exposures that may facilitate transmission. We then compared these findings with the recommended IPC measures.

Results: Nosocomial transmission of SARS-CoV-2 in healthcare settings occurs through droplets, aerosols, and the oral-fecal or fecal-droplet route. However, the IPC guidelines fail to cover all transmission modes, and the recommendations also conflict with each other. Most guidelines recommend surgical masks for healthcare providers during routine care and N95 respirators for aerosol-generating procedures. However, recommendations regarding the type of face mask varied, and the CDC recommends cloth masks when surgical masks are unavailable.

Conclusion: IPC strategies should consider all the possible routes of transmission and should target all patient care activities involving risk of person-to-person transmission. This review may assist international health agencies in updating their guidelines.
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http://dx.doi.org/10.1017/ice.2020.237DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7253768PMC
October 2020

Reflecting on the updates to the World Health Organisation 2019 Tuberculosis Infection Control Guidelines through the lens of a low-income/high TB burden country.

J Infect Public Health 2020 Aug 30;13(8):1057-1060. Epub 2020 Mar 30.

School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Kensington, Australia.

Hospital-acquired tuberculosis infection among healthcare workers is a global concern due to the increased attributable risk of tuberculosis infection among this group. To reduce healthcare workers' exposure to airborne Mycobacterium tuberculosis, various policies and guidelines have been developed and updated by the World Health Organisation (WHO) since 1999. In March 2019, the WHO published the updated tuberculosis infection control guidelines. It had previously been suggested that the existence of multiple guidelines and the changes in the contents across versions may confuse end-users and challenge the implementation. With this issue in mind, we examined the updated WHO 2019 TB infection control guidelines. The WHO 2019 updated guideline is a shorter and more focused document that includes more of the evidence from published systematic reviews for TB infection prevention and control. The guidelines focus on implementing TB infection control as an integrated infection control and prevention 'package'. However, a few key elements have been omitted or integrated with other WHO policies that were previously included in the guidelines, many of which are also still present in other international and in many national level TB infection control guidelines. In this commentary, we highlighted the inconsistencies in the different versions of the guidelines, the challenges that the high TB burden and low-income countries may face while implementing the guidelines and some factors that may be considered in the future guidelines. The arguments we made have important implications for tuberculosis infection control strategy development and implementation in low-income and high TB burden countries.
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http://dx.doi.org/10.1016/j.jiph.2020.02.039DOI Listing
August 2020
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