Publications by authors named "Karin Leder"

161 Publications

Sociodemographic indicators of COVID-19 testing amongst working-age Australians.

Health Promot J Austr 2021 Mar 15. Epub 2021 Mar 15.

School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.

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http://dx.doi.org/10.1002/hpja.472DOI Listing
March 2021

Variants, vaccines and vaccination passports: Challenges and chances for travel medicine in 2021.

Travel Med Infect Dis 2021 Mar-Apr;40:101996. Epub 2021 Feb 23.

School of Public Health and Preventive Medicine, Monash University, Victoria, Australia.

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http://dx.doi.org/10.1016/j.tmaid.2021.101996DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7899929PMC
February 2021

Acute kidney injury secondary to severe delayed haemolysis in intravenous artesunate use for severe malaria.

BMJ Case Rep 2021 Jan 26;14(1). Epub 2021 Jan 26.

Victorian Infectious Diseases Service, Royal Melbourne Hospital, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia

The use of artemisinin derivatives has been recommended by the WHO guidelines in malaria treatment largely due to its rapid parasite clearance and safety profile. This case report details the development of delayed haemolysis and subsequent severe acute kidney injury (AKI) 13 days after commencing intravenous artesunate treatment for malaria in an Australian returned traveller. Delayed haemolysis may be an under-recognised complication following artesunate use and if severe, can be complicated by AKI. Therefore, close patient follow-up following treatment is required to ensure prompt recognition of this phenomenon.
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http://dx.doi.org/10.1136/bcr-2020-237501DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7839869PMC
January 2021

Study design, rationale and methods of the Revitalising Informal Settlements and their Environments (RISE) study: a cluster randomised controlled trial to evaluate environmental and human health impacts of a water-sensitive intervention in informal settlements in Indonesia and Fiji.

BMJ Open 2021 01 8;11(1):e042850. Epub 2021 Jan 8.

Monash Sustainable Development Institute, Monash University, Melbourne, Victoria, Australia.

Introduction: Increasing urban populations have led to the growth of informal settlements, with contaminated environments linked to poor human health through a range of interlinked pathways. Here, we describe the design and methods for the Revitalising Informal Settlements and their Environments (RISE) study, a transdisciplinary randomised trial evaluating impacts of an intervention to upgrade urban informal settlements in two Asia-Pacific countries.

Methods And Analysis: RISE is a cluster randomised controlled trial among 12 settlements in Makassar, Indonesia, and 12 in Suva, Fiji. Six settlements in each country have been randomised to receive the intervention at the outset; the remainder will serve as controls and be offered intervention delivery after trial completion. The intervention involves a water-sensitive approach, delivering site-specific, modular, decentralised infrastructure primarily aimed at improving health by decreasing exposure to environmental faecal contamination. Consenting households within each informal settlement site have been enrolled, with longitudinal assessment to involve health and well-being surveys, and human and environmental sampling. Primary outcomes will be evaluated in children under 5 years of age and include prevalence and diversity of gastrointestinal pathogens, abundance and diversity of antimicrobial resistance (AMR) genes in gastrointestinal microorganisms and markers of gastrointestinal inflammation. Diverse secondary outcomes include changes in microbial contamination; abundance and diversity of pathogens and AMR genes in environmental samples; impacts on ecological biodiversity and microclimates; mosquito vector abundance; anthropometric assessments, nutrition markers and systemic inflammation in children; caregiver-reported and self-reported health symptoms and healthcare utilisation; and measures of individual and community psychological, emotional and economic well-being. The study aims to provide proof-of-concept evidence to inform policies on upgrading of informal settlements to improve environments and human health and well-being.

Ethics: Study protocols have been approved by ethics boards at Monash University, Fiji National University and Hasanuddin University.

Trial Registration Number: ACTRN12618000633280; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2020-042850DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7798802PMC
January 2021

Weekly updates of national living evidence-based guidelines: methods for the Australian living guidelines for care of people with COVID-19.

J Clin Epidemiol 2021 03 11;131:11-21. Epub 2020 Nov 11.

School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia. Electronic address:

Background And Objectives: The Australian National COVID-19 Clinical Evidence Taskforce is a consortium of 31 Australian health professional organisations developing living, evidence-based guidelines for care of people with COVID-19, which are updated weekly. This article describes the methods used to develop and maintain the guidelines.

Methods: The guidelines use the GRADE methods and are designed to meet Australian NHMRC standards. Each week, new evidence is reviewed, current recommendations are revised, and new recommendations made. These are published in MAGIC and disseminated through traditional and social media. Relevant new questions to be addressed are continually sought from stakeholders and practitioners. For prioritized questions, the evidence is actively monitored and updated. Evidence surveillance combines horizon scans and targeted searches. An evidence team appraises and synthesizes evidence and prepares evidence-to-decision frameworks to inform development of recommendations. A guidelines leadership group oversees the development of recommendations by multidisciplinary guidelines panels and is advised by a consumer panel.

Results: The Taskforce formed in March 2020, and the first recommendations were published 2 weeks later. The guidelines have been revised and republished on a weekly basis for 24 weeks, and as of October 2020, contain over 90 treatment recommendations, suggesting that living methods are feasible in this context.

Conclusions: The Australian guidelines for care of people with COVID-19 provide an example of the feasibility of living guidelines and an opportunity to test and improve living evidence methods.
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http://dx.doi.org/10.1016/j.jclinepi.2020.11.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7657075PMC
March 2021

Humanising medicine in the era of universal masking.

Intern Med J 2020 10;50(10):1297

School of Medicine, Monash University, Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1111/imj.15008DOI Listing
October 2020

Effect of aspirin on deaths associated with sepsis in healthy older people (ANTISEPSIS): a randomised, double-blind, placebo-controlled primary prevention trial.

Lancet Respir Med 2021 02 17;9(2):186-195. Epub 2020 Sep 17.

Australian Institute of Tropical Health and Medicine, James Cook University, Douglas, QLD, Australia.

Background: Sepsis is a serious global health issue and a major cause of death and disability. The availability of a simple, community-based preventive strategy could substantially reduce the burden of sepsis. We aimed to establish whether low-dose aspirin reduced deaths or hospital admissions associated with sepsis in older people.

Methods: ANTISEPSIS was a substudy of ASPREE (a randomised controlled primary prevention trial of low-dose aspirin [100 mg per day] compared with placebo in community dwelling older adults conducted in Australia and the USA), with the Australian cohort included in the ANTISEPSIS substudy. Inclusion criteria were participants aged at least 70 years who did not have major illnesses. Participants were block randomised (1:1) via a centralised web portal and stratified by general practice and age. Participants, investigators, and staff were masked to the intervention. Teams of clinical specialist investigators assessed potential sepsis events to establish if they satisfied the primary endpoint of death associated with sepsis. The analyses were by intention-to-treat with univariate survival analysis methods, the log-rank test, and Cox proportional hazards regression. This study is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12613000349741.

Results: Between March 10, 2010, and Dec 24, 2014, of 20 288 individuals assessed for eligibility, 16 703 participants aged 70 years and older at trial entry were enrolled and followed up for a median of 4·6 years (IQR 3·6-5·6). 8322 (49·8%) participants were assigned to receive aspirin and 8381 (50·2%) to placebo. 203 deaths were considered to be associated with sepsis. Univariate analysis showed similar rates of death associated with sepsis in the two study groups (hazard ratio for aspirin vs placebo 1·08, 95% CI 0·82-1·43; p=0·57). Adverse events were previously reported in the ASPREE trial.

Interpretation: Daily low-dose aspirin treatment did not reduce deaths associated with sepsis in community dwelling older adults. Our findings do not support the use of aspirin as a primary prevention strategy to reduce the burden of sepsis in this population.

Funding: National Health and Medical Research Council of Australia, National Institutes of Health, Monash University.
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http://dx.doi.org/10.1016/S2213-2600(20)30411-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7957956PMC
February 2021

Epidemiological and Clinical Characteristics of International Travelers with Enteric Fever and Antibiotic Resistance Profiles of Their Isolates: a GeoSentinel Analysis.

Antimicrob Agents Chemother 2020 10 20;64(11). Epub 2020 Oct 20.

Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA.

Enteric fever, caused by serovar Typhi ( Typhi) and serovar Paratyphi ( Paratyphi), is a common travel-related illness. Limited data are available on the antimicrobial resistance (AMR) patterns of these serovars among travelers. Records of travelers with a culture-confirmed diagnosis seen during or after travel from January 2007 to December 2018 were obtained from GeoSentinel. Traveler demographics and antimicrobial susceptibility data were analyzed. Isolates were classified as nonsusceptible if intermediate or resistant or as susceptible in accordance with the participating site's national guidelines. A total of 889 travelers ( Typhi infections,  = 474; Paratyphi infections,  = 414; coinfection,  = 1) were included; 114 (13%) were children of <18 years old. Most individuals (41%) traveled to visit friends and relatives (VFRs) and acquired the infection in South Asia (71%). Child travelers with Typhi infection were most frequently VFRs (77%). The median trip duration was 31 days (interquartile range, 18 to 61 days), and 448 of 691 travelers (65%) had no pretravel consultation. Of 143 Typhi and 75 Paratyphi isolates for which there were susceptibility data, nonsusceptibility to antibiotics varied (fluoroquinolones, 65% and 56%, respectively; co-trimoxazole, 13% and 0%; macrolides, 8% and 16%). Two Typhi isolates (1.5%) from India were nonsusceptible to third-generation cephalosporins. Typhi fluoroquinolone nonsusceptibility was highest when infection was acquired in South Asia (70 of 90 isolates; 78%) and sub-Saharan Africa (6 of 10 isolates; 60%). Enteric fever is an important travel-associated illness complicated by AMR. Our data contribute to a better understanding of region-specific AMR, helping to inform empirical treatment options. Prevention measures need to focus on high-risk travelers including VFRs and children.
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http://dx.doi.org/10.1128/AAC.01084-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577154PMC
October 2020

Travel-related hepatitis E: a two-decade GeoSentinel analysis.

J Travel Med 2020 Nov;27(7)

Department of Global Health, Boston University School of Public Health, Boston, USA.

Background: Hepatitis E virus (HEV) is widely distributed worldwide and is endemic in developing countries. Travel-related HEV infection has been reported at national levels, but global data are missing. Moreover, the global availability of HEV diagnostic testing has not been explored so far. The aim of this study is to describe the epidemiology of HEV infections in returning travellers and availability of HEV diagnostic testing in the GeoSentinel surveillance network.

Methods: This was a multicentre retrospective cross-sectional study. All confirmed and probable HEV travel-related infections reported in the GeoSentinel Network between 1999 and 2018 were evaluated. GeoSentinel sites were asked to complete a survey in 2018 to assess the availability and accessibility of HEV diagnostic procedures (i.e. serology and molecular tests) throughout the study period.

Results: Overall, 165 travel-related HEV infections were reported, mainly since 2010 (60%) and in tourists (50%). Travellers were exposed to hepatitis E in 27 countries; most travellers (62%) were exposed to HEV in South Asia. One patient was pregnant at the time of HEV infection and 14 had a concomitant gastrointestinal infection. No deaths were reported. In the 51% of patients with information available, there was no pre-travel consultation. Among 44 GeoSentinel sites that responded to the survey, 73% have access to HEV serology at a local level, while 55% could perform (at a local or central level) molecular diagnostics.

Conclusion: Reported access to HEV diagnostic testing is suboptimal among sites that responded to the survey; this could negatively affect diagnosing HEV. Pre-travel consultations before travel to South Asia and other low-income and high-prevalence areas with a focus on food and water precautions could be helpful in preventing hepatitis E infection. Improved HEV diagnostic capacity should be implemented to prevent and correctly diagnose travel-related HEV infection.
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http://dx.doi.org/10.1093/jtm/taaa132DOI Listing
November 2020

A high proportion of interseasonal childhood influenza cases in 2019 were travel related.

Public Health Res Pract 2020 06 30;30(2). Epub 2020 Jun 30.

University of Sydney Children's Hospital Westmead Clinical School, NSW, Australia; Department of Infectious Diseases and Microbiology, The Children's Hospital at Westmead, Sydney, NSW, Australia;

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http://dx.doi.org/10.17061/phrp3022012DOI Listing
June 2020

Zika among international travellers presenting to GeoSentinel sites, 2012-2019: implications for clinical practice.

J Travel Med 2020 Jul;27(4)

Department of Epidemiology and Global Health, University of Umea, Petrus Laestadius Väg, 901 87, Umeå, Sweden.

Introduction: International travellers contribute to the rapid spread of Zika virus (ZIKV) and its sentinel identification globally. We describe ZIKV infections among international travellers seen at GeoSentinel sites with a focus on ZIKV acquired in the Americas and the Caribbean, describe countries of exposure and traveller characteristics, and assess ZIKV diagnostic testing by site.

Methods: Records with an international travel-related diagnosis of confirmed or probable ZIKV from January 2012 through December 2019 reported to GeoSentinel with a recorded illness onset date were included to show reported cases over time. Records from March 2016 through December 2019 with an exposure region of the Americas or the Caribbean were included in the descriptive analysis. A survey was conducted to assess the availability, accessibility and utilization of ZIKV diagnostic tests at GeoSentinel sites.

Results: GeoSentinel sites reported 525 ZIKV cases from 2012 through 2019. Between 2012 and 2014, eight cases were reported, and all were acquired in Asia or Oceania. After 2014, most cases were acquired in the Americas or the Caribbean, a large decline in ZIKV cases occurred in 2018-19.Between March 2016 and December 2019, 423 patients acquired ZIKV in the Americas or the Caribbean, peak reporting to these regions occurred in 2016 [330 cases (78%)]. The median age was 36 years (range: 3-92); 63% were female. The most frequent region of exposure was the Caribbean (60%). Thirteen travellers were pregnant during or after travel; one had a sexually acquired ZIKV infection. There was one case of fetal anomaly and two travellers with Guillain-Barré syndrome. GeoSentinel sites reported various challenges to diagnose ZIKV effectively.

Conclusion: ZIKV should remain a consideration for travellers returning from areas with risk of ZIKV transmission. Travellers should discuss their travel plans with their healthcare providers to ensure ZIKV prevention measures are taken.
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http://dx.doi.org/10.1093/jtm/taaa061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7604850PMC
July 2020

Household Water Storage Management, Hygiene Practices, and Associated Drinking Water Quality in Rural India.

Environ Sci Technol 2020 04 30;54(8):4963-4973. Epub 2020 Mar 30.

School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria 3004, Australia.

Household drinking water storage is commonly practiced in rural India. Fecal contamination may be introduced at the water source, during collection, storage, or access. Within a trial of a community-level water supply intervention, we conducted five quarterly household-level surveys to collect information about water, sanitation, and hygiene practices in rural India. In a random subsample of households, we tested stored drinking water samples for , concurrently observing storage and access practices. We conducted 9961 surveys and collected 3296 stored water samples. Stored water samples were frequently contaminated with (69%), and levels were the highest during the wet season. Most households contributing two or more drinking water samples had detectable in some (47%) or all (44%) samples. Predictors of stored water contamination with included consumption of river water and open defecation; consumption of reverse osmosis-treated water and safe water access practices appeared to be protective. Until households can be reached with on-premises continuous safe water supplies, suboptimal household water storage practices are likely to continue. Improvements to source water quality alone are unlikely to prevent exposure to contaminated drinking water unless attention is also given to improving household water storage, access, and sanitation practices.
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http://dx.doi.org/10.1021/acs.est.9b04818DOI Listing
April 2020

GeoSentinel surveillance of travel-associated infections: What lies in the future?

Travel Med Infect Dis 2020 Jul - Aug;36:101600. Epub 2020 Mar 7.

J.D. MacLean Centre for Tropical Medicine, McGill University, Montreal, Canada.

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http://dx.doi.org/10.1016/j.tmaid.2020.101600DOI Listing
March 2020

Barriers and Enablers to Intervention Uptake and Health Reporting in a Water Intervention Trial in Rural India: A Qualitative Explanatory Study.

Am J Trop Med Hyg 2020 03;102(3):507-517

School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.

Consumption of unsafe drinking water contributes to the global disease burden, necessitating identification and implementation of effective, acceptable, and sustainable water interventions in resource-limited settings. In a quantitative stepped-wedge cluster randomized trial of a community-based water intervention in rural India, we identified low rates of intervention uptake and reported diarrhea. To better understand and explain these findings, we performed a qualitative study examining barriers and enablers to intervention uptake and health reporting using the COM-B model, where capabilities, opportunities, and motivators interact to generate behavior. We conducted 20 focus groups and one semi-structured interview with participants and four focus groups with data collectors. Multifactorial barriers to intervention uptake included distorted perceptions of water-related health effects, implementation issues that reduced treated water availability; convenience of, and preference for, alternative drinking water sources; delivery of water to plastic storage tanks (perceived as affecting water quality and taste); and resistance to change. Enablers included knowledge of water-related health risks, proximity to tanks, and social opportunity. Barriers to health reporting included variability in interpretation of illness, suspicion regarding the consequences of reporting disease, weariness with repeated questions, and perceived inaction on health data already provided; low survey implementation fidelity was also important. Enablers included surveyor initiatives to encourage reporting and a sense of social responsibility. This qualitative explanatory study allowed better understanding of our quantitative results. It also identified obstacles and facilitators to implementing and evaluating community water interventions, providing insight on how to achieve better intervention uptake and health reporting in future studies.
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http://dx.doi.org/10.4269/ajtmh.19-0486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7056424PMC
March 2020

Progress towards the Control of Strongyloidiasis in Tropical Australia?

Am J Trop Med Hyg 2020 02;102(2):249-250

Victorian Infectious Diseases Service, Royal Melbourne Hospital at Doherty Institute for Infection and Immunity, Melbourne, Australia.

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http://dx.doi.org/10.4269/ajtmh.19-0922DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7008327PMC
February 2020

Complex choices: Which malaria chemoprophylaxis can be recommended for the pregnant traveller?

Travel Med Infect Dis 2019 Nov 20:101525. Epub 2019 Nov 20.

National Travel Health Network and Centre, University College London Hospital NHS Foundation Trust, London, UK.

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http://dx.doi.org/10.1016/j.tmaid.2019.101525DOI Listing
November 2019

Influenza and pertussis vaccination of women during pregnancy in Victoria, 2015-2017.

Med J Aust 2019 11 3;211(10):474-474.e1. Epub 2019 Nov 3.

Monash University, Melbourne, VIC.

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http://dx.doi.org/10.5694/mja2.50386DOI Listing
November 2019

A Stepped Wedge Cluster-Randomized Trial Assessing the Impact of a Riverbank Filtration Intervention to Improve Access to Safe Water on Health in Rural India.

Am J Trop Med Hyg 2020 03;102(3):497-506

School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.

Sustainable and low-cost methods for delivery of safe drinking water in resource-limited settings remain suboptimal, which contributes to global diarrhea morbidity. We aimed to assess whether delivery of riverbank filtration-treated water to newly installed water storage tanks (improved quality and access, intervention condition) reduced reported diarrhea in comparison to delivery of unfiltered river water (improved access alone, control condition) in rural Indian villages. We used a stepped wedge cluster-randomized trial (SW-CRT) design involving four clusters (villages). Selection criteria included village size, proximity to a river, and lack of existing or planned community-level safe water sources. All adults and children were eligible for enrollment. All villages started in the control condition and were sequentially randomized to receive the intervention at 3-month intervals. Our primary outcome was 7-day-period prevalence of self- or caregiver-reported diarrhea, measured at 3-month intervals (five time points). Analysis was by intention to treat. Because blinding was not possible, we incorporated questions about symptoms unrelated to water consumption to check response validity (negative control symptoms). We measured outcomes in 2,222 households (9,836 participants). We did not find a measurable reduction in diarrhea post-intervention (RR: 0.98 [95% CI: 0.24-4.09]); possible explanations include low intervention uptake, availability of other safe water sources, low baseline diarrheal prevalence, and reporting fatigue. Our study highlights both the difficulties in evaluating the impact of real-world interventions and the potential for an optimized SW-CRT design to address budgetary, funding, and logistical constraints inherent in such evaluations.
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http://dx.doi.org/10.4269/ajtmh.19-0260DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7056407PMC
March 2020

Inconsistency in Diarrhea Measurements when Assessing Intervention Impact in a Non-Blinded Cluster-Randomized Controlled Trial.

Am J Trop Med Hyg 2019 07;101(1):51-58

Stanford University, Stanford, California.

To explore the consistency in impact evaluation based on reported diarrhea, we compared diarrhea data collected through two different surveys and with observed diarrhea-associated hospitalization for children aged ≤ 5 years from a non-blinded cluster-randomized trial conducted over 2 years in urban Dhaka. We have previously reported that the interventions did not reduce diarrhea-associated hospitalization for children aged ≤ 5 years in this trial. We randomly allocated 90 geographic clusters comprising > 60,000 low-income households into three groups: cholera vaccine only, vaccine plus behavior change (cholera vaccine and handwashing plus drinking water chlorination promotion), and control. We calculated reported diarrhea prevalence within the last 2 days using data collected from two different survey methods. The "census" data were collected from each household every 6 months for updating household demographic information. The "monthly survey" data were collected every month from a subset of randomly selected study households for monitoring the uptake of behavior change interventions. We used binomial regression with a logarithmic link accounting for clustering to compare diarrhea prevalence across intervention and control groups separately for both census and monthly survey data. No intervention impact was detected in the census (vaccine only versus control: 2.32% versus 2.53%; = 0.49; vaccine plus behavior change versus control: 2.44% versus 2.53%; = 0.78) or in the vaccine only versus control in the monthly survey (3.39% versus 3.80%; = 0.69). However, diarrhea prevalence was lower in the vaccine-plus-behavior-change group than control in the monthly survey (2.08% versus 3.80%; = 0.02). Although the reasons for different observed treatment effects in the census and monthly survey data in this study are unclear, these findings emphasize the importance of assessing objective outcomes along with reported outcomes from non-blinded trials.
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http://dx.doi.org/10.4269/ajtmh.18-0872DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6609177PMC
July 2019

Influenza and pertussis vaccination of women during pregnancy in Victoria, 2015-2017.

Med J Aust 2019 06 21;210(10):454-462. Epub 2019 Apr 21.

Monash University, Melbourne, VIC.

Objectives: To assess variations by time of year and hospital in the uptake of influenza and pertussis vaccinations by pregnant women in Victoria; to identify factors associated with vaccination uptake.

Design, Setting: Retrospective analysis of data in the Victorian Perinatal Data Collection (VPDC), a population surveillance system for obstetric conditions, procedures, and pregnancy and birth outcomes.

Participants: Women whose pregnancies ended in a live or stillbirth during July 2015 - June 2017.

Main Outcome Measures: Influenza and pertussis vaccinations during pregnancy.

Results: 153 980 pregnancies in 67 hospitals ended during July 2015 - June 2017; 59 968 pregnant women (39.0%) were vaccinated against influenza and 98 583 (64.0%) against pertussis. Coverage varied by pregnancy end date, rising for influenza during winter and spring, but for pertussis rising continuously across the two years from 37.5% to 82.2%. Differences between hospitals in coverage were marked. Factors associated with vaccination included greater maternal age, primigravidity, early antenatal care, and GP-led care. The odds of vaccination were statistically significantly lower for women born overseas and those who smoked during pregnancy; the odds of vaccination were also lower for Aboriginal and Torres Strait Islander women.

Conclusions: Pertussis vaccination of pregnant women in Victoria has increased, but influenza vaccination rates remain moderate and variable. Structural changes at the system level may improve maternal vaccination rates. Embedding the delivery of maternal vaccination programs in antenatal care pathways should be a priority.
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http://dx.doi.org/10.5694/mja2.50125DOI Listing
June 2019

A Prospective Study on the Impact and Out-of-Pocket Costs of Dengue Illness in International Travelers.

Am J Trop Med Hyg 2019 06;100(6):1525-1533

Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom.

Although the costs of dengue illness to patients and households have been extensively studied in endemic populations, international travelers have not been the focus of costing studies. As globalization and human travel activities intensify, travelers are increasingly at risk for emerging and reemerging infectious diseases, such as dengue. This exploratory study aims to investigate the impact and out-of-pocket costs of dengue illness among travelers. We conducted a prospective study in adult travelers with laboratory-confirmed dengue and recruited patients at travel medicine clinics in eight different countries from December 2013 to December 2015. Using a structured questionnaire, we collected information on patients and their health-care utilization and out-of-pocket expenditures, as well as income and other financial losses they incurred because of dengue illness. A total of 90 patients participated in the study, most of whom traveled for tourism (74%) and visited countries in Asia (82%). Although 22% reported hospitalization and 32% receiving ambulatory care while traveling, these percentages were higher at 39% and 71%, respectively, after returning home. The out-of-pocket direct and indirect costs of dengue illness were US$421 (SD 744) and US$571 (SD 1,913) per episode, respectively, averaging to a total out-of-pocket cost of US$992 (SD 2,052) per episode. The study findings suggest that international travelers incur important direct and indirect costs because of dengue-related illness. This study is the first to date to investigate the impact and out-of-pocket costs of travel-related dengue illness from the patient's perspective and paves the way for future economic burden studies in this population.
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http://dx.doi.org/10.4269/ajtmh.18-0780DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6553920PMC
June 2019

Impact of a Large-Scale Handwashing Intervention on Reported Respiratory Illness: Findings from a Cluster-Randomized Controlled Trial.

Am J Trop Med Hyg 2019 03;100(3):742-749

Stanford University, Stanford, California.

We assessed the impact of handwashing promotion on reported respiratory illness as a secondary outcome from among > 60,000 low-income households enrolled in a cluster-randomized trial conducted in Bangladesh. Ninety geographic clusters were randomly allocated into three groups: cholera-vaccine-only; vaccine-plus-behavior-change (handwashing promotion and drinking water chlorination); and control. Data on respiratory illness (fever plus either cough or nasal congestion or breathing difficulty within previous 2 days) and intervention uptake (presence of soap and water at handwashing station) were collected through monthly surveys conducted among a different subset of randomly selected households during the intervention period. We determined respiratory illness prevalence across groups and used log-binomial regression to examine the association between respiratory illness and presence of soap and water in the handwashing station. Results were adjusted for age, gender, wealth, and cluster-randomized design. The vaccine-plus-behavior-change group had more handwashing stations with soap and water present than controls (45% versus 25%; < 0.001). Reported respiratory illness prevalence was similar across groups (vaccine-plus-behavior-change versus control: 2.8% versus 2.9%; 95% confidence interval [CI]: -0.008, 0.006; = 0.6; cholera-vaccine-only versus control: 3.0% versus 2.9%; 95% CI: -0.006, 0.009; = 0.4). Irrespective of intervention assignment, respiratory illness was lower among people who had soap and water present in the handwashing station than among those who did not (risk ratio: 0.82; 95% CI: 0.69-0.98). With modest uptake of the handwashing intervention, we found no impact of this large-scale intervention on respiratory illness. However, those who actually had a handwashing station with soap and water had less illness. This suggests improving the effectiveness of handwashing promotion in achieving sustained behavior change could result in health benefits.
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http://dx.doi.org/10.4269/ajtmh.18-0644DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6402932PMC
March 2019

Socioeconomic disparities and infection: it's complicated.

Lancet Infect Dis 2019 02 14;19(2):116-117. Epub 2018 Dec 14.

Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.

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http://dx.doi.org/10.1016/S1473-3099(18)30511-5DOI Listing
February 2019

Use of data linkage to improve communicable disease surveillance and control in Australia: existing practices, barriers and enablers.

Aust N Z J Public Health 2019 Feb 5;43(1):33-40. Epub 2018 Dec 5.

School of Public Health and Preventive Medicine, Monash University, Victoria.

Objectives: To review the use of data linkage by Australian state and territory communicable disease control units, and to identify barriers to and enablers of data linkage to inform communicable disease surveillance and control activities.

Methods: Semi-structured telephone interviews were carried out with one key informant from communicable disease control units in all eight Australian states and territories between October 2017 and January 2018.

Results: Key informants from all Australian states and territories participated in the interview. A variety of existing practices were identified, with few jurisdictions making systematic use of available data linkage infrastructure. Key barriers identified from the review included: a lack of perceived need; system factors; and resources. Existing regulatory tools enable data linkage to enhance communicable disease surveillance and control.

Conclusions: We identified considerable variation in the use of data linkage to inform communicable disease surveillance and control activities between jurisdictions. We suggest that routinely collected, disparate data are systematically integrated into existing surveillance and response policy cycle to improve communicable disease prevention and control efforts. Implications for public health: Existing gaps in communicable disease surveillance data may affect prevention and control efforts. Data linkage is recognised as a valuable method to close surveillance gaps and should be used to enhance the value of publicly held health data.
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http://dx.doi.org/10.1111/1753-6405.12846DOI Listing
February 2019

Rabies post-exposure prophylaxis started during or after travel: A GeoSentinel analysis.

PLoS Negl Trop Dis 2018 11 13;12(11):e0006951. Epub 2018 Nov 13.

Department of Global Health, Boston University School of Public Health and Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States of America.

Background: Recent studies demonstrate that rabies post-exposure prophylaxis (RPEP) in international travelers is suboptimal, with only 5-20% of travelers receiving rabies immune globulin (RIG) in the country of exposure when indicated. We hypothesized that travelers may not be receiving RIG appropriately, and practices may vary between countries. We aim to describe the characteristics of travelers who received RIG and/or RPEP during travel.

Methodology/principal Findings: We conducted a multi-center review of international travelers exposed to potentially rabid animals, collecting information on RPEP administration. Travelers who started RPEP before (Group A) and at (Group B) presentation to a GeoSentinel clinic during September 2014-July 2017 were included. We included 920 travelers who started RPEP. About two-thirds of Group A travelers with an indication for rabies immunoglobulin (RIG) did not receive it. Travelers exposed in Indonesia were less likely to receive RIG in the country of exposure (relative risk: 0.30; 95% confidence interval: 0.12-0.73; P = 0.01). Travelers exposed in Thailand [Relative risk (RR) 1.38, 95% Confidence Interval (95% CI): 1.0-1.8; P = 0.02], Sri Lanka (RR 3.99, 95% CI: 3.99-11.9; P = 0.013), and the Philippines (RR 19.95, 95% CI: 2.5-157.2; P = 0.01), were more likely to receive RIG in the country of exposure.

Conclusions/significance: This analysis highlights gaps in early delivery of RIG to travelers and identifies specific countries where travelers may be more or less likely to receive RIG. More detailed country-level information helps inform risk education of international travelers regarding appropriate rabies prevention.
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http://dx.doi.org/10.1371/journal.pntd.0006951DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6258561PMC
November 2018

Infectious diseases acquired by international travellers visiting the USA.

J Travel Med 2018 08;25(1)

Orlando Health Infectious Disease, University of Central Florida College of Medicine, Orlando, FL, USA.

Background: Estimates of travel-related illness have focused predominantly on populations from highly developed countries visiting low- or middle-income countries, yet travel to and within high-income countries is very frequent. Despite being a top international tourist destination, few sources describe the spectrum of infectious diseases acquired among travellers to the USA.

Methods: We performed a descriptive analysis summarizing demographic and travel characteristics, and clinical diagnoses among non-US-resident international travellers seen during or after travel to the USA at a GeoSentinel clinic from 1 January 1997 through 31 December 2016.

Results: There were 1222 ill non-US-resident travellers with 1393 diagnoses recorded during the 20-year analysis period. Median age was 40 (range 0-86 years); 52% were female. Patients visited from 63 countries and territories, most commonly Canada (31%), Germany (14%), France (9%) and Japan (7%). Travellers presented with a range of illnesses; skin and soft tissue infections of unspecified aetiology were the most frequently reported during travel (29 diagnoses, 14% of during-travel diagnoses); arthropod bite/sting was the most frequently reported after travel (173 diagnoses, 15% after-travel diagnoses). Lyme disease was the most frequently reported arthropod-borne disease after travel (42, 4%). Nonspecific respiratory, gastrointestinal and systemic infections were also among the most frequently reported diagnoses overall. Low-frequency illnesses (<2% of cases) made up over half of diagnoses during travel and 41% of diagnoses after travel, including 13 cases of coccidioidomycosis and mosquito-borne infections like West Nile, dengue and Zika virus diseases.

Conclusions: International travellers to the USA acquired a diverse array of mostly cosmopolitan infectious diseases, including nonspecific respiratory, gastrointestinal, dermatologic and systemic infections comparable to what has been reported among travellers to low- and middle-income countries. Clinicians should consider the specific health risks when preparing visitors to the USA and when evaluating and treating those who become ill.
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http://dx.doi.org/10.1093/jtm/tay053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6638561PMC
August 2018

Surveillance of travel-related infections in China.

Lancet Public Health 2018 08 20;3(8):e356-e357. Epub 2018 Jul 20.

School of Medicine, University of California, San Francisco, San Francisco, CA, USA; Harvard TH Chan School of Public Health, Boston, MA, USA.

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http://dx.doi.org/10.1016/S2468-2667(18)30136-1DOI Listing
August 2018

Travellers visiting friends and relatives: a high-risk, under-recognised group for imported infectious diseases.

Intern Med J 2018 07;48(7):759-762

School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1111/imj.13956DOI Listing
July 2018

Spectrum of illness among returned Australian travellers from Bali, Indonesia: a 5-year retrospective observational study.

Intern Med J 2019 Jan;49(1):34-40

Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia.

Background: Bali, Indonesia, presents significant infectious and non-infectious health risks for Australian travellers. Understanding this spectrum of illnesses has the potential to assist clinicians in evaluating unwell returning travellers and guide provision of pre-travel advice.

Aim: To describe the spectrum of illnesses seen in returned travellers from Bali.

Methods: Using a novel text mining approach, we performed a retrospective, observational study of all adult emergency department presentations to a metropolitan health service in Melbourne, from 2011 to 2015. Outcome measures included demographic, clinical and laboratory features of travel-related illnesses.

Results: A total of 464 patients met inclusion criteria. Gastroenteritis (119/464, 26%), systemic febrile illness (88/464, 19%) and respiratory tract infection (51/464, 11%) were the most common diagnoses. Dengue was the most common laboratory-confirmed diagnosis (25/464, 5%). No cases of malaria were identified. Common non-infectious presentations included traumatic injury (47/464, 10%) and animal bites requiring rabies post-exposure prophylaxis (29/464, 6%). A total of 110 patients (24%) was admitted to the hospital; those presenting with systemic febrile illness were more likely to be admitted compared to those presenting with other illnesses (odds ratio 3.42, 95% confidence interval 2.02-5.75, P < 0.001).

Conclusion: This is the first study to use a text mining approach to identify and describe emergency department presentations related to diseases acquired in Bali by Australian travellers. Although infections are important causes of illness, trauma and animal bites account for a significant number of hospital presentations. Our findings contribute to the knowledge on the health risks for travellers to Bali, and will assist clinicians in relevant pre- and post-travel evaluations.
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http://dx.doi.org/10.1111/imj.13993DOI Listing
January 2019

Effect of hygiene interventions on acute respiratory infections in childcare, school and domestic settings in low- and middle-income countries: a systematic review.

Trop Med Int Health 2018 08 10;23(8):816-833. Epub 2018 Jul 10.

Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.

Objectives: Acute respiratory infections (ARIs) disproportionately affect those living in low- and middle-income countries (LMICs). We aimed to determine whether hygiene interventions delivered in childcare, school or domestic settings in LMICs effectively prevent or reduce ARIs.

Methods: We registered our systematic review with PROSPERO (CRD42017058239) and searched MEDLINE, EMBASE, CENTRAL, and Scopus from inception to 17 October 2017 for randomised controlled trials (RCTs) examining the impact of hygiene interventions on ARI morbidity in adults and children in community-based settings in LMICs. We stratified data into childcare, school and domestic settings and used the Grading of Recommendations Assessment, Development and Evaluation approach to assess evidence quality.

Results: We identified 14 cluster RCTs evaluating hand-hygiene interventions in LMICs with considerable heterogeneity in setting, size, intervention delivery and duration. We found reduced ARI-related absenteeism and illness in childcare settings (low- to moderate-quality evidence). In school settings, we found reduced ARI-related absenteeism and laboratory-confirmed influenza (moderate- to high-quality evidence), but no reduction in ARI illness (low-quality evidence). In domestic settings, we found reduced ARI illness and pneumonia amongst children in urban settlements (high-quality evidence) but not in rural settlements (low-quality evidence), and no effect on secondary transmission of influenza in households (moderate-quality evidence).

Conclusions: Evidence suggests that hand-hygiene interventions delivered in childcare, school and domestic settings can reduce ARI morbidity, but effectiveness varies according to setting, intervention target and intervention compliance. Further studies are needed to develop, deliver and evaluate targeted and sustainable hygiene interventions in LMICs.
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http://dx.doi.org/10.1111/tmi.13080DOI Listing
August 2018