Natural airway as an alternative to intubation for pediatric endoscopic esophageal foreign body removal: A retrospective cohort study of 326 patients

BACKGROUND

Anesthesia is required for endoscopic removal of esophageal foreign bodies (EFBs) in children. Historically, endotracheal intubation has been the de facto gold standard for airway management in these cases. However, as more elective endoscopic procedures are now performed under propofol sedation with natural airway, there has been a move toward using similar Monitored Anesthesia Care (MAC) for select patients who require endoscopic removal of an EFB.

METHODS

In this single-center retrospective cohort study, we compared endoscopic EFB removal with either MAC or endotracheal intubation. Descriptive statistics summarized factors stratified by initial choice of airway technique, including intra- and postanesthesia complications and the frequency of mid-procedure conversion to endotracheal intubation in those initially managed with MAC. To demonstrate the magnitude of associations between these factors and the anesthesiologist's choice of airway technique, univariable Firth logistic and quantile regressions were used to estimate odds ratios (95% CI) and beta coefficients (95% CI).

RESULTS

From the initial search, 326 patients were identified. Among them, 23% (n = 75) were planned for intubation and 77% (n = 251) were planned for MAC. Three patients (0.9%) who were initially planned for MAC required conversion to endotracheal intubation after induction. Two (0.6%) of these children were admitted to the hospital after the procedure and treated for ongoing airway reactivity. No patient experienced reflux of gastric contents to the mouth or dislodgement of the foreign body to the airway, and no patient required administration of vasoactive medications or cardiopulmonary resuscitation. Patients had higher odds that the anesthesiologist chose to utilize MAC if the foreign body was a coin (OR, 3.3; CI, 1.9-5.7, p < .001) or if their fasting time was >6 h. Median total operating time was 15 min greater in intubated patients (11 vs. 26 min, p < .001).

CONCLUSIONS

This study demonstrates that MAC may be considered for select pediatric patients undergoing endoscopic removal of EFB, especially those who have ingested coins, who do not have reactive airways, who have fasted for >6 h, and in whom the endoscopic procedure is expected to be short and uncomplicated. Prospective multi-site studies are needed to confirm these findings.

Sustained Decline in Hospitalisations for Anogenital Warts in Australia: Analysis of National Hospital Morbidity Data 2003-2020

In Australia, school-based human papillomavirus (HPV) vaccination was introduced initially for girls in 2007, and then also for boys in 2013. While studies have shown declines in the incidence of anogenital warts, there is a paucity of recent data analysis assessing the impact of vaccination on more severe disease. The National Hospital Morbidity Database of the Australian Institute of Health and Welfare (AIHW) hospitalisation admission data that included ICD-10-AM code A63.0 ('anogenital warts') as the diagnoses, for the years 2003-2020, were analysed to estimate hospitalisation rates per 100,000 mid-year population. The annual average hospitalisation rates per 100,000 population for anogenital warts in both genders combined in the age groups 10-19 years, 20-29 years, and 30-39 years decreased, respectively, from 16.9, 49.6, and 23.6 in 2003-2007 (pre-vaccine period) to 2.6, 15.2, and 14.6 in 2008-2020 (post-vaccine period), equating to declines of 84.7%, 69.4%, and 38.2%, respectively. Following the introduction of the boy's vaccination, hospitalisation rates decreased further in the respective age bands from 4.3, 22.8, and 18.4 in 2008-2013 (early post-vaccine period) to 1.1, 9.3, and 11.7 in 2014-2020 (late post-vaccine period), equating to respective declines of 73.4%, 59.3%, and 36.4%. This analysis confirms that there is a substantial incremental decline in anogenital warts hospitalisations among Australians aged 10-39 years.

Morphometric characteristics and microsatellite markers based diversity and differentiation recognizes the first prospective cattle breed from the Jharkhand state of India

India is bestowed with immense cattle biodiversity with 50 registered breeds. However, the majority (59.3%) is yet not characterized. Identification and characterization are the gateways to the management of prized indigenous resources. Present research described a unique cattle population of Jharkhand state, managed under a traditional low-input, low-output system. It was characterized by morphological traits, performance parameters, and management practices. Animals have the characteristic pre-scapular location of the hump. Genetic variation within this population and its differentiation with the six closely distributed cattle breeds were evaluated using FAO recommended microsatellite markers. Jharkhandi cattle have substantial genetic variation based on gene diversity (>0.6) and the average number of alleles per locus (>8). The population did not suffer from a genetic bottleneck in the recent past. Pairwise Nei's genetic distance, phylogenetic relationship, population differentiation, and the correct assignment of all the animals to self group substantiated its separate genetic identity. Since gene flow (Nm = 2.8-7.32) was identified and admixture was indicated by the Bayesian analysis there is a pressing need for scientific management of this population. Results endow authorities with critical information for registering a new Indian cattle breed (Medini) that contributes to the food security, livelihood, and economic sustainability of rural tribal households.

Australian vaccine preventable disease epidemiological review series: tetanus 2003-2019

Background We examined trends in tetanus notification, hospitalisation and death data from 2003-2019 to assess the impact of adult tetanus booster recommendations in Australia. Methods Tetanus notifications and deaths from the National Notifiable Diseases Surveillance System; hospitalisations from the Australian Institute of Health and Welfare National Hospital Morbidity Database; and deaths from the Australian Coordinating Registry were analysed by age group, sex, Aboriginal and Torres Strait Islander status and state/territory. Annual rates were calculated using Australian Bureau of Statistics mid-year estimated resident populations from 2003-2019 as denominators. To assess the impact of a recommended booster dose of reduced antigen content diphtheria-tetanus-acellular pertussis (dTpa) vaccine for adults aged ≥ 65 years, notification, hospitalisation and death rates of tetanus per 100,000 population were compared pre (2003-2012) and post (2013-2019) the recommendation's introduction. Results There were 63 notifications of tetanus from 2003-2019 with an average annual incidence rate of 0.02/100,000. Similar to previous studies, the burden of tetanus in the Australian population continues to disproportionately affect the elderly, with those aged ≥ 65 years encompassing 63% (40/63) of notifications and 100% (11/11) of the deaths observed in this timeframe. Following the introduction of a recommendation for those aged ≥ 65 years to receive a dTpa booster, average annual notification and hospitalisation rates in those aged ≥ 65 years were significantly lower (notifications: 0.11/100,000 in 2003-2012 and 0.05/100,000 in 2013-2019, p = 0.01; hospitalisations: 0.24/100,000 in 2003-2012 and 0.10/100,000 in 2013-2019, p = 0.01]). The average annual death rate was similar in the two periods (0.002/100,000), although based on small numbers. Conclusions The findings of this analysis suggest a positive impact from the 2013 recommendation. However, the burden is still disproportionately higher in those aged ≥ 65 years and strategies to improve vaccination coverage in older Australians are recommended.

Tumor lysis syndrome in premature infant prompting early resection of a large sacrococcygeal teratoma: a case report

BACKGROUND

Sacrococcygeal teratomas (SCTs) are the most common congenital neoplasm and often require resection soon after birth. There are rare reports of cardiac arrest during surgery due to manipulation of the tumor triggering secondary necrosis and hyperkalemia.

CASE PRESENTATION

This case describes a very preterm infant with a SCT who develops spontaneous preoperative tumor lysis syndrome (TLS). The medical team utilized rasburicase and the patient underwent total gross resection at 40 h of life.

CONCLUSIONS

We emphasize the importance of the early recognition and management of tumor lysis syndrome in SCT with rasburicase, aggressive management of hyperkalemia and consideration of early resection of SCTs even in the case of a very premature infant.

Annual immunisation coverage report 2021

Introduction

We analysed Australian Immunisation Register (AIR) data as at 3 April 2022 for children, adolescents and adults for the calendar year 2021, with data on trends from previous years also presented.

Children

'Fully vaccinated' coverage in Australian children in 2021 was 0.6-0.8 of a percentage point lower than in 2020 at the 12-month (94.2%) and 60-month (94.0%) age assessment milestones, but stable at the 24-month milestone (92.1%). Due to the lag time involved in assessment at milestone ages, 'fully vaccinated' coverage figures for 2020 and 2021 predominantly reflect vaccinations due in 2019 and 2020, respectively, and hence show a small impact on childhood coverage in the first year of the coronavirus disease 2019 (COVID-19) pandemic. 'Fully vaccinated' coverage in Aboriginal and Torres Strait Islander (hereafter respectfully referred to as Indigenous) children was 0.7-1.5 percentage points lower in 2021 than 2020 at the 12-month (91.6%), 24-month (90.1%) and 60-month (96.3%) milestones, although 2.3 percentage points higher than children overall at 60 months. Influenza vaccination coverage in children aged 6-59 months was approximately 20 percentage points lower in 2021 than 2020, both for children overall (26.5%) and for Indigenous children (22.5%). 'On time' vaccination (within 30 days of the recommended age) was up to two percentage points lower in 2021 than 2020 for vaccines due at 4 and 6 months of age, suggesting possible pandemic impacts, but was similar or higher for vaccines due at 12 months of age. While on-time vaccination in Indigenous children has improved progressively since 2012, it remained 6-13 percentage points lower than in children overall in 2021. 'Fully vaccinated' coverage at the earlier milestones (3 months after due date of last scheduled vaccine) of 9, 15, 21 and 51 months was 1.5-2.8 percentage points lower for children living in the least advantaged residential area quintile than the most advantaged, a similar disparity as in 2020. Coverage at the earlier milestones was 2.3-10.0 percentage points lower for Indigenous children living in remote areas than in major cities and regional areas, with disparity at 21 months of age 2.1-2.2 percentage points higher in 2021 than in 2020, and 1.2-2.1 percentage points higher at 51 months.

Adolescents

In 2021, a total of 80.3% of girls and 77.2% of boys (and 73.3% and 66.2% of Indigenous girls and boys) had completed the human papillomavirus (HPV) vaccination schedule by 15 years of age, 0.2-0.4 of a percentage point lower than 2020 (1.7-1.8 percentage points for Indigenous), reflecting vaccinations due in school programs prior to the pandemic with possible pandemic impact on catch-up vaccination. However, the proportion of adolescents completing the two-dose HPV vaccination schedule within a calendar year was 15.3 percentage points lower in 2021 than 2020 and 26.9 percentage points lower than in 2019, likely due to pandemic-related disruption to school-based programs. Additionally, 87.3% of adolescents (83.8% for Indigenous) had received the recommended booster dose of diphtheria-tetanus-acellular pertussis (dTpa) vaccine by 15 years, and 76.1% (66.7% for Indigenous) the recommended meningococcal ACWY vaccine dose by 17 years of age.

Adults

Zoster vaccine coverage in 2021 remained relatively low, at just over 30%, in adults aged 70 years, but increased to 47% in those aged 71-79 years, reflecting ongoing catch-up vaccination. Coverage of 13vPCV was low in 2021, reaching 17.2% in adults aged 70 years and 20.1% in those aged 71-79 years. Influenza vaccination coverage in adults in 2021 was progressively higher with increasing age, reaching 62.1% in the 65-74 years age group (64.6% in Indigenous) and 68.5% in the 75+ years age group (67.7% in Indigenous). Influenza vaccine coverage for other National Immunisation Program (NIP)-eligible Indigenous adult age groups was only 22.0% for those aged 20-49 years, and 43.5% for those aged 50-64 years. By the end of 2021, a total of 91.6% of people in Australia aged 16+ years had received a second dose of a COVID-19 vaccine (71.8% for Indigenous), with over 99% of those aged 70+ years having received a second dose.

Conclusions

Vaccination coverage in children and adolescents remained relatively high in 2021, although with some evidence of COVID-19 pandemic impacts, particularly on receipt of two doses of HPV vaccine within the same calendar year. It will be important to ensure catch-up vaccination in children and adolescents occurs. A strengthened focus on adult vaccination is needed, as coverage remained suboptimal in 2021. The impact of mandatory reporting of all NIP vaccinations from mid-2021, on completeness of AIR data, has not yet been formally evaluated.

Summary of National Surveillance Data on Vaccine Preventable Diseases in Australia, 2016-2018 Final Report

Erratum Two tables within this report, as originally published, contained errors which are notified and corrected here.

Disseminated varicella zoster virus infection following live attenuated herpes zoster vaccine: descriptive analysis of reports to Australia's spontaneous vaccine pharmacovigilance system, 2016-2020

OBJECTIVES

To examine the reported incidence and features of disseminated varicella zoster virus (VZV) infection following live attenuated herpes zoster vaccine live (ZVL: Zostavax, Merck) in immunocompromised people in Australia.

DESIGN AND SETTING

ZVL was funded in 2016 in Australia for people aged 70 years, with a catch-up programme for those 71-79 years. From 2016 to 2020, three deaths due to disseminated vaccine-strain VZV infection occurred following inadvertent ZVL administration in individuals with varying levels of immunocompromise. This descriptive study examined 4 years of national surveillance data reported to the Therapeutic Goods Administration's Adverse Event Monitoring System (AEMS). Denominator data for rates were from doses recorded in the Australian Immunisation Register.

PARTICIPANTS

Individuals vaccinated between 1 November 2016 and 31 December 2020 who experienced adverse event(s) following immunisation (AEFI) after ZVL recorded in the AEMS.

PRIMARY AND SECONDARY OUTCOME MEASURES

Rates and outcomes of confirmed (Oka strain positive) or probable disseminated VZV infection, and inadvertent administration of ZVL in immunocompromised individuals.

RESULTS

854 AEFI were reported from 1 089 966 doses of ZVL administered (78.4 per 100 000 doses). Of those, 14 were classified as confirmed (n=6, 0.55 per 100 000) or probable (n=8) disseminated VZV infection. The confirmed cases were all hospitalised, and most (5/6) were immunocompromised; three cases died. Thirty-seven individuals were reported as vaccinated despite a contraindication due to immunocompromise (3.4 per 100 000), with 12/37 (32%) hospitalised.

CONCLUSIONS

Disseminated VZV is potentially life-threatening and occurs mostly in those with severe immunocompromise. Inadvertent administration of ZVL to immunocompromised individuals has occurred despite initial provider guidance and education. Multiple additional strategies to assist providers to identify contraindications have been implemented to prevent adverse outcomes.

Micro-morpho-anatomical transitions at various stages of in vitro development of Crinum malabaricum Lekhak and Yadav: A critically endangered medicinal plant

Crinum malabaricum Lekhak & Yadav is a recently discovered and critically endangered aquatic bulbous plant of the family Amaryllidaceae. It gained attention as a wild source of the acetylcholinesterase inhibiting alkaloid 'galanthamine' used to treat Alzheimer and Parkinson diseases. The bulbs of this plant contain the highest amount of galanthamine among Crinum species. In vitro regeneration systems were developed to produce quality uniform plantlets of C. malabaricum. Bright field light microscopy was used to analyse micro-morpho-anatomical developments taking place in the leaves and roots during in vitro, ex vitro and in vivo transitions of plantlets. Leaves and roots of plants raised in vitro possessed a higher degree of microscopic structural anomalies, such as underdeveloped epicuticular wax deposition, immature and non-functional stomata, more aquiferous parenchyma with a reduced lumen. Roots developed in vitro were characterized by extremely large, uneven cortical cells and reduced intercellular spaces. The vascular tissues were under-developed and only primary vascular tissues were observed. As a result of ex vitro acclimation, there was a significant acceleration in the improvement of tissue systems in leaves and roots. Such plantlets can tolerate elevated temperatures and light under in vivo conditions. Thus, the microscopic evaluation of the structural trajectory in different stages of plantlet development provides an understanding of the acclimation process and structural adaptations, which could help enhance survival of in vitro raised plantlets under ex vitro and in vivo conditions.

Stakeholder Perspectives of Australia's National HPV Vaccination Program

Australia has been a world leader in human papillomavirus (HPV) vaccination and was the first country to implement a fully funded national HPV vaccination program, from 2007 for girls and 2013 for boys. In 2018 the program changed from a 4-valent to 9-valent HPV vaccine and a 3-dose to 2-dose standard schedule. We assessed stakeholder perspectives on factors influencing program outcomes and impact as part of a comprehensive program evaluation. In late 2019 and early 2020, we conducted 26 interviews with 42 key stakeholder participants and received 1513 survey responses from stakeholders including general practice staff and school-based nurse immunisers. Findings included that the 2-dose schedule is better accepted by schools and students and has reduced program cost and resource requirements. However, course completion rates have not increased as much as anticipated due to the 6-12 month dosing interval and reduced opportunities for school-based catch-up vaccination. Major reported barriers to increased vaccine coverage were absenteeism and consent form return. Vaccine hesitancy is not currently a major issue but remains a potential threat to the program. While Australia's HPV vaccination program is perceived as highly successful, measures to further enhance the program's impact and mitigate potential threats are important.

Surgical Outcome of Cauda Equina Syndrome Secondary to Disc Herniation Presenting Late in Developing Countries

Cauda equina syndrome (CES) is a serious neurologic state in which neurological dysfunction affects the lumbar and sacral nerve roots within the vertebral canal. The nerves of the cauda equine provide the muscles that manage the bladder, bowel and the legs and the dysfunction producing impairment of bladder, bowel or sexual function and perianal or saddle numbness. Identification of CES is not only important to neurosurgeons and spine surgeons, but also to prime care practitioners, emergency room physicians, physiotherapists and allied health care professionals concerned in management of back pain. It is a significant diagnosis from a clinical and medico-legal outlook. Early surgical decompression is endorsed by most authors to best support patient's revival and trim down long term disability. This cross sectional observational study was conducted at Shaheed Suhrawardy Medical College Hospitals, Dhaka, Bangladesh from January 2015 to January 2021 and the aim of this study was to find the predictors and the clinical outcome of cauda equina syndrome after spinal decompression with delayed presentation. Among 680 patients of degenerative disc diseases; 32 cases (4.7%) had CES, those presenting late in course of disease. Time interval between bladder and bowel dysfunction and admission to hospital varied from 2-64 days with mean delay of 15.4 days. The average follow-up was 22.6 months, ranging from 12 to 34 months. There was significant positive correlation (p<0.05) between duration taken for total recovery and delay in surgery and between delayed decompression and a poor outcome. Also there was a clear correlation between the presence of complete perineal anaesthesia and absence of anal wink as both univariate and multivariate predictors of a poor outcome. There was significant association between a slower onset of CES and a favourable outcome. There was no significant correlation found between initial motor function loss, bilateral sciatica and level of the lesions as predictors of a poor outcome.

Annual immunisation coverage report 2020

We analysed Australian Immunisation Register (AIR) data as at 31 March 2021 for children, adolescents and adults. This is the first time that adolescent and adult coverage data from the AIR have been included in our annual coverage report.

Surveillance of adverse events following immunisation in Australia annual report, 2020

This report summarises Australian spontaneous surveillance data for adverse events following immunisation (AEFI) for 2020, reported to the Therapeutic Goods Administration (TGA), and describes reporting trends over the 21-year period from 1 January 2000 to 31 December 2020. There were 3,827 AEFI records for vaccines administered in 2020, an annual AEFI reporting rate of 14.9 per 100,000 population. There was a slight (3.8%) decrease in the overall AEFI reporting rate in 2020 compared with 2019 (15.5 per 100,000 population). This decrease in the AEFI reporting rate in 2020 is potentially due to the impact of coronavirus disease 2019 (COVID-19) and was mainly from a decline in reported adverse events related to HPV, dTpa, and seasonal influenza vaccines. AEFI reporting rates for most individual vaccines in 2020 were similar to 2019. The most commonly reported adverse events were injection site reaction (37.1%); pyrexia (18.1%); rash (15.8%); vomiting (7.6%); pain (7.4%); headache (5.7%); and urticaria (5.1%). There were six deaths reported to the TGA. In one of the reports, the timing and clinical findings were consistent with a causal association with vaccination. In the remaining five reports, no clear causal relationship with vaccination was found.

Australian vaccine preventable disease epidemiological review series: diphtheria 1999–2019

Background Diphtheria is rare in Australia, but an increasing number of cases have been notified in recent years. Alongside notifications from 1999 to 2019, we analysed other relevant national data sources to evaluate trends over the past two decades. Methods Diphtheria notifications (National Notifiable Diseases Surveillance System [NNDSS]), hospitalisations (National Hospital Morbidity Database [NHMD]) and deaths (Australian Bureau of Statistics and the Australian Coordinating Registry) were separately analysed by site of infection, age group, sex, state/territory, Aboriginal and Torres Strait Islander status, and vaccination status. Results During the study period, eight (0.002 per 100,000 population per year) cases of respiratory diphtheria and 38 (0.008 per 100,000 population per year) cases of cutaneous diphtheria were recorded in the NNDSS, with 45/46 reported in the nine years since 2011. Corynebacterium diphtheriae accounted for 87% of notified cases, who had a median age of 31.5 years (respiratory diphtheria) and 52.5 years (cutaneous diphtheria); no respiratory diphtheria was notified in those under 15 years of age. A majority of the cutaneous diphtheria cases (27/38; 71%) were acquired overseas, as were 3/8 (38%) of the respiratory diphtheria cases. Rates of both presentation types were higher in Aboriginal and Torres Strait Islander people (respiratory: 0.007 per 100,000 population per year; cutaneous: 0.021 per 100,000 population per year) than were rates in the overall population. Queensland had the highest rate of notified respiratory cases (0.007 per 100,000 population per year), and the Northern Territory the highest rate of cutaneous notifications (0.043 per 100,000 population per year). There were 29 hospitalisations with a principal-diagnosis diphtheria code in the NHMD between 2002 and 2018, of which eight were designated as respiratory (0.002 per 100,000 population per year), eight as cutaneous (0.002 per 100,000 population per year), and 13 with an unknown site of infection. Among notified cases, two deaths were reported in unvaccinated people in Queensland. Conclusions Although diphtheria remains rare in Australia, 45 cases were notified in the years 2011–2019, compared with one case between 1999 and 2010. Robust surveillance remains important to detect all cases. High immunity will need to be maintained across all age groups to prevent outbreaks, and travel and adult booster doses should be encouraged.

Australian vaccine preventable disease epidemiological review series: measles, 2012–2019

Background Data sources, relevant to measles epidemiology from 2012 to 2019, were reviewed in the context of Australia’s certification, by the World Health Organization in 2014, of the elimination of measles. Methods Data on measles notifications, hospitalisations, and deaths were obtained from the National Notifiable Diseases Surveillance System, the National Hospital Morbidity Database, and the Australian Coordinating Registry. Data were analysed by age group, state/territory, Aboriginal and Torres Strait Islander status, genotype, place of acquisition, source of infection (importation status), and vaccination status. Results Between 2012 and 2019, there were 1,337 measles notifications (average annual notifications 0.7 per 100,000 population per year) and 425 hospitalisations with measles as principal diagnosis (0.3 per 100,000 population per year) were recorded. The highest annual notification rate was in 2014, when the rate in the Northern Territory was 21.4 per 100,000 population per year. Although notification and hospitalisation rates were highest in infants < 12 months (respectively 5.8 and 2.1 per 100,000 population per year), people aged 10 to 39 years (10–19y: 272 notifications; 20–29y: 347; 30–39y: 266) accounted for 66% of notified cases. Of cases with a known vaccination status, only 20/169 (11.8%) of those aged 1–9 years had received at least one dose of measles-containing vaccine, compared with 215/571 (37.7%) of those aged 10–39 years. Persons born before 1966 (at least 47 years of age during the study period) are likely to have immunity from wild-type measles infection and had the lowest notification rates in each year. Of notified cases, 98.1% were imported or import related, and of the 900 measles viruses genotyped, D8 and B3 accounted for 89.1%. Conclusion This review’s findings of low measles incidence, in the presence of robust surveillance and high two-dose measles vaccination coverage, provide evidence of continued elimination of endemic measles in Australia, with almost all cases imported or epidemiologically linked to an imported case. Most cases eligible for vaccination are unvaccinated, which should remain the primary focus for prevention. Potential waning immunity in older age groups requires monitoring. Continued high population immunity and high-quality public health response to cases will be needed to maintain Australia’s elimination status, particularly once international borders reopen.

Influenza vaccination among pregnant women in two hospitals in Sydney, NSW: what we can learn from women who decline vaccination

OBJECTIVE

Pregnant women are recognised as being at risk of serious illness from influenza. Despite this, and longstanding national recommendations for vaccination in pregnancy, vaccine uptake remains suboptimal. This study aims to determine factors associated with women declining influenza vaccination in pregnancy.

METHOD

We surveyed pregnant women from antenatal clinics at two Sydney hospitals as part of an evaluation of the New South Wales (NSW) Health 2017 influenza vaccination in pregnancy campaign. Factors associated with a woman's decision to decline influenza vaccination were assessed using Pearson's chi-square test and multivariable logistic regression.

RESULTS

Among 642 women surveyed, 58% self-reported influenza vaccination during pregnancy and 19% reported they had declined vaccination. Factors associated with a decision to decline vaccination included lack of a recommendation from a maternity care provider (adjusted odds ratio [aOR] 6.06; 95% confidence interval [CI] 3.50, 10.50), recommendation against vaccination (aOR 4.17; 95% CI 2.07, 8.38), having never previously been vaccinated for influenza (aOR 2.75; 95% CI 1.64, 4.59) and, among third-trimester women, not having been vaccinated for pertussis (aOR 2.55; 95% CI 1.32, 4.89). On univariate analyses, women who declined vaccination were more likely to disagree or feel uncertain about vaccine safety or effectiveness compared with women who chose to be vaccinated.

CONCLUSION

Recommendations from maternity care providers remain key to a woman's decision to be vaccinated for influenza during pregnancy. Time should be allocated for vaccine discussions early in pregnancy as part of routine care. Continued efforts are needed to improve messaging to pregnant women on the benefits, safety and efficacy of influenza vaccination.

How accurately does the Australian Immunisation Register identify children overdue for vaccine doses? A national cross-sectional study

Abstract

The accuracy of data recorded in the Australian Immunisation Register (AIR) is important for assessment of population-level vaccine coverage but has not been assessed nationally since 2001. We undertook a cross-sectional study in five states in 2017 using standard criteria to validate AIR records classified as three months overdue for any vaccine at 12, 24 and 48 months. Of 2,000 records selected for audit, 905 were assessable, of which 124 (14%) were misclassified as overdue (errors). Among 563 general practice (GP) records, 91 (16.1%) were errors. Compared with Victoria (1/99; 1%), errors were significantly higher in Western Australia (11/106; 10.4%), Queensland (13/104; 12.5%), South Australia (23/110; 20.9%) and New South Wales (43/144; 29.9%); p < 0.01 for all. Among 165 council and community health centre providers, the overall error rate (17; 10.3%) was non-significantly lower than for GP providers, with an odds ratio (OR) of 0.6 and a 95% confidence interval (95% CI) of 0.3-1.1, and did not differ between states. Records were transmitted to the AIR by paper-based methods in 13 cases, with significantly higher error rates (7/13; 54%) than for practice management software (77/630; 12.2%); OR 9.8 (95% CI 2.8-36.4) or the AIR secure site (23/87; 26.4%); OR 2.6 (95% CI 1.4-4.5). Accuracy is increasingly important, with mandatory reporting to the AIR for all National Immunisation Program vaccines from July 2021, and best achieved by uniform use of practice management software.

HPV vaccination coverage: slightly improved two-dose schedule completion estimates and historical estimates lower on AIR than HPV Register

OBJECTIVE

To compare Australian Immunisation Register (AIR) human papillomavirus (HPV) vaccination coverage against historical data from the former National HPV Vaccination Program Register and estimate two-dose vaccination coverage.

METHODS

Cross-sectional analysis of registry data for adolescent birth cohorts (1998-2007). Denominator populations were Medicare enrolments (AIR) and ABS estimated resident populations (HPV register).

RESULTS

For adolescents aged <17 years, AIR coverage estimates were several percentage points lower than HPV register estimates due to a larger Medicare enrolment denominator. Completed course coverage (two or three valid doses) for 15-year-old females in 2020 was 81.5% and for males 78.6%, higher than completed course coverage in 15-year-olds in 2019 (79.7 and 76.8% respectively). First dose coverage was similar for Indigenous adolescents but course completion was lower, although improving over time. Course completion was slightly lower (3.5-5.7%) in areas of lowest socioeconomic status and greatest remoteness.

CONCLUSIONS

Coverage is slightly lower using AIR than HPV register estimates. Moving from three to two doses has slightly improved completion, likely due to the wider dose spacing, but equity gaps remain.

IMPLICATIONS FOR PUBLIC HEALTH

An ongoing focus on equity in vaccine delivery is needed. Systems, reminders and catch-up opportunities to ensure course completion remain important.

Antibiofilm and anticancer activities of unripe and ripe Azadirachta indica (neem) seed extracts

BACKGROUND

Antibiotic resistances of pathogens and breast cancer warrant the search for new alternative strategies. Phytoextracts can eradicate microbe-borne diseases as well as cancer with lower side effects compared to conventional antibiotics.

AIM

Unripe and ripe Azadirachta indica (neem) seed extracts were explored as potential antibiofilm and anticancer agents in combating multidrug-resistant infectious bacteria as well as anticancer agents against the MDR breast cancer cell lines.

METHODS

Shed-dried neem seeds (both unripe and ripe) were pulverized and extracted using methanol. The chemical components were identified with FTIR and gas chromatography - mass spectrometry. Antibiofilm activity of neem seed extracts were assessed in terms of minimum biofilm inhibitory concentration (MBIC), minimum biofilm eradication concentration (MBEC), and fluorescence microscopic studies on Staphylococcus aureus and Vibrio cholerae. Bacterial cells were studied by fluorescence microscopy using acridine orange/ethidium bromide as the staining agents. Minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) values were evaluated to observe the antibacterial activities. Cytotoxicity of the extracts against human blood lymphocytes and the anticancer activity against drug-resistant breast cancer cell lines were assessed by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay and fluorescence-activated cell sorting (FACS) studies.

RESULTS

4-Ethyl-2-hydroxy-2-cyclopentene-1-one, phthalic acid, and 2-hexyl-tetrahydro thiophane were the major compounds in unripe neem seed, whereas 3,5-dihydroxy-6-methyl-2,3-dihydro-4-H-pyran-4-one and 4-ethylbenzamide were predominant in ripe neem seed. Triazine derivatives were also common for both the extracts. MBIC values of unripe and ripe neem seed extracts for S. aureus are 75 and 100 µg/mL, respectively, and for V. cholerae, they are 100 and 300 µg/mL, respectively. MBEC values of unripe and ripe seed extracts are 500 and 300 µg/mL, respectively for S. aureus and for V. cholerae the values are 700 and 500 µg/mL, respectively. Fluorescence microscopic studies at 16 and 24 h, after bacterial culture, demonstrate enhanced antibiofilm activity for the ripe seed extract than that of the unripe seeds for both the bacteria. MTT assay reveals lower cytotoxicity of both the extracts towards normal blood lymphocytes, and anticancer activity against breast cancer cell line (MDA-MB-231) with superior activity of ripe seed extract. FACS studies further supported higher anticancer activity for ripe seed extract.

CONCLUSIONS

Methanolic extract of neem seeds could substantially inhibit and eradicate biofilm along with their potent antibacterial and anticancer activities. Both the extracts showed higher antibiofilm and antibacterial activity against S. aureus (gram-positive) than V. cholerae (gram-negative). Moreover, ripe seed extract showed higher antibiofilm and anticancer activity than unripe extracts.

Australian vaccine preventable disease epidemiological review series: Pertussis, 2013–2018

Introduction Significant recent changes in Australian pertussis immunisation policy include the progressive introduction of funded pertussis immunisation programs for pregnant women, from late 2014 to mid-2015 at jurisdictional level and then under the National Immunisation Program from July 2018, and reintroduction of the 18-month booster dose in 2016. This study analyses pertussis notification, hospitalisation, and mortality data from 2013 to 2018 in the context of trends since 1995. Methods This study used data from the National Notifiable Diseases Surveillance System, the National Hospital Morbidity Database, and the Australian Coordinating Registry, for descriptive analysis of pertussis notifications, hospitalisations and deaths in Australia by Aboriginal and Torres Strait Islander (Indigenous) status from 2013 to 2018, examining trends between 1995 and 2012 at both the national and jurisdictional level. Incidence rate ratios (IRR) were utilised to compare pertussis incidence in infants aged < 2 months and 6–11 months for each year from the 2015–2018 (post-maternal-vaccination) period against the 2010–2013 (pre-maternal-vaccination) period. Results and Discussion Annual national all-age incidence of pertussis notifications between 2013 and 2018 was 63.6 per 100,000 population, 40% less than between 2006 and 2012. Between 2016 and 2018, infants aged < 2 months had the lowest notification rates of age groups < 5 years old, with the highest notification rates in pre-adolescents aged 9–11 years. Compared with the baseline period (2010–2013), the IRR for infants aged < 2 months decreased in each year during the post-maternal-vaccination period from 0.4 (95% confidence interval [95% CI]: 0.3–0.5) in 2015 to 0.1 (95% CI: 0.1–0.2) in 2018. For infants aged 6–11 months, the IRR was 0.9 (95% CI: 0.8–1.0) in 2015, 1.1 (95% CI: 1.0–1.2) in 2016 and declined to 0.7 (95% CI: 0.6–0.8) in 2017 and 2018. Notification and hospitalisation rates in Indigenous children were 3–8 times as high as rates in non-Indigenous children across all age groups < 5 years old. Conclusion Pertussis remains the second most frequently notified vaccine preventable disease in Australia, after influenza, but dramatic decreases in incidence have been observed in infants too young to receive any doses of pertussis-containing vaccine.

The Evolution of Very Early Onset Inflammatory Bowel Disease, Autoimmune Hepatitis, and Primary Sclerosing Cholangitis in a Young Girl

Very early onset inflammatory bowel disease, autoimmune hepatitis (AIH), or primary sclerosing cholangitis (PSC) alone is a rare condition in young children. The combination of all 3 autoimmune disorders in a 16-month-old child is even rarer. The onset and etiology of these diseases is multifactorial and typically unknown. However, when the children are diagnosed, the accepted view point is that the inflammation was likely present for months to years prior. This case is unique because the gastrointestinal problems started from infancy, and evolved to the development of Crohn’s disease, AIH, and PSC at a very early age. This case helps bring to light that very early onset autoimmune disorders may in fact present with symptoms of feeding difficulties, growth failure, and formula intolerance. Patients may be diagnosed initially with allergic enterocolitis in infancy. Although few children with these symptoms evolve to develop autoimmune diseases at an older age, clinicians should consider following these children more closely. This case also demonstrates how hard it is to diagnose very early onset autoimmune disorders, as they mimic other illnesses.

956 Retained Appendiceal Tip and Abdominal Wall Appendicolith - A Rare Combination of Post Appendicectomy Complications

Appendicitis involving the appendix stump is a recognised post appendicectomy complication but the same involving the appendiceal tip is rare. Similarly, abdominal wall abscess secondary to retained appendicolith is also infrequently encountered. Our case highlights a rare combination of both complications arising separately.

A 29-year-old man presented with 3 days of generalised malaise and progressively worsening right iliac fossa pain some ten months after a laparoscopic appendicectomy. This had been complicated by residual right iliac fossa inflammation that was treated conservatively and serial scans demonstrated gradually resolving inflammation. He also had well controlled ulcerative colitis.

On examination, he was noted to be pyrexial with a tender fluctuant mass in the right flank. An ultrasound scan demonstrated inflammatory changes in the abdominal wall with no intra-abdominal collections. A diagnostic laparoscopy found an inflamed appendix tip, attached to the residual mesoappendix and embedded in the abdominal wall behind the mid-ascending colon. A completion appendicectomy was performed.

The patient recovered well but returned 4 months later with persistent pain and a fluctuant mass over the right iliac fossa. Radiological investigation revealed an abdominal wall collection containing a calcified appendicolith. The collection was refractory to ultrasound guided drainage and an exploration of the abdominal wall allowed extraction of the appendicolith followed by symptomatic relief.

This case emphasizes the importance of complete excision of the appendix and extraction of debris, which can be challenging when the appendix lies in a retro-colic position.

399 A Re-Audit of Secondary Prevention Medications Following Coronary Artery Bypass Grafting: Are We Still Compliant with The Updated Guidelines?

Introduction

In the years following myocardial revascularisation with bypass grafts, patients remain at risk for subsequent ischemia as a result of native coronary artery disease progression or development of graft occlusion. Therefore, secondary measures, primarily medical therapy, play an indispensable role in post-operative care. An audit conducted in 2014 identified reduced compliance to prescription of secondary prevention medications. This audit aims to re- evaluate the level of compliance to updated guidelines.

Method

A retrospective case-note review of 100 patients, who underwent CABG (Coronary Artery Bypass-Grafts), was conducted primarily focusing on prescription of secondary prevention drugs at discharge, indications, and contraindications.

Results

99% patients were discharged on anti-platelet agents. However, 12%, discharged on dual anti-platelet agents, did not have any indications for them. 97 % patients were discharged on beta-blocker. Of the 3 defaulters, one had contraindication to beta blockade. 96% patients were discharged on one or more lipid lowering agents and 74% were discharged on ACEi/ARBs. Of the 26% patients discharged without RAAS (Renin Angiotensin Aldosterone System) inhibitor, 9% had no clear indication for it whereas for 7%, it was contraindicated at discharge.

Conclusions

A generalised improvement in compliance rate is noted for secondary prevention medications prescription according to updated guidelines from the previous audit.

637 Enterolith Ileus Secondary to Small Bowel Diverticulum: A Rare Cause of Small Bowel Obstruction

Small intestinal diverticula are rare and possibly acquired secondary to bowel dyskinesia, abnormal peristalsis, or high intraluminal pressures. Enterolith formation and obstruction are a less encountered complication of these diverticula.

An elderly man, with no history of abdominal surgery, presented with 10 days of colicky right iliac fossa pain and recurrent episodes of bilious vomiting. He initially reported diarrhoea but complained of eventual absolute constipation for last 5 days. Physical examination revealed distended abdomen with right-sided tenderness and no mass or faeces on rectal examination. Abdominal CT revealed a 3.5 cm calculus in the distal ileum causing obstruction initially flagged as gallstone ileus. No gallstones or pneumobilia were identified although some intrahepatic duct dilatation was noted. An emergency laparotomy was conducted, where the radiological findings were reinforced, and the calculus was extracted via enterotomy. There were no abnormal communications between gallbladder and intestinal tract. The small bowel traced from duodenojejunal flexure to terminal ileum did not reveal any further calculi or diverticula. FTIR spectrum analysis of the extracted specimen indicated similarities to enterolith. Retrospective analysis of radiological images revealed a possible duodenal diverticulum. The case highlights the diagnostic conundrum and therapeutic challenges of small bowel diverticular enterolith.

Surveillance of adverse events following immunisation in Australia annual report, 2019

Abstract

This report summarises Australian spontaneous surveillance data for adverse events following immunisation (AEFI) for 2019 reported to the Therapeutic Goods Administration (TGA) and describes reporting trends over the 20-year period from 1 January 2000 to 31 December 2019. There were 3,782 AEFI records for vaccines administered in 2019, an annual AEFI reporting rate of 14.9 per 100,000 population. There was an 11.8% decrease in the overall AEFI reporting rate in 2019 compared to 2018 (16.9 per 100,000 population). This decrease in the AEFI reporting rate in 2019 was mainly attributable to a decline in reported adverse events related to the human papillomavirus (HPV), dTpa, meningococcal ACWY and seasonal influenza vaccines. AEFI reporting rates for most individual vaccines in 2019 were similar to 2018. The most commonly-reported adverse events were injection site reaction (35.8%), rash (16.6%), pyrexia (15.3%), vomiting (8.1%), urticaria (5.8%), pain (5.8%) and headache (5.7%). There were five deaths reported to the TGA. In one report, the timing and clinical findings were consistent with a causal association with vaccination. In the remaining four reports, no clear causal relationship with vaccination was found.

Immunization of Mothers of Children with Cerebral Palsy in Rural Bangladesh

BACKGROUND

Vaccination is one of the most effective public health tools for the prevention of infectious diseases, morbidity and disability. Little is known about the rate of maternal immunization among mothers of children with Cerebral Palsy (CP), as well as any possible role of maternal immunization in development of CP in the newborns.

OBJECTIVE

To determine the socio-demographic characteristics and self-reported vaccination status of mothers of children with CP and compare vaccination coverage in this cohort with national data on immunization. The study also aims to assess the vaccination status of children with CP.

METHODS

A subset of the Bangladesh CP Register (BCPR) cohort of women who had children with CP were recruited during April 2017 from a community based early intervention and rehabilitation program going on in Shahjadpur. Socio-demographic characteristics and maternal immunization status were assessed using a semi-structured questionnaire. The vaccination status of the children was also assessed by interviewing mother and observing the BCG marks. All data were compared with the corresponding information among general population using national vaccination coverage survey reports of the Ministry of Health and Family Welfare, Bangladesh.

RESULT

Sixty-eight mothers were interviewed of which 17.6% of mothers reported not receiving any vaccine during pregnancy. Tetanus vaccine was most commonly (82.0%) received during pregnancy. Overall coverage for at least two doses of tetanus toxoid (TT) among mothers of children with CP was significantly lower than the national tetanus coverage (79.4% versus 96.4%, p<0.01). Forty-two (61.7%) mothers with a child with CP reported having not received tetanus vaccine during their pregnancy compared to only twenty (29.4%) mothers with healthy children reported missing tetanus vaccination during their pregnancy. This difference was statistically significant (p<0.01). Hepatitis B and influenza vaccine were received by mothers of children with CP during the antenatal period (2 and 6 respectively).

CONCLUSION

Immunization among mothers of children with CP is significantly poorer than the national coverage. Also, the immunization of the children with CP is poorer than the national EPI coverage. Our findings reflect the necessity for specific strategies to improve the vaccination coverage among mothers of children with disabilities especially CP and the children with CP.

e-TEP repair for midline primary and incisional hernia: technical considerations and initial experience

INTRODUCTION

The Enhanced-View Totally Extra Peritoneal Rives-Stoppa (e-TEP-RS) Technique for the repair of large, complex, ventral abdominal hernias has gained popularity especially in overcoming the disadvantages with Intra Peritoneal Onlay Mesh (IPOM) repairs and to enable siting of a large prosthetic mesh in an anatomical plane distinct from the abdominal cavity and its contents. Evolving variations of the original technique have allowed the definitive repair of such defects in a reproducible manner. We present our initial experience of this approach and detailed steps of our native technical modifications in overcoming the challenges in performing this complex and potentially challenging procedure.

MATERIALS AND METHODS

This is a retrospective review of the clinical data of midline, large, complex, ventral abdominal hernia patients who underwent e-TEP-RS with and without Transversus Abdominis Release (TAR). Patients, with or without Diastasis of Rectus Abdominis Muscle (DRAM) were included. Key outcomes measured were post-operative pain, operative morbidity, readmission, Quality of Life (QoL), hernia recurrence.

RESULTS

A total of 58 midline, ventral abdominal hernia patients who underwent e-TEP-RS with and without Transversus Abdominis Release (TAR), between March 2018 and December 2019 were studied. Mean defect area was 41.0 ± 28 cm² and the mean mesh surface area was 473.5 ± 165 cm². e-TEP-RS was done in 35 cases, e-TEP RS TAR in 15 cases and e-TEP-RS with e-TEP inguinal in 08 cases. There was no intraoperative morbidity. Mean duration of surgery was 156.2 ± 40 min and mean blood loss was 40.5 ± 26 cc. The CCS QoL scores improved from 34.6 (± 2) pre-operatively to 27.2 (± 4) at the end of 6 months. One patient had a supra-umbilical recurrence following bilateral TAR over the superior edge of the mesh. Follow-up ranged from 6 to 22 months, with a mean of 14 months. Major complications (n = 12; 20.7%) were seroma formation and prolonged ileus.

CONCLUSION

The e-TEP-RS technique for large, complex, midline, ventral abdominal hernias can be used with excellent results and acceptable morbidity. This technique is technically challenging and should be mastered in relatively smaller ventral hernias to achieve good results before attempting it in larger, complex ones.

Immunisation Coverage Annual Report 2019

Australian Immunisation Register data have been analysed for children aged < 5 years, focusing on changes in vaccination coverage at standard age milestones (12, 24 and 60 months) between 2018 and 2019. ‘Fully vaccinated’ coverage in 2019 increased by 0.1–0.4% at the three age milestones to 94.3% at 12 months, 90.2% at 24 months (in the context of additional antigens required at 24 months) and 94.2% at 60 months. Rotavirus vaccine coverage (2 doses) increased from 90.9% in 2018 to 91.9% in 2019. ‘Fully vaccinated’ coverage in Aboriginal and Torres Strait Islander (hereafter respectfully referred to as Indigenous) children increased by 0.5–1.1% in 2019, reaching 92.9% at 12 months, 88.9% at 24 months and 96.9% at the 60 months (2.7 percentage points higher than in children overall). Recorded influenza vaccination coverage in children aged 6 months to < 5 years increased by 11.4 percentage points to 42.7% in Indigenous children in 2019, and by 15.6 percentage points to 41.8% in children overall. Longstanding issues with timeliness of vaccination in Indigenous children persisted, although the disparity between Indigenous and non-Indigenous children in on-time coverage (within 30 days of due date), for vaccines due at 4 months of age, decreased from 10.4–10.7 to 9.6–9.8 percentage points between 2018 and 2019. The timeliness of ‘fully vaccinated’ coverage was also examined at earlier age milestones (3 months after due date of last scheduled vaccine) of 9, 15, 21 and 51 months, by Indigenous status, socioeconomic status and remoteness of area of residence. Coverage in children living in the least-advantaged residential area quintile was 2.6–2.7% lower than that for those living in the most-advantaged quintile at the 9-, 15- and 21-month milestones, although these disparities were 0.5–1.5 percentage points lower than in 2018. Coverage at the earlier milestones in Indigenous children in remote areas was 1.5–6.7% percentage points lower than that for Indigenous children in major cities and regional areas, although there were some improvements since 2018. Importantly, although Indigenous children had lower coverage for the second dose of measles-mumps-rubella vaccine at 24 months (92.7% versus 93.3% overall), coverage increased to 98.8% at 60 months; coverage was also high overall at 96.4%, above the 95% target critical to measles control. In conclusion, this report demonstrates continuing improvements across a range of immunisation indicators in Australia in 2019. However, some issues with timeliness persist, particularly in Indigenous and socioeconomically disadvantaged children. New coverage targets for earlier protection in the first 2 years of life may be indicated, along with a review of current ‘fully vaccinated’ assessment algorithms, particularly at the 60-month age milestone.

Immunisation Coverage Annual Report 2018

Abstract

Australian Immunisation Register data have been analysed for children aged < 5 years, focusing on changes in coverage at key milestone ages (12, 24 and 60 months) between 2017 and 2018, while also documenting longer term trends. Fully vaccinated coverage increased at the 12- and 60-months milestones to 93.9% and 94.0%, respectively, but, in the context of additional antigens required, decreased to 90.1% at 24 months. Following the move to a two-dose rotavirus vaccine schedule across Australia from mid-2017, rotavirus vaccine coverage increased from 86.8% to 90.9%. In 2018, most jurisdictions funded influenza vaccine for non-Indigenous children aged 6 months to < 5 years; the National Immunisation Program has funded influenza vaccine for Aboriginal and Torres Strait Islander children and medically at-risk children since 2015 and 2010, respectively. Recorded influenza vaccine coverage in Aboriginal and Torres Strait Islander children doubled from 14.9% to 31.4%, and increased fivefold in non-Indigenous children from 5.0% to 25.9% in 2018. The timeliness of fully vaccinated coverage was also examined at earlier milestones (3 months after due date of last scheduled vaccine) of 9, 15, 21 and 51 months, by area of residence. For all children, coverage among those living in the least advantaged residential area quintile was 3-4% lower than that for those in the most advantaged quintile at the 9-, 15- and 21-month milestones. Importantly, although Aboriginal and Torres Strait Islander children had lower coverage for the second dose of measles-mumps-rubella vaccine at 24 months (91.8% versus 93.1% for non-Indigenous), coverage increased to 98.5% at 60 months; coverage was also high in non-Indigenous children at 96.2%, above the 95% target critical to measles control. These data demonstrate continuing improvements in immunisation coverage and suggest potential new coverage targets for earlier protection in the first two years of life.

Immunisation Coverage Annual Report 2019

Australian Immunisation Register data have been analysed for children aged < 5 years, focusing on changes in vaccination coverage at standard age milestones (12, 24 and 60 months) between 2018 and 2019. ‘Fully vaccinated’ coverage in 2019 increased by 0.1–0.4% at the three age milestones to 94.3% at 12 months, 90.2% at 24 months (in the context of additional antigens required at 24 months) and 94.2% at 60 months. Rotavirus vaccine coverage (2 doses) increased from 90.9% in 2018 to 91.9% in 2019. ‘Fully vaccinated’ coverage in Aboriginal and Torres Strait Islander (hereafter respectfully referred to as Indigenous) children increased by 0.5–1.1% in 2019, reaching 92.9% at 12 months, 88.9% at 24 months and 96.9% at the 60 months (2.7 percentage points higher than in children overall). Recorded influenza vaccination coverage in children aged 6 months to < 5 years increased by 11.4 percentage points to 42.7% in Indigenous children in 2019, and by 15.6 percentage points to 41.8% in children overall. Longstanding issues with timeliness of vaccination in Indigenous children persisted, although the disparity between Indigenous and non-Indigenous children in on-time coverage (within 30 days of due date), for vaccines due at 4 months of age, decreased from 10.4–10.7 to 9.6–9.8 percentage points between 2018 and 2019. The timeliness of ‘fully vaccinated’ coverage was also examined at earlier age milestones (3 months after due date of last scheduled vaccine) of 9, 15, 21 and 51 months, by Indigenous status, socioeconomic status and remoteness of area of residence. Coverage in children living in the least-advantaged residential area quintile was 2.6–2.7% lower than that for those living in the most-advantaged quintile at the 9-, 15- and 21-month milestones, although these disparities were 0.5–1.5 percentage points lower than in 2018. Coverage at the earlier milestones in Indigenous children in remote areas was 1.5–6.7% percentage points lower than that for Indigenous children in major cities and regional areas, although there were some improvements since 2018. Importantly, although Indigenous children had lower coverage for the second dose of measles-mumps-rubella vaccine at 24 months (92.7% versus 93.3% overall), coverage increased to 98.8% at 60 months; coverage was also high overall at 96.4%, above the 95% target critical to measles control. In conclusion, this report demonstrates continuing improvements across a range of immunisation indicators in Australia in 2019. However, some issues with timeliness persist, particularly in Indigenous and socioeconomically disadvantaged children. New coverage targets for earlier protection in the first 2 years of life may be indicated, along with a review of current ‘fully vaccinated’ assessment algorithms, particularly at the 60-month age milestone.

Immunisation Coverage Annual Report 2018

Abstract

Australian Immunisation Register data have been analysed for children aged < 5 years, focusing on changes in coverage at key milestone ages (12, 24 and 60 months) between 2017 and 2018, while also documenting longer term trends. Fully vaccinated coverage increased at the 12- and 60-months milestones to 93.9% and 94.0%, respectively, but, in the context of additional antigens required, decreased to 90.1% at 24 months. Following the move to a two-dose rotavirus vaccine schedule across Australia from mid-2017, rotavirus vaccine coverage increased from 86.8% to 90.9%. In 2018, most jurisdictions funded influenza vaccine for non-Indigenous children aged 6 months to < 5 years; the National Immunisation Program has funded influenza vaccine for Aboriginal and Torres Strait Islander children and medically at-risk children since 2015 and 2010, respectively. Recorded influenza vaccine coverage in Aboriginal and Torres Strait Islander children doubled from 14.9% to 31.4%, and increased fivefold in non-Indigenous children from 5.0% to 25.9% in 2018. The timeliness of fully vaccinated coverage was also examined at earlier milestones (3 months after due date of last scheduled vaccine) of 9, 15, 21 and 51 months, by area of residence. For all children, coverage among those living in the least advantaged residential area quintile was 3-4% lower than that for those in the most advantaged quintile at the 9-, 15- and 21-month milestones. Importantly, although Aboriginal and Torres Strait Islander children had lower coverage for the second dose of measles-mumps-rubella vaccine at 24 months (91.8% versus 93.1% for non-Indigenous), coverage increased to 98.5% at 60 months; coverage was also high in non-Indigenous children at 96.2%, above the 95% target critical to measles control. These data demonstrate continuing improvements in immunisation coverage and suggest potential new coverage targets for earlier protection in the first two years of life.

Long-term Impact of Pneumococcal Conjugate Vaccines on Invasive Disease and Pneumonia Hospitalizations in Indigenous and Non-Indigenous Australians

BACKGROUND

Universal pneumococcal conjugate vaccine (PCV) programs began in Indigenous Australian children in 2001 and all children in 2005, changing to 13-valent PCV (PCV13) in 2011. We used laboratory data for invasive pneumococcal disease (IPD) and coded hospitalizations for noninvasive pneumococcal community-acquired pneumonia (PnCAP) to evaluate long-term impact.

METHODS

Annual incidence (per 100 000 population) was calculated for age-specific total IPD, PCV13 non-7-valent PCV (PCV7) serotypes, and PnCAP by Indigenous status. Incidence in the pre-universal PCV7 (2002-2004), early PCV7 (2005-2007), pre-PCV13 (2008 to mid-2011), and post-PCV13 (mid-2011 to 2016) periods was used to calculate incidence rate ratios (IRRs).

RESULTS

In the total population, all-age incidence of IPD declined from 11.8 pre-PCV7 to 7.1 post-PCV13 (IRR, 0.61 [95% confidence interval {CI}, .59-.63]) but for PnCAP declined among ages <1 year (IRR, 0.34 [95% CI, .25-.45]) and 1-4 years (IRR, 0.50 [95% CI, .43-.57]) but increased significantly among age ≥5 years (IRRs, 1.08-1.14). In Indigenous people, baseline PCV13 non-PCV7 IPD incidence was 3-fold higher, amplified by a serotype 1 epidemic in 2011. By 2015-2016, although incidence of IPD and PnCAP in children aged <5 years decreased by 38%, neither decreased in people aged ≥5 years.

CONCLUSIONS

Fifteen years post-PCV and 5 years post-PCV13, direct and indirect impact on IPD and PnCAP differed by age and between Indigenous and non-Indigenous people, with potential implications for long-term PCV impact in comparable settings.Fifteen years after pneumococcal conjugate vaccine (PCV) introduction and 5 years post-PCV13, direct and indirect impact on invasive pneumococcal disease and pneumococcal community-acquired pneumonia differed by age and between Indigenous and non-Indigenous people, with potential implications for long-term PCV impact in comparable settings.

Airway Management for Initial PEG Insertion in the Pediatric Endoscopy Unit: A Retrospective Evaluation of 168 Patients

PURPOSE

Percutaneous endoscopic gastrostomy (PEG) tube placements are commonly performed pediatric endoscopic procedures. Because of underlying disease, these patients are at increased risk for airway-related complications. This study compares patient characteristics and complications following initial PEG insertion with general endotracheal anesthesia (GETA) vs. anesthesia-directed deep sedation with a natural airway (ADDS).

METHODS

All patients 6 months to 18 years undergoing initial PEG insertion within the endoscopy suite were considered for inclusion in this retrospective cohort study. Selection of GETA vs. ADDS was made by the anesthesia attending after discussion with the gastroenterologist.

RESULTS

This study included 168 patients (GETA n=38, ADDS n=130). Cohorts had similar characteristics with respect to sex, race, and weight. Compared to ADDS, GETA patients were younger (1.5 years vs. 2.9 years, p=0.04), had higher rates of severe American Society of Anesthesiologists (ASA) disease severity scores (ASA 4-5) (21% vs. 3%, p<0.001), and higher rates of cardiac comorbidities (39.5% vs. 18.5%, p=0.02). Significant associations were not observed between GETA/ADDS status and airway support, 30-day readmission, fever, or pain medication in unadjusted or adjusted models. GETA patients had significantly increased length of stay (e^β=1.55, 95% confidence interval [CI]=1.11-2.18) after adjusting for ASA class, room time, anesthesia time, fever, and cardiac diagnosis. GETA patients also had increased room time (e^β=1.20, 95% CI=1.08-1.33) and anesthesia time (e^β=1.50, 95% CI=1.30-1.74) in adjusted models.

CONCLUSION

Study results indicate that younger and higher risk patients are more likely to undergo GETA. Children selected for GETA experienced longer room times, anesthesia times, and hospital length of stay.

Limited Role of Bots in Spreading Vaccine-Critical Information Among Active Twitter Users in the United States: 2017-2019

Objectives. To examine the role that bots play in spreading vaccine information on Twitter by measuring exposure and engagement among active users from the United States.Methods. We sampled 53 188 US Twitter users and examined who they follow and retweet across 21 million vaccine-related tweets (January 12, 2017-December 3, 2019). Our analyses compared bots to human-operated accounts and vaccine-critical tweets to other vaccine-related tweets.Results. The median number of potential exposures to vaccine-related tweets per user was 757 (interquartile range [IQR] = 168-4435), of which 27 (IQR = 6-169) were vaccine critical, and 0 (IQR = 0-12) originated from bots. We found that 36.7% of users retweeted vaccine-related content, 4.5% retweeted vaccine-critical content, and 2.1% retweeted vaccine content from bots. Compared with other users, the 5.8% for whom vaccine-critical tweets made up most exposures more often retweeted vaccine content (62.9%; odds ratio [OR] = 2.9; 95% confidence interval [CI] = 2.7, 3.1), vaccine-critical content (35.0%; OR = 19.0; 95% CI = 17.3, 20.9), and bots (8.8%; OR = 5.4; 95% CI = 4.7, 6.3).Conclusions. A small proportion of vaccine-critical information that reaches active US Twitter users comes from bots.

Coronavirus disease 2019: scientific overview of the global pandemic

Coronavirus disease 2019 (COVID-19) is the disease caused by the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Genome sequencing of the virus revealed that it is a new zoonotic virus that might have evolved by jumping from bats to humans with one or more intermediate hosts. The immediate availability of the sequence information in the public domain has accelerated the development of quantitative RT-PCR-based diagnostics. Numerous clinical trials have been prioritized globally for testing new vaccines and treatments against this disease. This review provides a broad insight into different aspects of COVID-19, an introduction to SARS-CoV-2 mitigation strategies and the present status of diagnostics and therapeutics.

"No jab, no pay": catch-up vaccination activity during its first two years

Objectives

To assess catch‐up vaccination of older children and adolescents during the first two years of the “No jab, no pay” policy linking eligibility for federal family assistance payments with childhood vaccination status.

Design, setting, participants

Cross‐sectional analysis of Australian Immunisation Register data on catch‐up vaccination of children aged 5 to less than 7 years before (January 2013 – December 2014; baseline) and during the first two years of “No jab, no pay” (December 2015 – December 2017), and of children aged 7 to less than 10 years and young people aged 10 to less than 20 years (“No jab, no pay” period only).

Main outcomes

Catch‐up vaccination rates for measles–mumps–rubella vaccine second dose (MMR2), by age group, Indigenous status, and socio‐economic status; catch‐up vaccination of children aged 5 to less than 7 years (third dose of diphtheria–tetanus–pertussis vaccine [DTPa3], MMR1), before and after introduction of “No jab, no pay”.

Results

The proportion of incompletely vaccinated children aged 5 to less than 7 years who received catch‐up DTPa3 was higher under “No jab, no pay” than during the baseline period (15.5% v 9.4%). Of 407 332 incompletely vaccinated people aged 10 to less than 20 years, 71 502 (17.6%) received catch‐up MMR2 during the first two years of “No jab, no pay”, increasing overall coverage for this age group from 86.6% to 89.0%. MMR2 catch‐up activity in this age group was greater in the lowest socio‐economic status areas than in the highest status areas (29.1% v 7.6%), and also for Indigenous than for non‐Indigenous Australians (35.8% v 17.1%). MMR2 catch‐up activity in 2016 and 2017 peaked mid‐year.

Conclusions

Linking family assistance payments with childhood vaccination status and associated program improvements were followed by substantial catch‐up vaccination activity, particularly in young people from families of lower socio‐economic status.

Assessing inequities in community health worker’s interaction and its impact in Uttar Pradesh, India

Given the high Neo-natal mortality in the state of Uttar Pradesh, India, an emphasis has been given to community health workers (CHW). CHW provides behavior push to pregnant women for utilizing health services, through the strategies of household contact and messaging. However, the disparity in health outcomes and interaction of CHW is profoundly affected by socio-economic determinants; still, the evidence is limited. This study aims to explore socio-economic inequities in quantity and quality of contacts by the CHW and its differential effect on health service utilization.

Multistage sampling design identified live births in the last 12 months across the 25 highest-risk districts of Uttar Pradesh(n = 3703). Regression models described the relation between household demographics and CHW contact & specific messaging and interactions of demographics and CHW contact & messaging in predicting health service utilization ( &gt; = 4 antenatal care (ANC) visits, Institutional delivery and 100 iron folic acid (IFA) consumption).

No differential likelihood in contact of CHW and specific messaging is found. Further, association of CHW contacts and specific messaging with health outcomes were significantly affected by socio-economic determinants.2 or more contacts along with specific messaging increased the odds of 4+ ANC to a higher degree among illiterate women compared to literate women(AOR:3.39, 95% CI:2.28-5.04 vs AOR:1.44, 95% CI:1.09-1.92). Similarly, the odds of facility delivery increased to a higher degree among lower wealth women compared to higher wealth women (AOR:3.41, 95% CI:2.47-4.71 vs. AOR:1.53, 95% CI: 1.09-2.15).

Specific messaging, along with CHW contacts, have a higher magnitude of effects on the marginalized population. This study provides evidence for adjusting implementation strategies based on socio-economic determinants to achieve equitable health service utilization. However, further research on training of CHW on heterogeneous interaction is recommended

Key messages

There exists differential effects of quantity and quality of contact by community health workers on health service utilization across the different socio-economic strata. Implementation agencies in the LMIC can reduce health inequity by shifting from coverage-oriented target approach towards more prioritized and focused interaction across socio-economic groups.

A systematic review of studies that measure parental vaccine attitudes and beliefs in childhood vaccination

Background

Acceptance of vaccines is an important predictor of vaccine uptake. This has public health implications as those who are not vaccinated are at a higher risk of infection from vaccine preventable diseases. We aimed to examine how parental attitudes and beliefs towards childhood vaccination were measured in questionnaires through a systematic review of the literature.

Methods

We systematically reviewed the literature to identify primary research studies using tools to measure vaccine attitudes and beliefs, published between January 2012 and May 2018. Studies were included if they involved a quantitative survey of the attitudes and beliefs of parents about vaccinations recommended for children. We undertook a synthesis of the results with a focus on evaluating the tools used to measure hesitancy.

Results

A total of 116 studies met the inclusion criteria, 99 used a cross sectional study design, 5 used a case control study design, 4 used a pre-post study design and 8 used mixed methods study designs. Sample sizes of included studies ranged from 49 to 12,259. The most commonly used tool was the Parent Attitudes about Childhood Vaccines (PACV) Survey (n = 7). The most common theoretical framework used was the Health Belief Model (n = 25). Questions eliciting vaccination attitudes and beliefs varied widely.

Conclusions

There was heterogeneity in the types of questionnaires used in studies investigating attitudes and beliefs about vaccination in parents. Methods to measure parental attitudes and beliefs about vaccination could be improved with validated and standardised yet flexible instruments. The use of a standard set of questions should be encouraged in this area of study.