A decision support tool for risk-benefit analysis of Japanese encephalitis vaccine in travellers

BACKGROUND

During pre-travel consultations, clinicians and travellers face the challenge of weighing the risks verus benefits of Japanese encephalitis (JE) vaccination due to the high cost of the vaccine, low incidence in travellers (~1 in 1 million), but potentially severe consequences (~30% case-fatality rate). Personalised JE risk assessment based on the travellers' demographics and travel itinerary is challenging using standard risk matrices. We developed an interactive digital tool to estimate risks of JE infection and severe health outcomes under different scenarios to facilitate shared decision-making between clinicians and travellers.

METHODS

A Bayesian network (conditional probability) model risk-benefit analysis of JE vaccine in travellers was developed. The model considers travellers' characteristics (age, sex, co-morbidities), itinerary (destination, departure date, duration, setting of planned activities) and vaccination status to estimate the risks of JE infection, the development of symptomatic disease (meningitis, encephalitis), clinical outcomes (hospital admission, chronic neurological complications, death) and adverse events following immunization.

RESULTS

In low-risk travellers (e.g. to urban areas for <1 month), the risk of developing JE and dying is low (<1 per million) irrespective of the destination; thus, the potential impact of JE vaccination in reducing the risk of clinical outcomes is limited. In high-risk travellers (e.g. to rural areas in high JE incidence destinations for >2 months), the risk of developing symptomatic disease and mortality is estimated at 9.5 and 1.4 per million, respectively. JE vaccination in this group would significantly reduce the risk of symptomatic disease and mortality (by ~80%) to 1.9 and 0.3 per million, respectively.

CONCLUSION

The JE tool may assist decision-making by travellers and clinicians and could increase JE vaccine uptake. The tool will be updated as additional evidence becomes available. Future work needs to evaluate the usability of the tool. The interactive, scenario-based, personalised JE vaccine risk-benefit tool is freely available on www.VaxiCal.com.

SARS-CoV-2 seroprevalence, cumulative infections, and immunity to symptomatic infection - A multistage national household survey and modelling study, Dominican Republic, June-October 2021

Background

Population-level SARS-CoV-2 immunological protection is poorly understood but can guide vaccination and non-pharmaceutical intervention priorities. Our objective was to characterise cumulative infections and immunological protection in the Dominican Republic.

Methods

Household members ≥5 years were enrolled in a three-stage national household cluster serosurvey in the Dominican Republic. We measured pan-immunoglobulin antibodies against the SARS-CoV-2 spike (anti-S) and nucleocapsid glycoproteins, and pseudovirus neutralising activity against the ancestral and B.1.617.2 (Delta) strains. Seroprevalence and cumulative prior infections were weighted and adjusted for assay performance and seroreversion. Binary classification machine learning methods and pseudovirus neutralising correlates of protection were used to estimate 50% and 80% protection against symptomatic infection.

Findings

Between 30 Jun and 12 Oct 2021 we enrolled 6683 individuals from 3832 households. We estimate that 85.0% (CI 82.1-88.0) of the ≥5 years population had been immunologically exposed and 77.5% (CI 71.3-83) had been previously infected. Protective immunity sufficient to provide at least 50% protection against symptomatic SARS-CoV-2 infection was estimated in 78.1% (CI 74.3-82) and 66.3% (CI 62.8-70) of the population for the ancestral and Delta strains respectively. Younger (5-14 years, OR 0.47 [CI 0.36-0.61]) and older (≥75-years, 0.40 [CI 0.28-0.56]) age, working outdoors (0.53 [0.39-0.73]), smoking (0.66 [0.52-0.84]), urban setting (1.30 [1.14-1.49]), and three vs no vaccine doses (18.41 [10.69-35.04]) were associated with 50% protection against the ancestral strain.

Interpretation

Cumulative infections substantially exceeded prior estimates and overall immunological exposure was high. After controlling for confounders, markedly lower immunological protection was observed to the ancestral and Delta strains across certain subgroups, findings that can guide public health interventions and may be generalisable to other settings and viral strains.

Funding

This study was funded by the US CDC.

Understanding the effectiveness of policy instruments to encourage adoption of farming practices to improve water quality for the Great Barrier Reef

Governments in Australia and internationally are experimenting with policy instruments to facilitate the adoption of farming practices with reduced environmental impacts. The Great Barrier Reef (Australia) is one such case, where sustained efforts over 20 years have yielded insufficient progress towards targets to reduce the impacts of agriculture on water quality in downstream marine ecosystems. We present a critical review of policy instruments as implemented in Great Barrier Reef catchments. We catalogue the evolving mix of policy instruments employed in reef programs, and examine evidence of the effectiveness of agricultural extension, financial incentives, and direct regulation of farming practices. There is little robust evidence to assess instrument effectiveness, in part due to the evolving mix of the instruments employed, weak program evaluation and heterogeneity of agricultural enterprises. We identify the need to improve the understanding of instrument fit to landholders and enterprises. We recommend a modelling approach to clarify pathways to impact and guide improved policy evaluation.

Implications of a travel connectivity-based approach for infectious disease transmission risks in Oceania

INTRODUCTION

The increase in international travel brought about by globalisation has enabled the rapid spread of emerging pathogens with epidemic and pandemic potential. While travel connectivity-based assessments may help understand patterns of travel network-mediated epidemics, such approaches are rarely carried out in sufficient detail for Oceania where air travel is the dominant method of transportation between countries.

DESIGN

Travel data from the Australian Bureau of Statistics, Stats NZ and the United Nations World Tourism Organization websites were used to calculate travel volumes in 2018 within Oceania and between Oceania and the rest of the world. The Infectious Disease Vulnerability Index (IDVI) was incorporated into the analysis as an indicator of each country's capacity to contain an outbreak. Travel networks were developed to assess the spread of infectious diseases (1) into and from Oceania, (2) within Oceania and (3) between each of the Pacific Island Countries and Territories (PICTs) and their most connected countries.

RESULTS

Oceania was highly connected to countries in Asia, Europe and North America. Australia, New Zealand and several PICTs were highly connected to the USA and the UK (least vulnerable countries for outbreaks based on the IDVI), and to China (intermediate low vulnerable country). High variability was also observed between the PICTs in the geographical distribution of their international connections. The PICTs with the highest number of international connections were Fiji, French Polynesia, Guam and Papua New Guinea.

CONCLUSION

Travel connectivity assessments may help to accurately stratify the risk of infectious disease importation and outbreaks in countries depending on disease transmission in other parts of the world. This information is essential to track future requirements for scaling up and targeting outbreak surveillance and control strategies in Oceania.

Biogeochemical assessment of natural attenuation of JP-4-contaminated ground water in the presence of fluorinated surfactants

The biogeochemistry of the natural attenuation of petroleum-contaminated ground water was investigated in a field study. The focus of the study was a fire training site located on Tyndall Air Force Base in Florida. The site has been used by the Air Force for approximately 11 years in fire fighting exercises. An on-site above-ground tank of JP-4 provided fuel for setting controlled fires for the exercises. Various amounts of water and aqueous film forming foams (AFFF) were applied to extinguish the fires. The sources of contamination included leaks from pipelines transporting the fuel, leaks from an oil/water separator and runoff and percolation from the fire fighting activities. Previous investigations had identified jet fuel contamination at the site, however, no active remediation efforts have been conducted to date. The goal of this study was to use biogeochemical monitoring data to delineate redox zones within the site and to identify evidence of natural attenuation of JP-4 contamination. In addition to identifying several hydrocarbon metabolites, fluorinated surfactants (AFFF) were detected down-gradient of the hydrocarbon plume.

Obstetrics-gynecology in the physical therapy curriculum: a follow-up study

This article reports the results of two questionnaire surveys conducted five years apart to evaluate the status and changes in obstetrics-gynecology (Ob-Gyn) units taught in physical therapy education programs. Sixteen new Ob-Gyn units were implemented in the five-year period between 1981 and 1986. Laboratory time for breathing and relaxation exercises decreased 50% between 1981 and 1986, whereas total hours for the Ob-Gyn unit remained the same. Fifteen respondents in the 1986 survey indicated gynecologic topic area content included reproductive anatomy, gynecological disorders, and evaluation techniques. The authors recommend increased laboratory time, development of Ob-Gyn internships, and further research. Threading Ob-Gyn concepts throughout the curriculum as well as having a concentrated Ob-Gyn unit are recommended.