Hospital health care workers' use of facial protective equipment before the COVID-19 pandemic, implications for future policy

BACKGROUND

Prepandemic routine use of facial (respiratory and eye) protective equipment (FPE) by health care workers was suboptimal. Understanding factors affecting routine use would facilitate escalation to high level use during infectious disease emergencies. This study explored health care workers FPE-related knowledge, attitudes and behaviors.

METHODS

Mixed methods were used in a respiratory ward and adult and pediatric emergency departments (EDs), prior to the COVID-19 pandemic. Study design and thematic analysis were based on the theoretical domains framework. Emergent themes were categorized, using the COM-B behavior model, into capability(C), opportunity(O) and motivation(M), which influence behavior(B).

RESULTS

22 emergent themes, representing factors influencing FPE use, were mapped to theoretical domains framework domains. Personal experience and departmental cultures influenced motivation. Compared with respiratory ward staff, ED clinicians were less knowledgeable about FPE; the unique ED environment and culture inhibited opportunities and motivation for FPE use. Eye protection was infrequently used.

DISCUSSION

Optimal FPE use is challenged by ED care models and settings. Changes are needed to translate pandemic-related improvements into routine care of other respiratory infections.

CONCLUSIONS

This study identified key determinants of FPE behavior. A review of context-specific FPE guidance for ED by infection prevention and control professionals would help to promote practicable, sustainable compliance.

Exploring the safety and quality of mobile X-ray imaging in a new infectious disease biocontainment unit: an in situ simulation and video-reflexive study

OBJECTIVES

During a precommissioning inspection of a new biocontainment centre, radiographers noted structural features of quarantine rooms that could compromise staff and patient safety and the X-ray image quality, even after significant modifications had been made to an earlier radiography protocol. The aim of this study was to explore the safety and effectiveness of the modified protocol, in the new space, and identify improvements, if required.

DESIGN

A qualitative study using in situ simulation and video-reflexive methods.

SETTING

A newly built biocontainment centre, prior to its commissioning in 2021, in a large, tertiary hospital in Sydney, Australia.

PARTICIPANTS

Five radiographers, and a nurse and a physician from the biocontainment centre, consented to participate. All completed the study.

INTERVENTIONS

Two simulated mobile X-ray examinations were conducted in the unit prior to its commissioning; simulations were videoed. Participants and other stakeholders analysed video footage, collaboratively, and sessions were audio recorded, transcribed and analysed thematically. Problems and potential solutions identified were collated and communicated to the hospital executive, for endorsement and actioning, if possible.

RESULTS

Four themes were identified from the data: infection exposure risks, occupational health and exposure risks, communication and X-ray image quality. Facilitated group reviews of video footage identified several important issues, across these four areas of risk, which had not been identified previously.

CONCLUSIONS

In situ simulation is used, increasingly, to evaluate and improve healthcare practices. This study confirmed the added value of video-reflexive methods, which provided experienced participants with a richer view of a familiar protocol, in a new setting. Video footage can be examined immediately, or later if required, by a broader group of stakeholders, with diverse experience or expertise. Using video reflexivity, clinicians identified potential safety risks, which were collated and reported to the hospital executive, who agreed to implement modifications.

Pneumococcal bacteraemia in adults over a 10-year period (2011-2020): a clinical and serotype analysis

BACKGROUND

Streptococcus pneumoniae (pneumococcus) is a human nasopharyngeal tract coloniser responsible for invasive pneumococcal disease, which is largely vaccine preventable. Vaccination is recommended from birth for all, and through adulthood for those with risk conditions.

AIMS

To describe the clinical and serotype analysis of pneumococcus bacteraemia over a 10-year period.

METHODS

A 10-year (February 2011-December 2020) retrospective review was performed on all adult (age ≥18 years) pneumococcus bacteraemia presenting to the four public hospitals in Western Sydney, Australia. Comorbidities and risk factors were recorded.

RESULTS

Three hundred unique episodes of S. pneumoniae bloodstream infection (SPBI) were identified during the study period. The median age for SPBI was 63 years with 31.7% aged 70 years or older. A 94.7% had one or more risks factors for SPBI. Pneumonia was reported in 80% of all SPBI, whereas meningitis was reported in 6% and infective endocarditis in <1%. Asplenia was noted in 2.4%. Seven- and 30-day mortality was 6.6% and 11.9%, with a higher 30-day mortality in those aged ≥70 years (24.4%). The serotype distribution showed 7-valent conjugate vaccine covered 11.0% of all isolates, whereas 13-valent conjugate vaccine (13vPCV) and a 23-valent polysaccharide vaccine (23vPPV) covered 41.7% and 69.0% respectively. Immunisation details were available for 110 individuals, of whom, only 7.3% had received pneumococcal vaccination.

CONCLUSIONS

Most patients with pneumococcal bacteraemia had age- or comorbidity-related risk factors but were not vaccinated. Two-thirds of cases occurred in people aged <70 years. 13vPCV and 23vPPV covered 41.7% and 69.0% of bacteraemic isolates.

Effectiveness of adjunctive rifampicin for treatment of Staphylococcus aureus bacteraemia: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

To assess whether the addition of rifampicin to conventional treatment of Staphylococcus aureus bacteraemia (SAB) reduces bacteriological or clinical failure or death.

DATA SOURCES

PubMed, Embase and Cochrane CENTRAL databases were searched from inception to 31 December 2022. Reference lists and PubMed citations of eligible studies were checked.

REVIEW METHODS

Two study authors independently identified randomized controlled trials (RCTs) involving adult participants with SAB, in which an intervention group received adjunctive rifampicin and the control group received usual care with or without a placebo. Dichotomous data (bacteriological and clinical failure and deaths) were analysed and pooled across studies using risk ratio (RR) with 95% confidence intervals (CI) using a Mantel-Haenszel random-effect model. The key variable of interest being whether rifampicin was used.

RESULTS

Six RCTs including 894 participants-of which 758 (85%) were from one trial-met the inclusion criteria. The addition of rifampicin to conventional treatment of SAB significantly reduced bacteriological failure by 59% (RR 0.41, 95% CI 0.21-0.81, I2 = 0%, number need to treat 27). However, it did not reduce clinical failure (RR 0.70, 95% CI 0.47-1.03, I2 = 0%) or deaths (RR 0.96, 95% CI 0.70-1.32, I2 = 0%). Further, it did not reduce the duration of bacteraemia, or the length of hospital stay. Adjunctive rifampicin reduced SAB recurrences (1% versus 4%, P = 0.01). Emergence of rifampicin resistance during treatment was uncommon (<1%).

CONCLUSION

Although adjunctive rifampicin reduced the risk of bacteriological failure and recurrences, we found no mortality benefit to support its use in SAB.

Why ethical frameworks fail to deliver in a pandemic: Are proposed alternatives an improvement?

In the past decade, numerous ethical frameworks have been developed to support public health decision-making in challenging areas. Before the COVID-19 pandemic began, members of the authorship team were involved in research programmes, in which the development of ethical frameworks was planned, to guide (a) the use of new technologies for emerging infectious disease surveillance; and (b) the allocation of scarce supplies of pandemic influenza vaccine. However, as the pandemic evolved, significant practical challenges emerged that led to our questioning the value of these frameworks. We now believe that a normative instrument, such as a framework, cannot adequately or reliably provide the ethical guidance that needs to be incorporated into public health decision-making during natural disasters or infectious disease emergencies. Recently it has been suggested that there are potentially more dynamic, flexible, and effective ways to navigate decisions involving complex considerations entailed in policies and practices during a public health emergency. In this paper, we first outline the key functions of a public health ethics framework, before describing why we believe it would not be fit for purpose during a crisis. We end by considering whether proposed alternative methods to promote ethical public health decision-making goals have the potential to meet these objectives.

Understanding routine (non-outbreak) respiratory protective equipment behaviour of hospital workers in different clinical settings - lessons for the future post COVID-19

BACKGROUND

The COVID-19 pandemic has drawn attention to the importance of facial (respiratory and eye) protective equipment (FPE). Optimal use of FPE in non-outbreak situations, will enable frontline staff, such as emergency department (ED) clinicians, to adapt more rapidly and safely to the increased demands and skills required during an infectious disease outbreak.

METHODS

A survey, designed to determine the attitudes, beliefs and knowledge of HCWs around the use of FPE for protection against respiratory infections, was distributed to staff in a respiratory ward, an adult ED and a paediatric ED in Sydney, Australia prior to COVID-19.

RESULTS

The survey revealed differences between the respiratory ward and the EDs and between professional groups. ED staff, particularly paediatric clinicians, were less likely than ward staff to use FPE appropriately during routine care. Medical staff were more likely to work outside of IPC policies.

DISCUSSION

The busy, relatively chaotic ED environment presents unique challenges for optimal compliance with safe FPE use when caring for patients with respiratory symptoms.

CONCLUSIONS

Building upon the lessons of the pandemic, it is timely to address the specific infection prevention and control needs of the ED environment to improve FPE compliance during non-outbreak situations.

Disagreement among experts about public health decision making: is it polarisation and does it matter?

It is common for aspects of the COVID-19 response-and other public health initiatives before it-to be described as polarised. Public health decisions emerge from an interplay of facts, norms and preferred courses of action. What counts as 'evidence' is diverse and contestable, and disagreements over how it should be interpreted are often the product of differing choices between competing values. We propose a definition of polarisation for the context of public health expertise that acknowledges and accounts for epistemic and social values as part of evidence generation and its application to public health practice. The 'polarised' label should be used judiciously because the descriptor risks generating or exacerbating the problem by oversimplifying complex issues and positions and creating groups that seem dichotomous. 'Independence' as a one-size-fits-all answer to expert polarisation is insufficient; this solution is premised on a scientistic account of the role of evidence in decision making and does not make room for the value difference that is at the heart of both polarisation and evidence-based decision making.

Real world impact of 13vPCV in preventing invasive pneumococcal pneumonia in Australian children: A national study

BACKGROUND

We aimed to assess the direct protective effect of 13 valent pneumococcal conjugate vaccine (13vPCV) against invasive pneumococcal pneumonia (IPP; including pneumonia and empyema) in children using a nation-wide case-control study across 11 paediatric tertiary hospitals in Australia.

METHODS

Children < 18 years old admitted with pneumonia were eligible for enrolment. IPP was defined as Streptococcus pneumoniae (SP) cultured or detected by polymerase chain reaction (PCR) from blood or pleural fluid. Causative SP serotype (ST) was determined from blood or pleural fluid SP isolates by molecular methods in PCR positive specimens or else inferred from nasopharyngeal isolates. For each IPP case, 20 population controls matched by age and socio-economic status were sampled from the Australian Immunisation Register. Conditional logistic regression was used to estimate the adjusted odds ratio (aOR) of being fully vaccinated with 13vPCV (≥3 doses versus < 3 doses) among IPP cases compared to controls, adjusted for sex and Indigenous status.

RESULTS

From February 2015 to September 2018, we enrolled 1,168 children with pneumonia; 779 were 13vPCV-eligible and were individually matched to 15,580 controls. SP was confirmed in 195 IPP cases, 181 of whom had empyema. ST3 and ST19A were identified in 52% (102/195) and 11% (21/195) of IPP cases respectively. The aOR of being fully vaccinated with 13vPCV was 0.8 (95% CI 0.6-1.0) among IPP cases compared to matched controls.

CONCLUSION

We failed to identify a strong direct protective effect of 13vPCV against IPP among Australian children, where disease was largely driven by ST3.

Exploring healthcare workers' perspectives of video feedback for training in the use of powered air purifying respirators (PAPR) at the onset of the COVID-19 pandemic

BACKGROUND

With the advent of COVID-19, many healthcare workers (HWs) in Australia requested access to powered air purifying respirators (PAPR) for improved respiratory protection, comfort and visibility. The urgency of the response at our hospital required rapid deployment of innovative training to ensure the safe use of PAPRs, in particular, a video-feedback training option to prepare HWs for PAPR competency.

AIM

To explore the feasibility, acceptability, and utility of video-feedback in PAPR training and competency assessment.

METHODS

Semi-structured interviews were conducted with 12 HWs, including clinicians from Intensive Care, Anaesthetics and Respiratory Medicine, at a large teaching hospital in Australia.

FINDINGS

Participants believed that the use of video-feedback in PAPR training was feasible, acceptable and useful. They described a variety of benefits to learning and retention, from a variety of ways in which they engaged with the personal video-feedback. Participants also described the impact of reviewing personalised practice footage, compared to generic footage of an ideal performance.

CONCLUSION

By conceptualising video-feedback using a pedagogical approach, this study contributes to knowledge around optimising methods for training HWs in PPE use, particularly when introducing a new and complex PPE device during an infectious disease outbreak.

'Like building a plane and flying it all in one go': an interview study of infection prevention and control in Australian general practice during the first 2 years of the SARS-CoV-2 pandemic

OBJECTIVES

General practitioners (GPs) and their staff have been at the frontline of the SARS-CoV-2 pandemic in Australia. However, their experiences of responding to and managing the risks of viral transmission within their facilities are poorly described. The aim of this study was to describe the experiences, and infection prevention and control (IPC) strategies adopted by general practices, including enablers of and challenges to implementation, to contribute to our understanding of the pandemic response in this critical sector.

DESIGN

Semistructured interviews were conducted in person, by telephone or online video conferencing software, between November 2020 and August 2021.

PARTICIPANTS

Twenty general practice personnel working in New South Wales, Australia, including nine GPs, one general practice registrar, four registered nurses, one nurse practitioner, two practice managers and two receptionists.

RESULTS

Participants described implementing wide-ranging repertoires of IPC strategies-including telehealth, screening of patients and staff, altered clinic layouts and portable outdoor shelters, in addition to appropriate use of personal protective equipment (PPE)-to manage the demands of the SARS-CoV-2 pandemic. Strategies were proactive, influenced by the varied contexts of different practices and the needs and preferences of individual GPs as well as responsive to local, state and national requirements, which changed frequently as the pandemic evolved.

CONCLUSIONS

Using the 'hierarchy of controls' as a framework for analysis, we found that the different strategies adopted in general practice often functioned in concert with one another. Most strategies, particularly administrative and PPE controls, were subjected to human variability and so were less reliable from a human factors perspective. However, our findings highlight the creativity, resilience and resourcefulness of general practice staff in developing, implementing and adapting their IPC strategies amidst constantly changing pandemic conditions.

"One minute it's an airborne virus, then it's a droplet virus, and then it's like nobody really knows…": Experiences of pandemic PPE amongst Australian healthcare workers

BACKGROUND

The SARS-CoV-2 pandemic has challenged health systems globally. A key controversy has been how to protect healthcare workers (HCWs) using personal protective equipment (PPE).

METHODS

Interviews were performed with 63 HCWs across two states in Australia to explore their experiences of PPE during the SARS-CoV-2 pandemic. Thematic analysis was performed.

RESULTS

Four themes were identified with respect to HCWs' experience of pandemic PPE: 1. Risk, fear and uncertainty: HCWs experienced considerable fear and heightened personal and professional risk, reporting anxiety about the adequacy of PPE and the resultant risk to themselves and their families. 2. Evidence and the ambiguities of evolving guidelines: forms of evidence, its interpretation, and the perception of rapidly changing guidelines heightened distress amongst HCWs. 3. Trust and care: Access to PPE signified organisational support and care, and restrictions on PPE use were considered a breach of trust. 4. Non-compliant practice in the context of social upheaval: despite communication of evidence-based guidelines, an environment of mistrust, personal risk, and organisational uncertainty resulted in variable compliance.

CONCLUSION

PPE preferences and usage offer a material signifier of the broader, evolving pandemic context, reflecting HCWs' fear, mistrust, sense of inequity and social solidarity (or breakdown). PPE therefore represents the affective (emotional) demands of professional care, as well as a technical challenge of infection prevention and control. If rationing of PPE is necessary, policymakers need to take account of how HCWs will perceive restrictions or conflicting recommendations and build trust through effective communication (including of uncertainty).

What is needed to sustain improvements in hospital practices post-COVID-19? a qualitative study of interprofessional dissonance in hospital infection prevention and control

Background

Hospital infection prevention and control (IPC) depends on consistent practice to achieve its purpose. Standard precautions are embedded in modern healthcare policies, but not uniformly observed by all clinicians. Well-documented differences in attitudes to IPC, between doctors and nurses, contribute to suboptimal IPC practices and persistence of preventable healthcare-associated infections. The COVID-19 pandemic has seriously affected healthcare professionals’ work-practices, lives and health and increased awareness and observance of IPC. Successful transition of health services to a ‘post-COVID-19’ future, will depend on sustainable integration of lessons learnt into routine practice.

Methods

The aim of this pre-COVID-19 qualitative study was to investigate factors influencing doctors’ IPC attitudes and practices, whether they differ from those of nurses and, if so, how this affects interprofessional relationships. We hypothesised that better understanding would guide new strategies to achieve more effective IPC. We interviewed 26 senior clinicians (16 doctors and 10 nurses) from a range of specialties, at a large Australian tertiary hospital. Interview transcripts were reviewed iteratively, and themes identified inductively, using reflexive thematic analysis.

Results

Participants from both professions painted clichéd portraits of ‘typical’ doctors and nurses and recounted unflattering anecdotes of their IPC behaviours. Doctors were described as self-directed and often unaware or disdainful of IPC rules; while nurses were portrayed as slavishly following rules, ostensibly to protect patients, irrespective of risk or evidence. Many participants believed that doctors object to being reminded of IPC requirements by nurses, despite many senior doctors having limited knowledge of correct IPC practice. Overall, participants’ comments suggested that the ‘doctor-nurse game’—described in the 1960s, to exemplify the complex power disparity between professions—is still in play, despite changes in both professions, in the interim.

Conclusions

The results suggest that interprofessional differences and inconsistencies constrain IPC practice improvement. IPC inconsistencies and failures can be catastrophic, but the common threat of COVID-19 has promoted focus and unity. Appropriate implementation of IPC policies should be context-specific and respect the needs and expertise of all stakeholders. We propose an ethical framework to guide interprofessional collaboration in establishing a path towards sustained improvements in IPC and bio-preparedness.

Experiences of the SARS-CoV-2 pandemic amongst Australian healthcare workers: from stressors to protective factors

BACKGROUND

The SARS-CoV-2 pandemic has critically challenged healthcare systems globally. Examining the experiences of healthcare workers (HCWs) is important for optimizing ongoing and future pandemic responses.

OBJECTIVES

In-depth exploration of Australian HCWs' experiences of the SARS-CoV-2 pandemic, with a focus on reported stressors vis-à-vis protective factors.

METHODS

Individual interviews were performed with 63 HCWs in Australia. A range of professional streams and operational staff were included. Thematic analysis was performed.

RESULTS

Thematic analysis identified stressors centred on paucity of, or changing, evidence, leading to absence of, or mistrust in, guidelines; unprecedented alterations to the autonomy and sense of control of clinicians; and deficiencies in communication and support. Key protective factors included: the development of clear guidance from respected clinical leaders or recognized clinical bodies, interpersonal support, and strong teamwork, leadership, and a sense of organizational preparedness.

CONCLUSIONS

This study provides insights into the key organizational sources of emotional stress for HCWs within pandemic responses and describes experiences of protective factors. HCWs experiencing unprecedented uncertainty, fear, and rapid change, rely on clear communication, strong leadership, guidelines endorsed by recognized expert groups or individuals, and have increased reliance on interpersonal support. Structured strategies for leadership and communication at team, service group and organizational levels, provision of psychological support, and consideration of the potential negative effects of centralizing control, would assist in ameliorating the extreme pressures of working within a pandemic environment.

Should Digital Contact Tracing Technologies be used to Control COVID-19? Perspectives from an Australian Public Deliberation

Mobile phone-based applications (apps) can promote faster targeted actions to control COVID-19. However, digital contact tracing systems raise concerns about data security, system effectiveness, and their potential to normalise privacy-invasive surveillance technologies. In the absence of mandates, public uptake depends on the acceptability and perceived legitimacy of using technologies that log interactions between individuals to build public health capacity. We report on six online deliberative workshops convened in New South Wales to consider the appropriateness of using the COVIDSafe app to enhance Australian contact tracing systems. All groups took the position (by majority) that the protections enacted in the app design and supporting legislation were appropriate. This support is contingent on several system attributes including: the voluntariness of the COVIDSafe app; that the system relies on proximity rather than location tracking; and, that data access is restricted to local public health practitioners undertaking contact tracing. Despite sustained scepticism in media coverage, there was an underlying willingness to trust Australian governing institutions such that in principle acceptance of the new contact tracing technology was easy to obtain. However, tensions between the need to prove system effectiveness through operational transparency and requirements for privacy protections could be limiting public uptake. Our study shows that informed citizens are willing to trade their privacy for common goods such as COVID-19 suppression. But low case numbers and cautionary public discourses can make trustworthiness difficult to establish because some will only do so when it can be demonstrated that the benefits justify the costs to individuals.

Entanglements of affect, space, and evidence in pandemic healthcare: An analysis of Australian healthcare workers' experiences of COVID-19

The COVID-19 pandemic continues to highlight both global interconnectedness and schisms across place, context and peoples. While countries such as Australia have securitised their borders in response to the global spread of disease, flows of information and collective affect continue to permeate these boundaries. Drawing on interviews with Australian healthcare workers, we examine how their experiences of the pandemic are shaped by affect and evidence ‘traveling’ across time and space. Our analysis points to the limitations of global health crisis responses that focus solely on material risk and spatial separation. Institutional responses must, we suggest, also consider the affective and discursive dimensions of health-related risk environments.

Testing the efficacy and acceptability of video-reflexive methods in personal protective equipment training for medical interns: a mixed methods study

OBJECTIVES

To test the efficacy and acceptability of video-reflexive methods for training medical interns in the use of personal protective equipment (PPE).

DESIGN

Mixed methods study.

SETTING

A tertiary-care teaching hospital, Sydney, January 2018-February 2019.

PARTICIPANTS

72 of 90 medical interns consented to participate. Of these, 39 completed all three time points.

INTERVENTIONS

Participants received a standard infection prevention and control (IPC) education module during their hospital orientation. They were then allocated alternately to a control or video group. At three time points (TPs) over the year, participants were asked to don/doff PPE items based on hospital protocol. At the first two TPs, all participants also participated in a reflexive discussion. At the second and third TPs, all participants were audited on their performance. The only difference between groups was that the video group was videoed while donning/doffing PPE, and they watched this footage as a stimulus for reflexive discussion.

PRIMARY AND SECONDARY OUTCOME MEASURES

The efficacy and acceptability of the intervention were assessed using: (1) comparisons of audit performance between and within groups over time, (2) comparisons between groups on survey responses for evaluation of training and self-efficacy and (3) thematic analysis of reflexive discussions.

RESULTS

Both groups improved in their PPE competence over time, although there was no consistent pattern of significant differences within and between groups. No significant differences were found between groups on reported acceptability of training, or self-efficacy for PPE use. However, analysis of reflexive discussions shows that the effects of the video-reflexive intervention were tangible and different in important respects from standard training.

CONCLUSIONS

Video reflexivity in group-based training can assist new clinicians in engagement with, and better understanding of, IPC in their clinical practice. Our study also highlights the need for ongoing and targeted IPC training during medical undergraduate studies as well as regular workplace refresher training.

Education and training in infection prevention and control: Exploring support for national standards

BACKGROUND

Effective infection prevention and control (IPC) programmes comprise a hierarchy of preventive measures, one of which is appropriate use of personal protective equipment (PPE). A poor understanding of the role of PPE and sub-optimal use may fail to prevent or even increase pathogen transmission during routine care or an infectious disease outbreak. Variability in delivery and content of IPC and PPE education and training across organisations can lead to confusion, unsafe practice, and lack of confidence among clinicians. In a national survey we explored the perspectives of Australian and New Zealand IPC professionals on the value and feasibility of a national IPC training and monitoring programme to improve and standardise PPE practice and raise the profile of IPC.

METHODS

A population-based online survey that examined hospital PPE training programmes was distributed to members of three major Australasian organisations representing IPC professionals. Quantitative results of the survey have been reported previously. This paper is a qualitative analysis of responses to two open-ended questions about a national approach to training in IPC and the use of PPE.

RESULTS

Most respondents agreed that standardising IPC and PPE training could achieve more consistent practice nationally, supported through the provision of educational resources. Including competency in the use of PPE in mandatory IPC standards would assist in improving the practice and raising the profile of IPC more generally.

CONCLUSION

The results of this study suggest that that there is support for national programmes and standards for use of PPE in Australia and New Zealand.

Assessing the impact of the 13 valent pneumococcal vaccine on childhood empyema in Australia

BACKGROUND

Empyema is a serious complication of pneumonia frequently caused by Streptococcus pneumoniae (SP). We assessed the impact of the 13-valent pneumococcal conjugate vaccine (13vPCV) on childhood pneumonia and empyema after inclusion in the Australian National Immunisation Program.

METHODS

For bacterial pneumonia and empyema hospitalisations, we ascertained incidence rates (IRs) using the National Hospital Morbidity Database International Statistical Classification of Disease discharge codes and relevant population denominators, and calculated incidence rate ratios (IRR) comparing the 13vPCV period (June 2012-May 2017) with the 7vPCV period (June 2007-May 2011). Blood and pleural fluid (PF) cultures and PF PCR of 401 children with empyema from 11 Australian hospitals during the 13vPCV period were compared with our previous study in the 7vPCV period.

FINDINGS

Across 7vPCV and 13vPCV periods, IRs per million children (95% CIs) were 1605 (1588 to 1621) and 1272 (1259 to 1285) for bacterial pneumonia, and 14.23 (12.67 to 15.79) and 17.89 (16.37 to 19.42) for empyema hospitalisations. IRRs were 0.79 (0.78 to 0.80) for bacterial pneumonia and 1.25 (1.09 to 1.44) for empyema. Of 161 empyema cases with SP serotypes, 147 (91.3%) were vaccine types. ST3 accounted for 76.4% of identified serotypes in the 13vPCV period, more than double than the 7vPCV period (p<0.001); ST19A decreased from 36.4% to 12.4%. No cases of ST1 empyema were identified in the 13vPCV period versus 14.5% in the 7vPCV period.

INTERPRETATION

13vPCV resulted in a significant reduction in all-cause hospitalisations for bacterial pneumonia but empyema hospitalisations significantly increased, with emergence of pneumococcal ST3 as the dominant serotype in empyema.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trial Registry ACTRN 12614000354684.

Priority allocation of pandemic influenza vaccines in Australia - Recommendations of 3 community juries

BACKGROUND

Pandemic planning has historically been oriented to respond to an influenza virus, with vaccination strategy being a key focus. As the current COVID-19 pandemic plays out, the Australian government is closely monitoring progress towards development of SARS-CoV2 vaccines as a definitive intervention. However, as in any pandemic, initial supply will likely be exceeded by demand due to limited manufacturing output.

METHODS

We convened community juries in three Australian locations in 2019 to assess public acceptability and perceived legitimacy of influenza pandemic vaccination distribution strategies. Preparatory work included literature reviews on pandemic vaccine allocation strategies and on vaccine allocation ethics, and simulation modelling studies. We assumed vaccine would be provided to predefined priority groups. Jurors were then asked to recommend one of two strategies for distributing remaining early doses of vaccine: directly vaccinate people at higher risk of adverse outcomes from influenza; or indirectly protect the general population by vaccinating primary school students, who are most likely to spread infection.

RESULTS

Thirty-four participants of diverse backgrounds and ages were recruited through random digit dialling and topic-blinded social media advertising. Juries heard evidence and arguments supporting different vaccine distribution strategies, and questioned expert presenters. All three community juries supported prioritising school children for influenza vaccination (aiming for indirect protection), one by 10-2 majority and two by consensus. Justifications included that indirect protection benefits more people and is likely to be more publicly acceptable.

CONCLUSIONS

In the context of an influenza pandemic, informed citizens were not opposed to prioritising groups at higher risks of adverse outcomes, but if resources and epidemiological conditions allow, achieving population benefits should be a strategic priority. These insights may inform future SARS-CoV-2 vaccination strategies.

Changes in public preferences for technologically enhanced surveillance following the COVID-19 pandemic: a discrete choice experiment

OBJECTIVES

As governments attempt to navigate a path out of COVID-19 restrictions, robust evidence is essential to inform requirements for public acceptance of technologically enhanced communicable disease surveillance systems. We examined the value of core surveillance system attributes to the Australian public, before and during the early stages of the current pandemic.

DESIGN

A discrete choice experiment was conducted in Australia with a representative group of respondents, before and after the WHO declared COVID-19 a Public Health Emergency of International Concern. We identified and investigated the relative importance of seven attributes associated with technologically enhanced disease surveillance: respect for personal autonomy; privacy/confidentiality; data certainty/confidence; data security; infectious disease mortality prevention; infectious disease morbidity prevention; and attribution of (causal) responsibility. Specifically, we explored how the onset of the COVID-19 outbreak influenced participant responses.

SETTING AND PARTICIPANTS

2008 Australians (general public) completed the experiment: 793 before COVID-19 outbreak onset (mean age 45.9 years, 50.2% male) and 1215 after onset (mean age 47.2 years, 49% male).

RESULTS

All seven attributes significantly influenced respondents' preferences for communicable disease surveillance systems. After onset, participants demonstrated greater preference for a surveillance system that could prevent a higher number of illnesses and deaths, and were less concerned about their personal autonomy. However, they also increased their preference for a system with high data security.

CONCLUSIONS

Public acceptance of technology-based communicable disease surveillance is situation dependent. During an epidemic, there is likely to be greater tolerance of technologically enhanced disease surveillance systems that result in restrictions on personal activity if such systems can prevent high morbidity and mortality. However, this acceptance of lower personal autonomy comes with an increased requirement to ensure data security. These findings merit further research as the pandemic unfolds and strategies are put in place that enable individuals and societies to live with SARS-CoV-2 endemicity.

Hospital infection control: old problem - evolving challenges

Hospital infection prevention and control (IPC) is often regarded by doctors as mundane and unnecessarily rigid, but the continued occurrence of preventable healthcare-associated infections, increasing antimicrobial resistance (to which hospitals are major contributors) and rare, but potentially devastating hospital outbreaks of emerging infectious diseases, suggest that IPC must be taken seriously. Healthcare professionals often fail to comply with effective, evidence-based IPC practices and there is ample evidence that doctors, generally, do so less consistently than nurses. However, doctors' practices are highly variable, apparently because of a perceived entitlement to clinical autonomy. In practice, most doctors observe safe IPC practices, most of the time. However, some are ignorant or dismissive of IPC policies and some respond angrily, when reminded. Among a small proportion of senior consultants, negative attitudes to IPC are perceived by their peers to correlate with a more general failure to meet their public hospital commitments, apparently because of conflicting demands, including private practice. The fact that breaches of IPC practice have significant, although often hidden, consequences indicates a need for continued improvement based on new strategies that might include: better surveillance, to identify and inform doctors of the true burdens of healthcare-associated infections; professional self-reflection on falsely dichotomous claims of medical professionalism namely: clinical autonomy versus regard for patient welfare by complying with 'rules' designed to protect them; and review of the consequences of recent changes in healthcare delivery, including proliferation of multiple, part-time consultant contracts at the expense of public hospital culture and status.

Medical interns' reflections on their training in use of personal protective equipment

BACKGROUND

The current COVID-19 pandemic has demonstrated that personal protective equipment (PPE) is essential, to prevent the acquisition and transmission of infectious diseases, yet its use is often sub-optimal in the clinical setting. Training and education are important to ensure and sustain the safe and effective use of PPE by medical interns, but current methods are often inadequate in providing the relevant knowledge and skills. The purpose of this study was to explore medical graduates' experiences of the use of PPE and identify opportunities for improvement in education and training programmes, to improve occupational and patient safety.

METHODS

This study was undertaken in 2018 in a large tertiary-care teaching hospital in Sydney, Australia, to explore medical interns' self-reported experiences of PPE use, at the beginning of their internship. Reflexive groups were conducted immediately after theoretical and practical PPE training, during hospital orientation. Transcripts of recorded discussions were analysed, using a thematic approach that drew on the COM-B (capability, opportunity, motivation - behaviour) framework for behaviour.

RESULTS

80% of 90 eligible graduates participated. Many interns had not previously received formal training in the specific skills required for optimal PPE use and had developed potentially unsafe habits. Their experiences as medical students in clinical areas contrasted sharply with recommended practice taught at hospital orientation and impacted on their ability to cultivate correct PPE use.

CONCLUSIONS

Undergraduate teaching should be consistent with best practice PPE use, and include practical training that embeds correct and safe practices.

Characteristics of personal protective equipment training programs in Australia and New Zealand hospitals: A survey

Background

Using personal protective equipment (PPE) is one of several fundamental measures to prevent the transmission of infection and infectious diseases and is particularly pertinent in the current COVID-19 pandemic. Appropriate use of PPE by healthcare workers is, however, often suboptimal. Training and monitoring of PPE competency are essential components of an infection prevention and control program but there is a paucity of research and data on the content of such training programs across Australasia. This paper reports the results of a survey that characterised the nature of PPE training in Australian and New Zealand hospitals.

Methods

A population-based online survey was distributed to members of three major Australasian colleges representing infection prevention and control.

Results

Results indicate that, although training is frequently provided at orientation, many healthcare workers do not receive regular updates. Training programmes combine online and classroom sessions, but over a third do not include a practical component. The frequency of monitoring PPE competency is variable with one third of respondents indicating that no auditing occurs. PPE items used for high-level training are variable, with use of powered air purifying respirators (PAPRs) uncommon.

Conclusion

The results of this study suggest that HCWs’ confidence, competence and familiarity with PPE are a concern, which in the context of the current global COVID-19 pandemic is problematic. More research is needed into how PPE training programs could be better designed, to prepare HCWs for practice using PPE safely and confidently.

•

Most HCW orientation programmes include PPE training but fewer than half are updated annually.

•

One third of PPE programmes do not include a practical component.

•

Only two thirds of PPE training programmes monitor PPE compliance.

•

Future research should consider the design of PPE training programs to optimise HCW PPE practice.

Citizens' juries give verdict on whether private practice veterinarians should attend unvaccinated Hendra virus suspect horses

BACKGROUND

Hendra virus (HeV) is endemic in Australian flying foxes, posing a threat to equine and human health. Equine vaccination remains the most effective risk mitigation strategy. Many horses remain unvaccinated - even in higher-risk regions. Debate surrounding the vaccine's use is characterised by conflicting perspectives, misunderstanding and mistrust. Private veterinary practitioners are critical to early identification of public health risk through recognition, sampling and management of suspect-equine-HeV-cases. However, managing such cases can be burdensome, with some veterinarians opting not to attend unvaccinated horses or to abandon equine practice because of risk posed by HeV disease and liability.

OBJECTIVE

Ascertain the perspectives of informed citizens on what obligations (if any) private veterinarians have to attend unvaccinated horses with HeV or HeV-like disease.

METHODS

Three citizens' juries were tasked with considering approaches to managing HeV risk in Australia, including (reported here) roles and obligations of private veterinarians in responding to HeV-suspect-cases.

RESULTS

Jurors acknowledged that HeV management posed an important challenge for private veterinarians. A clear majority (27 of 31 jurors) voted that veterinarians should not be obliged to attend unvaccinated horses. All recognised that greater support for veterinarians should be a priority.

CONCLUSIONS

When informed of HeV risks and strategies for control and management, citizens appreciated the need to support veterinarians performing this critical 'One Health' role for public benefit. The current governance framework within which zoonotic disease recognition and response operates limits the contingency and scope for increasing support and efficacy of these important veterinary public health practices.

Community perspectives on the benefits and risks of technologically enhanced communicable disease surveillance systems: a report on four community juries

Background

Outbreaks of infectious disease cause serious and costly health and social problems. Two new technologies – pathogen whole genome sequencing (WGS) and Big Data analytics – promise to improve our capacity to detect and control outbreaks earlier, saving lives and resources. However, routinely using these technologies to capture more detailed and specific personal information could be perceived as intrusive and a threat to privacy.

Method

Four community juries were convened in two demographically different Sydney municipalities and two regional cities in New South Wales, Australia (western Sydney, Wollongong, Tamworth, eastern Sydney) to elicit the views of well-informed community members on the acceptability and legitimacy of:

making pathogen WGS and linked administrative data available for public health research

using this information in concert with data linkage and machine learning to enhance communicable disease surveillance systems

Fifty participants of diverse backgrounds, mixed genders and ages were recruited by random-digit-dialling and topic-blinded social-media advertising. Each jury was presented with balanced factual evidence supporting different expert perspectives on the potential benefits and costs of technologically enhanced public health research and communicable disease surveillance and given the opportunity to question experts.

Results

Almost all jurors supported data linkage and WGS on routinely collected patient isolates for the purposes of public health research, provided standard de-identification practices were applied. However, allowing this information to be operationalised as a syndromic surveillance system was highly contentious with three juries voting in favour, and one against by narrow margins. For those in favour, support depended on several conditions related to system oversight and security being met. Those against were concerned about loss of privacy and did not trust Australian governments to run secure and effective systems.

Conclusions

Participants across all four events strongly supported the introduction of data linkage and pathogenomics to public health research under current research governance structures. Combining pathogen WGS with event-based data surveillance systems, however, is likely to be controversial because of a lack of public trust, even when the potential public health benefits are clear. Any suggestion of private sector involvement or commercialisation of WGS or surveillance data was unanimously rejected.

Sustained fall in inpatient MRSA prevalence after a video-reflexive ethnography project; an observational study

BACKGROUND

Maintaining optimal infection prevention and control (IPC) in a busy, clinical environment is challenging. Video-reflexive ethnography (VRE) is a collaborative, interventionist approach to practice improvement. We hypothesised that giving clinicians opportunities to view and reflect on video footage of everyday ward activities would raise awareness of, and suggest strategies to reduce, pathogen transmission risks. We undertook a VRE project, between March and September 2013, in two tertiary hospital surgical wards, with persistently high methicillin resistant Staphylococcus aureus (MRSA) endemicity, despite previous IPC interventions.

METHODS

This study was a retrospective/prospective observational study, using interrupted time-series analyses, to assess the effects of the VRE project on hand hygiene compliance, inpatient MRSA infections (newly infected patients, per 1000 occupied bed days) and inpatient MRSA colonisation prevalence, measured by serial point prevalence surveys. Follow-up continued until June 2016.

RESULTS

The VRE project was associated with changes in IPC behaviour and outcomes. Hand hygiene compliance increased (from 62% to 75%; p < 0.0001) and MRSA colonisation prevalence decreased significantly, in both wards (baseline 42%; average post-VRE 12%; p=<0.0001), MRSA infection rate decreased in one ward. Interpretation of results was complicated by a potential confounding effect of unplanned environmental hydrogen peroxide decontamination (HPD). Improved hand hygiene compliance was a predicted outcome of VRE, but also a potential contributor to reduced MRSA transmission.

CONCLUSION

Separate contributions of VRE (the intervention), HPD and hand hygiene compliance were uncertain, but their combined effect was significantly reduced MRSA endemicity, which previously had been resistant to attempted IPC interventions.

One Health and Zoonotic Uncertainty in Singapore and Australia: Examining Different Regimes of Precaution in Outbreak Decision-Making

A One Health approach holds great promise for attenuating the risk and burdens of emerging infectious diseases (EIDs) in both human and animal populations. Because the course and costs of EID outbreaks are difficult to predict, One Health policies must deal with scientific uncertainty, whilst addressing the political, economic and ethical dimensions of communication and intervention strategies. Drawing on the outcomes of parallel Delphi surveys conducted with policymakers in Singapore and Australia, we explore the normative dimensions of two different precautionary approaches to EID decision-making—which we call regimes of risk management and organizing uncertainty, respectively. The imperative to act cautiously can be seen as either an epistemic rule or as a decision rule, which has implications for how EID uncertainty is managed. The normative features of each regime, and their implications for One Health approaches to infectious disease risks and outbreaks, are described. As One Health attempts to move upstream to prevent rather than react to emergence of EIDs in humans, we show how the approaches to uncertainty, taken by experts and decision-makers, and their choices about the content and quality of evidence, have implications for who pays the price of precaution, and, thereby, social and global justice.

Enablers of, and barriers to, optimal glove and mask use for routine care in the emergency department: an ethnographic study of Australian clinicians

Background

The risk of healthcare-acquired infection increases during outbreaks of novel infectious diseases. Emergency department (ED) clinicians are at high risk of exposure to both these and common communicable diseases. Personal protective equipment (PPE) is recommended to protect clinicians from acquiring, or becoming vectors of, infection, yet compliance is typically sub-optimal. Little is known about factors that influence use of PPE—specifically gloves and masks—during routine care in the ED.

Methods

This was an ethnographic study, incorporating documentation review, field observations and interviews. The theoretical domains framework (TDF) was used to aid thematic analysis and identify relevant enablers of and barriers to optimal PPE use.

Results

Thirty-one behavioural themes were identified that influenced participants’ use of masks and gloves. There were significant differences, namely: more reported enablers of glove use vs more barriers to mask use. Reasons included more positive unit culture towards glove use, and lower perception of risk via facial contamination.

Conclusion

Emerging infectious diseases, spread (among other routes) by respiratory droplets, have caused global outbreaks. Emergency clinicians should ensure that, as with gloves, the use of masks is incorporated into routine cares where appropriate. Further research which examines items of PPE independently is warranted.

Factors influencing the behaviour and perceptions of Australian veterinarians towards antibiotic use and antimicrobial resistance

Antimicrobial resistance (AMR) is a global crisis with impacts on the future health and welfare of humans and animals. Determining key factors that influence veterinarians' antimicrobial prescribing behaviours can bridge the gap between prescribing guidelines and clinical usage. Veterinarians practicing in Australia were surveyed on their frequency in prescribing different antibiotics; factors influencing their antibiotic prescribing behaviours; and their perceptions of current drivers of AMR. Antibiotics were prescribed in a third of consultations with key differences in the frequency of use of specific antibiotics by small companion animal (SCA), equine and livestock veterinarians, which broadly aligned with antibiotic registration restrictions in Australia. SCA veterinarians reported prescribing broad-spectrum antibiotics of higher importance to human health more frequently than livestock veterinarians. Factors that were reported as 'strong' or 'moderate' barriers to appropriate antibiotic prescribing were the 1) cost of culture and susceptibility testing and 2) lack of access to rapid and affordable diagnostic tests. Fear of losing clients, colleague pressure, and lack of their own understanding about antibiotics were considered to be 'no' or 'somewhat' of a barrier to appropriate prescribing by respondents. SCA veterinarians placed greater importance on the contribution of antibiotic use in livestock to AMR, than antibiotic use in companion animals. Despite reporting use of fewer, mostly narrow spectrum antibiotics of lower importance to human and animal health, livestock veterinarians were generally more aware of their potential contribution to AMR. This study provides insights into the similarities and differences in SCA, equine and livestock veterinarians practicing in Australia and informs sector-specific strategies to improve antimicrobial stewardship.

Infections in pregnancy

Infections in pregnancy represent a challenging and often underappreciated area of concern for many specialists and general practitioners and can cause serious sequelae. Antenatal status should be highlighted on pathology request forms, as this serves to alert the laboratory of the need to store serum for an extended period. Prior antenatal specimens can be forwarded to other laboratories to enable testing in parallel with the more recent sample. Women with a confirmed, potentially vertically transmissible infection should be referred to a specialist with expertise in the management of perinatal infections. Cytomegalovirus infection is the most common congenital infection. Women who care for young children are at greater risk of exposure to the virus. Preventive steps including hand hygiene and avoiding contact with children's urine, mucous and saliva are recommended for all pregnant women. The incidence of parvovirus B19 infection in pregnancy is unknown. This infection is highly contagious and may result in fetal loss; particularly in the first half of pregnancy, pregnant women should avoid contact with adults or children who may have an infection.

Communicable Disease Surveillance Ethics in the Age of Big Data and New Technology

Surveillance is essential for communicable disease prevention and control. Traditional notification of demographic and clinical information, about individuals with selected (notifiable) infectious diseases, allows appropriate public health action and is protected by public health and privacy legislation, but is slow and insensitive. Big data-based electronic surveillance, by commercial bodies and government agencies (for profit or population control), which draws on a plethora of internet- and mobile device-based sources, has been widely accepted, if not universally welcomed. Similar anonymous digital sources also contain syndromic information, which can be analysed, using customised algorithms, to rapidly predict infectious disease outbreaks, but the data are nonspecific and predictions sometimes misleading. However, public health authorities could use these online sources, in combination with de-identified personal health data, to provide more accurate and earlier warning of infectious disease events-including exotic or emerging infections-even before the cause is confirmed, and allow more timely public health intervention. Achieving optimal benefits would require access to selected data from personal electronic health and laboratory (including pathogen genomic) records and the potential to (confidentially) re-identify individuals found to be involved in outbreaks, to ensure appropriate care and infection control. Despite existing widespread digital surveillance and major potential community benefits of extending its use to communicable disease control, there is considerable public disquiet about allowing public health authorities access to personal health data. Informed public discussion, greater transparency and an ethical framework will be essential to build public trust in the use of new technology for communicable disease control.

Molecular epidemiology of methicillin-resistant Staphylococcus aureus isolates in New South Wales, Australia, 2012-2017

BACKGROUND

To better understand the molecular epidemiology of MRSA and to assess the utility of 19-target binary typing we undertook large-scale epidemiological surveillance of MRSA from invasive and non-invasive clinical specimens, and screening swabs.

METHODS

Binary typing was performed on clinical MRSA isolates collected in New South Wales (NSW), Australia between 01/01/2012 - 31/12/2017. Binary type (BT) predicted multilocus sequence type (ST) and spa types based on results from isolates which had been characterised by both methods.

RESULTS

7624 MRSA isolates were analysed of which 3581 (47%) were wounds or skin & softtissue isolates (W/SSTI), 2436 (32%) screening swabs, 469 (6%) blood cultures (BC), 780 (10%) others, and 358 (5%) unknown. We identified 731 BTs, 54 spa types, and 31 STs. ST239 was the commonest MRSA clone in 2012 (30%), but it decreased to 7% in 2017 (p <0.001). In contrast, <0.5% of MRSA were ST45 in 2012 compared to 14% in 2017 (p<0.001). An emergence of PVL-positive ST22 was also noted. Of all isolates, 28% (2122/7624) were lukS/PVL positive; the proportion, among prospectively collected isolates increased from 24% (1406/5858) to 33% (1933/5858) between 2012 and 2017 (p <0.0001). 43% (1534/3581) W/SSTI, 20% (95/469) BC and 10% (239/2436) screening swabs were PVL-positive.

CONCLUSIONS

A major change in the epidemiology of MRSA was noted with a decline of ST239, an emergence of ST45 and PVL-positive ST22, and a significant increase in PVL-positive isolates. Binary typing can be a useful routine laboratory test for prospective molecular surveillance of MRSA colonisation and infection.

Advancing Planetary Health in Australia: focus on emerging infections and antimicrobial resistance

With rising population numbers, anthropogenic changes to our environment and unprecedented global connectivity, the World Economic Forum ranks the spread of infectious diseases second only to water crises in terms of potential global impact. Addressing the diverse challenges to human health and well-being in the 21st century requires an overarching focus on ‘Planetary Health’, with input from all sectors of government, non-governmental organisations, academic institutions and industry. To clarify and advance the Planetary Health agenda within Australia, specifically in relation to emerging infectious diseases (EID) and antimicrobial resistance (AMR), national experts and key stakeholders were invited to a facilitated workshop. EID themes identified included animal reservoirs, targeted surveillance, mechanisms of emergence and the role of unrecognised human vectors (the ‘invisible man’) in the spread of infection. Themes related to AMR included antimicrobial use in production and companion animals, antimicrobial stewardship, novel treatment approaches and education of professionals, politicians and the general public. Effective infection control strategies are important in both EID and AMR. We provide an overview of key discussion points, as well as important barriers identified and solutions proposed.

Perspectives of Australian policy-makers on the potential benefits and risks of technologically enhanced communicable disease surveillance - a modified Delphi survey

Background

Event-based social media monitoring and pathogen whole genome sequencing (WGS) will enhance communicable disease surveillance research and systems. If linked electronically and scanned systematically, the information provided by these technologies could be mined to uncover new epidemiological patterns and associations much faster than traditional public health approaches. The benefits of earlier outbreak detection are significant, but implementation could be opposed in the absence of a social licence or if ethical and legal concerns are not addressed.

Methods

A three-phase mixed-method Delphi survey with Australian policy-makers, health practitioners and lawyers (n = 44) was conducted to explore areas of consensus and disagreement over (1) key policy and practical issues raised by the introduction of novel communicable disease surveillance programmes; and (2) the most significant and likely risks from using social media content and WGS technologies in epidemiological research and outbreak investigations.

Results

Panellists agreed that the integration of social media monitoring and WGS technologies into communicable disease surveillance systems raised significant issues, including impacts on personal privacy, medicolegal risks and the potential for unintended consequences. Notably, their concerns focused on how these technologies should be used, rather than how the data was collected. Panellists held that social media users should expect their posts to be monitored in the interests of public health, but using those platforms to contact identified individuals was controversial. The conditions of appropriate use of pathogen WGS in epidemiological research and investigations was also contentious. Key differences amongst participants included the necessity for consent before testing and data-linkage, thresholds for action, and the legal and ethical importance of harms to individuals and commercial entities. The erosion of public trust was seen as the most significant risk from the systematic use of these technologies.

Conclusions

Enhancing communicable disease surveillance with social-media monitoring and pathogen WGS may cause controversy. The challenge is to determine and then codify how these technologies should be used such that the balance between individual risk and community benefit is widely accepted. Participants agreed that clear guidelines for appropriate use that address legal and ethical concerns need to be developed in consultation with relevant experts and the broader Australian public.

Electronic supplementary material

The online version of this article (10.1186/s12961-019-0440-3) contains supplementary material, which is available to authorized users.

The politics and ethics of hospital infection prevention and control: a qualitative case study of senior clinicians' perceptions of professional and cultural factors that influence doctors' attitudes and practices in a large Australian hospital

BACKGROUND

Hospital infection prevention and control (IPC) programs are designed to minimise rates of preventable healthcare-associated infection (HAI) and acquisition of multidrug resistant organisms, which are among the commonest adverse effects of hospitalisation. Failures of hospital IPC in recent years have led to nosocomial and community outbreaks of emerging infections, causing preventable deaths and social disruption. Therefore, effective IPC programs are essential, but can be difficult to sustain in busy clinical environments. Healthcare workers' adherence to routine IPC practices is often suboptimal, but there is evidence that doctors, as a group, are consistently less compliant than nurses. This is significant because doctors' behaviours disproportionately influence those of other staff and their peripatetic practice provides more opportunities for pathogen transmission. A better understanding of what drives doctors' IPC practices will contribute to development of new strategies to improve IPC, overall.

METHODS

This qualitative case study involved in-depth interviews with senior clinicians and clinician-managers/directors (16 doctors and 10 nurses) from a broad range of specialties, in a large Australian tertiary hospital, to explore their perceptions of professional and cultural factors that influence doctors' IPC practices, using thematic analysis of data.

RESULTS

Professional/clinical autonomy; leadership and role modelling; uncertainty about the importance of HAIs and doctors' responsibilities for preventing them; and lack of clarity about senior consultants' obligations emerged as major themes. Participants described marked variation in practices between individual doctors, influenced by, inter alia, doctors' own assessment of patients' infection risk and their beliefs about the efficacy of IPC policies. Participants believed that most doctors recognise the significance of HAIs and choose to [mostly] observe organisational IPC policies, but a minority show apparent contempt for accepted rules, disrespect for colleagues who adhere to, or are expected to enforce, them and indifference to patients whose care is compromised.

CONCLUSIONS

Failure of healthcare and professional organisations to address doctors' poor IPC practices and unprofessional behaviour, more generally, threatens patient safety and staff morale and undermines efforts to minimise the risks of dangerous nosocomial infection.

Public preferences for One Health approaches to emerging infectious diseases: A discrete choice experiment

There is increasing scientific consensus that a One Health approach (acknowledging links between human, animal and environmental health) is the most effective way of responding to emerging infectious disease (EID) threats. However, reviews of past EID events show that successful implementation of control strategies hinge on alignment with public values. Given the limited evidence about public values in this area, we sought to understand public preferences for attributes associated with One Health strategies for EID prevention and control, using a discrete choice experiment (DCE). The DCE was conducted in 2016 using an online panel of Australian respondents aged over 18. Participants were presented with 18 pairs of scenarios describing One Health strategies and outcomes, and asked to select their preferred one. Scenarios were described by nine attributes with varying levels: personal autonomy, economic development, environmental health, community cohesion, free trade and travel, zoonotic risk, mortality, animal welfare and food security. Respondents were broadly representative of the Australian population (n = 1999, mean age 45.3 years (range 18-89); 50.7% male). The public preferred scenarios in which individual freedoms are not restricted for the greater good; unemployment is low; the environment is healthy; there is good community cohesion; travel, imports and exports are tightly controlled; there is lower mortality and incidence of disease; and where animal welfare and food security are protected. Although lower morbidity and mortality were preferable, respondents were willing to accept extra cases of severe disease and deaths to avoid reductions in some attributes. However, a mixed logit model indicated significant heterogeneity. A latent class analysis suggested wide variability across respondent classes in the valuation of attributes, and the trade-offs respondents were willing to accept. Therefore, a single approach to managing EID using One Health is unlikely to be acceptable to all community members.

Managing the risk of Hendra virus spillover in Australia using ecological approaches: A report on three community juries

BACKGROUND

Hendra virus (HeV) infection is endemic in Australian flying-fox populations. Habitat loss has increased the peri-urban presence of flying-foxes, increasing the risk of contact and therefore viral 'spillovers' into horse and human populations. An equine vaccine is available and horse-husbandry practices that minimize HeV exposure are encouraged, but their adoption is suboptimal. Ecological approaches-such as habitat creation and conservation-could complement vaccination and behavioural strategies by reducing spillover risks, but these are controversial.

METHODS

We convened three community juries (two regional; one metropolitan) to elicit the views of well-informed citizens on the acceptability of adding ecological approaches to current interventions for HeV risk. Thirty-one participants of diverse backgrounds, mixed genders and ages were recruited using random-digit-dialling. Each jury was presented with balanced factual evidence, given time to ask questions of expert presenters and, after deliberation, come to well-reasoned conclusions.

RESULTS

All juries voted unanimously that ecological strategies should be included in HeV risk management strategies but concluded that current interventions-including vaccination and changing horse-husbandry practices-must remain the priority. The key reasons given for adopting ecological approaches were: (i) they address underlying drivers of disease emergence, (ii) the potential to prevent spillover of other bat-borne pathogens, and (iii) there would be broader community benefits. Juries differed regarding the best mechanism to create/conserve flying-fox habitat: participants in regional centres favoured direct government action, whereas the metropolitan jury preferred to place the burden on landholders.

CONCLUSIONS

Informed citizens acknowledge the value of addressing the drivers of bat-borne infectious risks but differ substantially as to the best implementation strategies. Ecological approaches to securing bat habitat could find broad social support in Australia, but disagreement about how best to achieve them indicates the need for negotiation with affected communities to co-develop fair, effective and locally appropriate policies.

To follow a rule? On frontline clinicians' understandings and embodiments of hospital-acquired infection prevention and control rules

This article reports on a study of clinicians' responses to footage of their enactments of infection prevention and control. The study's approach was to elicit clinicians' reflections on and clarifications about the connections among infection control activities and infection control rules, taking into account their awareness, interpretation and in situ application of those rules. The findings of the study are that clinicians responded to footage of their own infection prevention and control practices by articulating previously unheeded tensions and constraints including infection control rules that were incomplete, undergoing change, and conflicting; material obstructions limiting infection control efforts; and habituated and divergent rule enactments and rule interpretations that were problematic but disregarded. The reflexive process is shown to elicit clinicians' learning about these complexities as they affect the accomplishment of effective infection control. The process is further shown to strengthen clinicians' appreciation of infection control as necessitating deliberation to decide what are locally appropriate standards, interpretations, assumptions, habituations and enactments of infection control. The article concludes that clinicians' 'practical wisdom' is unlikely to reach its full potential without video-assisted scrutiny of and deliberation about in situ clinical work. This enables clinicians to anchor their in situ enactments, reasonings and interpretations to local agreements about the intent, applicability, limits and practical enactment of rules.

Perinatal microbial exposure may influence aortic intima-media thickness in early infancy

Background

The maternal and infant microbiome may influence infant cardiovascular risk through immune programming. The maternal vagino-enteric microbiome is often sampled for group B streptococcus (GBS) colonization during pregnancy. Our aim was to investigate the association between maternal GBS colonization, intrapartum antibiotics, antenatal pet exposure and infant aortic intima-media thickness (aIMT), an intermediate vascular phenotype, and whether this association varied by mode of delivery.

Methods

The Barwon Infant Study is a population-derived pre-birth cohort. Perinatal data were collected on participants. Women were tested for vagino-enteric group B streptococcus (GBS) colonization during third trimester. Six-week infant aIMT was measured by trans-abdominal ultrasound. Adjustment for confounders included maternal age, pre-pregnancy body mass index (BMI), smoking, socioeconomic status, gestational diabetes, length of gestation, infant sex, birthweight and aortic internal diameter.

Results

Data were available on 835 mother-infant pairs. Of these, 574 (69%) women delivered vaginally; of those, 129 (22%) were GBS-colonized; and of these women, 111 (86%) received prophylactic intrapartum antibiotics. An association between maternal GBS colonization and infant aIMT was observed among those delivered vaginally (β = 19.5 µm, 95% CI 9.5, 29.4; P  < 0.0001) but not by Caesarean section ( P for interaction = 0.02). A similar pattern was seen for intrapartum antibiotics. There was a negative association between antenatal pet exposure and aIMT observed in those delivered vaginally.

Conclusion

Maternal GBS colonization and intrapartum antibiotics were associated with increased infant aIMT in those delivered vaginally, whereas antenatal pet exposure was associated with decreased aIMT. These data suggest that differences in early life microbial experience may contribute to an increased cardiovascular risk.

Opportunities and challenges to improving antibiotic prescribing practices through a One Health approach: results of a comparative survey of doctors, dentists and veterinarians in Australia

OBJECTIVES

To explore and compare the knowledge, attitudes and experiences of doctors, dentists and veterinarians (as prescribers) in relation to antibiotic use and antibiotic resistance (AbR), and to consider the implications of these for policy-making that support a One Health approach.

DESIGN

A cross-sectional survey conducted online.

SETTING

Doctors, dentists and veterinarians practising in primary, secondary or tertiary care in Australia.

PARTICIPANTS

547 doctors, 380 dentists and 403 veterinarians completed the survey.

MAIN OUTCOME MEASURES

Prescribers' knowledge, attitudes and perceptions of AbR, the extent to which a range of factors are perceived as barriers to appropriate prescribing practices, and perceived helpfulness of potential strategies to improve antibiotic prescribing in practice.

RESULTS

There was substantial agreement across prescriber groups that action on AbR is required by multiple sectors and stakeholders. However, prescribers externalised responsibility to some extent by seeing the roles of others as more important than their own in relation to AbR. There were common and context-specific barriers to optimal prescribing across the prescriber groups. Prescriber groups generally perceived restrictive policies as unhelpful to supporting appropriate prescribing in their practice.

CONCLUSIONS

The results have implications for implementing a One Health approach that involves doctors, dentists and veterinarians as key players to tackling the crisis of AbR. The findings are that (1) prescribers understand and are likely receptive to a One Health policy approach to AbR, (2) policy development should be sensitive to barriers that are specific to individual prescriber groups and (3) the development and introduction of interventions that might be perceived as reducing prescriber autonomy will need to be carefully designed and implemented.

Assessing the public acceptability of proposed policy interventions to reduce the misuse of antibiotics in Australia: A report on two community juries

Objective

To elicit the views of well‐informed community members on the acceptability of proposed policy interventions designed to improve community use of antibiotics in Australia.

Design

Two community juries held in 2016.

Setting and participants

Western Sydney and Dubbo communities in NSW, Australia. Twenty‐nine participants of diverse social and cultural backgrounds, mixed genders and ages recruited via public advertising: one jury was drawn from a large metropolitan setting; the other from a regional/rural setting.

Main outcome measure

Jury verdict and rationale in response to a prioritization task and structured questions.

Results

Both juries concluded that potential policy interventions to curb antibiotic misuse in the community should be directed towards: (i) ensuring that the public and prescribers were better educated about the dangers of antibiotic resistance; (ii) making community‐based human and animal health‐care practitioners accountable for their prescribing decisions. Patient‐centred approaches such as delayed prescribing were seen as less acceptable than prescriber‐centred approaches; both juries completely rejected any proposal to decrease consumer demand by increasing antibiotic prices.

Conclusion

These informed citizens acknowledged the importance of raising public awareness of the risks, impacts and costs of antibiotic resistance and placed a high priority on increasing social and professional accountability through restrictive measures. Their overarching aim was that policy interventions should be directed towards creating collective actions and broad social support for changing antibiotic use through establishing and explaining the need for mechanisms to control and support better prescribing by practitioners, while not transferring the burdens, costs and risks of interventions to consumers.

Australia's response to Ebola Virus disease in West Africa, 2014-15

In March 2016, the World Health Organization declared the 2014-15 Ebola virus disease (EVD) outbreak officially over. With around 29 000 cases and 11 000 deaths in 27 months, this EVD outbreak was more than 60 times larger than any before, and unique in its cross-border spread and involvement of urban centres. Local and international responses were slow and initially inadequate, but establishment of the United Nations Mission for Ebola Emergency Response, 9 months after the outbreak began, allowed a coordinated effort that slowed and eventually controlled the spread of disease. Internationally, there were fears that EVD would spread widely beyond Africa, despite reassurances from public health authorities. However, after nurses in the US became infected, public fear and concern for the safety of healthcare workers led to political intervention and varied, sometimes excessive, border controls, quarantine arrangements and hospital preparations. Altogether, fewer than 30 EVD cases were managed in countries outside Africa, all but three of which were acquired in West Africa. In Australia, the Australian Health Protection Principal Committee led the internal response, including enhanced screening of incoming passengers at international airports and development of public health and laboratory testing protocols by expert subcommittees. States and territories nominated designated hospitals to care for EVD patients. Development of EVD infection prevention and control (IPC) guidelines was initially poorly coordinated within and between jurisdictions, often with significant discrepancies, causing confusion and fear among healthcare workers. The Infection Prevention and Control Expert Advisory Group was established to develop national IPC guidelines. There were no confirmed cases in Australia, but investigation of several people with suspected EVD provided valuable experience in use of protocols and high-level containment facilities. The Australian Government was initially reluctant to send aid workers to West Africa, but later contracted a private company to staff and manage a treatment centre in Sierra Leone, which treated 91 patients with EVD during 4 months of operation. Among the lessons learnt for Australia was the need to increase awareness of routine IPC practices in hospitals, where significant deficiencies were exposed, and to maintain a high enough level of preparedness to protect healthcare workers and the public from the next, inevitable, infectious disease emergency.