An exploration of the political, social, economic and cultural factors affecting how different global regions initially reacted to the COVID-19 pandemic

Responses to the early (February–July 2020) COVID-19 pandemic varied widely, globally. Reasons for this are multiple but likely relate to the healthcare and financial resources then available, and the degree of trust in, and economic support provided by, national governments. Cultural factors also affected how different populations reacted to the various pandemic restrictions, like masking, social distancing and self-isolation or self-quarantine. The degree of compliance with these measures depended on how much individuals valued their needs and liberties over those of their society. Thus, several themes may be relevant when comparing pandemic responses across different regions. East and Southeast Asian populations tended to be more collectivist and self-sacrificing, responding quickly to early signs of the pandemic and readily complied with most restrictions to control its spread. Australasian, Eastern European, Scandinavian, some Middle Eastern, African and South American countries also responded promptly by imposing restrictions of varying severity, due to concerns for their wider society, including for some, the fragility of their healthcare systems. Western European and North American countries, with well-resourced healthcare systems, initially reacted more slowly, partly in an effort to maintain their economies but also to delay imposing pandemic restrictions that limited the personal freedoms of their citizens.

Future Pandemic Influenza Virus Detection Relies on the Existing Influenza Surveillance Systems: A Perspective from Australia and New Zealand

The anniversary of the 1918–1919 influenza pandemic has allowed a refocusing on the global burden of influenza and the importance of co-ordinated international surveillance for both seasonal influenza and the identification of control strategies for future pandemics. Since the introduction of the International Health Regulations (IHR), progress had been slow, until the emergence of the novel influenza A(H1N1)2009 virus and its global spread, which has led to the World Health Organization (WHO) developing a series of guidance documents on global influenza surveillance procedures, severity and risk assessments, and essential measurements for the determination of national pandemic responses. However, the greatest burden of disease from influenza occurs between pandemics during seasonal influenza outbreaks and epidemics. Both Australia and New Zealand utilise seasonal influenza surveillance to support national influenza awareness programs focused on seasonal influenza vaccination education and promotion. These programs also serve to promote the importance of pandemic preparedness.

Multiplex-PCR for the detection of viruses in the CSF of infants and young children

We aimed to establish the utility of the Fast-track diagnostics Viral meningitis multiplex PCR kit for the diagnosis of central nervous system infection in infants. The multiplex assay had reduced sensitivity for the detection of enterovirus, the predominant pathogen in young infants, when compared to our in-house singleplex PCR. In our infant population, multiple singleplex PCR assays perform better than a multiplex assay for the detection of CSF viruses. J. Med. Virol. 89:559-561, 2017. © 2016 Wiley Periodicals, Inc.

Effectiveness of border screening for detecting influenza in arriving airline travelers

OBJECTIVES

We measured symptom and influenza prevalence, and the effectiveness of symptom and temperature screening for identifying influenza, in arriving international airline travelers.

METHODS

This cross-sectional study collected data from travelers to Christchurch International Airport, New Zealand, in winter 2008, via a health questionnaire, temperature testing, and respiratory sampling.

RESULTS

Forms were returned by 15 976 (68%) travelers. Of these, 17% reported at least 1 influenza symptom, with runny or blocked nose (10%) and cough (8%) most common. Respiratory specimens were obtained from 3769 travelers. Estimated prevalence of influenza was 1.1% (4% among symptomatic, 0.2% among asymptomatic). The sensitivity of screening criteria ranged from 84% for "any symptom" to 3% for a fever of 37.8 °C or greater. The positive predictive value was low for all criteria.

CONCLUSIONS

Border screening using self-reported symptoms and temperature testing has limitations for preventing pandemic influenza from entering a country. Using "any symptom" or cough would lead to many uninfected people being investigated, yet some infected people would remain undetected. If more specific criteria such as fever were used, most infected people would enter the country despite screening.

Eficacia de la detección sistemática de la gripe en las fronteras en los viajeros que llegan por vía aérea

Objetivos. Se midieron los síntomas y la prevalencia de la gripe (también llamada influenza), así como la eficacia del mecanismo de detección sistemática basado en los síntomas y la temperatura para diagnosticar la gripe en viajeros internacionales que llegaban por vía aérea.

Métodos. El presente estudio transversal recopiló datos de viajeros que llegaron al aeropuerto internacional de Christchurch (Nueva Zelandia) en el invierno del 2008 mediante un cuestionario de salud, medición de la temperatura y toma de muestras de las vías respiratorias.

Resultados. De los viajeros, 15 976 (68%) entregaron los formularios completos. De ellos, 17% notificaron al menos un síntoma de gripe; los síntomas más comunes fueron rinorrea o congestión nasal (10%) y tos (8%). Se tomaron muestras de las vías respiratorias de 3 769 viajeros. La prevalencia estimada de la gripe fue de 1,1% (4% en las personas sintomáticas, 0,2% en las asintomáticas). La sensibilidad de los criterios de detección varió de 84% para “cualquier síntoma” a 3% para la fiebre de 37,8 °C o mayor. El valor predictivo positivo fue bajo para todos los criterios.

Conclusiones. El método de detección sistemática en las fronteras mediante la autonotificación de síntomas y la toma de la temperatura presenta limitaciones para impedir que una gripe pandémica entre en un país. Basarse en criterios como “cualquier síntoma” o la tos haría que se investigara a varias personas no infectadas, mientras que algunas personas infectadas pasarían inadvertidas. Si se usaran criterios más específicos como la fiebre, la mayoría de las personas infectadas entrarían en el país a pesar del mecanismo de detección.

Respiratory viruses in airline travellers with influenza symptoms: Results of an airport screening study

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A symptom screening tool was used at the border to predict which travellers were more likely to have respiratory virus infections.

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The most frequently identified viruses were rhinoviruses, enteroviruses and influenza B.

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The positive predictive value (PPV) of any symptom for any respiratory virus infection was low at 26%.

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There was a substantial overlap in the symptom profiles between the respiratory viruses found in the study participants.

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It is unlikely that clinical symptoms alone can be used to predict infections with specific respiratory viruses.

Background

There is very little known about the prevalence and distribution of respiratory viruses, other than influenza, in international air travellers and whether symptom screening would aid in the prediction of which travellers are more likely to be infected with specific respiratory viruses.

Objectives

In this study, we investigate whether, the use of a respiratory symptom screening tool at the border would aid in predicting which travellers are more likely to be infected with specific respiratory viruses.

Study design

Data were collected from travellers arriving at Christchurch International Airport, New Zealand, during the winter 2008, via a symptom questionnaire, temperature testing, and respiratory sampling.

Results

Respiratory viruses were detected in 342 (26.0%) of 1313 samples obtained from 2714 symptomatic travellers. The most frequently identified viruses were rhinoviruses (128), enteroviruses (77) and influenza B (48). The most frequently reported symptoms were stuffy or runny nose (60%), cough (47%), sore throat (27%) and sneezing (24%). Influenza B infections were associated with the highest number of symptoms (mean of 3.4) followed by rhinoviruses (mean of 2.2) and enteroviruses (mean of 1.9). The positive predictive value (PPV) of any symptom for any respiratory virus infection was low at 26%.

Conclusions

The high prevalence of respiratory virus infections caused by viruses other than influenza in this study, many with overlapping symptotology to influenza, has important implications for any screening strategies for the prediction of influenza in airline travellers.

The contrasting phylodynamics of human influenza B viruses

A complex interplay of viral, host, and ecological factors shapes the spatio-temporal incidence and evolution of human influenza viruses. Although considerable attention has been paid to influenza A viruses, a lack of equivalent data means that an integrated evolutionary and epidemiological framework has until now not been available for influenza B viruses, despite their significant disease burden. Through the analysis of over 900 full genomes from an epidemiological collection of more than 26,000 strains from Australia and New Zealand, we reveal fundamental differences in the phylodynamics of the two co-circulating lineages of influenza B virus (Victoria and Yamagata), showing that their individual dynamics are determined by a complex relationship between virus transmission, age of infection, and receptor binding preference. In sum, this work identifies new factors that are important determinants of influenza B evolution and epidemiology.

Effect of monthly vitamin D3 supplementation in healthy adults on adverse effects of earthquakes: randomised controlled trial

OBJECTIVE

To determine whether supplementation with vitamin D improves resilience to the adverse effects of earthquakes.

DESIGN

Opportunistic addition to an established randomised double blind placebo controlled trial.

SETTING

Christchurch, New Zealand, where a prolonged series of catastrophic earthquakes beginning on 4 September 2010 occurred, which caused widespread destruction, fatalities, and extensive psychological damage.

PARTICIPANTS

322 healthy adults (241 women; 81 men) aged 18-67 who were already participating in the vitamin D and acute respiratory infections study (VIDARIS) between February 2010 and November 2011.

INTERVENTION

Participants were randomised to receive an oral dose of either 200,000 IU vitamin D3 monthly for two months then 100,000 IU monthly (n=161) or placebo (n=161) for a total of 18 months.

MAIN OUTCOME MEASURE

This is a post hoc analysis from the previously published VIDARIS trial. The primary endpoint in the current analysis was the self reported effects and overall adverse impact of the Christchurch earthquakes as assessed by questionnaire four months after the most destructive earthquake on 22 February 2011, which was used as the index event. The secondary end point was the number of "psychological" adverse events that participants reported at their usual monthly appointments as part of the original VIDARIS trial.

RESULTS

308 participants completed the earthquake impact questionnaire (n=152 in the vitamin D group and 156 in the placebo group). There was no significant difference in the number of self reported adverse effects between those receiving vitamin D supplementation and those receiving placebo. There was also no difference in the overall adverse impact score between treatment groups (χ(2) P=0.44). The exception was that those in the vitamin D group experienced more adverse effects on family relationships (22% v 13%; χ(2) P=0.03). The number of psychological adverse events-such as fatigue, stress, anxiety, and insomnia-that participants reported at their usual monthly appointments was significantly higher after the earthquake (χ(2) P=0.007) but did not differ between treatment groups.

CONCLUSION

In this trial, vitamin D supplementation did not reduce the adverse impact of earthquakes in healthy adults. Trial registration Australian New Zealand Clinical Trials Registry (anzctr.org.au) ACTRN12609000486224.

Long-Term High-Dose Vitamin D 3 Supplementation and Blood Pressure in Healthy Adults

Previous randomized controlled trials of vitamin D supplementation and blood pressure (BP) mainly have given vitamin D for short periods (<6 months) or at low doses (400 IU per day). This study aims to determine whether long-term high-dose vitamin D taken for 18 months lowers BP. Adults were recruited from a healthcare organization or university into a double-blind controlled trial and randomized to receive either vitamin D 3 200 000 IU for 2 months followed by 100 000 IU monthly up to 18 months (n=161) or placebo (n=161). BP was measured at baseline, 5, and 18 months. Subjects had a mean (SD) age of 47.6 (9.7) years, 75% were women, and 94% were of European ancestry (white). Mean (SD) 25-hydroxyvitamin D 3 changed from 73 (22) nmol/L at baseline to 124 (28) nmol/L at 18 months in the vitamin D group, and from 71 (22) nmol/L to 56 (22) nmol/L in the placebo group. Mean BP was similar for the vitamin D and placebo groups at baseline (123.4/76.3 versus 122.6/75.6 mm Hg; respectively). The mean change (95% confidence interval) in BP at 18 months minus baseline in the vitamin D group compared with placebo group was −0.6 (−2.8 to 1.6) mm Hg for systolic ( P =0.61) and 0.5 (−1.1, 2.2) mm Hg for diastolic ( P =0.53). Long-term vitamin D supplementation, which increased mean 25-hydroxyvitamin D 3 concentration >100 nmol/L for 18 months, had no effect on systolic or diastolic BP in predominantly white, healthy adults without severe vitamin D deficiency. Beneficial effects on BP cannot be ruled out for other populations.

Lack of effect of seasonal trivalent influenza vaccine against influenza A(H3N2) infections in hospitalised patients in winter 2012

AIM

This study sought to assess the effectiveness of the 2012 trivalent inactivated influenza vaccine in preventing admission with confirmed influenza A(H3N2) infection and whether vaccination status influenced the duration or outcome.

METHODS

We used the CDHB Delphic Laboratory Information System to identify 100 consecutive patients with confirmed influenza A(H3N2) infection. The patients were contacted via telephone and asked whether they had received the seasonal influenza vaccine prior to their hospital admission. We collected information such as age, gender, documented co-morbidities, smoking status, ICU admission, length of stay, and final outcome of admission and compared these between the vaccinated and non-vaccinated groups.

RESULTS

A total of 92 participants could be contacted and participated; 67 these reported having been vaccinated with the 2012 seasonal influenza vaccine prior to their admission. There were no significant differences in length of stay or final outcome in vaccinated and non-vaccinated patients.

CONCLUSION

This audit shows that the 2012 seasonal influenza vaccine did not provide significant protection against the H3N2 influenza strain in Canterbury. Vaccination did not alter the clinical course or final outcome in patients infected with H3N2 influenza.

Influenza vaccines: an Asia-Pacific perspective

This article provides an overview of some aspects of seasonal, pre-pandemic and pandemic influenza vaccines and initiatives aimed to increase influenza vaccine use within the Asia-Pacific region. Expanding the use of influenza vaccines in the Asia-Pacific region faces many challenges. Despite the recent regional history for the emergence of novel viruses, SARS, the H5N1 and H7N9, and the generation of and global seeding of seasonal influenza viruses and initiatives by WHO and other organisations to expand influenza awareness, the use of seasonal influenza vaccines remains low. The improvement in current vaccine technologies with the licensing of quadrivalent, live-attenuated, cell culture-based, adjuvanted and the first recombinant influenza vaccine is an important step. The development of novel influenza vaccines able to provide improved protection and with improved manufacturing capacity is also advancing rapidly. However, of ongoing concern are seasonal influenza impact and the low use of seasonal influenza vaccines in the Asia-Pacific region. Improved influenza control strategies and their implementation in the region are needed. Initiatives by the World Health Organization (WHO), and specifically the Western Pacific Regional Office of WHO, are focusing on consistent vaccine policies and guidelines in countries in the region. The Asian-Pacific Alliance for the Control of Influenza (APACI) is contributing through the coordination of influenza advocacy initiates.

[Effectiveness of border screening for detecting Influenza in arriving airline travelers]

OBJECTIVES

We measured symptom and influenza prevalence, and the effectiveness of symptom and temperature screening for identifying influenza, in arriving international airline travelers.

METHODS

This cross-sectional study collected data from travelers to Christchurch International Airport, New Zealand, in winter 2008, via a health questionnaire, temperature testing, and respiratory sampling.

RESULTS

Forms were returned by 15 976 (68%) travelers. Of these, 17% reported at least 1 influenza symptom, with runny or blocked nose (10%) and cough (8%) most common. Respiratory specimens were obtained from 3769 travelers. Estimated prevalence of influenza was 1.1% (4% among symptomatic, 0.2% among asymptomatic). The sensitivity of screening criteria ranged from 84% for "any symptom" to 3% for a fever of 37.8 ºC or greater. The positive predictive value was low for all criteria.

CONCLUSIONS

Border screening using self-reported symptoms and temperature testing has limitations for preventing pandemic influenza from entering a country. Using "any symptom" or cough would lead to many uninfected people being investigated, yet some infected people would remain undetected. If more specific criteria such as fever were used, most infected people would enter the country despite screening.

Report of the first Asia-Pacific influenza summit, Asia-Pacific Alliance for the Control of Influenza (APACI), Bangkok, 12-13 June 2012

On June 12-13, 2012, the Asia-Pacific Alliance for the Control of Influenza (APACI) convened jointly with the Influenza Foundation of Thailand and the Thailand Department of Disease Control, the First Asia-Pacific Influenza Summit. The objectives of the meeting were to review the current state of official influenza control policies in Asia-Pacific countries; identify, summarize and communicate influenza control strategies that have successfully increased vaccine uptake in the region; develop policy and advocacy approaches to improve influenza vaccine uptake in high-risk groups and healthcare workers in the region; and establish collaborative relationships to promote best practices for the control of influenza. In moving forward, the challenge for the region will be establishing collaborations able to effectively communicate risk and key messages about influenza vaccination.

Effect of vitamin D3 supplementation on Staphylococcus aureus nasal carriage: a randomized, double-blind, placebo-controlled trial in healthy adults

Observational studies have reported an inverse association between serum 25-hydroxyvitamin D (25OHD) concentrations and Staphylococcus aureus nasal carriage; however, clinical trials of vitamin D supplementation are lacking. To assess the effect of vitamin D3 supplementation on persistent S. aureus nasal carriage we conducted a randomized, double-blind, placebo-controlled trial among 322 healthy adults. Participants were given an oral dose of either 200 000 IU vitamin D3 for each of 2 months, followed by 100 000 IU monthly or placebo in an identical dosing regimen, for a total of 18 months. Nasal swabs for S. aureus culture and serum for 25OHD measurement were obtained at baseline, 6, 12 and 18 months of study. The mean baseline concentration of 25OHD was 72 nM (SD 22 nM). Vitamin D3 supplementation increased 25OHD levels which were maintained at >120 nM throughout the study. Nasal colonization by S. aureus was found in 31% of participants at baseline. Persistent carriage, defined as those that had positive S. aureus nasal cultures for all post-baseline swabs, occurred in 20% of the participants but vitamin D3 supplementation was not associated with a reduction in persistent carriage (OR = 1.39, 95% CI 0.63-3.06). Risk factor analysis showed that only gender was significantly associated with carriage, where women were less likely to be carriers than men (relative risk 0.83, 95% CI 0.54-0.99). Serum 25OHD concentrations were not associated with the risk of carriage. In conclusion, monthly administration of 100 000 IU of vitamin D3 did not reduce persistent S. aureus nasal carriage.

Report of the first Asia-Pacific Forum on antiviral treatment of influenza, Asia-Pacific Alliance for the Control of Influenza, Bangkok, 14 June 2012

On 14 June 2012, the Asia–Pacific Alliance for the Control of Influenza (APACI) convened the first Antiviral Forum jointly with the Influenza Foundation of Thailand and the Thailand Department of Disease Control. The goals of the meeting were to improve pandemic planning in the region from lessons learned during the 2009 pandemic, particularly with regard to the safety and efficacy of antiviral use; gain a better understanding of the therapeutic use of antivirals in seasonal influenza; review and analyse the official influenza control policies of Asia–Pacific countries and evidence gaps to support policy development; and to establish collaborative relationships to promote best practices in the use of antivirals for the treatment of influenza. The urgent need for education highlighting the importance of influenza and the benefits of antiviral drug use in the Asia–Pacific region was identified.

Biomarkers of cardiac dysfunction and mortality from community-acquired pneumonia in adults

Background

Cardiac dysfunction is common in acute respiratory diseases and may influence prognosis. We hypothesised that blood levels of N-terminal B-type natriuretic peptide (NT-proBNP) and high-sensitivity Troponin T would predict mortality in adults with community-acquired pneumonia.

Methods and Findings

A prospective cohort of 474 consecutive patients admitted with community-acquired pneumonia to two New Zealand hospitals over one year. Blood taken on admission was available for 453 patients and was analysed for NT-proBNP and Troponin T. Elevated levels of NT-proBNP (>220 pmol/L) were present in 148 (33%) and 86 (19%) of these patients respectively. Among the 26 patients who died within 30 days of admission, 23 (89%) had a raised NT-proBNP and 14 (53%) had a raised Troponin T level on admission compared to 125 (29%) and 72 (17%) of the 427 who survived (p values<0.001). Both NT-proBNP and Troponin T predicted 30-day mortality in age-adjusted analysis but after mutual adjustment for the other cardiac biomarker and the Pneumonia Severity Index, a raised N-terminal pro-brain natriuretic peptide remained a predictor of 30-day mortality (OR = 5.3, 95% CI 1.4–19.8, p = 0.013) but Troponin T did not (OR = 1.3, 95% CI 0.5–3.2, p = 0.630). The areas under the receiver-operating curves to predict 30-day mortality were similar for NT-proBNP (0.88) and the Pneumonia Severity Index (0.87).

Conclusions

Elevated N-terminal B-type natriuretic peptide is a strong predictor of mortality from community-acquired pneumonia independent of clinical prognostic indicators. The pathophysiological basis for this is unknown but suggests that cardiac involvement may be an under-recognised determinant of outcome in pneumonia and may require a different approach to treatment. In the meantime, measurement of B-type natriuretic peptides may help to assess prognosis.

Systematic application of multiplex PCR enhances the detection of bacteria, parasites, and viruses in stool samples

OBJECTIVES

To determine whether systematic testing of faecal samples with a broad range multiplex PCR increases the diagnostic yield in patients with diarrhoea compared with conventional methods and a clinician initiated testing strategy.

METHODS

1758 faecal samples from 1516 patients with diarrhoea submitted to two diagnostic laboratories were tested for viral, bacterial, and parasitic pathogens by Fast-Track Diagnostics multiplex real-time PCR kits and conventional diagnostic tests.

RESULTS

Multiplex PCR detected pathogens in 530 samples (30%): adenovirus (51, 3%), astrovirus (95, 5%), norovirus (172, 10%), rotavirus (3, 0.2%), Campylobacter jejuni/coli (85, 5%), Salmonella spp. (22, 1%), Clostridium difficile (72, 4%), entero-haemorrhagic Escherichia coli (21, 1%), Cryptosporidium spp. (3, 0.2%), Entamoeba histolytica (1, 0.1%), and Giardia lamblia (59, 3%). In contrast, conventional testing detected a pathogen in 324 (18%) samples.

CONCLUSIONS

Using a systematic approach to the diagnosis of gastroenteritis improved diagnostic yield. This enhanced detection with PCR was achieved by a combination of improved detection of individual pathogens and detection of pathogens not requested or unable to be tested by conventional tests. This approach also allowed earlier identification for most pathogens and created a workflow which is likely to adapt well for many diagnostic laboratories.

Comparison of four multiplex PCR assays for the detection of viral pathogens in respiratory specimens

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This study will compare 4 different multiplex PCR assays.

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The xTAG RVP, Fast-track RP, Easyplex and an in-house rt-PCR assay were included.

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The performance of the assays was similar, with 93–100% agreement for comparisons.

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Non-performance aspects are key to deciding which of these assays to use.

Multiplex PCR has become the test of choice for the detection of multiple respiratory viruses in clinical specimens. However, there are few direct comparisons of different PCR assays. This study compares 4 different multiplex PCR assays for the recovery of common respiratory viruses. We tested 213 respiratory specimens using four different multiplex PCR assays: the xTAG respiratory viral panel fast (Abbott Molecular Laboratories), Fast-track Respiratory Pathogen assay (Fast-track Diagnostics), Easyplex respiratory pathogen 12 kit (Ausdiagnostics), and an in-house multiplex real-time PCR assay. The performance of the four assays was very similar, with 93–100% agreement for all comparisons. Other issues, such as through-put, technical requirements and cost, are likely to be as important for making a decision about which of these assays to use given their comparative performance.

Effectiveness of border screening for detecting influenza in arriving airline travelers

OBJECTIVES

We measured symptom and influenza prevalence, and the effectiveness of symptom and temperature screening for identifying influenza, in arriving international airline travelers.

METHODS

This cross-sectional study collected data from travelers to Christchurch International Airport, New Zealand, in winter 2008, via a health questionnaire, temperature testing, and respiratory sampling.

RESULTS

Forms were returned by 15 976 (68%) travelers. Of these, 17% reported at least 1 influenza symptom, with runny or blocked nose (10%) and cough (8%) most common. Respiratory specimens were obtained from 3769 travelers. Estimated prevalence of influenza was 1.1% (4% among symptomatic, 0.2% among asymptomatic). The sensitivity of screening criteria ranged from 84% for "any symptom" to 3% for a fever of 37.8 °C or greater. The positive predictive value was low for all criteria.

CONCLUSIONS

Border screening using self-reported symptoms and temperature testing has limitations for preventing pandemic influenza from entering a country. Using "any symptom" or cough would lead to many uninfected people being investigated, yet some infected people would remain undetected. If more specific criteria such as fever were used, most infected people would enter the country despite screening.

Effect of vitamin D3 supplementation on upper respiratory tract infections in healthy adults: the VIDARIS randomized controlled trial

CONTEXT

Observational studies have reported an inverse association between serum 25-hydroxyvitamin D (25-OHD) levels and incidence of upper respiratory tract infections (URTIs). However, results of clinical trials of vitamin D supplementation have been inconclusive.

OBJECTIVE

To determine the effect of vitamin D supplementation on incidence and severity of URTIs in healthy adults.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, double-blind, placebo-controlled trial conducted among 322 healthy adults between February 2010 and November 2011 in Christchurch, New Zealand.

INTERVENTION

Participants were randomly assigned to receive an initial dose of 200,000 IU oral vitamin D3, then 200,000 IU 1 month later, then 100,000 IU monthly (n = 161), or placebo administered in an identical dosing regimen (n = 161), for a total of 18 months.

MAIN OUTCOME MEASURES

The primary end point was number of URTI episodes. Secondary end points were duration of URTI episodes, severity of URTI episodes, and number of days of missed work due to URTI episodes.

RESULTS

The mean baseline 25-OHD level of participants was 29 (SD, 9) ng/mL. Vitamin D supplementation resulted in an increase in serum 25-OHD levels that was maintained at greater than 48 ng/mL throughout the study. There were 593 URTI episodes in the vitamin D group and 611 in the placebo group, with no statistically significant differences in the number of URTIs per participant (mean, 3.7 per person in the vitamin D group and 3.8 per person in the placebo group; risk ratio, 0.97; 95% CI, 0.85-1.11), number of days of missed work as a result of URTIs (mean, 0.76 days in each group; risk ratio, 1.03; 95% CI, 0.81-1.30), duration of symptoms per episode (mean, 12 days in each group; risk ratio, 0.96; 95% CI, 0.73-1.25), or severity of URTI episodes. These findings remained unchanged when the analysis was repeated by season and by baseline 25-OHD levels.

CONCLUSION

In this trial, monthly administration of 100,000 IU of vitamin D did not reduce the incidence or severity of URTIs in healthy adults.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12609000486224.

Five years of non-prescription oseltamivir: effects on resistance, immunization and stockpiling

Objectives

In 2007 New Zealand (NZ) became the first country to make oseltamivir (Tamiflu®) available off-prescription. This study investigated the extent of pharmacist supply of oseltamivir over 5 years, including during the influenza A(H1N1) pandemic, and the impact of pharmacist supply of oseltamivir on influenza virus oseltamivir susceptibility, personal stockpiling and influenza vaccine uptake.

Methods

Randomly selected community pharmacies in NZ reported oseltamivir provision by prescription and through pharmacist supply from 1 January 2007 to 15 September 2011. Oseltamivir resistance data on influenza viruses isolated during influenza surveillance from 2008 to 2011 were obtained, along with influenza vaccine uptake data from 2005 to 2011 and influenza detection data.

Results

Seventy of 85 eligible pharmacies completed the study (82% response rate). Most supplies of oseltamivir throughout the 5 years were dispensed against a prescription rather than pharmacist supplied, with pharmacist supply responsible for 11% of supplies during the pandemic years (2009–10) versus 27% and 31% during 2007 and 2008, respectively. Pharmacist-supplied oseltamivir did not appear to be associated with the development of resistance, with identified likely stockpiling or with a decline in influenza immunization. Pharmacist supplies largely matched the timing of influenza in the community and peaked in June 2009, as did prescription supplies.

Conclusions

Five years of non-prescription oseltamivir in NZ has resulted in no significant change in the development of resistance or rates of influenza immunization. Supplies remained modest and significant consumer stockpiling through pharmacist supply has not occurred, even during the influenza A(H1N1)pdm09 pandemic in 2009 and 2010. Pharmacists could be better utilized in ensuring fast distribution of antivirals to influenza sufferers during a pandemic.

Epidemiologic and virologic assessment of the 2009 influenza A (H1N1) pandemic on selected temperate countries in the Southern Hemisphere: Argentina, Australia, Chile, New Zealand and South Africa

Please cite this paper as: Van Kerkhove et al. (2011) Epidemiologic and virologic assessment of the 2009 influenza A (H1N1) pandemic on selected temperate countries in the Southern Hemisphere: Argentina, Australia, Chile, New Zealand and South Africa. Influenza and Other Respiratory Viruses 5(6), e487–e498.

Introduction and Setting  Our analysis compares the most comprehensive epidemiologic and virologic surveillance data compiled to date for laboratory‐confirmed H1N1pdm patients between 1 April 2009 ‐ 31 January 2010 from five temperate countries in the Southern Hemisphere–Argentina, Australia, Chile, New Zealand, and South Africa.

Objective  We evaluate transmission dynamics, indicators of severity, and describe the co‐circulation of H1N1pdm with seasonal influenza viruses.

Results  In the five countries, H1N1pdm became the predominant influenza strain within weeks of initial detection. South Africa was unique, first experiencing a seasonal H3N2 wave, followed by a distinct H1N1pdm wave. Compared with the 2007 and 2008 influenza seasons, the peak of influenza‐like illness (ILI) activity in four of the five countries was 3‐6 times higher with peak ILI consultation rates ranging from 35/1,000 consultations/week in Australia to 275/100,000 population/week in New Zealand. Transmission was similar in all countries with the reproductive rate ranging from 1.2–1.6. The median age of patients in all countries increased with increasing severity of disease, 4–14% of all hospitalized cases required critical care, and 26–68% of fatal patients were reported to have ≥1 chronic medical condition. Compared with seasonal influenza, there was a notable downward shift in age among severe cases with the highest population‐based hospitalization rates among children <5 years old. National population‐based mortality rates ranged from 0.8–1.5/100,000.

Conclusions  The difficulty experienced in tracking the progress of the pandemic globally, estimating its severity early on, and comparing information across countries argues for improved routine surveillance and standardization of investigative approaches and data reporting methods.

Viral pneumonia

About 200 million cases of viral community-acquired pneumonia occur every year-100 million in children and 100 million in adults. Molecular diagnostic tests have greatly increased our understanding of the role of viruses in pneumonia, and findings indicate that the incidence of viral pneumonia has been underestimated. In children, respiratory syncytial virus, rhinovirus, human metapneumovirus, human bocavirus, and parainfluenza viruses are the agents identified most frequently in both developed and developing countries. Dual viral infections are common, and a third of children have evidence of viral-bacterial co-infection. In adults, viruses are the putative causative agents in a third of cases of community-acquired pneumonia, in particular influenza viruses, rhinoviruses, and coronaviruses. Bacteria continue to have a predominant role in adults with pneumonia. Presence of viral epidemics in the community, patient's age, speed of onset of illness, symptoms, biomarkers, radiographic changes, and response to treatment can help differentiate viral from bacterial pneumonia. However, no clinical algorithm exists that will distinguish clearly the cause of pneumonia. No clear consensus has been reached about whether patients with obvious viral community-acquired pneumonia need to be treated with antibiotics. Apart from neuraminidase inhibitors for pneumonia caused by influenza viruses, there is no clear role for use of specific antivirals to treat viral community-acquired pneumonia. Influenza vaccines are the only available specific preventive measures. Further studies are needed to better understand the cause and pathogenesis of community-acquired pneumonia. Furthermore, regional differences in cause of pneumonia should be investigated, in particular to obtain more data from developing countries.

Thermal image scanning for influenza border screening: results of an airport screening study

Background

Infrared thermal image scanners (ITIS) appear an attractive option for the mass screening of travellers for influenza, but there are no published data on their performance in airports.

Methods

ITIS was used to measure cutaneous temperature in 1275 airline travellers who had agreed to tympanic temperature measurement and respiratory sampling. The prediction by ITIS of tympanic temperature (37.8°C and 37.5°C) and of influenza infection was assessed using Receiver Operating Characteristic (ROC) curves and estimated sensitivity, specificity and positive predictive value (PPV).

Findings

Using front of face ITIS for prediction of tympanic temperature ≥37.8°C, the area under the ROC curve was 0.86 (95%CI 0.75–0.97) and setting sensitivity at 86% gave specificity of 71%. The PPV in this population of travellers, of whom 0.5% were febrile using this definition, was 1.5%. We identified influenza virus infection in 30 travellers (3 Type A and 27 Type B). For ITIS prediction of influenza infection the area under the ROC curve was 0.66 (0.56–0.75), a sensitivity of 87% gave specificity of 39%, and PPV of 2.8%. None of the 30 influenza-positive travellers had tympanic temperature ≥37.8°C at screening (95%CI 0% to 12%); three had no influenza symptoms.

Conclusion

ITIS performed moderately well in detecting fever but in this study, during a seasonal epidemic of predominantly influenza type B, the proportion of influenza-infected travellers who were febrile was low and ITIS were not much better than chance at identifying travellers likely to be influenza-infected. Although febrile illness is more common in influenza A infections than influenza B infections, many influenza A infections are afebrile. Our findings therefore suggest that ITIS is unlikely to be effective for entry screening of travellers to detect influenza infection with the intention of preventing entry of the virus into a country.

Including viral infection data supports an association between particulate pollution and respiratory admissions

OBJECTIVE

To refine and revise previous air pollution, climate and health time series analysis in Christchurch, New Zealand, introducing viral identification data (positive identification count and outbreak, defined as two of more positive tests).

METHOD

The effects on daily respiratory admissions for five years (1998-2002) of air pollution (PM(10) ), climate and virology (incorporating actual counts and outbreaks of influenza A and B (INF), para influenza virus type 3 (PIV) and respiratory syncytial virus (RSV) were examined using generalised additive models (GAMs), which are one of semiparametric models. Results were also compared with a model that included climate and air pollution parameters but without the inclusion of virology data. The data were analysed aggregately and then stratified by age group and season.

RESULTS

Different virology data detected various association levels. The highest estimates were a 3.93% (CI: 2.69-5.17) and a 3.88% (CI: 2.65-5.12) rise in respiratory admissions for a rise of 10 µg/m(3) annual PM(10) with outbreak and actual counts of PIV respectively for 0-19 years old with a three-day lag.

CONCLUSION

Refining a statistical model with the addition of virology data gives a similar estimation of the association between PM(10) levels and respiratory admissions to previous research. Use of the indicator of an outbreak of viral infection appears to be similar to actual count of viruses detected.

Emerging advances in rapid diagnostics of respiratory infections

Recent developments in rapid diagnostics for respiratory infections have mostly occurred in the areas of antigen and nucleic acid detection. Nucleic acid amplification tests have improved the ability to identify respiratory viruses in clinical specimens and have played pivotal roles in the rapid characterization of new viral pathogens. Antigen-detection assays in immunochromatographic or similar formats are most easily developed as near-patient tests, although they have been developed commercially only for a limited range of respiratory pathogens. New approaches for respiratory pathogen detection are needed, and breath analysis is an exciting area with enormous potential.

Screening for influenza infection in international airline travelers

We sought the collaboration of an international airline and border control agencies to study the feasibility of entry screening to identify airline travelers at increased risk of influenza infection. Although extensive and lengthy negotiations were required, we successfully developed a multisector collaboration and demonstrated the logistical feasibility of our screening protocol. We also determined the staffing levels required for a larger study to estimate the prevalence of influenza in international airline travelers.

Effect of rapid influenza testing on the clinical management of paediatric influenza

Background  Rapid tests are now widely available to assist the diagnosis of influenza; implementation may optimise the use of antiviral and antibiotic agents in the clinical management of influenza.

Objective  To explore the clinical management of children with influenza‐like illness (ILI) when rapid influenza tests were and were not performed.

Methods  Between 15 January 2007 and 30 April 2007, a standardised questionnaire was used to record the clinical features of children aged 1–12 years who presented to office‐based paediatricians in Germany with febrile ILI during periods of local influenza activity. For each paediatric contact, a clinical diagnosis of either ‘influenza positive’, ‘influenza negative’ or ‘suspected ILI’ was made. Where performed, the outcome of a Clearview Exact Influenza A + B rapid test was recorded. Prescriptions for antiviral agents and antibiotic medications were also recorded.

Results  A total of 16 907 questionnaires were evaluated. After fever (an entry criteria for all children), cough (84·6%), fatigue/decreased activity (83·0%), rhinorrhoea (73·7%) and headache (67·1%) were the most common symptoms. Influenza was clinically diagnosed in 56·8% (9596/16 907) of cases. The antiviral oseltamivir was prescribed for 24·6% (178/725) of children who were influenza positive by symptom assessment alone and 60·1% (4618/7685) of children who were influenza positive by rapid test. Antibiotics were less commonly prescribed for children who were influenza positive by rapid test [3·5% (271/7685) versus 17·2% (125/725) for symptom assessment alone].

Conclusions  In children with ILI, a positive rapid test result for influenza promotes the rational use of antiviral agents and reduces the inappropriate use of antibiotic medications.

Association of respiratory virus activity and environmental factors with the incidence of invasive pneumococcal disease

OBJECTIVES

To correlate the incidence rate of invasive pneumococcal disease (IPD) with fluctuations in respiratory virus activity and environmental factors in Christchurch, New Zealand.

METHODS

Ecological study comparing incidence rates of IPD with incidence rates of respiratory virus detection, meteorologic and air pollution data during 1995-2006. The relationship between annualized monthly rates of IPD and annualized monthly rates of respiratory virus detection and monthly meteorologic recordings and air pollution data was assessed using Spearman's rank correlation coefficient and negative binomial regression analysis.

RESULTS

Incidence rates of IPD were statistically significantly correlated with increasing detection rates of influenza viruses, respiratory syncytial virus (RSV), adenovirus and parainfluenza virus 3. Furthermore, rates of IPD were statistically significantly correlated with decreasing daily temperature, sunshine hours and wind speed, and with increasing air pollution levels and humidity. After regression analysis, the only statistically significant associations in the total population were between influenza virus activity, parainfluenza virus 3 activity and air pollution levels and increased rates of IPD, although RSV activity was associated with increased rates of IPD in children <5 years old.

CONCLUSIONS

Incidence rates of IPD are associated with the increased activity of some respiratory viruses and with air pollution in Christchurch.

Stockpiling prepandemic influenza vaccines: a new cornerstone of pandemic preparedness plans

The history of pandemic influenza, along with the evolving epizootic of the highly pathogenic avian influenza A (H5N1) virus and the severity of associated human infections, serve as a warning to the world of the threat of another influenza pandemic. Conservative estimates suggest that up to 350 million people could die and many more would be affected, causing disruption to health-care systems, society, and the world's economy. WHO has encouraged countries to prepare in advance by developing influenza pandemic preparedness plans that involve public-health and pharmaceutical interventions. Vaccination is a cornerstone of these plans; however, a pandemic vaccine cannot be manufactured in advance because the next pandemic virus cannot be predicted. The concepts of vaccine stockpiling and prepandemic vaccination have thus become attractive. Human H5N1 vaccines are currently available and can induce heterotypic immunity. WHO and governments should give urgent consideration to the use of these vaccines for the priming of individuals or communities who would be at greatest risk of infection if an H5N1 influenza pandemic were to emerge.

Incidence and characteristics of viral community-acquired pneumonia in adults

BACKGROUND

In adults, viral causes of community-acquired pneumonia (CAP) are poorly characterised. The aims of this study were to characterise the viral aetiology of CAP in adults by using an extensive array of viral diagnostic tests and to compare the characteristics of viral pneumonia with those of pneumococcal pneumonia.

METHODS

Adults admitted to Christchurch Hospital over a 1-year period with CAP were included in the study. Microbiological testing methods included blood and sputum cultures, urinary antigen testing for Streptococcus pneumoniae and Legionella pneumophila, antibody detection in paired sera and detection of respiratory viruses in nasopharyngeal swabs by immunofluorescence, culture and PCR.

RESULTS

Of 304 patients with CAP, a viral diagnosis was made in 88 (29%), with rhinoviruses and influenza A being the most common. Two or more pathogens were detected in 49 (16%) patients, 45 of whom had mixed viral and bacterial infections. There were no reliable clinical predictors of viral pneumonia, although several variables were independently associated with some aetiologies. The presence of myalgia was associated with pneumonia caused by any respiratory virus (OR 3.62, 95% CI 1.29 to 10.12) and influenza pneumonia (OR 190.72, 95% CI 3.68 to 9891.91). Mixed rhinovirus/pneumococcal infection was associated with severe disease.

CONCLUSIONS

Virus-associated CAP is common in adults. Polymicrobial infections involving bacterial and viral pathogens are frequent and may be associated with severe pneumonia.

Comparison of the NOW Influenza A & B, NOW Flu A, NOW Flu B, and Directigen Flu A+B assays, and immunofluorescence with viral culture for the detection of influenza A and B viruses

To evaluate the Binax NOW Influenza A & B combination assay, we tested upper respiratory tract samples in parallel with the Binax NOW Flu A and Binax NOW Flu B assays, the Becton-Dickinson Directigen Flu A+B assay, and immunofluorescence, and the results were compared with viral culture. Of the 521 samples tested, influenza A was cultured from 113 and influenza B from 6. There were no significant differences in the performance of all rapid antigen tests, with sensitivities of 53% to 59% for detecting influenza A compared with culture and immunofluorescence (80%). The sensitivities for all rapid tests were significantly higher for nasopharyngeal samples than for throat swabs. The Binax NOW Influenza A & B assay performed as well as other rapid assays. Commercial antigen detection assays are useful tools for the rapid diagnosis of influenza; however, confirmatory testing is always recommended. The use of nasopharyngeal samples for all rapid detection methods should be strongly encouraged.

A model for the spread and control of pandemic influenza in an isolated geographical region

In the event of an influenza pandemic, the most probable way in which the virus would be introduced to an isolated geographical area is by an infected traveller. We use a mathematical model, structured on the location at which infection occurs and based on published parameters for influenza, to describe an epidemic in a community of one million people. The model is then modified to reflect a variety of control strategies based on social distancing measures, targeted antiviral treatment and antiviral prophylaxis and home quarantine, and the effectiveness of the strategies is compared. The results suggest that the only single strategy that would be successful in preventing an epidemic (with R0=2.0) is targeted antiviral treatment and prophylaxis, and that closing schools combined with either closing work places or home quarantine would only prevent such an epidemic if these strategies were combined with a modest level of antiviral coverage.

Viral etiology of acute respiratory tract infections in children presenting to hospital: role of polymerase chain reaction and demonstration of multiple infections

BACKGROUND

Viral lower respiratory tract infections are a leading cause of hospitalization for young children.

METHODS

We used polymerase chain reaction (PCR) and conventional methods of cell culture and antigen detection to establish the viral etiology of acute respiratory tract infections in 75 hospitalized children.

RESULTS

One or more viral pathogens were detected in 65 (87%) children, with respiratory syncytial virus being the most commonly identified virus (36 children). Other viruses identified included influenza virus types A and B, parainfluenzavirus type 3, adenovirus, enterovirus, rhinovirus, coronavirus and human metapneumovirus. PCR increased the diagnostic yield significantly compared with antigen detection and culture, with 39 (21%) diagnoses identified by this method. Multiple infections were identified in 20 (27%) children.

CONCLUSIONS

PCR-based methodologies offer increased sensitivity for the detection of most respiratory viruses in young children. The inclusion of PCR into diagnostic testing strategies is needed to broaden our understanding of the natural ecology of respiratory viruses and the significance of multiple infections.

Human metapneumovirus in children with bronchiolitis or pneumonia in New Zealand

OBJECTIVES

To confirm the presence of human metapneumovirus (hMPV) in New Zealand and establish its prevalence in selected paediatric patient groups.

METHODS

Nasopharyngeal swabs were collected in two separate paediatric studies enrolling children clinically diagnosed with either bronchiolitis or pneumonia and tested for hMPV by polymerase chain reaction.

RESULTS

Nucleic acid detection tests demonstrated 5.3% of paediatric bronchiolitis cases were positive for hMPV RNA and 2.7% of children admitted with pneumonia tested positive for hMPV RNA.

CONCLUSIONS

The presence of hMPV in New Zealand has been confirmed in two selected paediatric patient groups, namely children diagnosed with bronchiolitis and pneumonia. These results indicate that hMPV is associated with a minority of cases of bronchiolitis or pneumonia in this patient group.

The role of the Asia-Pacific advisory committee on influenza

In recent years it has become clear that a coordinated approach to the promotion of influenza awareness, with the intent to improve the prevention and control of influenza, is needed in the Asia-Pacific region. The APACI was established in early 2002 to address issues relating to influenza and the impact of the disease in Asia. Its members include influenza researchers, and public health and infectious disease experts from countries in the Asia-Pacific region. The committee is a joint initiative of key opinion leaders in the region, supported by four pharmaceutical companies: Aventis Pasteur, Chiron, GlaxoSmithKline and Wyeth. The activities of the APACI are aligned with, and supplemental to, those of the World Health Organization (WHO) for the global control of influenza. The APACI intends to work in cooperation with the WHO to complement its work on influenza surveillance and promote influenza awareness throughout Asia.

Evaluation of a PCR assay for detection of Streptococcus pneumoniae in respiratory and nonrespiratory samples from adults with community-acquired pneumonia

Streptococcus pneumoniae is the most common cause of community-acquired pneumonia, but it is undoubtedly underdiagnosed. We used a nested PCR assay (targeting the pneumolysin gene) to detect S. pneumoniae DNA in multiple sample types from 474 adults with community-acquired pneumonia and 183 control patients who did not have pneumonia. Plasma or buffy coat samples were PCR positive in only 6 of the 21 patients with positive blood cultures for S. pneumoniae and in 12 other patients (4 of whom had no other laboratory evidence of S. pneumoniae infection). Buffy coat samples from two control patients (neither having evidence of S. pneumoniae infection), but no control plasma samples, were PCR positive. Although pneumococcal antigen was detected in the urine from 120 of 420 (29%) patients, only 4 of 227 (2%) urine samples tested were PCR positive. Overall, 256 of 318 (81%) patients had PCR-positive sputum samples, including 58 of 59 samples from which S. pneumoniae was cultured. Throat swab samples from 229 of 417 (55%) patients were PCR positive and, in those who produced sputum, 96% also had positive PCR results from sputum. Throat swabs from 73 of 126 (58%) control patients were also PCR positive. We conclude that the pneumolysin PCR assay adds little to existing diagnostic tests for S. pneumoniae and is unable to distinguish colonization from infection when respiratory samples are tested.

Interferon-alpha2a/ribaviran versus interferon-alpha2a alone for the retreatment of hepatitis C patients who relapse after a standard course of interferon

AIM

To compare the efficacy of a descalating dose of interferon (48 weeks) versus a combination therapy of interferon and ribavirin (24 weeks) in hepatitis C positive subjects who relapsed within six months of cessation of a standard six month course of interferon three million units thrice weekly.

METHODS

All 32 subjects had biopsy proven chronic hepatitis C, were PCR positive and had elevated transaminase enzymes at least one and a half times the upper limit of normal. Subjects were randomly assigned to either a descalating dose of interferon-alpha-2a; six million units thrice weekly for 24 weeks followed by 3 MIU 3x for 24 weeks or interferon three million units thrice weekly for 24 weeks plus ribavirin 1,000 mg/day for 12 weeks. A complete virological response was defined as a negative PCR for HCV RNA at 24 weeks after cessation of therapy.

RESULTS

Sixteen patients were assigned to each arm and the sustained virological response was 50% for both the interferon and combination therapy arm (pNS). The biochemical response correlated with the virological response; 7/8 virological responders in the interferon alone had normalisation of transaminase 24 weeks post treatment as did 8/8 of those in the combination arm. One patient withdrew from treatment in the descalating interferon group and three required dose reduction. No subjects in the combination arm discontinued therapy but dose reduction was required in three subjects.

CONCLUSION

High dose descalating interferon-alpha 2a and a combination of interferon-alpha 2a and ribavirin were effective in achieving a sustained virological response in 50% of subjects who had relapsed after a standard six month course of interferon.