Influenza and pertussis vaccine coverage in pregnancy in Australia, 2016-2021

Vaccination in pregnancy is the best strategy to reduce complications from influenza or pertussis infection in infants who are too young to be protected directly from vaccination. Pregnant women are also at risk of influenza complications preventable through antenatal vaccination. Both vaccines are funded under the National Immunisation Program for pregnant women in Australia, but coverage is not routinely reported nationally. We reviewed all reported Australian maternal influenza and pertussis vaccine coverage data for the period 2016-2021, to identify gaps and information needs. Maternal influenza vaccine coverage was suboptimal at < 58% for 2016-2018, with higher coverage of 62-75% reported in two states (Victoria and Western Australia) for 2019-2021. Maternal pertussis vaccine coverage from 2016 was generally higher than for influenza at > 70%, with the highest jurisdictional coverage of 89% reported in Western Australia in 2020. Vaccination rates were often suboptimal among First Nations pregnant women and up to 20% lower than among non-First Nations Australian women; while data were limited, coverage was low among culturally and linguistically diverse women and among women of lower socio-economic status. Jurisdictional perinatal data collections were the best source of information on antenatal vaccine coverage but were only available for a minority of the population; a nationally consistent systematic approach is lacking. Timely and comprehensive data are needed to provide feedback to improve maternal vaccination coverage, particularly among groups with higher risk and/or low uptake, and as new vaccines are recommended, including COVID-19 vaccination.

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

OBJECTIVES

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

DESIGN AND SETTING

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

PARTICIPANTS

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

PRIMARY AND SECONDARY OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

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

Abstract

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

Seroprevalence of SARS-CoV-2-specific antibodies in Australia following the first epidemic wave in 2020: a national survey

Background

As of mid-2021, Australia’s only nation-wide COVID-19 epidemic occurred in the first six months of the pandemic. Subsequently there has been limited transmission in most states and territories. Understanding community spread during the first wave was hampered by initial limitations on testing and surveillance. To characterize the prevalence of SARS-CoV-2-specific antibody seroprevalence generated during this time, we undertook Australia’s largest national SARS-CoV-2 serosurvey.

Methods

Between 19 June-6 August 2020, residual specimens were sampled from people undergoing general pathology testing (all ages), women attending antenatal screening (20–39 years) and blood-donors (20–69 years) based on the Australian population’s age and geographic distributions. Specimens were tested by Wantai total SARS-CoV-2-antibody assay. Seroprevalence estimates adjusted for test performance were produced. SARS-CoV-2 antibody-positive specimens were characterized with microneutralization assays.

Results

Of 11,317 specimens (5132 general pathology; 2972 antenatal; 3213 blood-donors), 71 were positive for SARS-CoV-2-specific antibodies. Seroprevalence estimates were 0.47% (95% credible interval: 0.04-0.89%), 0.25% (0.03-0.54%) and 0.23% (0.04-0.54%), respectively. No seropositive specimens had neutralizing antibodies.

Conclusions

Australia’s seroprevalence was extremely low (&lt;0.5%) following the only national COVID-19 wave thus far. These data and the subsequent limited community transmission highlight the population’s naivety to SARS-CoV-2 and the urgency of increasing vaccine-derived protection.

Seroprevalence of SARS-CoV-2-specific antibodies in Sydney after the first epidemic wave of 2020

OBJECTIVES

To estimate SARS-CoV-2-specific antibody seroprevalence after the first epidemic wave of coronavirus disease 2019 (COVID-19) in Sydney.

SETTING, PARTICIPANTS

People of any age who had provided blood for testing at selected diagnostic pathology services (general pathology); pregnant women aged 20-39 years who had received routine antenatal screening; and Australian Red Cross Lifeblood plasmapheresis donors aged 20-69 years.

DESIGN

Cross-sectional study; testing of de-identified residual blood specimens collected during 20 April - 2 June 2020.

MAIN OUTCOME MEASURE

Estimated proportions of people seropositive for anti-SARS-CoV-2-specific IgG, adjusted for test sensitivity and specificity.

RESULTS

Thirty-eight of 5339 specimens were IgG-positive (general pathology, 19 of 3231; antenatal screening, 7 of 560; plasmapheresis donors, 12 of 1548); there were no clear patterns by age group, sex, or location of residence. Adjusted estimated seroprevalence among people who had had general pathology blood tests (all ages) was 0.15% (95% credible interval [CrI], 0.04-0.41%), and 0.29% (95% CrI, 0.04-0.75%) for plasmapheresis donors (20-69 years). Among 20-39-year-old people, the age group common to all three collection groups, adjusted estimated seroprevalence was 0.24% (95% CrI, 0.04-0.80%) for the general pathology group, 0.79% (95% CrI, 0.04-1.88%) for the antenatal screening group, and 0.69% (95% CrI, 0.04-1.59%) for plasmapheresis donors.

CONCLUSIONS

Estimated SARS-CoV-2 seroprevalence was below 1%, indicating that community transmission was low during the first COVID-19 epidemic wave in Sydney. These findings suggest that early control of the spread of COVID-19 was successful, but efforts to reduce further transmission remain important.

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

Objectives

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

Design, setting, participants

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

Main outcomes

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

Results

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

Conclusions

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

Lower immunity to poliomyelitis viruses in Australian young adults not eligible for inactivated polio vaccine

There are limited long-term data on seroprevalence of neutralising antibody (nAb) to the three poliovirus serotypes following the switch from oral polio vaccine (OPV) to inactivated polio vaccine (IPV). In Australia, combination vaccines containing IPV replaced OPV in late 2005. Using serum and plasma specimens collected during 2012 and 2013, we compared prevalence of nAb to poliovirus type 1 (PV1), type 2 (PV2) and type 3 (PV3) in birth cohorts with differing IPV and OPV eligibility from an Australian population-based sample. In the total sample of 1673 persons aged 12 months to 99 years, 85% had nAb against PV1, 83% PV2 and 67% PV3. In the cohort 12 to <18 years (eligible for 4 OPV doses, last dose 8-14 years prior), a significantly lower proportion had nAb than in the 7 to <12 year cohort (eligible for 3 OPV doses and an IPV booster, last dose 3-8 years prior) for all poliovirus types: [PV1: 87.1% vs. 95.9% (P = 0.01), PV2: 80.4% vs. 92.9% (P = 0.003) and PV3: 38.1% vs. 84.0% (P < 0.0001)]. These data suggest individual-level immunity may be better maintained when an OPV primary schedule is boosted by IPV, and support inclusion of an IPV booster in travel recommendations for young adults who previously received only OPV.

Australian rubella serosurvey 2012-2013: On track for elimination?

BACKGROUND

The World Health Organization has targeted rubella virus for elimination regionally. Australia was one of the first countries to implement a nationally funded rubella immunisation program, in 1971, and conducts regular national rubella serosurveillance studies. We aimed to estimate the seroprevalence of rubella-specific IgG antibody in the Australian population by age and sex in 2012-2013, to compare the results with three previous serosurveys conducted in 1996-1999, 2002 and 2007 and to estimate the effective reproduction numbers (R_n).

METHODS

This study used 2729 serum and plasma specimens, randomly selected from a specimen bank collected in 2012-2013 across Australia. Age groups included in the sample ranged from 1 to 49 years. Sera were tested for rubella-specific IgG-antibody using the Enzygnost anti-rubella IgG enzyme immunoassay and classified as positive, negative or equivocal according to rubella-specific IgG concentrations of >7 IU/ml, <3 IU/ml and 3-7 IU/ml, respectively.

RESULTS

The overall proportions seropositive, seronegative and equivocal for rubella-specific IgG were 92.1% (95% CI, 91.0-93.2), 6.7% (95% CI, 5.7-7.7) and 1.2% (95% CI, 0.8-1.6), respectively. The proportion of males seropositive was significantly lower than females in the 30-34 (83.1% vs. 96.8%, p = 0.003), 35-39 (86.1% vs. 96.3%, p = 0.02) and 40-44 (86.1% vs. 95.7%, p = 0.03) year age groups. R_n for rubella in 2012-2013 was estimated to be 0.33 (95% CI 0.28-0.39).

DISCUSSION

The 2012-2013 national serosurvey showed levels of rubella-specific IgG seropositivity in the Australian population are relatively high with no evidence of decrease compared to previous serosurveys conducted in 1996-1999, 2002 and 2007. The lower proportion of seropositive males aged 30-44 years likely reflects the initial immunisation program targeting females only. To our knowledge this study represents the longest period of serosurveillance following introduction of a nationally funded rubella immunisation program. The lack of evidence of decreasing rubella-specific IgG seropositivity is therefore reassuring for Australia and other countries with longstanding high vaccine coverage.

Evaluation of bacille Calmette-Guérin immunisation programs in Australia

bacille Calmette-Guérin (BCG) immunisation programs in Australia are funded and operated by the individual states and territories. In recent years BCG vaccine shortages have required use of unregistered products. We aimed to evaluate BCG immunisation programs in Australia, with particular reference to program implementation and national consistency.
 Methods: Between September and November 2015, 12 key stakeholders, representing Australian states and territories, completed surveys. We analysed BCG vaccination coverage data from the Australian Childhood Immunisation Register (ACIR), and data on adverse events following immunisation (AEFI) with BCG vaccine from the Therapeutic Goods Administration's Adverse Drug Reactions System, for 2001 to 2014.
 Results: Access to BCG vaccination varies between jurisdictions, with some states providing this only in major city locations. Analysis of ACIR data suggests significant differences in vaccine delivery between jurisdictions, but varying levels of under-reporting to the ACIR were also acknowledged. The rate of BCG AEFI appeared to increase between 2011 and 2014; however, these data need to be interpreted with caution due to small numbers, likely under-reporting of both numerator (AEFI) and denominator (vaccine doses administered), and the general increase in reporting of AEFI related to other vaccines in children over this period.
 Conclusions: BCG immunisation programs aim to prevent severe forms of tuberculosis in young children who live in or travel to high burden settings. A range of factors, particularly inconsistent vaccine supply are leading to low, variable and inequitable vaccine delivery across Australian jurisdictions. Improved BCG vaccination uptake and AEFI data quality are required for accurate monitoring of program delivery and vaccine safety - this is particularly important given the current need to use unregistered vaccines. Improved and consistent access to BCG vaccine is suggested to optimise equity for at-risk children Australia-wide.

Immunisation coverage annual report, 2014

This 8th annual immunisation coverage report shows data for 2014 derived from the Australian Childhood Immunisation Register and the National Human Papillomavirus Vaccination Program Register. This report includes coverage data for 'fully immunised' and by individual vaccines at standard age milestones and timeliness of receipt at earlier ages according to Indigenous status. Overall, 'fully immunised' coverage has been mostly stable at the 12- and 24-month age milestones since late 2003, but at 60 months of age, it has increased by more than 10 percentage points since 2009. As in previous years, coverage for 'fully immunised' at 12 months of age among Indigenous children was 3.7% lower than for non-Indigenous children overall, varying from 6.9 percentage points in Western Australia to 0.3 of a percentage point in the Australian Capital Territory. In 2014, 73.4% of Australian females aged 15 years had 3 documented doses of human papillomavirus vaccine (jurisdictional range 67.7% to 77.4%), and 82.7% had at least 1 dose, compared with 71.4% and 81.5%, respectively, in 2013. The disparity in on-time vaccination between Indigenous and non-Indigenous children in 2014 diminished progressively from 20.2% for vaccines due by 12 months to 11.5% for those due by 24 months and 3.0% at 60 months of age.

Adverse events following immunisation with bacille Calmette-Guérin vaccination: baseline data to inform monitoring in Australia following introduction of new unregistered BCG vaccine

In recent years there has been a global shortage of bacille Calmette-Guérin (BCG) vaccine and, from September 2012, unregistered vaccines have needed to be used in Australia (a Danish product initially until the end of 2015, and a Polish product used in some jurisdictions from early 2016). We examined rates and types of adverse events following immunisation (AEFI) with BCG vaccine reported to the Therapeutic Goods Administration between 2009 and 2014 in children aged less than 7 years. Reporting rates of AEFI with BCG vaccine increased from 87 per 100,000 doses (registered Sanofi Pasteur product) in 2009 to 201 per 100,000 doses (unregistered Danish Statens Serum Institute product) in 2014, with Victoria having the highest rate each year. Substantial variation between jurisdictions exists, suggesting differential reporting of BCG vaccine doses administered and/or BCG vaccine-related AEFI. The most commonly reported reactions were abscess (31%), injection site reaction (27%) and lymphadenopathy/lymphadenitis (17%). This study provides baseline data on BCG vaccine safety to inform surveillance. Given the current use of unregistered vaccines in the context of vaccine supply issues, improved recording of both administered BCG vaccine doses and the reporting of BCG vaccine-related AEFI are required to facilitate close monitoring of vaccine safety.

Rise in invasive serogroup W meningococcal disease in Australia 2013-2015

Since 2013, there has been an increase in the number of notified cases of invasive meningococcal disease (IMD) due to serogroup W (MenW) in Australia. In response to this observed increase, the Communicable Diseases Network Australia convened a working group in 2015 to collate and analyse the epidemiology of MenW disease nationally. Enhanced surveillance data collected by jurisdictions were collated and analysed, and whole genome sequencing (WGS) of MenW isolates assessed the genomic relatedness of strains between 2012 and 2015. This report describes that epidemiology. Since 2013, the incidence and proportion of MenW has increased in Australia, rising from an average of 2% of all IMD cases annually (range 0% to 5%) between 1991 and 2012; to 8% (12/149) of cases in 2013, 10% (17/169) in 2014, and 19% (34/182) in 2015. Victoria has been the main affected state, with 50% (17/34) of national cases in 2015. MenW has affected older populations, with a median age between 2003 and 2015 being 44 years. During this period, case fatality was 10.7% (17/159), 2.3 times higher than for all IMD serogroups combined (4.7%, 173/3720). There were 7 deaths due to MenW in 2015 (CFR 21%). WGS has found the majority of Australian isolates cluster within a group of W:P1.5,2:F1-1:ST11 isolates from the United Kingdom and South America, regions where rapid spread and endemic transmission has occurred since 2009. The recent increase in incidence of MenW in Australia is evolving and is being closely monitored. Lessons learned from the international experience will be important in informing the public health response.

Australian vaccine preventable disease epidemiological review series: Influenza 2006 to 2015

INTRODUCTION

Influenza is a major contributor to the preventable health burden of Australians each year. The National Immunisation Program provides influenza vaccine for those at highest risk of severe disease. This review of influenza epidemiology examines current data on influenza disease burden in Australia, in the context of several comparable countries having programs with much broader eligibility for influenza vaccine in children.

METHODS

Influenza notifications (2006-2015), hospitalisations, and deaths (2006-2013) were sourced and age-specific rates calculated. Comparisons were made across age groups in the pre-pandemic, pandemic, and post-pandemic periods and by Indigenous and non-Indigenous status.

RESULTS

The 2009 pandemic year and the 2012 non-pandemic season resulted in the highest rates of notification, hospitalisation and death. Influenza notification rates were 4.0 times higher and hospitalisation rates 2.1 times higher during 2011-2013 compared with 2006-2008. Death rates varied widely, but peaks corresponded to high-activity seasons. Influenza hospitalisation rates were highest among those aged <5 and ≥65 years, but influenza-attributable deaths were identified primarily in those aged ≥75 years. Significantly higher notification and hospitalisation rates were seen for all Indigenous people, but higher death rates were largely restricted to the 2009 pandemic year.

CONCLUSIONS

Based on notifications, hospitalisations and deaths, burden of disease from influenza is highest at the extremes of life and is significantly higher among Indigenous people of all ages. This pattern of disease burden warrants consideration of widened eligibility for influenza vaccine under the National Immunisation Program to all Indigenous people and all children less than 5 years of age.

Summary of National Surveillance Data on Vaccine Preventable Diseases in Australia, 2008-2011

This summary report on vaccine preventable diseases in Australia brings together the 3 most important national sources of routinely collected data on vaccine preventable diseases (notifications, hospitalisations and deaths) for all age groups for the period January 2008 to December 2011. The general trend towards improved control of disease is evident, particularly in the childhood years. Detailed results are available in 16 individual chapters. Although these data have limitations, which are discussed in detail in the body of the report, some clear trends are evident. Compared with the previous review period (2005-2007), there are continuing declines in the overall disease burden, driven by improving control of mumps, rubella, hepatitis B and meningococcal disease. There is an ongoing absence of disease due to polio and a continuing low incidence of tetanus. There have been continuing declines in the incidence of hepatitis A and B. However, there were 4 notified cases of diphtheria in 2011; prior to these reports there had been no notified diphtheria cases since 2001. Influenza and pertussis notifications have increased, whereas notifications and hospitalisations for mumps have remained stable and for meningococcal disease have declined. Influenza, pertussis and pneumococcal disease continue to contribute the greatest burden of serious disease.

Pertussis immunisation in pregnancy: a summary of funded Australian state and territory programs

The Australian Immunisation Handbook, 10th edition now recommends pertussis vaccination during pregnancy as the preferred option for protecting vulnerable young infants. Jurisdictionally funded pertussis immunisation programs for pregnant women have been progressively introduced in all Australian states and territories between August 2014 and June 2015. A meeting convened by the National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases was held on 31 May 2015 to share information regarding jurisdictional policies and program implementation. This report of that meeting provides the first published comparison of these jurisdictional programs, which are of a broadly similar nature but with important differences. Monitoring and evaluation of the uptake, safety and impact of the current programs in Australia will be important to inform future policy decisions.

Norovirus in residential care facilities: does prompt notification of outbreaks help?

Outbreaks of viral gastroenteritis occur regularly in residential care facilities (RCFs), with norovirus being the most common agent. Notification of outbreaks to public health authorities is encouraged in Australia, although there is limited evidence that this results in public health benefit. The aim of this study was to investigate if prompt notification of suspected norovirus outbreaks to public health authorities is associated with a reduction in either the duration or attack rate of outbreaks. Viral gastroenteritis outbreaks notified from Queensland RCFs between 2004 and 2007 were analysed. Foodborne outbreaks were excluded, along with 6 outbreaks where viruses other than norovirus were identified as the causative agent. Of the 264 remaining outbreaks, 70.8% were laboratory-confirmed as being due to norovirus. The average time to notification was 4 days and the average duration of outbreaks was 12 days. Outbreaks notified promptly (within 1 day) were of significantly shorter duration compared with outbreaks notified within 2-3 days (P < 0.02) or 4 or more days (P < 0.001). Early notification of outbreaks was not significantly associated with a reduced attack rate, however there was a significantly higher attack rate in facilities with less than 150 individuals at risk compared with facilities with 150 or more individuals at risk (30% versus 18%, respectively; P < 0.001). The shorter duration of promptly notified outbreaks provides some evidence to support recommendations from best practice guidelines for prompt notification of outbreaks by RCFs. However, further research is needed to unravel the interplay of factors that may influence the severity of viral gastroenteritis outbreaks in RCFs.

The changing phases of pandemic (H1N1) 2009 in Queensland: an overview of public health actions and epidemiology

A graded public health response was implemented to control the pandemic (H1N1) 2009 outbreak in Queensland. Public health measures to contain the outbreak included border control, enhanced surveillance, management of cases and contacts with isolation or quarantine and antivirals, school closures and public education messages. The first confirmed case in Australia was notified on 8 May 2009, in a traveller returning to Queensland from the United States. In Queensland, 593 laboratory-confirmed cases were notified with a date of onset between 26 April and 22 June 2009, when the Protect phase of the Australian Health Management Plan for Pandemic Influenza was implemented; 16 hospitalisations and no deaths were reported during this time. The largest number of confirmed cases was reported in the 10-19-years age group (167, 28% of cases), followed by the 20-29-years age group (153, 26% of cases). With ongoing community transmission, the focus has shifted from public health to the clinical domain, with an emphasis on protecting vulnerable groups. Considerable resources have been invested to prevent and control the spread of disease in Indigenous communities in Far North Queensland. The capacity of clinical services to cope with increased admissions, the potential for widespread antiviral resistance, and rollout of mass vaccination campaigns remain future challenges.

Pertussis in infants: how to protect the vulnerable?

In terms of adverse outcomes, infants remain the group most vulnerable to severe pertussis disease. Adult household contact is thought to be the main source of transmission to infants. This study reviews exposure history, vaccination status, admission outcome and quality of discharge coding of hospitalised infants with pertussis at a tertiary paediatric hospital. We identified cases between 1997 and 2006 from 2 sources: hospital discharge coding and positive Bordetella pertussis results from the hospital laboratory database. We assessed the completeness of each of these sources, compared with the dataset of all identified cases. We identified 55 hospitalised infants with pertussis. The 35 cases (64%) less than 3 months of age had greater risk of Intensive Care Unit admission, higher mortality, and were more likely to have parents as an identified source. On admission, only 5 cases (9%) were more than 2 weeks overdue for their previous scheduled pertussis vaccination. Discharge coding was more sensitive for identifying cases than the laboratory database. Nine cases (16%) had incorrect discharge coding. Even infants up to date for pertussis vaccine can have severe disease requiring hospitalisation. Immunising parents planning to have, or who have had, a newborn baby may help to prevent pertussis in infants.

Defense of the radical perineal prostatectomy

There is sharp disagreement as to what constitutes the proper surgical approach to localized carcinoma of the prostate. We have performed 31 radical perineal prostatectomies in a six-year period with no mortality and minimal morbidity. Thirteen of these patients were understaged preoperatively and had extraprostatic cancer; however, only one has died from his tumor. One patient is incontinent but none has troublesome local symptoms. These patients required an average of 15 postoperative days, none required more than two units of blood, and careful preoperative consultation has minimized the psychologic stress of impotence. These data contrast sharply with the published morbidity and mortality statistics associated with a preliminary staging lymphadenectomy and a definitive radical retropubic prostatectomy. Also, we are convinced that our patients with stage C cancer have been done a real service by removing the prostate gland even though cancer remains in the stumps of the seminal vesicles. Unless the advocates of the staged procedure can demonstrate an improvement in the patients' survival data, we believe the radical perineal prostatectomy remains the procedure of choice for the cure of localized prostatic cancer and we would advocate this operation as an acceptable palliative approach to selected patients with stage C lesions.