Clinical Manifestations and Genomic Evaluation of Melioidosis Outbreak among Children after Sporting Event, Australia

Melioidosis, caused by the environmental gram-negative bacterium Burkholderia pseudomallei, usually develops in adults with predisposing conditions and in Australia more commonly occurs during the monsoonal wet season. We report an outbreak of 7 cases of melioidosis in immunocompetent children in Australia. All the children had participated in a single-day sporting event during the dry season in a tropical region of Australia, and all had limited cutaneous disease. All case-patients had an adverse reaction to oral trimethoprim/sulfamethoxazole treatment, necessitating its discontinuation. We describe the clinical features, environmental sampling, genomic epidemiologic investigation, and public health response to the outbreak. Management of this outbreak shows the potential benefits of making melioidosis a notifiable disease. The approach used could also be used as a framework for similar outbreaks in the future.

Implementation of routine genomic surveillance provided insights into a locally acquired outbreak caused by a rare clade of Salmonella enterica serovar Enteritidis in Queensland, Australia

Salmonellosis is a significant public health problem globally. In Australia, Salmonella enterica serovar Enteritidis is one of the main causes of salmonellosis. This study reports how the implementation of routine genetic surveillance of isolates from human S. Enteritidis cases enabled identification of the likely source of an outbreak that occurred in a remote town in Far North Queensland, Australia. This study included patient, food and water samples collected during an outbreak investigation. S. Enteritidis of the novel sequence type 5438 was isolated from all seven patient samples and one bore water sample but not any of the food samples. Both whole-genome single nucleotide polymorphism (SNP) and core-genome multilocus sequence typing analysis revealed that S. Enteritidis isolated from outbreak-related patient samples and the bore water isolates clustered together with fewer than five SNP differences and ten allelic differences. This genetic relatedness informed the outbreak response team around public health interventions and no further cases were identified post-treatment of the bore water. This disease cluster was identified through the routine sequencing of S. Enteritidis performed by the state public health laboratory in an actionable time frame. Additionally, genomic surveillance captured a case with unknown epidemiological links to the affected community, ruled out a simultaneous outbreak in an adjacent state as the source and provided evidence for the likely source preventing further transmission. Therefore, this report provides compelling support for the implementation of whole-genome sequencing based genotyping methods in public health microbiology laboratories for better outbreak detection and management.

Limited Awareness of Melioidosis in High-risk Populations Despite an Increasing Incidence of the Disease in Far North Queensland, Australia

The incidence of melioidosis, an opportunistic infection caused by Burkholderia pseudomallei, has recently doubled in Far North Queensland (FNQ), Australia. This contrasts with the local burden of dengue, which is nearing elimination, and the stable incidence of leptospirosis. This questionnaire-based study assessed the awareness of melioidosis among people in FNQ with risk factors for the disease, using awareness of leptospirosis and dengue as comparators. There were 427 respondents; 361 (85%) reported one or more risk factors for melioidosis. Only 69 of 361 (19%) had heard of melioidosis compared with 301 of 361 (83%) who had heard of dengue (P < 0.001) and 137 of 361 (38%) who had heard of leptospirosis (P < 0.001). In FNQ, Australia, there is an increasing local incidence of melioidosis, but there is limited awareness of the disease among high-risk individuals. Greater community awareness of melioidosis is necessary to implement strategies to prevent disease and expedite the presentation of patients with this life-threatening infection.

Undetected serovars: leptospirosis cases in the Cairns region during the 2021 wet season

Background Leptospirosis infection can lead to serious renal and cardiopulmonary complications and can be fatal. Following heavy rainfall and localised flooding in early 2021, Tropical Public Health Services in Cairns were alerted to an increase in leptospirosis cases in the region, with notifications almost three times higher than usual by mid-February. An epidemiological investigation was undertaken. Methods Leptospirosis notification data were obtained from the Queensland Notifiable Conditions System. Confirmed and probable cases residing in the Cairns region, with an onset date between 1 January and 31 May 2021, were included in the investigation. Case demographics, pathology results, symptoms, hospital stay information and presumed exposure sources were obtained from Queensland Health records; local rainfall data was obtained from the Australian Bureau of Meteorology. Case characteristics and rainfall were compared to the prior ten-year period and the distribution of cases by week of onset, address, exposure source and infecting serovar analysed. Results A total of 43 leptospirosis cases were notified between January and May 2021, the highest number recorded for the region since 2011. Presumed exposure sources were available for 40 cases (93.0%), with 33 cases (82.5%) exposed occupationally, including 25 cases working on banana farms. Infecting Leptospira serovars were identified for five cases (11.6%), with four infected with serovar Australis and one with serovar Zanoni. Limited information about the specific exposure sites for each case and a low serovar detection rate hampered the ability to confirm the presence or absence of a leptospirosis outbreak. While heavy rainfall is likely to have contributed to the spike in cases, no factors were identified as clearly associated with the increase. Conclusions A number of pathways are proposed to improve the collection of exposure site data and the identification of infecting serovars, in order to strengthen local leptospirosis surveillance and the ability to detect outbreaks in the Cairns region.

Increased Incidence of Melioidosis in Far North Queensland, Queensland, Australia, 1998-2019

During January 1998–December 2019, the annual incidence of melioidosis in Far North Queensland, Queensland, Australia, more than doubled. Because climate and prevalence of predisposing medical conditions remained stable during that time, we hypothesize that the increased incidence was caused by urban expansion and increased construction, resulting in greater exposure to Burkholderia pseudomallei.

Outbreak of multi-drug-resistant (MDR) Shigella flexneri in northern Australia due to an endemic regional clone acquiring an IncFII plasmid

Epidemiological surveillance of Shigella spp. in Australia is conducted to inform public health response. Multi-drug resistance has recently emerged as a contributing factor to sustained local transmission of Shigella spp. All data were collected as part of routine public health surveillance, and strains were whole-genome sequenced for further molecular characterisation. 108 patients with an endemic regional Shigella flexneri strain were identified between 2016 and 2019. The S. flexneri phylogroup 3 strain endemic to northern Australia acquired a multi-drug resistance conferring blaDHA plasmid, which has an IncFII plasmid backbone with virulence and resistance elements typically found in IncR plasmids. This is the first report of multi-drug resistance in Shigella sp. in Australia that is not associated with men who have sex with men. This strain caused an outbreak of multi-drug-resistant S. flexneri in northern Australia that disproportionality affects Aboriginal and Torres Strait Islander children. Community controlled public health action is recommended.

A randomized controlled trial of an education and counselling intervention for families after stroke

OBJECTIVES

To determine whether education and counselling after stroke leads to improved family functioning and psychosocial outcomes for stroke patients and their spouses, and better functional and social outcomes for patients.

DESIGN

Two-group randomized controlled trial. Data were collected on admission to and discharge from rehabilitation, and again six months later.

SETTING

Rehabilitation units at Repatriation General Hospital and Griffith Hospital, in Adelaide, South Australia.

PARTICIPANTS

Sixty-two stroke patients and their spouses, 32 in the intervention group and 30 in the control group.

INTERVENTION

Stroke information package and three visits from a social worker trained in family counselling.

OUTCOME MEASURES

Family functioning: McMaster Family Assessment Device (FAD); functional status: Barthel Index (BI); social recovery: Adelaide Activities Profile (AAP); depression: Geriatric Depression Scale (GDS); anxiety: Hospital Anxiety and Depression Scale (HADS); mastery: Mastery Scale (MS); health status: SF-36.

RESULTS

At six months the intervention group had better family functioning for both patients (mean FAD difference 0.19) and spouses (mean difference 0.09). A modest benefit in functional status for intervention patients (mean BI difference 1.3) was related to improved family functioning. Intervention patients reported better social recovery (mean AAP differences: domestic chores 5.7, household maintenance 4.6, social activities 11.5), but there were no significant effects on depression, anxiety, mastery or health status.

CONCLUSIONS

An education and counselling intervention maintained family functioning, and in turn led to improved functional and social patient outcomes. This approach helps patients and their spouses to make the optimal adjustment to living with stroke.

Assessing health-related quality of life following myocardial infarction: is the SF-12 useful?

We report on the responsiveness of the SF-12 to changes in quality of life following acute myocardial infarction. Scores at 1, 6, 12, and 24 weeks postdischarge were compared with pre-MI health. Statistically significant differences and standardized response means were examined. Results were compared with the SF-36 subscales and previous reports. Respondents (n = 65) reported the expected poorer physical health at every follow-up, while expected changes in emotional health were observed at 6 but not 24 weeks. Comparison with the SF-36 subscales showed that although the SF-12 reflected the expected pattern of physical health, the summary score obscured an important association between perceptions of general health and participation in usual activities. This information is relevant for developing and evaluating rehabilitation interventions and self-managed recovery following MI. The SF-12 scores obscure important distinctions between quality of life domains, and are therefore not recommended for use following acute MI.

Home or hospital for stroke rehabilitation? results of a randomized controlled trial : I: health outcomes at 6 months

BACKGROUND AND PURPOSE

We wished to examine the effectiveness of an early hospital discharge and home-based rehabilitation scheme for patients with acute stroke.

METHODS

This was a randomized, controlled trial comparing early hospital discharge and home-based rehabilitation with usual inpatient rehabilitation and follow-up care. The trial was carried out in 2 affiliated teaching hospitals in Adelaide, South Australia. Participants were 86 patients with acute stroke (mean age, 75 years) who were admitted to hospital and required rehabilitation. Forty-two patients received early hospital discharge and home-based rehabilitation (median duration, 5 weeks), and 44 patients continued with conventional rehabilitation care after randomization. The primary end point was self-reported general health status (SF-36) at 6 months after randomization. A variety of secondary outcome measures were also assessed.

RESULTS

Overall, clinical outcomes for patients did not differ significantly between the groups at 6 months after randomization, but the total duration of hospital stay in the experimental group was significantly reduced (15 versus 30 days; P<0.001). Caregivers among the home-based rehabilitation group had significantly lower mental health SF-36 scores (mean difference, 7 points).

CONCLUSIONS

A policy of early hospital discharge and home-based rehabilitation for patients with stroke can reduce the use of hospital rehabilitation beds without compromising clinical patient outcomes. However, there is a potential risk of poorer mental health on the part of caregivers. The choice of this management strategy may therefore depend on convenience and costs but also on further evaluations of the impact of stroke on caregivers.

Home or hospital for stroke Rehabilitation? Results of a randomized controlled trial : II: cost minimization analysis at 6 months

BACKGROUND AND PURPOSE

The goal of the present study was to examine the resource and economic implications of an early hospital discharge and home-based rehabilitation scheme for patients with acute stroke.

METHODS

A cost minimization analysis in conjunction with a randomized controlled trial was carried out at 2 affiliated teaching hospitals in the southern metropolitan region of Adelaide, South Australia, between 1997 and 1998. Eighty-six hospitalized patients with acute stroke who required rehabilitation were randomized to receive both early hospital discharge and home-based rehabilitation, or conventional in-hospital rehabilitation and community care. Direct and indirect costs related to stroke rehabilitation were calculated, including hospital bed days, home-based intervention program, community services, and personal expenses during the 6 months after randomization.

RESULTS

The mean cost per patient was lower for patients randomized to the early hospital discharge and home-based rehabilitation ($8040) compared with those who received conventional care ($10 054). This cost saving was not statistically significant (P=0.14). However, sensitivity analyses indicated that the cost of home-based rehabilitation was consistently lower than that of conventional care except when hospital costs were assumed to be 50% less than those used in the main analysis. Multiple regression analysis demonstrated that the cost of the home-based program was significantly related to a patient's level of disability after adjustment for age, comorbidity, and the presence or absence of a caregiver.

CONCLUSIONS

The early hospital discharge and home-based rehabilitation scheme was less costly than conventional hospital care for patients with stroke. Limitation of the provision of such services to patients with mild disability is likely to be most cost effective.

Is health-related quality of life among older, chronically ill patients associated with unplanned readmission to hospital?

BACKGROUND

Assessment of health-related quality of life (HRQL) is being used increasingly to assess the impact of treatment.

AIMS

To determine if HRQL, assessed shortly after acute hospitalisation, is associated with readmission to hospital.

METHODS

In a prospective, longitudinal study, 163 chronically ill, medical and surgical patients (mean age 67.0+/-16.3 years) discharged to home following acute hospitalisation were studied. HRQL was assessed at one month post-hospital discharge using the MOS 36-Item Short-Form Health Survey (SF-36). Patients were followed-up for six months thereafter to determine subsequent incidence of unplanned readmission.

RESULTS

HRQL as measured by the eight health dimensions of the SF-36, for the entire cohort, was lower relative to age and gender matched norms for the local population (p<0.01). During study follow-up, 47 (35%) patients had an unplanned readmission and one patient died. Patients who had an unplanned readmission demonstrated both significantly lower physical (32.2+/-9.8 vs 38.6+/-10.1: p<0.001) and mental (45.1+/-12.7 vs 49.9+/-12.3: p=0.03) health component scores in comparison to the remainder of the cohort. On multivariate analysis, independent correlates of unplanned readmission were: 1) presence of formal home assistance (OR 6.4: p<0.01), 2) > or =five prescribed medications (OR 2.4: p=0.04), 3) > or =two admissions in the six months before follow-up (OR 4.3: p<0.01) and 4) an SF-36 physical component score of < or =40 (OR 2.2: p=0.05).

CONCLUSIONS

In this cohort of predominantly older and chronically ill patients recently discharged from acute hospital care, relatively lower SF-36 physical health component scores were independently associated with an increased risk of subsequent unplanned readmission.