Pandemic (H1N1) 2009 Influenza Outbreak in Australia: Impact on Emergency Departments.

Executive summary Objective: The aims of this study were to identify the impact of Pandemic (H1N1) 2009 Influenza on Australian Emergency Departments (EDs) and their staff, and to inform planning, preparedness, and response management arrangements for future pandemics, as well as managing infectious patients presenting to EDs in everyday practice. Methods This study involved three elements: 1. The first element of the study was an examination of published material including published statistics. Standard literature research methods were used to identify relevant published articles. In addition, data about ED demand was obtained from Australian Government Department of Health and Ageing (DoHA) publications, with several state health departments providing more detailed data. 2. The second element of the study was a survey of Directors of Emergency Medicine identified with the assistance of the Australasian College for Emergency Medicine (ACEM). This survey retrieved data about demand for ED services and elicited qualitative comments on the impact of the pandemic on ED management. 3. The third element of the study was a survey of ED staff. A questionnaire was emailed to members of three professional colleges—the ACEM; the Australian College of Emergency Nursing (ACEN); and the College of Emergency Nursing Australasia (CENA). The overall response rate for the survey was 18.4%, with 618 usable responses from 3355 distributed questionnaires. Topics covered by the survey included ED conditions during the (H1N1) 2009 influenza pandemic; information received about Pandemic (H1N1) 2009 Influenza; pandemic plans; the impact of the pandemic on ED staff with respect to stress; illness prevention measures; support received from others in work role; staff and others’ illness during the pandemic; other factors causing ED staff to miss work during the pandemic; and vaccination against Pandemic (H1N1) 2009 Influenza. Both qualitative and quantitative data were collected and analysed. Results: The results obtained from Directors of Emergency Medicine quantifying the impact of the pandemic were too limited for interpretation. Data sourced from health departments and published sources demonstrated an increase in influenza-like illness (ILI) presentations of between one and a half and three times the normal level of presentations of ILIs. Directors of Emergency Medicine reported a reasonable level of preparation for the pandemic, with most reporting the use of pandemic plans that translated into relatively effective operational infection control responses. Directors reported a highly significant impact on EDs and their staff from the pandemic. Growth in demand and related ED congestion were highly significant factors causing distress within the departments. Most (64%) respondents established a ‘flu clinic’ either as part of Pandemic (H1N1) 2009 Influenza Outbreak in Australia: Impact on Emergency Departments. the ED operations or external to it. They did not note a significantly higher rate of sick leave than usual. Responses relating to the impact on staff were proportional to the size of the colleges. Most respondents felt strongly that Pandemic (H1N1) 2009 Influenza had a significant impact on demand in their ED, with most patients having low levels of clinical urgency. Most respondents felt that the pandemic had a negative impact on the care of other patients, and 94% revealed some increase in stress due to lack of space for patients, increased demand, and filling staff deficits. Levels of concern about themselves or their family members contracting the illness were less significant than expected. Nurses displayed significantly higher levels of stress overall, particularly in relation to skill-mix requirements, lack of supplies and equipment, and patient and patients’ family aggression. More than one-third of respondents became ill with an ILI. Whilst respondents themselves reported taking low levels of sick leave, respondents cited difficulties with replacing absent staff. Ranked from highest to lowest, respondents gained useful support from ED colleagues, ED administration, their hospital occupational health department, hospital administration, professional colleges, state health department, and their unions. Respondents were generally positive about the information they received overall; however, the volume of information was considered excessive and sometimes inconsistent. The media was criticised as scaremongering and sensationalist and as being the cause of many unnecessary presentations to EDs. Of concern to the investigators was that a large proportion (43%) of respondents did not know whether a pandemic plan existed for their department or hospital. A small number of staff reported being redeployed from their usual workplace for personal risk factors or operational reasons. As at the time of survey (29 October –18 December 2009), 26% of ED staff reported being vaccinated against Pandemic (H1N1) 2009 Influenza. Of those not vaccinated, half indicated they would ‘definitely’ or ‘probably’ not get vaccinated, with the main reasons being the vaccine was ‘rushed into production’, ‘not properly tested’, ‘came out too late’, or not needed due to prior infection or exposure, or due to the mildness of the disease. Conclusion: Pandemic (H1N1) 2009 Influenza had a significant impact on Australian Emergency Departments. The pandemic exposed problems in existing plans, particularly a lack of guidelines, general information overload, and confusion due to the lack of a single authoritative information source. Of concern was the high proportion of respondents who did not know if their hospital or department had a pandemic plan. Nationally, the pandemic communication strategy needs a detailed review, with more engagement with media networks to encourage responsible and consistent reporting. Also of concern was the low level of immunisation, and the low level of intention to accept vaccination. This is a problem seen in many previous studies relating to seasonal influenza and health care workers. The design of EDs needs to be addressed to better manage infectious patients. Significant workforce issues were confronted in this pandemic, including maintaining appropriate staffing levels; staff exposure to illness; access to, and appropriate use of, personal protective equipment (PPE); and the difficulties associated with working in PPE for prolonged periods. An administrative issue of note was the reporting requirement, which created considerable additional stress for staff within EDs. Peer and local support strategies helped ensure staff felt their needs were provided for, creating resilience, dependability, and stability in the ED workforce. Policies regarding the establishment of flu clinics need to be reviewed. The ability to create surge capacity within EDs by considering staffing, equipment, physical space, and stores is of primary importance for future pandemics.

Genetic Composition and Complexity of Virus Populations at Tungro-Endemic and Outbreak Rice Sites

We have recently demonstrated the geographic isolation of rice tungro bacilliform virus (RTBV) populations in the tungro-endemic provinces of Isabela and North Cotabato, Philippines. In this study, we examined the genetic structure of the virus populations at the tungro-outbreak sites of Lanao del Norte, a province adjacent to North Cotabato. We also analyzed the virus populations at the tungro-endemic sites of Subang, Indonesia, and Dien Khanh, Vietnam. Total DNA extracts from 274 isolates were digested with EcoRV restriction enzyme and hybridized with a full-length probe of RTBV. In the total population, 22 EcoRV-restricted genome profiles (genotypes) were identified. Although overlapping genotypes could be observed, the outbreak sites of Lanao del Norte had a genotype combination distinct from that of Subang or Dien Khanh but a genotype combination similar to that identified earlier from North Cotabato, the adjacent endemic province. Sequence analysis of the intergenic region and part of the ORF1 RTBV genome from randomly selected genotypes confirms the geographic clustering of RTBV genotypes and, combined with restriction analysis, the results suggest a fragmented spatial distribution of RTBV local populations in the three countries. Because RTBV depends on rice tungro spherical virus (RTSV) for transmission, the population dynamics of both tungro viruses were then examined at the endemic and outbreak sites within the Philippines. The RTBV genotypes and the coat protein RTSV genotypes were used as indicators for virus diversity. A shift in population structure of both viruses was observed at the outbreak sites with a reduced RTBV but increased RTSV gene diversity

An examination of the predictors of blood donors' intentions to donate during two phases of an avian influenza outbreak

BACKGROUND: Data from prior health scares suggest that an avian influenza outbreak will impact on people’s intention to donate blood; however research exploring this is scarce. Using an augmented theory of planned behavior (TPB), incorporating threat perceptions alongside the rational decision-making components of the TPB, the current study sought to identify predictors of blood donors’ intentions to donate during two phases of an avian influenza outbreak. STUDY DESIGN AND METHODS: Blood donors (N = 172) completed an on-line survey assessing the standard TPB predictors as well as measures of threat perceptions from the health belief model (HBM; i.e., perceived susceptibility and severity). Path analyses examined the utility of the augmented TPB to predict donors’ intentions to donate during a low- and high-risk phase of an avian influenza outbreak. RESULTS: In both phases, the model provided a good fit to the data explaining 69% (low risk) and 72% (high risk) of the variance in intentions. Attitude, subjective norm, and perceived susceptibility significantly predicted donor intentions in both phases. Within the low-risk phase, gender was an additional significant predictor of intention, while in the high-risk phase, perceived behavioral control was significantly related to intentions. CONCLUSION: An augmented TPB model can be used to predict donors’ intentions to donate blood in a low-risk and a high-risk phase of an outbreak of avian influenza. As such, the results provide important insights into donors’ decision-making that can be used by blood agencies to maintain the blood supply in the context of an avian influenza outbreak.

Epidemiologic modeling with FluSurge for pandemic (H1N1) 2009 outbreak, Queensland, Australia

At the beginning of the pandemic (H1N1) 2009 outbreak, we estimated the potential surge in demand for hospital-based services in 4 Health Service Districts of Queensland, Australia, using the FluSurge model. Modifications to the model were made on the basis of emergent evidence and results provided to local hospitals to inform resource planning for the forthcoming pandemic. To evaluate the fit of the model, a comparison between the model's predictions and actual hospitalizations was made. In early 2010, a Web-based survey was undertaken to evaluate the model's usefulness. Predictions based on modified assumptions arising from the new pandemic gained better fit than results from the default model. The survey identified that the modeling support was helpful and useful to service planning for local hospitals. Our research illustrates an integrated framework involving post hoc comparison and evaluation for implementing epidemiologic modeling in response to a public health emergency.

Beliefs underlying blood donors’ intentions to donate during two phases of an avian influenza outbreak

Using a Theory of Planned Behavior (TPB) framework the current study explored the beliefs of current blood donors (N=172) about donating during a low and high-risk phase of a potential avian influenza outbreak. While the majority of behavioral, normative, and control beliefs identified in preliminary research differed as a function of donors’ intentions to donate during both phases of an avian influenza outbreak, regression analyses suggested that the targeting of different specific beliefs during each phase of an outbreak would yield most benefit in bolstering donors’ intentions to remain donating. The findings provide insight in how to best motivate donors in different phases of an avian influenza outbreak.

Investigation of a food poisoning outbreak due to nitrite contained in cooked peanut [一起因食用煮花生米引起亚硝酸盐中毒的调查报告]

Two workers were hospitalised with similar symptoms. Information was gathered from patients, doctors, colleagues and food seller. Laboratory tests were undertaken on remaining food and vomits. We identified the source food and toxin responsible for this outbreak, and subsequently helped doctors to treat these patients. The intake was estimated to be over the fatal limit but both were fully recovered after treatment. Abstract in Chinese 2001年11月20日，寿光市植物油厂的2名装卸工人因食用花生米引起亚硝酸盐急性中毒，现报告如下。 1 中毒经过 11月20日下午，市植物油厂装卸工人秦×下班后，到本厂职工食堂买了馒头、大米稀饭和少许咸菜，然后到厂外买了1瓶白酒，又到个体菜摊李×处买了2元钱的煮花生米，约400g。17：40与同事江×一同在宿舍内饮酒吃饭，其中花生米大部分被秦×吃掉，江×吃得少。18：30左右秦×在装卸过程中出现双腿发软、恶心、呕吐、呼吸困难、视物模糊，江×随后也出现类似症状，2人被迅速送往寿光市人民医院进行抢救。到医院时已进入昏迷状态，查体可见全身皮肤粘膜青紫、手指脚趾发黑，经吸氧并心电监护、应用美兰静推后，江×症状减轻，于次日出院；秦×因中毒严重，于次日脱离危险，11月23日痊愈出院。……

An outbreak of salmonellosis linked to a marine turtle

In September 1998, an outbreak of gastroenteritis occurred in a coastal Aboriginal community in the Northern Territory over a seven day period. An investigation was conducted by the Center for Disease Control, Territory Health Services. Thirty-six cases were detected and 17% (n=6) were hospitalized. Salmonella chester was isolated from eight of nine stool specimens. Sixty-two percent of cases interviewed (n=28) reported consumption of a green turtle (Chelonia mydas) within a median of 24 hours prior to onset of illness. Of the remainder, all but two were contacts of other cases. Salmonella chester was isolated from a section of partially cooked turtle meat. There are no previous published reports of salmonellosis associated with consumption of sea turtles despite them being a popular food source in coastal communities in the Pacific.

An outbreak of salmonellosis linked to a marine turtle

On 18 September 1998 the Centre for Disease Control (CDC), Darwin was notified of an outbreak of gastroenteritis predominantly affecting adults in a Top End coastal community. There had been no previous presentations to the community clinic in the month of September with vomiting or diarrhoea. On 14 September, a green turtle (Chledonia mydas) was cooked and distributed throughout the community. Water collected from a water hole near the community (known as the aerator) was used as drinking water at the cook site and to cook the meat. In addition, there were reports that kava, a plant derived tranquilliser,1 had been consumed the night before using water from the same source. An investigation was conducted to determine the aetiology and source and to instigate prevention and control measures.

Ongoing outbreak of dengue serotype 3 in Solomon Islands, January to May 2013

Introduction In January 2013, clinicians in Honiara, Solomon Islands noted several patients presenting with dengue-like illness. Serum from three cases tested positive for dengue by rapid diagnostic test. Subsequent increases in cases were reported, and the outbreak was confirmed as being dengue serotype-3 by further laboratory tests. This report describes the ongoing outbreak investigation, findings and response. Methods Enhanced dengue surveillance was implemented in the capital, Honiara, and in the provinces. This included training health staff on dengue case definitions, data collection and reporting. Vector surveillance was also conducted. Results From 3 January to 15 May 2013, 5254 cases of suspected dengue were reported (101.8 per 10 000 population), including 401 hospitalizations and six deaths. The median age of cases was 20 years (range zero to 90), and 86% were reported from Honiara. Both Aedes aegyti and Aedes albopictus were identified in Honiara. Outbreak response measures included clinical training seminars, vector control activities, implementation of diagnostic and case management protocols and a public communication campaign. Discussion This was the first large dengue outbreak documented in Solomon Islands. Factors that may have contributed to this outbreak include a largely susceptible population, the presence of a highly efficient dengue vector in Honiara, a high-density human population with numerous breeding sites and favourable weather conditions for mosquito proliferation. Although the number of cases has plateaued since 1 April, continued enhanced nationwide surveillance and response activities are necessary.

Predator Crown-of-Thorns Starfish (Acanthaster planci) Outbreak, Mass Mortality of Corals, and Cascading Effects on Reef Fish and Benthic Communities

Outbreaks of the coral-killing seastar Acanthaster planci are intense disturbances that can decimate coral reefs. These events consist of the emergence of large swarms of the predatory seastar that feed on reef-building corals, often leading to widespread devastation of coral populations. While cyclic occurrences of such outbreaks are reported from many tropical reefs throughout the Indo-Pacific, their causes are hotly debated, and the spatio-temporal dynamics of the outbreaks and impacts to reef communities remain unclear. Based on observations of a recent event around the island of Moorea, French Polynesia, we show that Acanthaster outbreaks are methodic, slow-paced, and diffusive biological disturbances. Acanthaster outbreaks on insular reef systems like Moorea's appear to originate from restricted areas confined to the ocean-exposed base of reefs. Elevated Acanthaster densities then progressively spread to adjacent and shallower locations by migrations of seastars in aggregative waves that eventually affect the entire reef system. The directional migration across reefs appears to be a search for prey as reef portions affected by dense seastar aggregations are rapidly depleted of living corals and subsequently left behind. Coral decline on impacted reefs occurs by the sequential consumption of species in the order of Acanthaster feeding preferences. Acanthaster outbreaks thus result in predictable alteration of the coral community structure. The outbreak we report here is among the most intense and devastating ever reported. Using a hierarchical, multi-scale approach, we also show how sessile benthic communities and resident coral-feeding fish assemblages were subsequently affected by the decline of corals. By elucidating the processes involved in an Acanthaster outbreak, our study contributes to comprehending this widespread disturbance and should thus benefit targeted management actions for coral reef ecosystems.

The challenge to know and control: Disease outbreak surveillance and alerts in China and India

Since the revisions to the International Health Regulations (IHR) in 2005, much attention has been turned to how states, particularly developing states, will address core capacity requirements. The question often examined is how states with poor health systems can strengthen their capacity to identify and verify public health emergencies of international concern. A core capacity requirement is that by 2012 states will have a surveillance and response network that operates from the local community to the national level. Much emphasis has turned to the health system capacity required for this task. In this article, I seek to understand the political capacity to perform this task. This article considers how the world's two most populous states,1 1. For the purposes of this paper, I use the word ‘state’ as a shorthand for the nation-state of China and India, or member state as used by the United Nations. View all notes China and India, have sought to communicate outbreak events in times of crisis and calm. I consider what this reporting performance tells us of their capacity to meet their IHR obligations given the two countries differing political institutions.