Awareness and Coverage of the National Health Insurance Scheme among Formal Sector Workers in Ilorin, Nigeria

A prepayment scheme for health through the National Health Insurance Scheme (NHIS) was commenced in Nigeria about ten years ago. Nigeria operates a federal system of government. Sub- national levels possess a high degree of autonomy in a number of sectors including health. It is important to assess the level of coverage of the scheme among the formal sector workers in Nigeria as a proxy to gauge the extent of coverage of the scheme and derive suitable lessons that could be used in its expansion. This is a cross-sectional, descriptive survey carried out among formal sector workers in Ilorin Kwara State, Nigeria. A stratified sampling technique was used to select study participants. A self-administered questionnaire was used to collect data from respondents. Data was analysed with the SPSS. Ethical approval to conduct the study was obtained from the Bowen University Teaching Hospital Research Ethics Committee. A total of 370 people participated in the study. Majority, (78.9%) of the respondents were aware of the NHIS, however only 13.5 % paid for health care services through the NHIS. Logistic regression analysis shows that respondents with post-secondary education (OR = 9.032, CI = 2.562 – 31.847, p = 0.001) and in federal civil service (OR = 2.679, CI = 1.036 – 6.929, p = 0.042) were over nine and three times more likely to be aware of the scheme than others. Coverage of the scheme among the respondents was unimpressive. A lot still need to be done to fast-track the expansion of the scheme among this sector of the population.

Early consumption of liquids different to breast milk in Mexican infants under 1 year: results of the probabilistic National Health and Nutrition Survey 2012

Introduction: Studies on infant dietary intake do not generally focus on the types of liquids consumed. Objective: To document by age and breastfeeding status, the types of liquids present in the diet of Mexican children under 1 year of age (< 1 y) who participated in the National Health and Nutrition Survey 2012 (ENSANUT-2012). Methods: Analysis of the infant < 1 y feeding practices from the ENSANUT-2012 survey in non-breastfed (non-BF) and breastfed (BF) infants by status quo for the consumption of liquids grouped in: water, formula, fortified LICONSA milk, nutritive liquids (NL; thin cereal-based gruel with water or milk and coffee with milk) and non-nutritive liquids (non-NL) as sugared water, water-based drinks, tea, beans or chicken broth, aguamiel and coffee. In this infants < 1 y we analyzed the not grouped consumption of liquids in the first three days of life (newborns) from the mother's recall. Percentage and confidence intervals (95% CI) were calculated adjusting for survey design. Statistical differences were analyzed by Z test. Results: We observed a high consumption of human milk followed by formula (56.7%) and water (51.1%) in infants under 6 months of age (< 6 mo). The proportion of non-BF infants consuming non-NL was higher than for BF infants (p < 0.05). More than 60% of older infants (6 mo and < 1 y) consumed formula and were non-BF. In newborns formula consumption was predominant, followed by tea or infusion and water. Conclusions: Non-breast milk liquids are present undesirably in Mexican infants' diet and non-NL are consumed earlier than NL, revealing inadequate early dietary practices.

A construção do Sistema Nacional de Vigilância Sanitária: uma análise das relações intergovernamentais na perspectiva do federalismo

Este estudo focaliza a construção do Sistema Nacional de Vigilância Sanitária (SNVS) e a analisa do ponto de vista das relações intergovernamentais. Nessa construção, ressalta-se que o modelo de descentralização, adotado pela esfera federal até 2003, seguiu um caminho diferente das ações assistenciais, centrado no reforço à esfera estadual. E um caminho diferenciado em relação à partilha federativa que beneficiou a esfera municipal, e nesta, os pequenos municípios. Dos quatro princípios básicos do federalismo, enfatizam-se a cooperação e a coordenação. A cooperação se relaciona com a autonomia dos entes federados e com o grau de descentralização vigente. A coordenação é vista como necessária para se obter a cooperação. O pano de fundo é a heterogeneidade estrutural dos municípios brasileiros. Examinam-se: a evolução do regime federativo nas constituições republicanas e as relações intergovernamentais que se estabelecem; a trajetória históricas da vigilância sanitária e epidemiológica; o processo de descentralização da vigilância sanitária no Estado do Rio de Janeiro. Aponta-se que a estratégia adotada no âmbito do SUS, de municipalização das ações de saúde, tendo proporcionado ganhos na cobertura assistencial e fragmentação da rede de serviços, merece maior reflexão na sua transposição para a vigilância sanitária. A natureza de sua função de Estado, o grau potencialmente alto de externalidade negativa e a heterogeneidade estrutural municipal colocam: a imprescindibilidade da coordenação efetiva pela União; a necessidade de reforço ao papel da esfera estadual no contexto da necessidade de cooperação regional e local; a urgência na reformulação dos critérios para descentralização e financiamento das ações de vigilância sanitária. Sem pretender esgotar a questão federativa da vigilância sanitária, apresentam-se algumas propostas para discussão visando superar alguns dos problemas detectados.

MANICURE/PEDICURE TECHNICIANS: BIOSECURITY KNOWLEDGE AND PRACTICES FOR VIRAL HEPATITIS

Objetivo: Investigar o conhecimento e as práticas de biossegurança para hepatites virais de manicures/pedicures. Métodos: Estudo descritivo, transversal, quantitativo, através de questionário, utilizando instrumento de coleta de dados autoaplicado elaborado pelos pesquisadores, contendo dados da população (sexo, idade, tempo de atuação profissional) e conhecimentos básicos sobre transmissão de hepatite e práticas de biossegurança e higiene. Resultados: Entrevistaram-se 96 manicures/pedicures que atuam no Noroeste do Paraná. A maioria das profissionais já ouviu falar da patologia, mas somente 41,7% (n=40) fizeram o exame para detecção do vírus da hepatite; 38,39% (n=77) relataram como via de transmissão o sangue e 31,8% (n=63), a relação sexual. A reutilização de materiais descartáveis foi relatada por 60,4% (n=58); 55,2% (n=53) realizam esterilização de materiais e 27,1% (n=26) não a realizam. Não ficou evidenciada associação significativa entre tempo de profissão e as variáveis utilizadas: ouviu sobre hepatite (p=0,77025), realização de exames (p=0,035476), reutilização de materiais descartáveis (p=0,42691), lavagem de mãos (p=0,32876), uso de luvas descartáveis (p=0,33752) e esterilização de materiais (p=0,84443). Conclusão: As manicures entrevistadas não conhecem as exigências da Vigilância Sanitária no que concerne à prevenção da transmissão de hepatites.

A new national women's health policy : legal, ethical and policy initiatives to support women's health

In 1989 the first National Women's Health Policy was launched in Australia. Now, 20 years later, the Federal Government has announced plans for the development of a new National Women's Health Policy to address the health needs of Australian women. The Policy will be based on five principles: gender equity; health equity between women; a focus on prevention; an evidence base for interventions; and a life course approach. This editorial examines the role for law in the development of a new National Women's Health Policy. It considers the relevance of regulatory frameworks for health research in supporting an evidence base for health interventions and analyses the requirement in the National Health and Medical Research Council's National Statement on Ethical Conduct in Human Research for "fair inclusion" of research participants. The editorial argues for a holistic approach to women's health that includes regulatory frameworks for research, identification of funding priorities for research, and the need for a dedicated government department or agency to promote women's health.

Healthcare-associated infections in Australia : time for national surveillance

Abstract Objective. Healthcare-associated infection (HAI) surveillance programs are critical for infection prevention. Australia does not have a comprehensive national HAI surveillance program. The purpose of this paper is to provide an overview of established international and Australian statewide HAI surveillance programs and recommend a pathway for the development of a national HAI surveillance program in Australia. Methods. This study examined existing HAI surveillance programs through a literature review, a review of HAI surveillance program documentation, such as websites, surveillance manuals and data reports and direct contact with program representatives. Results. Evidence from international programs demonstrates national HAI surveillance reduces the incidence of HAIs. However, the current status of HAI surveillance activity in Australian states is disparate, variation between programs is not well understood, and the quality of data currently used to compose national HAI rates is uncertain. Conclusions. There is a need to develop a well-structured, evidence-based national HAI program in Australia to meet the increasing demand for validated reliable national HAI data. Such a program could be leveraged off the work of existing Australian and international programs.

Variation in health care-associated infection surveillance practices in Australia

In the absence of a national health care-associated infection surveillance program in Australia, differences between existing state-based programs were explored using an online survey. Only 51% of respondents who undertake surveillance have been trained, fewer than half perform surgical site infection surveillance prospectively, and only 41% indicated they risk adjust surgical site infection data. Wide- spread variation of surveillance methods highlights future challenges when considering the development and implementation of a national program in Australia.

Novel application of a discrete choice experiment to identify preferences for a national healthcare-associated infection surveillance programme: A cross-sectional study

Objective: To identify key stakeholder preferences and priorities when considering a national healthcare-associated infection (HAI) surveillance programme through the use of a discrete choice experiment (DCE). Setting: Australia does not have a national HAI surveillance programme. An online web-based DCE was developed and made available to participants in Australia. Participants: A sample of 184 purposively selected healthcare workers based on their senior leadership role in infection prevention in Australia. Primary and secondary outcomes: A DCE requiring respondents to select 1 HAI surveillance programme over another based on 5 different characteristics (or attributes) in repeated hypothetical scenarios. Data were analysed using a mixed logit model to evaluate preferences and identify the relative importance of each attribute. Results: A total of 122 participants completed the survey (response rate 66%) over a 5-week period. Excluding 22 who mismatched a duplicate choice scenario, analysis was conducted on 100 responses. The key findings included: 72% of stakeholders exhibited a preference for a surveillance programme with continuous mandatory core components (mean coefficient 0.640 (p<0.01)), 65% for a standard surveillance protocol where patient-level data are collected on infected and non-infected patients (mean coefficient 0.641 (p<0.01)), and 92% for hospital-level data that are publicly reported on a website and not associated with financial penalties (mean coefficient 1.663 (p<0.01)). Conclusions: The use of the DCE has provided a unique insight to key stakeholder priorities when considering a national HAI surveillance programme. The application of a DCE offers a meaningful method to explore and quantify preferences in this setting.

Metodologia para elaboração de glossários bilíngues para a Agência Nacional de Vigilância Sanitária – ANVISA

Dissertação (mestrado)—Universidade de Brasília, Instituto de Letras, Departamento de Línguas Estrangeiras e Tradução, Programa de Pós-Graduação em Estudos da Tradução, 2016.

Quality issues for the National Bowel Cancer Screening Program (NBCSP)

Purpose: This two-part research project was undertaken as part of the planning process by Queensland Health (QH), Cancer Screening Services Unit (CSSU), Queensland Bowel Cancer Screening Program (QBCSP), in partnership with the National Bowel Cancer Screening Program (NBCSP), to prepare for the implementation of the NBCSP in public sector colonoscopy services in QLD in late 2006. There was no prior information available on the quality of colonoscopy services in Queensland (QLD) and no prior studies that assessed the quality of colonoscopy training in Australia. Furthermore, the NBCSP was introduced without extra funding for colonoscopy service improvement or provision for increases in colonoscopic capacity resulting from the introduction of the NBCSP. The main purpose of the research was to record baseline data on colonoscopy referral and practice in QLD and current training in colonoscopy Australia-wide. It was undertaken from a quality improvement perspective. Implementation of the NBCSP requires that all aspects of the screening pathway, in particular colonoscopy services for the assessment of positive Faecal Occult Blood Tests (FOBTs), will be effective, efficient, equitable and evidence-based. This study examined two important aspects of the continuous quality improvement framework for the NBCSP as they relate to colonoscopy services: (1) evidence-based practice, and (2) quality of colonoscopy training. The Principal Investigator was employed as Senior Project Officer (Training) in the QBCSP during the conduct of this research project. Recommendations from this research have been used to inform the development and implementation of quality improvement initiatives for provision of colonoscopy in the NBCSP, its QLD counterpart the QBCSP and colonoscopy services in QLD, in general. Methods – Part 1 Chart audit of evidence-based practice: The research was undertaken in two parts from 2005-2007. The first part of this research comprised a retrospective chart audit of 1484 colonoscopy records (some 13% of all colonoscopies conducted in public sector facilities in the year 2005) in three QLD colonoscopy services. Whilst some 70% of colonoscopies are currently conducted in the private sector, only public sector colonoscopy facilities provided colonoscopies under the NBCSP. The aim of this study was to compare colonoscopy referral and practice with explicit criteria derived from the National Health & Medical Research Council (NHMRC) (1999) Clinical Practice Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer, and describe the nature of variance with the guidelines. Symptomatic presentations were the most common indication for colonoscopy (60.9%). These comprised per rectal bleeding (31.0%), change of bowel habit (22.1%), abdominal pain (19.6%), iron deficiency anaemia (16.2%), inflammatory bowel disease (8.9%) and other symptoms (11.4%). Surveillance and follow-up colonoscopies accounted for approximately one-third of the remaining colonoscopy workload across sites. Gastroenterologists (GEs) performed relatively more colonoscopies per annum (59.9%) compared to general surgeons (GS) (24.1%), colorectal surgeons (CRS) (9.4%) and general physicians (GPs) (6.5%). Guideline compliance varied with the designation of the colonoscopist. Compliance was lower for CRS (62.9%) compared to GPs (76.0%), GEs (75.0%), GSs (70.9%, p<0.05). Compliance with guideline recommendations for colonoscopic surveillance for family history of colorectal cancer (23.9%), polyps (37.0%) and a past history of bowel cancer (42.7%), was by comparison significantly lower than for symptomatic presentations (94.4%), (p<0.001). Variation with guideline recommendations occurred more frequently for polyp surveillance (earlier than guidelines recommend, 47.9%) and follow-up for past history of bowel cancer (later than recommended, 61.7%, p<0.001). Bowel cancer cases detected at colonoscopy comprised 3.6% of all audited colonoscopies. Incomplete colonoscopies occurred in 4.3% of audited colonoscopies and were more common among women (76.6%). For all colonoscopies audited, the rate of incomplete colonoscopies for GEs was 1.6% (CI 0.9-2.6), GPs 2.0% (CI 0.6-7.2), GS 7.0% (CI 4.8-10.1) and CRS 16.4% (CI 11.2-23.5). 18.6% (n=55) of patients with a documented family history of bowel cancer had colonoscopy performed against guidelines recommendations (for general (category 1) population risk, for reasons of patient request or family history of polyps, rather than for high risk status for colorectal cancer). In general, family history was inadequately documented and subsequently applied to colonoscopy referral and practice. Methods - Part 2 Surveys of quality of colonoscopy training: The second part of the research consisted of Australia-wide anonymous, self-completed surveys of colonoscopy trainers and their trainees to ascertain their opinions on the current apprenticeship model of colonoscopy in Australia and to identify any training needs. Overall, 127 surveys were received from colonoscopy trainers (estimated response rate 30.2%). Approximately 50% of trainers agreed and 27% disagreed that current numbers of training places were adequate to maintain a skilled colonoscopy workforce in preparation for the NBCSP. Approximately 70% of trainers also supported UK-style colonoscopy training within dedicated accredited training centres using a variety of training approaches including simulation. A collaborative approach with the private sector was seen as beneficial by 65% of trainers. Non-gastroenterologists (non-GEs) were more likely than GEs to be of the opinion that simulators are beneficial for colonoscopy training (χ2-test = 5.55, P = 0.026). Approximately 60% of trainers considered that the current requirements for recognition of training in colonoscopy could be insufficient for trainees to gain competence and 80% of those indicated that ≥ 200 colonoscopies were needed. GEs (73.4%) were more likely than non-GEs (36.2%) to be of the opinion that the Conjoint Committee standard is insufficient to gain competence in colonoscopy (χ2-test = 16.97, P = 0.0001). The majority of trainers did not support training either nurses (73%) or GPs in colonoscopy (71%). Only 81 (estimated response rate 17.9%) surveys were received from GS trainees (72.1%), GE trainees (26.3%) and GP trainees (1.2%). The majority were males (75.9%), with a median age 32 years and who had trained in New South Wales (41.0%) or Victoria (30%). Overall, two-thirds (60.8%) of trainees indicated that they deemed the Conjoint Committee standard sufficient to gain competency in colonoscopy. Between specialties, 75.4% of GS trainees indicated that the Conjoint Committee standard for recognition of colonoscopy was sufficient to gain competence in colonoscopy compared to only 38.5% of GE trainees. Measures of competency assessed and recorded by trainees in logbooks centred mainly on caecal intubation (94.7-100%), complications (78.9-100%) and withdrawal time (51-76.2%). Trainees described limited access to colonoscopy training lists due to the time inefficiency of the apprenticeship model and perceived monopolisation of these by GEs and their trainees. Improvements to the current training model suggested by trainees included: more use of simulation, training tools, a United Kingdom (UK)-style training course, concentration on quality indicators, increased access to training lists, accreditation of trainers and interdisciplinary colonoscopy training. Implications for the NBCSP/QBCSP: The introduction of the NBCSP/QBCSP necessitates higher quality colonoscopy services if it is to achieve its ultimate goal of decreasing the incidence of morbidity and mortality associated with bowel cancer in Australia. This will be achieved under a new paradigm for colonoscopy training and implementation of evidence-based practice across the screening pathway and specifically targeting areas highlighted in this thesis. Recommendations for improvement of NBCSP/QBCSP effectiveness and efficiency include the following: 1. Implementation of NBCSP and QBCSP health promotion activities that target men, in particular, to increase FOBT screening uptake. 2. Improved colonoscopy training for trainees and refresher courses or retraining for existing proceduralists to improve completion rates (especially for female NBCSP/QBCSP participants), and polyp and adenoma detection and removal, including newer techniques to detect flat and depressed lesions. 3. Introduction of colonoscopy training initiatives for trainees that are aligned with NBCSP/QBCSP colonoscopy quality indicators, including measurement of training outcomes using objective quality indicators such as caecal intubation, withdrawal time, and adenoma detection rate. 4. Introduction of standardised, interdisciplinary colonoscopy training to reduce apparent differences between specialties with regard to compliance with guideline recommendations, completion rates, and quality of polypectomy. 5. Improved quality of colonoscopy training by adoption of a UK-style training program with centres of excellence, incorporating newer, more objective assessment methods, use of a variety of training tools such as simulation and rotations of trainees between metropolitan, rural, and public and private sector training facilities. 6. Incorporation of NHMRC guidelines into colonoscopy information systems to improve documentation, provide guideline recommendations at the point of care, use of gastroenterology nurse coordinators to facilitate compliance with guidelines and provision of guideline-based colonoscopy referral letters for GPs. 7. Provision of information and education about the NBCSP/QBCSP, bowel cancer risk factors, including family history and polyp surveillance guidelines, for participants, GPs and proceduralists. 8. Improved referral of NBCSP/QBCSP participants found to have a high-risk family history of bowel cancer to appropriate genetics services.

Food and Brisbane households : dietary, social and health consequences of food insecurity

Background & Aims: Access to sufficient amounts of safe and culturally-acceptable foods is a fundamental human right. Food security exists when all people, at all times, have physical, social, and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life. Food insecurity therefore occurs when the availability or access to sufficient amounts of nutritionally-adequate, culturally-appropriate and safe foods, or, the ability to acquire such foods in socially-acceptable ways, is limited. Food insecurity may result in significant adverse effects for the individual and these outcomes may vary between adults and children. Among adults, food insecurity may be associated with overweight or obesity, poorer self-rated general health, depression, increased health-care utilisation and dietary intakes less consistent with national recommendations. Among children, food insecurity may result in poorer self or parent-reported general health, behavioural problems, lower levels of academic achievement and poor social outcomes. The majority of research investigating the potential correlates of food insecurity has been undertaken in the United States (US), where regular national screening for food insecurity is undertaken using a comprehensive multi-item measurement. In Australia, screening for food insecurity takes place on a three yearly basis via the use of a crude, single-item included in the National Health Survey (NHS). This measure has been shown to underestimate the prevalence of food insecurity by 5%. From 1995 – 2004, the prevalence of food insecurity among the Australian population remained stable at 5%. Due to the perceived low prevalence of this issue, screening for food insecurity was not undertaken in the most recent NHS. Furthermore, there are few Australian studies investigating the potential determinants of food insecurity and none investigating potential outcomes among adults and children. This study aimed to examine these issues by a) investigating the prevalence of food insecurity among households residing in disadvantaged urban areas and comparing prevalence rates estimated by the more comprehensive 18-item and 6-item United States Department of Agriculture (USDA) Food Security Survey Module (FSSM) to those estimated by the current single-item measure used for surveillance in Australia and b) investigating the potential determinants and outcomes of food insecurity, Methods: A comprehensive literature review was undertaken to investigate the potential determinants and consequences of food insecurity among developed countries. This was followed by a cross-sectional study in which 1000 households from the most disadvantaged 5% of Brisbane areas were sampled and data collected via mail-based survey (final response rate = 53%, n = 505). Data were collected for food security status, sociodemographic characteristics (household income, education, age, gender, employment status, housing tenure and living arrangements), fruit and vegetable intakes, meat and take-away consumption, presence of depressive symptoms, presence of chronic disease and body mass index (BMI) among adults. Among children, data pertaining to BMI, parent-reported general health, days away from school and activities and behavioural problems were collected. Rasch analysis was used to investigate the psychometric properties of the 18-, 10- and 6-item adaptations of the USDA-FSSM, and McNemar's test was used to investigate the difference in the prevalence of food insecurity as measured by these three adaptations compared to the current single-item measure used in Australia. Chi square and logistic regression were used to investigate the differences in dietary and health outcomes among adults and health and behavioural outcomes among children. Results were adjusted for equivalised household income and, where necessary, for indigenous status, education and family type. Results: Overall, 25% of households in these urbanised-disadvantaged areas reported experiencing food insecurity; this increased to 34% when only households with children were analysed. The current reliance on a single-item measure to screen for food insecurity may underestimate the true burden among the Australian population, as this measure was shown to significantly underestimate the prevalence of food insecurity by five percentage points. Internationally, major potential determinants of food insecurity included poverty and indicators of poverty, such as low-income, unemployment and lower levels of education. Ethnicity, age, transportation and cooking and financial skills were also found to be potential determinants of food insecurity. Among Australian adults in disadvantaged urban areas, food insecurity was associated with a three-fold increase in experiencing poorer self-rated general health and a two-to-five-fold increase in the risk of depression. Furthermore, adults from food insecure households were twoto- three times more likely to have seen a general practitioner and/or been admitted to hospital within the previous six months, compared to their food secure counterparts. Weight status and intakes of fruits, vegetables and meat were not associated with food insecurity. Among Australian households with children, those in the lowest tertile were over 16 times more likely to experience food insecurity compared to those in the highest tertile for income. After adjustment for equivalised household income, children from food insecure households were three times more likely to have missed days away from school or other activities. Furthermore, children from food insecure households displayed a two-fold increase in atypical emotions and behavioural difficulties. Conclusions: Food insecurity is an important public health issue and may contribute to the burden on the health care system through its associations with depression and increased health care utilisation among adults and behavioural and emotional problems among children. Current efforts to monitor food insecurity in Australia do not occur frequently and use a tool that may underestimate the prevalence of food insecurity. Efforts should be made to improve the regularity of screening for food insecurity via the use of a more accurate screening measure. Most of the current strategies that aim to alleviate food insecurity do not sufficiently address the issue of insufficient financial resources for acquiring food; a factor which is an important determinant of food insecurity. Programs to address this issue should be developed in collaboration with groups at higher risk of developing food insecurity and should incorporate strategies to address the issue of low income as a barrier to food acquisition.

The epidemiology of severe Streptococcus pyogenes disease in Europe

Diseases caused by the Lancefield group A streptococcus, Streptococcus pyogenes, are amongst the most challenging to clinicians and public health specialists alike. Although severe infections caused by S. pyogenes are relatively uncommon, affecting around 3 per 100,000 of the population per annum in developed countries, the case fatality is high relative to many other infections. Despite a long scientific tradition of studying their occurrence and characteristics, many aspects of their epidemiology remain poorly understood, and potential control measures undefined. Epidemiological studies can play an important role in identifying host, pathogen and environmental factors associated with risk of disease, manifestation of particular syndromes or poor survival. This can be of value in targeting prevention activities, as well directing further basic research, potentially paving the way for the identification of novel therapeutic targets. The formation of a European network, Strep-EURO, provided an opportunity to explore epidemiological patterns across Europe. Funded by the Fifth Framework Programme of the European Commission s Directorate-General for Research (QLK2.CT.2002.01398), the Strep-EURO network was launched in September 2002. Twelve participants across eleven countries took part, led by the University of Lund in Sweden. Cases were defined as patients with S. pyogenes isolated from a normally sterile site, or non-sterile site in combination with clinical signs of streptococcal toxic shock syndrome (STSS). All participating countries undertook prospective enhanced surveillance between 1st January 2003 and 31st December 2004 to identify cases diagnosed during this period. A standardised surveillance dataset was defined, comprising demographic, clinical and risk factor information collected through a questionnaire. Isolates were collected by the national reference laboratories and characterised according to their M protein using conventional serological and emm gene typing. Descriptive statistics and multivariable analyses were undertaken to compare characteristics of cases between countries and identify factors associated with increased risk of death or development of STSS. Crude and age-adjusted rates of infection were calculated for each country where a catchment population could be defined. The project succeeded in establishing the first European surveillance network for severe S. pyogenes infections, with 5522 cases identified over the two years. Analysis of data gathered in the eleven countries yielded important new information on the epidemiology of severe S. pyogenes infections in Europe during the 2000s. Comprehensive epidemiological data on these infections were obtained for the first time from France, Greece and Romania. Incidence estimates identified a general north-south gradient, from high to low. Remarkably similar age-standardised rates were observed among the three Nordic participants, between 2.2 and 2.3 per 100,000 population. Rates in the UK were higher still, 2.9/100,000, elevated by an upsurge in drug injectors. Rates from these northern countries were reasonably close to those observed in the USA and Australia during this period. In contrast, rates of reports in the more central and southern countries (Czech Republic, Romania, Cyprus and Italy) were substantially lower, 0.3 to 1.5 per 100,000 population, a likely reflection of poorer uptake of microbiological diagnostic methods within these countries. Analysis of project data brought some new insights into risk factors for severe S. pyogenes infection, especially the importance of injecting drug users in the UK, with infections in this group fundamentally reshaping the epidemiology of these infections during this period. Several novel findings arose through this work, including the high degree of congruence in seasonal patterns between countries and the seasonal changes in case fatality rates. Elderly patients, those with compromised immune systems, those who developed STSS and those infected with an emm/M78, emm/M5, emm/M3 or emm/M1 were found to be most likely to die as a result of their infection, whereas those diagnosed with cellulitis, septic arthritis, puerperal sepsis or with non-focal infection were associated with low risk of death, as were infections occurring during October. Analysis of augmented data from the UK found use of NSAIDs to be significantly associated with development of STSS, adding further fuel to the debate surrounding the role of NSAIDs in the development of severe disease. As a largely community-acquired infection, occurring sporadically and diffusely throughout the population, opportunities for control of severe infections caused by S. pyogenes remain limited, primarily involving contact chemoprophylaxis where clusters arise. Analysis of UK Strep-EURO data were used to quantify the risk to household contacts of cases, forming the basis of national guidance on the management of infection. Vaccines currently under development could offer a more effective control programme in future. Surveillance of invasive infections caused by S. pyogenes is of considerable public health importance as a means of identifying long and short-term trends in incidence, allowing the need for, or impact of, public health measures to be evaluated. As a dynamic pathogen co-existing among a dynamic population, new opportunities for exploitation of its human host are likely to arise periodically, and as such continued monitoring remains essential.

Allied health growth: What we do not measure we cannot manage

Background Data describing the Australian allied health workforce is inadequate and so insufficient for workforce planning. National health policy reform requires that health-care models take into account future workforce requirements, the distribution and work contexts of existing practitioners, training needs, workforce roles and scope of practice. Good information on this workforce is essential for managing services as demands increase, accountability of practitioners, measurement of outcomes and benchmarking against other jurisdictions. A comprehensive data set is essential to underpin policy and planning to meet future health workforce needs. Discussion Some data on allied health professions is managed by the Australian Health Practitioner Regulation Agency; however, there is limited information regarding several core allied health professions. A global registration and accreditation scheme recognizing all allied health professions might provide safeguards and credibility for professionals and their clients. Summary Arguments are presented about inconsistencies and voids in the available information about allied health services. Remedying these information deficits is essential to underpin policy and planning for future health workforce needs. We make the case for a comprehensive national data set based on a broad and inclusive sampling process across the allied health population.

Surveillance of Surgical Site Infections following Major Hip and Knee Surgery in Finland

Background and aims. Since 1999, hospitals in the Finnish Hospital Infection Program (SIRO) have reported data on surgical site infections (SSI) following major hip and knee surgery. The purpose of this study was to obtain detailed information to support prevention efforts by analyzing SIRO data on SSIs, to evaluate possible factors affecting the surveillance results, and to assess the disease burden of postoperative prosthetic joint infections in Finland. Methods. Procedures under surveillance included total hip (THA) and total knee arthroplasties (TKA), and the open reduction and internal fixation (ORIF) of femur fractures. Hospitals prospectively collected data using common definitions and written protocol, and also performed postdischarge surveillance. In the validation study, a blinded retrospective chart review was performed and infection control nurses were interviewed. Patient charts of deep incisional and organ/space SSIs were reviewed, and data from three sources (SIRO, the Finnish Arthroplasty Register, and the Finnish Patient Insurance Centre) were linked for capture-recapture analyses. Results. During 1999-2002, the overall SSI rate was 3.3% after 11,812 orthopedic procedures (median length of stay, eight days). Of all SSIs, 56% were detected after discharge. The majority of deep incisional and organ/space SSIs (65/108, 60%) were detected on readmission. Positive and negative predictive values, sensitivity, and specificity for SIRO surveillance were 94% (95% CI, 89-99%), 99% (99-100%), 75% (56-93%), and 100% (97-100%), respectively. Of the 9,831 total joint replacements performed during 2001-2004, 7.2% (THA 5.2% and TKA 9.9%) of the implants were inserted in a simultaneous bilateral operation. Patients who underwent bilateral operations were younger, healthier, and more often males than those who underwent unilateral procedures. The rates of deep SSIs or mortality did not differ between bi- and uni-lateral THAs or TKAs. Four deep SSIs were reported following bilateral operations (antimicrobial prophylaxis administered 48-218 minutes before incision). In the three registers, altogether 129 prosthetic joint infections were identified after 13,482 THA and TKA during 1999-2004. After correction with the positive predictive value of SIRO (91%), a log-linear model provided an estimated overall prosthetic joint infection rate of 1.6% after THA and 1.3% after TKA. The sensitivity of the SIRO surveillance ranged from 36% to 57%. According to the estimation, nearly 200 prosthetic joint infections could occur in Finland each year (the average from 1999 to 2004) after THA and TKA. Conclusions. Postdischarge surveillance had a major impact on SSI rates after major hip and knee surgery. A minority of deep incisional and organ/space SSIs would be missed, however, if postdischarge surveillance by questionnaire was not performed. According to the validation study, most SSIs reported to SIRO were true infections. Some SSIs were missed, revealing some weakness in case finding. Variation in diagnostic practices may also affect SSI rates. No differences were found in deep SSI rates or mortality between bi- and unilateral THA and TKA. However, patient materials between these two groups differed. Bilateral operations require specific attention paid to their antimicrobial prophylaxis as well as to data management in the surveillance database. The true disease burden of prosthetic joint infections may be heavier than the rates from national nosocomial surveillance systems usually suggest.

Cruise Report: Summer 2008 Ecological Assessment of Stellwagen Bank National Marine Sanctuary NOAA Ship NANCY FOSTER NF-08-09-CCEHBR (June 14-June 21, 2008)

Summary: This cruise report is a summary of a field survey conducted within the Stellwagen Bank National Marine Sanctuary (SBNMS), located between Cape Cod and Cape Ann at the mouth of Massachusetts Bay. The survey was conducted June 14 – June 21, 2008 on NOAA Ship NANCY FOSTER Cruise NF-08-09-CCEHBR. Multiple indicators of ecological condition and human dimensions were sampled synoptically at each of 30 stations throughout SBNMS using a random probabilistic sampling design. Samples were collected for the analysis of benthic community structure and composition; concentrations of chemical contaminants (metals, pesticides, PAHs, PCBs, PBDEs) in sediments and target demersal biota; nutrient and chlorophyll levels in the water column; and other basic habitat characteristics such as depth, salinity, temperature, dissolved oxygen, turbidity, pH, sediment grain size, and organic carbon content. In addition to the fish samples that were collected for analysis of chemical contaminants relative to human-health consumption limits, other human-dimension indicators were sampled as well including presence or absence of fishing gear, vessels, surface trash, marine mammals, and noxious sediment odors. The overall purpose of the survey was to collect data to assess the status of ecosystem condition and potential stressor impacts throughout SBNMS, based on these various indicators and corresponding management thresholds, and to provide this information as a baseline for determining how such conditions may be changing with time. While sample analysis is still ongoing a few preliminary results and observations are reported here. A final report will be completed once all data have been processed. The results are anticipated to be of value in supporting goals of the SBNMS and National Marine Sanctuary Program aimed at the characterization, protection, and management of sanctuary resources (pursuant to the National Marine Sanctuary Reauthorization Act) as well as a new priority of NCCOS and NOAA to apply Ecosystem Based approaches to the Management of coastal resources (EBM) through Integrated Ecosystem Assessments (IEAs) conducted in various coastal regions of the U.S. including the Northeast Atlantic continental shelf. This was a multi-disciplinary partnership effort made possible by scientists from the following organizations:  NOAA, National Ocean Service (NOS), National Centers for Coastal Ocean Science (NCCOS), Center for Coastal Environmental Health and Biomolecular Research (CCEHBR), Charleston, SC.  U.S. Environmental Protection Agency (EPA), National Health and Environmental Effects Research Laboratory (NHEERL), Atlantic Ecology Division (GED), Narragansett, RI.  U.S. Environmental Protection Agency (EPA), National Health and Environmental Effects Research Laboratory (NHEERL), Gulf Ecology Division (GED), Gulf Breeze, FL.  U.S. Geological Survey (USGS), National Wetlands Research Center, Gulf Breeze Project Office, Gulf Breeze, FL.  NOAA, Office of Marine and Aviation Operations (OMAO), NOAA ship Nancy Foster. (31pp) (PDF contains 58 pages)