Strengthening field-based training in low and middle-income countries to build public health capacity: Lessons from Australia's Master of Applied Epidemiology program

BACKGROUND: The International Health Regulations (2005) and the emergence and global spread of infectious diseases have triggered a re-assessment of how rich countries should support capacity development for communicable disease control in low and medium income countries (LMIC). In LMIC, three types of public health training have been tried: the university-based model; streamed training for specialised workers; and field-based programs. The first has low rates of production and teaching may not always be based on the needs and priorities of the host country. The second model is efficient, but does not accord the workers sufficient status to enable them to impact on policy. The third has the most potential as a capacity development measure for LMIC, but in practice faces challenges which may limit its ability to promote capacity development. DISCUSSION: We describe Australia's first Master of Applied Epidemiology (MAE) model (established in 1991), which uses field-based training to strengthen the control of communicable diseases. A central attribute of this model is the way it partners and complements health department initiatives to enhance workforce skills, health system performance and the evidence-base for policies, programs and practice. SUMMARY: The MAE experience throws light on ways Australia could collaborate in regional capacity development initiatives. Key needs are a shared vision for a regional approach to integrate training with initiatives that strengthen service and research, and the pooling of human, financial and technical resources. We focus on communicable diseases, but our findings and recommendations are generalisable to other areas of public health

Incomplete protection against hepatitis B among remote Aboriginal adolescents despite full vaccination in infancy

The objective of this study was to determine long-term immunity to hepatitis B virus (HBV) in a cohort of adolescents who received plasma-derived HBV vaccine in 1989 and 1990 in a remote Australian Aboriginal community. This was done using a serological survey; primary outcome measures were cut-off titres of HBsAb, and the presence of HBcAb and/or HBsAg. Of 37 adolescents in the cohort, 4 (11%) had evidence of active infection, one with abnormal liver enzymes, 7 (19%) had evidence of past infection, 15 (41%) were HBsAb positive in low titre and 11 (30%) were classed as immune. It was concluded that there was relatively poor long-term serological immunity to HBV vaccination in this group; a finding which is in keeping with similar studies in Indigenous and remote populations elsewhere. This finding raises the concern that a significant proportion of Aboriginal adolescents in other remote communities (vaccinated in 1989 and 1990) were not adequately protected by the vaccine. If so, there will be an unexpected burden of chronic HBV infection in these settings and a substantial group who are non-immune, despite having received complete HBV vaccination courses as infants. The authors recommend follow-up serosurveys in remote Aboriginal communities to identify people with low HBsAb titres, especially those without an adequate anamnestic response to another dose of HBV vaccine. In addition, community-based active surveillance programs will be required to detect people with chronic HBV infection and provide access to monitoring and appropriate treatment

Incomplete protection against hepatitis B among remote Aboriginal adolescents despite full vaccination in infancy. CDI Quarterly Report

Abstract The objective of this study was to determine longterm immunity to hepatitis B virus (HBV) in a cohort of adolescents who received plasma-derived HBV vaccine in 1989 and 1990 in a remote Australian Aboriginal community. This was done using a serological survey; primary outcome measures were cut-off titres of HBsAb, and the presence of HBcAb and/or HBsAg. Of 37 adolescents in the cohort, 4 (11%) had evidence of active infection, one with abnormal liver enzymes, 7 (19%) had evidence of past infection, 15 (41%) were HBsAb positive in low titre and 11 (30%) were classed as immune. It was concluded that there was relatively poor long-term serological immunity to HBV vaccination in this group; a finding which is in keeping with similar studies in Indigenous and remote populations elsewhere. This finding raises the concern that a significant proportion of Aboriginal adolescents in other remote communities (vaccinated in 1989 and 1990) were not adequately protected by the vaccine. If so, there will be an unexpected burden of chronic HBV infection in these settings and a substantial group who are non-immune, despite having received complete HBV vaccination courses as infants. The authors recommend followup serosurveys in remote Aboriginal communities to identify people with low HBsAb titres, especially those without an adequate anamnestic response to another dose of HBV vaccine. In addition, community-based active surveillance programs will be required to detect people with chronic HBV infection and provide access to monitoring and appropriate treatment. Commun Dis Intell 2010;34(4):435-439

A systems approach to improving timeliness of immunisation

Timeliness of immunisation is important in achieving a protective effect at the individual and population levels. Recent international research has highlighted the importance of organisational features of the health system in timely immunisation. This paper reports on an analysis of the availability of records of timely delivery of childhood immunisations in Indigenous primary care services and organisational features of vaccination programs in different jurisdictions in Australia. The findings demonstrate wide variation in recorded timely delivery of immunisations between health centres within and between jurisdictions. Significant deficiencies in the approach to delivery and recording of immunisations appear to be principally related to fragmented systems of delivery, recording and communication between child health and primary care services. Understanding these deficiencies presents opportunities for improving timely immunisation

Outcomes from the first 2 years of the Australian National Hand Hygiene Initiative

Objective: To report outcomes from the first 2 years of the National Hand Hygiene Initiative (NHHI), a hand hygiene (HH) culture-change program implemented in all Australian hospitals to improve health care workers’ HH compliance, increase use of alcohol-based hand rub and reduce the risk of health care-associated infections. Design and setting: The HH program was based on the World Health Organization 5 Moments for Hand Hygiene program, and included standardised educational materials and a regular audit system of HH compliance. The NHHI was implemented in January 2009. Main outcome measures: HH compliance and Staphylococcus aureus bacteraemia (SAB) incidence rates 2 years after NHHI implementation. Results: In late 2010, the overall national HH compliance rate in 521 hospitals was 68.3% (168 641/246 931 moments), but HH compliance before patient contact was 10%–15% lower than after patient contact. Among sites new to the 5 Moments audit tool, HH compliance improved from 43.6% (6431/14 740) at baseline to 67.8% (106 851/157 708) (P < 0.001). HH compliance was highest among nursing staff (73.6%; 116 851/158 732) and worst among medical staff (52.3%; 17 897/34 224) after 2 years. National incidence rates of methicillin-resistant SAB were stable for the 18 months before the NHHI (July 2007–2008; P = 0.366), but declined after implementation (2009–2010; P = 0.008). Annual national rates of hospital-onset SAB per 10 000 patient-days were 1.004 and 0.995 in 2009 and 2010, respectively, of which about 75% were due to methicillin-susceptible S. aureus. Conclusions: The NHHI was associated with widespread sustained improvements in HH compliance among Australian health care workers. Although specific linking of SAB rate changes to the NHHI was not possible, further declines in national SAB rates are expected.5 page(s

Acellular pertussis vaccine effectiveness for children during the 2009-2010 pertussis epidemic in QueenslandAcellular pertussis vaccine effectiveness for children

OBJECTIVES To assess the effectiveness of three, four and five doses of acellular pertussis vaccine against pertussis notification for children aged 1 - < 4 years and 5 - < 12 years, and the effectiveness of three doses of acellular pertussis vaccine against pertussis hospitalisation for children aged 1 - < 4 years.A population-based retrospective study of children aged 1 - < 12 years residing in Queensland, Australia, during 2009 and 2010. Routinely collected notification, hospitalisation, testing and vaccination data were used to describe notification rates and testing patterns and to assess vaccine effectiveness (VE) by the screening method.VE against pertussis notification for children aged 1 - < 4 years and 5 - < 12 years, by birth year, and VE against pertussis hospitalisation for children aged 1 - < 4 years.1961 notifications and 29 hospitalisations were included in the VE calculations. VE point estimates against pertussis notification and hospitalisation in children aged 1 - < 4 years were similar in 2009 and 2010, and ranged between 83.5% and 89.4%. VE point estimates against notification among children aged 5 - < 12 years were between 71.2% and 87.7% in 2009, and between 34.7% and 70.3% in 2010. The numbers of pertussis tests performed for children, particularly polymerase chain reaction (PCR) tests, increased between 2009 and 2010.Acellular pertussis vaccine provided good protection within the first years of priming, but this waned as age increased. Changes in pertussis testing behaviour, because of increases in PCR use and awareness, may have contributed to increased pertussis notification rates and lower estimates of VE against notification owing to identification of milder disease

Correction: expanded HIV pre-exposure prophylaxis (PrEP) implementation in communities in new South Wales, Australia (EPIC-NSW): design of an open label, single arm implementation trial

Abstract After publication of the article [1], it has been brought to our attention that one of the members of the EPIC-NSW study group has had their name spelt incorrectly in the acknowledgements. The article mentions “Muhammad Hammoud” when in fact the correct spelling is “Mohamed Hammoud”