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Communicable Diseases Intelligence

Contents

Epidemiology and prevention of pneumococcal disease 41

Peter McIntyre

Hepatitis A outbreak in New South Wales 46

A case of human anthrax in Victoria 47

Rosemary Lester, Sheila Beaton, John Carnie, Diane Barbis and

Graham Rouch

Notice to Readers 48

Communicable Diseases Surveillance 49

Overseas Briefs 56

ISSN 0725-3141Volume 21Number 420 February 1997

Communicable Diseases Network - AustraliaA national network for communicable diseases surveillance Commonwealth

Department ofHealth and

Family Services

Epidemiology and prevention ofpneumococcal disease

Peter McIntyre, Department of Immunology and Infectious Diseases, Royal Alexandra Hospitalfor Children, PO Box 3515 Parramatta NSW 2124

AbstractThere are comparatively little data on the incidence and morbidity from pneumococcal diseasein Australia and elsewhere. Available data suggest that the overall incidence of invasivepneumococcal disease in Australia is comparable with similar populations. Very high rates arereported in Central Australian Aborigines, similar to invasive Haemophilus influenzae type b(Hib) disease. Disease incidence is probably greatly underestimated by case ascertainment fromsterile site isolates alone. New diagnostic methods, such as serology to detect components of thepneumococcal cell wall, promise to significantly enhance detection of pneumococci as a causeof pneumonia, especially in childhood, but are epidemiologic rather than clinical tools. Resis-tance to penicillin and other antibiotics is an increasing problem worldwide, promoted byexcessive antibiotic use, especially in children. This has focused attention on vaccine preven-tion. Fortunately, antibiotic-resistant pneumococci appear to belong to a limited range ofserotypes, those commonly colonising children, in all areas so far studied. If conjugate pneu-mococcal vaccines prove to eradicate carriage, in a similar fashion to conjugate Hib vaccines,vaccination may be the major weapon against the spread of antibiotic-resistant pneumococcalinfection. Conjugate pneumococcal vaccines are now in large scale efficacy trials, with out-comes of bacteraemia (California) and otitis media (Finland). Results of these trials are eagerlyawaited. Comm Dis Intell 1997;21:41-46.

IntroductionStreptococcus pneumoniae hasbeen recognised as a majorhuman pathogen since it wasdescribed by Pasteur in 1891.Two recent developments havebrought preventative strategiesfor pneumococcal infection intoprominence. First, penicillin-resistant and multi-resistantpneumococci have becomemore prevalent in many parts ofthe world1. Second, conjugate

vaccine technology is nowbeing applied to pneumococcalpolysaccharides, makingvaccines capable of protectingyoung children a possibility2.Recent evidence suggests thatconjugate pneumococcalvaccines reducenasopharyngeal carriage in thesame manner as conjugateHaemophilus influenzae type b(Hib) vaccines3,4. As paediatricserotypes are over-representedamong antibiotic-resistant

strains, immunisation of infantsand children may be the bestapproach to reducing theprevalence of serotypes ofpneumococci associated withantibiotic resistance5.

Incidence ofpneumococcal diseaseThere are a number ofdifficulties in caseascertainment and estimation

ContentsEpidemiology and prevention of pneumococcal disease 41

Peter McIntyre

Hepatitis A outbreak in New South Wales 46

A case of human anthrax in Victoria 47

Rosemary Lester, Sheila Beaton, John Carnie, Diane Barbis and Graham Rouch

Notices to readers 48

Communicable Diseases Surveillance 49

Overseas Briefs 56

ISSN 0725-3141Volume 21Number 420 February1997

of the incidence of pneumococcaldisease.

Sterile site isolates

Unlike invasive Haemophilusinfluenzae disease, which is usuallyassociated with bacteraemia and ispredominantly due to one serotype(b), pneumococci have at least 80different capsular types,and manysignificant pneumococcal infections,such as pneumonia, are uncommonlyassociated with bacteraemia6. Thus,pneumococcal isolates from sterilesites probably greatly underestimatethe incidence of significantpneumococcal infection.

Respiratory isolates

Respiratory specimens are alsoproblematic for case ascertainmentbecause carriage of pneumococci inthe respiratory tract is relativelycommon7. The significance of apneumococcal isolate from sputumtherefore depends on the clinical

picture and the adequacy of thespecimen. Sputum is not suitable fordiagnosis of pneumonia in childrenbelow the age of ten years, becauseadequate sputum specimens aredifficult to obtain.

Prior antibiotic therapy

In both adults and children withpneumonia, the apparent incidence ofpneumococcal infection is furtherreduced by preceding antibiotictherapy. In a recent study fromAdelaide, adult patients (mean age60 years) hospitalised withpneumonia had evidence ofpneumococcal infection in 44 cases(42%)8. Of these 44 cases, bloodcultures were positive in 5% of thosecases who had preceding antibiotictherapy compared with 19% ofothers.

Needle aspiration

Needle aspiration of the lung isprobably the closest to a gold

standard for bacteriologic diagnosisof pneumonia, but is limited toanatomically accessible sites.Published studies have demonstratedhigh rates of bacterial andpneumococcal pneumonia in thepre-antibiotic era and in developingcountries with a more severespectrum of disease, but needleaspiration is too invasive for routineuse9.

Serology

As pneumococcal pneumonia isassociated with bacteraemia in 5% orfewer of childhood cases inindustrialised countries, groups inSweden and Finland have developedand promoted serologic diagnosis asa non-invasive method of improvingcase ascertainment10. An antibodyresponse to pneumolysin was seensignificantly more frequently inchildren with acute lower respiratorytract infection (12.4% overall and9.0% below two years) than incontrols (2.7% overall and 3.6 %below two years). In addition, thesignificantly higher rate ofseropositivity in the presence ofradiologic infiltrates (51%) comparedwith children with normal chest X rays(17%) supports the validity ofserologic diagnosis11.

Estimates of the incidence and agedistribution of pneumococcaldisease

Population-based incidence data fromsterile site isolates in children inindustrialised countries, includingunpublished data from Sydney andVictoria, are summarised in Table 1.Recently, central AustralianAborigines have been reported tohave the highest incidence ofinvasive pneumococcal disease yetdescribed12. Population-based datafrom this and other indigenouspopulations are shown in Table 2. Inall populations, the highest incidenceof invasive pneumococcal disease isat the extremes of life (the first 12months of life and over 70 years ofage)13,14.

Mortality and morbidityData on short- and long-termmorbidity from childhoodpneumococcal disease in Australiaare sparse. In Sydney between 1981and 1992, 26 children (6.6%) died,with underlying conditions present in18 (69%)15. Long-term morbidity waslargely limited to meningitis, where 35

Incidence per 100,000 population

Study Children <5 years

Children <15 years

Sweden13 (1970 to 1980) 25.8a 4.6b

New Zealand29 (1984 to 1992) 36 13Finland18 (1985 to 1989) 24.2 8.9cNew York44 (1985 to 1989) 90.6 25.2b

Central Australia12 (1985 to 1990) 87 15Alaska23 (1986 to 1990) 73 22.2b

South Carolina45 (1986 to 1987) 162d Not availableIsrael19 (1988 to 1990) 42 19.9e

Victoria14 (1994 to 1995) 63d Not availableSydneyf (1991 to 1996) 32 11

a. under 1 year of ageb. under 19 years of agec. under 16 years of aged. under 2 years of agee. under 13 years of agef. manuscript in preparation: Liddle J, Davis C and McIntyre P

Table 1. Incidence of invasive pneumococcal disease in non-indigenouspopulations

Incidence per 100,000 population

Study Children <5 years

Children <15 years

New Zealand46 (1984 to 1992) 92 39Central Australia12 (1985 to 1990) 935 195Alaska22 (1986 to 1990) 327 88a

Apache47 (1983 to 1990) 530 9.9b

a. under 19 years of ageb. under 13 years of age

Table 2. Incidence of invasive pneumococcal disease in indigenouspopulations

CDI Vol 21, No 420 February 1997

of 104 surviving patients (34%) inSydney had one or more neurologicdeficits at discharge. These includedhearing loss, which was the onlydeficit in 12 patients, and a range ofother neurologic deficits in the other23 surviving children. In Victoriabetween 1994 and 1995, the overallcase fatality rate was 10%, withtwo-thirds of deaths occurring inpatients over 60 years of age withpneumonia14. These findings are inaccord with those from other studies,where the case fatality rate wasrelated to extremes of age and thepresence of underlying diseases13,15.

Prevalent pneumococcalserotypesThere are now more than 80serotypes of Streptococcuspneumoniae described. Their relativefrequency, vitally important forvaccine policy, varies according tosite of isolation, age, antibioticresistance and geography, and overtime. Five or six capsular typesaccount for 60-70% of disease inmost series from industrialisedcountries6.

Industrialised countries

Among infants and children in fourcentres in the United States ofAmerica between 1957 and 1978,types 6, 18, 19, 23 and 14 wereconsistently among the five mostcommon invasive isolates16. Morerecent data from the United States ofAmerica, based on 3,884 isolates,found the three most commonserotypes to be 14, 6B and 19F, withlittle variation by age (less than twoyears versus two to six years) orgeographic area 17. There wasvariation by site, with serotypes 3, 9Aand 23F significantly more frequentfrom the middle ear. Consequently,85% of invasive isolate serotypeswould be included in a putativeheptavalent vaccine, compared with65% of middle ear isolates. Incontrast to the United States ofAmerica, population-based studiesfrom Finland18 and Israel19 showimportant differences amongprevalent serotypes by age, locationand ethnic group. Types 6, 14 and 19accounted for 53% of 365 strains inFinland but only 33% of 205 strains inIsrael, with types 7, 18 and 23causing 25% of disease in Finlandand types 1, 5, 18 and 23 making up47% of isolates in Israel.

Australia

There are few published Australiandata on prevalent pneumococcalserotypes. Among 1,252 isolates inSydney, including 96 from blood orcerebrospinal fluid (CSF), between1965 and 1969, types 19, 23, 6, 3and 9 accounted for 43%20. Otherdata are unpublished or in abstractform. Hansman has reported themost common serotypes from 588invasive isolates in adults andchildren in five States between 1988and 1993 as 19, 6, 14, 23 and 321.The Australian Group onAntimicrobial Resistance (AGAR)serotyped all invasive orpenicillin-resistant isolates receivedfrom participating laboratories in 1994(J Bell, Australian Group onAntimicrobial Resistance, personalcommunication). Of 282 invasiveisolates in children (<15 years), types14 (40%), 6 (17%), 19 (14%) and 23(10%) accounted for 81% ofserotypes. Of 11 invasivepenicillin-resistant isolates, nine wereserogroup 6, and one each was type14 and 23. In Victoria in 1994 to1995, the most common serotypesamong 445 sterile site isolates frompatients of all ages were 14 (29%), 6(12%), 19 (11%) 9 (9%), 23 (8%), 4(7%) and 18 (6%), with these sevenserotypes/groups accounting for 93%of infections in those under two yearsof age and 80% of infections in thoseover 60 years of age14.

Less industrialised countries

The distribution of pneumococcalserotypes is much more diverse on aworldwide scale, making theformulation of a conjugate vaccinewith a feasible number of serotypessuitable for use in all areasproblematic. Workers from the UnitedStates of America Centers forDisease Control and Prevention, withcollaborators from all continents,have recently summarised serotypedata from sterile site isolatesincluding transtracheal aspirates,pleural fluid and lung aspirates, froma number of developed and lessdeveloped countries, with specialemphasis on pneumonia22.Serotypes 14, 6 and 19 wereconsistently important in allgeographic areas, while type 18 wasimportant only in developed countriesand types 1 and 5 only in developingcountries. A formulation containingtypes 6B, 14, 19F, 23F, 9V, 4 and18C was thought most appropriate for

developed countries. This coveredfrom 65% (Spain) to more than 85%(Finland and United States ofAmerica) of isolates from developedcountries, but less than 35%(Rwanda, Egypt and Papua NewGuinea) to 59% (Gambia) for a rangeof developing countries. Theirsuggested formulation for developingcountries substituted types 1 and 5for 4 and 9V, giving significantlyimproved coverage (58 - 73%) exceptfor some geographic areas, such asPapua New Guinea (42%) whichhave very diverse serotypes reported.

Indigenous populations inindustrialised countries

In contrast, the serotype distributionamong indigenous populations suchas Alaskan native Americans23 andAborigines in central Australia24 moreclosely resembles the industrialisedcountries to which they belong. InAlaska, seven serotypes (4, 6, 9, 14,18, 19 and 23) which are included inone prototype conjugate vaccine,accounted for 85% of invasive strainsfrom children less than two years old.Among persons older than 19 years,these serotypes accounted for only40% of invasive strains, although94% of isolates were covered in the23-valent polysaccharide vaccine. Incentral Australia, types 14, 6B, 9V, 4,18C and 19F accounted for 67% ofisolates from children under fiveyears old, while in adults, types 1, 7F,3, 4, 12F and 8 were most common,accounting for 68% of isolates.

The available data, particularly fromdeveloping countries, are limited bylack of control for age and antibioticand vaccine exposure. Controlledstudies of larger size and over alonger time frame are needed fromboth industrialised and developingcountries to judge the mostappropriate vaccine formulations.

Epidemiology of antibioticresistanceStreptococcus pneumoniae remainedvery sensitive to penicillin, withminimum inhibitory concentrations(MICs) less than 0.02 micrograms permL, for many years. Althoughantibiotic resistance was recognisedin vitro in the 1940s, it was firstdescribed as a clinical problem byHansman and Bullen in 196725.Initially isolates were only moderatelyresistant (MIC between 0.1 and 1.0microgram per mL) but highly


resistant isolates (MIC >2micrograms per mL) were thenreported, first from Spain and SouthAfrica and more recently fromEastern Europe and parts of theUnited States of America.

Resistance of Streptococcuspneumoniae to penicillin and otherantibiotics is increasing in all areas ofthe world26. The pattern of resistanceis notable for its uneven distributionboth between countries and withincountries. South Africa, Spain andEastern Europe report rates of any(intermediate or high level) penicillinresistance of up to 50%26, comparedwith less than 10% in most ofWestern Europe26. In the UnitedStates of America, high level penicillinresistance has steadily increasedfrom 0.02% to 1.3% overall, but isconcentrated in certain geographicareas27.

In Australia antibiotic resistance isalso increasing. In 1989, 31 (1.7%) of1,822 isolates from major laboratoriesin all States were penicillin resistant,but no isolates showed high levelresistance28. By 1994, of 2,181pneumococci studied, 127 (5.8%) hadintermediate sensitivity to penicillin,14 (0.6%), including two blood cultureisolates, were highly resistant and 8%of all isolates were multi-resistant,defined as resistance to three ormore antibiotics29. Resistance toother antimicrobials was alsosignificant, including approximately10% to erythromycin and tetracycline,6% to chloramphenicol and 40% tocotrimoxazole. Eight per cent of allisolates were multi-resistant29.

In some Aboriginal communities,levels of antibiotic resistance amongpneumococci are much higher. Asearly as 1981, a surveillance studyusing nasal swabs among Aboriginalchildren in central Australia found 27of 174 (15.5%) of pneumococciisolated to be penicillin resistant30. In1993 to 1994, a prospective study ofantibiotic prophylaxis for otitis mediain Aboriginal children in the NorthernTerritory found that the rate ofisolation of multi-resistantpneumococci from the nasopharynxincreased from 3/41 (7%) to 14/31(45%) as the study progressed31.There was also evidence oftransmission of multi-resistant strainsfrom treated, older infants tountreated, younger infants. A study ofchildren admitted to hospital inDarwin in 1994 to 1995 confirmed

high colonisation rates in ruralAboriginal children, and penicillin-resistant strains in Aboriginal andnon-Aboriginal children, with overallrates of penicillin resistance of30%32. As observed in Israel in 19815

and elsewhere26, a restricted groupof serogroups generally associatedwith carriage in children (6, 9, 14, 19and 23), were responsible for morethan 80% of penicillin-resistantinfections.

An important study from Iceland hasprovided convincing confirmation ofthe link between antibiotic usage andpenicillin resistance inpneumococci33. Nasopharyngealswabs for culture of pneumococciwere obtained from a cross-sectionalsample of children less than sevenyears of age attending day-carecentres in five regions. The overallrate of pneumococcal carriage was52.7%, with 47 (9.7%) ofnasopharyngeal isolates penicillinresistant. Antibiotic usage wasstrongly associated with carriage ofpenicillin-resistant pneumococci, aftercorrection for other variables in amultivariate model. Recent exposurewas also important, as 1.8% ofchildren who had no courses ofantimicrobials in the previous yearcarried resistant strains, comparedwith 14% who had any courses and61% of those who had receivedantimicrobials in the previous two toseven weeks33.

Strategies to promote accuratesurveillance of penicillin-resistantisolates, appropriate use ofpneumococcal vaccination anddecreased inappropriate antibioticuse, especially in young children, arecrucial to minimising the impact ofantibiotic-resistant pneumococcalinfections. Recommendationsrecently made by the Centers forDisease Control and Prevention arelikely to be generally applicable inindustrialised countries34.

Risk factors for invasivepneumococcal disease inchildrenRisk factors for childhoodpneumococcal disease amongpopulations in industrialised countrieshave been examined in case-controlstudies in Finland35 and California36.Day-care attendance was associatedwith significant risk only in childrenyounger than two years in Finland

(odds ratio (OR) = 36, 95% CI 5.7 -233) while in California, the OR forchildren less than five years old was2.6 (1.6 - 4.3). Recent otitis mediawas a significant risk factor in bothstudies (OR 1.6 to 5). Unlike invasiveHaemophilus influenzae type b (Hib)disease, breast feeding was notfound to be protective in either study.In California, an increased incidenceof invasive pneumococcal diseasewas found in Afro-American children(OR 2.8) and, unlike Hib disease, inchildren of Asian descent (OR 2.5).Both these populations differsubstantially from Australian urbanpopulations in a number ofdemographic features, and similarlyto Hib disease, risk factors may notbe generalisable.

Pneumococcal vaccinesPolysaccharide vaccine

The currently available pneumococcalvaccine contains purified capsularpolysaccharide antigens of 23serotypes of S. pneumoniae (Danishtypes 1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 10A,11A, 12F, 14, 15B, 17F, 18C, 19A,19F, 20, 22F, 23F, 33F)6. Each 0.5mldose of vaccine contains 25micrograms of each polysaccharideantigen, compared with 50micrograms of each in the 14-valentvaccine. Young adults have thestrongest responses topneumococcal polysaccharidevaccine and response is reduced atthe extremes of age and in a range ofunderlying conditions6. Almost noresponse is seen in individuals withleukaemia, lymphoma or Hodgkinsdisease. Even infants below one yearof age will respond to serotypes 3, 4,8 and 9, but antibody does notpersist. Children immunised at sixmonths have similar antibody levelsto controls at the age of two years,and demonstrate no boostingresponse6,37. Unfortunately, childrenbelow the age of five years show littleresponse to the prevalent serotypes6A, 14, 19F and 23F 6,37.

The high rates of invasivepneumococcal disease occurringearly in life in developing countries,many of which already have maternaltetanus immunisation programs,makes maternal pneumococcalimmunisation a potentially importantintervention in this setting. Acollaborative group of investigatorsfrom the United States of Americaand Bangladesh has studied


pneumococcal antibody in serum andbreast milk in 36 maternal-infant pairsfollowing pneumococcalpolysaccharide vaccine at 30-34weeks gestation, with meningococcalpolysaccharide vaccine as thecontrol38. Study infants hadgeometric mean titres (GMTs) two- tothree-fold higher than controls.Despite this, rates of nasopharyngealcolonisation with pneumococci werehigh (50% by three months) and didnot differ between study and controlinfants38. Whether these short-termdifferences in antibody wouldtranslate into disease reduction on apopulation basis or interfere withsubsequent active infantimmunisation with a conjugatevaccine is unknown.

Polysacchari de-protein conjugatevaccines

Following the success of proteinconjugate vaccines in eliminatingHaemophilus influenzae type b (Hib)disease in many areas of the world,largely through reduction innasopharyngeal colonisation, studiesof protein conjugate pneumococcalvaccines are of great interest. Eachserotype essentially requires aseparate vaccine, and probably limitsany conjugate formulation to amaximum of 7 to 9 serotypes,although the number of serotypesincluded has steadily increased withongoing vaccine development39.

Data on conjugate pneumococcalvaccines are currently limited toimmunogenicity studies, pending theresults of efficacy trials in Finland andCalifornia with endpoints of otitismedia and bacteraemia respectively.In contrast to the experience with thecomparable Hib conjugates, avaccine using the outer membrane ofNeisseria meningitidis type b (OMP)as the conjugating protein gaveresponses which seem to dependlargely on the nature of thepneumococcal polysaccharide40.After one dose, responses were seenonly to serotypes 14 and 19F, with aresponse to 6B and 23F, known to bepoorer immunogens, requiring twodoses irrespective of whethervaccination began at two or fourmonth of age. In a developing countrysetting, a vaccine using CRM197 asthe conjugating protein in a 2,3,4months schedule in Gambia gavesignificantly higher antibodyresponses than a control group whoreceived Hib vaccine with the same

protein conjugate. However, the GMTto all serotypes rose substantially inthe control group, probably due tohigh early rates of colonisation withpneumococci in this population41.The vaccine in the Gambian study,which had a five-fold greater dose ofpolysaccharide than the Finnishvaccine, was associated with a higherrate of local reactions40,41. This isanother possible limiting factor forincreasing the number of serotypes inpneumococcal conjugate vaccines,as polysaccharide dose is animportant determinant of response40.However, like conjugate Hibvaccines, conjugate pneumococcalvaccines provide immunologicpriming, so natural boosting mayoccur42. Data suggest that mucosalcolonisation with pneumococci maybe reduced following conjugatepneumococcal vaccine3 similar to Hibvaccines4, but this may be serotypespecific, with non-vaccine serotypesfilling the ecological niche43.Conclusions must await the results ofrandomised controlled trials.

ConclusionsInvasive pneumococcal diseaseremains an important cause ofmorbidity and mortality in Australia,especially in the very young, the veryold and other at-risk populations. Theemergence of antibiotic-resistantpneumococci is an importantdevelopment which will necessitatechanges in laboratory and clinicalpractice. This development shouldalso underline the need for prudentantibiotic use in the community,especially for young children, thegreat majority of whom have viralrather than bacterial respiratory tractinfections. Vaccination with thecurrent 23-valent vaccine (in at-riskadults) and with newly developedconjugate vaccines (in infants) mayoffer the best chance to control bothpneumococcal disease andantibiotic-resistant strains.

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5. Dagan R, Yagupsky P, Goldbart A etal. Increasing prevalence ofpenicillin-resistant pneumococcalinfections in children in southernIsrael. Pediatr Infect Dis J1994;13:782-786.

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11. Nohynek H, Eskola J, Kleemola M etal. Bacterial antibody assays in thediagnosis of acute lower respiratorytract infection in children. PediatrInfect Dis J 1995;14:478-484.

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13. Burman LA, Norrby R, Trollfors B.Invasive pneumococcal infections:incidence, predisposing factors andprognosis. Rev Inf Dis 1985;7:133-142.

14. Hogg G, Strachan J. Epidemiology ofinvasive pneumococcal disease inVictoria, Australia. Proceedings of the7th International Congress forInfectious Diseases; 1996 June 19 -21; Hong Kong. Boston: InternationalSociety for Infectious Diseases, 1996.

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16. Klein JO. The epidemiology ofpneumococcal disease in infants andchildren. Rev Inf Dis 1981;3:246-253.

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19. Dagan R, Englehard D, Piccard E.Epidemiology of invasive childhoodpneumococcal infections in Israel.JAMA 1992;286:3328-3332.

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31. Leach AJ, Shelby-James T, Mayo Met al. Report of a multi-drug resistantclone of Streptococcus pneumoniae inAboriginal infants in the NorthernTerritory. Comm Dis Intell1995;19:134-137.

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33. Aarson VA, Kristinsson KG,Sigurdsson JA et al. Do antimicrobialsincrease the carriage rate of penicillinresistant pneumococci in children?Cross sectional prevalence study. BrMed J 1996;313:387-391.

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36. Black S, Shinefield H, Elvin L et al.Pneumococcal epidemiology inchildhood in a large HMO population.Proceedings of the InterscienceConference on Antimicrobial Agents inChemotherapy; 1994 October; Florida.Washington: American Society ofMicrobiology, 1995.

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antibody after maternal immunisationwith pneumococcal vaccine. Lancet1995;346:1252-1257.

39. Siber GR. Pneumococcal disease:prospects for a new generation ofvaccines. Science1994;265:1385-1387.

40. Kayhty H, Ahman H, Ronnberg P-R etal. Pneumococcal polysaccharide-meningococcal outer membraneprotein complex conjugate vaccine isimmunogenic in infants and children. JInf Dis 1995;172:1273-1278.

41. Leach A, Ceesay SJ, Banya WAS,Greenwood BM. Pilot trial of apentavalent pneumococcalpolysaccharide/protein conjugatevaccine in Gambian infants. Pediatr InfDis J 1996;15:333-339.

42. O’Brien KL, Steinhoff MC, Edwards Ket al. Immunologic priming of youngchildren by pneumococccalglycoprotein conjugate, but notpolysaccharide, vaccines. Pediatr InfDis J 1996;15:425-430.

43. Obaro SK, Adegbola RA, Banya WAS,Greenwood BM. Carriage ofpneumococci after pneumococcalvaccination. Lancet 1996;348:271-278.

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45. Breiman R, Spika J, Navarro V et al.Pneumococcal bacteremia inCharleston County, South Carolina - adecade later. Arch Intern Med1990;150:1401-1405.

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47. Cortese MM, Wolff M, Almeido-Hill Jet al. High incidence rates of invasivepneumococcal disease in the WhiteMountain Apache population. Arch IntMed 1992;152:1-6.

Hepatitis A outbreak in New South WalesOver the past three weeksapproximately 150 cases of hepatitisA have been reported in New SouthWales. Cases have been notifiedfrom both regional and metropolitanareas. Two-thirds of those patientssampled to date reported eatingoysters. Half of these originated fromWallis Lake on the State’s mid-northcoast. The New South Wales HealthDepartment has urged people to

avoid eating oysters from WallisLake.

Hepatitis A is a viral disease with anaverage incubation period ofapproximately 30 days. Symptomsinclude fever, malaise, nausea,anorexia and abdominal discomfortfollowed by jaundice. The illnessusually lasts one to two weeks andoccasionally requires hospitalisation.

Further person-to-person spread canbe prevented by observing goodhygiene practices including handwashing before meals. Householdcontacts of cases should be givenimmunoglobulin.

The New South Wales HealthDepartment is continuing toinvestigate.


A case of human anthrax in VictoriaRosemary Lester1, Sheila Beaton1, John Carnie1, Diane Barbis2 and Graham Rouch1

A human case of anthrax was identified through surveillance of knackery workers who had been exposed toinfected cattle. The outbreak in cattle has affected 38 herds in the Stanhope/Tatura area of central northernVictoria. The human case, a 39 year old male, was treated in hospital and is recovering. Surveillance of otherknackery workers has now been completed, and no other cases were found. Public health measures are in placeto prevent further human cases. Comm Dis Intell 1997;21:47-48.

BackgroundAnthrax, caused by Bacillusanthracis, is primarily a disease ofruminants which occasionally infectshumans. Cases in animals,particularly cattle, occur sporadicallyin Victoria across a wide area in thesouth of the State, and along theGoulburn and Murray rivers. The lastcases of human anthrax in Victoriawere two in 1980, two in 1975, andan outbreak of nine cases in 1971 inassociation with an outbreak in cattle.Six of these human cases wereassociated with a knackery.

Outbreak in cattleAnthrax was detected on twoadjoining dairy farms in theStanhope/Tatura area in centralnorthern Victoria on Sunday, 26January 1997. The number ofaffected properties remained low untilthe weekend of 8 - 9 February, whenthe number of affected properties andcattle began to escalate rapidly. Up to14 February, 38 herds had beenaffected, including both milking andnon-milking dairy herds. The numberof cattle confirmed with anthrax was80. The affected properties areconfined to an irregular areaapproximately 15 kilometres by threekilometres, except for one outlyingproperty which is locatedapproximately 15 kilometres awayclose to a knackery.

Thirteen cattle died in the period 10January to 26 January before thediagnosis of anthrax was made. Eightof the carcasses had been sent to alocal knackery for disposal. Meatfrom these carcasses was sold as petfood from a shop at the knackery,and hides were sent to a tannery inMelbourne.

Immediate control measures taken bythe Department of Human Services

following identification of the outbreakof anthrax in cattle were:

• we requested that the localmedical officer of healthundertake surveillance ofworkers at the knackery;

• similar surveillance was institutedat the tannery;

• a public recall of all pet food soldthrough the knackery wasinitiated;

• local doctors were advised of theoutbreak, provided with a factsheet, and advised what steps totake if they saw a suspectedcase.

Measures taken by the Department ofNatural Resources and theEnvironment were:

• the knackery was closed anddisinfected;

• all infected cattle are beingcollected in sealed trucks andtransported to burn sites fordisposal. Burn sites are beingcarefully selected away fromareas with a high water table;

• disinfection of sites where cattlehave died and disinfection ofburn sites;

• immunisation of cattle on allaffected properties and alladjoining properties has beencarried out, along with penicillintreatment of cattle.

Three persons with suspiciouslesions were examined by a physicianbetween 31 January and 3 Februaryand specimens were sent to theVictorian Infectious DiseasesReference Laboratory (VIDRL). Allwere negative for anthrax.

Human caseOn 8 February the InfectiousDiseases Unit was informed that themedical officer who was conductingsurveillance on the knackery workers

had seen one of these men, who hadworked only on 26 January skinningand gutting cattle. The 39 year oldman had seen a local GP on 26January prior to the organisedsurveillance commencing. The GPadministered 1.5 gm cilicainepenicillin IM and amoxycillin 500 mgTDS for five days. As part of thesurveillance, the man was examinedon 7 February and stated he hadremained well until 5 February whenhe noticed an elevated skin lesion onthe lower right forearm which hethought was enlarging. Onexamination he had a one centimetreelevated reddish papular lesion butno axillary lymphadenopathy. Anisolate from a swab of the lesion waspresumptively identified as Bacillusanthracis by the local laboratory on 8February, and was confirmed byVIDRL on 11 February. The man wasadmitted to the local hospital on 8February and was commenced onbenzyl penicillin, 600 mg IV. Thefollowing day he became pyrexial,complained of a headache and jointpains and the dosage was increasedto 1.2 gm IV 4 hourly. By 10 Februarythe skin lesion on the forearm haddeveloped a blackened centresurrounded by small vesicles withincreasing oedema of the forearmand tender axillary lymphadenopathy.On 11 February he was transferred tothe Goulburn Valley Base Hospital inShepparton, where he is recovering.

Further public healthmeasuresSurveillance of the other knackeryworkers has now been completed,and no other cases were found. Aninformation sheet advising the publicin the area of the symptoms ofanthrax and the procedure to follow ifthey have a suspicious lesion, wasdistributed through the local media


1. Infectious Diseases Unit, Department of Human Services, Level One (South), 115 Victoria Pde, Fitzroy Victoria 3065.

2. Department of Human Services, Loddon Mallee Region, Victoria.

and delivered directly to the affectedfarms.

Further measures taken during theweek of 10-14 February, after theescalation of the number of affectedproperties, were:

• an information sheet wasproduced and distributed to allfamilies on affected properties;

• penicillin prophylaxis andsurveillance of the laboratoryworkers by the local medicalofficer of health was instituted;

• public meetings organised by theDepartment of NaturalResources and the Environmentwere attended by public healthofficers, and human health

information was presented atthese meetings.

On 14 February, there were no newcattle deaths, and immunisation of allcattle in the affected area was almostcompleted.

Notices to readersThe Pacific Public HealthSurveillance NetworkThe Pacific Public HealthSurveillance Network (PPHSNetwork) is an affiliation of membercountries and territories of the SouthPacific Commission and other officialbodies such as regional organisationsand universities. The aim of theNetwork is to enhance public healthsurveillance and responsecapabilities among Pacific islandnations. It was formally established atthe Pacific Island Meeting on PublicHealth Surveillance in Noumea, NewCaledonia in December 1996.

The PPHS Network has aCoordinating Body presentlycomposed of representatives fromfive Pacific island countries andterritories (Federated States ofMicronesia, Fiji, New Caledonia,Solomon Islands and WesternSamoa) and five international,regional and training institutions(Australian National University/National Centre for Epidemiology andPopulation Health, South PacificCommission, United NationsInternational Children’s EmergencyFund, University of Hawaii and WorldHealth Organization Regional Officefor the Western Pacific). The currentfocal point of the Coordinating Bodyis at the South Pacific CommissionCommunity Health Programme. Itsimmediate objective is to establish a

supportive framework for Pacificisland countries to enhance theirpublic health surveillance capabilities.Among other strategies, this includesthe development of an early warningsystem for outbreaks of disease andensuring a national response andinternational collaboration to controloutbreaks.

For further information on the PPHSNetwork contact Dr Yvan Souares,Epidemiologist, or Dr Tom Kiedrynski,Notifiable Disease Specialist, both atthe South Pacific Commission,Noumea, New Caledonia. Telephone(687) 260143, Facsimile (687)263818 or email: [email protected] [email protected].

WHO International Traveland Health VaccinationRequirements and HealthAdvice, 1997 EditionThe 1997 edition of InternationalTravel and Health has just beenpublished by the World HealthOrganization in English and French.This booklet is intended for nationalhealth administrations, practisingphysicians, tourist agencies, shippingcompanies, airline operators, andother bodies who are called upon togive health advice to travellers.

In addition to summarising thevaccination requirements of individualcountries, the booklet indicates themain areas where malariatransmission occurs and wherePlasmodium falciparum is resistant todrugs. The recommendedchemoprophylactic regimen is alsogiven for each country with malariousareas.

Other chapters cover certain healthhazards to which the traveller may beexposed, and indicate the areas inwhich these hazards are most likelyto occur. The booklet alsorecommends a number ofprecautions that travellers shouldtake when visiting unfamiliar places.

World Health Organization, 1997; 106 pages(available in English and French); ISBN 92 4158022 4; Order No. 1189700.


Communicable Diseases SurveillancePertussis epidemicIn the last six months, pertussis has claimed the livesof four children: three in New South Wales (Mr RobMenzies, New South Wales Health Department, personalcommunication) and one in Victoria (Dr Graham Tallis,Victorian Department of Human Services, personalcommunication). All were children under three months ofage.

Pertussis is a serious, highly infectious disease that killsabout one in every 200 children under six months of agewho become infected. The causative organism,Bordetella pertussis, is localised to the respiratory tractand transmission is believed to occur by aerosol dropletfollowing a cough or sneeze. Because transmissionrequires close contact, parents and older siblings areconsidered to be an important source of infection.Symptoms can include severe coughing spasmsfollowed by a gasp for breath resulting in the typical’whoop’ sound. Not all children ’whoop’ and it is relativelyuncommon among adults with pertussis. Vomiting oftenfollows the coughing spasm.

Pertussis has been epidemic in Australia since 1993 and itappeared the epidemic was declining. However, sinceSeptember 1996, there has been a substantialresurgence (Figure 1). There have been 1,911notifications with onset dates from October to December1996 compared with 1,154 for the same period in 1995and 1,584 in 1994. As further notifications are received,the number with onset dates in the most recent period islikely to increase, particularly those with onset in January1997.

Since 1991, there have been more females than malesnotified in each age group. The male:female ratio fornotifications with onset in 1996 was 1:1.3. Females havesignificantly higher attack rates, morbidity and mortalityfrom pertussis than males, although the reason for this isnot known.

During the epidemic period 1993 to 1996, attack rateshave consistently been highest among children under 15years of age and there has been a smaller secondarypeak among adults 30 - 49 years of age (Figure 2). Therecent outbreak has seen markedly increased notificationrates per 100,000 population in South Australia andVictoria (Figure 3). Although notification rates inQueensland and New South Wales appear to be declining,outbreaks occurred in both States during the last quarterof 1996. The rates for pertussis notifications with onset in1996 were moderate in the other States and Territories:Australian Capital Territory (12 per 100,000 population);Western Australia (10); Northern Territory (8); andTasmania (7).

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Figure 1. Pertussis notifications by month of onset,January 1991 to January 1997

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Figure 2. Pertussis notification rates by age groupand year of onset, 1993 to 1996

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Figure 3. Pertussis notification rates by selectedStates and year of onset, 1991 to 1996


Hepatitis A notificationsThere were 60 notifications of hepatitis A infectionreceived in the National Notifiable Diseases SurveillanceSystem for this period. High numbers of notifications havebeen seen at this time of year in 1995 and 1996 (Figure4), but the present data do not indicate an increase innotifications. Twenty-eight of the reports (47%) were fromNew South Wales, with an outbreak currently occurring inthis State (see page 46).

There was a sharp increase in notifications of hepatitis Ato the CDI Virology and Serology Reporting Scheme(LabVISE) in December 1996 (Figure 5). In the mostrecent reporting period reports were received from allStates and Territories except Queensland and Tasmania(Table 7).

Forty-seven per cent of reports to the National NotifiableDiseases Surveillance System for this period were for the20 - 34 years age group and this reflects the agedistribution seen for notifications in 1996 (Figure 6).

National Notifiable DiseasesSurveillance SystemThe NNDSS is conducted under the auspices of theCommunicable Diseases Network Australia New Zealand.The system coordinates the national surveillance of morethan 40 communicable diseases or disease groupsendorsed by the National Health and Medical ResearchCouncil (NHMRC). Notifications of these diseases aremade to State and Territory health authorities under theprovisions of their respective public health legislations.De-identified core unit data are supplied fortnightly forcollation, analysis and dissemination. For furtherinformation, see CDI 1997;21:5.

Reporting period 22 January to 4 February 1997

There were 1,984 notifications received for this two-weekperiod (Tables 1, 2 and 3). The numbers of reports forselected diseases have been compared with average datafor this period in the previous three years (Figure 7).

The number of notifications of campylobacteriosisdecreased this period, with 371 reports received. This isconsistent with previous years when notifications startedto decline in late summer. The 0 - 4 years age groupaccounted for 79 of the notifications, with 109 notificationsin the 20 - 34 years age range.

Ross River virus infection notifications continue toincrease, with 202 reports received for this period. Themajority of notifications were reported from Queensland(67) and Victoria (62). Fifty per cent of reports were for the30 - 49 years age range.

Salmonellosis was reported for 226 persons this period.One hundred and one of the cases were in the 0 - 4 yearsage group. Included were apparent clusters of 3 or morecases in postcode regions of South Australia (4) andQueensland (3).

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Figure 6. Hepatitis A infection notifications, to theNational Notifiable Diseases SurveillanceSystem, by age and sex, 1996

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Figure 4. Hepatitis A notifications to the NationalNotifiable Diseases Surveillance System,1995 to January 1997, by month of onset


Disease1,2 ACT NSW NT Qld SA Tas Vic WA

Thisperiod1997

Thisperiod1996

Year todate1997

Year todate1996

Diphtheria 0 0 0 0 0 0 0 0 0 0 0 0Haemophilus influenzae type B 0 0 0 0 1 0 0 0 1 1 8 6Measles 0 2 0 8 0 0 6 0 16 14 43 61Mumps 1 2 0 NN 1 0 2 0 6 5 16 14Pertussis 4 73 0 36 92 5 74 23 307 121 764 384Rubella 0 2 0 29 8 1 4 4 48 117 209 426Tetanus 0 0 0 0 0 0 0 0 0 1 1 1

Table 1. Notifications of diseases preventable by vaccines recommended by the NHMRC for routinechildhood immunisation, received by State and Ter ritory health authorities in the period22 January to 4 February 1997

NN Not Notifiable.

1. No notifications of poliomyelitis have been reported since 1986.

2. Totals comprise data from all States and Territories. Cumulativefigures are subject to retrospective revision, so there may bediscrepancies between the number of new notifications and the increment in the cumulative figure from the previous period.

Disease1,2 ACT NSW NT Qld SA Tas Vic WA

Thisperiod1997

Thisperiod1996

Year todate1997

Year todate1996

Arbovirus Infection (NEC)3,4 0 1 1 0 0 0 13 1 16 7 28 12Barmah Forest virus infection 1 0 0 15 1 0 0 - 17 23 61 43Campylobacteriosis5 7 - 11 134 84 13 73 49 371 454 1227 1191Chlamydial infection (NEC)6 3 NN 19 130 0 10 46 35 243 280 679 660Dengue 0 0 0 1 0 - 0 0 1 1 56 4Donovanosis 0 NN 0 0 NN 0 0 0 0 3 1 6Gonococcal infection7 0 5 28 34 0 1 13 19 100 119 250 312Hepatitis A 0 28 5 11 4 0 5 7 60 103 147 284Hepatitis B incident 0 1 0 0 0 0 0 5 6 8 16 25Hepatitis C incident 0 0 0 - 0 0 - - 0 2 2 4Hepatitis C unspecified 4 NN 21 79 NN 8 32 17 161 333 644 820Hepatitis (NEC) 0 2 0 0 0 0 0 NN 2 2 4 3Legionellosis 1 0 1 0 1 0 0 1 4 5 19 17Leptospirosis 0 0 0 0 0 0 1 0 1 6 14 25Listeriosis 0 0 0 2 0 0 2 2 6 2 11 7Malaria 2 4 0 0 2 0 4 0 12 36 72 70Meningococcal infection 0 1 0 4 2 1 0 0 8 7 34 25Ornithosis 0 NN 0 0 0 0 0 0 0 4 4 9Q Fever 0 2 0 4 1 0 0 0 7 7 43 40Ross River virus infection 0 24 7 67 30 0 62 12 202 208 452 303Salmonellosis (NEC) 3 16 13 78 68 5 23 20 226 299 733 731Shigellosis5 0 - 6 7 3 0 1 5 22 24 77 68Syphilis 0 6 10 8 0 0 0 1 25 36 83 106Tuberculosis 0 4 1 2 1 0 13 0 21 35 77 107Typhoid8 0 1 1 0 0 0 1 1 4 7 6 15Yersiniosis (NEC)5 0 - 0 10 3 0 0 0 13 11 42 29

Table 2. Notifications of other diseases received by State and Territory health authorities in the period22 January to 4 February 1997

1. For HIV and AIDS, see Tables 4 and 5. For rarely notified diseases,see Table 3.

2. Totals comprise data from all States and Territories. Cumulativefigures are subject to retrospective revision so there may be discrep-ancies between the number of new notifications and the increment inthe cumulative figure from the previous period.

3. Tas: includes Ross River virus and dengue.

4. NT, Vic and WA: includes Barmah Forest virus.

5. NSW: only as ’foodborne disease’ or ’gastroenteritis in an institution’.6. WA: genital only.

7. NT, Qld, SA and Vic: includes gonococcal neonatal ophthalmia.

8. NSW, Vic: includes paratyphoid.

NN Not Notifiable.

NEC Not Elsewhere Classified.

- Elsewhere Classified.

Disease2Total this

periodReporting States or

Territories Total notifications 1997

Brucellosis 2 Qld 7Cholera 1Hydatid infection 2

1. Fewer than 60 cases of each of these diseases were notified each year during the period 1988 to 1995.

2. No notifications were received during 1996 for the following rare diseases: botulism; chancroid; leprosy; lymphogranulomavenereum; plague; rabies; yellow fever; or other viral haemorrhagic fevers.

Table 3. Notifications of rare1 diseases received by State and Ter ritory healthauthorities in the period 22 January to 4 February 1997


0 50 100 150 200 250 300 350 400 450

Salmonellosis

Rubella

Q fever

Pertussis

Meningococcal infection

Measles

Legionellosis

Hepatitis A

Campylobacteriosis

Ross River virus infection

Historical Data

Reporting Period 22/01/97 to 4/02/97

Notifications

Figure 7. Selected National Notifiable Diseases Surveillance System reports, and historical data1

1. The historical data are the averages of the number of notifications in 9 previous 2-week reportingperiods: the corresponding periods of the last 3 years and the periods immediately preceding andfollowing those.

Totals for Australia

ACT NSW NT Qld SA Tas Vic WA

This period1996

This period1995

Year todate1996

Year todate1995

HIV diagnoses Female 0 5 0 0 0 0 0 1 6 3 56 63Male 3 31 0 18 3 0 11 6 72 61 588 587Sex not reported 0 1 0 0 0 0 0 0 1 0 5 8Total1 3 37 0 18 3 0 11 7 79 64 650 660

AIDS diagnoses Female 0 1 0 0 0 0 0 0 1 1 17 25Male 0 20 0 0 0 0 0 2 22 53 328 542Total1 0 21 0 0 0 0 0 2 23 54 345 568

AIDS deaths Female 0 0 0 0 0 0 0 0 0 1 14 29Male 0 15 0 0 0 0 0 0 15 31 306 449Total1 0 15 0 0 0 0 0 0 15 32 320 479

1. Persons whose sex was reported as transsexual are included in the totals.

Table 4. New diagnoses of HIV infection, new diagnoses of AIDS and deaths following AIDS occur ring in theperiod 1 to 30 September 1996, by sex and State or Ter ritory of diagnosis

ACT NSW NT Qld SA Tas Vic WA Australia

HIV diagnoses Female 15 529 3 102 45 4 169 77 944Male 174 10207 84 1665 585 76 3448 784 17023Sex not reported 0 2049 0 0 0 0 42 0 2091Total1 189 12799 87 1772 630 80 3668 863 20088

AIDS diagnoses Female 7 142 0 30 18 2 48 18 265Male 76 3985 26 670 284 32 1373 301 6747Total1 83 4137 26 702 302 34 1428 321 7033

AIDS deaths Female 2 105 0 24 13 2 37 11 194Male 50 2842 21 470 197 21 1084 222 4907Total1 52 2953 21 496 210 23 1127 234 5116

1. Persons whose sex was reported as transsexual are included in the totals.

Table 5. Cumulative diagnoses of HIV infection, AIDS and deaths following AIDS since the introduction ofHIV antibody testing to 30 September 1996, by sex and State or Ter ritory


HIV and AIDS SurveillanceNational surveillance for HIV disease is coordinated by theNational Centre in HIV Epidemiology and ClinicalResearch (NCHECR), in collaboration with State andTerritory health authorities and the Commonwealth ofAustralia. Cases of HIV infection are notified to theNational HIV Database on the first occasion of diagnosisin Australia, by either the diagnosing laboratory (ACT,New South Wales, Tasmania, Victoria) or by acombination of laboratory and doctor sources (NorthernTerritory, Queensland, South Australia, WesternAustralia). Cases of AIDS are notified through the Stateand Territory health authorities to the National AIDSRegistry.

Tabulations of diagnoses of HIV infection and AIDS arebased on data available three months after the end of thereporting interval indicated, to allow for reporting delay andto incorporate newly available information. More detailed

information on diagnoses of HIV infection and AIDS ispublished in the quarterly Australian HIV SurveillanceReport, available from the National Centre in HIVEpidemiology and Clinical Research, 376 Victoria Street,Darlinghurst NSW 2010. Telephone: (02) 332 4648Facsimile: (02) 332 1837.

HIV and AIDS diagnoses and deaths following AIDSreported for September 1996, as reported to 31December 1996, are included in this issue of CDI (Tables4 and 5).

Australian Sentinel PracticeResearch NetworkThe Australian Sentinel Practice Research Network(ASPREN) comprises 99 sentinel general practitionersfrom throughout the country. Approximately 9,000consultations are recorded each week for 12 conditions.Of these, CDI reports the consultation rates forchickenpox, HIV testing (doctor initiated), HIV testing(patient initiated), influenza, measles, pertussis, RossRiver virus infection, rubella and gastroenteritis. Forfurther information including case definitions see CDI1997;21:6.

Data for weeks 4 and 5 ending 26 January and 2 Februaryrespectively are included in this issue of CDI (Table 6).The consultation rate for influenza-like illness hasremained at low levels since the beginning of October.The consultation rate for gastroenteritis has been muchlower during the last 4 reporting weeks than over recentmonths (Figure 8). The consultation rate for chickenpoxhas declined from the higher rate reported duringDecember 1996. The numbers of reported cases ofmeasles, rubella and pertussis have remained low. HIVtesting, being reported for the first time this year, currentlyaccounts for 3 per 1,000 consultations, two-thirds of thesetests being patient initiated. Consultation rates for RossRiver virus infection remain low at present.0

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Figure 8. Australian Sentinel Practice ResearchNetwork consultation rate forgastroenteritis, 1996 to January 1997

Week 4, to 26 January 1997 Week 5, to 2 February 1997

Condition ReportsRate per 1,000

encounters ReportsRate per 1,000

encounters

Chickenpox 26 3.5 22 3.8Gastroenteritis 93 12.6 68 11.9HIV testing (doctor initiated) 7 1.0 4 0.7HIV testing (patient initiated) 17 2.3 13 2.3Influenza 10 1.4 10 1.7Measles 0 0.0 0 0.0Pertussis 2 0.3 4 0.7Ross River virus infection 7 1.0 1 0.2Rubella 5 0.7 1 0.2

Table 6. Australian Sentinel Practice Research Network reports, weeks 4 and 5, 1997


LabVISEThe Virology and Serology Laboratory Reporting Scheme,LabVISE, is a sentinel reporting scheme. Twenty-onelaboratories contribute data on the laboratory identificationof viruses and other organisms. Data are collated andpublished in Communicable Diseases Intelligence eachfortnight. These data should be interpreted with caution asthe number and type of reports received is subject to anumber of biases. For further information, see CDI1997;21:8-9.

There were 621 reports received in the CDI Virology andSerology Reporting Scheme this period (Tables 7 and 8).

Parvovirus was reported for 15 patients this periodincluding 10 from Victoria. A total of 268 reports withspecimen collection dates in 1996 have been received sofar. This is the highest annual total recorded by thisscheme.

Chlamydia trachomatis was reported for 107 patients thisperiod. The male:female ratio was 1:1.7 and 94% ofpatients were in the 15 - 44 years age group. Morelaboratory reports (3,766) were received for 1996 than forany previous year.

Fifty-three reports of Mycoplasma pneumoniae werereceived this fortnight. The male:female ratio was 1:1.3and 47% of patients were in the 5 - 14 years age group.The number of reports rose in the latter half of 1996(Figure 9). In December the number of reports was thehighest recorded by this scheme since September 1993.

Q fever was reported for 9 patients this period, 7 of whomwere from New South Wales. All were in the 18 - 48 yearsage group and all but one were male.

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Figure 9. Mycoplasma pneumoniae laboratoryreports, 1992 to 1996, by month ofspecimen collection

State or Territory1Total

reported

ACT NSW NT Qld SA Vic WATotal thisfortnight

Historicaldata2

in CDI in1997

Measles, mumps, rubellaMeasles virus 1 1 16.3 9Rubella virus 1 3 4 27.2 218Hepatitis virusesHepatitis A virus 6 1 1 4 3 4 19 18.3 87Hepatitis D virus 1 1 .5 6ArbovirusesRoss River virus 5 20 5 8 38 55.7 180Barmah Forest virus 2 2 4.5 41Flavivirus (unspecified) 1 1 1.0 5AdenovirusesAdenovirus type 3 2 2 3.0 10Adenovirus type 4 1 1 .2 1Adenovirus type 8 1 1 .3 5Adenovirus type 26 1 1 .0 1Adenovirus type 40 1 1 .0 6Adenovirus not typed/pending 1 1 8 3 5 18 32.2 178Herpes virusesCytomegalovirus 10 10 4 1 11 2 38 36.0 183Varicella-zoster virus 2 2 11 16 1 32 42.7 260Epstein-Barr virus 13 20 3 10 46 68.7 502Other DNA virusesParvovirus 1 4 10 15 6.2 93

Table 7. Virology and serology laboratory reports by State or Territory1 for the reporting period 16 to 29 January 1997, historical data2, and total reports for the year


State or Territory1Total

reported

ACT NSW NT Qld SA Vic WATotal thisfortnight

Historicaldata2

in CDI in1997

Picornavirus familyCoxsackievirus A16 3 3 .0 6Coxsackievirus B2 1 1 .3 8Coxsackievirus B3 1 1 .7 2Coxsackievirus B5 1 1 .5 3Echovirus type 5 1 1 .0 2Echovirus type 7 1 1 2 .2 13Poliovirus type 1 (uncharacterised) 1 1 .3 3Rhinovirus (all types) 13 3 1 17 11.0 140Enterovirus not typed/pending 3 3 22.5 136Ortho/ParamyxovirusesInfluenza A virus 3 1 4 8.5 89Influenza B virus 1 2 4 1 8 1.5 49Influenza virus - typing pending 15 15 .0 40Parainfluenza virus type 1 1 1 1.2 17Parainfluenza virus type 3 4 6 5 1 1 3 20 14.8 261Parainfluenza virus typing pending 19 19 .7 39Respiratory syncytial virus 68 16 1 85 15.5 131Other RNA virusesRotavirus 1 14 1 3 19 20.5 157Astrovirus 1 1 .0 2Norwalk agent 7 7 .0 36OtherChlamydia trachomatis not typed 37 5 19 22 4 20 107 98.5 784Chlamydia psittaci 1 1 2 5.2 20Chlamydia species 1 1 4.5 4Mycoplasma pneumoniae 9 22 1 6 5 10 53 14.7 351Coxiella burnetii (Q fever) 7 2 9 5.7 62Bordetella pertussis 17 17 26.8 356Cryptococcus species 1 1 2 .7 3TOTAL 145 91 26 26 154 108 71 621 566.8 4,499

Table 7. Virology and serology laboratory reports by State or Territory1 for the reporting period 16 to 29 January 1997, historical data2, and total reports for the year, continued

1. State or Territory of postcode, if reported, otherwise State or Territory of reporting laboratory.

2. The historical data are the averages of the numbers of reports in 6 previous 2 week reporting periods: the corresponding periods of the last 2 years and the periods immediately preceding and following those.

State or Territory Laboratory Reports

Australian Capital Territory Woden Valley Hospital, Canberra 171

New South Wales Institute of Clinical Pathology & Medical Research, Westmead 41Royal Prince Alfred Hospital, Camperdown 4South West Area Pathology Service, Liverpool 20

Queensland State Health Laboratory, Brisbane 26

South Australia Institute of Medical and Veterinary Science, Adelaide 154

Victoria Microbiological Diagnostic Unit, University of Melbourne 4Monash Medical Centre, Melbourne 16Royal Children’s Hospital, Melbourne 21Victorian Infectious Diseases Reference Laboratory, Fairfield Hospital 68

Western Australia Princess Margaret Hospital, Perth 14Royal Perth Hospital 6Western Diagnostic Pathology 76

TOTAL 621

Table 8. Virology and serology laboratory reports by contributing laboratories for the reporting period 16 to 29 January 1997


Overseas briefsSource: World Health Organization (WHO)

Bubonic plague, ZambiaAs at 3 February 1997, 267 cases of bubonic plague hadbeen reported in Namwala District in the SouthernProvince of Zambia. Among these, 26 (10%) died and 25patients were still under treatment. All reported deathsoccurred before 26 January. The clinical diagnosisestablished by the South West Regional Office has beenconfirmed by a team of experts from the UniversityTeaching Hospital in Lusaka. The strain of Yersinia pestiswhich has been isolated has been shown to be sensitiveto tetracycline and streptomycin.The outbreak could belinked to heavy rain and flooding causing rats to invadeinhabited areas. Fleas are also abundant. The first humancases presented with inguinal, axillary and cervicalabscesses in December and deaths began to occur inearly January.

When the first reports of an unusual disease outbreakwere received on 24 January, health authoritiesestablished treatment centres in the outbreak focus inKantengwa and satellite centres in Makobo, Chilala andKabulamwanda. Drugs, medical supplies and protectivematerial have been dispatched to the affected area. Allpatient contacts are followed up and treated, infectedhouseholds are disinfected and rodents and fleasdestroyed. A team of health workers monitors the situationand intervenes when needed. Movements in and out ofthe area are also monitored.

Plague is endemic in many countries in southern Africawhere natural foci still exist, including Angola, Malawi,Mozambique, Tanzania, Zimbabwe, Madagascar, Namibiaand South Africa. The cases reported in Zambia arebubonic plague which is not an airborne infection as is thepulmonary form of plague. There are no restrictions fortravellers visiting Zambia, or to transit in airports in thecountry.

Meningitis Togo . An outbreak of meningitis started in November1996 in Togo, with 1,235 cases and 151 deaths reportedup to 3 February. A team including an epidemiologist fromthe WHO Office for the Africa region is investigating theoutbreak to assess the epidemiology of the outbreak andspeed up laboratory confirmation. The work of this teamwill be further supported by technical experts andmaterials from non-government organisations. WHO issending an additional 100,000 doses of vaccine andinjection material.

On 7 February, an interagency appeal was issued to raiseover US$ 6 million needed to respond to the threat ofepidemic meningitis in countries at risk in the Africancontinent. The agencies behind the appeal are WHO,United Nations International Children’s Emergency Fund,Médecins Sans Frontières, and the Federation of the RedCross and Red Crescent Societies. The appeal is toestablish a fund that will ensure the purchase anddistribution of vaccine, antibiotics and autodestructibleinjection material for treatment during the 1997 meningitisseason in Africa. WHO has advanced US$ 1 million toensure the availability of vaccine pending the outcome ofthe appeal.

Burkina Faso . As at 28 January, 461 cases with 64 (14%)deaths have been reported. Vaccine is available to start avaccination campaign. Last year a large epidemic ofmeningococcal meningitis occurred in Burkina Faso withover 42,000 cases reported.

Other countries having reported cases of meningitis areGhana (181 cases, 17 deaths) and Mali (180 cases, 26deaths).

Acting Editor: Ana Herceg

Deputy Editor: Graham Andrews

Assistant Edi tor: Margaret Curran

Editorial Advisory Board

Charles Watson (Chair), Margaret Burgess, Scott Cameron,Jeffrey Hanna, John Kaldor, Margery Kennett, Cathy Mead,Christine Roberts

Editorial and Production Staff

Ross Andrews, Michelle Charlton, Scott Crerar, David Evans,Htoo Myint, Graeme Oliver, Corina Yong

Contributions covering any aspects of communicable disease areinvited. Instructions to authors can be found in CDI 1997;21:9.

CDI is produced fortnightly by the National Centre for DiseaseControl, Department of Health and Family Services, GPO Box9848 Canberra ACT 2601; fax: (06) 289 7791, telephone: (06)289 1555. For subscriptions or change of address please fax (06)269 1212 or write to PO Box 462, Fyshwick ACT 2609.

Opinions expressed in CDI are those of the authors and notnecessarily those of the Department of Health and FamilyServices or the Communicable Diseases Network Australia NewZealand. Data may be subject to revision.

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