Contents

Salmonellosis outbreak linked to the consumption of fried ice-cream 114

Testing for chlamydia among heterosexual males and females at sentinel surveillance sites in Victoria, 2007–2010 118

Prevalence of antimicrobial resistance among Neisseria gonorrhoeae in Victoria, 2001–June 2011 122

Invasive pneumococcal disease in Victoria – an update 126

Sarcocystosis in Malaysia: preventive advice for travellers 128

Strengthening immunisation for children 129

Immunisation coverage report, Victoria, September 2011 131

Communicable disease surveillance in Victoria, July–September 2011 134

Victorian Infectious Diseases Bulletinisbn 1 441 0575 Volume 14 issue 4 December 2011

114 VictorianInfectiousDiseasesBulletinVolume14Issue4December2011

Salmonellosis outbreak linked to the consumption of fried ice-cream L Kent1,2, J Gregory1, M Patel2

1Communicable Disease Prevention and Control Unit, Victorian Department of Health2national Centre for Epidemiology and Public Health, College of Medicine, Australian national University, Canberra

background On 8 April 2011, the Communicable Disease Prevention and Control Unit (CDPCU) of the Victorian Department of Health was advised that three adolescents from the same family had been admitted to a metropolitan hospital for treatment of dehydration secondary to diarrhoea. Other symptoms included fever and vomiting. initial enquires suggested that the adolescents may have become infected after eating fried eggs for breakfast at their aunt’s home over three consecutive days, or dinner at a Chinese restaurant. six days later two more notifications of salmonellosis were received by CDPCU; both cases had eaten at the same Chinese restaurant. Also on this day, the Department was notified that Salmonella spp. was isolated from two of the original adolescent’s faecal specimens.

An investigation was initiated to characterise the outbreak, identify the source and possible cause of the infection and to prevent ongoing transmission of the infection.

MethodsA retrospective cohort study was conducted using the booking list of patrons to the Chinese restaurant. A standard CDPCU questionnaire for gastrointestinal illness, tailored to include food and drink from the restaurant menu, was used to collect data through telephone interviews. A confirmed case was defined as a patron who had eaten at the restaurant between five and 11 April, who reported diarrhoea and one or more of the following symptoms: vomiting, fever, nausea, lethargy, abdominal pain and/or headache, and had a laboratory confirmed infection with Salmonella Typhimurium phage type 170. A probable case included the definition of a confirmed case but without the laboratory confirmed infection. Active case finding through the surveillance system for notified cases of salmonellosis living within a 20km radius from the restaurant was also conducted. A possible case had laboratory confirmed Salmonella spp. and resided within the 20km distance from the restaurant.

The local government environmental health officers inspected the restaurant and the aunt’s kitchen, taking egg samples from both venues, as well as frozen ice-cream balls from the restaurant. These were submitted for microbiological investigation to the Microbiological Diagnostic Unit (MDU).

Data were entered into Excel and analysed with stata version 9. Where several food items were statistically associated with salmonellosis, stratified analyses were used to adjust for potential confounding.

Results

Epidemiologic investigation

Of the 307 patrons recorded in the restaurant booking list over the seven day period in question, 91 telephone contact numbers were available. Of these, 68 patrons were able to be contacted and subsequently interviewed by telephone (22 per cent of the cohort).

nine people notified to CDPCU with Salmonella Typhimurium 170 had eaten at the restaurant between the

7th and 10th of April (Figure 1). Three of these cases were identified during active case finding through routine surveillance systems. An additional six probable cases were reported during interviews with the confirmed cases; they became ill after eating at the restaurant with friends or family but faecal specimens had not been collected. Food histories and time of illness onset were not available for three of these individuals. in total, diet histories were available for 82 patrons of the restaurant sourced via the booking list and active case finding.

Five further possible cases were identified during active case finding. Salmonella Typhimurium 170 was isolated from faecal specimens of four of the cases; however, none reported eating at the restaurant. Salmonella newport was cultured from the fifth case. These cases were therefore excluded from the cohort investigation.

All 15 confirmed and probable cases reported fever and diarrhoea, while 80 per cent reported abdominal pain and 73 per cent reported vomiting. Time

VictorianInfectiousDiseasesBulletinVolume14Issue4December2011 115

of symptom onset was reported by all confirmed cases; incubation periods ranged from six to 14 hours (median 11 hours). six confirmed cases were hospitalised.

Table one shows the risk associated with consuming various foods at the restaurant. Of the 33 food and drink items consumed by patrons, six had significantly elevated risk ratios. All cases interviewed had consumed fried ice-cream giving an attack rate of 100 per cent for this item. Patrons that did not eat the fried ice-cream reported no disease. Relative

Figure 1: Epidemic curve by date of illness onset, outbreak investigation, April 2011

Num

ber

of

case

s

Date of illness onset

0

1

2

3

4

5

6

7

8

14 April13 April12 April11 April10 April9 April8 April7 April6 April5 April

Qtr4Qtr3Qtr2Qtr1

risks (RR) were also elevated for consumption of abalone, noodle with crab, fried rice noodles, singapore noodles, and lychees with ice-cream.

stratified analysis showed that the effects of eating abalone, noodles with crab, fried rice noodles, singapore fried noodles and lychees with ice-cream were confounded by the effect of consuming fried ice-cream. There were no patrons who had eaten any of these food items (excluding the fried ice-cream) and become unwell.

Table 1: Food-specific attack rates, relative risk and 95% confidence intervals related to illness among restaurant patrons (n=82)

Food itemIll/exposed/

total (%)Ill/unexposed/

total (%) Relative risk (95% CI) P valueFried ice-cream 12/12 (100.00) 0/70 (0.00) inf (21.45–inf) <0.001Red bean soup 0/64 (0.00) 12/18 (66.67) 0.00 (0.00–0.10) <0.001steamed rice 2/67 (2.99) 10/15 (66.67) 0.04 (0.01–0.18) <0.001Clear soup 0/56 (0.00) 11/25 (44.00) 0.00 (0.00–0.19) <0.001Abalone 4/5 (80.00) 8/77 (10.39) 7.70 (3.50–16.95) <0.001noodles with crab 4.5 (80.00) 8/77 (10.39) 7.70 (3.50–16.95) <0.001Chinese tea 1/49 (2.04) 11/33 (33.33) 0.06 (0.01– 0.45) <0.001Chicken ribs in salty egg yolk 1/46 (2.17) 11/36 (30.56) 0.07 (0.01–0.53) <0.001sautéed mixed seasonal vegetables 1/34 (2.94) 11/48 (22.92) 0.13 (0.02–0.95) 0.012Fried rice noodle with soy bean sauce 1/1 (100.0) 11/81 (13.58) 7.36 (4.25–12.75) 0.015singapore fried noodle 1/1 (100.0) 11/81 (13.58) 7.36 (4.25–12.75) 0.015Lychees with ice-cream 1/1 (100.0) 11/81 (13.58) 7.36 (4.25–12.75) 0.015stir fried venison with XO chilli sauce 0/22 (0.00) 12/60 (20.00) 0.00 (0.00–1.03) 0.023Pork spare ribs with Peking sauce 0/22 (0.00) 12/60 (20.00) 0.00 (0.00–1.03) 0.023steamed barramundi 0/21 (0.00) 11/60 (18.33) 0.00 (0.00–1.08) 0.035Roast duck 1/28 (3.57) 11/54 (20.37) 0.18 (0.02–1.29) 0.041

Environmental investigation

The proprietors of the restaurant were instructed to clean and sanitise all kitchen surfaces using the Department of Health’s Guidelines for the investigation of gastroenteritis,1 to keep food safety records up to date and accessible and to rectify various items not functioning. staff’s hand-washing techniques were found to be inadequate and advice on the correct techniques was provided.

Laboratory investigations

Aunt’s house

Salmonella infantis was isolated from the external surface of eggs taken from the aunt’s house, but no Salmonella spp. were detected in the internal contents of these eggs.

Chinese restaurant

Salmonella Typhimurium phage type 170 was isolated from pre-prepared ice-cream balls taken from the freezer of the restaurant. no Salmonella spp. were detected in the pulp or the external surface of the eggs. The ice-cream used in the preparation of the fried ice-cream was not available for testing.

116 VictorianInfectiousDiseasesBulletinVolume14Issue4December2011

DiscussionSalmonella Typhimurium 170 was the aetiology of this outbreak. The symptoms and incubation periods were consistent with infection with S. Typhimurium. Salmonella Typhimurium 170 was cultured from faecal samples of nine cases that had eaten at the restaurant, as well as from samples of pre-prepared ice-cream balls made at the restaurant.

in Victoria from 1 January to 11 May 2011, Salmonella spp. was a causative agent in about one-third of sporadic cases gastroenteritis. Of these cases Salmonella Typhimurium accounted for more than two-thirds of all notifications of salmonellosis, while Phage type 170 was the most common serotype (about 20 per cent).2

The most common risk factors for salmonellosis are consumption of meats and eggs (3) and eggs as a raw or incompletely cooked ingredient are often implicated.4–10

Salmonella Typhimurium 170 was isolated from the ice-cream coated in raw egg/bread crumbs and kept in the freezer. As the same serotype was also isolated from the faecal specimens of the cases and no other pathogens were detected in the faeces and fried ice-cream, the food is the most likely source of infection. Results from the cohort study also implicated the fried ice-cream as the source of the outbreak. Salmonella Typhimurium has been implicated in fried ice-cream outbreaks in Australia since 2000. 7,9,11–13 The ice-cream used in the preparation of this product was purchased from the local supermarket. Although commercially prepared ice-cream has been linked to salmonellosis in

the United states14,15 it is unlikely that the ice-cream was the source of the Salmonella in this outbreak as no other outbreaks or cases investigated during this period were associated with commercially prepared ice-cream.

The fried ice-cream balls were prepared as follows: ice-cream was scooped from the tub and shaped into balls. it was then coated with raw egg before crumbing and then immediately refrozen until required. When fried ice-cream was ordered by a patron, the product was removed from the freezer and very rapidly fried in hot oil to brown the breadcrumbs. As raw or undercooked eggs are often implicated with salmonellosis, it is likely that the heat-treatment given to the ice-cream balls was not hot enough to kill the bacteria. Food needs to reach a temperature of at least 72°C for 15 seconds for Salmonella to be killed (16). This hypothesis is supported by the unsolicited information volunteered by a case that the breadcrumbs around the ice-cream ball did not appear completely cooked.

Eggs may become contaminated with Salmonella spp. via two routes: trans-ovarian (vertically) or trans-shell (horizontally)17. Vertical contamination occurs in vivo in infected birds before the egg is formed. Horizontal infection occurs in vitro by a number of external factors, which means that not every egg in a given batch is likely to be infected. in Australia, horizontal transmission is the primary mode of egg contamination. This may explain why cultures of the outside shell rinse or pulp of the eggs, obtained from the restaurant, did not yield Salmonella Typhimurium.

Conclusions and public health outcomesThe causative agent for this outbreak of gastroenteritis, Salmonella Typhimurium Phage Type 170, was linked epidemiologically and microbiologically to fried ice-cream prepared by the Chinese restaurant on or around 5th April. Prompt investigation by the Department of Health and confirmation of the source arrested further transmission.

This outbreak highlights the risk of consumption of raw or incompletely cooked eggs and egg products, and provides further evidence for the link between these foods and salmonellosis. The restaurant proprietors were advised to use pasteurised eggs to prepare the ice-cream balls before frying. The restaurant has subsequently resumed serving the fried ice-cream balls—made with pasteurised eggs—with no detectable difference in appearance or taste.

Furthermore, this outbreak highlights the importance of ongoing education of consumers, the food service industry, retailers, wholesalers, and egg producers of the risks associated with the improper handling of eggs and those associated with using raw or lightly cooked eggs in ready–to-eat foods.

Acknowledgements The authors gratefully acknowledge the assistance provided in this investigation by the staff at Greater Dandenong City Council, the University of Melbourne Microbiological Diagnostic Unit, especially nela subasinghe and Mary Valcanis, the Victorian infectious

VictorianInfectiousDiseasesBulletinVolume14Issue4December2011 117

Diseases Reference Laboratory and Geoffrey Prendergast from the Communicable Disease Prevention and Control Unit at the Department of Health.

References1. Victorian Government Department

of Health. Guidelines for the investigation of gastroenteritis. 2010 [updated 2010; cited 15/08/2011]; Available from: http://www.health.vic.gov.au/__data/assets/pdf_file/0006/512880/Gastro-guidelines-web.pdf

2. Victorian Government Department of Health. Victorian notifiable infectious Diseases surveillance system. 2011 [cited 15/08/2011]

3. Pires sA, Vigre H, Makela P, Hald T. Using outbreak data for source attribution of human salmonellosis and campylobacteriosis in Europe. Foodborne Pathogens and Disease. 2010;7(11):1351–61

4. EFsA Panel on biological Hazards. scientific opinion on a quantitative estimation of the public health impact of setting a new target for the reduction of Salmonella in laying hens. European Food Safety Authority Journal. 2010;8(4):1546–631

5. Mokhtari A, Moore CM, Yang H, Jaykus L, Morales R, Cates sC, et al. Consumer-Phase Salmonella enterica serovar Enteritidis risk assessment for egg-containing food products. Risk analysis. 2006;26(3):753–68

6. Molbak K, neimann J. Risk factors for sporadic infection with Salmonella enteritidis, Denmark, 1997–1999. American Journal of Epidemiology 2002;156:654–61

7. OzFoodnet Working Group. OzFoodnet quarterly report, 1 April to 30 June 2007. Journal [serial on the internet]. 2007 Date 26 July 2011]; 31(3): Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-cdi3103j.htm

8. OzFoodnet Working Group. OzFoodnet Quarterly report 1 January to 31 March 2008. Journal [serial on the internet]. 2008 Date 25 July 2011]; 32(2): Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-cdi3202-pdf-cnt.htm/$FILE/cdi3202k.pdf

9. OzFoodnet Working Group. OzFoodnet quarterly report, 1 October to 31 December 2010 Journal [serial on the internet]. 2011 Date 25 July 2011]; 35(1): Available from: http://www.yourhealth.gov.au/internet/main/publishing.nsf/Content/cda-cdi3501f.htm

10. sarna M, Dowse G, Evans G, Guest C. An outbreak of Salmonella Typhimurium PT135 gastroenteritis associated with a minimally cooked dessert containing raw eggs. Communicable Disease Intelligence. 2002;26(1):32-7.

11. OzFoodnet Working Group. OzFoodnet quarterly report, 1 April to 30 June 2009. Journal [serial on the internet]. 2009 Date 26 July 2011]; 33(3): Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-cdi3303k.htm

12. OzFoodnet Working Group. OzFoodnet quarterly report, 1 January to 31 March 2010 Journal [serial on the internet]. 2010a Date

26 July 2011]; 34(2): Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-cdi3402h.htm

13. OzFoodnet Working Group. OzFoodnet Quaterly Report 1 July to 30 september 2010. Journal [serial on the internet]. 2010b Date 25 July 2011]; 34 (4): Available from: http://www.health.gov.au/internet/main/publishing.nsf/content/cda-cdi3404-pdf-cnt.htm/$FILE/cdi3404h.pdf

14. Hennessey TW, Hedberg CW, L s, White KE, besser-Wiek JM, Moen ME, et al. A national outbreak of Salmonella Enteritidis infections from ice cream. New England Journal of Medicine. 1996;334(20):1281–6

15. Vought KJ, Tatini sR. Salmonella enteritidis contamination of ice cream associated with a 1994 multistate outbreak. Journal of Food Protection. 1998;61:5–10

16. Food standards Australian and new Zealand. Food standards Code Vol. 2 – standard 1.6.2. in: Zealand FsAan, editor.; 2003

17. Food standards Australian and new Zealand. Primary production and processing standard for eggs & egg products – Risk assessment of eggs and egg products. 2009 [updated 2009; cited 28 July 2011]; Available from: http://www.foodstandards.gov.au/_srcfiles/P301%20Eggs%20PPPS%20DAR%20SD1%20Risk%20Assessment.pdf (Peer reviewed)

118 VictorianInfectiousDiseasesBulletinVolume14Issue4December2011

Testing for chlamydia among heterosexual males and females at sentinel surveillance sites in Victoria, 2007–2010Anita Feigin, Phuong Nguyen and Carol El-Hayek, on behalf of the Victorian Primary Care Network for Sentinel Surveillance on BBVs and STIs

introductionChlamydia is the most frequently notified sexually transmissible infection (sTi) in Victoria, with the rate increasing from 69 per 100,000 population in 2000, to 238 per 100,000 population in 2008.1 Chlamydia is most commonly diagnosed among young people aged from 16 to 29 years.2 infections are often asymptomatic and if left untreated, chlamydia infection may lead to long term complications such as pelvic inflammatory disease (PiD), ectopic pregnancy and infertility.3

in order to monitor trends in the current epidemic and provide information on the characteristics and risk behaviours of individuals being tested for chlamydia, the sentinel surveillance of chlamydia through participating primary health care clinics was established. in this report we present data on heterosexual males and females testing for chlamydia at a network of sentinel surveillance sites in Victoria from 2007 to 2010.

Methods

Data collection

The Victorian Primary Care network for sentinel surveillance (VPCnss) on blood borne Viruses (bbV) and sexually Transmitted infections (sTi) is a network of clinical sites that see high caseloads of people at risk of HiV, syphilis and chlamydia in Victoria. Eight sites, including sexual health, family planning, hospital, community health and corrections facility clinics, participate in the heterosexual chlamydia network. At the largest sexual health clinic, behavioural data were collected using an electronic self-completed questionnaire. At the other clinics a paper-based questionnaire was used. some behavioural questions differ between the electronic and paper-based questionnaire and are indicated in the results where applicable. A more detailed description of the system can be found elsewhere.4

Data analysis

Testing, demographic and behavioural data captured from 2007 to 2010 were included in the analysis. Questionnaire data were matched to a test record by a unique number,

date of birth, date of test and clinic. Records were excluded for males who reported any male sex partners. The records of individuals reporting sex work were also excluded to adjust for potential bias relating to the high frequency of testing and low rates of chlamydia in sex worker populations compared to the general population.5 Chlamydia tests from multiple anatomical sites on the same day were collapsed as one record. Descriptive analyses were conducted using sTATA version 11 (statcorp, LP, Texas, UsA).

Results

Chlamydia testing

Overall, from 2007 to 2010, there were 52 per cent more chlamydia tests conducted among females compared to males, however the proportion of positive chlamydia tests was lower in females; 4.9 per cent compared to 7.8 per cent in males. six per cent of tests in males were among those aged 16–19 years compared to 17 per cent in females. Among those aged 50 years and over there were 74 per cent more tests among males compared to females (Tables 1a and 1b).

Males

From 2007 to 2010, 18,165 chlamydia tests were conducted among males at sentinel surveillance sites in Victoria, half of which were among males aged 20–29 years. ninety-one per cent of all tests among males were conducted at a sexual health clinic. The annual number of tests conducted increased from 2007 to 2010 with the greatest increase (19 per cent) being from 2009 to 2010 (Table 1a). Overall the proportion of positive tests among males testing for chlamydia at sentinel sites was 7.8 per cent. The proportion of positive tests was highest among those aged 20-24 years (11.5 per cent), followed by those aged 16-19 years (10.6 per cent). Tests conducted at sites other than the sexual health clinics had a higher proportion of positive results; 10.7 per cent compared to 7.5 per cent at the sexual health clinics. During the four year period, the highest proportion of positive tests among males occurred in 2010 (Table 1a).

Females

From 2007 to 2010, 27,700 chlamydia tests were conducted among females attending sentinel surveillance sites in Victoria.

VictorianInfectiousDiseasesBulletinVolume14Issue4December2011 119

Approximately 50 per cent of tests were conducted among females aged 16–24 years. Fifty-nine per cent of all tests among females were conducted at a sexual health clinic. The number of tests among females was similar in 2007 and 2008 but increased by eight per cent in 2009 and a further 17 per cent in 2010 (Table 1b).

Among females testing for chlamydia at sentinel sites, the highest proportion of positive tests was in those aged 16–19 years (7.6 per cent) and 20–24 years (6.7 per cent). Tests conducted at the sexual health clinics had a higher proportion of positive results compared with those at the other primary care sites; 5.3 per cent compared to 4.3 per cent. During the four year period the proportion of positive tests among females was highest in 2009 and 2010 (Table 1b).

Characteristics of heterosexuals tested for chlamydia

ninety-six per cent of chlamydia tests among males and 79 per cent of tests among females matched to a survey record. The following results include only matched records.

Males

Over half of chlamydia tests in males were among those who are Australian born (58 per cent) and less than one per cent were among males who reported being of Aboriginal and/or Torres strait islander origin (Table 2a). in 44 per cent of chlamydia tests among males, symptoms were reported. For a majority of tests, males reported having more than one sexual partner in the past 12 months (72 per cent) and 58 per cent of tests were among males who reported a new partner in the previous three months. seventy-five per cent of tests were among males who reported not always using condoms with their sexual partners.

The proportion of positive chlamydia tests was highest among males born overseas (9.2 per cent) and males with an Aboriginal and/or Torres strait islander background (8.3 per cent). The proportion positive

observed among males who reported symptoms at the time of test was 9.3 per cent compared to 6.6 per cent where symptoms were not reported.

Males who reported six or more sexual partners had a proportion

Table 1a: Chlamydia testing and positivity by age group, site type and year among heterosexual males, Victoria, 2007–2010

    Tests Positivity

    n % n %

Total tests 18165 100 1420 7.8

Age group (years)

16–19 1154 6.4 122 10.6

20–24 4550 25.1 521 11.5

25–29 4633 25.5 370 8.0

30–34 2751 15.2 169 6.1

35–39 1794 9.9 92 5.1

40–44 1234 6.8 60 4.9

45–49 888 4.9 31 3.5

50+ 1160 6.4 55 4.7

site typesexual health clinics 16585 91.3 1251 7.5

Other primary care sites 1580 8.7 169 10.7

Year 2007 3953 21.8 292 7.4

  2008 4392 24.2 345 7.9

  2009 4482 24.7 346 7.7

  2010 5338 29.4 437 8.2

Table 1b: Chlamydia testing and positivity by age group, site type and year among females, Victoria, 2007–2010

    Tests Positivity

    n % n %

Total tests   27700 100 1353 4.9

Age group (years)

16–19 4704 17.0 359 7.6

20–24 9098 32.9 611 6.7

25–29 6040 21.8 265 4.4

30–34 3090 11.2 59 1.9

35–39 2096 7.6 32 1.5

40–44 1236 4.5 12 1.0

45–49 759 2.7 7 0.9

50+ 666 2.4 8 1.2

site typesexual health clinics 16311 58.9 863 5.3

Other primary care sites 11389 41.1 490 4.3

Year 2007 6369 23.0 298 4.7

  2008 6365 23.0 298 4.7

  2009 6898 24.9 354 5.1

  2010 8068 29.1 403 5.0

120 VictorianInfectiousDiseasesBulletinVolume14Issue4December2011

positive more than double of those reporting just one partner; 11.3 per cent compared to 5.1 per cent respectively. The proportion positive was highest among males who reported not always using condoms with any sexual partner in the past 12 months (8.8 per cent), and those who reported a new partner in the past three months (12.5 per cent).

Females

Over half of chlamydia tests in females were among those who are Australian born (55 per cent) and less than one per cent were among females who reported being of Aboriginal and/or Torres strait islander background (Table 2b). in 39 per cent of chlamydia tests among females, symptoms were reported. For 52 per cent of tests, females reported having more than one sexual partner in the past 12 months and 41 per cent of tests were among females who reported a new partner in the previous three months. seventy per cent of tests were among females who reported not always using condoms with their sexual partners.

The proportion of positive chlamydia tests was highest among females born overseas (6.2 per cent) and females with an Aboriginal or Torres strait islander background (7.9 per cent). The proportion positive observed among females who reported symptoms at the time of test was 5.0 per cent compared to 5.7 per cent where symptoms were not reported.

Females who reported six or more sexual partners had a proportion positive double of those reporting just one partner; 6.9 per cent compared to 3.5 per cent respectively. The proportion positive among females who reported not always using

condoms with any sexual partner in the past 12 months was 6.1 per cent; 6.4 per cent among those who reported a new partner in the past three months.

DiscussionFrom 2007 to 2010 there were consistently more females than males presenting for chlamydia testing at sentinel surveillance sites in Victoria, although the number and proportion of positive tests was higher among males. The proportion of positive tests among both males and females increased between 2007 and 2010

which is possibly a reflection of increasing chlamydia prevalence in Victoria during this period.

The proportion of chlamydia positive tests was higher among males who reported symptoms. in females, the opposite was observed where proportion positive was highest in those who did not report symptoms. This difference between sexes may be related to different health seeking behaviour, with men testing more in response to symptoms or partner referral, and women receiving more opportunistic testing during visits for other reasons.

Table 2a: Reported characteristics among males testing for Chlamydia, Victoria, 2007–2010

    Tests Positivity

    n % n %

All matched records 17417 100.0 1347 7.7

Country of birth

Australia 10044 57.7 705 7.0

Other 6351 36.5 582 9.2

not answered 1022 5.9 60 5.9

Aboriginal and/or Torres strait islander

Yes 144 0.8 12 8.3

no 15319 88.0 1197 7.8

not answered 1954 11.2 138 7.1

Reported symptoms

Yes 7637 43.9 712 9.3

no 9039 51.9 600 6.6

not answered 743 4.3 35 4.7

number of female partners (past 12 months)

none 258 1.5 5 1.9

One 3040 17.5 154 5.1

2–5 8513 49.1 642 7.5

6–10 2699 15.6 273 10.1

>10 1338 7.7 183 13.7

not answered 1486 8.6 89 6.0

Condom use with any partner (past 12 months)

no sexual intercourse 92 0.5 5 5.4

Did not always use condoms 13134 75.4 1157 8.8

Always used condoms 2302 13.2 85 3.7

not answered 1759 10.1 96 5.5

new partners * (last three months)

Yes 506 58.3 63 12.5

no 342 39.4 34 9.9

not answered 20 2.3 3 15.0

*not asked at sexual health clinic

VictorianInfectiousDiseasesBulletinVolume14Issue4December2011 121

The majority of males and females who completed the questionnaire reported multiple sexual partners in the past 12 months, and over 70 per cent reported not always using condoms with their sexual partners. The clinics involved in this sentinel surveillance network were selected because they diagnose chlamydia more often than other general practice clinics so it is likely they see more individuals who engage in these high risk behaviours.

For both males and females the proportion of positive tests was highest in the younger age groups and in the groups with multiple partners, new partners and in those who did not always use condoms. This highlights the importance of the continued promotion of consistent condom use in safe sex interventions aimed at young heterosexuals.

Acknowledgments The VPCnss is managed in collaboration with Melbourne sexual Health Centre and the Victorian infectious Diseases Laboratory and funded by the Victorian Department of Health. We gratefully acknowledge their contribution as well as that of the clinicians, scientists and other staff at participating sentinel clinics and laboratories. We also thank the patients who attend the clinics for their HiV and sTi testing.

References1. Department of Health Victoria

2011. Surveillance of notifiable infectious diseases in Victoria 2008, (http://www.health.vic.gov.au/ideas)

2. Department of Health Victoria 2011. Victorian infectious Diseases bulletin, 14(3):september 2011, (http://www.health.vic.gov.au/ideas)

3. stoner b P. Sexually transmitted infections: overview. Elsevier 2008

4. Goller J, Gold J, Lim M, El-Hayek C, stoove M, bergeri i, Fairley C, Leslie D, Clift P, White b, Hellard M. Methods and attributes of a linked sentinel surveillance system for bbVs and sTis in Victoria, Australia. Sexual Health. 2010;7:425–33.

5. samaranayake A, Chen M, et al. Legislation requiring monthly testing of sex workers with low rates of sexually transmitted infections restricts access to services for higher-risk individuals. Sex Transm Infect. 2009; 85: 540–542.

Table 2b: Reported characteristics among females testing for Chlamydia, Victoria, 2007–2010

    Tests Positivity

    n % n %

All matched records 21811 100.0 1102 5.1

Country of birth

Australia 12076 55.4 523 4.3

Other 8626 39.6 533 6.2

not answered 1109 5.1 46 4.2

Aboriginal and/or Torres strait islander

Yes 127 0.6 10 7.9

no 19587 89.8 995 5.1

not answered 2097 9.6 97 4.6

Reported symptoms

Yes 8576 39.3 427 5.0

no 11105 50.9 628 5.7

not answered 2130 9.8 47 2.2

number of male partners (last 12 months)

none 569 2.6 7 1.2

One 6702 30.9 233 3.5

2–5 9235 42.5 607 6.7

6–10 1528 7.0 138 9.0

>10 563 2.6 37 6.6

not answered 3107 14.3 77 2.5

Condom use with any partner (past 12 months)

no sexual intercourse 521 2.4 20 3.8

Did not always use condoms

15195 70.4 929 6.1

Always used condoms 2465 11.4 69 2.8

not answered 3394 15.7 79 2.3

new partners * (last three months)

Yes 2286 40.8 146 6.4

no 3207 57.3 93 2.9

not answered 108 1.9 4 3.7

*not asked at sexual health clinic

122 VictorianInfectiousDiseasesBulletinVolume14Issue4December2011

Prevalence of antimicrobial resistance among Neisseria gonorrhoeae in Victoria, 2001–June 2011Kerrie Stevens and Marion Easton, Microbiological Diagnostic Unit, Public Health Laboratory, University of Melbourne

introductionGonorrhoea is the second most commonly reported sexually transmitted infection in Australia.1 The disease is of public health importance due to its impact on sexual and reproductive health and because it amplifies the risk of HiV transmission.2 in Victoria and other states and territories of Australia it is a notifiable disease.

Effective antimicrobial treatment of gonorrhoea is important for individual case management and for disease control at the population level. The causative agent, Neisseria gonorrhoeae, has the ability to undergo genetic transformation and recombination. This has resulted in the presence of resistance, rendering ineffective many of the low cost, oral antimicrobials previously used for treatment. There is increasing concern that susceptibility to the currently recommended first-line agents, the extended spectrum cephalosporins, is declining. in an attempt to slow the emergence of resistant strains, both the Us and the UK have updated guidelines for the management of uncomplicated gonorrhoea to dual therapy with ceftriaxone and azithromycin.3,4

The World Health Organization (WHO) stipulates a gonococcal standardised treatment regimen, suitable for syndromic management, should be effective in a minimum of 95 per cent of cases.5 it is therefore important to monitor the prevalence of antimicrobial resistance. Australia has a well

established program of antimicrobial surveillance through the Australian Gonococcal surveillance Programme (AGsP). The AGsP comprises a network of laboratories who conduct antimicrobial susceptibility testing (AsT) on gonococcal isolates received from public and private pathology laboratories in their state or Territory. The Microbiological Diagnostic Unit, Public Health Laboratory (MDU) at the University of Melbourne is the designated AGsP laboratory for Victoria.

We report here on the prevalence of antimicrobial resistance among isolates of N. gonorrhoeae submitted to MDU from 1 January 2001 to 31 June 2011.

Results

Number of isolates

There were 7822 isolates of N. gonorrhoeae submitted to MDU from 1 January 2001 to 30 June 2011. Age and sex were available for almost all (99 per cent) of the cases for which

an isolate was submitted. ninety per cent of cases were among males. The most common age group was 25 to 34 years (2904, 37 per cent).The number of gonococcal isolates submitted each year fluctuated; range of 527 to 889 (Figure 1).

These isolates submitted to MDU represent 62 per cent of the 12 544 disease notifications to the national notifiable Diseases surveillance system over this ten and a half year period.6 The number of isolates received, as a proportion of the number of disease notifications, has continually declined over this period from 86 per cent in 2001 to 47 per cent for the first half of 2011 (secondary axis of figure 1). This decline will be a direct consequence of laboratories moving away from traditional laboratory techniques of gonococcal detection, which rely on growing bacteria on agar plates, to nucleic acid amplification (nAA) methods, which detect gonococcal DnA directly in clinical samples.

Figure 1: Number of isolates of N. gonorrhoeae submitted to MDU and disease notifications, Victoria 2001-2011

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Antimicrobial susceptibility testing and prevalence of resistance

Antimicrobial susceptibility testing involves determining the minimum inhibitory concentration (MiC mg/L), which is the least amount of antibiotic that inhibits the growth of a strain in vitro under defined conditions. The MiC value of a strain categorises it as sensitive/susceptible, less sensitive, decreased susceptibility or resistant according to the interpretive criteria of the method used and the antimicrobial. in general, strains categorised as sensitive or susceptible are expected to respond to treatment with recommended doses of an antimicrobial. For the less susceptible/ decreased susceptibility strains, the outcome is less predictable and depends on other factors such as the site of infection.

The MiCs for penicillin, ciprofloxacin, tetracycline and ceftriaxone were determined by MDU using the methodology of the Australian Gonococcal surveillance Program.7 Azithromycin susceptibilities are not included in this report as testing has only recently been introduced. Provided the MiC values were identical, only one isolate per patient per infectious episode was included in the data analysis. Antimicrobial susceptibility data were available for almost all (99 per cent) isolates submitted to MDU.

Penicillin

N. gonorrhoeae has several mechanisms of resistance to penicillin. One is the plasmid mediated production of penicillinase, an enzyme which breaks down penicillin (PPnG). Other mechanisms involve chromosomal mutations that alter cell envelope structure and/or function (CMPR). All PPnG strains, and CMPR

strains with an MiC ≥1 mg/L, are categorised as penicillin resistant.

The prevalence of penicillin resistance increased from 27 per cent in 2001 to 56 per cent in 2008 (Figures 2 and 3) and has since declined. Forty per cent of gonococcal isolates in the first half of 2011 were resistant to penicillin.

in 2001 eighteen per cent of isolates were fully sensitive to penicillin (MiC ≤0.03 mg/L). The proportion of strains fully sensitive to penicillin declined in 2002 to four per cent. since 2009 no strains have been fully sensitive to penicillin. The majority of isolates (60 per cent) were in the category of less sensitive (MiC 0.06–0.5 mg/L) (Figure 3).

Ciprofloxacin

The proportion of gonococcal isolates that were ciprofloxacin resistant increased from 11 per cent in 2001 to 68 per cent in 2008 (Figure 2). in the first half of 2011 41 per cent of isolates were resistant to ciprofloxacin; the majority (81 per cent) of which exhibited high level resistance (MiC ≥4 mg/l).

Tetracycline

The prevalence of plasmid mediated high level tetracycline resistance (TRnG) is monitored for epidemiological purposes only. Tetracycline is not recommended for treatment of gonorrhoea. The rate of TRnG has fluctuated from a low of

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Figure 2: Proportion of isolates of Neisseria gonorrhoeae resistant to penicillin, ciprofloxacin and tetracycline, 2001 to mid 2011

Figure 3: Penicillin susceptibility of Neisseria gonorrhoeae isolates

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seven per cent in 2001 to a high of 25 per cent in 2005 (Figure 2). For the first half of 2011 ten per cent of gonococcal isolates were TRnG.

Ceftriaxone

Until data from verified clinical failures are available, MiC values that define ceftriaxone resistance cannot be established. MiC values ≥0.03 are considered indicative of decreased susceptibility. The proportion of isolates exhibiting decreased susceptibility to ceftriaxone appears to be increasing; 14 per cent for the last three months of 2009, 19 per cent in 2010 and 22 per cent in the first half of 2011. MDU data for ceftriaxone decreased susceptibility are not available prior to september 2009. This trend towards decreased susceptibility to ceftriaxone, has also been reported by gonococcal antimicrobial surveillance groups elsewhere in the world.8–10 A majority (80 per cent) of the isolates with decreased susceptibility to ceftriaxone were also penicillin (CMPR) and high level ciprofloxacin resistant.

Decreased susceptibility to ceftriaxone appears to be due to the cumulative effect of multiple chromosomal mutations.11 As a result these strains have a reduced uptake of ceftriaxone, less affinity for binding it and/or an increased ability to export it. so far there have been no reports of ceftriaxone treatment failure in genital or rectal infections, but there have been several reports of pharyngeal gonorrhoea not successfully eradicated by ceftriaxone.12–14

ConclusionEffective antibiotic treatment is an essential component for the control of gonococcal disease. in the first half of 2011 a significant proportion of N. gonorrhoeae isolates in Victoria exhibited a high prevalence of resistance to penicillin and

ciprofloxacin. A significant proportion also exhibit decreased susceptibility to ceftriaxone. Ongoing surveillance of antimicrobial susceptibilities, in particular ceftriaxone and azithromycin, is crucial to ensure that the standard treatment regimes meet the WHO 95 per cent effective criteria. As the numbers of gonococcal isolates available for AsT are diminishing due to the increasing use of nAA techniques for diagnosing gonorrhoea, strategies need to be devised to ensure that adequate numbers of demographically representative isolates of N. gonorrhoeae continue to be available for antimicrobial susceptibility testing in the future.

AcknowledgementsWe gratefully acknowledge the Victorian laboratories who submit isolates of N. gonorrhoeae to MDU for antimicrobial susceptibility testing and the technical assistance of Jocelyn Hibberd, Julia Griffith, Despina stylianos, samantha Tawil and Erin Lysaght. All data are subject to revision.

References 1. Australian Government of Health

and Ageing. sTis are spreading fast. Always use a condom. http://www.health.gov.au/internet/sti/publishing.nsf/Content/Gonorrhoea

2. Fleming D, Wasserheit J. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HiV infection. Sex Transm Inf 1999; 75:3–17

3. bignell C, FitzGerald M. (Guideline Development Group). UK national guideline for the management of gonorrhoea in adults, 2011. Int J STD AIDS 2011; 22:541–7

4. Centers for Disease Control and Prevention. sexually transmitted diseases treatment guidelines, 2010. MMWR 2010; 59 (no.RR-12)

5. World Health Organization. Guidelines for the management of sexually transmitted infections. http://www.who.int/hiv/pub/sti/en/STIGuidelines2003.pdf

6. Australian Government of Health and Ageing national notifiable Diseases surveillance scheme (nnDss). http://www9.health.gov.au/cda/Source/Rpt_4.cfm

7. Tapsall J, and members of the national Neisseria network of Australia. Antimicrobial testing and applications in the pathogenic Neisseria. in: Merlino J, ed. Antimicrobial susceptibility testing: methods and practices with an Australian perspective. Australian society for Microbiology, sydney, 2004. pp 175–188

8. Golparian D, Hellmark b, Fredlund H, Unemo M. Emergence, spread and characteristics of Neisseria gonorrhoeae isolates with in vitro decreased susceptibility and resistance to extended-spectrum cephalosporins in sweden. Sex Transm Infect. 2010;86: 454–460

9. Morbidity and Mortality Weekly Report. Cephalosporin susceptibility Among Neisseria gonorrhoeae isolates—United states, 2000–2010 JAMA. 2011; 306(6):599–602

10. Chisholm s, Mouton J, Lewis D et al. Cephalosporin MiC creep among gonococci: time for a pharmacodynamic rethink? Journal of Antimicrobial Chemotherapy. 2010 Oct; 65(10):2141–8

11. barry P, Klausner J. The use of cephalosporins for gonorrhea: the impending problem of resistance.

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Expert Opin. Pharmacother. 2009; 19(4):1–23

12. Tapsall J, Read P, Carmody C et al. Two cases of failed ceftriaxone treatment in pharyngeal gonorrhoea verified by molecular microbiological methods. J Med Microbiol 2009; 58: 683–7

13. Unemo M, Golparian D, Hestner A. Ceftriaxone treatment failure of pharyngeal gonorrhoea verified by international recommendations, sweden, July 2010. Euro Surveill. 2011;16(6)

14. Ohnish M, Golparian D, shimuta K, saika T, Hoshin s, iwasaku

K, is Neisseria gonorrhoeae initiating a Future Era of Untreatable Gonorrhea?: Detailed Characterization of the First strain with High-Level Resistance to Ceftriaxone. Antimicrob Agents Chemother. 2011; 55(7):3538–3545

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FreeWorkHealthchecksforthewholeteam!Think back for a second. When was the last time you had your cholesterol checked? How about your blood pressure and blood glucose levels? Would you know if you’re risk of diabetes or heart disease?

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126 VictorianInfectiousDiseasesBulletinVolume14Issue4December2011

Invasive pneumococcal disease in Victoria: an updateDr Benjamin Cowie, Communicable Disease Prevention and Control Unit, Department of Health

Streptococcus pneumoniae is one of the most common causes of bacterial meningitis, septicaemia and pneumonia worldwide. The overall incidence rate in Victoria is approximately nine per 100 000 population per year, with a case fatality rate approaching eight per cent, increasing to 20 per cent for pneumococcal meningitis. septicaemia and meningitis are more common in children, while pneumonia is more frequent in adults. Other much less common clinical presentations can include septic arthritis, peritonitis, endocarditis and pericarditis. The evolution of antibiotic-resistant strains of pneumococci is of increasing concern.

invasive pneumococcal disease (defined as the isolation of the organism from a normally sterile site such as blood or cerebrospinal fluid, but not sputum) is a notifiable disease in Victoria. notifications of invasive pneumococcal disease show strong seasonality, with a peak in cases notified in late winter (Figure 1). For example, in 2011 there were eight cases of invasive pneumococcal disease notified in February, compared with sixty-seven in July. This seasonality may in part be attributable to increased risk of invasive pneumococcal disease in association with viral respiratory illnesses, particularly influenza.

susceptibility to pneumococcal infection is universal, however the risk of invasive disease is highest for children aged less than two years and adults aged 65 and over. Other risk factors include prematurity and low birth weight, immune deficiency and immunosuppressive therapy, and exposure to tobacco smoke. The presence of other chronic illnesses also increases the risk of invasive pneumococcal disease, as does prior respiratory viral infection as mentioned previously. Aboriginal and Torres strait islander people are also at particular risk of invasive pneumococcal disease.

There are 90 recognised disease-causing strains of S. pneumoniae. no vaccine can protect against all of these, however, vaccines are available

to help prevent infection with the most common strains. There are two different vaccines, a conjugate vaccine (Prevenar®) used routinely for children on the national immunisation Program schedule at 2, 4 and 6 months of age; and a polysaccharide vaccine, Pneumovax23 ®, used for older children and adults.

Until July 1 this year, the conjugate vaccine used in children covered seven serotypes of pneumococcal bacteria that most commonly cause disease in children (4, 6b, 9V, 14, 18C, 19F, and 23F). However since July 2011 a new vaccine, Prevenar 13® has been added to the national immunisation Program which covers an additional six serotypes of S. pneumoniae – namely, serotypes 1, 3, 5, 6A, 7F, and 19A. These serotypes were responsible for

Figure 1: Notifications of invasive pneumococcal disease, Victoria, summer 2005/06 to winter 2011

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47 per cent of invasive pneumococcal disease cases in Victoria (where serotype information was available) from 1 January to 30 August 2011, with serotype 19A accounting for 23 per cent of total notified cases where serotype was known.

Children who were immunised for pneumococcal disease before the

introduction of the new 13-valent vaccine may be eligible to receive a one-off, free supplementary dose of the new vaccine. Eligible children are those aged between their first and third birthdays (12 to 35 months inclusive). The supplementary dose will be available from 1 October 2011 to 30 september 2012.

Acknowledgementsnotified iPD cases are followed up by Public Health Officers and isolate serotyping is conducted by the Microbiological Diagnostic Unit (MDU).

Further information regarding invasive pneumococcal disease is available at the following websites. For clinicians: http://ideas.health.vic.gov.au/bluebook/invasive-pneumococcal-disease.asp

For the community: http://www.health.vic.gov.au/immunisation/fact-sheets/factsheets/pneumococcal

Provider guidelines: http://immunise.health.gov.au/internet/immunise/publishing.nsf/Content/4F22B5FB0B270E64CA2578C0000B191F/$File/pneumococca-guidelines-V3.pdf

Information on the recent changes to pneumococcal vaccines provided under the National Immunisation Program: http://immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-pneumococcal

Fact sheet on the supplementary dose: http://www.health.vic.gov.au/immunisation/factsheets/supplementary-pneumococcal-vaccine.htm

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128 VictorianInfectiousDiseasesBulletinVolume14Issue4December2011

Sarcocystosis in Malaysia: preventive advice for travellersAdapted from: ProMED-mail 2011; 07 Dec: http://wwwnc.cdc.gov/travel/notices/outbreak-notice/sarcocystosis-malaysia.htm Accessed 07 Dec 2011

1 Geosentinel is a global sentinel surveillance system consisting of more than 50 participating travel and tropical medicine clinics located in 25 countries on six continents. surveillance data are collected on patients seen at these clinics during or after international travel. Geosentinel is managed through a cooperative agreement between the international society for Travel Medicine and the Centers for Disease Control and Prevention.

Geosentinel1 has reported a cluster of sarcocystosis among travellers returning from Malaysia. These travelers reported visiting Tioman island on the east coast of peninsular Malaysia before becoming unwell with prominent muscle pain, a symptom consistent with sarcocystosis, as well as fever and mild diarrhoea.

sarcocystosis is a disease caused by a parasite called sarcocystis. it occurs in tropical or subtropical countries, mainly countries in south East Asia. This disease usually affects animals but can also cause disease in humans. Two forms of the disease occur, one causes diarrhoea, and the other causes muscle pain, fevers and other symptoms. Most people infected with sarcocystis do not have symptoms.

Muscle sarcocystosis is spread through the ingestion of food, water, or soil contaminated with infected animal faeces. infection occurs when sporulated oocysts of sarcocystis are ingested and release sporocysts which enter the body through the intestinal wall. They then divide (asexual division) and are distributed throughout the body where they end up in muscles where they continue to divide for several months and develop cysts, which contain many bradyzoites.

intestinal infection occurs when sarcocystis infected meat is eaten and the cysts release bradyzoites, which invade the intestinal cells and develop into a male and female stage. sexual reproduction takes place in the

infected intestinal cells and oocysts containing sporocysts are excreted in the faeces and may contaminate the environment.

Muscle sarcocystosis can be suspected in people with signs and symptoms of myositis, with or without fever. ill patients may have an elevated eosinophil count and may have an elevated creatinine kinase with no other explanation for these findings. A muscle biopsy can be done using a conventional histologic staining and will show eosinophilic myositis but may or may not demonstrate classic sarcocysts. Molecular testing is not widely available. There is currently no vaccine or treatment for sarcocystosis; most infected people get better on their own.

How can travellers protect themselves?

Drink and use safe water

Use bottled water with unbroken seals or water that has been boiled or filtered to make it safe. Water purification tablets and chlorine products may not kill sarcocystis. Use safe water to brush your teeth, wash and prepare food, and make ice.

Clean food preparation areas and kitchenware with soap and safe water and let dry completely before reuse.

Do not use piped water sources. Do not drink beverages sold in cups or bags or use ice if you are not sure the ice was made with safe water. Do not swim in fresh water.

Eat safe food

Cook all meat well especially pork and beef and eat while piping hot. Keep all food covered. Do not eat raw foods, except for fruits and vegetables you can wash and peel yourself.

Wash your hands

Use soap and safe water. if you do not have soap, use an alcohol-based (60 per cent) hand cleaner.

Keep toilets clean

Clean toilets and surfaces contaminated with faeces using a solution of one part household bleach to nine parts water.

Do not defecate in any body of water.

Practice household hygiene

Clean up the areas you eat in and wash in. Wash yourself, your children, diapers, and clothes at least 30 meters away from drinking water sources.

Further informationA description of the life cycle of sarcocystis: http://dpd.cdc.gov/dpdx/html/Sarcocystosis.htm

A recent review of sarcocystis: R Fayer. sarcocystis spp. in human infections. Clin Microbiol Rev 2004;17:89–92

For the ProMED-mail HealthMap of the location of this outbreak, please see http://healthmap.org/r/1oaT

Strengthening immunisation for children

The Australian Government is introducing reforms to Australia’s childhood immunisation arrangements that aim to increase the immunisation rates of Australian children over time.

These changes mean:

• From 1 July 2012 families will need to have their children fully immunised to receive the existing $726 per child Family Tax benefit Part A supplement. This will replace the Maternity immunisation Allowance.

• From 1 July 2013 a new immunisation check will be introduced for one year olds to supplement the existing focus on immunisation at two and five years of age.

• From 1 July 2013 the meningococcal C, pneumococcal and varicella (chickenpox) vaccines will be included in the list of immunisations that are needed for a child to be fully immunised.

• From 1 July 2013 a combination vaccine for measles, mumps, rubella and varicella (chickenpox) for children aged 18 months will be added to the national immunisation Program schedule.

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Why is the government acting? immunisation is the safest and most effective way of giving protection against a disease.

Vaccination not only protects individuals, but also others in the community, by reducing the spread of disease. increasing the level of immunity in the community protects those people who cannot be vaccinated because they are too young or because of medical reasons.

immunisation rates in Australia are now the highest on record and, as a result, notification rates of vaccine-preventable diseases are low. However, they still exist. For example, in 2010 there were 66 cases of measles in children aged less than 10 years in Australia, a disease that can have serious consequences including death.

Most families immunise their children but some children are not vaccinated on time or as recommended by the national immunisation Program schedule, risking their child’s health and the health of other children.

What changes will be made?

Stronger incentives

From 1 July 2012 parents will need to have had their children fully vaccinated during the financial years that each child turns one, two and five years of age to receive the $726 Family Tax benefit Part A supplement (for each child each year). immunisation is already a condition for Australian Government child care payments.

These new requirements will replace the Maternity immunisation Allowance, which provided $129 when a child was immunised between 18 months and 24 months of age and between four and five years of age. immunisations will no longer attract the allowance after 1 July 2012.

The addition of a third age checkpoint (at one year) will help make sure important early vaccinations are received at the recommended times of two, four and six months of age.

The new arrangements will create a stronger financial incentive for parents. Over three immunisation check points,

families will have a $2,100 incentive to ensure their child is fully immunised.

To meet the immunisation requirements children will need to be fully immunised, be on a recognised immunisation catch up schedule or have an approved exemption.

Extra vaccinations required

The meningococcal C, pneumococcal and varicella (chickenpox) vaccines are currently listed on the national immunisation Program schedule. From 1 July 2013 these vaccines will be added to the list of immunisations that children need to receive to be assessed as fully immunised to receive the Family Tax benefit Part A supplement and Australian Government child care payments.

New combination vaccine added

From 1 July 2013 the combination vaccine Priorix-Tetra will be added to the national immunisation Program. This will replace individual doses of the MMR vaccine (for measles, mumps and rubella) and the varicella vaccine (for chickenpox).

This will reduce the number of vaccines children receive by one. Children will also finish their course of measles, mumps and rubella vaccine earlier; at 18 months of age, rather than four years of age under the existing schedule. Listing the combination vaccine will cost $15.7 million over four years.

Overall, these changes will deliver savings of $209.1 million over four years.

What do families need to do? The Australian Government will write to all families who are affected to explain the changes, and what immunisations their children need.

Families then need to make sure their children receive all the listed immunisations.

The Family Assistance office will check whether a child is assessed by the Australian Childhood immunisation Register as being fully immunised (or has an approved exemption) at the end of the financial year when a family’s payments are reconciled and the Family Tax benefit Part A supplement is provided. This happens after parents lodge their tax returns.

Further information about the changes to payments for families can be found at www.fahcsia.gov.au

How will immunisation providers be informed about these new changes? The Department of Health and Ageing in consultation with state and territory health departments, Medicare Australia and peak medical groups will be implementing an extensive communication strategy aimed at informing all immunisation providers about the changes and the proposed implementation approach.

This will occur over the coming months, ensuring all providers are fully informed of the new requirements prior to commencement in 1 July 2012.

What is the government already doing to support immunisation? The immunise Australia Program implements the national immunisation Program schedule, which currently includes vaccines against a total of 16 diseases.

The Australian Government provides funding for:

• free vaccines under the national immunisation Program

• the Australian Childhood immunisation Register (ACiR) that records details of vaccines given to children under seven years of age

• notification payments to immunisation providers that report vaccines administered to the ACiR

• the General Practice immunisation incentives scheme to provide financial incentives for monitoring, promoting and providing appropriate immunisation services to children

• facilitation and reward payment to states and territories to deliver the national immunisation Program in their jurisdictions.

Further information on the immunise Australia Program can be found at www.immunise.health.gov.au.

130 VictorianInfectiousDiseasesBulletinVolume14Issue4December2011

Immunisation coverage report, Victoria, July–September 2011Helen Pitcher, Department of Health

immunisation coverageImmunisation coverage data cited in this report are based on the Australian Childhood Immunisation Register (ACIR) coverage report. Table 1 presents immunisation coverage at 30 June 2011 for children aged 12–<15 months (cohort one), 24–<27 months (cohort two) and 60–<63 months of age (cohort three), by Local Government Areas (LGAs) and calculated at 31 September 2011. Only vaccines administered before 12 months of age were included in the coverage calculation for the first age cohort, and only those vaccines administered before 24 and 63 months of age were included in the coverage calculation for the second and third age cohorts.

The ACIR report measures vaccine coverage for diphtheria, tetanus, pertussis, poliomyelitis, hepatitis B, Haemophilus influenzae type b, measles, mumps, and rubella vaccines. The report does not measure vaccine coverage for the birth dose of hepatitis B, rotavirus, pneumococcal, meningococcal C and varicella vaccines. For a copy of the ACIR report listing immunisation coverage against individual vaccines for each LGA area, contact Catherine McNamara at the Department of Health (email immunisation@health.vic.gov.au).

in cohort one, 85 per cent (67 of 79) of LGAs achieved immunisation coverage greater than or equal to 90 per cent. Victoria achieved 92.71 per cent coverage in cohort one compared to the Australian coverage of 90.06 per cent. Victoria ranked fourth behind ACT (93.61 per cent), nT (93.31 per cent) and sA (93 per cent) in the coverage rate for children aged 12–<15 months. Mansfield LGA reported a coverage rate between 70 to less than 75 per cent in age cohort one.

in cohort two, 95 per cent (75 of 79) of LGAs achieved immunisation coverage greater than or equal to 90 per cent. state coverage for cohort two was 93.58 per cent compared to the Australian coverage of 92.84 per cent. Victoria ranked fourth behind ACT (94.51 per cent), Tas (94.28 per cent) and nT (93.65 per cent) in the coverage rate for children aged 24–<27 months.

in cohort three, 73 per cent (58 of 79) of LGAs achieved immunisation coverage greater than or equal to 90 per cent. state coverage for cohort three was 91.13 per cent compared to the Australian coverage of 89.26

per cent. Victoria ranked second behind ACT (91.34 per cent) in the coverage rate for children aged 60–<63 months. Loddon LGA reported a coverage rate between 75 to less than 80 per cent and swan Hill LGA reported a coverage rate between 70 to less than 75 per cent in age cohort three.

Vaccination program updates

Pneumovax 23® – new revaccination advice

in April 2011, following an increase in the notification of adverse events following revaccination of adults with Pneumovax 23®, the Therapeutic Goods Administration recommended that revaccination with Pneumovax 23® should not occur pending the outcome of further investigation and a review of previous advice on its use by the Australian Technical Advisory Group on immunisation (ATAGi).

The outcome of this investigation has led to the formulation of new advice on the safety, efficacy and effectiveness of Pneumovax 23®

and its place within the national immunisation Program.

Following the review, ATAGi’s revised revaccination recommendations are:

• A dose of 23vPPV should be given to adults at 65 years of age. Every effort should be made to provide a dose to anyone aged >65 years who has not previously received a dose of 23vPPV.

• For non-indigenous adults aged ≥65 years, a second dose (a single revaccination) of 23vPPV, to be given ≥5 years after the first dose, is recommended for those who have a condition that predisposes them to an increased risk of invasive pneumococcal disease.

• A second dose is no longer recommended for those without any of these predisposing conditions.

• Recommendations for the use of 23vPPV in those <65 years, including for Aboriginal and Torres strait islander adolescents and adults, are unchanged from the 9th edition of the Australian immunisation Handbook.

VictorianInfectiousDiseasesBulletinVolume14Issue4December2011 131

For further information and detailed ATAGi advice, please see the Pneumococcal information, immunisation of adults, 23 December 2011 at: http://immunise.health.gov.au/

Prevenar 13®

From 1 July 2011 7vPCV (Prevenar®) was replaced with 13vPCV (Prevenar 13®). Prevenar® protected babies against seven strains of pneumococcal bacteria. Prevenar 13® replaced Prevenar® in the infant primary immunisation schedule at two (which can start from six weeks of age), four and six months of age. Prevenar 13® has an expanded range of pneumococcal strains to protect children against pneumococcal bacteria, protecting against 13 strains of pneumococcal disease: 4, 6b, 9V, 14, 18C, 19F, 23F, 1, 5, 7F, 3, 6A, and 19A.

From 1 October 2011, the Commonwealth Government is providing a free single supplementary dose of Prevenar 13® to eligible children so they can benefit from protection from the additional six strains in the Prevenar 13® vaccine. This includes pneumococcal disease associated with the increasingly predominant serotype 19A. invasive

pneumococcal disease typed as serogroup 19A has increased eight-fold (or 840 per cent) between 2003 and 2010, up from ten cases in 2003 to 94 cases in 2010 for all ages. To be eligible for the supplementary dose, the child will be aged between 12 and 35 months inclusive. The supplementary dose program will be available for one year from 1 October 2011 to 30 september 2012.

A broad communication strategy involving the Australian Government and the Victorian Government Department of Health has been undertaken to inform parents and immunisation providers of the additional vaccine recommendation.

Vaccination at six weeks of age

During the current pertussis outbreak, timely immunisation has been promoted for the immunisation schedule points with a pertussis containing vaccine. The promotion has included encouraging the scheduled two month old vaccines to be given from six weeks of age. The rationale is to provide some pertussis immunisation as early as possible to the infant. An infant at six weeks of age should be administered the three vaccines scheduled at this time,

that is RotaTeq®, infanrix hexa® and Prevenar 13®. The infant should return at four and then six months of age to complete the primary schedule. The four year old booster vaccines of infanrix iPV® and Priorix® can be given as early as three years and six months of age for parental convenience if attending the clinic for another purpose.

Due to the increasing rise in pertussis notifications in Victoria, the Department of Health extended access to the free pertussis containing vaccine (boostrix®), for parents of newborn babies to 30 June 2012. boostrix® vaccine should also be administered to partners of pregnant women at any time before the birth of the baby. Earlier administration of the vaccine will reduce the risk of the infant contracting pertussis from a close contact.

Mothers should be offered the boostrix® vaccine as soon as possible after the birth of the newborn baby and ideally before leaving hospital. Any partner who did not receive the vaccine before the birth can continue to receive free boostrix® vaccine as soon as possible after the birth.

132 VictorianInfectiousDiseasesBulletinVolume14Issue4December2011

Table 1: Immunisation coverage by age cohort and local government area, Victoria, June 2011

Age group% fully

immunised Local government area (LGA)Total LGAs (%LGAs)

12<15 months

100 buloke, Loddon, Queenscliffe, Yarriambiack 4 (5)

95+Alpine, Ararat, boroondara, Colac-Otway, Horsham, indigo, Mitchell, Moonee Valley, Moyne, Murrindindi, surf Coast, Wangaratta, Warrnambool, Whittlesea, Wodonga

15 (19)

90–<95

ballarat, banyule, bass Coast, baw baw, bayside, brimbank, Campaspe, Cardinia, Casey, Central Goldfields, Darebin, East Gippsland, Frankston, Glen Eira, Glenelg, Golden Plains, Greater bendigo, Greater Dandenong, Greater Geelong, Greater shepparton, Hindmarsh, Hobsons bay, Hume, Kingston, Knox, Latrobe, Macedon Ranges, Manningham, Maroondah, Melton, Mildura, Moira, Monash, Moorabool, Moreland, Mornington Peninsula, northern Grampians, Port Phillip, Pyrenees, south Gippsland, stonnington, strathbogie, Towong, West Wimmera, Whitehorse, Wyndham, Yarra, Yarra Ranges

48 (61)

85–<90benalla, Corangamite, Maribyrnong, Melbourne, Mount Alexander, nillumbik, southern Grampians, swan Hill, Wellington

9 (11)

80–<85 Gannawarra, Hepburn 2 (3)

75–<80 Mansfield 1 (1)

24<27 months

100 buloke, Hindmarsh, Horsham, Queenscliffe, strathbogie, Towong, West Wimmera 7 (9)

95+Ararat, ballarat, Campaspe, Central Goldfields, Colac-Otway, Corangamite, East Gippsland, Gannawarra, Glenelg, Golden Plains, Latrobe, Maribyrnong, Melton, Mitchell, Moonee Valley, Moyne, Murrindindi, southern Grampians, Wangaratta, Warrnambool, Whittlesea, Wodonga

22 (28)

90–<95

Alpine, banyule, bass Coast, baw baw, bayside, benalla, boroondara, brimbank, Cardinia, Casey, Darebin, Frankston, Glen Eira, Greater bendigo Greater Dandenong, Greater Geelong, Hobsons bay, Hume, indigo, Kingston, Knox, Loddon, Macedon Ranges, Manningham, Maroondah, Melbourne, Mildura, Moira, Monash, Moorabool, Moreland, Mornington Peninsula, nillumbik, northern Grampians, Port Phillip, Pyrenees, south Gippsland, stonnington, surf Coast, swan Hill, Wellington, Whitehorse, Wyndham, Yarra, Yarra Ranges, Yarriambiack

46 (58)

85–<90 Greater shepparton, Mount Alexander 2 (3)

80–<85 Hepburn, Mansfield 2 (3)

60<63 months

100 buloke, Hindmarsh, Towong, West Wimmera 4 (5)

95+ benalla, Glen Eira, Golden Plains, Horsham, Latrobe, Wellington, Wodonga, Yarriambiack 8 (10)

90–<95

Ararat, ballarat, banyule, bass Coast, boroondara, brimbank, Campaspe Cardinia, Casey, Central Goldfields, Colac-Otway, Corangamite, Darebin Frankston, Gannawarra, Glenelg, Greater bendigo, Greater Geelong, Hepburn, Hume, indigo, Kingston, Knox, Manningham, Mansfield, Maribyrnong, Maroondah, Melton, Mildura, Mitchell, Moira, Monash, Moonee Valley, Moreland, Moyne, Murrindindi, nillumbik, Pyrenees, south Gippsland, southern Grampians, surf Coast, Wangaratta, Warrnambool, Whittlesea, Wyndham, Yarra

46 (58)

85–<90Alpine, baw baw, bayside, East Gippsland, Greater Dandenong, Greater shepparton, Hobsons bay, Macedon Ranges, Melbourne, Moorabool, Mornington Peninsula, Mount Alexander, Port Phillip, stonnington, strathbogie, Whitehorse, Yarra Ranges

17 (22)

80–<85 northern Grampians, Queenscliffe 2 (3)

75–<80 Loddon 1 (1)

70–<75 swan Hill 1 (1)

VictorianInfectiousDiseasesBulletinVolume14Issue4December2011 133

Communicable disease surveillance, Victoria, July–September 2011We report a summary of infectious disease notifications received until September 2011. Table 9 includes historical comparisons of selected diseases for the period 1 July–31 September 2011 at both the State and regional levels. Data are provisional and subject to revision as further information becomes available.

There were no notifications of Murray Valley encephalitis, diphtheria, Japanese encephalitis, Kunjin virus, plague, rabies, poliomyelitis, viral haemorrhagic fevers or yellow fever in this reporting period.

For more information: More information about notifiable infectious diseases in Victoria, including details for medical practitioners and laboratories on how to notify, general information about disease prevention and control, and additional surveillance data, can be found on the Communicable Disease Prevention and Control Unit website at http://www.health.vic.gov.au/ideas/

Enteric diseasesKarin Lalor, Department of Health and OzFoodNet Victoria

Outbreaks of gastrointestinal illness

There were 188 outbreaks of gastrointestinal illness reported to the Department’s Communicable Disease Prevention and Control Unit (CDPCU) during the third quarter of 2011 (Table 1). Of these, ten outbreaks were considered to be foodborne or probable foodborne. For the remaining 178 outbreaks, person-to-person transmission was suspected in 154 outbreaks. The mode of transmission was unknown for the remaining 24 outbreaks.

Foodborne disease outbreaks

Ten outbreaks were considered to be foodborne or probable foodborne this quarter, affecting at least 148 people. The outbreaks are summarised below.

Two separate groups of people complained to council of illness after eating at a restaurant on consecutive days. All four people in the first group and all three people in the second group had onset of nausea and diarrhoea approximately eight hours after their meal. Duration of illness was less than 24 hours. While

Table 1: Outbreaks of gastrointestinal illness, 1 July 2011–31 September 2011

Setting OutbreaksPersons affected Pathogen/toxin (number of outbreaks)

Aged care 105 2660

norovirus (69) suspected viral (17) Clostridium perfringens (3) Clostridium difficile (1) Unknown (15)

Camp 2 38 suspected viral (2)

Child care/play centre 17 188 norovirus (4) suspected viral (13)

Hospital 31 381 norovirus (24) suspected viral (4) Unknown (3)

Private residence 4 36

Salmonella Typhimurium 9 (1) Salmonella Typhimurium 135 (1) Salmonella Typhimurium 44 (1) Unknown (1)

*Residential facility (other) 21 155 norovirus (7) suspected viral (10) Unknown (4)

Restaurant 5 73 Salmonella Typhimurium170 (1) Clostridium perfringens (1) Unknown (3)

Workplace 1 7 Unknown (1)Community group 1 6 norovirus (1)Commercial caterer 1 28 Staphylococcus aureus (1)

TOTAL 188 3572

norovirus (105) suspected viral (46) Salmonella Typhimurium 9 (1) Salmonella Typhimurium 170 (1) Salmonella Typhimurium 135 (1) Salmonella Typhimurium 44 (1) Clostridium perfringens (4) Clostridium difficile (1) Staphylococcus aureus (1) Unknown (27)

* other residential facility includes: supported services accommodation or supported residential services (14) and disability services (7)

134 VictorianInfectiousDiseasesBulletinVolume14Issue4December2011

beef curry and coconut rice were consumed by both groups, it was unclear what other foods were eaten. beef curry, rice and chicken and pork satays were sampled by council and Clostridium perfringens was detected in the pork satay sample. However none of the foods sampled were the same batches as those consumed by the complainants. no faecal specimens were collected.

A doctor notified a Salmonella case to CDPCU, later confirmed as sTm 9, and reported that other family members had also been ill after a family function. investigation revealed that ten family members attended a dinner where chocolate mousse made with raw eggs was served for dessert. seven attendees developed diarrhoea after the function and all had eaten the mousse. The three people who remained well had not consumed any chocolate mousse. The brand of eggs used to make the mousse has previously been associated with several outbreaks of sTm 9.

Following the receipt of two doctors’ notifications of Salmonella from the same rural town, investigation revealed that both cases had attended a cooking class at a restaurant prior to the onset of diarrhoea. Twenty-two people attended the cooking class in early August where three chefs prepared the food. Twenty-two people were interviewed, of whom 13 attendees and a staff member experienced symptoms of diarrhoea and/or vomiting. Median incubation period was 24 hours. Eight cases presented to a doctor and one was admitted to hospital. Four cases were confirmed with sTm 170. The cooking class was held at a café/catering business. High risk foods served included a chicken noodle dish and chocolate mousse with raw eggs. Fourteen of the 21 people who ate the chocolate mousse were ill. The one

person who did not eat the chocolate mousse was not ill. The chef reported that they did not routinely make foods containing raw eggs in the café and catering business. no leftover foods or eggs were available for sampling.

Two year nine students at a boarding school were notified with Salmonella after attending a cooking class at a teacher’s home. Five students participated in the cooking class where they each made their own batch of ravioli filled with ricotta cheese, roasted pine nuts, fresh parsley, basil and lemon zest. Four of the students tasted the uncooked pasta dough containing raw eggs. The fifth student and the teacher did not taste the uncooked dough and were not ill. The two students initially notified were confirmed with sTm 135. There were three eggs leftover at the end of the class, which the teacher lightly scrambled for her young children’s breakfast the following day. both children became ill, and one was confirmed with sTm135.

Ambulance Victoria notified the CDPCU when a large number of ambulances were requested to attend a number of people with vomiting after consuming lunch at a community centre. sixty-nine people attended the lunch and 46 were interviewed. illness was reported by 28 of the people interviewed, and cases had a median incubation period of five hours. nine cases presented to their doctor. A further nine cases attended hospital, with one being admitted overnight. no faecal or vomit specimens were collected. The lunch consisted of a mixture of beef, eggplant, fish and sauces on a bed of rice (a traditional sri Lankan dish called lamprais). it had been provided by a catering company in individual foil containers with cardboard lids. Preparation of 90 meals commenced at six am. They were placed into containers

from 9:30am onwards and were collected at 11am and delivered to the community centre by car. All components of the meals were at room temperature during this time. it was reported that some meals were placed in a warm oven at the community centre and lunch was served at approximately 12:30pm. Attendees reported that the food was lukewarm. Thirteen food samples were collected including individual ingredients and complete leftover meals. High levels of Staphylococcus aureus and Staphylococcus aureus toxin were detected in the meals from two unopened containers sampled from the community centre. Excess meals were held hot at the catering premises for sale to the public and no illness was reported by customers who purchased these meals.

A regional environmental health officer notified CDPCU of 38 members of a sports club who reported onset of diarrhoea and abdominal pain the day after attending a dinner held at a function centre. Contact details were available only for those families that had contacted Council to report illness in individual members of their families. Consequently only 66 attendees out of the total of 184 attendees were interviewed. Forty-one of those interviewed reported an onset of diarrhoea within 24 hours of consuming the dinner. Analysis of the 66 interviews gave a relative risk of 12.7 (95% Ci 3.3–48.0) for consumption of the roast beef meal. The symptoms, duration and incubation period were consistent with Clostridium perfringens enterotoxin, which was subsequently detected in 11 out of the 12 faecal specimens collected. The same entrée and dessert was served to all attendees and the main course was roast beef or chicken with vegetables served alternately. The beef was roasted the day before the dinner, then

VictorianInfectiousDiseasesBulletinVolume14Issue4December2011 135

kept in the cool-room, and sliced on the following day on a meat slicer. The sliced meat was placed into a warmer without being re-heated. The meat slicer was found to be unclean with pieces of meat and meat juices behind the blade. Gravy was served with the roast and this contained meat juices. no leftover foods were available for testing.

During routine investigation of a single case of Salmonella it was found that several members of three families had consumed tiramisu containing raw eggs. One family made the tiramisu and ate it on the same day. The leftovers were taken to be shared with two other family groups on the following day. Of the 12 people who ate the tiramisu 11 became ill. A 13th person who did not eat the tiramisu was not ill. Faecal specimens were collected from three cases and all three were confirmed with sTm 44. no leftover tiramisu or eggs were available for testing. Trace back of eggs was requested.

Three of the suspected foodborne outbreaks during this quarter were in aged care facilities with aetiology either confirmed or suspected as being caused by Clostridium perfringens enterotoxin as follows:

An aged care facility notified nine residents with onset of gastroenteritis symptoms over a nine-day period. seven cases experienced diarrhoea, two had vomiting only and two had both diarrhoea and vomiting. Duration of symptoms was from one to five days. six faecal specimens were collected and Clostridium perfringens enterotoxin was detected in four specimens. All faecal specimens were negative for bacterial pathogens and norovirus. A food source for this outbreak was not identified.

An aged care facility notified six residents with onset of diarrhoea

over three days. One staff member reported having diarrhoea, vomiting and abdominal pain in the same time period. Five faecal specimens were collected and Clostridium perfringens enterotoxin was detected in two specimens. no specific foods were implicated.

CDPCU was notified of 14 residents of an aged care facility with onset of diarrhoea over a six-day period. no staff reported illness. Eight faecal specimens were collected and Clostridium perfringens enterotoxin was detected in four specimens. investigation of the food processes at the facility revealed that roasted meats were prepared in advance and cooled and reheated before serving. Roast meats prepared in this way were also used for vitamised meals up to three days after cooking. Council advised the facility on amendments to their food processes. A specific food source for this outbreak was not identified

Norovirus activity

norovirus and suspected viral activity this quarter (151 outbreaks) was similar to that reported for the second quarter of 2011 (152 outbreaks), but fewer than that reported for the same quarter in 2010 (187). ninety-five per cent of the norovirus outbreaks and sixty-seven per cent of the suspected

viral outbreaks were in aged care and healthcare settings.

blood borne virusesEllen Donnan, Department of Health, Victoria

Hepatitis B—newly acquired infections

in the third quarter of 2011 the department received notifications for 541 cases of hepatitis b, of which 12 (two per cent) were classified as newly acquired infections. This was similar to the 11 and 13 newly acquired cases notified in the previous two quarters but a 25 per cent decrease on the 16 newly acquired cases notified in the third quarter of 2010 (Figure 2). Cases notified from January to september 2011 totaled 36, a decrease of 32 per cent compared to the same period in 2010 with no changes to surveillance practices in this time.

Of the 12 newly acquired cases, nine were in males and three in females. All were aged between 23 and 61 years, with a median age of 34 years.

seven cases were Australian born, four were born overseas and country of birth was not reported for the remaining case. indigenous status was reported for all cases, with none

Figure 1: Norovirus outbreak activity by quarter, Victoria January 2005–September 2011

Num

ber

of

out

bre

aks

Quarter and month of notification

Novovirus Suspected viral

0

50

100

150

200

250

suspected viral

Norovirus

321432143214321432143214321 2005 2006 2007 2008 2009 2010 2011

136 VictorianInfectiousDiseasesBulletinVolume14Issue4December2011

Figure 3: Notified cases of newly acquired hepatitis C infections, by quarter, Victoria, January 2001–September 2011

Figure 2: Notified cases of newly acquired hepatitis B, by quarter, Victoria, January 2001–September 2011

identifying as Aboriginal and/or Torres strait islander. Eight cases were in residents of metropolitan Melbourne and four cases resided in regional Victoria.

Among the 12 newly acquired cases, 10 cases reported clinical symptoms of jaundice and 10 had elevated liver function tests (LFTs). The reason for testing for hepatitis b was reported in 10 cases as being symptomatic for hepatitis and seven cases reported elevated LFTs. All cases had at least one reason for testing recorded; cases may have reported multiple reasons for testing. Four cases were co-infected with hepatitis C either at the time of hepatitis b diagnosis or previously.

injecting drug use was reported for four cases (33 per cent) and one case reported having a hepatitis b positive sexual partner (heterosexual). Other risk factors identified included dental procedures (n=2), tattooing (n=1), acupuncture (n=1) and a surgical procedure (n=1) (more than one risk factor may be reported for those cases with no history of injecting drug use or sexual contact with a hepatitis b positive partner). The surgical procedure was not thought to be the likely source of hepatitis b infection for that case nor the dental procedure for one of the cases who

had this as a risk factor. The remaining dental procedure and tattooing was conducted outside Victoria and was referred to the appropriate authorities. Risk factors could not be determined for four cases.

Hepatitis C – newly acquired infections

A total of 578 cases of hepatitis C were notified during the third quarter of 2011, of which 35 cases (one per cent) were classified as newly acquired infections. This was an eight per cent reduction on the total number of notified cases compared to the previous quarter (n=38), but a 21 per cent increase on the number of newly acquired cases for the same period in 2010 (n=29) (Figure 3).

Of the 35 newly acquired hepatitis C cases reported in this quarter, 48 per cent (n=16) had a previous negative hepatitis C antibody testing history within the past 24 months.

seventy-four per cent of the cases (n=26) were in males and 26 per cent (n=9) were in females. Ages ranged from 17 to 54 years, with a median age of 25 years. seventy-four per cent (n=26) of cases resided in metropolitan Melbourne, 23 per cent (n=8) were from regional Victoria and for the remaining case postcode of residence was not reported. indigenous status was reported for 25 cases (71 per cent), with no cases reported as being Aboriginal and/or Torres strait islander origin this quarter. sixty-eight per cent of the cases (n=24) were Australian born, six were overseas born and country of birth was unknown or not reported for the remaining five cases.

Of the 35 newly acquired cases, the most common reason for testing was elevated liver function tests (n=12). Other reasons for testing reported included drug and alcohol screening (n=10), patient request for screening (n=9), screening for sexually transmissible infections (n=5), prisoner screening (n=4), presenting with signs and symptoms of acute hepatitis (n=1), screening as a result of other

Num

ber

of

notifi

ed c

ases

Year of notification

Q1 Q2 Q3 Q4

0

50

100

150

200

250

Qtr4Qtr3Qtr2Qtr1

20112010200920082007200620052004200320022001

Qtr4Qtr3Qtr2Qtr1

Num

ber

of

notifi

ed c

ases

Year of notification

Q1 Q2 Q3 Q4

0

50

100

150

200

250

Qtr4Qtr3Qtr2Qtr1

201120102009200820072006200520042003200220012000199919981997

Qtr4Qtr3Qtr2Qtr1

VictorianInfectiousDiseasesBulletinVolume14Issue4December2011 137

medical illness (n=1), screening of an asymptomatic person reporting sexual contact with a hepatitis C positive person (n=1) and other reasons for screening (n=3). (note that cases may report multiple reasons for testing).

injecting drug use (iDU) was the main risk factor reported for 28 cases (80 per cent). Risk factors reported for the remaining cases included having household contact with a hepatitis C positive person (n=1), having major dental procedures (n=1) and acupuncture (n=1). The dental procedure was not thought to be the likely source of hepatitis C infection for that case. (note that multiple risk factors may be reported for cases with no risk of iDU). A risk factor was not determined for four cases.

Hepatitis D

Four cases of hepatitis D were notified during the third quarter of 2011 compared to eight cases notified in the previous quarter. Three cases were in males and one was in a female. Ages ranged from 44 to 52 years. Three of the four cases resided in metropolitan Melbourne, with one case residing in a rural region. Three cases were born in Australia and one case was born overseas. no cases were of Aboriginal and/or Torres strait islander origin. notifying doctors nominated a history of hepatitis as the reason for testing for two cases and symptoms of acute hepatitis and liver decompensation for one case each. The three Australian-born cases had a history of injecting drug use, while the one case born overseas did not. notifying doctors reported one case had a super-infection and one case was co-infected with hepatitis b; this information was unknown or not reported for two cases.

Vaccine-preventable diseasesLucinda Franklin, Department of Health, Victoria

Haemophilus influenzae type b (Hib)

no cases of Hib were notified in the third quarter of 2011.

Influenza

There were 1,918 confirmed cases of influenza notified in the third quarter, compared to 1,377 cases notified in the previous quarter. The age range of those notified was seven days to 99 years (median age 28 years). Age was not reported for 20 cases.

There were 709 cases notified in children, 250 of whom were aged less than five years, and 285 cases were in persons aged 65 years or older. Fifty-three per cent of cases (n=1,024) were in females. sex was not stated for 12 cases. A majority of cases had influenza type A infections (n=1,210) of which 153 were further subtyped; 142 were identified as H1n1(09) pandemic strain, and 11 were H3n2 infections. seven hundred cases were identified as type b infections, six were identified as type A and b mixed infections, one case was identified as a type C infection and no typing was available for one case. no deaths due to influenza infection were reported during the quarter. Thirteen outbreaks, all in aged care facilities, were notified during the third quarter of which six were identified as influenza type A, and one as influenza type b. Two outbreaks were identified as due to RsV, one to picornavirus, and one to parainfluenza; no pathogen was isolated for two outbreaks.

Invasive pneumococcal disease (IPD)

A total of 171 cases of iPD were notified in the third quarter of 2011, 52 more than were notified in the previous quarter and 34 more than were notified in the corresponding period in 2010. Ages ranged from one month to 99 years with a median age of 59 years. Twenty cases were in children aged less than five years of whom six were aged less than 12 months. sixty-four cases were in persons aged 65 years or older (37 per cent), 36 of whom were aged 75 years or older. ninety-seven cases (57 per cent) were in males. indigenous status was reported for 134 cases (78 per cent) with two cases identified as being of Aboriginal and/or Torres strait islander origin. nine cases were reported to have died due to iPD during the quarter, all of whom were adults aged between 40 and 92 years (median age 74 years).

serotyping was completed for 163 case isolates; five isolates were not typable, and no typing was done for three cases. Eighteen cases (16 aged 0–2yrs and two aged 0–9 yrs with immunocompromising conditions) were eligible for free conjugate vaccine under the national immunisation Program, however only one case, a six year-old fully vaccinated child, was infected with a serotype contained within the conjugate vaccine. Thirty-nine of the 64 notified persons aged 65 years or older were infected with a serotype contained within the polysaccharide vaccine. Eight of these cases were reported to be fully vaccinated, 17 were not vaccinated, and three were partially vaccinated; vaccination status was unknown for 11 cases. Of the adult cases infected with non-polysaccharide vaccine serotypes (n=47), seven were fully vaccinated and 28 were not vaccinated;

138 VictorianInfectiousDiseasesBulletinVolume14Issue4December2011

vaccination status for the remaining 12 cases was unknown. Of the nine deaths reported during the quarter, eight were in cases aged 65 years or older. six of these cases were due to a serotype contained within the polysaccharide vaccine. Only one of those cases was fully vaccinated; this case was reported to have a chronic medical condition.

Measles

Two confirmed measles cases were notified to the department in the third quarter, eight fewer than in the previous quarter. This compares to five cases in the same period in 2010. both cases were in males, aged 17 and 36 years. neither were vaccinated for measles.

both cases were overseas-acquired infections. The 17 year-old was a recently-arrived exchange student from France who had had contact with a confirmed case of measles two days prior to his departure for Australia. The 36 year-old had recently visited family in new Zealand where there is an ongoing measles outbreak. Genotyping by the Victorian infectious Diseases Reference Laboratory revealed both cases to be genotype D4.

Mumps

Two cases of mumps were notified to the department in the third quarter of 2011, compared to four cases in the corresponding period in 2010. Cases were in males aged 12 and 32 years. The 12 year-old was fully vaccinated and vaccination status for the 32 year-old was unknown.

no epidemiological links between cases were identified in this period.

Rubella

Three confirmed and one probable case of rubella were notified in the third quarter of 2011 compared to ten cases in the corresponding period in

2010. Ages ranged from one year to 26 years (median age 23 years). Cases were in three males and one female. The one-year-old was fully vaccinated for rubella, the 21-year-old was not vaccinated, and vaccination status was unknown for the 24 and 26 year-olds. none had a history of recent overseas travel, although one case reported recent travel interstate. no links between cases were identified.

Pertussis

A total of 2,244 confirmed and probable cases of pertussis were notified to the department in the third quarter of 2011, representing a 21 per cent increase on the 1,853 cases notified in the previous quarter, and a 36 per cent increase on the 1,654 cases notified for the same period in 2010 (Figure 4). notifications for infants aged less than six months increased from 32 cases in the third quarter of 2010 to 46 cases for the corresponding period in 2011. The number of notifications for children aged one year to less than five years of age also increased from 52 cases in the third quarter of 2010 to 88 cases in the third quarter of 2011. increased notifications were also seen in the five to under15 years and 25 plus years age groups.

no deaths were reported in the third quarter.

Tetanus

no cases of tetanus were notified in the third quarter of 2011.

Varicella zoster virus

There were 1,105 notified cases of varicella zoster virus in the third quarter of 2011, compared to 878 cases in the previous period, and 818 cases for the same period in 2010. Of these, 190 (17 per cent) were probable or confirmed cases of chickenpox and 239 (22 per cent) were probable or confirmed cases of herpes zoster (shingles). The clinical manifestation was unspecified for the remaining 676 cases (61 per cent).

Chickenpox

Of the 190 chickenpox cases, 104 (55 per cent) were in males. Ages ranged from five months to 75 years (median age eight years), and age was not stated for three cases. Region of residence was available for 188 cases (99 per cent). A majority of cases resided in the metropolitan regions (75 per cent), with northern and Western Metropolitan Region reporting the highest number of cases (34 per cent).

Figure 4: Notified cases of pertussis by month of notification, Victoria, January 2005–September 2011

Num

ber

of

notifi

ed c

ases

Month and year of notification

<1 1 to <5 5 to <15 15 to <18 18 to <25 25+

0

200

400

600

800

1000

1200

25+18 to <2515 to <185 to <151 to <5<1

AJOJ JAJOJAJOJAJOJAJOJAJOJAJ

Qtr4Qtr3Qtr2Qtr1

2005 2006 2007 2008 2009 2010 2011

VictorianInfectiousDiseasesBulletinVolume14Issue4December2011 139

Herpes zoster (shingles)

Of the 239 shingles cases, 144 (60 per cent) were in females. Ages ranged from 14 months to 98 years with a median age of 53 years. Age was not stated for seven cases. Region of residence was available for all but two cases. A majority of shingles cases resided in the metropolitan regions (75 per cent), with northern and Western Metropolitan Region reporting the highest number of cases (n=65).

Other notifiable diseases

Invasive meningococcal disease

Lucinda Franklin, Department of Health

Fifteen confirmed and probable cases of invasive meningococcal disease were notified in the third quarter of 2011, one more than was notified in the previous quarter, and the same number as were notified in the corresponding period in 2010. Cases were in persons aged from two months to 69 years (median age 17 years). Two cases were in infants aged less than 12 months. Three cases were in children aged between 12 months and three years; a 13-month-old, a 19-month-old and a 30-month-old. Three cases were in older children aged between 11 and 17 years. The remainder of the cases were in adults, three aged between 18 and 20 years, and four aged between 54 and 69 years. nine of the 15 cases (60 per cent) were in males. Twelve of the 15 cases were serogroup b infections, two were serogroup W135 infections, and one was a serogroup Y infection. One death due to invasive meningococcal disease was reported during the quarter, in a 58-year-old female with a serogroup b infection. no epidemiological links between cases were identified.

Legionellosis

Lucinda Franklin, Department of Health

seven confirmed and probable cases of legionellosis were notified in the third quarter of 2011, 13 fewer than were notified in the previous period, and 11 fewer than were notified for the corresponding period in 2010. Cases were in persons aged 33 to 66 years (median age 59 years) and five of the seven cases were in males (71 per cent). Four cases were identified as Legionella pneumophila infections, three of which were serogroup 1 infections, and one case could not be further serogrouped. The remainder of the cases were identified as Legionella longbeachae infections. none of the cases notified in the third quarter died as a result of their infection. no outbreaks were reported during the third quarter.

Creutzfeldt-Jakob disease (CJD)

Alison Boyd, Australian National CJD Registry

Due to the nature of the disease, months or years may elapse between the notification date of suspected CJD cases and their subsequent confirmation (or rejection) by the Australian national Creutzfeldt-Jakob Disease Registry (AnCJDR). Thus the figures reported here will differ from those in Table 9, which counts confirmed and probable cases by their notification date.

nine new suspect cases of CJD were notified to the AnCJDR between July and september 2011. Five of these cases remain under investigation. The notification and confirmed case numbers are in keeping with the findings from previous quarters (Table 2).

Table 2: Notification of suspect and confirmed, definite and probable CJD cases by quarter, June 2004–September 2011

Suspect **Confirmed

Qtr *Notified CJD Not CJD

Jun–04 1 1  

sep–04 3    

Dec–04 1 1  

Mar–05 6 1  

Jun–05 2 1  

sep–05 10 4  

Dec–05 2 4 2

Mar–06 2 3 2

Jun–06 2 2  

sep–06 3    

Dec–06 4 5 3

Mar–07 4   2

Jun–07 3 1 1

sep–07 5    

Dec–07 5 1 2

Mar–08 7 6 2

Jun–08 5 2 2

sep–08 7 2  

Dec–08 4 3 2

Mar–09 4 3 1

Jun–09 5   2

sep–09 2   1

Dec–09 9 1 1

Mar–10 7 3 1

Jun–10 3 6

sep–10 4 1 1

Dec–10 4 2

Mar–11 7 2 1

Jun–11 4 1 2

sep–11 5 4

Total 130 60 28

* notified = suspect cases notified within the quarter

** confirmed = cases confirmed as definite or probable reclassified within the quarter

140 VictorianInfectiousDiseasesBulletinVolume14Issue4December2011

Mycobacterial infectionsLynne Brown, Department of Health

Tuberculosis

Owing to the slow growing nature of Mycobacterium tuberculosis, data are preliminary and subject to change.

The department received notifications for 112 cases of tuberculosis in the third quarter of 2011, twice the number than for the second quarter in 2011 (n=58) but similar to the same quarter in 2010 (n=108). Of the 112 cases, 51 were in females and 61 were in males. Patients aged 20 to 39 years comprised forty per cent of the cases notified. six children aged fifteen years or younger were notified with Tb in the third quarter in contrast to the previous quarter when only one child was notified (Figure 5). Three children were identified via contact tracing and three were diagnosed on clinical presentation. Two of these children were born overseas and the third was an Australian-born child, whose mother was treated for Tb while she was pregnant. The baby was assessed and treated with isoniazid (primary preventive therapy) following birth but there were considerable issues related to adherence to medications for both mother and baby. The child has now presented after being unwell for several months and with significant changes on chest X-ray.

in third quarter of 2011, 87 per cent (n=97) of notifications were for overseas-born patients. Of these, thirty-five per cent were born in india and a further 14 per cent were born in countries in northern Asia. There were no notifications in Aboriginals or Torres strait islanders for this reporting period. information about HiV testing was available for 101 of the 112 notifications: one patient was known to have HiV/Tb co-infection. seventy-two per cent of Tb patients were reported to have been tested

for HiV infection which was similar to the previous quarter. Thirteen patients (12 per cent) were notified with active tuberculosis as a result of investigation of a Tuberculosis Undertaking (TbU) or through refugee screening. Four patients were identified by contact investigation and twenty-three patients were overseas students, of whom only two were diagnosed with pulmonary Tb. seventeen notifications were for smear positive pulmonary Tb requiring extended screenings in either a workplace or educational institution. A contact investigation in Geelong identified significant transmission of infection in a workplace, as well as primary disease in a three-year-old child of the index case. All work colleagues were referred for further assessment and consideration of treatment of latent Tb infection.

Site of disease

Table 3: Notifications of tuberculosis, by site of disease, Victoria, July–September 2011

Site Number

Pulmonary 49

Pulmonary and other sites 16

Lymph nodes 30

bone / joint 1

Genito-urinary 3

Meningeal 1

Pleural 7

Peritoneal 2

Other 3

Total 112

Pulmonary disease accounted for 58 per cent (n=65) of all notifications. Additional sites, other than the lungs, were noted in 16 notifications with pulmonary Tb (Table 3). The most common additional sites were lymph

Figure 5: Notifications of tuberculosis, by age group, sex and per 100,000, Victoria, 1 July 2011–30 September 2011

Num

ber

of

notifi

ed c

ases

Rat

e p

er 1

00,0

00 p

op

ulat

ion

Age group (years)

Female Male Rate

0

5

10

15

85+80–8475–7970–7465–6960–6455–5950–5445–4940–4435–3930–3425–2920–2415–1910–145–90–40

2

4

6

Table 4: Confirmation of tuberculosis notifications, by diagnostic method, Victoria July–September 2011

Diagnostic methodExtra

pulmonaryPulmonary

onlyPulmonary + other sites Total

Culture 33 45 14 92

PCR/nAT 3 – – 3

Histology 4 1 1 6

Microscopic examination 2 – – 2

Radiological 2 2 1 5

Clinical signs 2 1 – 3

Tuberculin test 1 – – 1

Total 47 49 16 112

PCR/nAT: polymerase chain reaction/nucleic acid testing

VictorianInfectiousDiseasesBulletinVolume14Issue4December2011 141

nodes (n=6) with pleural and bone/joint TB accounting for an additional six cases. Two patients were noted to have miliary/disseminated TB, in addition to pulmonary disease. Extra pulmonary disease was reported in 42 per cent of notifications—the most common sites being lymphatic (64 per cent) with pleural TB accounting for a further 15 per cent of extra pulmonary notifications. Other sites of disease include patients with TB of the eye, pericardium, testes and pancreas.

Laboratory confirmation of diagnosis in some form (smear, culture, antigen detection or histology) was obtained in 92 per cent of cases (Table 4). Eighty-two per cent of cases were confirmed by culture, which was a four per cent increase on the same period in 2010. The diagnosis was confirmed by culture in 91 per cent of pulmonary cases, compared with 87 per cent in the previous quarter. There was one case of multi-drug-resistant (MDR) TB reported in the third quarter of 2011 and six isolates were resistant to at least one first-line drug.

Vector borne diseasesNasra Higgins, Department of Health, Victoria

Alphavirus infection

Ross River virus infections

Forty-one cases of Ross River virus disease were notified during the third quarter of 2011 compared to 34 cases in the same period in 2010. Earlier in 2011 there was an increase in the number of cases notified, however the number of cases has now decreased and returned to levels seen in previous years (Figure 6).

Of the 41 cases notified, 23 (56 per cent) were in females and 18 (44 per cent) were in males. Ages ranged from nine years to 83 years, with a median age of 44 years. Eighty-five per cent of the cases (n=35) were from rural regions of Victoria, with the

highest number of cases in Grampians Region (n=16), followed by the Loddon Mallee (n=11), Barwon South Western Region (n=5), Hume Region (n=2) and Gippsland Region (n=1). Six cases were residents of metropolitan regions of whom one case reported travel to Queensland during their incubation period and another reported travel along the Murray River. Enhanced data were not received for the remaining four cases.

Barmah Forest virus infection

Thirteen cases of Barmah Forest virus disease were notified during the third quarter of 2011 compared to five cases in the same period in 2010 (Figure 6).

Ten females and three males were notified this quarter with ages ranging from 15 years to 63 years, with a

median age of 39 years. Nine cases were from rural Victoria; five in Hume Region and four in Loddon Mallee Region. Four cases were residents of Metropolitan Regions, of which one person was reported to have travelled to Queensland. Travel history was unknown or not reported for the other three cases.

Flavivirus infection

Twenty-eight cases of Flavivirus infection, 23 due to dengue virus, were notified in the third quarter. This was a reduction on the 31 cases of dengue notified in the same period in 2010 (Figure 7). Of these 23 cases of dengue 12 were in males and 11 were in females. Their ages ranged from 22 years to 59 years, with a median age of 46 years. Twenty-two cases reported infection acquired overseas, with 11

Figure 6: Notified cases of Ross River virus disease and Barmah Forest virus disease by month, Victoria, January 2002–September 2011

Num

ber

of

notifi

ed c

ases

Month and year of notification

0

100

200

300

400

500

600Ross River virus Barmah Forest virus

AJO OJ JAJOJAJOJAJOJAJOJAJOJAJOJAJOJAJOJAJ 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Figure 7: Notified cases of dengue fever by month, Victoria, January 2002–September 2011

Num

ber

of

notifi

ed c

ases

Month of notification

0

5

10

15

20

25

JAJOJAJOJAJOJAJOJAJOJAJOJAJOJAJOJAJOJAJ 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

142 Victorian Infectious Diseases Bulletin Volume 14 Issue 4 December 2011

having travelled to Thailand, four to Indonesia, three to India and one case each to Sri Lanka, Maldives, South East Asia and Vietnam. The remaining case reported acquiring the infection in Queensland.

The five Flavivirus unspecified cases all had overseas travel reported; three to South East Asia, one to Philippines and one to Cambodia.

Malaria

Thirty-one cases of Malaria were notified during the third quarter of 2011 compared to 24 cases for the same period in 2010. Of these 31 cases, 24 were in males and seven were in females. Ages ranged from 14 years to 62 years, with a median age of 27 years. Seven of the 31 cases reported use of malaria prophylaxis.

Infection with Plasmodium vivax accounted for 15 cases (48 per cent). Seven cases reported acquired their illness in India, four reported Pakistan and one case each reported Vanuatu, Papua New Guinea, Solomon Islands, and Afghanistan.

Infection with P. falciparum accounted for 12 cases (39 per cent). Five cases reported acquiring the infection in Sudan and one case each in Ghana, Indonesia, Mozambique, North Africa, Sub Saharan Africa and Uganda.

One case of P. ovale reportedly acquired the infection in Sub Saharan Africa. Two cases of P.falciparum and P.malariae reportedly acquired the infection in Uganda and Liberia.

One case of P.malariae reportedly acquired the infection in Sierra Leone.

Chikungunya

Chikungunya became notifiable in Victoria on 1 January 2010.

Three cases of chikungunya were notified in the third quarter of 2011, the same number as were notified during the same period in 2010. Two

were females, aged 13 and 27 years and the third was a male aged 42 years. All had acquired their infection overseas, with one each having travelled to Thailand, Papua New Guinea and India.

ZoonosesLucinda Franklin, Department of Health, Victoria

Brucellosis

No cases of brucellosis were notified to the department in the third quarter of 2011.

Leptospirosis

Five cases of leptospirosis were notified in the third quarter of 2011, three more than were notified in the previous quarter and bringing the year-to-date total to 11 cases. All five were in males, aged from 43 to 62 years (median age 55 years). Of the five cases reported in the third quarter, two were identified as species Hardjo, two as species Arborea, and one as species Copenhagenii.

One case reported in the third quarter was an overseas resident, three were residents of metropolitan regions (one of Eastern Metropolitan Region and two of North and West Metropolitan Region), and one was a resident of Barwon South Western Region. Two of the five cases in the third quarter were overseas acquired; a 51-year-old male acquired his illness on his farm in New Zealand and a 62-year-old male had recently returned from holiday in Thailand and Laos. A further case, in a 43-year-old male, acquired his infection while on a camping holiday in northern Victoria. The remaining two cases were occupationally-acquired infections (in a 55-year-old dairy farmer and a 55-year-old hobby farmer/excavator).

Psittacosis

Ten confirmed and probable cases of psittacosis were notified to the

department in the third quarter of 2011, four fewer than were notified in the previous quarter, and seven more than for the same period in 2010. This brought the year-to-date total to 42 cases. Cases were in adults aged from 43 to 84 years (median age 57 years). Eight of the ten cases (80 per cent) were in males.

Cases were reported from five of the eight Victorian regions during the quarter, seven cases were residents of metropolitan regions (four from Eastern Metropolitan Region, three from North and West Metropolitan Region) and three were residents of rural regions (one case each from the Hume, Gippsland and Grampians Regions). Of the ten cases, four (40 per cent) reported exposure to domestic birds, three of whom owned psittacine birds. Eight cases reported contact with wild birds, three of which were occupationally acquired infections, in a gardener, a construction worker, and an operator of a caravan park situated adjacent to a national park.

Q fever

Five cases of Q fever were notified to the department in the third quarter of 2011, bringing the year-to-date total to 12 cases. Cases were in adults aged from 27 to 57 years (median age 46 years). Cases were in four males and one female. All five were residents of rural regions, three from Gippsland Region, and one each from Hume Region and Barwon South Western Region.

All five cases in this reporting period were occupationally-acquired infections. Two cases worked as farm hands, and one each as a kangaroo hide tanner, a saleyards worker, and a dairy and beef cattle farmer. Only one of the cases had been vaccinated against Q fever; a 28 year-old male who worked in a saleyards and had exposure to sheep and goats.

Victorian Infectious Diseases Bulletin Volume 14 Issue 4 December 2011 143

sexually transmissible infections (sTis)Ellen Donnan, Department of Health

Chlamydia

A total of 4,921 cases of chlamydia were notified to the department in the third quarter of 2011. This was a four per cent increase on the 4,715 cases notified in the previous quarter, and a 17 per cent increase on the 4,206 cases notified in the third quarter of 2010 (Figure 8).

Fifty-seven per cent of cases (n=2,826) were in females and 42 per cent (n=2,081) were in males. sex was not reported for 14 cases. Cases were in persons aged from 14 days to 91 years, with a median age of 23 years. infections were most commonly reported in the 20 to 24 year age group (39 per cent), which was consistent with the previous quarters. Eighty per cent of cases notified were aged 15 to 29 years (n=3,919).

indigenous status was reported for 55 per cent of cases, of which 41 (one per cent) were reported as being Aboriginal and/or Torres strait islander.

A majority of cases (n=3,518, 71 per cent) reported had a metropolitan

postcode of residence. Postcode of residence was not reported for 143 cases and the remaining cases (n=1,260, 26 per cent) were residents of rural Victoria.

Enhanced surveillance data were available for 1,401 cases (28 per cent) at the time of this report. Of the cases where enhanced surveillance data were available, 47 (three per cent) were reported as being HiV positive; 46 were male, 45 of whom reported a male sexual partner (MsM), and one was a female who reported a male sexual partner.

Among the 1,401 cases, screening for sTis (at either the doctor’s suggestion or patient request) was reported as the main reason for testing for 59 per cent of cases. Having clinical signs and symptoms was reported as the reason for testing by 19 per cent of cases; contact tracing by 13 per cent, pre-termination screening by one per cent and antenatal screening by one per cent. Four per cent reported other reasons for testing while for 43 cases (three per cent) this information was unknown or not reported.

Males

Of the 637 males for whom enhanced surveillance data were available, 62 per cent (n=392) reported a female sexual partner and 29 per

cent (n=183) reported a male sexual partner. source of infection was unknown or not reported for 10 per cent of cases (n=62).

Among the males reporting a female sexual partner, 55 per cent (n=392) reported having a casual sexual partner, 36 per cent (n=141) reported a regular sexual partner, one per cent (n=5) reported a sex worker as the likely source of infection, and sexual partner type was unknown or not reported for the remaining 32 cases. For those males reporting a male sexual partner, 76 per cent (n=139) reported having a casual sexual partner and 16 per cent (n=30) reported having a regular sexual partner. One case reported being a sex worker with likely acquisition from a client. This information was unknown or not reported for the remaining 13 cases.

Eighty-three per cent (n=526) of cases reported Victoria as the likely place of infection; eight per cent (n=49) reported overseas and one per cent reported interstate acquisition (n=6). This information was unknown or not reported for nine per cent of cases (n=56).

Females

Of the 760 females for whom enhanced surveillance data were available, 88 per cent reported a male sexual partner (n=607) and one per cent (n=10) reported a female sexual partner. source of infection was unknown or not reported for the remaining 11 per cent (n=80).

Fifty-one per cent of cases (n=384) reported a regular sexual partner and 32 per cent (n=242) reported a casual sexual partner as the likely source of the infection. nineteen females identified as sex workers with likely acquisition from a client and three cases reported a sex worker as the likely source of infection. For the

Figure 8: Notified cases of chlamydia by quarter, Victoria, January 1997–September 2011

Num

ber

of

notifi

ed c

ases

Year of notification

0

6,000

12,000

18,000

Qtr4

Qtr3

Qtr2

Qtr1

201120102009200820072006200520042003200220012000199919981997

Q1 Q2 Q3 Q4

144 VictorianInfectiousDiseasesBulletinVolume14Issue4December2011

remaining 112 cases (15 per cent) this information was unknown or not reported.

A majority of the cases (n=656, 86 per cent) reported that their infection was acquired in Victoria. Twenty-six cases (three per cent) reported overseas acquisition, and seven cases reported interstate acquisition; this information was unknown or not reported for 71 cases (nine per cent).

Gonorrhoea

There were 421 cases of gonorrhoea notified in the third quarter of 2011; a 24 per cent decrease on the 556 cases notified in the previous quarter, and a 12 per cent decrease when compared to the third quarter of 2010 (n=477) (Figure 9).

Eighty-three per cent of cases were in males (n=350) with an age range of 15 to 80 years. sixteen per cent of cases were in females (n=66) with an age range of 14 days to 70 years. sex was not reported for five cases. The overall median age was 30 years. infections were most frequently notified in the 20 to 24 year age group, with 42 per cent of gonorrhoea cases in young adults aged from 20 to 29 years.

Eighty-five per cent of cases (n=356) reported had a metropolitan postcode of residence, seven per cent of cases

were from regional Victoria (n=30) and postcode of residence was not reported for 35 cases (eight per cent). indigenous status was reported in 70 per cent of cases (n=293), with one case reported as being Aboriginal and/or Torres strait islander.

Enhanced surveillance data were received for 60 per cent of cases (n=252) at the time of this report. Of these 252 cases, 35 (14 per cent) were reported as being HiV positive; all males of whom 33 were reported as MsM. This informationr was unknown or not stated for the remaining two HiV positive cases.

Among the 252 cases, 51 per cent (n=129) were tested due to clinical signs and symptoms of sTis, followed by screening (36 per cent, n=129) and contact tracing (six per cent, n=16). Eight cases reported other reasons, and reason for testing was unknown or not reported for the remaining nine cases.

Males

Among the 216 males for whom enhanced surveillance data were available, 63 per cent (n=138) reported a male sexual partner and 25 per cent (n=55) reported a female sexual partner. For the remaining 11 per cent (n=23) this information was unknown or not reported.

Of the 138 males reporting a male sexual partner, 76 per cent (n=105) reported acquiring their infection from a casual sexual partner and 17 per cent (n=23) reported acquiring it from a regular partner. Three males reported being sex workers with likely acquisition from a client (two per cent). Partner type was unknown or not reported for seven cases.

Of the males reporting a female sexual partner (n=55), 56 per cent (n=31) reported acquiring the infection from a casual partner, 20 per cent (n=11) from a regular partner and 11 per cent (n=6) reported acquiring the infection from a female sex worker. Partner type was unknown for the seven remaining males.

Eighty-one per cent (n=174) reported that they acquired their infection in Victoria, 10 per cent reported overseas acquisition (n=22) and one per cent reported interstate (n=2). This information was unknown or not reported for 18 cases.

Females

Of the 32 females for whom enhanced surveillance data were available, 29 reported acquiring their infection from a male sexual partner (91 per cent). This information was unknown or not reported for the remaining three females.

Fifty per cent of females (n=16) reported acquiring the infection from a regular partner, and 19 per cent (n=6) from a casual partner. six females identified as sex workers, likely to have acquired the infection from a client. One case was in an infant with congenital or neonatal transmission, and for the remaining three females this information was unknown or not reported.

Eighty-eight per cent of the cases (n=28) reported that they acquired their infection in Victoria and three

Figure 9: Notified cases of gonorrhoea by quarter, Victoria, January 1997–September 2011

Num

ber

of

notifi

ed c

ases

Year of notification

0

500

1000

1500

2000Qtr4

Qtr3

Qtr2

Qtr1

201120102009200820072006200520042003200220012000199919981997

Q1 Q2 Q3 Q4

VictorianInfectiousDiseasesBulletinVolume14Issue4December2011 145

reported overseas acquisition (nine per cent). For the remaining case, this information was not reported.

Antibiotic resistance

Testing for susceptibility to ceftriaxone and ciprofloxacin was conducted by the Microbiological Diagnostic Unit. Of the 200 isolates tested for resistance to ceftriaxone, 93 per cent (n=185) were sensitive and the remaining 15 isolates had decreased susceptibility. Of the 201 isolates tested for ciprofloxacin resistance, 60 per cent (n=120) were sensitive, 40 per cent were resistant (n=80) and one isolate had decreased susceptibility.

Syphilis—infectious (less than two years duration)

During the third quarter of 2011 the department received notifications for 235 cases of syphilis, of which 87 (37 per cent) were classified as infectious syphilis. This was a 34 per cent increase on the number of infectious syphilis cases notified in the previous quarter (n=65), and a 45 per cent increase compared to the number of cases notified in the third quarter of 2010 (n=60) (Figure 10).

Of the 87 cases notified with infectious syphilis, 33 per cent (n=29) were classified as primary infections, 24 per cent (n=24) were classified as secondary infections and 43 per cent (n=37) were classified as early latent infections.

ninety per cent of cases (n=78) were in males, with an age range of 19 to 69 years and a median age of 40 years. There were nine cases in females notified this quarter, with an age range of 21 to 48 years and a median age of 35 years.

sixty-eight per cent of the cases were from metropolitan regions (n=59), nine per cent were from regional Victoria (n=8) and postcode of residence was unknown or not reported for

20 cases. indigenous status was reported for 80 cases (92 per cent), with one case reported as being of Aboriginal and/or Torres strait islander origin.

Enhanced surveillance data were collected for 84 (97 per cent) of infectious syphilis cases. Of these, 35 were HiV positive (40 per cent); all were males who reported a male sexual partner. Re-infection in those who have had previous episode/s of syphilis infection was reported for 15 cases, of which 11 were HiV positive.

The most common reported reason for testing was presenting with signs and symptoms of an sTi (44 per cent) followed by screening for sTis (37 per cent). Five cases were tested because of asymptomatic contact with an infected individual and three cases were found on antenatal screening. Other reasons for testing were reported for five cases while this information was unknown or not stated for four cases.

Males

Of the 78 males notified with syphilis this quarter, 62 (79 per cent) indicated likely acquiring the infection from

a male sexual partner, and 10 (13 per cent) indicated a female sexual partner; for the remaining six males this information was unknown or not reported.

Among the males reporting a male sexual partner, 82 per cent (n=51) reported acquiring their infection from a casual sexual partner, and 15 per cent (n=9) reported acquiring it from a regular sexual partner; for the remaining two cases sexual partner type was unknown or not reported.

Of the ten males reporting a female sexual partner, eight reported acquiring the infection from a casual sexual partner. This information was unknown or not reported for the remaining two cases.

Eighty-six per cent of the cases (n=67) reported that they acquired their infection in Victoria, five cases reported overseas acquisition and one case reported interstate acquisition; this information was not reported or unknown for the remaining five cases.

Females

nine females were notified with syphilis in this quarter, of whom five reported acquiring their infection from

Figure 10: Notified cases of infectious syphilis, by quarter, Victoria, January 1991–September 2011

Num

ber

of

notifi

ed c

ases

0

50

100

150

200

250

300

350

400

450

Qtr4

Qtr3

Qtr2

Qtr1

201120102009200820072006200520042003200220012000199919981997199619951994199319921991

Q1 Q2 Q3 Q4

Qtr4 3 0 1 1 0 4 0 1 0 2 2 8 11 28 34 80 81 80 90 73

Qtr3 2 3 3 5 3 4 5 0 0 1 6 8 20 16 29 67 140 83 100 60 87

Qtr2 1 7 3 5 2 1 4 1 2 4 5 10 14 21 31 59 99 103 109 80 65

Qtr1 0 5 4 6 3 2 1 2 0 2 3 2 10 19 23 28 103 111 92 77 88

Year (and quarter) of notification

146 VictorianInfectiousDiseasesBulletinVolume14Issue4December2011

a male sexual partner. This information was unknown or not reported for four cases. Three females reported a regular sexual partner and one reported a casual sexual partner as the likely source of infection. One female reported being a sex worker with likely acquisition from a client. Partner type was unknown or not reported for four cases. Three of the nine females reported that they acquired their infection in Victoria and three reported overseas acquisition; this information was unknown or not reported for the remaining three cases.

Human immunodeficiency virus (HiV) and acquired immunodeficiency syndrome (AiDs)Carol El-Hayek and Anita Feigin, Burnet Institute

Please note that numbers are subject to change as a result of ongoing case investigations and the annual audit of retrospective records.

There were 71 new HiV diagnoses1 during the third quarter of 2011, bringing the year-to-date total to 212, a 22 per cent increase on the number of diagnoses at the same time in 2010 and an eight per cent increase from

the same time in 2009 (Figure 11).

Age, sex and exposure categories

Of the 71 new HiV diagnoses in the third quarter of 2011, 89 per cent (n=63) were in males, of whom 29 per cent were under the age of 30 (Table 5). The median age of males diagnosed this quarter was 38 years compared to 34 years in the second quarter of 2011, and the median age of females diagnosed this quarter was 39.2 years compared to 30.1 years last quarter.

Male-to-male sexual contact

in the third quarter of 2011, 72 per cent (n=51) of all new HiV diagnoses were among men who have sex with men (MsM); a total of 165 MsM have been diagnosed with HiV year-to-date (Table 6). The median age

at HiV diagnosis among MsM this quarter was 37.8 years compared to 32.5 years in the second quarter of 2011. in this quarter there was also one male diagnosed with HiV who reported MsM and injecting drug use as possible exposures to HiV; three in total year-to-date.

in the third quarter of 2011, consistent with previous data, a majority of MsM diagnosed with HiV reported acquiring their infection in Victoria (75 per cent, n=38) (Figure 12) and 61 per cent (n=31) reported acquiring their HiV infection from a casual or anonymous partner (Figure 13).

Heterosexual exposure

seventeen HiV notifications (eight females) in the third quarter of 2011 were associated with heterosexual

Figure 11: Number of new HIV diagnoses by quarter, Victoria, 2002–2011

Num

ber

of

new

HIV

dia

gno

ses

Year of notification

Q1 Q2 Q3 Q4

0

50

100

150

200

250

300

Qtr4Qtr3Qtr2Qtr1

2011201020092008200720062005200420032002

Qtr4Qtr3Qtr2Qtr1

1 “new HiV diagnoses” refers to cases whose first ever HiV diagnosis was in Victoria.

Table 5: New HIV diagnoses by age group, Jul–Sep 2011, Jan–Sep 2011 and Jan–Dec 2011

Age group (years)

Third quarter 2011 July–September 2011

Year-to-date January–September 2011

Annual total 2010 January–December 2010

Males Females Total Males Females Total Males Females Total

n % n % n % n % n % n % n % n % n %

0–12 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 1 0.5 1 4.8 2 0.9

13–19 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 2 0.9 0 0.0 2 0.9

20–29 18 28.6 1 12.5 19 26.8 57 29.1 3 18.8 60 28.3 52 24.5 7 33.3 59 25.3

30–39 19 30.2 3 37.5 22 31.0 55 28.1 7 43.8 62 29.3 65 30.7 8 38.1 73 31.3

40–49 13 20.6 4 50.0 17 23.9 52 26.5 4 25.0 56 26.4 55 25.9 2 9.5 57 24.5

50–59 8 12.7 0 0.0 8 11.3 20 10.2 2 12.5 22 10.4 26 12.3 3 14.3 29 12.5

60+ 5 7.9 0 0.0 5 7.0 12 6.1 0 0.0 12 5.7 11 5.2 0 0.0 11 4.7

Total 63 100 8 100 71 100 196 100 16 100 212 100 212 100 21 100 233 100

VictorianInfectiousDiseasesBulletinVolume14Issue4December2011 147

exposure (Table 7), which was more than double the number of cases attributed to heterosexual exposure in previous quarter (n=7). six of these cases were among people born in an HiV high prevalence country (HPC)2.

The median age at diagnosis of people with heterosexually acquired HiV infection in the third quarter of 2011 was 38 years; 38 years among males and 39.2 years among females. This was younger than the median age of those diagnosed in the second quarter of 2011 (47.4 years).

Newly acquired infections3

in the third quarter of 2011, 38 per cent (n=27) of all new HiV diagnoses were classified as newly acquired infections, compared to 45 per cent in 2010 (Table 8), and 52 per cent in the second quarter of 2011. ninety-six per cent (n=26) of the newly acquired infections in this quarter were among MsM; 90 per cent year-to-date (n=90).

Figure 12: New HIV diagnoses associated with male to male sex by probable place infection acquired, Victoria, Jul–Sep 2011 and Jul–Sep 2010

Figure 13: New HIV diagnoses associated with male–to-male sex by source partner type, Victoria, Jul–Sep 2011 and Jul–Sep 2010

Pro

po

rtio

n o

f ne

w H

IV d

iag

nose

s (%

)

Probable place infection acquired

Jul–Sep 2011 Jul–Sep 2010

0

10

20

30

40

50

60

70

80

90

UnknownOverseasInterstateVictoria

Pro

po

rtio

n o

f ne

w H

IV d

iag

nose

s (%

)

Partner type

Jul-Sep 2011 Jul-Sep 2010

0

20

40

60

80

UnknownRegular and casualCasualRegular

Table 6: New HIV diagnoses by exposure category, Victoria, Jul–Sep 2011, Jan–Sep 2011 and Jan–Dec 2011

Exposure category

Third quarter 2011 July–September 2011

Year-to-date January–September 2011

Annual total 2010 January–December 2010

Males Females Total Males Females Total Males Females Total

n % n % n % n % n % n % n % n % n %Male to male sex 51 81.0 0 0.0 51 71.8 165 84.2 0 0.0 165 77.8 178 84.0 0 0.0 178 76.4

Male to male sex and iDU 1 1.6 0 0.0 1 1.4 3 1.5 0 0.0 3 1.4 5 2.4 0 0.0 5 2.2

iDU 2 3.2 0 0.0 2 2.8 4 2.0 0 0.0 4 1.9 0 0.0 0 0.0 0 0.0

Heterosexual contact 9 14.3 8 100 17 23.9 17 8.7 16 100 33 15.6 22 10.4 19 90.5 41 17.6

Other /unknown 0 0.0 0 0.0 0 0.0 7 3.6 0 0.0 7 3.3 7 3.3 2 9.5 9 3.9

Total 63 100 8 100 71 100 196 100 16 100 212 100 212 100 21 100 233 100

2 High prevalence country (HPC): defined as a country where the adult HiV prevalence is greater than one per cent and HiV is transmitted predominantly by heterosexual contact. This includes countries in sub-saharan Africa, Cambodia, Thailand, Myanmar, and some Caribbean countries.

3 newly acquired infections defined as having a previous negative HiV test and/or a seroconversion illness within the 12 months preceding HiV diagnosis.

148 VictorianInfectiousDiseasesBulletinVolume14Issue4December2011

Table 7: New HIV diagnoses associated with heterosexual contact, Jul–Sep 2011, Victoria, Jan–Sep 2011 and Jan–Dec 2011

Exposure category

Third quarter 2011 July–September 2011

Year-to-date January–September 2011

Annual total 2010 January–December 2010

Males Females Total Males Females Total Males Females Total

n % n % n % n % n % n % n % n % n %Person from an HPC1 3 33.3 3 37.5 6 35.3 4 23.5 7 43.8 11 33.3 4 18.2 9 47.4 13 31.7Hetero contact with person from an HPC1

2 22.2 0 0.0 2 11.8 4 23.5 0 0.0 4 12.1 3 13.6 1 5.3 4 9.8

Hetero contact with bisexual male

0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0

Hetero contact with an iDU 1 11.1 0 0.0 1 5.9 1 5.9 0 0.0 1 3.0 0 0.0 0 0.0 0 0.0

Hetero contact with person with HiV

1 11.1 1 12.5 2 11.8 2 11.8 4 25.0 6 18.2 1 4.6 3 15.8 4 9.8

Hetero contact, not otherwise specified

2 22.2 4 50.0 6 35.3 6 35.3 5 31.3 11 33.3 14 63.6 6 31.6 20 48.8

Total 9 100 8 100 17 100 17 100 16 100 33 100 22 100 19 100 41 100

Table 8: New HIV diagnoses in Victoria, by time since last negative test and/or seroconversion Illness, Jul–Sep 2011, Jan–Sep 2011 and Jan–Dec 2010

Time between HIV diagnosis and negative test and/or seroconversion illness

Third quarter 2011 July–September 2011

Year-to-date January–September 2011

Annual total 2010 January–December 2010

Males Females Total Males Females Total Males Females Total

n % n % n % n % n % n % n % n % n %

Less than 1 year (newly acquired) 26 41.3 1 12.5 27 38.0 96 49.0 4 25.0 100 47.2 98 46.2 6 28.6 104 44.6

1 year to less than 3 years 11 17.5 0 0.0 11 15.5 28 14.3 0 0.0 28 13.2 28 13.2 1 4.8 29 12.5

3 or more years 9 14.3 2 25.0 11 15.5 20 10.2 4 25.0 24 11.3 24 11.3 2 9.5 26 11.2

no previous negative test or seroconversion illness

11 17.5 5 62.5 16 22.5 34 17.4 8 50.0 42 19.8 40 18.9 5 23.8 45 19.3

History unknown 6 9.5 0 0.0 6 8.5 18 9.2 0 0.0 18 8.5 22 10.4 7 33.3 29 12.5

Total 63 100 8 100 71 100 196 100 16 100 212 100 212 100 21 100 233 100

Acquired immunodeficiency syndrome (AIDS)

seventeen notifications of AiDs were received in the third quarter of 2011; for 14 males and three females. Of the males, eight were MsM and six reported heterosexual exposure, two of whom were from an HPC. All of the females reported heterosexual exposure to HiV; two were also from an HPC. This brought the number of AiDs cases year-to-date to 45.

Deaths

There were eight deaths following HiV diagnosis in the third quarter of 2011, in seven males and one female. Of the males three were MsM and two were heterosexual (one from an HPC); for the female information about exposure to HiV was unavailable. Five of the eight deaths were attributed to AiDs. This brought the number of deaths following HiV diagnosis year-to-date to 20, nine of these were attributed to AiDs.

VictorianInfectiousDiseasesBulletinVolume14Issue4December2011 149

Table 9: Notifications of infectious diseases, by Department of Health region, 1 January–30 September 2011 and historical comparisonsnote—data are preliminary figures only and may be subject to revision (daily surveillance reports are available online at http://ideas.health.vic.gov.au/)

Barwon South Western Grampians Loddon Mallee Hume Gippsland

North and West Metropolitan Eastern Metropolitan

Southern Metropolitan Unknown Victoria

Notifiable disease 2011 ytd 2010 ytd 2011 ytd 2010 ytd 2011 ytd 2010 ytd 2011 ytd 2010 ytd 2011 ytd 2010 ytd 2011 ytd 2010 ytd 2011 ytd 2010 ytd 2011 ytd 2010 ytd 2011 ytd 2010 ytd 2011 ytd 2010 ytd 2010 total

Blood borne diseasesHepatitis b – newly acquired 5 3 0 8 5 2 1 2 1 1 11 22 5 6 12 7 0 1 40 52 70Hepatitis b – unspecified 24 21 7 17 29 23 11 28 12 25 680 647 309 303 349 337 37 45 1458 1446 1914Hepatitis C – newly acquired 13 16 6 9 3 3 4 8 7 6 60 46 16 21 16 21 5 5 130 135 178Hepatitis C – unspecified 118 115 72 73 102 100 77 87 107 112 620 654 165 219 373 411 62 101 1696 1872 2449Hepatitis D 2 0 0 0 0 0 0 0 1 0 5 3 3 0 4 1 1 0 16 4 6

Enteric diseasesCampylobacter infection 436 369 210 178 313 246 287 217 298 264 1482 1134 986 939 1146 1053 24 22 5182 4422 6636Cryptosporidiosis 19 24 4 6 6 16 8 21 29 40 46 91 37 69 46 88 0 3 195 358 445Food/water/environmental – other 11 8 32 7 26 14 20 10 9 23 199 423 61 69 92 135 599 506 1049 1195 1382Haemolytic uraemic syndrome 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 2 0 0 1 2 3Hepatitis A 2 1 1 10 2 2 2 6 0 1 7 20 5 5 6 42 0 3 25 90 99Hepatitis E 0 0 0 0 0 0 0 0 0 0 1 4 2 0 3 4 0 1 6 9 11Listeriosis 2 1 0 0 0 2 0 1 0 0 3 13 2 6 7 2 0 0 14 25 28Paratyphoid 0 0 0 1 0 0 0 0 0 0 9 8 5 5 3 6 0 0 17 20 27salmonellosis 168 112 103 90 180 130 141 140 73 82 593 501 389 257 436 388 21 13 2104 1713 2261shigellosis 2 1 0 2 1 3 1 1 1 0 30 23 8 10 31 31 1 0 75 71 87Typhoid 0 0 0 0 0 0 0 1 0 0 16 10 1 4 7 4 1 1 25 20 26Vero toxin producing E.coli 2 4 1 2 1 0 0 0 0 0 2 0 1 0 1 1 0 0 8 7 11

Other notifiable conditionsblood lead greater than 10µg/dL 8 56 6 10 8 11 1 2 3 6 38 187 9 37 40 348 2 5 115 662 751Creutzfeldt-Jakob disease 0 0 0 0 0 0 0 0 0 0 1 1 1 2 2 3 0 1 4 7 7invasive meningococcal disease – group b 4 2 1 3 2 1 2 2 3 1 10 8 5 6 7 1 2 0 36 24 33invasive meningococcal disease – group C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1invasive meningococcal disease – other 1 1 0 0 1 0 0 0 0 1 1 3 0 1 0 2 0 0 3 8 9Legionella – other 0 0 0 0 1 0 0 0 1 0 2 3 0 1 0 0 0 0 4 4 4Legionella longbeachae 0 0 0 0 1 1 1 1 2 1 0 3 0 1 3 2 0 0 7 9 11Legionella pneumophila – indeterminate serotype 0 0 1 0 0 0 1 0 0 0 2 0 0 1 1 0 0 0 5 1 1Legionella pneumophila 1 1 2 1 0 0 3 3 2 0 1 15 15 1 13 12 8 0 0 33 44 51Leprosy 0 0 0 0 0 0 0 0 0 1 2 1 1 0 0 1 0 0 3 3 4Mycobacterium infection (non-Tb) 1 1 0 0 1 1 2 2 1 0 4 6 7 8 6 3 1 0 23 21 28Mycobacterium ulcerans 35 14 1 0 1 1 0 1 0 1 7 2 4 2 9 3 0 0 57 24 32Tb complex 10 3 1 3 2 5 0 1 4 1 115 166 47 50 73 70 1 2 253 301 436

Sexually transmissible infectionsChlamydia 1088 880 506 462 738 654 737 579 607 538 4391 4008 2149 1865 3511 3114 619 512 14346 12612 16541Gonococcal infection 33 35 21 18 21 21 14 26 28 23 615 558 137 170 408 375 147 133 1424 1359 1758syphilis – infectious (less than two years duration) 8 2 5 1 1 4 2 2 7 6 88 86 20 24 71 70 39 24 241 219 293syphilis – two or more years duration 14 11 11 8 8 5 5 13 11 7 197 194 33 47 99 89 57 27 435 401 528

Vaccine preventable diseasesHaemophilus influenzae type b 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 1 2 5influenza 126 96 46 58 96 53 63 71 59 32 830 411 514 265 811 551 21 32 2566 1569 2051invasive pneumococcal disease 22 28 14 10 18 21 16 18 18 16 83 80 44 57 61 61 57 5 333 296 403Measles 2 2 4 0 0 0 0 1 0 0 17 1 5 2 3 6 0 0 31 12 14Mumps 1 1 0 1 2 0 0 0 0 0 10 1 1 0 6 5 0 0 20 8 10Pertussis 335 561 211 260 672 266 692 212 654 423 1699 1026 1172 573 1466 754 40 40 6941 4115 6968Rubella 0 0 0 0 0 0 0 0 0 0 6 9 5 5 0 6 0 1 11 21 22Tetanus 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1Varicella-zoster virus – chickenpox 34 20 13 12 26 13 18 10 21 17 151 102 96 91 97 81 2 2 458 348 542Varicella-zoster virus – shingles 28 27 27 23 21 12 35 26 49 39 191 144 186 153 178 94 4 5 719 523 694Varicella-zoster virus – unspecified 129 90 41 45 54 37 50 45 72 67 456 414 382 324 474 435 34 40 1692 1497 2051Vector borne diseasesbarmah Forest 7 2 15 2 101 3 41 3 12 10 10 2 7 2 7 4 0 0 200 28 53Chikungunya 0 1 0 0 1 0 0 0 1 0 2 5 6 2 3 4 0 0 13 12 17Dengue 8 1 0 3 4 1 1 2 2 8 27 11 10 10 31 20 0 0 83 56 112Flavivirus unspecified 0 0 0 0 1 1 0 0 0 0 9 3 0 0 1 2 0 0 11 6 12Malaria 5 3 1 1 4 2 2 3 2 1 28 20 11 13 18 15 3 2 74 60 67Ross River 103 15 489 19 482 127 70 67 19 50 40 30 23 23 53 22 0 0 1282 353 406

Zoonosesbrucellosis 0 0 0 0 0 0 0 0 0 0 1 2 0 0 0 0 0 0 1 2 2Leptospirosis 2 2 0 0 0 0 3 0 0 4 3 1 1 0 1 1 1 0 11 8 14Psittacosis 0 0 4 1 0 5 6 1 5 2 10 3 12 3 5 0 0 0 42 15 36Q fever 3 0 1 0 0 3 3 7 5 3 0 3 0 0 0 0 0 0 12 16 19

2007 ABS est. resident population 359,560 216,779 307,450 263,674 250,907 1,561,798 1,001,907 1,242,657 5,204,826

150 VictorianInfectiousDiseasesBulletinVolume14Issue4December2011

Table 9: Notifications of infectious diseases, by Department of Health region, 1 January–30 September 2011 and historical comparisonsnote—data are preliminary figures only and may be subject to revision (daily surveillance reports are available online at http://ideas.health.vic.gov.au/)

Barwon South Western Grampians Loddon Mallee Hume Gippsland

North and West Metropolitan Eastern Metropolitan

Southern Metropolitan Unknown Victoria

Notifiable disease 2011 ytd 2010 ytd 2011 ytd 2010 ytd 2011 ytd 2010 ytd 2011 ytd 2010 ytd 2011 ytd 2010 ytd 2011 ytd 2010 ytd 2011 ytd 2010 ytd 2011 ytd 2010 ytd 2011 ytd 2010 ytd 2011 ytd 2010 ytd 2010 total

Blood borne diseasesHepatitis b – newly acquired 5 3 0 8 5 2 1 2 1 1 11 22 5 6 12 7 0 1 40 52 70Hepatitis b – unspecified 24 21 7 17 29 23 11 28 12 25 680 647 309 303 349 337 37 45 1458 1446 1914Hepatitis C – newly acquired 13 16 6 9 3 3 4 8 7 6 60 46 16 21 16 21 5 5 130 135 178Hepatitis C – unspecified 118 115 72 73 102 100 77 87 107 112 620 654 165 219 373 411 62 101 1696 1872 2449Hepatitis D 2 0 0 0 0 0 0 0 1 0 5 3 3 0 4 1 1 0 16 4 6

Enteric diseasesCampylobacter infection 436 369 210 178 313 246 287 217 298 264 1482 1134 986 939 1146 1053 24 22 5182 4422 6636Cryptosporidiosis 19 24 4 6 6 16 8 21 29 40 46 91 37 69 46 88 0 3 195 358 445Food/water/environmental – other 11 8 32 7 26 14 20 10 9 23 199 423 61 69 92 135 599 506 1049 1195 1382Haemolytic uraemic syndrome 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 2 0 0 1 2 3Hepatitis A 2 1 1 10 2 2 2 6 0 1 7 20 5 5 6 42 0 3 25 90 99Hepatitis E 0 0 0 0 0 0 0 0 0 0 1 4 2 0 3 4 0 1 6 9 11Listeriosis 2 1 0 0 0 2 0 1 0 0 3 13 2 6 7 2 0 0 14 25 28Paratyphoid 0 0 0 1 0 0 0 0 0 0 9 8 5 5 3 6 0 0 17 20 27salmonellosis 168 112 103 90 180 130 141 140 73 82 593 501 389 257 436 388 21 13 2104 1713 2261shigellosis 2 1 0 2 1 3 1 1 1 0 30 23 8 10 31 31 1 0 75 71 87Typhoid 0 0 0 0 0 0 0 1 0 0 16 10 1 4 7 4 1 1 25 20 26Vero toxin producing E.coli 2 4 1 2 1 0 0 0 0 0 2 0 1 0 1 1 0 0 8 7 11

Other notifiable conditionsblood lead greater than 10µg/dL 8 56 6 10 8 11 1 2 3 6 38 187 9 37 40 348 2 5 115 662 751Creutzfeldt-Jakob disease 0 0 0 0 0 0 0 0 0 0 1 1 1 2 2 3 0 1 4 7 7invasive meningococcal disease – group b 4 2 1 3 2 1 2 2 3 1 10 8 5 6 7 1 2 0 36 24 33invasive meningococcal disease – group C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1invasive meningococcal disease – other 1 1 0 0 1 0 0 0 0 1 1 3 0 1 0 2 0 0 3 8 9Legionella – other 0 0 0 0 1 0 0 0 1 0 2 3 0 1 0 0 0 0 4 4 4Legionella longbeachae 0 0 0 0 1 1 1 1 2 1 0 3 0 1 3 2 0 0 7 9 11Legionella pneumophila – indeterminate serotype 0 0 1 0 0 0 1 0 0 0 2 0 0 1 1 0 0 0 5 1 1Legionella pneumophila 1 1 2 1 0 0 3 3 2 0 1 15 15 1 13 12 8 0 0 33 44 51Leprosy 0 0 0 0 0 0 0 0 0 1 2 1 1 0 0 1 0 0 3 3 4Mycobacterium infection (non-Tb) 1 1 0 0 1 1 2 2 1 0 4 6 7 8 6 3 1 0 23 21 28Mycobacterium ulcerans 35 14 1 0 1 1 0 1 0 1 7 2 4 2 9 3 0 0 57 24 32Tb complex 10 3 1 3 2 5 0 1 4 1 115 166 47 50 73 70 1 2 253 301 436

Sexually transmissible infectionsChlamydia 1088 880 506 462 738 654 737 579 607 538 4391 4008 2149 1865 3511 3114 619 512 14346 12612 16541Gonococcal infection 33 35 21 18 21 21 14 26 28 23 615 558 137 170 408 375 147 133 1424 1359 1758syphilis – infectious (less than two years duration) 8 2 5 1 1 4 2 2 7 6 88 86 20 24 71 70 39 24 241 219 293syphilis – two or more years duration 14 11 11 8 8 5 5 13 11 7 197 194 33 47 99 89 57 27 435 401 528

Vaccine preventable diseasesHaemophilus influenzae type b 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 1 2 5influenza 126 96 46 58 96 53 63 71 59 32 830 411 514 265 811 551 21 32 2566 1569 2051invasive pneumococcal disease 22 28 14 10 18 21 16 18 18 16 83 80 44 57 61 61 57 5 333 296 403Measles 2 2 4 0 0 0 0 1 0 0 17 1 5 2 3 6 0 0 31 12 14Mumps 1 1 0 1 2 0 0 0 0 0 10 1 1 0 6 5 0 0 20 8 10Pertussis 335 561 211 260 672 266 692 212 654 423 1699 1026 1172 573 1466 754 40 40 6941 4115 6968Rubella 0 0 0 0 0 0 0 0 0 0 6 9 5 5 0 6 0 1 11 21 22Tetanus 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1Varicella-zoster virus – chickenpox 34 20 13 12 26 13 18 10 21 17 151 102 96 91 97 81 2 2 458 348 542Varicella-zoster virus – shingles 28 27 27 23 21 12 35 26 49 39 191 144 186 153 178 94 4 5 719 523 694Varicella-zoster virus – unspecified 129 90 41 45 54 37 50 45 72 67 456 414 382 324 474 435 34 40 1692 1497 2051Vector borne diseasesbarmah Forest 7 2 15 2 101 3 41 3 12 10 10 2 7 2 7 4 0 0 200 28 53Chikungunya 0 1 0 0 1 0 0 0 1 0 2 5 6 2 3 4 0 0 13 12 17Dengue 8 1 0 3 4 1 1 2 2 8 27 11 10 10 31 20 0 0 83 56 112Flavivirus unspecified 0 0 0 0 1 1 0 0 0 0 9 3 0 0 1 2 0 0 11 6 12Malaria 5 3 1 1 4 2 2 3 2 1 28 20 11 13 18 15 3 2 74 60 67Ross River 103 15 489 19 482 127 70 67 19 50 40 30 23 23 53 22 0 0 1282 353 406

Zoonosesbrucellosis 0 0 0 0 0 0 0 0 0 0 1 2 0 0 0 0 0 0 1 2 2Leptospirosis 2 2 0 0 0 0 3 0 0 4 3 1 1 0 1 1 1 0 11 8 14Psittacosis 0 0 4 1 0 5 6 1 5 2 10 3 12 3 5 0 0 0 42 15 36Q fever 3 0 1 0 0 3 3 7 5 3 0 3 0 0 0 0 0 0 12 16 19

2007 ABS est. resident population 359,560 216,779 307,450 263,674 250,907 1,561,798 1,001,907 1,242,657 5,204,826

VictorianInfectiousDiseasesBulletinVolume14Issue4December2011 151

The Victorian Infectious Diseases Bulletin is published quarterly and provides summaries of infectious diseases surveillance data, local news, outbreak investigations, infection control procedures, clinical cases of general interest and brief reports on original clinical or laboratory based research. The bulletin is distributed free of charge to persons with an interest in the control and treatment of infectious diseases in Victoria.

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