Victorian Infectious Diseases Bulletin isbn 1 441 0575 Volume 15 issue 2 June 2012

Contents A cluster of mumps cases in Melbourne, Victoria linked to international transmission 42 Higher proportion of older influenza A(H1N1)pdm09 cases in Victoria, 2011 49 Hospitalisation with confirmed influenza in Victoria in the 2011 season 56 Anaphylaxis post trivalent influenza vaccine: a case report 59 Murray Valley virus encephalitis reappearance 2011: “Beat the bite” 60 Immunisation program report, Victoria, June 2012 65 Communicable disease surveillance in Victoria, January–March 2012 67 A cluster of mumps cases in Melbourne, Victoria linked to international transmission Aicha Brahmi1, Andrew Mahony1,3, Georgina Papadakis2, Lucinda Franklin1, Brett Sutton1

1. Communicable Disease Prevention and Control Unit, Department of Health, Melbourne, Victoria 2. Victorian Infectious Diseases Reference Laboratory, North Melbourne, Victoria 3. Infectious Diseases Department, Austin Health, Heidelberg, Victoria

The number of mumps cases has declined in most developed countries following the introduction of a two-dose mumps vaccine schedule. Outbreaks in highly vaccinated populations still occur, however, particularly among young adults such as students. Waning immunity and incomplete or absent vaccination have commonly been cited as the cause of outbreaks. The risk may be increased in tertiary institutions which host a high proportion of international students who may come from countries where mumps vaccine is not part of the World Health Organization’s Expanded Programme on Immunization. The use of vaccines based on different mumps strains may also have a relationship to risk of acquisition.

This is illustrated by the cluster of mumps that occurred in February 2011 which affected three French-born international students during their stay in Melbourne (Victoria, Australia). In addition, two family members of one of the students visiting them from France were also subsequently affected. Two cases were laboratory confirmed, and mumps virus genotype G was detected for both specimens. All cases were epidemiologically linked. Introduction Disease prevention transmission, mumps outbreaks still Prior to the introduction of a universal occur in highly immunised populations Mumps virus, pathogenesis, vaccination program, mumps was such as the USA, Canada, UK and clinical features 9–14 primarily a disease of childhood. Since France. Several of these outbreaks Mumps is an acute infectious viral 1978, various strains of live attenuated were characterised by high attack disease transmitted person-to-person mumps virus vaccines have been rates among children and young 15–17 via respiratory droplets or direct licensed in different countries. The adults who had received two 18,19 contact with the saliva of an infected effectiveness of mumps vaccine varies doses of mumps vaccine and individual. The incubation period depending on the virus strains and who were born in an era with little varies from 14 to 25 days. Parotid processing.2 exposure to wild mumps virus. swelling develops in 95 per cent of Waning immunity has been cited as Mumps vaccines are available as 20–23 individuals with clinical illness. The one cause of outbreaks. In an monovalent, bivalent (measles, rate of subclinical infection varies with outbreak of mumps in the USA in mumps) and trivalent measles, age but is approximately 30 per cent. 2006, 84 per cent of cases occurred mumps and rubella (MMR) vaccine. A prodromal illness typically consisting in the 18–24 years age group who Prevention of disease is achieved of headache, malaise, myalgia and had received two doses of mumps through administration of two doses low grade fever occurs one to two vaccine.In an outbreak in Canada in of the scheduled MMR vaccine. Eighty days before the onset of parotid 2009–2010, 28 per cent of cases had per cent of the 110 countries that swelling, which starts to subside after received two doses of vaccine (mean have included mumps vaccine in their four to seven days. Virus shedding age of 26 years). national immunisation program are into the saliva (the infectious period) using the two-dose schedule. In Australia, one dose of MMR begins a couple of days before the was introduced into the National onset of parotitis and ends seven to Post-vaccination disease Immunisation Program in 1989, eight days later. Complications such epidemiology followed in 1998 by the two-dose as deafness, meningitis and orchitis Since the introduction of the two-dose MMR vaccine schedule. As part of the (in post-pubertal males) may occur. MMR vaccine regime the incidence of introduction of the two-dose regimen Less frequently, pancreatitis, hepatitis, mumps has decreased significantly in a catch up campaign for 18–30 myocarditis, thyroiditis, oophoritis and most developed countries.3–8 Despite year-olds was implemented in 1999.1 mastitis (in post-pubertal females) are significant progress in reducing Despite this intervention, cases in this seen.1

42 Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 201242 age group continue to represent a Figure 1: Notified confirmed cases of mumps by year of notification, age Not OS-acquired Unknown consistently high proportion of overall group and proportion agedOverseas-acquir >18 edyears, Victoria, 2005–2011 cases each year24 (Figure 1). <18 18–39 40 and over % aged >18 years

50 120 % of cases aged 18 years or older Mumps is a notifiable disease in 100 Victoria. Medical practitioners and 40 laboratories are required to notify the 80 Communicable Disease Prevention 30 and Control Unit (CDPCU) at the 60 20 Department of Health when they 40 suspect that an individual has mumps. 10 For the purpose of confirming a Number of notified cases 20 case, mumps is clinically defined as 0 0 2005 2006 2007 2008 2009 2010 2011 ‘unilateral or bilateral swelling of the Year of notification parotid or other salivary glands lasting 25 two days or more’. A confirmed Figure 2: Notified confirmed cases of mumps by country of acquisition and Not OS-acquired Unknown case requires either laboratory year of notification, Victoria,Overseas-acquir 2005–2011ed definitive evidence or laboratory Overseas-acquired Not OS-acquired Unknown suggestive evidence with clinical 50 evidence or clinical evidence with epidemiological evidence. 40 Notified cases of mumps are followed 30 up by a public health officer by telephone, with a focus on the public 20 health aspects of the case, including Number of cases ascertaining where the disease may 10 have been acquired. 0 2005 2006 2007 2008 2009 2010 2011 Methods Year of notification Notified cases of mumps data were virus small hydrophobic (SH) gene Approximately one third of notified extracted from the Victorian Notifiable performed at the Victorian Infectious cases each year were known to have Infectious Diseases Surveillance Diseases Reference Laboratory been overseas-acquired infections database by date of notification for (VIDRL) using primers modified from (Figure 2). the period 2005–2011. A review of those previously described.26 The surveillance data was undertaken and From 2005 to 2010 one to two same primers were used to sequence case demographics were ascertained, notified cases per year were identified the PCR product. including likely place of acquisition. in students (Table 1). In 2011, of those cases where occupation was known, Cluster outbreak investigation and Results seven (35 per cent) were identified active case finding was conducted by A total of 143 cases of mumps were as students. These data were not oral questionnaire of cases regarding notified to the department from further categorised into education their contact and knowledge of the 2005–2011 (Figure 2) of which 59 per level (primary, secondary, tertiary) cohort of student travellers. cent were in males. Cases occurred and some students in employment Laboratory testing for mumps in persons aged from 19 months to may have been notified as employed, included serological analysis for 80 years (median age 28 years, modal rather than as students. mumps IgG and IgM and polymerase age group 20–24 years). Most cases Three outbreaks of mumps have chain reaction (PCR) of nose and were in individuals aged over 18 years been identified in Victoria since throat swabs. Further molecular of age with the 18–39 year-old age data collection began in 1991. In analysis included a single round group representing 78–100 per cent 2007, three cases were linked to reverse transcriptase PCR targeting of cases notified. a workplace cluster and in 2009 a 285bp fragment of the mumps

Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 43 Table 1: Occupational status of notified mumps cases, 2005–2011, Victoria Case 3: A 20 year-old female who was fully immunised for mumps (1991 2005 2006 2007 2008 2009 2010 2011 Occupational status (%) (%) (%) (%) (%) (%) (%) and 1998, validated by an electronic 11 9 16 3 25 6 9 copy of her immunisation card) also Employed (69%) (69%) (94%) (50%) (86%) (67%) (45%) arrived in Melbourne on 31 January Child at home 2 1 1 and travelled through Australia until Home duties 1 21 February when she had contact

Retired and/or pensioner 1 1 1 1 2 with case 1. Illness onset date was 25 2 2 2 2 1 7 February, and on 27 February she was Student (12.5%) (15%) (33%) (7%) (11%) (35%) admitted to hospital with symptoms Unemployed 1 1 1 1 of parotitis, headache, fever and vomiting. A nose and throat swab was Missing/ not stated 4 3 8 16 1 5 positive by PCR and serology results 20 16 17 14 45 10 25 on blood collected on 27 February were IgG positive and IgM negative. ten cases were identified as part with written documentation, and her The incubation period was estimated of a community outbreak in central serology collected on 12 February to have commenced around 7–9 Victoria. A third outbreak occurred in was negative for mumps IgG and IgM. February, with a potential range from 2011; three cases in a family cluster The incubation period was estimated 31 January to as late as 13 February. were linked to overseas travel from to have commenced from 25–27 The infectious period was from 18 the Philippines. January, with a potential range from February until 6 March. 18 January to as late as 31 January. Cluster investigation The infectious period was estimated to Genotype In February 2011 a cluster of five have been 5–21 February, depending To confirm that the Victorian cases cases (including three international on persistence of parotid swelling. had a common source, further students and both parents of one Case 2: A 20 year-old male who had molecular analysis of throat swabs of the students) was identified in received one dose of MMR in 1991. from case 1 and case 3 was metropolitan Melbourne. All three The immunisation date was confirmed undertaken. Comparison of PCR students were born in France and by email after the case returned to sequences showed that they were were part of an international exchange France and verified the immunisation identical, and they were confirmed as program organised by their school. record. This case was identified after genotype G strain related sequences One student was fully immunised for case 3 (his partner). He arrived in when submitted to GenBank. mumps; one had received one dose Melbourne on 31 January 2011 and of MMR; and the immunisation status Active case finding travelled in Australia from 1 to 21 for the third was unknown. Neither of February. He had been in contact Two further cases (cases 4 and 5) the parents were immunised against with the index case (case 1) on 21 were identified during the interview mumps, although one reported having February (at the end of her infectious with case 2 (their son) who advised mumps as a child. period) and on 23 February developed that his parents visited Melbourne The characteristics of the cases were symptoms of headache, fever, sore while he was infectious, (16 February as follows: throat and later, epididymo-orchitis. to 4 March) and had subsequently been diagnosed with serologically Case 1 (index case): A 23 year-old Unaware of his contact with mumps, confirmed mumps in France. The female student arrived in Melbourne the doctor ordered a mid-stream urine parents were aged 52 years and had from France on 12 February. On the culture and a testicular ultrasound. visited Australia between 30 January same day, she developed bilateral No further specimens were taken and 19 February. Neither had been parotitis. She was admitted to hospital from this case. His incubation period immunised for mumps. The mother and mumps was confirmed by PCR was estimated to have commenced developed unilateral salivary gland from a throat swab. Despite the case’s around 5–7 February, with a potential inflammation on 1 March and four recollection that she had previously range from 29 January to as late as days later developed complications of had at least one dose of MMR 11 February. The infectious period permanent unilateral hearing loss. The vaccine, this could not be confirmed was from 16 February until 4 March.

44 Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 father developed bilateral parotitis on of health insurance cover are less likely A further factor which may impact on 5 March with no other complications. to seek medical care. overall herd immunity in Victoria is the common age groups of international Cases 1–3 were part of a group of Herd immunity students. Even in countries with high students from the same school in Major outbreaks have been reported herd immunity, the age group of France. Case 2 and case 3 had social in several other countries among cases needs to be taken into account interaction with students for four and population groups of young adults or when assessing risk exposures. two days respectively during their in student environments.27,28 In order A survey conducted in schools in infectious period while in Melbourne. to prevent community transmission, France from 2001 to 2004 indicated According to case 3, no other an estimated herd immunity that the immunisation rate was students from the group in Australia threshold of 88–97 per cent has been 93–94 per cent after the first dose of presented with symptoms of mumps. recommended.29,30 mumps vaccine but much lower for On enquiry, an outbreak of mumps In Victoria in March 2012, 91 per cent the second dose (24–61 per cent). was identified at the students’ school of five-year-olds were fully vaccinated This lower rate concerned mainly in France. with MMR31 which falls within the children born in 1990 and 1991 who herd immunity threshold. However, were too old (such as our cases) to Discussion this rate may be lower in adults and have been included in the two dose MMR schedule.35 In Australia this This cluster of mumps cases may further reduce in the coming age group seems equally vulnerable. highlights several issues relating to years with a demographic shift in the Figure 1 illustrates that the 18–39 exposure and to mumps vaccine population due to ethnicity, age and year old group is still vulnerable, strain efficacy. the associated immunisation status of that demographic. despite the MMR catch-up campaign The average incubation period for implemented in 1999.36 mumps is 14–25 days so it was highly Australian Bureau of Statistics (ABS) probable that the index case was data from 2005 to 2009 show the Mumps vaccine strain exposed in France prior to coming number of international students Genotype G was detected on the to Australia. Although cases 2 and 3 increased by 205 per cent in specimens of case 1 and case 3. were part of the same French student Victoria.32 Students originate from Genotype G has been the most group in Australia, it was unlikely that some 200 different countries although commonly reported mumps strain they were directly infected by case 1 those from India and China account in outbreaks across Western as their only contact was on the last for more than half (54.5 per cent) of Europe over the past 10 years, with possible day of her infectious period. the international student population descriptions from the Netherlands, However, it was possible that the in Victoria (29.7 and 24.8 per cent Germany, Scotland, England, Wales, three cases had shared exposure with respectively).33 Victoria has the highest and Luxembourg.37–41 As mumps is a common contact within the student number of international students of all not a notifiable condition in France group in France (for case 1) and in the Australian States and Territories. there are no data from passive Australia (for cases 2 and 3). Students originate from countries surveillance or data on molecular where immunisation rates for mumps epidemiology. The results from It is possible that some cases may be low because although the cases involved in the Victorian may have been asymptomatic; they subscribe to World Health outbreak indicate that at least one of misdiagnosed (as for case 2); did Organization’s (WHO) Expanded the circulating genotypes in France is not consult a practitioner; or were Programme on Immunization (EPI), genotype G. not notified to the Department of only measles is included in the EPI Health. We can, however, expect in Surveillance of circulating genotypes schedule, not mumps and—for more these environments that the risk of of mumps has implications for than 60 countries—rubella.34 With the transmission and therefore outbreaks understanding the effectiveness of high numbers of international students may be increased due to frequent the current mumps vaccine and originating from these countries intermingling and close contact in such the strains used. The Urabe strain, we can expect the herd immunity student groups. Case ascertainment which has not been used in France for mumps to decline and thereby in this group may also be reduced since 1994,42 is likely to have been increasing the risk of outbreaks. because young adults with low levels the viral strain administered to the

Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 45 immunised case. Mumps infection in cases may have occurred. Indeed, as who provided valuable additional cases 2 and 3 indicated that vaccine- highlighted in this paper, one case had information via email after they had left induced immunity was insufficient been misdiagnosed, which suggests Australia. In addition, we are indebted for protection. The Urabe vaccine that others may have also been to Karin Leder, Associate Professor strain has a reported effectiveness missed. This may be due to atypical Head Infectious Disease Epidemiology of 54–87 per cent depending on presentations as well as challenges Unit at Monash University who shared the manufacturer and the epidemic for general practitioners in a period her knowledge on immunisation of conditions.43–46 In Australia the Jeryl of changing disease demographics international students in Victoria and Lynn vaccine strain is the genotype and more limited clinical exposure to our counterparts in France: Dr. used. Although this vaccine strain compared to the pre-vaccination era. Daniel Levy-Bruhl from the Institut de was found to induce immunity in 95 Veille Sanitaire and Prof. Dr. Francois Secondly, the university student per cent of vaccine recipients after Freymuth from Centre National de environment constitutes a potential one dose, other studies suggest Reference de la Rougeole et des setting for a mumps outbreak lower seroconversion.Two doses of Paromyxoviridae who provided because of a non-immune cohort Jeryl Lynn mumps strain have shown information on mumps surveillance in among students; their high level a seroconversion rate of up to 86 France. of close social interaction; and per cent in Finland but measured their tendency not to seek formal effectiveness can be as low as 62 health consultations when unwell. References per cent in epidemic conditions.47 The distinctiveness of the tertiary 1. National Health & Medical Of potential relevance to Victoria, environment means that it is crucial Research Council (NHMRC). The the S79 strain mumps virus used in to provide feedback to institutions Australian Immunisation Handbook China48 and the Leningrad-Zagreb on notified mumps cases and to 9th Edition 2008. Commonwealth mumps virus strain used in India49 assist them in the dissemination of of Australia, Canberra provide vaccine effectiveness reported public health messages, including the 2. World Health Organization. to be similar to the Urabe strain.50 importance of seeking medical care if Mumps virus vaccines. Weekly symptoms appear. This will ultimately Conclusion Epidemiological Record. assist doctors in case identification Available at: http://www.who.int/ Prior to this cluster, only three and prompt notification, thereby immunization/wer8207mumps_ mumps outbreaks had been triggering early contact tracing. Feb07_position_paper.pdf reported in Victoria since 1991, the Finally, the findings show that it Accessed 15 November 2011 largest being ten cases with three is crucial to collect data on the 3. Deeks SL, Lim GH, Simpson MA, generations of transmission. The immunisation status and demographic Gagne L, et.al. An assessment of lack of major outbreaks can be profile of notified cases. Detailed mumps vaccine effectiveness by attributed to the state’s high rates of surveillance data combined with dose during outbreak in Canada. immunisation. However with changing collection of appropriate specimens CMAJ 2011; 183 (9):1014–1020 demographics, the investigation of for laboratory confirmation and the 4. Antona D, Fonteneau L, Levy-Bruhl this February 2011 cluster shows that identification of genotypes during D, et.al. La couverture vaccinale the potential for outbreaks of public outbreaks would allow for linking des enfants et des adolescents health significance remains. The cases and tracking importations. In en France: résultats des enquêtes outbreak also highlights several key addition, genotyping can help in the menées en milieu scolaire 2001– public health issues. evaluation of the immunogenicity of 2004. IVS Bulletin Epidémiologique Firstly it emphasises the importance various mumps vaccine strains. This Hebdomadaire 2007; 6:45–49 of early identification of cases and is of particular relevance to Victoria, 5. Watson-Creed G, Saunders also of establishing epidemiological which has a high and increasing A, Scott J, Lowe L, Pettipas J, links. In this cluster, case identification number of international students. Hatchette TF. Two successive was only possible because of the outbreaks of mumps in Nova close relationship between the cases. Acknowledgements Scotia among vaccinated However these cases may represent adolescents and young adults. We gratefully acknowledge the only a proportion of actual cases, with CMAJ 2006; 175(5):483–488 contribution of the affected individuals the possibility that other non-notified

46 Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 6. Public Health Agency in Canada. mumps_update_093006 induced immunity. J Infect Dis Guidelines for the prevention and Accessed 15 November 2011 1994;169:77–82 control of mumps outbreaks in 15. Cortese MM, Jordan HT, Curns 24. babbington G. Mumps risk up in Canada. Can Commun Dis Rep AT, et.al. Mumps vaccine young adults. Australian Doctor. 2010; 36S1:46 performance among university 2007 Feb 16:6 7. Flahault A, Garnerin P, Chauvin students during a mumps 25. Communicable Diseases Network P, et.al. Epidémiologie des outbreak. CID. 2008:46(8):1172– of Australia. National Notifiable maladies transmissibles en 1180 Diseases Case Definitions. CDNA. médicine libéral – Bilan du réseau 16. Dayan GH, Dayan M, Quinlisk 2004. Available at: http://www. “Sentinelles” en 1995. IVS Bulletin MP, et.al. Recent resurgence of health.gov.au/internet/main/ Epidémiologique Hebdomadaire mumps in the United States. N publishing.nsf/Content/cdna- 1995; 33:143–145 Engl J Med 2008; 358(15):1580–9 casedefinitions.htmAccessed 15 8. Guy RJ, Andrews RM, Kelly HA, 17. Carr MJ , Moss E, Waters November 2011 et.al. Mumps and rubella: a year A, Dean et.al. Molecular 26. Palacios G, Jabado O, Cisterna of enhanced surveillance and epidemiological evaluation of D, et.al. Molecular identification laboratory testing. Epidemiol Infect the recent resurgence in mumps of mumps virus genotypes from 2004; 132 (3):391–398 virus infections in Ireland. Journal clinical samples: standardized 9. Centres of Disease Control and of Clinical Microbiology 2010; method of analysis. J Clin Prevention. Mumps epidemic: 48(9):3288–3294 Microbiol 2005; 43:1869–1878 United Kingdom, 2004–2005. 18. Centers for Disease Control and 27. Health Protection Surveillance MMWR 2006; 55 (7):173–175 Prevention. Mumps outbreak at a Centre, Ireland. Mumps Outbreak 10. barskey AE, Glasser JW, LeBaron summer camp-New York, 2005. Escalates. Epi-Insight. 2009. CW. Mumps resurgences in MMWR 2006; 55(07):175–177 10(4):1–4 Available at: http:// the United States: A historical 19. Cortese MM, Jordan HT, Curns www.hpsc.ie/hpsc/EPI-Insight/ perspective on unexpected AT, et.al. Mumps vaccine Volume102009/File.3543.en.pdf elements. Vaccine 2009; 27:6186– performance among university Accessed 15 November 2011 6195 students during a mumps 28. barons S, Guibert M, Soltysiak 11. Centers for Disease Control and outbreak. Clin Infect Dis, C, Lorente E, Artières R, Labro. Prevention. Mumps outbreak New 2008:46(8):1172–80 Une épidémie d’oreillons a Millau York and New Jersey, June 2009– 20. Public Health Agency of Canada (Aveyron): Estimation de l’efficacité January 2010. MMWR. 2010. Statement on Mumps. Can vaccinale de la souche Urabe. 59(5):125–9 Commun Dis Report 2007; 33S IVS Bulletin Epidémiologique 12. schaffzin JK, Pollock L, Schulte 8–1 Hebdomadaire 1997, 39: 177– C, et.al. Effectiveness of previous 21. Vandermeulen C, Roelants M, 178 mumps vaccination during Vermoere M et.al. Outbreak of 29. Anderson RM, May RM. a summer camp outbreak. mumps in a vaccinated child Vaccination and herd immunity to Pediatrics 2007; 120:e862–868 population: a question of vaccine infectious diseases. Nature 1985; 13. Minnesota Department of Health. failure? Vaccine 2004; 22:2713–6 318:323–329 Mumps 2007. Available at: http:// 22. Park DW, Nam MH, Kim JY, 30. barskey AE, Glasser JW, LeBaron www.health.state.mn.us/divs/ et.al. Mumps outbreak in a highly CW. Mumps resurgences in idepc/newsletters/dcn/sum07/ vaccinated school population: the United States: A historical mumps.html Accessed 15 assessment of secondary perspective on unexpected November 2011 vaccine failure using IgG elements. Vaccine 2009; 14. iowa Department of Public avidity measurements. Vaccine 27(44):6186–6195 Health, Centre for Acute Disease 2007;25(24):4665–70 31. national Centre for Immunisation. Epidemiology. IOWA Mumps 23. briss P, Fehrs L, Parker R, et.al. Childhood immunisation Coverage update through Saturday, Sustained transmission of mumps estimates Available at: http:// September 30, 2006. Available in a highly vaccinated population: www.ncirs.edu.au/immunisation/ at: http//www.idph.state.ia.us/ assessment of primary vaccine coverage/estimates/index.php adper/common/pdf/mumps/ failure and waning vaccine- Accessed 15 August 2012

Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 47 32. Australian Bureau of Statistics. 38. Otto W, Mankertz A, Santibanez 46. schlegel M, Osterwalder JJ, International students contributing S, et.al. Ongoing outbreak of Galeazzi RL, Vernazza PL. to Net Overseas Migration. mumps affecting adolescents Comparative efficacy of three Available at: http://www.abs.gov. and young adults in Bavaria, mumps vaccines during disease au/ausstats/[email protected]/Latestprod Germany, August to October outbreak in Eastern Switzerland: ucts/89DD41C56ED5637FCA25 2010. Eurosurveillance 2010; cohort study. BMJ 1999; 78B0001198D8?opendocument 15(60):19748 319(7206):352 Accessed 15 November 2011 39. Walker J, Huc S, Sinka K, 47. Chamot E, Toscani L, Egger 33. Australian Government Tissington A, Oates K. Ongoing P, Germann D, Bourquin C. Department of Education, outbreak of mumps infection in Estimation de l’efficacité de trois Employment and Workplace Oban, Scotland, November 2010 souches vaccinales ourliennes au Relations. International student to January 2011. Eurosurveillance cours d’une épidémie d’oreillon enrolment data. 2009. Available 2011; 16(8):19803 dans le canton de Genève at: http://www.aei.gov.au/ 40. Cui A, Myers R, Xu W, Jin L. (Suisse). Rev Epidemiol Sante research/International- Analysis of the genetic variability Publique 1998; 46(2):100–107 Student-Data/Documents/ of the mumps SH gene in viruses 48. World Health Organization. INTERNATIONAL%20 circulating in the UK between Mumps virus vaccines. Weekly STUDENT%20DATA/2009/2009_ 1996 and 2005. Infect Genet Evol Epidemiological Record. TableD_pdf.pdf Accessed 1 2009;9:71–80 Available at: http://www.who.int/ November 2011 41. Mossong J, Bonert C, immunization/wer8207mumps_ 34. WHO Recommendation for Weicherding P, et.al. Mumps Feb07_position_paper.pdf Routine Immunization: A user’s outbreak among the military Accessed 15 November 2011 guide to the summary tables. in Luxembourg in 2008: 49. Raut SK, Kulkarni PS, Phadke MA, Available at: http://www.who.int/ epidemiology and evaluation of et.al. Persistence of antibodies immunization/policy/WHO_EPI_ control measures. Eurosurveillance induced by Measles-Mumps- Sum_tables_Def_200713.pdf 2009; 14(7):19121 Rubella Vaccine in children in Accessed 15 November 2011 42. Direction générale de la santé. India. Clin Vaccine Immunol 2007; 35. Antona D, Fonteneau L, Levy- Guide des vaccinations. 14(10):1370–1371 Bruhl D, et.al. La couverture La vaccination contre les 50. Fu C, Liang J, Wang M. Matched vaccinale des enfants et des oreillons Comité technique des case-control study of effectiveness adolescents en France: résultats vaccinations ed inpes 2008 of live, attenuated S79 mumps des enquêtes menées en milieu 43. Toscani L, Batou M, Bouvier P, virus vaccine against clinical scolaire 2001–2004, IVS Bulletin Schlaepfer A. Comparaison de mumps. Clin Vaccine Immunol Epidémiologique Hebdomadaire l’efficacité de différentes souches 2008; 15(9):1425–1428 2007; 6:45–49 de vaccin ourlien: une enquête en 36. Communicable Disease Prevention milieu scolaire. Soz Praventivmed. and Control Unit. Surveillance 1996; 41:341–347 of notifiable infectious diseases. 44. Peltola H, Heinonen OP, Valle M, Available at: http://ideas.health. et.al. The elimination of indigenous vic.gov.au/surveillance.asp Measles, Mumps, and Rubella Accessed 1 November 2011 from Finland by a 12-Year, Two- 37. Whelan J, van Binnendijk R, dose vaccination program. N Engl Greenland K, et.al. Ongoing J Med 1994; 331:1397–1402 mumps outbreak in a student 45. Ong G, Goh KT, Ma S, Chew SK. population with high vaccination Comparative efficacy of Rubini, coverage, Netherlands, 2010. Jeryl-Lynn and Urabe mumps Eurosurveillance 2010;15:1 9554 vaccine in an Asian population. J Infect. 2005; 51(4):294–8

48 Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 Higher proportion of older influenza A(H1N1)pdm09 cases in Victoria, 2011 Kristina A Grant1, Lucinda J Franklin4, Aeron C Hurt2, Katherine T Garcia1, James E Fielding1,3

1 Victorian Infectious Diseases Reference Laboratory, North Melbourne, Victoria 2 WHO Collaborating Centre for Reference and Research on Influenza, North Melbourne, Victoria 3 The Australian National University, Canberra, Australian Capital Territory 4 Communicable Disease Prevention and Control Unit, Victorian Government Department of Health, Melbourne, Victoria

The influenza surveillance system in Victoria is comprised of several components, including a general practitioner sentinel surveillance system, surveillance for influenza-like illness (ILI) in consultations made by the Melbourne Medical Deputising Service, laboratory confirmed influenza notified to the Victorian Department of Health and strain typing performed by the World Health Organization Collaborating Centre for Reference and Research on Influenza.

As measured by ILI from both the MMDS and GPSS, the 2011 influenza season in Victoria was mild compared to previous seasons and was not dominated by any type or subtype of influenza. There were 13 laboratory confirmed influenza outbreaks in 2011, nearly all of which were in aged care facilities.

GPs continue to swab more patients, a trend started in 2009, with a significantly lower percent of these testing positive for influenza than previous years. The proportion of ILI and swabbed patients who were vaccinated was also significantly lower in 2011 than previously. Strain analysis undertaken by the WHO Collaborating Centre indicated a good antigenic match between the 2011 vaccine and circulating strains.

The Victorian influenza surveillance system continues to provide a reliable, consistent system for monitoring the epidemiology of ILI and laboratory confirmed influenza in Victoria.

Background confirmed influenza in Victoria, a and new or emerging respiratory prescribed Group B notifiable disease diseases; and A sentinel general practice (GP) under the Victorian Public Health and • estimate influenza vaccine program for the surveillance of Wellbeing Act 2008 and Public Health effectiveness each year. influenza-like illness (ILI) has been and Wellbeing Regulations 2009 for In this paper we summarise coordinated by the Victorian Infectious which notification is required within findings from the Victorian influenza Diseases Reference Laboratory five days of diagnosis. (VIDRL) in partnership with the surveillance system in 2011. Victorian Government Department of The objectives of the influenza Health (DH) since 1993. Laboratory surveillance system are to: Methods testing of a sample of ILI cases from • monitor the epidemiology of General practice sentinel the surveillance program commenced laboratory confirmed influenza in surveillance in 1998.1 The program operates Victoria; In 2011, 94 GPs (65 from 23 between May and October each • identify the onset, duration and metropolitan practices and 29 from year and is approved for continuing relative severity of annual influenza 13 rural practices) participated in the professional development points seasons in Victoria; by the Royal Australian College VIDRL GP Sentinel Surveillance (GPSS) • provide samples for the of General Practitioners and the program (Figures 1a and 1b). The characterisation of circulating Australian College of Rural and GPSS program for 2011 operated from influenza strains in the community Remote Medicine. VIDRL also 2 May to 30 October (weeks 18–43) to assist in the evaluation of the monitors diagnoses of ILI made by the inclusive in which participating GPs current season; and formulation of locum medical practitioners through reported total number of consultations the following season’s vaccine; the Melbourne Medical Deputising per week and age, sex and vaccination • provide potential for early Service (MMDS). The DH coordinates status of any patients presenting recognition of new influenza viruses the surveillance of all laboratory with influenza like illness (ILI). GPs

Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 49 Figure 1a: Distribution of sentinel surveillance practices in metropolitan and the presence of a co-morbidity Victoria, 2011 for which influenza vaccination is recommended.4

RNA was extracted from clinical specimens and in-house validated real-time multiplex PCR assays were used to detect type A influenza viruses (matrix gene), type B influenza viruses (nucleoprotein gene) and type C influenza viruses (matrix gene). Influenza A virus-positive samples were sub-typed using individual real-time PCR assays incorporating primers and probes specific for the haemagglutinin gene of A(H1N1)pdm09,5 pre- pandemic A(H1N1) and A(H3N2) strains.

Melbourne medical deputising service Figure 1b: Distribution of sentinel surveillance practices in rural Victoria, 2011 The MMDS is the largest medical locum service in Australia and has contributed to the Victorian influenza surveillance system since 2003. The MMDS provides a 24-hour medical service to patients in their own home or aged care facility in the Melbourne metropolitan area and Geelong. Weekly rates of influenza-related diagnoses by MMDS clinicians per 1,000 consultations were calculated from records returned from the MMDS clinical database using the search terms ‘influenza’ and ‘flu’. To avoid inclusion of those immunised prophylactically, records that contained the terms ‘Fluvax’, ‘at risk’ and ‘immunisation’ were excluded from the rate calculation.

Notified laboratory confirmed submitted the data weekly by fax GPs were requested to collect either influenza or online submission (http://www. a nose or throat swab from patients Records of all laboratory confirmed victorianflusurveillance.com.au). A presenting within four days of the influenza cases with a 2011 case of ILI was defined as fever, cough onset of symptoms, chosen at the notification date were extracted from and fatigue/malaise.2 ILI rates were discretion of the GP. Data collected the department’s Notifiable Infectious calculated as the number of ILI patients on swabbed patients included: Diseases Surveillance database on per 1,000 consultations and compared age, sex, symptoms (fever; cough; 24 February 2012. For the purposes to previously established activity fatigue; myalgia; other), vaccination of analysis, ‘routinely notified cases’ thresholds for Victorian influenza status (for 2011 and the previous were those identified by clinical seasons.3 2010 vaccine), date of vaccination/s presentation, and excluded those

50 Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 identified from outbreak investigations 28 years (range one to 88 years). GPs swabbed a total of 670 (71 per and the GPSS. Fourteen per cent of ILI cases were cent) ILI patients in 2011, of which reported as vaccinated in 2011. 185 (28 per cent) tested positive to Data from the three surveillance influenza. Of these, 102 (55 per cent) programs were analysed descriptively ILI rates during the 2011 season were type A, 82 (44 per cent) were using Microsoft Excel software. generally fell within the range of type B and one was type C. Of the The chi squared test was used to normal seasonal activity, and were low 102 type A influenza viruses detected, compare proportions in Stata version compared to previous years (Figure 26 (25 per cent) were A(H1N1)pdm09, 10.0 statistical software, with p<0.05 2). The overall (metropolitan and rural) 62 (61 per cent) were A(H3N2) and considered statistically significant. ILI rate rose above baseline levels the remaining 14 (14 per cent) were of 2.5 ILI per 1,000 consultations not further sub-typed (Table 1). Strain typing in week 19 (week commencing 9 A selection of specimens and isolates May), and declined to baseline levels Among the influenza positive patients, collected in Victoria during 2011 were by week 41 (week commencing 10 164 (86 per cent) were reported as referred to the WHO Collaborating October). ILI activity peaked at 10.5 not vaccinated (Table 1). Twenty-five Centre for Reference and Research on ILI per 1,000 consultations in week patients (four influenza positive and 21 Influenza (WHO Collaborating Centre). 32 (week commencing 8 August) in influenza negative) had an unknown Tissue culture was attempted for all metropolitan practices and at 6.2 ILI vaccination status. Overall, 14 per of the specimens/isolates received. per 1,000 consultations in week 35 cent (92/645) of swabbed patients Viruses that were successfully cultured (week commencing 29 August) in rural were vaccinated but significantly were analysed by a haemagglutination practices (Figure 3). more influenza negative patients were inhibition assay to determine antigenic similarity to the current vaccine strains Figure 2: General Practice Sentinel Surveillance and Melbourne Medical and a neuraminidase inhibition assay to Deputising Service influenza-like illness consultation rates, Victoria, 2003– determine susceptibility to the antiviral 2011 drugs oseltamivir and zanamivir. The MMDS ILI Rate GPSS ILI Rate 140 haemagglutinin and neuraminidase genes of a selection of specimens and 120 isolates were genetically analysed by 100 EPIDEMIC Sanger sequencing or pyrosequencing. 80 Results 60 40 General practice sentinel ILI/1000 consultations HIGHER THAN EXPECTED SEASONAL ACTIVITY 20 surveillance NORMAL SEASONAL ACTIVITY 0 For the 26 week surveillance period, 1997 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 an average of 94 per cent (88/94) Figure 3: General Practice Sentinel Surveillance and Melbourne Medical of GPs submitted tally sheets Deputising Service influenza-like illness rates and routinely notified laboratory to VIDRL. GPs reported having confirmed influenza cases by week, Victoria, 2011 conducted 194,469 consultations Influenza A notified cases Metro ILI rate (135,593 metropolitan and 58,876 Rural ILI rate Influenza B notified cases MMDS ILI rate rural) and identified 945 ILI cases 300 18

(769 metropolitan and 176 rural), ILI rate per 1,000 consulations 250 15 corresponding to metropolitan and rural rates across the surveillance 200 12 period of 5.7 and 3.0 ILI cases per 150 9 1,000 consultations respectively. 100 6 Among the 945 ILI cases reported by Number of notified cases GPs, 50 per cent were in females, 47 50 3 per cent in males and the remainder 0 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 unknown. The median age was Week number

Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 51 Table 1: Number (%) of General Practice Sentinel Surveillance swabs and routinely notified cases by influenza type/ subtype, vaccination status, co-morbidity and median age, Victoria, 2011

GPSS Routinely notified cases Total swabs Vaccinated (%) Co-morbidity (%) Median age Total (%) Median age Influenza A A(H1N1)pdm09 26 0 (0) 1 (4) 32 213 33 A(H3N2) 62 6 (10) 7 (11) 27 15 44 Untyped 14 3 (21) 0 (0) 2,080 Total influenza A 102 9 (9) 8 8) Influenza B 82 7 (9) 7 (9) 14 787 20 Influenza A and B co-infection 34 Influenza C 1 1 (100) 0 (0) NA 2 Negative 485 75 (15) 56 (12) 30 Grand total 670 92 (14) 71 (11) 29 3,007

Figure 4a: Routinely notified cases of laboratory confirmed influenza by age The median age of influenza A(H1N1) group, Victoria, 2011 pdm09 cases detected from the

Influenza A (H1N1) pmd09 Influenza A (H3N2) Influenza A (Untyped) Influenza B Influenza C GPSS was 32 years (range: 1–55 1250 years), compared to 27 years for A(H3N2) (range: 1–72 years) and 14 1000 years for type B influenza (range: 1–74 years). The one influenza C case was 750 aged 51 years. Forty-three percent of GPSS influenza positive patients outine notifications 500 were in the 20–49 year age group (Figure 4). Fifty-six percent of influenza 250 type B cases were younger than 20 Number of r

0 years while 67 per cent of A(H1N1) 0–4 5–19 20–49 50–64 65+ pdm09 cases were in the 20–49 years Age group age group. There was no statistically Figure 4b: GPSS cases of laboratory confirmed influenza by age group, significant difference in the proportion Victoria, 2011 of ILI patients that were swabbed across age groups (p=0.23) (Figure Influenza A (H1N1) pmd09 Influenza A (H3N2) Influenza A (Untyped) Influenza B Influenza C 100 5). The proportion of patients that were vaccinated increased with age, 80 particularly those aged 65 years and older, while the proportion positive for 60 influenza was highest in the 20–49 years age group. 40 Notified laboratory confirmed 20 influenza

Number of GPSS influenza cases There were 3,007 routinely notified 0 0–4 5–19 20–49 50–64 65+ cases of influenza made to the Age group department in 2011. Of these, 2,184 (73 per cent) were type A, 787 (26 vaccinated (15 per cent) than influenza influenza vaccination between those per cent) were type B, 34 (1 per cent) positive patients (nine per cent; that were positive for influenza (eight were type A and B co-infections, and p=0.01). There was no significant per cent) and those that were negative two were type C influenza (Table 1). difference in the proportion of patients (12 per cent; p=0.10). The number of cases, particularly with a co-morbidity recommended for influenza A, increased from week

52 Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 Figure 5: General Practice Sentinel Surveillance ILI and swabs by age group, Strain typing vaccination status and percent positive, Victoria, 2011 Of the 771 specimens and four ILI – not swabbed % ILI vaccinated % swabs positive for influenza isolates received at the WHO ILI – swabbed % swabbed vaccinated 500 100 Collaborating Centre, 388 (50 per cent) yielded an influenza positive isolate 400 80 following cell culture. Of these, 243

Per (63 per cent) were type A and 145 (37 300 60 centage per cent) were type B. Of the influenza

200 40 A viruses, 89 were A(H1N1)pdm09 (A/California/7/09) strains and 154 Number of ILI cases 100 20 were A(H3N2) viruses. Eighty-eight (98 per cent) of the A(H1N1) viruses 0 0 0–4 5–19 20–49 50–64 65+ were antigenically similar to the 2011 Age group vaccine strain A/California/7/2009, while 135 (88 per cent) of the A(H3N2) 28 (week commencing 18 July) in a Outbreak investigations strain viruses were similar to the 2011 pattern that was generally consistent In 2011, a total of 25 respiratory vaccine strain A/Perth/16/2009. with GPSS and MMDS ILI rates outbreaks were notified to the All influenza type B strains except (Figure 3). Notified cases of both department, of which 13 were one were of the B/Victoria/2/87 type A and type B influenza peaked confirmed as caused by influenza. Of lineage, with 130 (90 per cent) being in week 39 (week commencing 19 these, one was in a prison setting, similar to the 2011 vaccine strain B/ September), two weeks and four and 12 (one type B and 11 type Brisbane/60/2008. One type B virus weeks after the peaks in the MMDS A, of which two were subtyped was from the B/Yamagata/16/88 and the GPSS ILI rates respectively. as A(H3N2) and one as A(H1N1) lineage. All of the Victorian influenza Of the 2,184 type A cases, 213 (10 pdm09) were in aged care facilities. positive isolates were tested for per cent) were A(H1N1)pdm09, 15 The first outbreak occurred in week susceptibility to the neuraminidase (<1 per cent) were A(H3N2), and 3 (week commencing 17 January). inhibitors oseltamivir and zanamivir. 2,080 (95 per cent) were untyped. The remainder of the outbreaks were One of the 89 A(H1N1)pdm09 viruses The median age of routinely notified notified between early August and tested (one per cent) was found influenza A(H1N1)pdm09 cases was early November, with five outbreaks to be oseltamivir resistant due to a 33 years (range: 0–88 years), 44 notified in September. H275Y mutation in the neuraminidase years for A(H3N2) (range: 3–90 years) gene. It is unknown if this patient was Melbourne medical deputising and 20 years for type B cases (range: being treated with oseltamivir prior service 0–90 years) (Table 1). Fifty-five per to specimen collection. None of the A total of 757 patients had a recorded cent of notified influenza A(H1N1) A(H3N2) or B viruses were resistant to “flu” or “influenza” diagnosis by the pdm09 cases were in the 20–49 oseltamivir or zanamivir. MMDS during the 2011 surveillance years age group (55 per cent) (Figure season, corresponding to 0.6 per cent 4). Females comprised 53 per cent of Discussion of all consultations. ILI activity rose the routinely notified cases in 2011. The 2011 influenza season in sharply in week 31 (week commencing Victoria, as measured by ILI from Seven cases were reported to have 18 July) and peaked in week 36 (week both the MMDS and GPSS, was mild died as a result of their influenza commencing 5 September) with compared to previous seasons. The infection in 2011. These cases were 13.8 ILI per 1,000 consultations, two season overall was not dominated aged 24 to 85 years with a median of weeks after the peak of the GPSS ILI by any type or subtype of influenza, 63 years. With the exception of one rate (Figure 3). Like the GPSS, although type A cases tended to be case, all were due to type A infection, the peak ILI rate from the MMDS was more common earlier in the season of which three were further subtyped: low compared to previous seasons and type B in the latter part. There two as A(H1N1)pdm09 and one as (Figure 2). The peak occurred in week were no detections of pre-pandemic A(H3N2). One death was due to 36 (week commencing 5 September). type B. H1N1 influenza strains, confirming

Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 53 that influenza A(H1N1)pdm09 is now pdm09 has risen from 20 years in in 2011 GPSS ILI rates peaked two the seasonal influenza A(H1N1) strain. 2009, 26 (GPSS) and 21 (routine weeks prior to that of the MMDS. The There were 13 laboratory confirmed notifications) in 2010 to 32 (GPSS) reasons for this are unclear, but may influenza outbreaks in 2011, nearly and 33 (routine notifications) in be an artefact of a season with low all of which were in aged care 2011. This increase in age was also or mild ILI activity in which a peak is facilities, and although this represents observed in the United Kingdom less well defined and exacerbated by a considerable increase on the six Severe Influenza Surveillance System the non-specific ILI case definition. reported in 20106 it may be indicative where the median age of A(H1N1) Routine notifications, given the time of the re-emergence of influenza pdm09 increased from 20 years in taken for testing and the notification A(H3N2) which is generally associated 2009 to 35 years in 2010.12 Such to be made to the department peaked with older age groups.7 a shift in the median age of cases the latest. The age distribution of is not unexpected following the laboratory confirmed influenza was In 2011 the proportion of GPSS ILI emergence of a pandemic influenza consistent with previous years, with cases that were swabbed was 71 strain in which higher attack rates a majority of those from the GPSS per cent, similar to 2010 (70 per in younger age groups that have no comprised of working age adults, cent)6 and 2009 (68 per cent) but prior immunity are observed during while there was a higher proportion significantly higher than from 2003 to the initial outbreak, followed by a of elderly among the cases routinely 2008 in which 35–50 per cent of ILI shift to older age groups as immunity notified to the department, likely to be patients were swabbed (p<0.001).8 increases in the young.13,14 a reflection of hospitalised influenza This suggests higher awareness and/ patients. or concern regarding influenza and an The trivalent influenza vaccine for the increase in the ease of testing since 2011 southern hemisphere season The Victorian influenza surveillance the 2009 pandemic. However, only contained California/7/2009 (H1N1)- system continues to provide a reliable, 28 per cent of tests were positive for like virus, A/Perth/16/2009 (H3N2)- consistent system for monitoring the influenza, which was low compared like virus and B/Brisbane/60/2008-like epidemiology of ILI and laboratory to the previous years 2006 to 2010 in virus. Strain analysis undertaken confirmed influenza in Victoria. which the median proportion positive by the WHO Collaborating Centre Victorian influenza surveillance system was 35 per cent (range: 28–45 per indicated a good antigenic match reports are available at https://www. cent) (p<0.001). between the 2011 vaccine and victorianflusurveillance.com.au/ circulating strains, with 88 per cent The proportion of total ILI cases that of the A(H1N1) viruses matching the were vaccinated was 14 per cent Acknowledgements vaccine strain A/California/7/2009, in 2011, significantly lower than the 88 per cent of the A(H3N2) viruses We gratefully acknowledge the average of the years 2006–2010 (18 matching the vaccine strain A/ ongoing support of general per cent, p<0.001).6,9–11 Similarly, Perth/16/2009 and 90 per cent practitioners and their practice staff 14 per cent of swabbed ILI cases in of type B viruses similar to the B/ participating in the GP Sentinel 2011 were vaccinated, significantly Brisbane/60/2008 strain in the Surveillance and Ms Josie Adams, lower than the average of the previous vaccine. We have previously shown Executive Director for the continued five years 2006–2010 (19 per cent, that type- and subtype-stratified involvement of Melbourne Medical p<0.001). This suggests that while adjusted vaccine effectiveness Deputising Service in influenza patients are being tested more, fewer estimates (A(H1N1)pdm09: 78 per surveillance in Victoria. We also thank are being vaccinated. cent; A(H3N2): 58 per cent; B: 53 per private pathology providers who As indicated by the median ages cent) were broadly consistent with a assisted with transport of respiratory and age distributions for both GPSS good match between vaccine and specimens from metropolitan and laboratory confirmed influenza and circulating strains.15 rural general practices. routine notifications, type B influenza In previous years the ILI rate as Laboratory testing was conducted cases were generally younger than measured by the MMDS has generally by the Viral Identification Laboratory type A(H3N2) cases, consistent peaked prior to that of the GPSS, at VIDRL and public health with the typically observed age followed several weeks later by a follow up was undertaken by the distributions for these influenza peak in routine notifications. However Investigation and Response Section, types.7 The median age of A(H1N1)

54 Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 Communicable Disease Prevention 5. World Health Organization. 11. Fielding JE, Miller ER, Adams J, and Control Unit in the Department Standardization of terminology Hawking B, Grant K, Kelly HA. of Health. Staff of the WHO of the pandemic A(H1N1)2009 Influenza surveillance in Victoria, Collaborating Centre for Reference virus. 2011 [updated 2011; cited]; 2006. Commun Dis Intell. 2007 and Research on Influenza who Available from: http://www.who. Mar;31(1):100–6 provided influenza strain identification int/influenza/gisrs_laboratory/ 12. Bolotin S, Pebody R, White PJ, data to the weekly VIDRL surveillance terminology_ah1n1pdm09/en/ McMenamin J, Perera L, Nguyen- report. index.html. Van-Tam JS, et al. A new sentinel VIDRL receives support for its 6. Grant KA FL, Kaczmarek M, surveillance system for severe influenza surveillance program Hurt AC, Kostecki R, Kelly influenza in England shows a shift from the Victorian Government HA, Fielding JE. Continued in age distribution of hospitalised Department of Health. The Melbourne dominance of pandemic A(H1N1) cases in the post-pandemic WHO Collaborating Centre for 2009 influenza in Victoria, period. PLoS One.7(1):e30279 Reference and Research on Influenza Australia in 2010. Western Pacific 13. Ferguson NM, Galvani AP, is supported by the Australian Surveillance and Response. Bush RM. Ecological and Government Department of Health 2011;2(3): www.wpro.who.int/ immunological determinants of and Ageing. wpsar. influenza evolution. Nature. 2003 7. Kelly H, Grant K, Williams S, Mar 27;422(6930):428–33 References Smith D. H1N1 swine origin 14. Miller MA, Viboud C, Balinska influenza infection in the United M, Simonsen L. The Signature 1. Kelly H, Murphy A, Leong W, States and Europe in 2009 may Features of Influenza Pandemics Leydon J, Tresise P, Gerrard be similar to H1N1 seasonal – Implications for Policy. N M, et al. Laboratory-supported influenza infection in two Engl J Med. 2009 June 18, influenza surveillance in Victorian Australian states in 2007 and 2009;360:2595–8 sentinel general practices. 2008. Influenza Other Respi 15. Fielding JE GK, Tran T, Kelly Commun Dis Intell. 2000 Viruses. 2009 Jul;3(4):183–8 HA. Moderate influenza vaccine Dec;24(12):379–83 8. Kelly HA, Grant KA, Fielding JE, effectiveness in Victoria, 2. Thursky K, Cordova SP, Smith Carville KS, Looker CO, Tran Australia, 2011. Euro Surveill. D, Kelly H. Working towards a T, et al. Pandemic influenza 2012;17(11):pii=20115 simple case definition for influenza H1N1 2009 infection in Victoria, surveillance. J Clin Virol. 2003 Australia: No evidence for harm Jul;27(2):170–9 or benefit following receipt of 3. Watts CG, Andrews RM, Druce seasonal influenza vaccine JD, Kelly HA. Establishing in 2009. Vaccine. 2011 Apr thresholds for influenza 5;29(37):6419–26 surveillance in Victoria. Aust N Z J 9. Grant KA, Carville K, Fielding JE, Public Health. 2003;27(4):409–12 Barr IG, Riddell MA, Tran T, et al. 4. Australian Government High proportion of influenza B Department of Health and Ageing. characterises the 2008 influenza Immunise Australia Program – season in Victoria. Commun Dis Influenza 2012 [updated 2012; Intell. 2009 Sep;33(3):328–36 cited]; Available from: http:// 10. Miller ER, Fielding JE, Grant KA, www.immunise.health.gov.au/ Barr IG, Papadakis G, Kelly HA. internet/immunise/publishing. Higher than expected seasonal nsf/Content/immunise-influenza. influenza activity in Victoria, 2007. Commun Dis Intell. 2008 Mar;32(1):63–70

Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 55 Hospitalisation with confirmed influenza in Victoria in the 2011 season Allen C Cheng1, Louis Irving2, Deborah Friedman3, Tony Korman4, Heath A. Kelly5, Tom Kotsimbos6, Paul Kelly7

1 Infectious Diseases Unit, Alfred Hospital; Department of Epidemiology and Preventive Medicine, Monash University, Victoria 2 Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital; Department of Medicine, University of Melbourne 3 Department of Infectious Diseases, Geelong Hospital, Barwon Health, Victoria 4 Infectious Diseases and Microbiology, Monash Medical Centre; Department of Medicine, Monash University, Victoria 5 Epidemiology Unit, Victorian Infectious Diseases Reference Laboratory, Melbourne 6 Department of Allergy Immunology and Respiratory Medicine, Alfred Hospital, Department of Medicine, Monash University. Victoria 7 Population Health Division, ACT Government Health Directorate, Canberra

Introduction Details of medical comorbidities were vaccinated with the 2011 seasonal determined from the hospital medical vaccine. In the 36 patients over Hospitalisation due to influenza is an record. Influenza vaccination was 65 years of age, 61 per cent were uncommon complication associated defined as receipt of the seasonal vaccinated and in the 80 patients with with significant morbidity and mortality. trivalent vaccine in 2011 and was medical comorbidities, 47 per cent In 2009, with the emergence of the determined from the hospital medical were vaccinated. pandemic H1N1/09 strain, there was record and/or patient self-report. Radiologically-confirmed pneumonia a marked change in the epidemiology Ethical approval to perform active was reported in 36 patients (25 per of influenza infection with a shift surveillance and report de-identified cent). Of all patients with confirmed to younger age groups. We have data was obtained from Human influenza, 19 patients (13 per cent) conducted sentinel hospital-based Research Ethics Committees at were admitted to intensive care (of surveillance for patients admitted to each participating hospital and at the which 12 patients had pneumonia) hospital for all strains of influenza in the Australian National University. Influenza Complications Alert Network and five patients (four per cent) died 1 in hospital. The median length of stay (FluCAN) since 2009. FluCAN was Results likely to produce more accurate was four days (IQR 3, 7 days; mean data than influenza and pneumonia During the period May–November 6.6 days). diagnoses based on routine coding, as 2011, 146 patients were admitted clinical diagnoses are not specific. We to the four participating Victorian Discussion hospitals with confirmed influenza. report on our findings on admissions We have previously shown that The peak number of cases was due to influenza to Victorian hospitals sentinel surveillance accurately reported in early September, 2011. in 2011. reflects population based surveillance Of these patients, 58 per cent were systems for severe influenza.1 The female and the median age was 54 Methods comorbidities reported in patients years (inter-quartile range (IQR) 33, 73 hospitalised in this study were In 2011, The Alfred Hospital, the years); 51 patients (35 per cent) were broadly consistent with those Royal Melbourne Hospital, Monash over the age of 65 years (Figure 1). Of reported previously and in northern Medical Centre and Geelong Hospital all patients, 112 patients (72 per cent) hemisphere surveillance systems reported details of adult patients had a chronic comorbidity, with a high for adult admissions,1,3 although the admitted with confirmed influenza proportion having chronic respiratory proportion of patients over 65 years using methods as previously and/or cardiac disease (Table 1); 29 1,2 appears to be increasing over time. described. Detection of influenza patients (20 per cent) did not have This may be due to a decrease in the was by polymerase chain reaction comorbidities and were less than 65 rate of severe influenza in people less at the Victorian Infectious Diseases years of age. Reference Laboratory or at each than 65 years attributable to immunity site. Subtyping was not available at Of the 99 patients where vaccination following natural infection, although all hospitals but where these data status was ascertained, 40 patients we are not able to examine this in this were available this was reported. (40 per cent) reported having been sentinel system.

56 Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 Figure 1: Admissions with confirmed influenza, by hospital and date of The number of admissions reported admission here is likely to underestimate the true burden of severe influenza, as Each box represents one admission. we relied on detection of influenza ICU admission H1N1/09 infection virus using polymerase chain reaction. influenza A not subtyped influenza B infection. Therefore, patients who present with D complications following influenza, such as those with secondary bacterial pneumonia, may not be diagnosed. We have also previously shown that not all hospitalised patients with C influenza have an influenza-like illness syndrome,4 and therefore it is likely that not all hospitalised patients with

Hospital influenza are tested. Influenza strain subtyping was not available at all sites, B but laboratory and primary care-based surveillance suggested that the both A/H1N1/09 and A/H3N2 strains co- circulated during the 2011 season in Victoria.5

A Previous community-based work has found that around 70–80 per cent of Victorians over the age of 65 years were vaccinated between 2002–2009, 01 May 2011 29 May 2011 26 June 2011 24 July 2011 and around 55 per cent of Victorians 21 August 2011 16 October 2011 18 September 2011 13 November 2011 with chronic disease were vaccinated Date of admission in 2009.6 In patients presenting to primary care with test-negative Table 1: Demographics and risk factors in patients admitted with confirmed influenza like illnesses, 59 per cent of influenza patients over 65 years but only 12 per cent of patients less than 65 years Factor Number Proportion (%) were immunised in the 2011 season.5 Total patients 146 A recent systematic review has Male 61 41.8 reiterated that the influenza vaccine Indigenous 1 0.7 is moderately protective against Pregnant 8 5.5 confirmed disease7 and we have also Nursing home resident 3 2.1 found that influenza vaccine appears Medical co-morbidities 112 76.7 to be protective against hospitalisation 2 chronic respiratory disease 66 45.2 with H1N1/09 influenza. The diabetes 20 13.7 epidemiology of H1N1/09 influenza appears to be changing towards a chronic liver disease 3 2.1 more seasonal pattern with a higher immunosuppressed 42 28.8 proportion of elderly patients, and a malignancy 1 0.7 high proportion of patients hospitalised chronic cardiac disease 29 19.9 had chronic comorbidities. These chronic neurological disease 11 7.5 data support the continued inclusion chronic renal disease 10 6.8 of influenza vaccine on the National Immunisation Programme for the elderly and those with chronic co- morbidities.

Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 57 Figure 2: Age and sex distribution of patients hospitalised with confirmed Acknowledgements influenza Female We thank study staff at all sites Male for their contributions. This study

>80years was supported by the Victorian Department of Health, the National Health and Medical Research Council, 65–80 years Commonwealth Department of Health and Ageing, and the Victorian 40–65 years Infectious Diseases Reference Laboratory. 18–40 years

40 30 20 10 0 10 20 30

Number of patients References 3. CDC. FluView: 2010–2011 Australia, 2011. Euro Surveill. Influenza Season Summary2011: 2012;17(11):20115 1. Kelly PM, Kotsimbos T, Reynolds Available from: http:// 6. Australian Institute for Health and A, Wood, et al. FluCAN 2009: initial www.cdc.gov/flu/weekly/ Welfare. 2009 Adult Vaccination results from sentinel surveillance weeklyarchives2010-2011/10- Survey: summary results. for adult influenza and pneumonia 11summary.htm Canberra: Australian Institute for in eight Australian hospitals. Med J 4. Cheng AC, Kotsimbos T, Health and Welfare 2011 Contract Aust. 2011;194(4):169–74 Reynolds A, et al. Clinical and No.: Cat. no. PHE 135 2. Cheng AC, Kotsimbos AT, Kelly H, epidemiological profile of patients 7. Osterholm MT, Kelley NS, Sommer Irving L, Bowler SB, S., Holmes with severe H1N1/09 pandemic A, Belongia EA. Efficacy and M, et al. Effectiveness of H1N1/09 influenza in Australia and New effectiveness of influenza vaccines: monovalent and trivalent influenza Zealand: an observational cohort a systematic review and meta- vaccines against hospitalization study. BMJ Open. 2011;1:100 analysis. Lancet Infect Dis. 2011 with laboratory-confirmed 5. Fielding JE, Grant KA, Tran T, Oct 25 H1N1/09 influenza in Australia: a Kelly HA. Moderate influenza test-negative case control study. vaccine effectiveness in Victoria, Vaccine. 2011;29(43):7320–5

58 Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 Anaphylaxis post trivalent influenza vaccine: a case report Julie Quinn, Alissa McMinn and Nigel Crawford. SAEFVIC, Murdoch Childrens Research Institute, Melbourne, Victoria

A 25 year old intensive care nurse is confirmed when there is a Influenza vaccine was indicated received an influenza vaccine at her combination of signs as below: for this patient being a health care workplace at the end of her shift. professional and in addition having • Skin – itchiness, erythema She was advised at the time of a history of asthma and therefore (redness), urticaria, or angiodema. vaccination to remain in a nearby at risk of severe influenza-related • Respiratory – cough, wheeze, area for a minimum of 15 minutes for complications for this patient. stridor, or signs of respiratory observation. SAEFVIC has arranged follow-up distress. in the vaccine safety clinic at the Immediately post immunisation • Cardiovascular – tachycardia, Royal Melbourne Hospital for further she left to go home. While driving, weak/absent peripheral and carotid assessment. SAEFVIC uses the approximately ten minutes post pulse, hypotension. specialist allergy teams at the Royal vaccine administration, she developed • Gastrointestinal – nausea, vomiting Children’s and Royal Melbourne symptoms of chest tightness and • Neurological – sense of severe Hospital for children and adults shortness of breath which progressed anxiety and distress. Loss who have significant allergic events to a wheeze with swelling of lips and of consciousness and no following vaccinations. tongue. She was able to drive herself improvement once supine or in a to the emergency department of a Anaphylaxis can be reported to head down position. metropolitan hospital where she was SAEFVIC. Surveillance of Adverse Events treated for anaphylaxis and admitted Following Vaccination in the For further information please contact overnight. She was discharged the Community the service has received the SAEFVIC team on: next day fully recovered. Of note, 30 reports of anaphylaxis from all she has a history of asthma requiring 1300 882 924 vaccines since SAEFVIC commenced previous admissions to ICU and an in 2007, including 13 reports following Or online: www.saefvic.org.au allergy to morphine. She had also a trivalent influenza vaccine (TIV). received the influenza vaccine for While a rare AEFI, all immunisation References several years previously with no providers need to be aware of the adverse events. 1. Bohlke K, Davis RL, Marcy SM, signs of anaphylaxis and administer et al. Risk of anaphylaxis after Anaphylaxis following adrenaline (1:1000) at the appropriate vaccination of children and immunisation dose (0.01 ml per kg of bodyweight adolescents. Pediatrics. 2003; Anaphylaxis is a serious adverse to a maximum of 0.5ml by deep IM 112: 815–20 injection). event following immunisation (AEFI). 2.Vellozzi et al. Adverse events It is usually of rapid onset, occurring following influenza A (H1N1) 2009 within 15–30 minutes of administering Discussion monovalent vaccines reported a vaccine. It is a rare AEFI with rates This case highlights the importance to the Vaccine Adverse Event described between zero to 3.5 per of recipients remaining under Reporting System, United States, 1 million cases for vaccines given observation for at least 15 minutes October 1, 2009–January 31, to children and adolescents. The following a vaccination. It is also 2010. Vaccine. 2010;28(45):7248– United States Adverse Event (VAERS) recommended that adults are warned 55 reporting rate for verified anaphylaxis of the risk of driving, with a wait of at was 1.4 per million 2009-H1N1 least 30 minutes after vaccination. 2 vaccinations. SAEFVIC has previously reported the There are multiple systems involved death of a vaccinee involved in a car with anaphylaxis. The diagnosis accident driving home less than 30 minutes post immunisation.

Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 59 Murray Valley encephalitis virus Reappearance, 2011: Beat the Bite Rodney Moran, Communicable Disease Prevention and Control Unit, Department of Health, Victoria

Background Twelve municipal councils, seven reviewed and updated its Contingency from across the Murray Valley plan for the reappearance of Murray Ross River virus (RRv), Barmah Region (northern Victoria), two Valley encephalitis and worked closely Forest virus (BFv) and Murray Valley from the Gippsland Region (south with local councils, particularly in encephalitis virus (MVE) are mosquito- eastern Victoria) and three in the northern Victoria, in preparing for the borne diseases. RRv and BFv are Bellarine area (south western Victoria) summer period. In early October 2010 endemic throughout Victoria although receive funding to implement local councils that participated in the annual the number of cases per year varies surveillance and control strategies mosquito management programs widely depending on seasonal and on vector mosquito populations. were offered additional funding to other conditions. In contrast MVE This takes place between November commence their program early (the presents infrequently. Major outbreaks and April each year; the period when program usually starts on of MVE occurred in Victoria in 1918, the greatest numbers of arbovirus 1 November) if local conditions 1951, 1956 and 1974. notifications are received. The State showed early season breeding. The Victoria has conducted arboviral Government provides funding on the offer was accepted by Mildura and disease surveillance and mosquito basis that the local council matches Gannawarra shires. The sentinel control programs since the 1974 the funding dollar for dollar. chicken program was also brought outbreak of MVE. The Department forward with flocks placed on-site of Health has responsibility, under Lead up events two weeks earlier than usual (on 19 the Public Health & Wellbeing Act October). 2010 2008, for disease control activities. A one day mosquito control training In September 2010 parts of northern The Victorian program is designed session was held in Echuca on Victoria were affected by flood to reduce human arboviral infections 30 November. Twenty six local events following a number of years through surveillance for viral activity government officers attended from of drought conditions. Following the in mosquitoes and animals and for various councils across the state and flood event the Bureau of Meteorology infections in humans, control of border NSW. The State Government advised that, while it was difficult vector mosquito populations where also committed to additional funding to make predictions regarding the appropriate and education of the for prevention and control programs. community. The department also weather outlook at that time of the supports training for local government year, there was a 50 to 60 per cent 2011 personnel on mosquito identification chance of above median rainfall In January 2011 a major flood event and control. across Victoria for the summer occurred throughout predominantly months to March. This was due to The department gives an annual the western and north western a very strong and persistent La Niña grant to the Department of Primary parts of the state. In response, which was likely to bring tropical air Industries (DPI) to provide virology and additional adult mosquito and sentinel as far south as Victoria, leading to entomology expertise, as well as the surveillance was established in possible hot periods and heat waves necessary laboratory facilities required Hamilton, Horsham, Warracknabeal, interspersed with periods of humidity to support these services. The Dimboola, Castlemaine and Bendigo and rain. There was also therefore the department also funds the Victorian (Figure 1). This consisted of weekly possibility of future flooding events Infectious Diseases Reference adult mosquito trapping at two sites and humidity across Victoria during Laboratory (VIDRL) to perform the per council and weekly bleeding of the the 2010–2011 summer. necessary serological tests on human sentinel chickens. The chickens were sera. Given the predicted increase in on private properties, mainly show mosquito breeding, the department birds.

60 Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 Figure 2: Existing and additional mosquito trapping and sentinel chicken Summary of 2010–2011 summer surveillance locations weather conditions

Mildura • The summer of 2010–11 was Sentinals the wettest in Victoria since Robinvale Trapping records began. Victoria received Existing Program Tooleybuc New Surveillance a statewide averaged rainfall Swan Hill total in excess of 300 millimetres Kerang Barooga for the season, breaking the Rutherglen Barmah previous record for the highest Warracknambeal Wodonga summer rainfall in Victoria of 237 Toolamba millimetres, set 100 years ago in Horsham Bendigo Maryborough 1910–11. The average summer Castlemaine rainfall in Victoria is 121.1 mm.

Gippsland was the only area of Hamilton the state to record near normal Geelong Sale rainfall totals for the season • Victoria endured significant rainfall and flooding events during each of December, January and February. These The Central Government Response • Reducing vector mosquito events contributed to the state Committee formed a Mosquito populations at adult and larval recording its: Borne Virus Task Force under the stages through environmental – 5th wettest December on coordination of Victoria Police with control (water reduction) and record, and wettest since the Department of Health as the chemical/biological control. 1992 control agency. Additional funding was • Increasing public awareness of – Wettest January on record provided by government to respond the potential risks associated with – Wettest February since at to the event. mosquito bites and the personal least 1973, and provisionally The response was undertaken protection strategies that can be the 6th wettest on record in partnership with the following taken to reduce those risks. • Daytime maximum temperatures agencies: • Implementing enhanced were below average across surveillance for early identification • Local councils in affected areas Victoria this summer, while of potential human MVE infections. • Department of Sustainability & overnight minimum temperatures Environment (Office of Water) Whole of government activities were above average. There was also a below average number of • Department of Business and A number of actions were very hot days and very cold days Innovation implemented across government for the season. • Department of Primary Industries since confirmation of the presence of the virus in late February 2011. These Adapted from: source Bureau of Meteorology • Department of Health – 1 March 2011 • Department of Human Services included: • Department of Education and Early • Reducing the vector populations The response Childhood Development through aggressive mosquito In February 2011 surveillance • NSW Police control programs in affected programs in the Murray Valley area • NSW Department of Health townships, implemented by local detected the presence of MVE in • Municipal Association of Victoria councils. sentinel chickens and in horses—this • Strategic pumping of flood The aim of the Task Force was to presented not only a possible risk waters in Mildura, Benjeroop and reduce the potential risk of morbidity to public health but also potential Murrabit coordinated though the and mortality caused by Murray Valley impacts on the economy in affected Department of Sustainability and encephalitis virus through: areas. Environment.

Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 61 • Developing and implementing a developed in collaboration with to be vigilant for MVE in patients comprehensive communication Tourism Victoria and was delivered presenting with compatible campaign, through television, radio in conjunction with a Tourism symptoms. and print media. This provided Victoria campaign. • Testing of human blood samples education on mosquito avoidance • Distribution of health alerts to all for evidence of infection with MVE. and personal protection. It was Victorian doctors and hospitals

Table 1: Priority activities by agency – March 2011

Objectives Activities Outcome Responsibility • Prepare local vector control • Local vector control plans developed and DH/Councils plans, which will inform the State implemented. Plan. • State Plan developed. • Spray areas where water • Decreased flavivirus antibodies in sentinel reduction is not viable. chickens. • Reduction in numbers of trapped mosquitoes. Assess funding issues at IDC on Funding issues resolved and funding provided. DH 28/2/11, to assist with mosquito control programs. Reduction of mosquito numbers through integrated mosquito Identify problematic water bodies in Mapping provided by Office of Water illustrating DSE/councils management and control affected townships. water bodies and size of areas. Conduct a risk assessment and Mapping of high-risk areas provided. VicPol/DSE highlight high-risk areas to inform pumping activities. Reduce water pools through Reduction in mosquito populations. DSE/Councils pumping and drainage. Mosquito monitoring. • Reduction in numbers of trapped mosquitoes. DH/DPI/Councils • Absence of MVE in collected mosquitoes. • Decreased flavivirus antibodies in sentinel chickens. Increase public awareness of the Develop and deliver public Communication Strategy developed and DH/DBI risks associated with mosquito information campaign. implemented. exposures. No reported cases of MVE. Education of tourists visiting ‘at risk’ areas. Formation of Communications Sub- Sub-committee formed. DH/DBI Committee to inform Emergency Key messages developed around preventative Management Public Information measures. Committee. Public events identified in ‘at risk’ areas. Increased surveillance for human • Distribution of alerts to general • Materials prepared and distributed. DH infections practitioners, hospital emergency • Study design finalised and providers engaged. departments and infectious disease physicians. • Develop an MVE sero- surveillance study in humans through local pathology providers. Prepare an engagement and Engagement and communication strategy DH communication strategy. developed and implemented. Develop a risk assessment DH framework.

DH – Department of Health DBI – Department of Business Innovation DSE – Department of Sustainability and Environment VicPol – Victoria Police DPI – Department of Primary Industries

62 Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 Surveillance results Horses antibodies were detected in 20 Arbovirus and flavivirus activity was per cent of equine samples; MVE Adult mosquitoes 1 detected in equine diagnostic samples antibodies in six per cent of samples. From November 2010 to May 2011 processed by the DPI Attwood there were 875,682 mosquitoes Human surveillance Arbovirology Laboratory. trapped in Victoria. Of these, 754,640 The department received increased were from the 23 traps in the Murray Over the 2010–11 season 50 numbers of arbovirus notifications region, 80,890 were from the four per cent (160/320) of the equine during this period—a 2.5 fold increase coastal traps and 27,151 were samples tested positive for RRv IgM on 2010 case numbers. The increase from the two traps in metropolitan antibodies. IgM positive samples were was mainly due to an increase in Melbourne. Limited trapping was identified in every month of testing Ross River infections (Figure 3). No completed in the Western region except June 2010. Current RRV confirmed cases of MVE were notified where 13,001 mosquitoes were infections, indicated by a positive in Victoria. However a 69-year old collected. IgM result, were twice as common man from the Murray River town compared with the 2009–10 season A range of mosquito species was of Mildura presented to hospital in (26 per cent positive). caught, however the key arbovirus early March with a three-day history vector, Cx. annulirostris, was Over the 2010–11 season, 31 per of symptoms consistent with MVE. dominant in most locations. cent (104/337) of the equine samples Diagnostic testing was unable to tested positive for RRv IgG. IgG confirm the clinical suspicion. Virus isolation was attempted for over positive samples were detected 9,700 pooled mosquito samples. From February to April, the Victorian in every month of testing except Alphaviruses were isolated by Infectious Diseases Reference June and November 2010. During Westmead Hospital. Sindbis was Laboratory (VIDRL) tested 197 the 2009–10 season, 11 per cent detected in Cx. annulirostris and residual sera of samples of patients of samples were IgG positive. The Cx. australicus mosquito samples with postcodes from the Murray Valley threefold increase in IgG activity was trapped at Swan Hill and Kerang. area. These samples were referred a reflection of the RRV activity during Ross River virus was isolated from to VIDRL for other clinical reasons the season, and corresponded to the Aedes camptorhynchus caught at and were tested opportunistically to increase in IgM antibody detection. Wellington. No flaviviruses were assess the prevalence of antibodies isolated from mosquito samples, Equine diagnostic samples are not to MVE and Kunjin virus. Of 197 sera, however MVE was detected by PCR routinely tested for flavivirus and MVE eight (four per cent) were positive for in Cx. annulirostris caught at Kerang. specific antibodies; the number of antibodies to MVE; all eight of the specimens submitted for testing in people from whom these samples Sentinel chickens 2010–11 was over 100 times greater were collected were born before the Arbovirus activity, including both than that for 2009–10. Flavivirus 1974 outbreak, meaning that they MVE and Kunjin virus (KUNV) activity, Figure 3: Number of notified cases of Ross River virus and Barmah Forest was detected in the sentinel chicken virus, by year of notification, Victoria, January 2000–April 2011 surveillance program. Antibodies Ross River Barmah Forest 1400 to MVE were first detected in the sentinel chicken flocks during week 1200 six of 2011. The flocks continued to 1000 seroconvert to flaviviruses through to week 18. MVE activity was confirmed 800 in chickens from Barmah, Bendigo, 600 Cobram, Kerang, Mildura, Robinvale, 400 Swan Hill, Toolamba and Tooleybuc. Number of notified cases Sixty-nine of the 260 sentinel chickens 200 tested positive for flavivirus antibodies; 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 47 of these were MVE specific. Year of notification

1 DPI data source: Victorian Arbovirus Disease Control Program 2010–11 Annual Report

Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 63 could have been exposed to the virus A range of larvicides and adulticides Summer 2011–12 in 1974 and still returned a positive were made available. These were preparedness antibody result in 2011. Of 193 sera generally selected from the below list tested for Kunjin virus, seven (3.5 per however other products may have Winter surveillance cent) tested positive. For comparison been used depending on local need. Sentinel chicken flocks remained VIDRL also tested sera of 78 Larval control at Mildura, Kerang and Barmah. Melbourne metropolitan patients; all These flocks were bled fortnightly to • organophosphates (ABATE) tested negative for antibodies to MVE test for the presence of flaviviruses microbials (Teknar) – Bacillus and Kunjin viruses. including MVE. Sites were selected thuringiensis var. israelensis The results of this opportunistic based on the presence of virus over • IGRs (ProLink) – (S)-methoprene testing of residual sera suggested the summer months and the impacts that prevalence of antibodies to MVE Adult control of January 2011 flood event. Adult and Kunjin viruses in humans in • Pyrocide ULV mosquito trapping (one trap per the Murray Valley area was low and • Twilight ULV fortnight) also continued at these similar to previous serosurveys that locations and mosquitoes collected • perimeter residual insecticide such have estimated a seroprevalence of were tested for viruses. as bifenthrin or lambda cyhalothrin between one and seven per cent for or alpha cypermethrin No virus was detected in either the both viruses. Weed control (herbicide) sentinel chickens or mosquitoes during the winter months. Mosquito control • Round Up Given the detection of MVE in the Application equipment Prevention messages sentinel chickens and the flood event As part of the annual program the A communications campaign ‘Beat in north western Victoria in January department and local councils the Bite’ was developed. It included 2011, an enhanced mosquito control had mosquito control equipment two separate media bites including plan was developed and initially available. This included: four-wheel- television, radio, press and online implemented in Mildura, Swan Hill and drive motorbikes with granule and advertising over March and April Gannawarra shires. A watching brief liquid applicators; handheld portable 2011. The campaign gave information occurred in the other municipalities in foggers; backpack blowers and on how to avoid mosquito-borne the Murray Valley area. misters; handheld pressure sprayers diseases. An escalation strategy was As the virus was detected in a local and; trailer mounted ULV cold aerosol developed in case there was a human council area, local mosquito control generators. Additional handheld case of MVE confirmed in Victoria but plans were developed by the affected portable foggers, backpack blowers this was not used. councils shifting the primary focus and misters were purchased and from larviciding to adulticiding. loaned to councils where needed. Reference Knockdown of adult mosquitoes Victorian Arbovirus Disease Control potentially infected with viruses may Program annual report 2010–11. prevent cases of human disease. Larval control supplemented adult mosquito strategies. Given the extent of mosquito breeding in some areas, local councils–where applicable– prioritised activities by undertaking site assessment, taking into account legal status, physical characteristics and the risk of environmental and social impacts from the proposed treatment.

64 Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 Immunisation program report, Victoria, June 2012 Helen Pitcher, Department of Health

Immunisation report against invasive pneumococcal disease • all Indigenous people 15 years of afforded by the vaccine for adults, age and over The Australian Childhood including older adults, especially • residents of nursing homes and Immunisation Register data is those without underlying chronic other long-term care facilities currently being analysed by the medical conditions. Systemic and local • any person six months of age and Commonwealth Government to reactions after 23vPPV are common. over who is predisposed to severe determine the coverage data that Local reactions, including severe influenza due to a chronic condition can be released in the future under injection site reactions, occur more that requires regular medical the Health Insurance Act 1973. commonly in repeat dose recipients follow-up or hospitalisation such as Therefore, the local government compared with first dose recipients. cardiac disease, respiratory disease area immunisation coverage table including severe asthmatics, for children at the three measured ATAGI stated the use of a second ® renal disease, diabetes, impaired cohorts for children up to five years dose of Pneumovax 23 for those immunity and neuromuscular of age and a comparison of interstate aged greater than 65 years without disease. and national coverage cannot be any predisposing conditions provided. is no longer recommended. In 2011, the ATAGI recommended Recommendations for the use of that children aged six months to less ® Vaccination program Pneumovax 23 in those aged less than 10 years be immunised with updates than 65 years, including for Aboriginal either Influvac® or Vaxigrip®. The and Torres Strait Islander adolescents registration of Fluvax® was changed Pneumovax 23® and adults, are unchanged from The by the TGA in 2010 as not registered Australian Immunisation Handbook In December 2011, the Australian for use in children aged between 9th Edition 2008. Technical Advisory Group on six months to less than five years. Immunisation (ATAGI) revised Further information about the In 2010, there was an increased revaccination recommendations revaccination recommendation incidence of high fevers and febrile for non-Indigenous adults aged 65 for Pneumovax 23® and the risk convulsions following administration of ® years and over under the National factors predisposing to invasive Fluvax (CSL Biotherapies) vaccine in Immunisation Program (NIP) for pneumococcal disease is available children less than five years of age. ® Pneumovax 23 the 23-valent at the Immunisation Section web Pertussis vaccine pneumococcal polysaccharide site: http: //www.health.vic.gov.au/ The free pertussis vaccine program vaccine (23vPPV). The new immunisation/ and the Immunise for all parents of newborn babies recommendations were released as Australia web site: http://www. ceased 30 June 2012. Since that a result of an increase in the reported immunise.health.gov.au/ date, pertussis vaccine is available number of adverse events following Seasonal influenza vaccines on prescription for parents or people the administration of Pneumovax planning pregnancy and other carers 23®. Previously, the Therapeutic The government-supplied free of infants who choose to receive it. Goods Administration (TGA) had influenza vaccine brands for the 2012 The pertussis epidemic activity has advised health professionals against seasonal influenza vaccine program ® now decreased and with the uncertain administering a second or subsequent are Fluvax (CSL Biotherapies), ® ® effectiveness of the cocooning dose of Pneumovax 23® due to the Vaxigrip and Vaxigrip Junior ® strategy, the Victorian Health vaccine reaction. (Sanofi-aventis) and Fluarix (GSK). These vaccines are provided free for Department continues to review ATAGI reviewed available evidence on the following eligible groups: the evidence on its effectiveness in the safety, efficacy and effectiveness preventing severe whooping cough ® • everyone 65 years of age and over of Pneumovax 23 and its place within infections in new babies. the NIP. It determined there was a • pregnant women at any stage of definite modest level of protection pregnancy

Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 65 Prevenar 13® supplementary Gardasil® for boys Check your immunisation dose A human papillomavirus vaccine HALO From 1 October 2011 to 30 secondary school program for boys Check your immunisation HALO September 2012 the Australian commences from 2013. On 12 July is a new poster to recommend Government provided a free single 2012, the Minister for Health, the immunisation for all ages. Your Health, supplementary dose of Prevenar Hon Tanya Plibersek MP announced Age, Lifestyle and Occupation (HALO) 13®, a 13 valent pneumococcal funding for the HPV vaccine are the four factors that determine conjugate vaccine (13vPCV), to Gardasil® for Year 7 boys, in addition your immunisation needs. The HALO eligible children aged between 12 and to Year 7 school girls, through school- graphic poster can be viewed and 35 months inclusive. These children based programs under the National downloaded for display in a health will have routinely received a course Immunisation Program. Year 9 boys service to create an interest from the of the seven valent (7vPCV) vaccine will also be able to get the vaccine public regarding their immunisation Prevenar®, therefore will benefit from at school under a catch-up program needs. Access the poster at the icon from protection from the additional six for the next two years. For more picture at: www.health.vic.gov.au/ strains in the Prevenar 13® vaccine. information, please visit the Immunise immunisation/ Prevenar® was replaced with Prevenar Australia website at: 13® in July 2011 on the NIP schedule. http://immunise.health.gov.au Prevenar 13® is 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 six additional strains to protect children against pneumococcal bacteria. The pneumococcal bacteria strains in Prevenar 13® are 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F.

66 Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 Communicable disease surveillance, Victoria, January– March 2012 We report a summary of infectious disease notifications received until March 2012. Table 10 includes historical comparisons of selected diseases for the period 1 January–31 March 2012 at both the state and regional levels. Data are provisional and subject to revision as further information becomes available.

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 diseases Table 1: Outbreaks of gastrointestinal illness, January–March 2012 Joy Gregory, Department of Health Persons Pathogen/toxin Setting Outbreaks affected (number of outbreaks) and OzFoodNet Victoria Aged care 29 453 Norovirus ( 10) Suspected viral (11) Outbreaks of gastrointestinal Unknown (8) illness Camp 2 32 Suspected viral (1) There were 96 outbreaks of Unknown (1) gastrointestinal illness reported to the Child care/play centre 30 447 Norovirus (1) Adenovirus (1) Communicable Disease Prevention Suspected viral (27) and Control Unit (CDPCU) during Unknown (1) the first quarter of 2012 (Table 1). Commercial caterer 2 35 Norovirus (1) Of these, seven outbreaks were Unknown (1) Hospital 11 87 Clostridium difficile (1) considered to be foodborne or Norovirus (4) suspected foodborne. Person to Suspected viral (4) person transmission was suspected Unknown (2) in 72 outbreaks and one outbreak *Residential facility (other) 11 65 Norovirus (1) was suspected to have been caused Suspected viral (8) Unknown (2) by ingestion of contaminated water Restaurant 5 45 Salmonella Typhimurium 170 (1) during recreational water activity. The Unknown (4) mode of transmission was unknown School 3 116 Suspected viral (3) for the remaining 16 outbreaks. Take-away 1 9 Unknown (1) Recreational water park 1 15 Suspected viral (1) Foodborne and waterborne Unknown 1 8 Campylobacter (1) disease outbreaks Total 96 1312 Norovirus (17) Suspected Viral (55) Seven outbreaks were considered Salmonella Typhimurium 170 (1) to be foodborne or suspected Campylobacter (1) foodborne, affecting at least 80 Adenovirus (1) Clostridium difficile (1) people. These outbreaks are Unknown (20) summarised below: * other residential facility includes: supported services accommodation or supported residential In late January, CDPCU was notified services (7), independent living units (1) and disability services (3) of an outbreak of gastrointestinal illness occurring in two separate after consumption of battered fish as the first group. All nine cases groups of people who had eaten and chips. The second group of six reported vomiting and three reported take away fish and chips purchased people consumed fish, chips and diarrhoea and described these from a local food premises. The first potato cakes purchased from the symptoms lasting a short duration of group of three people experienced same premises on the same evening. between two and 24 hours. Leftover sudden onset of nausea and All six experienced onset of vomiting fish and chips were available from vomiting approximately two hours with an incubation period the same the meals purchased by the first

Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 67 group, however, they had been This caterer supplied two additional department by a general practitioner. stored at room temperature overnight groups on the same day; however the The confirmed case was reported by and refrigerated the next morning. menus comprised mostly hot cooked the doctor to have become unwell Laboratory analyses of these foods and no illness was reported. after eating at a local café with a leftovers detected coagulase positive friend who had also become unwell Investigation revealed that a chef had Staphylococci at a moderately high but had declined to submit a faecal been absent from work for one day level. Subsequent testing however specimen. Investigation revealed due to gastroenteritis, four days prior detected no Staphylococcal that the case and her friend had to assisting with the preparation of the enterotoxin. Despite negative shared a vegetable foccacia, chips, sandwiches supplied to the groups enterotoxin results Staphylococcus conolli and gelati and had an onset with illness. It was suspected that he aureus was suspected as the cause of diarrhoea approximately 24 hours may have still been excreting virus of this outbreak as the symptoms, later. Council revealed that they had and contaminated the sandwiches short incubation period and duration received a separate complaint of during preparation. of illness were consistent with this two people (mother and daughter) aetiology and was supported by the In late February, an outbreak of being hospitalised and subsequently isolation of this organism from leftover diarrhoea affecting ten residents diagnosed with salmonellosis food eaten by one of the groups. of a particular section of an aged after sharing a vegetable foccacia care facility was notified to CDPCU. purchased from the same café. Case An outbreak of diarrhoea affecting Onsets of illness were all within finding was conducted by interviewing eight residents of an aged care a six hour window and median notified cases of salmonellosis that facility was notified to CDPCU. Seven symptom duration was less than 24 had a residential address in one of cases had onsets over a 12 hour hours. All cases submitted faecal three municipalities surrounding the period and median duration of illness specimens of which one tested café. An additional five confirmed was one day. Six faecal specimens positive for Clostridium perfringens cases were found to have eaten at were collected. One tested enterotoxin and all were negative the café. Another two confirmed positive for Clostridium perfringens for viral pathogens. Of the ten ill Salmonella cases were identified in enterotoxin and another positive for residents, nine were on vitamised the children of a suspected case who Campylobacter. A review of the food meals. An analysis of this exposure ate at the café. The children did not safety procedures did not identify any for all residents in the facility eat at the café and were therefore issues that may have contributed to showed a significant association likely to have been secondary cases, this outbreak. with consumption of vitamised infected through person-to-person In late February, CDPCU was notified meals and illness (RR 29.3: 95%CI transmission from their mother. of an outbreak of gastroenteritis 4–221; p<0.00001). A review of food Cases ate a variety of different foods, affecting two separate groups who processes, especially vitamising, however, the investigation did not had eaten food prepared by the failed to identify any issues which may determine any ingredient common to same caterer on the same day. have caused this outbreak. all of the foods. The variety of different Similar foods consisting of a variety An outbreak of diarrhoea at an aged foods consumed and the seven day of sandwiches and fruit platters had care facility was notified to CDPCU in period over which cases had eaten been prepared for both groups and late February. Five residents from the at the café, suggested that cross one group also had cakes. Of the same wing of the facility experienced contamination during preparation and combined total of 45 people who had onset of diarrhoea over an 18 hour handling and inadequate cleaning attended one of these two functions, period with a short duration. No faecal and sanitising of equipment and/ 25 became ill with vomiting and/or specimens were collected. A review or food contact surfaces may have diarrhoea between 24 to 48 hours of the food safety procedures did occurred. Investigation also revealed after eating. One secondary case not identify any issues that may have possible temperature abuse of pre- occurred in a family member who contributed to this outbreak. prepared foods. In total, there were attended the larger function. Six nine confirmed cases of Salmonella faecal specimens were collected from In early March an outbreak of Typhimurium 170, two suspected cases and three tested positive for salmonellosis was identified cases and two secondary cases norovirus. through the investigation of a single associated with this outbreak. Salmonella case notified to the Salmonella was not isolated from any

68 Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 of the food or environmental samples Figure 1: Norovirus outbreak activity by quarter, Victoria, January 2005– submitted for analysis. A specific food March 2012 source responsible for this outbreak Novovirus Suspected viral 250 was not determined. suspected viral In March, a cluster investigation of 200 Norovirus Campylobacter cases living in one of eaks three adjacent municipalities in the 150 eastern suburbs of Melbourne was 100 initiated after two cases complained to their local council that they suspected Number of outbr 50 the source of their illness was chicken purchased from a local take-away 0 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 food premises. The two cases lived 2005 2006 2007 2008 2009 2010 2011 2012 together and had shared the meal Quarter and month of notification during their incubation period. Another case, that had purchased take away Blood borne viruses Six of the 14 cases were Australian chicken salad from the same premises born, seven were born overseas and Nasra Higgins, Department of a day after the other cases, was country of birth was unknown or not Health, Victoria identified. Five additional cases were reported for one case. Indigenous interviewed but none identified eating Hepatitis B—newly acquired status was reported for 13 cases, at this premises in the two weeks infections with one case reported as being of Aboriginal and/or Torres Strait Islander prior to the onset of their illness. In the first quarter of 2012 there were origin. Nine cases were resident in Recall of foods consumed during their 456 cases of hepatitis B notified metropolitan Melbourne and five incubation period may have been an of which 14 (three per cent) were resided in regional Victoria. issue as interviews were conducted classified as newly acquired infections several weeks after the onset of illness. (Figure 2). This was nearly a 50 per One case was reported with a Council inspected the initial implicated cent reduction on the number of hepatitis C co-infection. food premises and did not identify any cases notified in the previous quarter food handling issues. Due to the long Among the 14 newly acquired cases, however similar to the number of 10 were tested for hepatitis B due to incubation period for Campylobacter cases notified at same time last year. (up to ten days) and the commonality elevated liver function tests, of which of this infection in the community, it Of the 14 newly acquired cases, nine five reported having symptomatic could not be confirmed that these were in males and five in females. All hepatitis, two were tested due to three cases had acquired their illness were aged between 23 and 59 years, having a medical condition, two were from consuming food at this premises. with a median age of 39 Qtryears.1 testedQtr2 upon patientQtr3 request and Qtr4

Norovirus activity Figure 2: NotifiedQtr1 cases of newlyQtr2 acquired hepatitisQtr3 B, by quarter,Qtr4 Victoria, 2001–2011 Norovirus and suspected viral activity in the first quarter of 2012 (72 Q1 Q2 Q3 Q4 250 outbreaks) was higher than the first quarter in 2011 and higher than the 200 five-year mean for the first quarter (61 outbreaks 2007–2011) (Figure 1). 150 Eighty-eight per cent of the norovirus outbreaks and forty-two per cent 100 of the suspected viral outbreaks 50 occurred in aged-care or health-care Number of notified cases settings. A large number of suspected 0 viral outbreaks this quarter (forty-nine 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 per cent) were in child care settings. Year of notification

Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 69 one case each reported psychiatric years, with a median age of 24 years. the remaining cases included having screening and other medical condition Fifty-five per cent (n=22) of cases a hepatitis C positive sexual partner as the reason for testing. were from metropolitan Melbourne, 37 (n=3), having household contact with per cent (n=15) from regional Victoria a hepatitis C positive person (n=2) and Injecting drug use was reported for six and for the remaining three cases body piercing (n=1). A risk factor was cases, and two cases reported having postcode of residence was unknown not determined for two cases. Multiple a hepatitis B positive sexual partner. or not reported. risk factors may be reported for cases Other risk factors identified included with no history of IDU. body piercing (n=1), tattooing (n=1), Sixty-three per cent of cases (n=25) household carrier (n=1) and other were Australian born, five were Hepatitis D (n=2) (more than one risk factor may reported as overseas born and Two cases of hepatitis D were notified be reported for those cases with country of birth was unknown or not during the first quarter of 2012: a 31 no history of injecting drug use or reported for remaining 10 cases. year old Sudanese born male, with sexual contact with a hepatitis B Indigenous status was reported for 30 a super-infection and reported risk positive partner). Risk factors were not cases (75 per cent), with two cases of transmission through household/ determined for three cases. reported as being of Aboriginal and/or sexual contact and a 28 year old male Torres Strait Islander origin. Hepatitis C – newly acquired with unknown risk factor information. infections Of the 40 newly acquired cases, the most common reason for testing A total of 587 cases of hepatitis C Vaccine-preventable was as part of drug and alcohol were notified during the first quarter diseases screening and screening for sexually of 2012, of which 40 (seven per cent) transmissible infections for 11 and Lucinda Franklin, Department of were classified as newly acquired 10 cases respectively. Other reasons Health, Victoria infections. This was similar to the for testing reported included patient previous quarter and six cases less Haemophilus influenzae request for screening (n=9), prisoner compared to the same period in 2011 type b (Hib) screening (n=6), elevated liver function (Figure 3). One case of Haemophilus influenzae tests (n=5), symptoms of acute type b was notified in the first quarter Of the 40 newly acquired hepatitis C hepatitis (n=4), routine antenatal of 2012. The case was in a 45 cases notified in this quarter, 68 per screening (n=1) and other reasons year-old female with multiple chronic cent (n=27) reported a previous for screening (n=1). Note that cases medical conditions. Her vaccination negative hepatitis C antibody testing may have multiple reasons for testing status was unknown. history within the past 24 months. reported.

Seventy per cent of the cases (n=24) Injecting drug use (IDU) was the main Influenza were in males and 40 per cent (n=16) risk factor reported for 29 cases (73 There were 179 cases of influenza in females. Ages rangedQtr from1 15 to 43 Qtr2per cent). Risk factorsQtr3 reported for Qtr4 notified in the first quarter of 2012, 168 fewer than for the same period

Figure 3: NotifiedQtr1 cases of newlyQtr2 acquired hepatitisQtr3 C infections,Qtr4 by quarter, in 2011. Cases were in persons Victoria, January 2001–March 2012 aged from one to 90 years with a median age of 45 years. Eight cases Q1 Q2 Q3 Q4 250 were in children aged less than ten years and 44 cases were in persons 200 aged 65 years and older. Just over

150 fifty per cent (n=90) of the cases were in males. More than three

100 quarters of cases were type A virus infections (n=144), of which two were 50 further subtyped and identified as Number of notified cases H1N1(2009) pandemic strain. Thirty 0 four cases were identified as type 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 B virus, and one was type A and B Year of notification

70 Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 mixed infection. No deaths due to infected with serotypes contained Mumps influenza were reported during the within the polysaccharide vaccine. Eleven cases of mumps were notified quarter. Two cases were fully vaccinated, and to the department in the first quarter three cases were not vaccinated. Seven respiratory outbreaks were of 2012, compared with 13 cases in All five cases had risk factors for reported during the quarter, all of the corresponding period in 2011. infection. which were in aged-care facilities. Cases were in persons aged from six None of the outbreaks were Measles to 55 years, with a median age of 27 confirmed as influenza; a range of years. Eight cases (73 per cent) were Six confirmed cases of measles other respiratory pathogens were among males. One case was partially were notified to the department in identified in four of the outbreaks and vaccinated for age, and five were not the first quarter of 2012, compared no pathogen was identified for the vaccinated. Vaccination status for two to 19 cases for the same period in remaining three outbreaks. of the cases was unknown. 2011 (Figure 4). All six cases were in Invasive pneumococcal adults aged from 27 to 43 years with No epidemiological links between disease (IPD) a median age of 32 years. Four cases cases were reported during the (67 per cent) were in males. quarter. Fifty-two cases of IPD were notified in the first quarter of 2012, compared Only one case was fully vaccinated Rubella with 46 cases for the same period in for measles (not able to be validated); Three cases of rubella were notified 2011. Cases were in children aged one case was not vaccinated and to the department in the first quarter from five months to adults of 96 years vaccination status was unknown of 2012, compared with six cases in with a median age of 56 years. Eight for the remaining four cases. All six the corresponding period in 2011. cases (15 per cent) were in children cases were residents of metropolitan Cases were in adults aged from 26 to aged less than five years, and 29 regions (one from Northern & Western 46 years. Two cases were in females. cases (55 per cent) were in persons Metropolitan Region, two from Eastern One case was fully vaccinated for age aged 50 years or older. Thirty two Metropolitan Region and three cases (26-year-old female), one was not cases (60 per cent) were in females. from Southern Metropolitan Region). vaccinated, and vaccination status for Indigenous status data were complete All six cases were sporadic cases the remaining case was unknown. for 50 cases (94 per cent) of which that acquired their infections overseas one case identified as Aboriginal and/ Pertussis (Myanmar, Indonesia and Thailand). or Torres Strait Islander. Five cases Genotyping by the Victorian Infectious A total of 1,262 confirmed and 45 died due to their IPD infection, all in Diseases Reference Laboratory probable cases of pertussis were adults aged over 65 years and one revealed three of the cases to be due notified to the department in the first case died due to other causes. to genotype D8, two were genotype quarter of 2012, compared with 2,918 Serotyping was completed for 51 D9, and one case was not able to be cases for the same time in 2011, case isolates (96 per cent); one case genotyped. representing a 55 per cent decrease Qtr1 Qtr2 Qtr3 Qtr4 was not typable. Nine cases were Figure 4: Notified cases of measles by month of notification, Victoria, eligible for free conjugate vaccine January 2003–March 2012 under the National Immunisation 20 Program, however only three of these cases were infected with a serotype 16 contained within the conjugate vaccine. Among the 18 cases in 12 persons aged 65 years or older, 12 were infected with a serotype 8 contained within the polysaccharide 4 vaccine. Of these 12 cases, four Number of notified cases were fully vaccinated and seven were 0 not vaccinated. Of the five deaths J A J O J A J O J A J O J A J O J A J O J A J O J A J O J A J O J A J O J 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 reported among cases in persons Month of notification aged 65 years or older, all five were

Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 71 <1 1 to <5 5 to <15 18 to <25 25+

Figure 5: NotifiedQtr1 cases of Qtr2pertussis by monthQtr3 of notification, Victoria,Qtr4 two years, a one-month-old and a January 1997–March 2012 13-month-old. Two cases were in youths aged less than 18 years (a <1 1 to <5 5 to <15 15 to <18 18 to <25 25+ 1200 15-year-old and a 17-year-old). The remainder of the cases were in adults. 1000 Four of the eight cases (fifty per 800 cent) were in females. Seven of the eight cases were due to serogroup 600 B infection and one was due to 400 serogroup Y infection. No deaths were reported during the quarter and no Number of notified cases 200 epidemiological links between cases

0 J A J O J A J O J A J O J A J O J A J O J A J O J A J O J A J O J A J O J A J O J A J O J A J O J A J O J A J O J A J O J A were identified. 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Month of notification Legionellosis in the number of cases notified to Region of residence was available for Lucinda Franklin, Department of the department for the same period 99 per cent of cases with a majority Health in 2011 (Figure 5). Notification rates residing in metropolitan regions (75 Fourteen confirmed and two probable among infants aged less than 12 per cent), with Northern and Western cases of legionellosis were notified in months had decreased by 29 per cent Metropolitan Region reporting the the first quarter of 2012, compared over the same period, with 54 cases highest number of cases (35 per with 22 cases for the corresponding in this age group notified in 2012, cent). period in 2011. The age range of compared with 76 cases for the same Herpes zoster (shingles) persons reported was from 41 to 87 period in 2011. Of the 278 shingles cases, 58 per years (median age 55 years). Twelve No deaths were reported during the cent were in females. Cases were in cases (75 per cent) were in males. quarter. persons aged from nine to 99 years Nine of the sixteen cases during the quarter were Legionella pneumophila Tetanus with a median age of 57 years. Age was missing for six cases. Region of infections, all of which were serogroup No cases of tetanus were notified in residence was available for all cases. 1 infections. Six cases were identified this quarter. Consistent with previous reports, a as Legionella longbeachae infections, Varicella zoster virus majority of herpes zoster cases (79 and one case could not be further speciated (Table 2). One case that died There were 919 confirmed and 231 per cent) resided in metropolitan during the quarter was a Legionella probable cases of varicella zoster regions, with Northern and Western longbeachae infection in a 47-year-old virus notified to the department in Metropolitan Region reporting the male who also had lung cancer. the first quarter of 2012, compared highest number of cases (29 per cent). with 889 cases for the same time in None of the notified cases this quarter 2011. Of these, 150 (13 per cent) Other notifiable diseases reported a recent history of overseas were probable or confirmed cases of travel. Invasive meningococcal chickenpox and 278 were probable disease or confirmed cases of herpes zoster Table 2: Confirmed and probable (shingles). The clinical manifestation Lucinda Franklin, Department of cases of Legionella, Victoria, was not specified for the remaining Health January–March 2012 722 cases (63 per cent). Eight confirmed cases of invasive No. meningococcal disease were notified Legionella species cases Chickenpox in the first quarter of 2012 compared L. pneumophila 9 Of the 150 chickenpox cases, 50 per with ten cases for the same period in L. longbeachae 6 Legionella other species 0 cent were in females. Cases were 2011. Cases were in children aged Legionella laboratory confirmed in persons aged from 10 months to 1 from one month to adults aged 46 (NOS) 1 86 years with a median age of ten years (median age 17 years). Two Total 16 years. Age was missing for one case. cases were in infants aged less than 1. NOS = not further speciated or serogrouped

72 Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 Five of the nine cases diagnosed Creutzfeldt-Jakob disease Mycobacterial infections with Legionella pneumophila infection (CJD) Lynne Brown, Department of Health during the first quarter had worked Genevieve Klug, Australian National in the transport industry: two as CJD Registry Tuberculosis couriers, and one each as a taxi driver, Owing to the slow growing nature of a truck driver and a motor mechanic, Due to the nature of the disease, Mycobacterium tuberculosis, data are respectively. months or years may elapse between the notification date of suspected preliminary and subject to change. CJD cases and their subsequent Eighty-eight cases of tuberculosis confirmation (or rejection) by the were notified to the department in the Table 3: Notification of suspect and Australian National Creutzfeldt-Jakob first quarter of 2012, an eighteen per confirmed, definite and probable disease Registry (ANCJDR). Thus cent reduction on the previous quarter CJD cases by quarter, Victoria, June the figures reported here will differ (n=108) but a similar number to the 2004–March 2012 from those in Table 10, which counts first quarter in 2011 (n=85). Of the 88 confirmed and probable cases by their cases notified in the first quarter of Suspect Confirmed** notification date. 2012, 39 (44 per cent) were in females Qtr Notified* CJD Not CJD Jun–04 1 1 In the first quarter of 2012, four new and 49 in males. Patients aged 25–29 Sep–04 3 suspect CJD cases were notified to years comprised twenty-five per cent Dec–04 1 1 the ANCJDR. All four cases remain of the total notifications (n=22), and Mar–05 6 1 under investigation. For the same 56 per cent were aged from 20 to 34 Jun–05 2 1 period, nine previously notified cases years (Figure 6). In this quarter, two Sep–05 10 4 were classified as confirmed CJD and children aged less than fifteen years Dec–05 2 4 2 a further four cases were classified were notified with TB. Both children Mar–06 2 3 2 as non-CJD (Table 3). The number were Australian-born and diagnosed Jun–06 2 2 of cases classified with CJD within on clinical presentation. A four year Sep–06 3 the quarter represents a two-fold old male had recently returned from Dec–06 4 5 3 increase from the long-term average a visit to Vietnam where the family Mar–07 4 2 (four cases per quarter) and can stayed with relatives, and a fourteen Jun–07 3 1 1 be explained by a focused effort year old boy diagnosed with erythema Sep–07 5 by the ANCJDR to classify notified induratum, positive for AFB on skin Dec–07 5 1 2 cases who did not undergo post- biopsy. The teenager had previously Mar–08 7 6 2 mortem examination. Confirmation been treated with isoniazid for latent Jun–08 5 2 2 of disease in non-autopsied cases TB twelve years ago when his brother Sep–08 7 2 relies on clinical criteria, which must was diagnosed with pulmonary TB. Dec–08 4 3 2 Mar–09 4 3 1 be ascertained and then reviewed for In the first quarter of 2012, 92 per Jun–09 5 2 classification purposes. cent (n=81) of notifications were for Sep–09 2 1 Figure 6: Notified tuberculosis cases, by age group and sex, Victoria, Dec–09 9 1 1 January–March 2012 Mar–10 7 3 1 Female Male Jun–10 3 6 16 Sep–10 4 1 1 Dec–10 4 2 12 Mar–11 7 2 1 Jun–11 4 1 2 Sep–11 5 4 0 8 Dec–11 6 5 8 Mar–12 4 9 4 4

Total 140 74 40 Number of notified cases * notified = suspect cases notified within the quarter 0 ** confirmed = cases confirmed as definite or 0–4 5–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80–84 85+ probable reclassified within the quarter Age group (years)

Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 73 overseas-born patients. Of these, lungs, were noted in nine notifications Vector borne diseases 42 per cent were born in India and with pulmonary TB (Table 4). The a further 20 per cent were born most common additional site was Nicola Stephens, Department of in Vietnam or Philippines. Twelve lymph nodes (n=5) but two patients Health notifications were for overseas visitors also had pleural disease and another Alphavirus infection or students, and three notifications two patients had peritoneal and were for patients who had recently genitourinary disease respectively. Ross River virus infections arrived under Australia’s refugee and Extra pulmonary disease was reported Eighty-seven cases of Ross River humanitarian entry program. One in 51 per cent of notifications— virus infection were notified during case was in a person identifying as the most common sites being the first quarter of 2012. This was Indigenous Australian. Information lymphatic (44 per cent) with pleural consistent with the average of 79 about HIV testing was available for TB accounting for a further 20 per cases notified in first quarter periods 78 of the 88 cases and two were cent of extra pulmonary notifications. over the five year period 2007–2010 known to have HIV/TB co-infection. ‘Other’ sites of disease included four and in contrast to the large increase Ten patients were notified with active patients with TB of the skin (erythema in 2011 when 978 cases were notified tuberculosis as a result of investigation induratum or nodosum) and TB of the (Figure 1). of a Tuberculosis Undertaking (TBU) gastrointestinal tract, omentum, and Of the 87 cases notified in the first and one was identified by contact pancreas. quarter, 55 cases (63 per cent) were investigation. Laboratory confirmation of diagnosis in females and 32 (37 per cent) were Site of disease in some form (smear, culture, antigen in males. Cases were in persons detection or histology) was obtained aged from 14 to 85 years, with a Pulmonary disease accounted for just in 91 per cent of notifications (Table median of 43 years. Sixty-seven per under 50 per cent of all notifications 5). Only sixty-seven per cent of all cent of the cases (n=58) were in (n=43). Additional sites, other than the notifications were confirmed by residents of rural regions of Victoria, Table 4: Notifications of culture, which was similar to the with the highest number notified tuberculosis, by site of disease, previous quarter but a seven per cent from Loddon Mallee Region (n=20), Victoria, January–March 2012 decrease on the same period in 2011. followed by the Grampians Region Importantly however, the diagnosis (n=15) and Gippsland Region (n=12). Site Number Twenty-nine cases were in residents Pulmonary 34 was confirmed by culture in 81 per Pulmonary and other sites 9 cent of pulmonary notifications. Drug of metropolitan regions of which Lymph nodes 20 sensitivity testing did not identify any eight had reported travel to rural Bone / joint 4 MDRTB cases in this quarter, although areas of Victoria. A further six cases Pleural 9 five isolates were resistant to at least reported interstate travel to Northern Miliary 1 one anti-TB drug, including one isolate Territory (n=2), Perth (n=2), New Meningeal 1 that had intermediate resistance South Wales (n=1) and Queensland Peritoneal 2 to isonaizid and was resistant to (n=1) during their incubation periods. Other 8 ethionamide. For the remaining fifteen cases this Total 88 information was unknown.

Table 5: Confirmation of tuberculosis notifications, by diagnostic method, Barmah Forest virus infection Victoria January–March 2012 Fourteen cases of Barmah Forest Pulmonary + virus were notified during the first Diagnostic method Extra pulmonary Pulmonary only other sites Total quarter of 2012, which was similar to Culture 25 27 8 60 the average number of notifications PCR/NAT 2 3 1 6 observed for this time period between Histology 13 – 13 2007 and 2010 (n=11). Similar to Microscopic examination 1 – 1 Ross River virus, an above average Radiological 3 3 6 number of Barmah Forest virus Clinical signs 1 1 2 notifications occurred in the first Total 45 34 9 88 quarter of 2011 (n=146) (Figure 7). PCR/NAT: polymerase chain reaction/nucleic acid testing

74 Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 Figure 7: Notified cases of Ross River virus disease and Barmah Forest virus Infection with P. falciparum accounted disease by month, Victoria, January 2007–March 2012 for 10 cases (63 per cent) with

Barmah Forest virus Ross River virus infection reportedly acquired in North 600 Africa, Ghana, Kenya, Papua New

500 Guinea, Nigeria and Sudan. Infection with Plasmodium vivax 400 accounted for five cases (31 per cent) 300 and reported as acquired in Indonesia and Papua New Guinea. 200 One case (in a six year old male with Number of notified cases 100 travel to Cameroon) had a mixed P. 0 J A J O J A J O J A J O J A J O J A J O J falciparum and P. vivax infection. 2007 2008 2009 2010 2011 2012 Month of notification Chikungunya Three cases of chikungunya were The fourteen cases reported were 29.5 years. Ninety-one per cent of notified in the first quarter of 2012 in three females, aged 21, 40 and cases were able to be contacted for compared with six cases notified in 46 years, and in 11 males with follow up and all reported infection as the same time period in both 2011 ages ranging from 21 to 74 years. acquired overseas; with 52 reporting and 2010. Two cases were in males Eleven cases were from rural areas travel to Indonesia, 11 reporting travel aged 55 and 59 years, and one and the remaining three were from to East Timor, 10 to Thailand, five to case was in a 65 year old female. All metropolitan areas. the Philippines, four to India, three acquired their infection overseas, two each to Sri Lanka and Fiji, two to reported travel to Indonesia and one Flavivirus infection Malaysia, and one case each to South travel to India. There were 106 cases of Flavivirus East Asia, Central America, Cuba, infection notified in the first quarter of Ghana, Samoa and Singapore. 2012, all of which were due to dengue Zoonoses Malaria virus. This was a significant increase Lucinda Franklin, Department of in the number of notifications when Sixteen cases of Malaria were notified Health compared to the same time period in during the first quarter of 2012, the previous five years (Figure 8). compared with 26 cases notified in Brucellosis 2011 and 16 cases in 2010 for the No cases of brucellosis were notified Of the dengue cases notified, 66 same time period. Of the 16 cases to the department in the first quarter were in females (62 per cent) and 40 Barmah Forest virus notified this quarter, 14 were in males of 2012. in males (38 per cent). Cases were and two in females. Ages ranged from in persons aged from two years to six to 53 years, with a median age of Leptospirosis 78 years old, with a median age of 26 years. Three cases of leptospirosis were notified to the department in the first Figure 8: Notified cases of dengue fever by month, Victoria, January 2007– quarter of 2012, compared with four 60 March 2012 cases for the same period in 2011. Of

50 the three cases, two were Leptospira hardjo infections, and one was a 40 Leptospira arborea infection. All three

30 were males, aged 29, 30 and 76 years respectively. Two of the three 20 cases resided in metropolitan regions

Number of notified cases 10 (Northern and Western Metropolitan Region and Southern Metropolitan 0 J A J O J A J O J A J O J A J O J A J O J Region) and one was a resident 2007 2008 2009 2010 2011 2012 of Gippsland Region. Two were Month of notification occupationally-acquired infections, in

Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 75 a farmer and a landscape gardener. Two cases were occupationally- of 25 years. Infections were most One case of L. hardjo was acquired in acquired, both cattle farmers from commonly reported in the 20 to 24 Thailand. Gippsland Region. The remaining case year age group (39 per cent), which was associated with interstate travel. has remained consistent with previous Psittacosis quarters. Seventy-nine per cent of A cluster of two cases of Q fever One confirmed and two probable cases notified were in persons aged was detected during the quarter, at cases of psittacosis were notified to 15 to 29 years (n=4,323). a Gippsland property. The first case the department in the first quarter of was notified to the department in Indigenous status was reported for 2012, compared with 18 cases for the November 2011 and the second was 55 per cent of cases, of which 35 same period in 2011. Two cases were notified in early February 2012. Both (one per cent) were reported as being in females. The age range of cases cases worked on the same farm. The Indigenous Australians. was 44 to 63 years (median age 45 cluster was notified to Worksafe. years). All three cases during this A majority of cases (n=3,831, 70 per quarter were residents of metropolitan cent) reported had a metropolitan regions (two in Northern and Western Sexually transmissible postcode of residence. Postcode Metropolitan and one case in infections (STIs) of residence was not reported for Southern Metropolitan Region). 177 cases and the remaining cases Nasra Higgins, Department of (n=1,479, 27 per cent) were residents All three cases were hospitalised. Two Health of rural Victoria. of the three cases reported exposure Chlamydia to domestic birds and the third case Enhanced surveillance data were was in a hobby farmer who reported A total of 5,487 cases of chlamydia available for 1,586 cases (29 per exposure to wild birds. None were were notified in the first quarter of cent). Of these, 72 (five per cent) occupationally-acquired. 2012. This represented a 12 per cent were reported as being HIV positive; increase on the number of cases all were male and 69 reported a male Q fever notified in the previous quarter and a sexual partner (MSM). For three cases Three cases of Q fever were notified 16 per cent increase on the number this information was unknown or not in the first quarter of 2012, compared of cases notified in the same period in reported. with one for the same period in 2011 2011 (Figure 10). Among the 1,586 cases, STI screening (Figure 9). Two cases were in males Fifty-six per cent of cases (n=3,084) was reported as the main reason for and ages ranged from 36 to 75 years were in females and 44 per cent testing for 59 per cent of cases. Having (median age 57 years). All three cases (n=2,388) were in males. Sex was clinical signs and symptoms was were residents of rural regions (two not reported for 15 cases. The reported as the reason for testing in from Gippsland Region and one from females were aged from 18 days to 22 per cent of cases. Others reasons Barwon South West Region). One 90 years, with a median age of 22 for testing were reported as contact case was hospitalised. years. The males were aged from 28 tracing (13 per cent) pre-termination days to 78 years, with a median age screening (two per cent) and antenatal screening (one per cent). Three per Figure 9: Notified cases of Q fever by month, Victoria, January 2001– cent reported other unspecified March 2012 30 reasons for testing while for 25 cases (two per cent) this information was 25 unknown or not reported.

20 Males

15 Enhanced surveillance data were available for 779 males, of which 58 10 per cent (n=449) reported a female Number of notified cases 5 sexual partner and 33 per cent (n=257) reported a male sexual partner. Three 0 J A J O J A J O J A J O J A J O J A J O J A J O J A J O J A J O J A J O J A J O J A J O J cases reported having had sexual 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 contact with both male and female Month and year of notification

76 Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 Figure 10: Notified cases of chlamydia by quarter, Victoria, January 1997– Gonorrhoea March 2012 There were 645 cases of gonorrhoea Q1 Q2 Q3 Q4 notified in the first quarter of 2012, 20000 a nearly 50 per cent increase on Qtr4 the number of cases notified in the 15000 Qtr3 previous quarter and the same period in 2011 (Figure 11). Qtr2 10000 Eighty-four per cent of the casesQtr1 were in males (n=541) with an age range 5000 of 16 to 71 years. Sixteen per cent Number of notified cases of the cases were in females (n=104) 0 with an age range of 17 to 61 years. 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Year of notification The overall median age was 29 years. Infections were most frequent in the partners and one reported contact was unknown or not reported for 20 to 24 year age group, with 45 per with a transgender partner. Source of the remaining 10 per cent of females cent of gonorrhoea cases in persons infection was unknown or not reported (n=85). aged from 20 to 29 years. for nine per cent of males (n=69). Forty-five per cent of females (n=364) Eighty-one per cent of cases (n=521) Among the males reporting a female reported a regular sexual partner and reported had a metropolitan postcode sexual partner, 55 per cent (n=248) 36 per cent (n=289) reported a casual of residence. Postcode of residence reported having a casual sexual sexual partner as the likely source of was not reported for 72 cases (11 partner, 31 per cent (n=139) a regular the infection. Fifteen females identified per cent) and the remaining six per sexual partner, two per cent (n=9) as sex workers with likely acquisition cent of cases were from regional a sex worker as the likely source of from a client and two reported a Victoria (n=38). Indigenous status infection, and sexual partner type sex worker as the likely source of was reported for 69 per cent of cases was unknown or not reported for the infection. For the remaining 132 (n=447), of which one case reported remaining 53 cases. For those males females (16 per cent) this information as being an Indigenous Australian. reporting a male sexual partner, 82 was unknown or not reported. per cent (n=210) reported having Enhanced surveillance data were A majority of the females (n=671, 84 a casual sexual partner and 14 per received for 402 cases (62 per cent), per cent) reported that their infection cent (n=36) a regular sexual partner. of which 53 cases (13 per cent) were was acquired in Victoria. The remainder This information was unknown or not reported as being HIV positive; 49 reported overseas acquisition (n=35, reported for 11 males . reported as MSM, one reported a four per cent), interstate (n=8, one per female sexual partner and for the Eighty-four per cent (n=657) of males cent) and unknown or not reported remaining three cases this information reported Victoria as the likely place (n=88, 11 per cent). was unknown or not reported. of infection; overases and interstate acquisition accounted for 14 males Figure 11: Notified cases of gonorrhoea by quarter, Victoria, January 1997– (seven each). This information was March 2012 unknown or not reported for seven Q1 Q2 Q3 Q4 2000 per cent (n=58). Qtr4

Females 1500 Qtr3 Of the 802 females for whom Qtr2 enhanced surveillance data were 1000 Qtr1 available, 89 per cent reported a male sexual partner (n=712), one 500 per cent (n=8) reported a female Number of notified cases sexual partner and one reported both a female and male partner as the 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 source of infection. Source of infection Year of notification

Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 77 Among the 402 cases, 47 per cent a regular partner, 10 from a casual had decreased susceptibility to (n=189) were tested due to clinical partner and six females identified ciprofloxacin. signs and symptoms of STIs, followed as being sex workers likely to have by screening (40 per cent, n=161) and acquired the infection from a client. Syphilis—infectious (less than contact tracing (six per cent, n=26). This information was unknown or not two years duration) Eleven cases reported other reasons reported for the remaining six females. A total of 254 cases were notified and reason for testing was unknown during the first quarter of 2012 of Two females reported female sexual or not reported for the remaining 16 which 109 (43 per cent) were classified partner as the source of infection; cases. as infectious syphilis. This was nearly one acquired the infection from a sex a 60 per cent increase compared with worker and one with unknown source. Males the number of infectious syphilis cases Among the 346 males for whom For 11 of the 56 females, sex of the notified in the previous quarter and a enhanced surveillance data were sexual partner type was not reported. 24 per cent increase compared with available, 69 per cent (n=240) the same period in 2011 (Figure 12). Forty-seven females reported that reported a male sexual partner and they acquired their infection in Victoria, Of the 109 cases notified with 21 per cent (n=72) a female sexual three reported overseas and for the infectious syphilis, 39 were classified partner. For the remaining 10 per cent remaining six females this information as primary infections, 20 as secondary (n=34) this information was unknown was unknown or not reported. infections and the remaining 50 or not reported. cases were classified as early latent Antibiotic resistance Of the 240 males reporting a male infections. sexual partner, 81 per cent (n=194) Testing for susceptibility to ceftriaxone Ninety four per cent of cases (n=103) reported acquiring their infection from and ciprofloxacin was conducted were in males, with an age range of a casual sexual partner and 17 per by the Microbiological Diagnostic 19 to 65 years and a median age of cent (n=41) from a regular partner. Unit. Of the 308 isolates tested for 34 years. Six cases in females were One case reported being a sex worker resistance to ceftriaxone, 93 per cent notified this quarter, with an age range with likely acquisition from a client (n=288) were sensitive and 20 isolates of 25 to 69 years and a median age of and partner type was unknown or not had decreased susceptibility. Of the 31 years. reported for four males. 312 isolates tested for ciprofloxacin resistance, 46 per cent (n=146) Eighty-six per cent of the cases were For the males reporting a female were sensitive, 52 per cent were from metropolitan regions (n=94), five sexual partner, 58 per cent (n=42) resistant (n=163) and three isolates per cent were from regional Victoria reported acquiring the infection from a casual partner, 17 per cent (n=12) Figure 12: Notified cases of infectious syphilis, by quarter, Victoria, January from a regular partner, 19 per cent 1991–March 2012 (n=14) from a sex worker and partner Q1 Q2 Q3 Q4 type was unknown for the four 450 remaining males. 400 Qtr4 Eighty-three per cent of males 350 Qtr3 (n=286) reported that they acquired 300 Qtr2 their infection in Victoria, nine per 250 cent reported overseas acquisition 200 Qtr1

(n=30) and three cases reported 150 infection acquired from interstate. 100 Number of notified cases This information was unknown or not 50 reported for 27 males. 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Females Qtr4 3 0 1 1 0 4 0 1 0 2 2 8 11 28 34 80 81 80 90 74 69 Of the 56 females for whom enhanced Qtr3 2 3 3 5 3 4 5 0 0 1 6 8 20 16 29 67 140 83 100 60 87 surveillance data were available, 43 Qtr2 1 7 3 5 2 1 4 1 2 4 5 10 14 21 31 59 99 103 109 80 65 reported acquiring their infection Qtr1 0 5 4 6 3 2 1 2 0 2 3 2 10 19 23 28 103 111 92 77 88 109 from a male sexual partner; 21 from Year (and quarter) of notification

78 Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 (n=5) and postcode of residence the infection from a casual sexual There were 69 new HIV diagnoses1 was unknown or not reported for partner, one reported a regular sexual during the first quarter of 2012; the 10 cases. Indigenous status was partner and four reported sex worker same number of diagnoses for the reported for 102 cases (94 per cent) as the source of their infection. first quarter in 2011 (Figure 13). and one case was reported as being Seventy-nine males (81 per cent) an Indigenous Australian. Age, sex and exposure reported that they acquired their categories Enhanced surveillance data were infection in Victoria, seven reported Of the 69 new HIV diagnoses in the collected for 103 of the 109 cases overseas acquisition, two reported first quarter of 2012, 90 per cent (98 males and five females), of interstate acquisition and this (n=62) were in males of which 40 per which 35 were HIV positive (34 information was unknown or not cent were under the age of 30 years per cent); all males, one of whom reported for the remaining 10 males. (Table 6). The median age of males reported a female sexual partner, 31 Females diagnosed in this quarter was 33.5 reported male sexual partner and years compared to 39.5 years in the this information was unknown or Of the five females, two reported same quarter of 2011. The median not reported for the remaining three acquiring their infection from a male age of females diagnosed this quarter cases. Re-infection in persons who sexual partner and this information was 30.6 years compared with 36.1 had previous episode/s of syphilis was unknown or not reported for the years in the same quarter of 2011. infection was reported for 14 cases, of remaining three females. One case which nine were HIV positive. was reported as an infection acquired Male-to-male sexual contact in Victoria, two from overseas and The most frequent reported reason In the first quarter of 2012, 75 per this information was unknown or not for testing was screening for STI (51 cent (n=52) of all new HIV diagnoses reported for the remaining two females. per cent) followed by presenting with were among men who have sex with men (MSM) compared with 83 per signs and symptoms of an STI (41 per Human immunodeficiency cent). Two cases were tested because cent for the same quarter in 2011 of asymptomatic contact with an virus (HIV) and acquired and 80% overall in 2011 (Table 7).The infected individual and two cases immunodeficiency median age at HIV diagnosis among were found on antenatal screening. syndrome (AIDS) MSM this quarter was 33.4 years Other reasons for testing were compared with 37.8 years in the first reported for three cases and unknown Carol El-Hayek and Alyce Vella, quarter of 2011. In this quarter there or not reported for one case. Burnet Institute were no MSM who also reported Please note that numbers are subject injecting drug use as a possible Males to change as a result of ongoing case exposure to HIV. Of the 98 males, 79 (81 per cent) investigations and the annual audit of In this quarter, 75 per cent of MSM indicated likely acquiring the infection retrospective records. diagnosed with HIV reported acquiring from a male sexual partner, 11 (11 Qtr1 Qtr2 Qtr3 Qtr4 their HIV infection in Victoria (n=39) per cent) indicated a female sexual and 76 per cent (n=39) reported partner and for the remaining eight Qtr1 Qtr2 Qtr3 Qtr4 males this information was unknown Figure 13: Number of new HIV diagnoses by quarter, Victoria, 2002–2012 or not reported. Q1 Q2 Q3 Q4 300 Among the males reporting a male sexual partner, 82 per cent (n=65) 250 reported acquiring their infection from 200 a casual sexual partner, 10 per cent (n=8) from a regular sexual partner 150 and for the remaining six males sexual 100 partner type was unknown or not reported. 50 Number of new HIV diagnoses Of the 11 males reporting a female 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 sexual partner, six reported acquiring Year of notification

1 “New HIV diagnoses” refers to cases whose first ever HIV diagnosis was in Victoria.

Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 79 Table 6: New HIV diagnoses by age group, Jan–Mar 2012, Jan–Mar 2011 and Jan–Dec 2011

January–March 2012 January–March 2011 January–December 2011 Age group Males Females Total Males Females Total Males Females Total (years) 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 0 0.0 0 0.0 0 0.0 13–19 2 3.2 0 0.0 2 2.9 0 0.0 0 0.0 0 0.0 1 0.4 1 5.0 2 0.7 20–29 23 37.1 3 42.9 26 37.7 14 21.5 1 25.0 15 21.7 78 30.0 3 15.0 81 28.9 30–39 17 27.4 3 42.9 20 29.0 19 29.2 2 50.0 21 30.4 75 28.8 9 45.0 84 30.0 40–49 10 16.1 1 14.3 11 15.9 21 32.3 0 0 21 30.4 64 24.6 5 25.0 69 24.6 50–59 7 11.3 0 0.0 7 10.1 6 9.2 1 25.0 7 10.1 27 10.4 2 10.0 29 10.4 60+ 3 4.8 0 0.0 3 4.3 5 7.7 0 0 5 7.2 15 5.8 0 0.0 15 5.4 Total 62 100 7 100 69 100 65 100 4 100 69 100 260 100 20 100 280 100

Table 7: New HIV diagnoses by exposure category, Jan–Mar 2012, Jan–Mar 2011 and Jan–Dec 2011

January–March 2012 January–March 2011 January–December 2011 Males Females Total Males Females Total Males Females Total Exposure category n % n % n % n % n % n % n % n % n % Male to male sex 52 83.9 0 0.0 52 75.4 57 87.7 0 0.0 57 82.6 219 84.2 0 0.0 219 78.2 Male to male sex 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 4 1.5 0 0.0 4 1.4 and IDU IDU 1 1.6 0 0.0 1 1.4 1 1.5 0 0.0 1 1.5 4 1.5 0 0.0 4 1.4 Heterosexual contact 9 14.5 7 100 16 23.2 5 7.7 4 100 9 13.0 24 9.2 20 100 44 15.7 Other /unknown 0 0.0 0 0.0 0 0.0 2 3.1 0 0.0 2 2.9 9 3.5 0 0.0 9 3.2 Total 62 100 7 100 69 100 65 100 4 100 69 100 260 100 20 100 280 100

Table 8: New HIV diagnoses associated with heterosexual contact, Victoria, Jan–Mar 2012, Jan–Mar 2011 and Jan–Dec 2011

January–March 2012 January–March 2011 January–December 2011 Males Females Total Males Females Total Males Females Total Exposure category n % n % n % n % n % n % n % n % n % Person from an HPC2 1 11.1 3 42.9 4 25.0 0 0.0 2 50.0 2 22.2 6 25.0 11 55.0 17 38.6 Hetero contact with 0 0.0 0 0.0 0 0.0 1 20.0 0 0.0 1 11.1 5 20.8 1 5.0 6 13.6 person from an HPC2 Hetero contact with 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 bisexual male Hetero contact with an IDU 0 0.0 1 14.3 1 6.2 0 0.0 0 0.0 0 0.0 1 4.2 0 0.0 1 2.3 Hetero contact with person 0 0.0 2 28.6 2 12.5 1 20.0 2 50.0 3 33.3 2 8.3 3 15.0 5 11.4 with HIV Hetero contact, not 8 88.9 1 14.3 9 56.3 3 60.0 0 0.0 3 33.3 10 41.7 5 25.0 15 34.1 otherwise specified Total 9 100 7 100 16 100 5 100 4 100 9 100 24 100 20 100 44 100 Table 9: New HIV diagnoses in Victoria, by time since last negative test and/or seroconversion illness, Jan–Mar 2012, Jan–Mar 2011 and Jan–Dec 2011

Time between January–March 2012 January–March 2011 January–December 2011 HIV diagnosis and negative test and/or Males Females Total Males Females Total Males Females Total seroconversion illness n % n % n % n % n % n % n % n % n % Less than 1 year 33 53.2 1 14.3 34 49.3 34 52.3 2 50.0 36 52.2 116 44.6 5 25.0 121 43.2 (Newly acquired) 1 year to less than 3 years 9 14.5 0 0.0 9 13.0 6 9.2 0 0.0 6 8.7 40 15.4 0 0.0 40 14.3 3 or more years 6 9.7 0 0.0 6 8.7 7 10.8 1 25.0 8 11.6 27 10.4 4 20.0 31 11.1 No previous negative test or 9 14.5 3 42.9 12 17.4 12 18.5 1 25.0 13 18.8 49 18.9 9 45.0 58 20.7 seroconversion illness History unknown 5 8.1 3 42.9 8 11.6 6 9.2 0 0.0 6 8.7 28 10.8 2 10.0 30 10.7 Total 62 100 7 100 69 100 65 100 4 100 69 100 260 100 20 100 280 100

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.

80 Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 acquiring their infection from a casual Figure 14: New HIV diagnoses associated with male to male sex by probable or anonymous partner (Figures 14 place infection acquired, Victoria, Jan–Mar 2012 and Jan–Mar 2011 and 15). Jan–Mar 2012 Jan–Mar 2011 90 Heterosexual exposure 80 Oct-Dec 2010 70 Sixteen HIV notifications were Oct-Dec 2011 60 associated with heterosexual 50 exposure; seven of which were for 40 females and four were among people 30 born in a high HIV prevalence country 20 (HPC) 2. For nine cases no further 10 exposure information was ascertained oportion of new HIV diagnoses (%) Pr 0 (Table 8). Victoria Interstate Overseas Unknown Probable place infection acquired The median age at diagnosis of people with heterosexually acquired Figure 15: New HIV diagnoses associated with male to male sex by source HIV infection was 35.8 years in the partner type, Victoria, Jan–Mar 2012 and Jan–Mar 2011 first quarter of 2012 compared with Jan–Mar 2012 Jan–Mar 2011 46.4 years for the same period in 80 2011. Oct–Dec 2010

Oct–Dec 2011 Newly acquired infections3 60 Forty-nine per cent (n=34) of all new HIV diagnoses this quarter were 40 classified as newly acquired infections, similar to the previous quarter and 20 same quarter in 2011 (Table 9). In oportion of new HIV diagnoses (%) the first quarter of 2012, 94 per cent Pr 0 (n=32) of newly acquired infections Regular Casual Regular and casual Unknown Partner type were among MSM, similar to the 92 per cent (n=33) in the same quarter in 2011 and 83 (n=20) in 2010. Deaths Acquired In the first quarter of 2012 one death following HIV diagnosis was immunodeficiency reported in a male. The death was not syndrome (AIDS) attributed to AIDS. Six deaths were Ten cases of AIDS were reported in the reported in the first quarter. first quarter of 2012 compared with 15 in the first quarter of 2011; in nine males and one female. Of the males, four were MSM and three reported heterosexual exposure with no other information specified for the remaining two males. The one female AIDS notification this quarter was associated with heterosexual exposure to HIV.

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

Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 81 Table 10. Notifications of infectious diseases, by Department of Health Region, 1 January–31 March 2012 and historical comparisons Note—These data are preliminary figures only and may be subject to revision (daily surveillance reports are available online athttp://www.health.vic.gov.au/ideas)

Barwon South North and West Southern Western Grampians Loddon Mallee Hume Gippsland Metropolitan Eastern Metropolitan Metropolitan Unknown Victoria Notifiable disease 2012 ytd 2011 ytd 2012 ytd 2011 ytd 2012 ytd 2011 ytd 2012 ytd 2011 ytd 2012 ytd 2011 ytd 2012 ytd 2011 ytd 2012 ytd 2011 ytd 2012 ytd 2011 ytd 2012 ytd 2011 ytd 2012 ytd 2011 ytd 2011 total Blood borne diseases Hepatitis B – newly acquired 1 1 2 0 1 1 0 0 1 0 3 6 3 1 3 6 0 0 14 15 67 Hepatitis B – unspecified 9 8 5 1 21 4 2 5 1 5 205 209 107 95 85 105 7 8 442 440 1925 Hepatitis C – newly acquired 3 7 3 3 4 2 2 2 3 1 12 21 3 5 7 6 3 2 40 49 174 Hepatitis C – unspecified 27 40 11 21 35 37 25 27 45 31 177 200 67 66 128 142 31 13 546 577 2190 Hepatitis D 0 0 0 0 0 0 0 0 0 0 0 2 0 2 2 0 0 0 2 4 17 Enteric diseases Campylobacter infection 161 187 80 91 101 146 79 124 107 103 508 539 338 391 417 429 6 8 1797 2018 6799 Cryptosporidiosis 3 3 0 2 3 0 7 0 14 3 25 18 12 7 29 9 0 0 93 42 256 Food/water/environmental – other 1 3 3 1 5 4 1 1 0 0 8 38 12 4 5 11 48 49 83 111 1254 Haemolytic uraemic syndrome 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 4 Hepatitis A 0 1 0 0 0 1 0 2 1 0 8 4 4 3 3 2 0 0 16 13 34 Hepatitis E 0 0 0 0 0 0 0 0 0 0 4 0 1 2 4 0 0 0 9 2 7 Listeriosis 0 1 0 0 1 0 0 0 0 0 5 0 4 1 3 0 0 0 13 2 19 Paratyphoid 1 0 0 0 0 0 0 0 0 0 4 5 1 1 3 1 0 0 9 7 24 Salmonellosis 52 79 50 34 73 71 49 51 18 31 286 287 116 226 167 202 5 4 816 985 2695 Shigellosis 0 2 0 0 0 0 1 1 0 0 13 8 2 5 15 7 0 0 31 23 96 Typhoid 0 0 0 0 0 0 3 0 0 0 8 7 1 0 4 2 1 1 17 10 36 Vero toxin producing E.coli 1 1 0 1 0 1 0 0 0 0 2 2 0 1 0 0 0 0 3 6 10 Other notifiable conditions Blood lead greater than 10µg/dL 3 0 2 3 1 1 0 0 2 2 8 4 1 2 4 4 0 2 21 18 151 Creutzfeldt-Jakob disease 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 2 0 0 1 4 11 Invasive meningococcal disease – group B 2 1 1 0 0 1 0 2 1 0 2 2 1 3 0 1 0 0 7 10 44 Invasive meningococcal disease – group C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 Invasive meningococcal disease – other 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 4 Legionella – other 0 0 0 0 0 1 0 0 1 1 0 1 0 0 0 0 0 0 1 3 7 Legionella longbeachae 0 0 0 0 0 0 0 0 0 1 3 0 1 0 2 2 0 0 6 3 12 Legionella pneumophila – indeterminate serotype 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 3 8 Legionella pneumophila 1 0 1 0 0 0 0 0 1 0 0 4 6 3 0 2 5 0 0 9 13 48 Leprosy 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 Mycobacterium infection (non-TB) 0 0 0 0 0 1 1 1 1 0 1 1 2 1 0 4 0 0 5 8 33 Mycobacterium ulcerans 6 2 0 0 0 1 0 0 1 0 0 0 0 0 3 1 0 0 10 4 80 TB complex 4 2 1 0 0 1 2 0 1 2 39 38 14 18 28 25 1 0 90 86 360 Sexually transmissible infections Chlamydia 377 383 263 171 320 235 251 226 266 181 1682 1410 749 684 1398 1095 177 327 5483 4712 19238 Gonococcal infection 8 11 14 6 10 6 11 6 9 9 252 154 77 51 192 145 72 58 645 446 1863 Syphilis – less than 2 years duration 2 1 1 1 2 1 0 1 1 0 43 39 18 9 39 28 11 9 117 89 321 Syphilis – greater than 2 years duration 5 4 2 3 4 4 1 2 3 2 66 65 11 11 31 28 13 18 136 137 536 Vaccine preventable diseases Haemophilus influenzae type b 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 Influenza 7 7 6 4 19 7 6 4 5 5 49 98 38 77 49 142 0 1 179 345 3226 Invasive pneumococcal disease 3 3 3 1 4 1 3 2 2 4 17 14 11 6 7 9 3 4 53 44 431 Measles 0 2 0 3 0 0 0 0 0 0 1 9 2 2 3 3 0 0 6 19 40 Mumps 0 1 0 0 0 2 0 0 0 0 4 7 6 0 1 3 0 0 11 13 25 Pertussis 70 168 25 99 97 239 94 263 99 272 403 626 268 521 247 660 1 26 1304 2874 8808 Rubella 0 0 0 0 1 0 0 0 0 0 1 3 0 3 1 0 0 0 3 6 11 Varicella-zoster virus – chickenpox 9 9 6 8 13 8 6 1 3 6 52 34 35 28 25 26 1 0 150 120 682 Varicella-zoster virus – shingles 8 12 8 12 6 9 11 13 24 15 81 62 69 74 71 82 0 1 278 280 993 Varicella-zoster virus – unspecified 47 32 23 12 16 12 11 13 24 17 230 122 163 123 194 144 14 11 722 486 2383 Vector borne diseases Barmah Forest 0 6 0 12 5 74 3 33 2 7 2 6 2 4 2 4 0 0 16 146 210 Chikungunya 0 0 0 0 0 0 0 0 1 0 0 1 1 4 1 1 0 0 3 6 17 Dengue 5 2 3 0 4 2 4 0 3 0 41 17 20 4 37 19 1 0 118 44 109 Flavivirus 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 1 0 0 0 4 13 Malaria 0 3 0 0 1 1 0 1 1 0 9 12 2 3 3 4 0 1 16 25 95 Ross River 4 67 15 394 20 383 8 41 12 12 5 30 11 17 11 31 0 0 86 978 1328 Zoonoses Brucellosis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 Leptospirosis 0 1 0 0 0 0 0 3 1 0 1 0 0 0 1 0 0 0 3 4 12 Psittacosis 0 0 0 1 0 0 0 3 0 1 2 4 0 6 1 3 0 0 3 18 62 Q fever 1 0 0 1 0 0 0 0 2 0 0 0 0 0 0 0 0 0 3 1 21 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

82 Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 Table 10. Notifications of infectious diseases, by Department of Health Region, 1 January–31 March 2012 and historical comparisons Note—These data are preliminary figures only and may be subject to revision (daily surveillance reports are available online at http://www.health.vic.gov.au/ideas)

Barwon South North and West Southern Western Grampians Loddon Mallee Hume Gippsland Metropolitan Eastern Metropolitan Metropolitan Unknown Victoria Notifiable disease 2012 ytd 2011 ytd 2012 ytd 2011 ytd 2012 ytd 2011 ytd 2012 ytd 2011 ytd 2012 ytd 2011 ytd 2012 ytd 2011 ytd 2012 ytd 2011 ytd 2012 ytd 2011 ytd 2012 ytd 2011 ytd 2012 ytd 2011 ytd 2011 total Blood borne diseases Hepatitis B – newly acquired 1 1 2 0 1 1 0 0 1 0 3 6 3 1 3 6 0 0 14 15 67 Hepatitis B – unspecified 9 8 5 1 21 4 2 5 1 5 205 209 107 95 85 105 7 8 442 440 1925 Hepatitis C – newly acquired 3 7 3 3 4 2 2 2 3 1 12 21 3 5 7 6 3 2 40 49 174 Hepatitis C – unspecified 27 40 11 21 35 37 25 27 45 31 177 200 67 66 128 142 31 13 546 577 2190 Hepatitis D 0 0 0 0 0 0 0 0 0 0 0 2 0 2 2 0 0 0 2 4 17 Enteric diseases Campylobacter infection 161 187 80 91 101 146 79 124 107 103 508 539 338 391 417 429 6 8 1797 2018 6799 Cryptosporidiosis 3 3 0 2 3 0 7 0 14 3 25 18 12 7 29 9 0 0 93 42 256 Food/water/environmental – other 1 3 3 1 5 4 1 1 0 0 8 38 12 4 5 11 48 49 83 111 1254 Haemolytic uraemic syndrome 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 4 Hepatitis A 0 1 0 0 0 1 0 2 1 0 8 4 4 3 3 2 0 0 16 13 34 Hepatitis E 0 0 0 0 0 0 0 0 0 0 4 0 1 2 4 0 0 0 9 2 7 Listeriosis 0 1 0 0 1 0 0 0 0 0 5 0 4 1 3 0 0 0 13 2 19 Paratyphoid 1 0 0 0 0 0 0 0 0 0 4 5 1 1 3 1 0 0 9 7 24 Salmonellosis 52 79 50 34 73 71 49 51 18 31 286 287 116 226 167 202 5 4 816 985 2695 Shigellosis 0 2 0 0 0 0 1 1 0 0 13 8 2 5 15 7 0 0 31 23 96 Typhoid 0 0 0 0 0 0 3 0 0 0 8 7 1 0 4 2 1 1 17 10 36 Vero toxin producing E.coli 1 1 0 1 0 1 0 0 0 0 2 2 0 1 0 0 0 0 3 6 10 Other notifiable conditions Blood lead greater than 10µg/dL 3 0 2 3 1 1 0 0 2 2 8 4 1 2 4 4 0 2 21 18 151 Creutzfeldt-Jakob disease 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 2 0 0 1 4 11 Invasive meningococcal disease – group B 2 1 1 0 0 1 0 2 1 0 2 2 1 3 0 1 0 0 7 10 44 Invasive meningococcal disease – group C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 Invasive meningococcal disease – other 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 4 Legionella – other 0 0 0 0 0 1 0 0 1 1 0 1 0 0 0 0 0 0 1 3 7 Legionella longbeachae 0 0 0 0 0 0 0 0 0 1 3 0 1 0 2 2 0 0 6 3 12 Legionella pneumophila – indeterminate serotype 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 3 8 Legionella pneumophila 1 0 1 0 0 0 0 0 1 0 0 4 6 3 0 2 5 0 0 9 13 48 Leprosy 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 Mycobacterium infection (non-TB) 0 0 0 0 0 1 1 1 1 0 1 1 2 1 0 4 0 0 5 8 33 Mycobacterium ulcerans 6 2 0 0 0 1 0 0 1 0 0 0 0 0 3 1 0 0 10 4 80 TB complex 4 2 1 0 0 1 2 0 1 2 39 38 14 18 28 25 1 0 90 86 360 Sexually transmissible infections Chlamydia 377 383 263 171 320 235 251 226 266 181 1682 1410 749 684 1398 1095 177 327 5483 4712 19238 Gonococcal infection 8 11 14 6 10 6 11 6 9 9 252 154 77 51 192 145 72 58 645 446 1863 Syphilis – less than 2 years duration 2 1 1 1 2 1 0 1 1 0 43 39 18 9 39 28 11 9 117 89 321 Syphilis – greater than 2 years duration 5 4 2 3 4 4 1 2 3 2 66 65 11 11 31 28 13 18 136 137 536 Vaccine preventable diseases Haemophilus influenzae type b 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 Influenza 7 7 6 4 19 7 6 4 5 5 49 98 38 77 49 142 0 1 179 345 3226 Invasive pneumococcal disease 3 3 3 1 4 1 3 2 2 4 17 14 11 6 7 9 3 4 53 44 431 Measles 0 2 0 3 0 0 0 0 0 0 1 9 2 2 3 3 0 0 6 19 40 Mumps 0 1 0 0 0 2 0 0 0 0 4 7 6 0 1 3 0 0 11 13 25 Pertussis 70 168 25 99 97 239 94 263 99 272 403 626 268 521 247 660 1 26 1304 2874 8808 Rubella 0 0 0 0 1 0 0 0 0 0 1 3 0 3 1 0 0 0 3 6 11 Varicella-zoster virus – chickenpox 9 9 6 8 13 8 6 1 3 6 52 34 35 28 25 26 1 0 150 120 682 Varicella-zoster virus – shingles 8 12 8 12 6 9 11 13 24 15 81 62 69 74 71 82 0 1 278 280 993 Varicella-zoster virus – unspecified 47 32 23 12 16 12 11 13 24 17 230 122 163 123 194 144 14 11 722 486 2383 Vector borne diseases Barmah Forest 0 6 0 12 5 74 3 33 2 7 2 6 2 4 2 4 0 0 16 146 210 Chikungunya 0 0 0 0 0 0 0 0 1 0 0 1 1 4 1 1 0 0 3 6 17 Dengue 5 2 3 0 4 2 4 0 3 0 41 17 20 4 37 19 1 0 118 44 109 Flavivirus 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 1 0 0 0 4 13 Malaria 0 3 0 0 1 1 0 1 1 0 9 12 2 3 3 4 0 1 16 25 95 Ross River 4 67 15 394 20 383 8 41 12 12 5 30 11 17 11 31 0 0 86 978 1328 Zoonoses Brucellosis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 Leptospirosis 0 1 0 0 0 0 0 3 1 0 1 0 0 0 1 0 0 0 3 4 12 Psittacosis 0 0 0 1 0 0 0 3 0 1 2 4 0 6 1 3 0 0 3 18 62 Q fever 1 0 0 1 0 0 0 0 2 0 0 0 0 0 0 0 0 0 3 1 21 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

Victorian Infectious Diseases Bulletin Volume 15 Issue 2 June 2012 83 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.

Contributions are invited on any topic dealing with the control of infectious diseases. These may be in the form of articles, short reports or letters. Lead articles will be subject to peer review. As a guide, lead articles should be no more than 2500 words with a 200 word abstract, non-peer reviewed articles 2000 words and short reports and letters 800 words. Submissions should be in Microsoft Word IBM- compatible format with Vancouver-style references. We encourage submissions in electronic format. Original data from which graphs and figures have been prepared should be included. Submissions will be edited to conform with the style of the bulletin.

The editors recognise and thank the individuals and organisations who contribute to the surveillance and management of infectious diseases. We remind authors of their responsibility to cite appropriate persons as authors and to acknowledge separately those whose work contributed significantly but did not justify authorship.

Any material included in the Victorian Infectious Diseases Bulletin may be reproduced in whole or part if appropriately acknowledged. Opinions expressed in the bulletin are those of the authors and not necessarily those of the Department of Health. Data are subject to revision.

Editorial correspondence and subscription enquiries should be directed to:

The Editor Victorian Infectious Diseases Bulletin Communicable Disease Prevention and Control Unit Department of Health 50 Lonsdale Street Melbourne Victoria 3000

Email [email protected] Phone: 1300 651 160

Editorial group: Hazel Clothier, Nicola Stephens, Marion Easton, James Fielding, Benjamin Cowie and Rebecca Gelsi Production editor: Judy Bennett Planning editor: Hazel Clothier To receive this document in an accessible format phone 1300 651 160. Authorised and published by the Victorian Government, 50 Lonsdale St, Melbourne. Except where otherwise indicated, the images in this publication show models and illustrative settings only, and do not necessarily depict actual services, facilities or recipients of services. © Department of Health, Setember 2012 Print managed by Finsbury Green.