Effectiveness of digital contact tracing for COVID-19 in New South Wales, Australia

Background: Digital proximity tracing applications were rolled out early in the COVID-19 pandemic in many countries to complement conventional contact tracing. Empirical evidence about their benefits for pandemic response remains scarce. We evaluated the effectiveness and usefulness of 'COVIDSafe', Australia's national smartphone-based proximity tracing application for COVID-19. Methods: In this prospective study, conducted in New South Wales, Australia between May and November 2020, we calculated the positive predictive value and sensitivity of COVIDSafe, its additional contact yield, and the number of averted public exposure events. Semi-structured interviews with public health staff were conducted to assess the application's usefulness. Results: There were 619 confirmed COVID-19 cases and over 25,300 close contacts during the study period. COVIDSafe was used by 137 (22%) cases and detected 79 (0.3%) close contacts. It had a positive predictive value of 39% and a sensitivity of 15%, and detected 17 (0.07%) additional close contacts that were not identified by conventional contact tracing. The application generated a substantial additional workload for public health staff and was not considered useful. Conclusions: COVIDSafe was not sufficiently effective to make a meaningful contribution to the COVID-19 response in Australia's most populous state over a 6-month period. This contrasts optimistic projections from modelling studies about the added value of digitally supported contact tracing. We found no evidence that it adds value to conventional contact tracing, and recommend that their implementation should always include comprehensive effectiveness evaluations.

Breast Feeding in Pandemic Situation. How Does Sri Lanka Face the Challenge?

Objectives Sri Lanka has been awarded the first-ever ‘Green’ breastfeeding (BF) nation status by the World Breastfeeding Trends Initiative (WBTi) in January 2020 (1) with the support of public health system. But, deviating attention of health services towards emergency pandemic situation has resulted in strained health systems and interruptions in humanitarian response leading to eroding access to essential and often life-saving nutrition services. Therefore, optimal breast feeding practices are at risk due to infected mothers’ isolation practices, exhausted public health system and misbeliefs among the community (2). This finds out how Sri Lanka plans to maintain high standards of breast feeding in pandemic situation. Methods We searched for the publications on breast feeding, Sri Lanka in pandemic situation from January 2020 to date. Results As a low and middle income country with an unbeatable public health system, Sri Lanka has already issued an interim guideline for public health staff in continuation maternal and child care services (3). It ensures domiciliary visits by public health midwives (PHMs), although the clinic based teaching sessions on breast feeding have been cancelled. Community awareness has been created that no evidence of transmission of SARS COV-2 via breast milk is available and how the benefits of breast feeding outweigh the risk of infection (4). It is recommended that breast feeding shouldn't be interrupted at all and hand hygienic practices before touching the baby are ideal. Infected mothers can wear a protective mask and rooming in, and kangaroo mother care should be practiced. Sri Lanka already had guidelines on ensuring adequate and appropriate infant feeding guidelines in emergency situations (5). Conclusions Despite the challenges faced by community and public health staff, Sri Lanka make efforts to maintain the achieved breast feeding standards. Further studies are needed to assess the impact of the pandemic on breast feeding practices in near future. Funding Sources None

Feasibility of implementation of CARD™ for school-based immunizations in Calgary, Alberta: a cluster trial

Background Negative experiences with school-based immunizations can contribute to vaccine hesitancy in youth and adulthood. We developed an evidence-based, multifaceted and customizable intervention to improve the immunization experience at school called the CARD™ (C-Comfort, A-Ask, R-Relax, D-Distract) system. We evaluated the feasibility of CARD™ implementation for school-based immunizations in Calgary, Canada. Methods In a mixed methods study, two Community Health Centres providing immunization services, including 5 schools each with grade 9 students (aged approximately 14 years), were randomized to CARD™ or control (usual care). In the CARD™ group, public health staff and students were educated about coping strategies prior to immunization clinics. Clinics were organized to reduce fear and to support student’s choices for coping strategies. Public health staff in the CARD™ group participated in a focus group discussion afterwards. We sought a recruitment rate of 80% for eligible schools, an external stakeholder focus group (e.g., school staff) with 6 or more individuals, 85% of individual injection-related data acquisition (student and immunizer surveys), and 80% absolute agreement between raters for a subset of data that were double-coded. Across focus groups, we examined perceptions of acceptability, appropriateness, feasibility and fidelity of CARD™. Results Nine (90%) of eligible schools participated. Of 219 students immunized, injection-related student and immunizer data forms were acquired for 195 (89.0%) and 196 (89.5%), respectively. Reliability of data collection was high. Fifteen public health and 5 school staff participated in separate focus groups. Overall, attitudes towards CARD™ were positive and compliance with individual components of CARD™ was high. Public health staff expressed skepticism regarding the value of student participation in the CARD™ system. Suggestions were made regarding processes to refine implementation. Conclusion While most outcome criteria were satisfied and overall perceptions of implementation outcomes were positive, some important challenges and opportunities were identified. Feedback is being used to inform a large cluster trial that will evaluate the impact of CARD™ during school-based immunizations. Trial registration The trial is registered at ClinicalTrials.gov (NCT03948633); Submitted April 24, 2019.

A “Clinician’s Probability Calculator” to convert pre-test to post-test probability of COVID-19 , based on method validation from each laboratory

During coronavirus pandemic testing and identifying the virus has been a unique and constant challenge for the scientific community. In this paper, we discuss a practical solution to help guide clinicians and public health staff with the interpretation of the probability that a positive, or negative, COVID-19 test result indicates an infected person, based on their clinical estimate of pre-test probability of infection. The LinkedIn survey confirmed that the pre-test probability of COVID-19 increases with patient age, known contact, and severity of symptoms, as well as prevalence of disease in the local population. PPA (Positive Percent Agreement, PPA) and NPA (Negative Percent Agreement, specificity), differ between individual methods. Results vary between laboratories and the manufacturer for the same method. The confidence intervals of results vary with the number of samples tested, often adding a large range of possibilities to the reported test result. The online calculator met the objective.The authors postulated that the clinical pre-test probability of COVID-19 increases relative to local prevalence of disease plus patient age, known contact, and severity of symptoms. We conducted a small survey on LinkedIn to confirm that hypothesis. We examined results of PPA (Positive Percent Agreement, sensitivity) and NPA (Negative Percent Agreement, specificity) from 73 individual laboratory experiments for molecular tests for SARS-CoV-2as reported to the FIND database,(1) and for selected methods in FDA EUA submissions (2,3). We calculated likelihood ratios to convert pre-test to post-test probability of disease, then further calculated the number of true and false results expected in every ten positive or negative test results, plus an estimate that one in ‘x’ test results is true. We designed an online calculator to create graphics and text to fulfill the objective. A positive or negative test result from one laboratory conveys a higher probability for the presence or absence of COVID-19 than the same result from another laboratory, depending on clinical pre-test probability of disease plus proven method PPA and NPA in each laboratory. Likelihood ratios and confidence intervals provide valuable information but are seldom used in clinical settings. We recommend that testing laboratories verify PPA and NPA, and utilize a tool such as the “Clinician’s Probability Calculator” to verify acceptable test performance and create reports to help guide clinicians and public health staff with estimation of post-test probability of COVID-19 .

Implementation, Monitoring and Evaluation of a Novel In-Service Training Strategy of Public Health Staff: Evidence from Colombo Regional Directorate of Health Services, Sri Lanka

Introduction: Continuous in-service training sessions help in updating and upgrading the competency of the public health field staff. Implementation of these sessions with the uniform delivery of the quality assured content has been a challenge in the Sri Lankan well-established preventive healthcare system. Aim: To describe the implementation, monitoring and evaluation of a novel in-service training strategy of public health staff including Pubic Health Inspectors (PHI) and Public Health Midwives (PHM) conducted in the Colombo Regional Directorate of Health, Sri Lanka from January to June 2018. Methods: A consultative meeting and a workshop was conducted with the participation of all stakeholders in reviewing the existing in-service training methodology and in recommending the strategies of overcoming the limitations of it. A novel strategy was developed for the implementation of in-service sessions with multi-level implementation and evaluation components. The in-service training sessions were conducted to improve the knowledge and quality of service provision by Public Health Inspectors, Public Health Midwives and other public health staff. Four evaluation indicators were defined. Descriptive statistics and the Wilcoxon signed rank test were used in the evaluation. Results: By the consultative meetings and workshops, four main weaknesses of the existing in-service training system were revealed, and three characteristics of an ideal system were defined. Two process indicators have shown a coverage of the intervention of 100% while the median satisfaction scores were observed to be 85% or above. Two output/outcome indicators have shown that the interventions have yielded significantly higher post-intervention scores compared to the pre-intervention scores as perceived by the staff members (p<0.05), while the reception of feedback reports was 100%. Conclusions and Recommendations: The novel strategy is seemingly effective in relation to the four evaluation indicators used. Possibility of implementing similar strategies in other areas must be explored with the view of disseminating quality assured content with uniformity among the public health field staff categories in the monthly in-service sessions.

Is it or is it not? Lessons learned from a case of suspected vaccine strain measles

Background Measles continues to be a threat to Australia. While post eradication risks are low, imported measles cases from overseas travellers who are non-immune can cause small outbreaks. This case report discusses the challenge of identifying wild-type measles in an individual who was recently vaccinated with measles - containing vaccine (MCV). Methods A positive polymerase chain reaction (PCR) result for measles for an adult who had recently received a measles -containing vaccine was notified. Investigation revealed no known epidemiological link, recent overseas travel or contact with recent measles cases during the incubation period. Results The results of the initial sequencing to distinguish between wild-type and vaccine-strain measles were inconclusive. A decision was made to re-run the genotyping, collect additional specimens, and quarantine the case until a definitive result was obtained. Sequencing and genotyping revealed that this indeed was a wild-type measles strain. Conclusions Changing epidemiology of measles means distinguishing between wild-type and vaccine-strain measles has become a new challenge. The reflection of the public health management of this case has provided is a valuable teaching tool for public health professionals globally, particularly in low incidence measles countries. Key messages The lack of an epidemiological link can create confusion for public health staff when investigating possible measles cases. Changes in the epidemiology of measles means distinguishing between wild type and vaccine strain measles is a challenge.

Microcystin Incidence in the Drinking Water of Mozambique: Challenges for Public Health Protection

Microcystins (MCs) are cyanotoxins produced mainly by freshwater cyanobacteria, which constitute a threat to public health due to their negative effects on humans, such as gastroenteritis and related diseases, including death. In Mozambique, where only 50% of the people have access to safe drinking water, this hepatotoxin is not monitored, and consequently, the population may be exposed to MCs. The few studies done in Maputo and Gaza provinces indicated the occurrence of MC-LR, -YR, and -RR at a concentration ranging from 6.83 to 7.78 µg·L−1, which are very high, around 7 times above than the maximum limit (1 µg·L−1) recommended by WHO. The potential MCs-producing in the studied sites are mainly Microcystis species. These data from Mozambique and from surrounding countries (South Africa, Lesotho, Botswana, Malawi, Zambia, and Tanzania) evidence the need to implement an operational monitoring program of MCs in order to reduce or avoid the possible cases of intoxications since the drinking water quality control tests recommended by the Ministry of Health do not include an MC test. To date, no data of water poisoning episodes recorded were associated with MCs presence in the water. However, this might be underestimated due to a lack of monitoring facilities and/or a lack of public health staff trained for recognizing symptoms of MCs intoxication since the presence of high MCs concentration was reported in Maputo and Gaza provinces.

Healthy public policy competences for public health: interactive and practice-oriented curriculum

Background Developing and implementing healthy public policy (HPP) is one of the practical competences expected of public health professionals in Europe and beyond (ASPHER 2018, Public Health Agency of Canada 2015, US Public Health Foundation 2014). Yet, organizational practices in building public health capacity to promote HPP are seldom documented. In order to improve its HPP interventions, the Montreal Public Health Unit has been leading and evaluating a HPP multidisciplinary community of practice since 2014. In response to participants’ requests, we recently formalized a HPP curriculum. Objectives Over a period of 12 months in 2018-2019, our objectives were to: (1) develop and pre-test a competency-based professional development curriculum in HPP for public health staff and interns (2) provide a repository of relevant references (3) identify dynamic pedagogical strategies applicable to a community of practice. Results As community of practice members and facilitators, we developed a HPP curriculum with the support of pedagogical and HPP experts. It was pre-tested and iteratively adjusted with members of the community of practice. We drew content from various disciplines including political sciences, public health, communication studies and public relations. We identified relevant: (1) competences; (2) core concepts; (3) practical skills; (4) key references; (5) practical case studies, (6) interactive pedagogical strategies such as an open-source online learning system. Conclusions We developed an innovative healthy public policy (HPP) curriculum in order to support an existing community of practice among public health staff. Dynamic pedagogical strategies and a more formal HPP curriculum can support competence development among public health staff, and this can be achieved while relying mostly on in-house expertise. This constitutes a stimulating capacity-building initiative for the enhancement of public health core competences. Key messages Developing healthy public policy is a core practical competence expected of public health professionals. Yet, organizational practices in building healthy public policy capacity are seldom documented. Developing dynamic pedagogical strategies and a more formal healthy public policy curriculum can support competence development among public health staff, while relying mostly on in-house expertise.